Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents

Abstract

SummaryThe availability of an increasing number of antiretroviral agents and the rapid evolution of new information has introduced extraordinary complexity into the treatment of HIV-infected persons. In 1996, the Department of Health and Human Services and the Henry J. Kaiser Family Foundation convened the Panel on Clinical Practices for the Treatment of HIV to develop guidelines for the clinical management of HIV-infected adults and adolescents.This report recommends that care should be supervised by an expert, and makes recommendations for laboratory monitoring with particular emphasis on measurement of plasma levels of HIV RNA. The report also provides guidelines for antiretroviral therapy, including when to start treatment, what drugs to initiate, when to change therapy, and therapeutic options when changing therapy. Special considerations are provided for adolescents and pregnant women. As with treatment of other chronic conditions, therapeutic decisions require a mutual understanding between the patient and the health care provider regarding the benefits and risks of treatment. Like the treatment of most chronic diseases, antiretroviral regimens are complex, have major side effects, pose difficulty with compliance, and carry serious potential consequences with the risk of resistance from non-adherence to the drug regimen or suboptimal levels of antiretroviral agents. Patient education and involvement in therapeutic decisions is important for all medical conditions, but is considered especially critical for HIV infection and its treatment.With regard to specific recommendations, treatment should be offered to all patients with the acute HIV syndrome, those within six months of seroconversion, and all patients with symptoms ascribed to HIV infection. Recommendations for offering antiretroviral therapy in asymptomatic patients depend on virologic and immunologic factors. In general, treatment should be + 3 offered to individuals with fewer than 500 CD4 T cells/mm or plasma HIV RNA levels exceeding 10,000 copies/ml (bDNA assay) or 20,000 copies/ml (RT-PCR assay). The strength of the recommendation to treat asymptomatic patients should be based on the patient's willingness to accept therapy, the probability of adherence with the prescribed regimen, and the prognosis in terms of time to an + AIDS-defining complication as predicted by plasma HIV RNA levels and CD4 T cell counts, which independently help to predict prognosis. Once the decision has been made to initiate antiretroviral therapy, the goal is maximum viral suppression for as long as possible. Results of clinical trials to date indicate that this may currently be best achieved with a potent protease inhibitor (PI) in combination with two nucleoside analogue reverse transcriptase inhibitors (NRTIs). Another option is the combination of saquinavir plus ritonavir combined with one or two NRTIs. Other currently available regimens may be used in selected settings, but are considered by many to be less likely to produce maximum viral suppression. Results of t...

Development and Initial Feasibility of a Hospital-Based Acceptance and Commitment Therapy Intervention to Improve Retention in Care for Out-of-Care Persons with HIV: Lessons Learned from an Open Pilot Trial

“…Unfortunately, roughly 40% of people with HIV (PWH) in the United States are not consistently involved in HIV primary care [ 1 , 2 , 3 ]. For PWH, the U.S. Department of Health and Human Services (DHHS) recommends regular primary care medical visits (e.g., once every 3–6 months) after initiating care [ 4 ]. In fact, a widely used quality indicator requires at least two visits, separated by at least 90 days, within 12 months for established patients [ 5 ].…”

“…Although avoidant coping can lead to short-term relief, it can result in negative long-term consequences (See Figure 1 ). Evidence bears this out: avoidance coping is predictive of poor outcomes in PWH, including lower motivation to attend appointments and lower rates of viral suppression [ 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 ]. Addressing avoidance-based coping could improve HIV treatment outcomes [ 38 ].…”