United States guidelines for the use of highly active antiretroviral therapy (HAART) in adults have been updated. Changes include revisions to the use of viral load to assess when an individual should start therapy, which drugs should be used in first line therapy, and the special considerations involved in HIV therapy for certain groups, including drug users and patients with tuberculosis.
The latest revisions bring the United States guidelines more into line with those of the British HIV Association, which were last updated in the summer of 2003.
When to start treatment
A level of viral load which should prompt an asymptomatic patient with a CD4 cell count above 350 cells/mm3 to consider treatment has been increased from 50,000 to 100,000 copies/ml. The guidelines note, however, that a patient with CD4 cell count of 350 cells/mm3 and a viral load of 100,000 would still have a low risk of HIV disease progression.
What to start anti-HIV therapy with
The nucleoside analogue (NRTI) d4T (stavudine, Zerit) has been relegated from a “preferred” to an “alternative” drug due to its side-effect profile, particularly fat loss. In 2003 the British HIV Association ceased to recommend d4T for first-line HIV therapy because of these concerns.
Tenofovir (Viread) and FTC (emtricitabine, Emtriva), have both been recommended for use in as an NRTI-backbone with 3TC (lamivudine, Epivir) with both non-nucleoside and protease inhibitor regimens.
Special considerations
Discussion of the additional issues involved in HAART for adolescents, drug users, individuals coinfected with hepatitis B or C, and tuberculosis are now included in the guidelines.
Hydroxyurea
Hydroxyurea (Hydrea) has been removed from the list of drugs that can not be used in HIV therapy. The guideline authors took the decision that they should limit the guidelines to discussing the use of anti-HIV drugs approved by the United States Food and Drug Administration. Although hydroxyurea is used as an adjunct to HIV therapy for some individuals, it is not an antiretroviral drug, and the guideline authors therefore concluded that it should not be included in their guidelines.
The full guidelines can be read here. The guidelines of the British HIV Association can be read here.