The United States Department of Health and Human Services (DHHS) today published an update to its Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents, which includes significant changes to the list of drugs recommended for people starting antiretroviral (ARV) therapy for the first time. Notable changes included adding Norvir (ritonavir)-boosted Prezista (darunavir) to the list of preferred protease inhibitors (PIs) and removing the nucleoside reverse transcriptase inhibitor (NRTI) combination backbone Epzicom (abacavir plus lamivudine) from the preferred to the alternative category.

The DHHS guidelines panel meets twice yearly to review data and revise its official U.S. treatment recommendations as necessary. Since the last update in January 2008, the panel recommended a number of changes. Some of the changes are more cosmetic in nature. For instance, the panel changed the coding for the strength of various recommendations and the quality of the data behind each recommendation to make the guidelines more consistent with other types of treatment guidelines.

More substantial recommended changes include a list of laboratory tests that should be obtained before a person starts treatment and for the duration of his or her time on treatment, such as viral load, HIV resistance testing and cholesterol and blood sugar levels. The panelists also suggest conducting resistance testing when a person on therapy has a viral load between 500 and 1,000—despite the fact that testing at such low viral levels is not always as accurate.

Other changes included additions or changes to the list of drugs that are now preferred by the panel for first-line treatment. Norvir-boosted Prezista, which was approved in the past two weeks for people who’ve never taken ARV treatment, was added to the list of top choices. Epzicom, however, was moved from the preferred to the alternative list, due to an accumulation of data linking the drug to a higher risk of heart attacks and, for those starting ARVs with viral loads above 100,000 copies, a higher rate of treatment failure.