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2006 Recommendations of the International AIDS Society–USA Panel

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

JAMA. 2006;296:827-843.

Context  Guidelines for antiretroviral therapy are important for clinicians worldwide given the complexity of the field and the varied clinical situations in which these agents are used. The International AIDS Society–USA panel has updated its recommendations as warranted by new developments in the field.

Objective  To provide physicians and other human immunodeficiency virus (HIV) clinicians with current recommendations for the use of antiretroviral therapy in HIV-infected adults in circumstances for which there is relatively unrestricted access to drugs and monitoring tools. The recommendations are centered on 4 key issues: when to start antiretroviral therapy; what to start; when to change; and what to change. Antiretroviral therapy in special circumstances is also described.

Data Sources and Study Selection  A 16-member noncompensated panel was appointed, based on expertise in HIV research and patient care internationally. Data published or presented at selected scientific conferences from mid 2004 through May 2006 were identified and reviewed by all members of the panel.

Data Extraction and Synthesis  Data that might change previous guidelines were identified and reviewed. New guidelines were drafted by a writing committee and reviewed by the entire panel.

Conclusions  Antiretroviral therapy in adults continues to evolve rapidly, making delivery of state-of-the-art care challenging. Initiation of therapy continues to be recommended in all symptomatic persons and in asymptomatic persons after the CD4 cell count falls below 350/µL and before it declines to 200/µL. A nonnucleoside reverse transcriptase inhibitor or a protease inhibitor boosted with low-dose ritonavir each combined with 2 nucleoside (or nucleotide) reverse transcriptase inhibitors is recommended with choice being based on the individual patient profile. Therapy should be changed when toxicity or intolerance mandate it or when treatment failure is documented. The virologic target for patients with treatment failure is now a plasma HIV-1 RNA level below 50 copies/mL. Adherence to antiretroviral therapy in the short-term and the long-term is crucial for treatment success and must be continually reinforced.

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

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