Review of the Recently Revised Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents

During the “State-of-the-Art Information on the HIV Treatment Guidelines” workshop at the 2013 United States Conference on AIDS, presenters offered a practical review of the latest version of the “Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents.” Danielle Houston, MSPH, a member of the guidelines panel, led the workshop with Matt Sharp, an HIV educator and a long-term survivor.

Houston began by emphasizing that this document provides guidance for medical providers, “but it’s not a mandate.” Clinicians still must use their own clinical judgment. The Department of Health and Human Services oversees the production of the guidelines, which are generally based on studies published in peer-reviewed journals, and which are updated when needed.

Recommendations in the guidelines are graded both on their strength (strongest A to weakest C) and on the quality of the evidence for the recommendation (strongest evidence I to weaker evidence III). The guidelines address a variety of aspects of HIV care: baseline evaluation, laboratory testing, treatment goals, when and what treatments to start, adherences, and preventing secondary transmission. The guidelines provide helpful information about treating treatment naïve and experienced patients, as well as special patient populations.

“One of the groundbreaking recommendations that the Guidelines made was recommending ART [antiretroviral therapy] for all HIV patients,” Houston noted. “This recommendation aims to improve the individual’s health and also to reduce transmission.” For patients who have CD4 counts of <350 cells/mm³, this is a strong recommendation with the strongest quality of evidence available (AI). The panel still recommends ART for patients with counts of 350-500 (AII). For patients with CD4 levels over 500, the panel also recommends ART, but only moderately (BIII).

The guidelines also acknowledge that patients and providers may opt to postpone treatment on the basis of certain clinical and psychosocial factors. Certain factors should make practitioners more hesitant to postpone treatment, like having a higher viral load, coinfection with hepatitis C virus (HCV), or pregnancy. The document also provides recommendations for initial baseline tests.

The guidelines recommend the following as preferred treatment regimens (all with the strongest level of recommendation) because they are highly effective, easy to take, and less toxic than other regimens:

• Efavirenz/tenofovir disoproxil fumarate/emtricitabine
• Ritonavir-boosted atazanavir + tenofovir disoproxil fumarate/emtricitabine
• Ritonavir-boosted darunavir + tenofovir disoproxil fumarate/emtricitabine
• Raltegravir + tenofovir disoproxil fumarate/emtricitabine
• The tenofovir disoproxil fumarate/emtricitabine component (also known as Truvada) can be considered the anchor medication

Another important component of the guidelines is assessing whether a given treatment is successful. As Houston explained, “If someone has been on treatment for 48 weeks, and they haven’t gotten to an undetectable viral load, they may not be on the right regimen.” Other factors to consider are the CD4 count and the patient’s physical symptoms. This assessment must be synergistic; it may be unwise to change a patient’s medications because of a single poor lab value. Patients may also need to change their medications due to side effects or toxicities, or just to simplify their medication regimen. In deciding what new medication to choose, the clinician and patient must consider a variety of factors, like the reason for the change, other drugs previously used, coinfections, laboratory tests, and new clinical information.

The most recent guidelines are available at the AIDSinfo clinical guidelines portal. This site provides recommendations for adults and adolescents with HIV, as well as for special populations like children and pregnant women.