title: Antiretroviral treatment of adult HIV infection: 2008 recommendations of the International AIDS Society-USA panel.
abstract: BACKGROUND
  The availability of new antiretroviral drugs and formulations, including drugs in new classes, and recent data on treatment choices for antiretroviral-naive and -experienced patients warrant an update of the International AIDS Society-USA guidelines for the use of antiretroviral therapy in adult human immunodeficiency virus (HIV) infection.
  
  
  OBJECTIVE
  To summarize new data in the field and to provide current recommendations for the antiretroviral management and laboratory monitoring of HIV infection. This report provides guidelines in key areas of antiretroviral management: when to initiate therapy, choice of initial regimens, patient monitoring, when to change therapy, and how best to approach treatment options, including optimal use of recently approved drugs (maraviroc, raltegravir, and etravirine) in treatment-experienced patients.
  
  
  METHODS
  A 14-member panel with expertise in HIV research and clinical care was appointed. Data published or presented at selected scientific conferences since the last panel report (August 2006) through June 2008 were identified.
  
  
  METHODS
  Data that changed the previous guidelines were reviewed by the panel (according to section). Guidelines were drafted by section writing committees and were then reviewed and edited by the entire panel. Recommendations were made by panel consensus.
  
  
  CONCLUSIONS
  New data and considerations support initiating therapy before CD4 cell count declines to less than 350/microL. In patients with 350 CD4 cells/microL or more, the decision to begin therapy should be individualized based on the presence of comorbidities, risk factors for progression to AIDS and non-AIDS diseases, and patient readiness for treatment. In addition to the prior recommendation that a high plasma viral load (eg, >100,000 copies/mL) and rapidly declining CD4 cell count (>100/microL per year) should prompt treatment initiation, active hepatitis B or C virus coinfection, cardiovascular disease risk, and HIV-associated nephropathy increasingly prompt earlier therapy. The initial regimen must be individualized, particularly in the presence of comorbid conditions, but usually will include efavirenz or a ritonavir-boosted protease inhibitor plus 2 nucleoside reverse transcriptase inhibitors (tenofovir/emtricitabine or abacavir/lamivudine). Treatment failure should be identified and managed promptly, with the goal of therapy, even in heavily pretreated patients, being an HIV-1 RNA level below assay detection limits.
authors.affiliation: Division of Infectious Diseases, Columbia University College of Physicians and Surgeons, 630 W 168th St, New York, NY 10032, USA. smh48@columbia.edu
authors.forename: Scott M
authors.initials: SM
authors.lastname: Hammer
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Eron
authors.forename: Peter
authors.initials: P
authors.lastname: Reiss
authors.forename: Robert T
authors.initials: RT
authors.lastname: Schooley
authors.forename: Melanie A
authors.initials: MA
authors.lastname: Thompson
authors.forename: Sharon
authors.initials: S
authors.lastname: Walmsley
authors.forename: Pedro
authors.initials: P
authors.lastname: Cahn
authors.forename: Margaret A
authors.initials: MA
authors.lastname: Fischl
authors.forename: Jose M
authors.initials: JM
authors.lastname: Gatell
authors.forename: Martin S
authors.initials: MS
authors.lastname: Hirsch
authors.forename: Donna M
authors.initials: DM
authors.lastname: Jacobsen
authors.forename: Julio S G
authors.initials: JS
authors.lastname: Montaner
authors.forename: Douglas D
authors.initials: DD
authors.lastname: Richman
authors.forename: Patrick G
authors.initials: PG
authors.lastname: Yeni
authors.forename: Paul A
authors.initials: PA
authors.lastname: Volberding
mesh_terms: D015492:AIDS Serodiagnosis / Q000592:standards; D016263:AIDS-Associated Nephropathy; D017088:AIDS-Related Opportunistic Infections; D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage*; D023241:Antiretroviral Therapy, Highly Active / Q000592:standards*; D018791:CD4 Lymphocyte Count; D015897:Comorbidity; D016903:Drug Monitoring; D024921:Drug Resistance, Multiple, Viral; D019317:Evidence-Based Medicine; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy*; D015497:HIV-1 / Q000472:pathogenicity; D006801:Humans; D008297:Male; D015166:Monitoring, Immunologic; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious; D018570:Risk Assessment; D017211:Treatment Failure; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents