The 2001 update of the British HIV Association guidelines are now available following a three month consultation period.
Key changes since the 1999 guidelines
- Treatment should start before the CD4 cell count falls below 200; in patients with CD4 cell counts below 350 (but above 200), treatment should be encouraged only if the CD4 cell count is falling rapidly
- The strongest recommendation for first line therapy is for two NRTIs and an NNRTI
- A switch from PI-containing to a PI-sparing regimen is recommended in individuals with elevated cholesterol > 6.5mmol/L or triglycerides > 8mmol/L if it is the first regimen
- In all patients with lipodystrophy, dietary advice and exercise sessions of at least 30 minutes two to three times weekly are recommended.
- Glucose intolerance should be treated according to fasting glucose and body mass index; those with diabetes and BMI greater than 25 should receive metformin 500mg bid for at least three months, while those with BMI 25 should be considered for metformin 500mg bid and a switch to a PI-sparing regimen.
- If viral load rises above 50 copies/ml, it should be monitored again within 2 weeks; a rising trend indicates virological failure rather than transient low-level viremia, and should be considered the trigger for changing therapy
- Resistance testing continues to be recommended prior to all treatment switches that are associated with virological failure, and should be conducted on samples taken while the patient is still on therapy, although clinicians may consider whether it is advisable to stop treatment after testing in order to minimise the risk of accumulating further resistance mutations
- Results of resistance testing on non-subtype B viruses should be referred to experts if any doubts arise about interpretation
- It may be better to defer the use of new drug classes in patients with experience of several regimens until it is possible to put together a regimen to which the patient has maximum sensitivity
- There is currently insufficient evidence to support the use of therapeutic drug monitoring in all patients on HAART, but it may be useful in patients with liver impairment, in children or in the case where toxicities may be related to plasma levels of drugs. There is stronger evidence for its use in optimising treatment with nelfinavir or indinavir compared to other drugs. It may also be useful to investigate interactions between PIs and NNRTIs or where drugs are being used at doses other than licensed doses.
- In hepatitis B co-infection, 3TC treatment might be best delayed until combination strategies for HBV treatment are more fully explored. In moderate HBV, 3TC has been shown to improve liver function and histology.
- Screening for hepatitis C infection should be considered in all patients, regardless of risk group with an antibody test confirmed by HCV polymerase reaction, and a PCR test should be carried out in all cases where individuals have unexplained liver disease and no antibodies to HCV.
- In HCV-positive patients, genotyping should be carried out and a liver biopsy should be considered to asess the degree of disease progression. Those with moderate to severe HCV infection should consider therapy with twelve months of pegylated interferon and ribavirin, although the guidelines note that limited data are available on interactions between this combination and drugs used in HIV treatment. Interferon treatment is contraindicated in patients with decompensated liver disease, and pegylated interferon treatment may be possible only with dose reduction.