Updated HIV Treatment Guidelines Recommend More Drug Options, Less CD4 Testing

The latest revision to the official U.S. HIV treatment guidelines highlights the growing number of excellent first-line HIV treatment regimens and a deepening agreement among experts that viral load, not CD4 count, is what really matters when gauging treatment success.

The revised guidelines, posted to AIDSinfo on May 1, represent the cumulative wisdom of a diverse panel of HIV experts convened by the U.S. Department of Health and Human Services (HHS). This marks the first full update to the guidelines since Feb. 12, 2013.

Among the most noteworthy changes this time around:

• There's no such thing as a "preferred" first-line regimen anymore. We now have so many viable options for people starting HIV treatment that calling all of them "preferred" no longer felt appropriate to the expert panel. Instead, we now have 10 different "recommended" regimens, and the value of each option will vary depending on the nuances of a person's health. There are also additional "alternative" regimens that are considered safe and effective, just not as widely useful (or well-proven) as the recommended regimens.

• Three new "recommended" regimens have been added. All involve the use of new integrase inhibitors: Tivicay (dolutegravir) plus Epzicom (abacavir/3TC), Tivicay plus Truvada (tenofovir/FTC) and Stribild (a fixed-dose, single-pill regimen consisting of elvitegravir, cobicistat, tenofovir and FTC).

• Many drugs have been removed from the guidelines entirely. We are now up to 33 individual drugs and drug combinations being actively manufactured and sold in the U.S. Not all of them are going to be ideal for first-line therapy, particularly not in comparison to newer medications. Fortovase/Invirase (saquinavir) boosted with Norvir (ritonavir), Lexiva (fosamprenavir) boosted with Norvir, Retrovir (zidovudine, part of Combivir and Trizivir), Reyataz unboosted (it's still recommended if boosted with Norvir), Selzentry (maraviroc) and Viramune (nevirapine) have all been snipped off the guidelines' first-line drug list.

• CD4 testing can be less frequent if treatment is going well. In fact, for people who have been on HIV meds for two or more years and have a consistently undetectable viral load, CD4 tests are now only recommended once per year if their count is 300 or higher -- and if it's over 500, CD4 testing is now considered to be completely optional.

• Testing other T-cell levels is not generally recommended. Looking at CD8, CD19 and other types of immune cell numbers adds expense to a person's medical care without providing clinical value, the expert panel suggests.

• New guidance on HIV treatment switching has been added. The decision of whether to change regimens -- and what to change to -- can often be complicated, especially if people are technically doing well (meaning their viral load is suppressed) on their current regimen. The guidelines have added a bushel of expert advice regarding regimen switches when individuals can't or shouldn't remain on their current HIV meds, whether due to severe side effects or other issues.

Myles Helfand is the editorial director of TheBody.com and TheBodyPRO.com.

Follow Myles on Twitter: @MylesatTheBody.