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Updated DHHS Guidelines on HIV Treatment

Guideline Watch |
April 2, 2012

Updated DHHS Guidelines on HIV Treatment

  1. Charles B. Hicks, MD

Key revisions focus on HIV treatment for all, HIV management in older patients, the coadministration of new hepatitis C drugs with antiretrovirals, and the timing of ART initiation in patients with tuberculosis.

  1. Charles B. Hicks, MD

On March 27, 2012, the U.S. Department of Health and Human Services released updated HIV treatment guidelines. Key revisions and additions are as follows:

  • Antiretroviral therapy (ART) is recommended more emphatically than previously for all HIV-infected individuals, irrespective of CD4-cell count. The strength of the recommendation varies according to pretreatment CD4-cell count: AI for patients with CD4 counts <350 cells/mm3, AII for those with CD4 counts of 350 to 500 cells/mm3, and BIII for those with CD4 counts >500 cells/mm3. This revised recommendation is based on a growing body of evidence demonstrating the harmful effects of ongoing HIV replication and on the results of the HPTN 052 study, which demonstrated that ART significantly reduces the likelihood of HIV transmission (JW AIDS Clin Care Jul 19 2011).

  • A new section on “HIV and the older patient” recommends ART for all patients aged ≥50, again without regard to CD4-cell count, because the risk for non–AIDS-related complications may be elevated — and the immunologic response to ART reduced — in older HIV-infected patients (BIII). This new section also encourages HIV providers to work closely with primary care physicians to coordinate care in older patients with comorbidities.

  • A new appendix lists the average wholesale cost of available antiretroviral agents, including fixed-dose combinations. Although the costs listed may not accurately reflect actual costs to the patient, they allow comparisons to be made between different treatment options and also show the (so far modest) effect of generic forms of the drugs.

  • Preliminary recommendations are provided for coadministering antiretrovirals with boceprevir and telaprevir in patients with HIV/hepatitis C virus coinfection.

  • New recommendations are given on the timing of ART initiation in HIV-infected patients with tuberculosis, based on studies showing differential effects related to the degree of HIV-associated immunosuppression.

  • The discussion of hormonal contraception in HIV-infected women has been expanded to include drug-drug interactions between combined oral contraceptives and antiretrovirals, as well as the possible association between hormonal contraception and HIV transmission.

Comment

This update provides helpful new recommendations in several areas of importance to HIV providers and continues the trend toward recommending ART for all HIV-infected individuals, presuming they are willing and able to commit to adherence. Although not new, the more enthusiastic endorsement of ART for all reflects a recognition of the range of benefits of treatment coupled with longer-term safety and tolerability data on contemporary ART regimens. The new appendix listing drug costs may reflect increasing concerns about healthcare budgets and may be setting the stage for factoring cost into treatment choices, particularly as more generic antiretroviral options become available.

Citation(s):

Reader Comments (2)

Burzin Kamas Kavina

How to check early treatment failure in older patients in need for 2nd line ART other than CD4 count if any. So that we can give maximum immunolgic, clinical and virologic benefit to patient.

Competing interests: None declared

Bob Spencer Ananda

Very useful to me

Competing interests: None declared

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