HIV treatment Guidelines Updated for Adults and Adolescents

Guidelines recommended consideration of therapy at lower levels of plasma HIV (10,000 copies/ml
measured by branched DNA, or 20,000 copies/ml measured by RT-PCR).
The Panel stresses that the Guidelines should be considered as a tool to help patients and their
physicians make individual treatment decisions based on the best available information, but that much
remains to be learned about how best to treat HIV-infected individuals.
"The updated Guidelines recognize that we do not yet have the data we need to make definitive
recommendations about the optimal time to start treatment," says John G. Bartlett, M.D., chief of the
division of infectious diseases at the Johns Hopkins University Medical Center and co-chair of the
Panel. "We highlight the uncertainty, allow for flexibility, encourage an individualized approach to
treatment, and, at the same time, try to provide guidance."
The Guidelines also include new drug-specific recommendations. Two new entries are included
in the "strongly recommended" category of anti-HIV drug treatments. One of these is the recently
approved protease inhibitor Kaletra, which is a co-formulation of ritonavir (approved in 1996) and
lopinavir. The other new entry is the combination of ritonavir and indinavir (another protease inhibitor
approved in 1996). These treatment options take advantage of the ability of ritonavir to boost the levels
of other protease inhibitors, creating a potent anti-HIV combination. The protease inhibitor
combinations are used along with combinations of certain nucleoside analogue reverse transcriptase
inhibitors, which represent the "backbone" of anti-HIV treatments.
Also in the revised Guidelines is a section on the importance of adherence to therapy.
"Extraordinarily high rates of adherence to an antiviral drug regimen are necessary to maintain control
over HIV replication," says Dr. Bartlett. "HIV is very unforgiving in this regard. It is impossible to
over-emphasize the importance of maximizing adherence once the decision is made to begin therapy."
Another important addition to the Guidelines is an updated section on the expanding scope of
antiretroviral drug toxicities. "We are very concerned about a number of toxicities associated with the
long-term use of antiretroviral drugs," says Dr. Fauci. "Particularly alarming is the alteration of fat
metabolism that can emerge during treatment. We are seeing an increasing number of patients with
dangerously high levels of cholesterol and triglycerides. The good news is that new anti-HIV treatments
have dramatically improved the quality of life for many patients, and the incidence of AIDS and AIDSrelated deaths has dramatically decreased. The bad news is that we now must find ways to deal with
unanticipated toxicities, including the potential for premature coronary disease."
The updated Guidelines are available at www.hivatis.org in two formats, a typeset version (PDF)
and a Web version (HTML). Single copies can be ordered by calling 1-800-448-0440 (international

callers may call 1-301-519-0459), or by sending an e-mail request to [email protected].

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