US treatment guidelines updated (2008)

The US Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents have been updated to include significant changes in some recommendations, even though the last major update was in December 2007.

The latest updates include new sections on what to start, treatment interruptions, TB/HIV coinfection, and acute HIV infection.

What to Start: Initial Combination Regimens for the Antiretroviral-naive Patient?

Changes, highlighted in yellow in the PDF document include:

  • Revised recommendations for several “preferred” and “alternative” antiretroviral components for treatment-naive patients:
    • Abacavir+3TC has been changed from “alternative” to “preferred” 2-NRTI component in patients who have tested negative for HLA-B*5701 (AII).
    • AZT+3TC has been changed from “preferred” to “alternative” 2-NRTI component (BII).
    • Ritonavir-boosted saquinavir has been changed from a PI-option that was considered as “Acceptable as initial antiretroviral components but inferior to preferred or alternative components” to an “alternative” PI component (BII).
  • The following options are no longer recommended as components for initial therapy in treatment-naive patients:
    • Nelfinavir as PI component
    • d4T + 3TC as 2-NRTI components
    • Abacavir+AZT+3TC as a triple-NRTI combination
  • A new topic entitled “Other Treatment Options Under Investigation: Insufficient Data to Recommend” has been added, which includes a review of recent clinical trial data in treatment-naive patients for ritonavir-boosted darunavir°©-based regimens, maraviroc-based regimens, and raltegravir-based regimens.

Treatment Interruption

This section has been updated with recent data on short-term and long-term treatment interruption. The Panel reaffirms our recommendation that aside from unplanned or planned short-term interruption due to illnesses precluding oral therapy or toxicities, long-term treatment interruption is not recommended unless in the context of a clinical trial (DI).

Acute HIV Infection

  • A new table on “Identifying, diagnosing, and managing acute HIV- 1 infection” has replaced the table on “Associated signs and symptoms of acute retroviral syndrome and percentage of expected frequency”.
  • The Panel also recommends that since clinically significant resistance to PIs is less common than resistance to NNRTIs in antiretroviral-naive persons who harbor drug resistant virus, if therapy is initiated before drug resistance test results are available, consideration should be given to using a PI-based regimen (BIII).

Mycobacterium Tuberculosis Disease or Latent Tuberculosis Infection with HIV Coinfection

This section has been updated with the following information:

  • Discussions and recommendations on the timing of initiation of antiretroviral therapy in patients with active tuberculosis (TB), with emphasis on the risks and benefits of concomitant therapy related to overlapping toxicities, drug interactions, CD4 cell counts, and potential for immune reconstitution inflammatory syndrome.
  • Recommendation for repeat testing to detect latent TB infection in persons who had CD4 count <200 cells/mm3 and have tested negative prior to antiretroviral therapy and have improved CD4 count to >200 cells/mm3 (BII).

The guidelines available at:

Links to other websites are current at date of posting but not maintained.