DHHS Treatment Guidelines Tweaked Again

Only 2 months have passed since the U.S. Department of Health and Human Services (DHHS) last revised its treatment guidelines (ACC Dec 10 2007), and, already, an additional set of updates has been released. The latest guidelines incorporate information about the newest agents and adjust the hierarchy of preferred initial treatment. In addition, the section on HIV/tuberculosis (TB) coinfection has been completely revised.

Specific changes include the following:

• Several venerable antiretrovirals have been “downgraded” for initial treatment: The combination of AZT/3TC is now an alternative rather than a preferred NRTI option, and the combination of d4T + 3TC is no longer recommended. Among the PIs, nelfinavir is no longer recommended as either a preferred or alternative option.

• Two other drug combinations have been “upgraded”: Coformulated abacavir/3TC (only if preceded by negative results on HLA-B*5701 screening) is now a preferred NRTI combination, and ritonavir-boosted saquinavir, having performed similarly to lopinavir/ritonavir in the GEMINI study, is no longer considered inferior to other acceptable PI combinations.

• Although descriptive information about the newest antiretrovirals (maraviroc, raltegravir, and etravirine) has been added to the guidelines, the DHHS specifically recommends against using these agents as initial therapy because of insufficient safety data among treatment-naive patients.

• Specific dosing guidelines are provided to address the common clinical dilemma arising from the need to use atazanavir with proton-pump inhibitors or histamine-2–receptor antagonists.

• For treatment instituted during acute HIV infection, when resistance-testing results are often not yet available, the guidelines suggest that PI-based treatment might be preferred to NNRTI-based treatment, because clinically significant resistance to PIs is less common.

• In a rewritten section on HIV/TB coinfection, clinicians are reminded to perform repeat testing for latent TB in patients receiving antiretroviral therapy who initially tested negative while their CD4 counts were <200 cells/mm³.