This is the first major revision for more than two years and contains many significant changes. These include:
Treatment should aim to be initiated while CD4 count is above 200 cells/mm3 or at higher levels if symptomatic. Exact timing depends on various factors, including short-term risk.
Triple nucleoside combinations previously recommended such as Trizivir (AZT/3TC/abacavir) are not now recommended, even for patients with a lower baselines viral load.
d4T is not recommended for first line therapy due to increased association with lipodystrophy.
Unboosted PI regimens are not recommended for first choice due to poorer pharmacokinetics, and less convenient dosing.
The committee believes there is no definitive evidence on which to base a preference for either choice of nucleosides or choice of PI or NNRTI.
Considerations for regimens include ease of adherence and minimising toxicity, and should take account of individual factors such as hepatitis B/C, risk of cardiovascular disease, diabetes, psychiatric disease, and lifestyle.
Treatment in primary HIV infection is recommended if needed to relieve severe symptoms but is not generally recommended otherwise, unless as part of a clinical trial.
Use of resistance testing is recommended for all treatment naïve patients prior to starting treatment. In practice, this means that people should receive or have a sample stored for later testing when diagnosed.
Therapeutic drug monitoring (TDM) is seen as being of value in specific circumstances, such as reducing toxicity, and adjusting doses in significant hepatic or renal impairment.
Interrupting or stopping treatment may benefit patients who started treatment earlier than currently recommended – ie with a high pre-treatment CD4 count (specified as ‘perhaps 300 cells/mm3’). The importance of careful monitoring is stressed.
New sections include monitoring tests, management of patients who are using treatment combinations not now recommended in the guidelines (such as Trizivir or d4T), and a table on drug costs.
Sections on the management of side effects such as lactic acidosis, metabolic changes and lipodystrophy have been updated and include, for example, a stronger recommendation for New-Fill).
The guidelines will also be published as a supplement to the October issue of HIV Medicine.
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Important note: Information in this article was accurate in October 2003. The state of the art may have changed since the publication date.
