HIV treatment guidelines updated

An updated version of the "Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents" has been released by the Panel on Clinical Practices for the Treatment of HIV Infection, a joint effort of the Department of Health and Human Services and the Menlo Park, CA-based Henry J. Kaiser Family Foundation.

"Although antiretroviral therapy has provided extraordinary benefits to many patients, we know that we cannot eradicate HIV infection with currently available medications," said Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases. "We also recognize that serious toxicities are associated with the long-term use of antiretroviral drugs. The new treatment guidelines provide patients and their doctors with evidence-based recommendations for initiating antiretroviral therapy that take into account both the benefits and potential risks of currently available treatment regimens."

The new guidelines recommend that doctors and patients consider starting antiretroviral therapy when an asymptomatic HIV-infected person's CD4+ T-cell count falls below 350 cells per cubic millimeter (mm3); previous guidelines recommended consideration of therapy for asymptomatic patients with a CD4+ T-cell count lower than 500 cells/mm3.

The panel stresses that the guidelines should be considered a tool to help patients and their physicians make individual treatment decisions based on the best available information, but that much remains to be learned about how best to treat HIV-infected individuals.

"The updated guidelines recognize that we do not yet have the data we need to make definitive recommendations about the optimal time to start treatment," said John G. Bartlett, co-chair of the panel. "We highlight the uncertainty, allow for flexibility, encourage an individualized approach to treatment and, at the same time, try to provide guidance."

Adherence to therapy

Also in the revised guidelines is a section on the importance of adherence to therapy. "Extraordinarily high rates of adherence to an antiviral drug regimen are necessary to maintain control over HIV replication," said Bartlett. "HIV is very unforgiving in this regard. It is impossible to overemphasize the importance of maximizing adherence once the decision is made to begin therapy."

Another important addition to the guidelines is an updated section on the expanding scope of antiretroviral drug toxicities. "We are very concerned about a number of toxicities associated with the long-term use of antiretroviral drugs," said Fauci. "Particularly alarming is the alteration of fat metabolism that can emerge during treatment. We are seeing an increasing number of patients with dangerously high levels of cholesterol and triglycerides. The good news is that new anti-HIV treatments have dramatically improved the quality of life for many patients, and the incidence of AIDS and AIDS-related deaths has dramatically decreased. The bad news is that we now must find ways to deal with unanticipated toxicities, including the potential for premature coronary disease."

Initially published in 1998, the guidelines were constructed as a "living document" and are updated by the panel as new data emerge. PR