Volume 11 Number 1/2 January/February2010

Welcome to the first issue of HTB for 2010 which includes reports from the EACS Conference and updates of three important guidelines.

At EACS, we start with a review that focused on the lack of screening programmes for anal cancer for HIV-positive people. Many studies have already
highlighted that the increased risks, especially for gay men, are comparable to rates of cervical cancer in women prior to those screening programmes.
Focussing on the benefits of newer treatment options to successfully reverse this disease, the review suggests that there is now compelling evidence
supporting more active monitoring.

An ongoing UK review due in April 2010 will hopefully reverse the decision made at the previous review (in 2003), though this will also be related to
whether HIV-positve gay men are seen as a group that deserves further interventions. The study reported later in this issue of HTB, by Bini and
colleagues, adds to the growing evidence to at least support a UK pilot screening programme in the highest risk groups.

Our coverage of guidelines includes new communications from the US DHHS panel, WHO, and PENTA.

Each document includes valuable guidance for clinical management of HIV-positive patients and is essential reading. However, as the remit for each
guideline ranges between defining a minimum standard of care and a more aspirational summary of best possible care, they also highlight controversial
issues for which evidence is still lacking.

In the US DHHS panel review, the recommendation to universally start treatment at any CD4 count lower than 500 cells/mm3 is problematic given the
confounding issues from cohort studies on which the recommendation is based.

As the large randomised START study addressing the risks and benefits of earlier treatment is just enrolling, the decision to guess these results is
premature.

START, and its related sub-studies, is likely to provide the most important dataset to inform not only the question of when to start treatment, but also
about the pathogenesis of essential aspects of HIV, treatment and aging including neurological and bone health. It is welcomed that the WHO guidelines
also recommend earlier treatment (at CD4 <350) and that they place a stronger emphasis on using alternative nucleosides to d4T. However, arguably
earlier treatment should only be recommended in settings where non-d4T-based regimens are freely accessible, and in this aspect of management is not
discussed.

We also include latest reviews of drug interactions from HIV-druginteractions.org and basic science reviews from Richard Jefferys excellent
weblog.