ART recommended for all with HIV, regardless of CD4 count

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ART recommended for all with HIV, regardless of CD4 count
ART recommended for all with HIV, regardless of CD4 count

HealthDay News -- The USA Panel of the International Antiviral Society announced new recommendations that all patients with HIV be treated with antiretroviral therapy (ART) regardless of CD4 cell count.

The recommendation is based on recent data published or presented within the past two years examining ART for  adults with HIV living in resource-rich settings, panel member Melanie A. Thompson, MD, of the AIDS Research Consortium of Atlanta and colleagues announced in a special Journal of the American Medical Association theme issue on HIV/AIDs. The publication coincides with the International AIDS Conference, held from July 22-27, 2012, in Washington, D.C. 

The panel conlcuded that the strength of the recommendation and the quality of evidence increases as CD4 cell-counts decrease along with the presence of specific concurrent conditions.

Among patients recommended to initiate ART are pregnant women, those receiving treatment for tuberculosis, patients with hepatitis B virus and those aged older than 60 years. Patients receiving treatment for hepatitis C virus may need to delay ART until HCV treatment is complete, as administering the two therapies concurrently may reduce the efficacy of either treatment.

Initial regimens should include two nucleoside reverse transcriptase inhibitors (tenofovir/emtricitabine or abacavir/lamivudine) plus a non-nucleoside reverse transcriptase inhibitor (efavirenz), a ritonavir-boosted protease inhibitor (atazanavir or darunavir) or an integrase strand transfer inhibitor (raltegravir).

In each class, alternatives are recommended for patients with or at risk of certain comorbidities. Specialized treatment plans are recommended for pregnant women, patients with comorbid diseases and those with opportunistic infections, cirrhosis, hepatitis B, hepatitis C or malignancy.

CD4 count, HIV-1 RNA level, engagement in care, ART adherence, HIV drug resistance and quality-of-care indicators should all be monitored. Acceptable reasons for altering therapeutic regimens include virologic, immunologic, or clinical failure and drug toxicity or intolerance.

Additional recommendations include monitoring plasma HIV RNA levels and CD4 count every three months after ART is initiated. After viral suppression and CD4 cell counts are stable for one year, monitoring can occur every six months.

Clinicians should consider changes to the treatment regimen in patients with sustained elevated HIV RNA. Prior to initiating treatment changes, health-care providers must confirm detectable HIV RNA levels in a subsequent sample taken within two to four weeks, the recommendations state.

Several panel members disclosed financial ties to the pharmaceutical industry. The study was funded by the International Antiviral Society-USA, which receives funding from pharmaceutical companies.

Thompson MA. JAMA. 2012;308:387-402.

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