Newly updated US antiretroviral treatment guidelines are recommending antiretroviral treatment for all people with HIV infection, with particular emphasis on treatment for: people with CD4 cell counts below 500; anyone at risk of transmitting HIV to partners; pregnant women; and people with hepatitis B co-infection or HIV-related kidney disease.
The new recommendations strengthen previous US recommendations on when to start treatment, which recommended initiating treatment at CD4 cell counts between 350 and 500 cells/mm3. The 2009 guidelines panel was, however, divided as to the strength of this recommendation: based on available evidence, 55% of the panel considered it a 'strong' recommendation and 45% 'moderate'.
The new Department of Health and Human Services (DHHS) guidelines state that “antiretroviral therapy is recommended for all HIV-infected individuals”.
In support of this recommendation, the new guidelines cite a range of evidence showing associations between viral replication and increased risk of illness and death in people with HIV, but do not discuss the absolute reduction in risk that might be associated with earlier treatment, nor the number of people who would need to receive treatment in order to prevent one new death or event in a year.
In contrast, recently issued draft British HIV Association treatment guidelines continue to recommend treatment when the CD4 cell count falls below 350 cells, although treatment may be started earlier in people with hepatitis B or by people concerned about the risk of transmitting HIV to partners. British guidelines also recommend earlier treatment where a number of other conditions are present.
The new US guidelines draw attention to data from two large cohort studies which show that any degree of uncontrolled viral replication above 500 copies/ml, and the duration of uncontrolled viral replication, are each associated with a higher risk of death.
The guidelines also note an association between HIV infection, immunosuppression and an increased risk of cardiovascular disease and of malignancies.
They highlight the fact that older patients consistently have poorer CD4 cell responses after starting treatment, and suggest that starting treatment earlier may result in better CD4 cell responses to treatment.
In common with new recommendations in the British HIV Association guidelines, the US guidelines also discuss the new evidence from the HPTN 052 study showing that HIV treatment greatly reduces the risk of HIV transmission. This information should be discussed with all patients, the US guidelines recommend, and antiretroviral therapy should be offered to all patients at risk of transmitting HIV to their partners.
Note: This article has been amended since it was first published on March 29 after a discrepancy between between the .pdf version of the March 2012 guidelines and the HTML version of the March 2012 guidelines posted to aidsinfo.nih.gov was drawn to our attention. The erroneous information, suggesting that expert opinion was evenly divided regarding antirtetroviral treatment initiation in people with CD4 counts above 500 in the March 2012 guidelines, has been corrected here and on aidsinfo.nih.gov.
Further information
Read "What's new in the Guidelines?" here.