New Guidelines for HIV Treatment; Resistance Testing Now Recommended
The January 28, 2000 revision of the government Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents is available at http://aidsinfo.nih.gov/ (or to request a copy by mail, call 1-800-448-0440). The guidelines now recommend HIV resistance testing, for some but not all patients."This report recommends that care should be supervised by an expert, and makes recommendations for laboratory monitoring including plasma HIV RNA, CD4+ T cell counts and HIV drug resistance testing. The report also provides guidelines for antiretroviral therapy, including when to start treatment, what drugs to initiate, when to change therapy, and therapeutic options when changing therapy. Special considerations are provided for adolescents and pregnant women. As with treatment of other chronic conditions, therapeutic decisions require a mutual understanding between the patient and the health care provider regarding the benefits and risks of treatment. Antiretroviral regimens are complex, have major side effects, pose difficulty with adherence, and carry serious potential consequences from the development of viral resistance due to non-adherence to the drug regimen or suboptimal levels of antiretroviral agents. Patient education and involvement in therapeutic decisions is important for all medical conditions, but is considered especially critical for HIV infection and its treatment. [from the Summary, page 2]
A major change in these guidelines is that viral resistance testing is recommended--in case of virologic failure during antiretroviral therapy, or of less than optimal suppression of viral load after starting therapy. Resistance testing should also be considered in acute HIV infection (but treatment should begin immediately, not wait for the results of the test).
But resistance testing is not generally recommended before starting treatment of chronic infection--or after discontinuation of antiretroviral drugs--because when the drugs are absent, the resistant virus is likely to become a minor species which is missed by the test but ready to come back quickly when the drugs are started again. Also, resistance testing is not recommended when viral load is under 1000 copies/mL, because current tests are unreliable when the viral load is very low.
These guidelines (which are 100 pages of text, including the tables and references) were developed by a panel of experts convened by the U.S. Department of Health and Human Services, and the Henry J. Kaiser Family Foundation. There is a list of major changes, showing where this version differs from the previous one.
Note: Similar but not identical HIV treatment guidelines, from a different panel (convened by the International AIDS Society-USA), were published January 19 in JAMA, (Journal of the American Medical Association). They are available at http://jama.ama-assn.org/content/vol283/issue3/index.dtl
