Updated Guidelines for Use of Antiretroviral Therapies in HIV

The Department of Health and Human Services (DHHS) Panel on Antiretroviral Guidelines for Adults and Adolescents issued new guidelines December 1, 2009 for the use of antiretroviral agents in HIV-1-infected adults and adolescents. The revised recommendations update the November 3, 2008 version of the guidelines. “The guidelines serve as a living document and are updated regularly using electronic distribution channels,” says Paul E. Sax, MD, who is on the DHHS panel. In the guidelines, recommendations are based on the best evidence from prospective trials in HIV therapy with defined endpoints. When to Start Antiretroviral Therapy There are several key changes from the November 3, 2008 DHHS guidelines, and one of the most important, in Dr. Sax’s opinion, addresses when to start antiretroviral therapy (ART). “In recent cohort studies, findings support that starting therapy in patients with a higher CD4 cell count is associated with improved outcomes,” he says. “Most of the available evidence recommends starting ART earlier, with specific considerations [Figure 1]. For example, one study suggested that treatment be started before the CD4 cell count falls below 350 cells/mm3 while another found that 500 cells/mm3 should be the threshold. Considering data from observational studies and data from prospective clinical trials, the panel decided that the threshold for starting ART should be increased to between 350 cells/mm3 and 500 cells/mm3.” While there is clearly a movement in the updated DHHS guidelines to begin treatment earlier, Dr. Sax says this strategy does not apply to everyone. “Some patients are clearly not ready to start therapy because they can’t commit to lifelong medication adherence. Providers and patients must work together to...