An evaluation of recent data has led to an update in the guidelines and recommendations for antiretroviral treatment of adult HIV infection, according to an article in the Aug. 6 issue of JAMA, a theme issue on HIV/AIDS.

Scott Hammer of Columbia University and the International AIDS Society-USA Panel analyzed new data in the field from the last two years to provide guidelines in key areas of antiretroviral management, including when to start therapy, choice of initial regimens, patient monitoring, and the approach to treatment failure.

New data and considerations support initiating therapy before CD4 cell count declines to less than 350/L. In patients with 350 CD4 cells/L or more, patient readiness, drug interactions, adherence challenges, toxicities and cost should be considered when determining whether to initiate therapy.

Rapid decline in CD4 cell count (i.e., more than 100/L per year), risk factors for cardiovascular disease, and the presence of certain other diseases should be considered in deciding whether to initiate therapy in patients with CD4 cell counts more than 350/l.

The authors write that the initial regimen must be individualized, particularly in the presence of other existing illnesses, but usually will include efavirenz or a ritonavir-boosted protease inhibitor plus two nucleoside reverse transcriptase inhibitors (nRTIs).

The goal of antiretroviral therapy is to reduce and maintain a plasma HIV-1 RNA level of less than 50 copies/mL. Plasma HIV-1 RNAlevels should be monitored frequently when treatment is started or changed for virologic failure until it reaches levels below the assay detection limits, and regularly thereafter. Genotypic testing for drug resistance should be performed for certain patients. Appropriate assessment of other conditions and monitoring for toxicity should be performed before initiating treatment and during follow-up.

Virologic failure on an initial no nucleoside reverse transcriptase inhibitor (NNRTI)- or ritonavir-boosted protease inhibitor-based regimen should be treated early with, ideally, three fully active drugs. For multi-drug resistance, three active drugs, including new classes of agents whenever possible, should be used.

The appropriate use of new agents in combination with older agents can help achieve the goal of maintaining a plasma HIV-1 RNA level below 50 copies/ml even in patients with high degrees of treatment experience and multidrug resistant virus.

The authors write that despite advances in the treatment of HIV infection, "disease management remains challenged by toxicities, maintenance of adherence, clinical manifestations related to both the drugs and the HIV infection itself, and the threat of drug resistance."

(Xinhua News Agency August 5, 2008)