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New HIV Guidelines Pull Back on Antiretroviral Drugs

Consensus panels agree that symptomatic patients and those with CD4 counts lower than 200 cells/mm³ should receive antiretroviral therapy; the panels differ in their recommendations for asymptomatic patients with higher cell counts.

When potent antiretroviral drugs became available in the mid-1990s, a policy of "hit early, hit hard" guided their use: Experts endorsed treatment for all symptomatic HIV-infected patients and for most patients still in the asymptomatic stages of disease. Now that experience with the long-term side effects of the drugs has accumulated, new treatment guidelines have emerged.

In 2 new sets of guidelines, expert panels continue to endorse treating all patients with symptomatic HIV infection or AIDS and all those with CD4 counts lower than 200 cells/mm³. The guidelines agree that, for asymptomatic patients with CD4 counts higher than 200 cells/mm³, the optimal time to begin treatment has not been established.

One panel¹ cited data from cohort studies in which no morbidity or mortality advantage was demonstrated for asymptomatic patients who began treatment at CD4 counts >200 cells/mm³. The panel suggests that treatment decisions in such patients be individualized, with clinicians taking into account individual rates of CD4-cell-count decline, viral load, and interest in long-term treatment.

The other panel² cited data that the 3-year risk for progression to AIDS might exceed 30% in asymptomatic patients with CD4 counts of 200-350 cells/mm³ and viral loads of 20,001-55,000 copies/mL; this panel continues to endorse antiretroviral treatment in such patients. This panel also recommends that patients with higher CD4-cell counts or lower viral loads be managed on an individual basis, and that the potential immunologic benefits of early treatment be balanced against the risks for long-term drug side effects.

Another set of recently released guidelines³ updates recommendations for the prevention of AIDS-associated opportunistic infections. The guidelines uniformly endorse the discontinuation of prophylactic antibiotics after CD4 counts have been restored durably by antiretroviral therapy. They recommend that primary and secondary prophylaxis against Pneumocystis carinii pneumonia be stopped when CD4 counts have been >200 cells/mm³ for 3 months, that primary prophylaxis against Mycobacterium avium complex (MAC) be stopped when CD4 counts have been >100 cells/mm³ for 3 months, and that primary prophylaxis against toxoplasmosis be stopped when CD4 counts have been >200 cells/mm³ for 3 months. Patients who have had clinical MAC can stop antibiotics after 12 months of successful treatment, whereas toxoplasmosis patients can stop treatment after all symptoms and signs of infection have resolved and CD4 counts have exceeded 200 cells/mm³ for 6 months.

Comment: Overall, the treatment of HIV infection has evolved substantially during the past 5 years and will continue to change as both the life-saving benefits and substantial risks of antiretroviral drugs are integrated further into clinical practice. The second and third sets of guidelines also have been published in MMWR Recomm Rep 2002; 51(RR-7):1 and MMWR Recomm Rep 2002; 51(RR-8):1 and are available on the web free of charge.

— Abigail Zuger, MD

Published in Journal Watch General Medicine September 24, 2002

Citation(s):

1. Yeni PG et al. Antiretroviral treatment for adult HIV infection in 2002: Updated recommendations of the International AIDS Society-USA Panel. JAMA 2002 Jul 10; 288:222-35.

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2. Dybul M et al. Guidelines for using antiretroviral agents among HIV-infected adults and adolescents: The Panel on Clinical Practices for Treatment of HIV. Ann Intern Med 2002 Sep 3; 137:381-433.

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• Medline abstract (Free)

3. Masur H et al. Guidelines for preventing opportunistic infections among HIV-infected persons -- 2002: Recommendations of the U.S. Public Health Service and the Infectious Diseases Society of America. Ann Intern Med 2002 Sep 3; 137:435-77.

• Original article (Subscription may be required)
• Medline abstract (Free)