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As the number of marketed single and combination antiretroviral agents approaches three dozen, experts continue to modify recommendations on who should receive these drugs, and which combinations are most effective.
The newest iteration of HIV treatment guidelines from the International AIDS Society–USA (1 of 2 sets that dictate standard practice in the U.S.) points to recent epidemiologic data that suggest that, even in people with high CD4-cell counts, untreated HIV infection constitutes risk for cancer and organ failure. The guidelines suggest that individuals with a rapid rate of CD4 decline, HIV viral loads >100,000 copies/mL, hepatitis B or C coinfection, HIV-associated nephropathy, or substantial cardiovascular risk factors be considered for treatment, even when they have CD4 counts ≥350 cells/µL — the trigger level in previous guidelines.
Recommended drugs for initial treatment include efavirenz or one of several ritonavir-boosted protease inhibitors, in conjunction with two nucleoside drugs. Neither azidothymidine (AZT) nor stavudine (d4T) is endorsed for initial treatment because of their relative toxicity. The newest antiretroviral agents, belonging to novel drug families, including the integrase inhibitor raltegravir (Isentress) and the CCR5 antagonist maraviroc (Selzentry), should still be reserved for treatment-experienced patients, and the new nonnucleoside drug etravirine (Intelence) also is not proposed for initial treatment. When abacavir-containing regimens are considered, patients should be prescreened for human leukocyte antigen (HLA) B-5701, which predicts hypersensitivity to that drug.
Hammer SM et al. Antiretroviral treatment of adult HIV infection: 2008 recommendations of the International AIDS Society–USA panel. JAMA 2008 Aug 6; 300:555.
Comment
Asymptomatic HIV-positive patients were more likely to be treated 2 decades ago than in recent years, but now, as treatment regimens become less cumbersome, the pendulum is swinging back. As with all previous guidelines, this new set recognizes that considerations of drug intolerance, drug interactions, and individual patient preference inevitably will force creative modifications to both timing and content of antiretroviral regimens.