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Start treatment when CD4 cell count is 350, say revised US guidelines
Michael Carter, Wednesday, December 05, 2007
The US Department of Health and Human Services (DHHS) has issued revised adult antiretroviral treatment guidelines. The US guidelines, like the revised European guidelines issued in October, now recommend that antiretroviral therapy should be started by all patients with a CD4 cell count of 350 cells/mm3 or below.

Other revisions to the guidelines reflect recent advances in HIV medicine.

The guidelines recommend that patients considered for treatment with a CCR5 inhibitor, such as maraviroc (Selzenry in the US, Celsentri in Europe) should have a tropism test to ensure that treatment with this class of drug is appropriate. Tropism testing should also be considered for patients failing on maraviroc treatment. The revised guidelines also discuss the optimal role for maraviroc in the treatment of heavily treatment-experienced patients.

Resistance tests should, the guidelines now recommend, be performed on all patients before they start anti-HIV therapy. This is because a significant proportion of individuals have primary drug resistance.

HLA-B*5701 testing should be undertaken before a patients starts treatment with abacavir (Ziagen) to reduce the risk of a hypersensitivity reaction to the drug. Patients who are HLA-B*5701-positive must not initiate abacavir therapy and their allergy to the drug must be recorded on their medical records. In settings where HLA-B*5701 testing is not available, the guidelines state that it is reasonable to offer treatment with abacavir after “appropriate clinical counselling” with close monitoring for signs of abacavir allergy.

Recent research evidence points to significant advantages in initiating antiretroviral therapy when an individual has a CD4 cell count of 350 cells/mm3 rather than 200 cells/mm3. US guidelines now recommend that patients with a CD4 cell count of 350 cells/mm3 or below should start anti-HIV treatment, as should all patients who have progressed to AIDS.

Antiretroviral therapy should also be offered to other groups of patients regardless of CD4 cell count including pregnant women, hepatitis-B coinfected individuals who require anti-hepatitis B therapy, and individuals with nephropathy (serious kidney disease).

The guidelines acknowledge that the benefits of antiretroviral therapy at CD4 cell counts above 350 cells/mm3 are uncertain, and state that decisions about treatment in such patients “should take into account the potential benefits and risks associated with therapy, comorbidities, and patient readiness and willingness to adhere to long-term treatment.”

The full revised guidelines can be read online in PDF format here