The United States is to follow UK practice and recommend that anti-HIV treatment need not begin until an individual’s CD4 cell count has fallen below 350 cells/mm3
The US Department of Health and Human Services guidelines for the use of antiretrovirals have swung into line with British HIV Association guidelines on HIV therapy as a result of increasing concern over long term side effects and the recognition that there is no greater clinical benefit to starting treatment earlier.
“Although antiretroviral therapy has provided extraordinary benefits to many patients, we know that we cannot eradicate HIV infection with currently available medications,” said Dr Anthony Fauci, co-chair of the panel which drew up the guidelines.
“We also recognise that serious toxicities are associated with the long-term use of antiretroviral drugs. The new treatment guidelines provide patients and their doctors with evidence-based recommendations for initiating antiretroviral therapy that take into account both the benefits and the potential risks of currently available therapy”.
The new guidelines recommend considering starting antiretroviral therapy when an individual’s CD4 cell count falls below 350mm3; previous guidelines recommended consideration of therapy for patients with CD4 cell counts lower than 500 cells/mm3. For HIV-positive individuals with CD4 cell counts above 350, treatment should be considered if the viral load is higher than 55,000 copies by RT-PCR or 30,000 copies by bDNA assay (indicating a high risk of rapid disease progression). The previous edition of the guidelines recommended therapy when HIV levels rose above 10,000 copies per ml by bDNA or 20,000 copies by RT-PCR assay.
The new recommendations on when to start mirror those first issued by the British HIV Association in 1998.
The new guidelines also place two `boosted’ protease inhibitor combinations – ritonavir/lopinavir and ritonavir/indinavir in the `Strongly Recommended’ category.