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Review
July 25, 2012

Antiretroviral Treatment of Adult HIV Infection2012 Recommendations of the International Antiviral Society–USA Panel

Author Affiliations

Author Affiliations: AIDS Research Consortium of Atlanta, Atlanta, Georgia (Dr Thompson); New York University School of Medicine (Dr Aberg) and Columbia University College of Physicians and Surgeons (Dr Hammer), New York, New York; The Alfred Hospital and Monash University, Melbourne, Australia (Dr Hoy); University Hospital of Lausanne, Lausanne, Switzerland (Dr Telenti); University of California San Diego School of Medicine (Drs Benson and Richman) and Veterans Affairs San Diego Healthcare System (Dr Richman), San Diego; Hospital Juan Fernandez/University of Buenos Aires Medical School and Fundacion Huesped, Buenos Aires, Argentina (Dr Cahn); University of North Carolina at Chapel Hill (Dr Eron); University Hospital Zurich, Zurich, Switzerland (Dr Günthard); Academic Medical Center University of Amsterdam, Amsterdam, the Netherlands (Dr Reiss); Ospedale Luigi Sacco-Milano, Milan, Italy (Dr Rizzardini); The Johns Hopkins University School of Medicine, Baltimore, Maryland (Dr Thomas); International Antiviral Society–USA (Ms Jacobsen) and University of California San Francisco (Dr Volberding), San Francisco.

JAMA. 2012;308(4):387-402. doi:10.1001/jama.2012.7961
Abstract

Context New trial data and drug regimens that have become available in the last 2 years warrant an update to guidelines for antiretroviral therapy (ART) in human immunodeficiency virus (HIV)–infected adults in resource-rich settings.

Objective To provide current recommendations for the treatment of adult HIV infection with ART and use of laboratory-monitoring tools. Guidelines include when to start therapy and with what drugs, monitoring for response and toxic effects, special considerations in therapy, and managing antiretroviral failure.

Data Sources, Study Selection, and Data Extraction Data that had been published or presented in abstract form at scientific conferences in the past 2 years were systematically searched and reviewed by an International Antiviral Society–USA panel. The panel reviewed available evidence and formed recommendations by full panel consensus.

Data Synthesis Treatment is recommended for all adults with HIV infection; the strength of the recommendation and the quality of the evidence increase with decreasing CD4 cell count and the presence of certain concurrent conditions. Recommended initial regimens include 2 nucleoside reverse transcriptase inhibitors (tenofovir/emtricitabine or abacavir/lamivudine) plus a nonnucleoside reverse transcriptase inhibitor (efavirenz), a ritonavir-boosted protease inhibitor (atazanavir or darunavir), or an integrase strand transfer inhibitor (raltegravir). Alternatives in each class are recommended for patients with or at risk of certain concurrent conditions. CD4 cell count and HIV-1 RNA level should be monitored, as should engagement in care, ART adherence, HIV drug resistance, and quality-of-care indicators. Reasons for regimen switching include virologic, immunologic, or clinical failure and drug toxicity or intolerance. Confirmed treatment failure should be addressed promptly and multiple factors considered.

Conclusion New recommendations for HIV patient care include offering ART to all patients regardless of CD4 cell count, changes in therapeutic options, and modifications in the timing and choice of ART in the setting of opportunistic illnesses such as cryptococcal disease and tuberculosis.

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