NIH updates HIV treatment guidelines

The National Institutes of Health's National Institute of Allergy and Infectious Disease recently issued an updated version of the "Guidelines for the Use of Antiretroviral Agents in HIV-infected Adults and Adolescents" at www.hivatis.gov.

The guidelines were developed by the Panel on Clinical Practices for the Treatment of HIV Infection, a joint effort of the Department of Health and Human Services, Washington, and the Menlo Park, CA-based Henry J. Kaiser Family Foundation. The initial "Guidelines" document, published in 1998, was intended to be a "living" document to be frequently updated by the panel as new data emerge. With the advent of increasing treatment options for HIV-infected individuals, physicians face increasingly complex decisions when it comes to therapy, according Anthony S. Fauci, M.D., Director of the National Institute of Allergy and Infectious Disease.

New recommendations

The guidelines include recommendations for the use of recently developed tests that help determine whether patients' virus has developed resistance to one or more antiretroviral drug. "The likelihood of reducing viral load to undetectable levels is significantly increased when results of resistance testing are available to guide the selection of a new drug regimen for patients who are not doing well on their current regimens," said John G. Bartlett, M.D., chief of the division of infectious diseases at the Johns Hopkins Medical Center.

In a new section titled "The Goals of Therapy," the panel enumerates the primary goals of antiretroviral therapy while reiterating the goal of suppressing plasma viral load to below detectable levels for as long as possible. This shift of focus is due to the emerging realization that eradication of HIV infection is probably not possible with current treatments, so the panel has emphasized the need to think strategically about antiretroviral therapy. In this vein, the updated guidelines include the following other primary goals: Restoration and/or preservation of the patients' immunologic function, improvement of patients' quality of life and reduction of HIV-related illness and death.

The new guidelines also delineate tools to help physicians achieve these goals, including maximizing patient adherence to a regimen, selecting user-friendly regimens when possible and prescribing drugs in a rational sequence in order to preserve future treatment options and utilizing drug resistance assays when treatment fails.

In the guidelines site, a link to information on the use of antiretroviral drugs in pregnant patients has also been added.

Revised antiretroviral A list

The panel's reorganized recommendations for the use of antiretroviral medicines includes a "strongly recommended" drug list of the following products (to be used specifically in accordance with the guidelines): Efavirenz, Idinavir, Nelfinavir, Ritonavir + Saquinavir (soft-gel or hard-gel capsules), Stavudine + Lamivudine, Stavudine + Didanosine, Zidovudine + Lamivudine and Zidovudine + Didanosine. According to the guidelines, these products were placed in this category based on their ability to accomplish many therapeutic goals with minimal negative effects on an HIV-infected person's quality of life with considerations such as pill burden, dosing frequency, food requirements, convenience, toxicity and drug interaction profiles underpinning the revisions. Previously, antiretrovirals were placed in the preferred category based solely on their ability to suppress plasma viral load. PR