Updates to US HIV treatment guidelines

The United States Department of Health and Human Services released a number of updates to its HIV treatment guidelines for adults on January 10^th.

These include:

• A refinement of recommendations on when to start antiretroviral treatment in people diagnosed with tuberculosis. In people with CD4 counts below 200 cells/mm³ antiretroviral treatment should begin no more than two to four weeks after starting TB treatment. In people with CD4 counts between 200 and 500 antiretroviral treatment should be delayed no more than two to eight weeks after starting TB treatment. A majority of the guidelines panel also recommend that HIV treatment should be commenced within eight weeks of starting TB treatment in people with CD4 counts above 500 cells/mm³.
• CD4 cell counts in people on suppressive antiretroviral therapy should only be monitored every 6 to 12 months, unless there is a concomitant clinical condition or the patient is receiving immunosuppressive drugs.
• Virological failure should be defined as a viral load above 200 copies/ml, in order to rule out isolated blips or assay varations.
• Maraviroc /AZT/3TC is added to the list of acceptable regimens for first-line treatment. Combining maraviroc with either Truvada (Tenofovir/FTC) or Epzicom (abacavir/3TC, marketed as Kivexa outside North America) is described as `may be acceptable but more data needed`.
• Saquinavir-based treatment is downgraded from `Alternative` to `Acceptable but use with caution` as a result of a recent warning regarding abnormalities in cardiac rhythm in healthy volunteers who received the drug.
• Genotypic resistance testing for integrase inhibitor resistance should be considered at the time of failure of integrase inhibitor-containing treatment, in order to guide any future use of integrase inhibitors. At present there is only one integrase inhibitor, raltegravir, available for prescription. Subsequent viral suppression after failure of raltegravir treatment may make it difficult to determine the integrase inhibitor resistance profile, should a patient require a new integrase inhibitor in the future. The panel also encourages physicians to think about the possibility of transmitted integrase inhibitor resistance in patients new to treatment, and in particular to consider whether the patient’s source of infection was receiving an integrase inhibitor, since integrase inhibitor resistance is not currently a part of the standard panel of genotypic resistance tests that ought to be carried out for any patient starting treatment.