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2004 Recommendations of the International AIDS Society-USA Panel

Patrick G. Yeni, MD; Scott M. Hammer, MD; Martin S. Hirsch, MD; Michael S. Saag, MD; Mauro Schechter, MD, PhD; Charles C. J. Carpenter, MD; Margaret A. Fischl, MD; Jose M. Gatell, MD, PhD; Brian G. Gazzard, MA, MD; Donna M. Jacobsen, BS; David A. Katzenstein, MD; Julio S. G. Montaner, MD; Douglas D. Richman, MD; Robert T. Schooley, MD; Melanie A. Thompson, MD; Stefano Vella, MD; Paul A. Volberding, MD

JAMA. 2004;292:251-265.

Context  Substantial changes in the field of human immunodeficiency virus (HIV) treatment have occurred in the last 2 years, prompting revision of the guidelines for antiretroviral management of adults with established HIV infection.

Objective  To update recommendations for physicians who provide HIV care regarding when to start antiretroviral therapy, what drugs to start with, when to change drug regimens, and what drug regimens to switch to after therapy fails.

Data Sources  Evidence was identified and reviewed by a 16-member noncompensated panel of physicians with expertise in HIV-related basic science and clinical research, antiretroviral therapy, and HIV patient care. The panel was designed to have broad US and international representation for areas with adequate access to antiretroviral management.

Study Selection  Evidence considered included published basic science, clinical research, and epidemiological data (identified by experts in the field or extracted through MEDLINE searches using terms relevant to antiretroviral therapy) and abstracts from HIV-oriented scientific conferences between July 2002 and May 2004.

Data Extraction  Data were reviewed to identify any information that might change previous guidelines. Based on panel discussion, guidelines were drafted by a writing committee and discussed by the panel until consensus was reached.

Data Synthesis  Four antiretroviral drugs recently have been made available and have broadened the options for initial and subsequent regimens. New data allow more definitive recommendations for specific drugs or regimens to include or avoid, particularly with regard to initial therapy. Recommendations are rated according to 7 evidence categories, ranging from I (data from prospective randomized clinical trials) to VII (expert opinion of the panel).

Conclusion  Further insights into the roles of drug toxic effects, drug resistance, and pharmacological interactions have resulted in additional guidance for strategic approaches to antiretroviral management.

Author Affiliations: Department of Infectious Diseases, Hôpital Bichat-Claude Bernard, X. Bichat Medical School, Paris, France (Dr Yeni); Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY (Dr Hammer); Department of Immunology and Infectious Diseases, Harvard Medical School, Boston, Mass (Dr Hirsch); Department of Medicine, University of Alabama, Birmingham (Dr Saag); Department of Preventive Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil (Dr Schechter); Department of Biomedicine, Brown University School of Medicine, Providence, RI (Dr Carpenter); Department of Medicine, University of Miami School of Medicine, Miami, Fla (Dr Fischl); Department of Medicine, University of Barcelona, Barcelona, Spain (Dr Gatell); Department of HIV Medicine, Chelsea and Westminster Hospital, London, England (Dr Gazzard); International AIDS Society-USA, San Francisco, Calif (Ms Jacobsen); Department of Medicine, Stanford University Medical Center, Stanford, Calif (Dr Katzenstein); Department of Medicine, University of British Columbia, Vancouver (Dr Montaner); Departments of Pathology and Medicine, University of California and San Diego VA Healthcare System, San Diego (Dr Richman); Department of Medicine, University of Colorado School of Medicine, Denver (Dr Schooley); AIDS Research Consortium of Atlanta, Ga (Dr Thompson); Istituto Superiore di Sanità, Rome, Italy (Dr Vella); Department of Medicine, University of California and San Francisco Veterans Affairs Medical Center, San Francisco (Dr Volberding).

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