By Paul E. Sax, M.D.
With the International AIDS Conference in Washington just starting, the International Antiviral (ahem) Society-USA has revised it's HIV treatment guidelines, updating the 2010 version.
As has been the case for several years now, it's published in JAMA and also available on the IAS-USA web site. It's a well written, evidence-driven summary of the current state of HIV treatment, with a highly respected authorship group, headed again this time by Melanie Thompson.
It is more fully covered by Abbie Zuger on Journal Watch: AIDS Clinical Care, but some medical highlights:
- HIV treatment recommended for all, with the possible exception of HIV controllers and long-term nonprogressors.
- They have shifted towards listing full regimens rather than "NRTI pair + key third drug".
- Some abacavir/3TC-based regimens have moved into the "Recommended" category, provided the HLA-B*5701 is negative and the HIV RNA is < 100,000 copy/mL.
- Tenofovir/FTC/elvitegravir/cobicistat ("Quad") is listed as an alternative treatment, with an acknowledgment that this treatment is not yet approved.
- There's a section on PrEP with tenofovir/FTC.
- Viral load and CD4 monitoring can be reduced to twice-yearly in clinically stable patients. (Of course you don't need to measure CD4 at all once someone is stable on treatment -- see here for an explanation.)
- There's a box nicely summarizing all the changes since the 2010 version.
Now for the non-medical summary:
- The "USA" part of IAS-USA is to distinguish this from the other IAS, which is still called the International AIDS Society.
- Abbreviation for "integrase inhibitors"? In STIs, which is hard to type, but not nearly as hard as iPrEx.
- If you want to target the areas of controversy in the field that nonetheless deserve some sort of comment -- timing of HIV therapy with HCV, abacavir and CVD, use of therapeutic drug monitoring, etc -- simply do a search on the word "might." Guidelines writers love that word when the data are inconclusive.
Finally, lots of the the IAS-USA content is similar to what's in the DHHS Guidelines -- I'm a panel member on that one, and some people have been/are a panel member on both. One might (there it is again) wonder why two such entities are necessary, but I for one value the slightly different perspectives.
Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.
