International panel updates treatment guidelines for HIV infectionAugust 04, 2008An evaluation of recent data has led to an update in the guidelines and recommendations for antiretroviral treatment of adult human immunodeficiency virus (HIV) infection, according to an article in the August 6 issue of JAMA, a theme issue on HIV/AIDS. Scott M. Hammer, M.D., of Columbia University College of Physicians and Surgeons, New York, and the International AIDS Society-USA Panel, presented the recommendations of the panel at a JAMA media briefing on HIV/AIDS. The field of antiretroviral therapy continues to evolve rapidly, and, to maintain the highest possible standard of care, treatment guidelines must continually be refined to assist the complex decision-making process, according to the authors. "For a disease that has been transformed from almost uniformly fatal to manageable over decades, the impact of treatment decisions is substantial." They add that the availability of new antiretroviral drugs and formulations, including drugs in new classes, and recent data on treatment choices for antiretroviral patients warrants an update of the International AIDS Society-USA guidelines.
Dr. Hammer and members of the 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. The latter emphasizes the role of recently approved drugs in assisting clinicians with constructing regimens that will keep HIV suppressed even in the face of multidrug resistant virus. When to Start Antiretroviral Therapy New data and considerations support initiating therapy before CD4 cell count declines to less than 350/μL. In patients with 350 CD4 cells/µL 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/μL per year), a plasma HIV-1 RNA level more than 100,000 copies/mL, risk factors for cardiovascular disease, and the presence of certain other diseases (e.g., active hepatitis B or C virus co-infection and HIV-associated nephropathy [a disease affecting the kidneys]) should be considered in deciding whether to initiate therapy in patients with CD4 cell counts more than 350/μl. What Antiretroviral Regimen to Start 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 (or nucleoside plus nucleotide) reverse transcriptase inhibitors (nRTIs). Recommended nRTIs in the initial regimen are the fixed-dose combinations tenofovir/emtricitabine or abacavir/lamivudine. Simplicity of therapy, pill number, tolerability, desire for pregnancy, drug interactions and primary drug resistance are likely to influence the choice between these recommended options. Patient Monitoring 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 RNA levels should be monitored frequently when treatment is started or changed for virologic failure (e.g., at 2, 4, 8, and every 4 weeks thereafter) until it reaches levels below the assay detection limits, and regularly thereafter (e.g., 3-4 times per year). 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. Changing Therapies Virologic failure on an initial nonnucleoside 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, such as raltegravir (an integrase strand transfer inhibitor), maraviroc (a CCR5 antagonist), and etravirine (a "second generation" NNRTI), 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. Sustainability and expansion of the progress achieved will depend on maintaining a robust drug development pipeline and the ability to deliver effective therapy and monitoring tools to the world's affected populations." "With creativity and political will, the progress and individualized approach to antiretroviral therapy evident in the developed world can be adapted to the public health approach in the developing world, where 90 percent of the world's HIV-infected population lives." JAMA and Archives Journals | |||||||||||||||||||||
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Related Antiretroviral Current Events and Antiretroviral News Articles Landmark study defines benefits of early HIV testing and treatment for infected infants Testing very young babies for HIV and giving antiretroviral therapy (ART) immediately to those found infected with the virus dramatically prevents illness and death, according to a report in the New England Journal of Medicine. Researchers use chemical from medicinal plants to fight HIV Like other kinds of cells, immune cells lose the ability to divide as they age because a part of their chromosomes known as a telomere becomes progressively shorter with cell division. As a result, the cell changes in many ways, and its disease fighting ability is compromised. Engineered killer T cell recognizes HIV-1's lethal molecular disguises Researchers at the University of Pennsylvania School of Medicine and colleagues in the United Kingdom have engineered T cells able to recognize HIV-1 strains that have evaded the immune system. Protein identified that turns off HIV-fighting T cells In HIV-infected patients the body's immune system is unable to fight off the virus. A new study to be published online on November 10th in the Journal of Experimental Medicine shows that T cells in HIV-infected individuals express a protein called TIM-3, which inactivates their virus killing capacity. UCLA develops safer, more effective TB vaccine for HIV-positive people UCLA scientists engineered a new tuberculosis (TB) vaccine specifically designed for HIV-positive people that was shown to be safer and more potent than the current TB vaccine in preclinical trials. Markers of inflammation and blood-clotting tied to hazards of intermittent HIV treatment Episodic treatment of HIV/AIDS with antiretroviral drugs increases the overall risk of death when compared with continuous antiretroviral treatment (ART), but the reasons why have been unknown. Researchers estimate lives lost due to delay in antiretroviral drug use for HIV/AIDS in South Africa More than 330,000 lives were lost to HIV/AIDS in South Africa from 2000 and 2005 because a feasible and timely antiretroviral (ARV) treatment program was not implemented, assert researchers from the Harvard School of Public Health (HSPH) in a study published online by the Journal of Acquired Immune Deficiency Syndromes (JAIDS) (http://www.jaids.com/). Integrating antiretroviral therapy with TB treatment for co-infections reduces mortality A South African treatment study conducted by researchers in the Department of Epidemiology at the Mailman School of Public Health shows that mortality among TB-HIV co-infected patients can be reduced by a remarkable 55%, if antiretroviral therapy (ART) is provided with TB treatment at the same time. Efavirenz-Based Initial Therapies Associated with Better Outcomes in HIV-Infected Adults A study led by researchers at the Johns Hopkins Bloomberg School of Public Health found that HIV-infected patients taking the antiretroviral drug efavirenz were more likely to adhere to treatment and less likely to experience virologic failure and death compared to patients taking nevirapine. Urbanization in Africa at dawn of 20th century marked outbreak of HIV New research indicates that the most pervasive global strain of HIV began spreading among humans between 1884 and 1924, suggesting that growing urbanization in colonial Africa set the stage for the HIV/AIDS pandemic. More Antiretroviral Current Events and Antiretroviral News Articles |
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