SAN FRANCISCO — New federal guidelines recommend earlier initiation of antiretroviral therapy for adolescents and adults with HIV and come close to recommending therapy for nearly everyone with HIV.
“We're moving towards treating most people who are infected with HIV,” Dr. Diane V. Havlir said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.
She suggested, only somewhat tongue-in-cheek, that future guidelines may focus on which patients should not start antiretrovirals. Those future guidelines might look something like this: Do not start HIV therapy if there are no antiretroviral options due to drug intolerance, drug interactions, or transmitted multidrug resistance, and be cautious about starting antiretroviral therapy in a patient with a CNS lesion, said Dr. Havlir, professor of medicine at the university and chief of the HIV/AIDS division at San Francisco General Hospital.
Guidelines released Dec. 1, 2009, by the Department of Health and Human Services (HHS) recommend starting antiretrovirals for HIV in patients with CD4 counts of 350–500 cells/mm
Of the guidelines committee members, half favored starting antiretrovirals in patients with CD4 counts higher than 500 cells/mm
The new guidelines eclipse 2008 recommendations from the International AIDS Society–USA to start antiretroviral therapy in asymptomatic patients with CD4 cell counts less than 350 cells/mm
Shortly before the HHS announcement, the World Health Organization (WHO) changed its guidelines to advise starting antiretrovirals in adolescents and adults with AIDS or tuberculosis or when CD4 counts drop below 350 cells/mm
“Countries will have to weigh the pros and cons of the guidelines and their financial constraints to see if they will be able to adopt them,” Dr. Havlir said.
The move toward earlier antiretroviral therapy is due to “tectonic shifts in thinking about HIV as a disease,” she noted.
There is increasing recognition that HIV infection not only increases susceptibility to opportunistic infections, complications, and malignancies, but also damages the renal and cardiac systems and contributes to liver disease, CNS changes, and probably aging.
Antiretroviral therapy can prevent some of the newly recognized harms to organ systems as well as the classic AIDS complications, she said. Earlier treatment initiation also may result in less drug resistance and better cognitive function.
Two studies in particular prompted the guideline changes.
The North American AIDS Cohort Collaboration on Research and Design studied 17,517 people with asymptomatic HIV infection who had not taken antiretrovirals. Patients who deferred treatment until CD4 counts fell below 350 cells/mm
Another analysis of data on 21,247 antiretroviral-naive patients found a higher risk of death if treatment was deferred until CD4 counts fell to 350 cells/mm
Dr. Havlir reported no conflicts of interest related to these topics.
'We're moving towards treating most people who are infected with HIV.'
Source DR. HAVLIR