IAS-USA Panel Updated Treatment Guidelines

IAS-USA Panel Updated Treatment Guidelines
Jules Levin, NATAP

In the Jan 19 2000 Jnl of American Medical Association (JAMA), updated treatment guidelines from the IAS-USA Panel are published. I've selected highlights which are below. Of particular interest regarding treatment for women is a brief discussion of gender viral load differences and 3 references listed below for further reading. I suggest reading details for more information. Just below is link to article.

Link to article is:

http://jama.ama-assn.org/issues/v283n3/full/jst90023.html

Interesting highlights from the updated guidelines which may differ from past treatment recommendations:

1. Recognition and consideration of "emerging long-term complications of therapy": fat redistribution, elevated triglycerides, cholesterol and glucose, adherence diffuculties, issues in failing therapy.

2. Therapy should be individualized.

3. Recognition of the challenges and barriers to eradication using currently available drugs.

4. With emerging recognition of the challenges associated with long-term therapy, these updated guidelines recommend a delay in therapy compared to previous recommendations. (1) Therapy is generally recommended when plasma viral load is confirmed above 30,000 c/ml (irrespective of CD4 count) and when CD4s are below 350 (irrespective of viral load). (2) Treatment recommended when viral load is 5,000 to 30,000 and CD4 is between 350 and 500. (3) When CD4s are above 500 and HIV-RNA is below 5,000 c/ml, its "reasonable to defer therapy".

5. "Viral load in women appears to be lower than in men in early infection but as immune deficiency advances, sex differences generally disappear. Thus treatment recommendations are not different for women."

References--
(34) Farzadegan H, Hoover DR, Astemborski J. Sex differences in HIV-1 viral load and progression to AIDS. Lancet. 1998;352:1510-1514

(35) Anastos K, Ganges SJ, Lau B et al. Gender differences in quantitative HIV-1 RNA levels. 6th Conference on Retroviruses and Opportunistic Infections, Jan 31-Feb 4, 1999, abstract #274.

(36) Sterling TR, Lyles CM, Viahov D, et al Sex differences in longitudinal HIV RNA levels among seroconvertersJ Infect Dis. 1999;180:666-672

6. Long-term clinical benefits of initiating therapy during acute infection are unknown and its recommended that patient enter study. If study is not available caveats should be discusssed.

7. For patients high viral load (above 100,000 c/ml, below 50 copies/ml, a 4-drug regimen consisting of drugs from all 3 classes should be considered, although although effectiveness has not yet been truely established.

8. "Adherence should be routinely addressed and reinforced".

9. The HIV-RNA nadir response and achieving an early response (by week 4 or 8) is predictive of subsequent suppression and durability.

10. Failure to get below 50 copies/ml is concerning.

11. Intensification should be considered if viral load is not undetectable at weeks 12 or 16 after initiating therapy, although maximal suppression may take longer.

12. Use of drug level monitoring is discussed. Guideline authors conclude its not ready for primetime yet.

13. Limitations of resistance testing are discussed, but guidelines say "accurate and correctly interpreted test information may improve patient treatment".

14. Guidelines address considerations in when to change therapy, and stopping therapy.

15. Failure to achieve the target level of less than 50 copies/mL by 16 to 24 weeks should raise concern and prompt consideration of poor adherence, inadequate drug absorption, or drug resistance. Precise data are not available regarding optimal frequency, but in general, HIV RNA levels should be monitored within 1 month of therapy initiation or change, monthly until the goal of therapy (levels below detection) is reached, and every 2 to 3 months thereafter. Monitoring HIV RNA levels proximal to intercurrent illnesses, treatment lapses, and vaccinations should be avoided because of associated transient viral rebound. Because of biologic and assay variation at low HIV RNA levels (eg, around detection limits), there may be intermittently detectable virus; thus, any significant rebound in HIV RNA should be confirmed with a second test before changing treatment.