By Ed Susman
MEXICO CITY -- August 4, 2008 -- Earlier initiation of therapy is warranted for the treatment of human immunodeficiency virus (HIV), before the CD4-positive cell count falls below 350 cells/mcL, according to new guidelines presented here at the 17th International AIDS Conference (AIDS 2008).
"We have eliminated the upper threshold for initiating treatment … with these new recommendations," said Scott Hammer, MD, Columbia University, New York, New York. Dr. Hammer presented the 2008 Recommendations of the International AIDS Society-USA Panel here on August 3 at a media briefing held by the Journal of the American Medical Association (JAMA). "Previously we had indicated that if a person with HIV infection had a CD4-positive cell count around 500 cells/mcL, then treatment was probably not necessary."
The recommendations suggest starting therapy with an efavirenz-based therapy or a protease inhibitor/ritonavir-boosted therapy. The backbone of the combination therapy should be tenofovir plus emtricitabine or a combination of abacavir and lamivudine if the patient is infected with a susceptible strain of virus, the panel stated. If the abacavir/lamivudine regimen is preferred, clinicians should perform the genetic susceptibility test HLA-B*5701 to rule out possible reactions to abacavir.
The recommendations also suggest that doctors change regimens if a patient is intolerant to the medications selected, if there is toxicity to the regimen, or if the regimen fails to maintain viral suppression below the level of detection using the more stringent threshold of less than 50 copies/mL.
"We should be aiming to reduce the virus levels to below 50 copies/mL, even among patients for whom resistance to an original or subsequent regimen has emerged," Dr. Hammer stated.
Options have improved to the point that accomplishing that level of viral suppression can be achieved, Dr. Hammer concluded, adding that treatment options have been enhanced with the approval of the integrase strand inhibitor raltegravir, the CCR5-antagonist maraviroc, and second-generation non-nucleoside reverse transcriptase inhibitor etravirine.
The recommendations are aimed at community settings where state-of-the-art medications are available and accessible.
The new guidelines will be published this week in the HIV/AIDS-themed issue of JAMA on August 6, 2008. They were developed over the past 2 years through consultations among 14 panel members who reviewed research to arrive at their conclusions.
[Presentation title: Antiretroviral Treatment of Adult HIV Infection: 2008 Recommendations of the International AIDS Society-USA Panel.]
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