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2008 Recommendations of the International AIDS Society–USA Panel

Scott M. Hammer, MD; Joseph J. Eron Jr, MD; Peter Reiss, MD, PhD; Robert T. Schooley, MD; Melanie A. Thompson, MD; Sharon Walmsley, MD; Pedro Cahn, MD; Margaret A. Fischl, MD; Jose M. Gatell, MD, PhD; Martin S. Hirsch, MD; Donna M. Jacobsen, BS; Julio S. G. Montaner, MD; Douglas D. Richman, MD; Patrick G. Yeni, MD; Paul A. Volberding, MD

JAMA. 2008;300(5):555-570.

Context  The availability of new antiretroviral drugs and formulations, including drugs in new classes, and recent data on treatment choices for antiretroviral-naive and -experienced patients warrant an update of the International AIDS Society–USA guidelines for the use of antiretroviral therapy in adult human immunodeficiency virus (HIV) infection.

Objectives  To summarize new data in the field and to provide current recommendations for the antiretroviral management and laboratory monitoring of HIV infection. This report provides guidelines in key areas of antiretroviral management: when to initiate therapy, choice of initial regimens, patient monitoring, when to change therapy, and how best to approach treatment options, including optimal use of recently approved drugs (maraviroc, raltegravir, and etravirine) in treatment-experienced patients.

Data Sources and Study Selection  A 14-member panel with expertise in HIV research and clinical care was appointed. Data published or presented at selected scientific conferences since the last panel report (August 2006) through June 2008 were identified.

Data Extraction and Synthesis  Data that changed the previous guidelines were reviewed by the panel (according to section). Guidelines were drafted by section writing committees and were then reviewed and edited by the entire panel. Recommendations were made by panel consensus.

Conclusions  New data and considerations support initiating therapy before CD4 cell count declines to less than 350/µL. In patients with 350 CD4 cells/µL or more, the decision to begin therapy should be individualized based on the presence of comorbidities, risk factors for progression to AIDS and non-AIDS diseases, and patient readiness for treatment. In addition to the prior recommendation that a high plasma viral load (eg, >100 000 copies/mL) and rapidly declining CD4 cell count (>100/µL per year) should prompt treatment initiation, active hepatitis B or C virus coinfection, cardiovascular disease risk, and HIV-associated nephropathy increasingly prompt earlier therapy. The initial regimen must be individualized, particularly in the presence of comorbid conditions, but usually will include efavirenz or a ritonavir-boosted protease inhibitor plus 2 nucleoside reverse transcriptase inhibitors (tenofovir/emtricitabine or abacavir/lamivudine). Treatment failure should be identified and managed promptly, with the goal of therapy, even in heavily pretreated patients, being an HIV-1 RNA level below assay detection limits.

Author Affiliations: Columbia University College of Physicians and Surgeons, New York, New York (Dr Hammer); University of North Carolina at Chapel Hill (Dr Eron); Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (Dr Reiss); University of California San Diego, La Jolla (Dr Schooley); AIDS Research Consortium of Atlanta, Atlanta, Georgia (Dr Thompson); University of Toronto, Toronto, Ontario, Canada (Dr Walmsley); Hospital Juan Fernandez/University of Buenos Aires Medical School and Fundacion Huesped, Buenos Aires, Argentina (Dr Cahn); University of Miami, Miami, Florida (Dr Fischl); University of Barcelona, Barcelona, Spain (Dr Gatell); Harvard Medical School, Boston, Massachusetts (Dr Hirsch); International AIDS Society–USA (Ms Jacobsen) and University of California San Francisco and San Francisco Veterans Affairs Medical Center (Dr Volberding), San Francisco; University of British Columbia, Vancouver, British Columbia, Canada (Dr Montaner); University of California San Diego and Veterans Affairs San Diego Healthcare System, San Diego (Dr Richman); and Hôpital Bichat-Claude Bernard and Xavier Bichat Medical School, Paris, France (Dr Yeni).

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