New Guidelines for When to Start Antiretroviral Therapy - An Optimistic View

As we approach the 20th anniversary of the original description of the clinical syndrome now known as AIDS, treatment paradigms (patterns) continue to evolve and the pendulum still swings. Nowhere is this more evident than in the guidelines for when to start antiretroviral therapy for HIV. In fact, the only constant regarding the recommendations for initiating treatment is that they keep changing. In February 2001, the Department of Health and Human Services Panel on Clinical Practices for Treatment of HIV Infection, to much fanfare, changed these recommendations once again. In this article, I will summarize the new guidelines, place them into historical perspective, and then clarify what the modifications mean in clinical practice.

Details of the most recent guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents can be found at www.hivatis.org. The recommendations for starting antiretroviral therapy have been modified to reflect a trend towards delaying the initiation of treatment. These current guidelines for initiation of therapy are summarized in the table below.

Clinical Category

CD4 Cells
(Cells/ul)

HIV RNA
(Copies/ml)

Recommendations

Symptomatic

Any

Any

Treat

Asymptomatic
(no symptoms)

<200

Any

Treat

Asymptomatic

200-350

Any

Offer Treatment
Controversy Exists

Asymptomatic

>350

>30,000 (bDNA) or
>55,000 (RT-PCR)

Experts Differ,
but Many Treat

Asymptomatic

>350

<30,000 (bDNA)
<55,000 (RT-PCR)

Many Experts Defer,
With Observations

TABLE: Guidelines for starting antiretroviral therapy. The number of CD4 cells reflects the status of the body's immune (defense) system. (Over 500 = normal; under 200 = suppressed immune system.) The bDNA and RT-PCR are different methods for measuring the amount (load) of virus.