BETHESDA, MdRevised guidelines for treating HIV-infected
adults provide new recommendations for when physicians should initiate anti-HIV
therapy. "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," said Anthony S. Fauci, MD, director of the National
Institute of Allergy and Infectious Diseases (NIAID).
The Guidelines for the Use of Anti-retroviral Agents in
HIV-Infected Adults and Adolescents were first published in 1998 by the Panel
on Clinical Practices for the Treatment of HIV Infection. The panel, a joint
effort of the Department of Health and Human Services and the
Henry J. Kaiser Family Foundation, designed the guidelines as an Internet-based
"living document" that would be updated as significant new data
The new guidelines recommend that physicians initiate
antiretroviral therapy when an asymptomatic patient’s CD4+ T-cell count drops
below 350 cells/mm3.
Previously, the guidelines advised starting HIV treatment of
asymptomatic patients when CD4+ T-cell counts fell below a level of 500/mm3.
The new recommendations also suggest that treatment in
asymptomatic HIV patients with CD4+ counts higher than 350 cells/mm3 should be
considered when the virus level in plasma reaches more than 30,000 copies/mL,
as measured by the branched DNA test, or 55,000 copies/mL using the RT-PCR
Previously, the recommendations advised treating such patients
when their HIV plasma levels reached 10,000 and 20,000 copies/mL, respectively.
The guidelines continue previous recommendations that all
individuals with acute HIV syndrome, those within 6 months of HIV
seroconversion, and those with symptoms ascribed to HIV-related infections
receive antiretroviral therapy.
The panel emphasized the importance of patient compliance with
therapy. "Extraordinarily high rates of adherence to an antiviral drug
regimen are necessary to maintain control over HIV replications," said
co-chair John G. Bartlett, MD, chief of infectious diseases, Johns Hopkins
University Medical Center. "HIV is very unforgiving in this regard."
The new guidelines include some new drug-specific
recommendations for treatment. Two combinations were "strongly
recommended"Kaletra, a co-formulation of the protease inhibitors
ritonavir and lopinavir (Norvir), and a combination of ritonavir and indinavir
"These treatment options take advantage of the ability of
ritonavir to boost the levels of other protease inhibitors, creating a potent
anti-HIV combination," the NIAID said.
The updated guidelines also contain a revised section on the
expanding scope of toxicities associated with antiretroviral drug therapy. Dr.
Fauci cited specifically the "alarming" changes in fat metabolismin
particular, dangerously high levels of cholesterol and triglyceridesassociated
The panel noted that the new recommendations are only intended
to help patients and their physicians make treatment decisions and should not
be regarded as medical gospel. "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," Dr. Bartlett said.