Why guidelines are needed

Guidelines on optimum treatment are now available for many diseases, but in few diseases does the standard of care evolve as quickly as it has done in the treatment of HIV infection. Whilst it may take three to five years for the results of major clinical trials in fields such as heart disease to be translated into improvements in the standard of care, treatment of HIV infection tends to change much more quickly.

In order to ensure that patients are offered a uniform minimum standard of care, and to help persuade funders to pay for new treatments, several organisations have developed guidelines for using anti-HIV drugs. Three key organisations preparing antiretroviral treatment guidelines are the British HIV Association (BHIVA), the US Department of Health and Human Services (USDHHS), and the World Heath Organization (WHO). Highlights from the UK and US guidelines are summarised below; however, given the dynamic nature of HIV treatment and research, it is recommended that readers go to the internet site of each organisation to view current guidelines and check for updates. The respective websites are:

In 2010, WHO published newly updated guidelines for antiretroviral treatment of adults and adolescents1, as well as for treatment of infants and children2, for prevention of mother-to-child transmission of HIV3, and for infant feeding. One key revision was the recommendation that HIV-positive adults, adolescents, and children five years of age or older should start treatment when their CD4 count falls below 350 cells/mm3, regardless of whether symptoms are present or not. The recommendation replaces previous guidelines for low- and middle-income countries that recommended treatment for people with advanced symptoms of HIV disease or a CD4 count below 200 without symptoms.

The new guidance also recommends antiretroviral treatment with an efavirenz-based regimen for everyone with TB regardless of CD4 count, with antiretroviral therapy to be initiated soon after TB treatment. People with HIV and hepatitis B co-infection who have hepatitis B infection that requires treatment should also receive antiretroviral treatment with a regimen containing tenofovir and either 3TC or FTC, regardless of CD4 count.

The new guidance aims to bring treatment practice in low- and middle-income countries into line with recommendations in Europe, North America and Australia, where earlier treatment has been the norm for several years.

Under the revised guidelines for prevention of mother-to-child transmission (PMTCT), pregnant women are now to receive antiretroviral drugs throughout pregnancy and for the entire duration of breastfeeding, regardless of whether or not they meet the criteria for treatment in adults. The guidelines for PMTCT, treatment of infants and children, and infant feeding are discussed in the corresponding chapters.

The European AIDS Clinical Society also released updated 2009 guidelines for The Clinical Management and Treatment of HIV-infected Adults in Europe and these can be accessed at www.europeanaidsclinicalsociety.org

New guidelines for the care of HIV-positive patients were also issued by the Infectious Diseases Society of America (IDSA) in 2009 and are published in the online edition of Clinical Infectious Diseases, available at www.journals.uchicago.edu/doi/pdf/10.1086/605292. The IDSA care guidelines are distinct from those produced by the USDHHS, but should be read in conjunction with them.4 

References

  1. World Health Organization Antiretroviral therapy for HIV infection in adults and adolescents: recommendations for a public health approach: 2010 rev. WHO. Available online at http://www.who.int/hiv/pub/arv/adult2010/en/index.html [Accessed Nov 9, 2010],
  2. World Health Organization Antiretroviral therapy of HIV infection in infants and children: towards universal access: recommendations for a public health approach - 2010 revision. WHO. Available online at www.who.int/hiv/pub/paediatric/infants2010/en/index.html (Date accessed: 12 Nov 2010), 2010
  3. World Health Organization Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: Recommendations for a public health approach: 2010 version. World Health Organization, Geneva 2010. Available online at http://www.who.int/hiv/pub/mtct/antiretroviral2010/en/index.html. [Accessed November 9, 2010], 2010
  4. Aberg JA et al. Primary care guidelines for the management of persons infected with Human Immunodeficiency Virus: 2009 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 49: 651-681; available online at journals.uchicago.edu/doi/pdf/10.1086/605292, 2009