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Newest DHHS Guidelines Shuffle HIV Drug Rankings

Ritonavir-boosted darunavir is now a "preferred" component of initial regimens, and abacavir/3TC is only an "alternative."

Released less than a year after the last update, the latest HIV treatment guidelines from the U.S. Department of Health and Human Services (DHHS) promote darunavir, demote abacavir, and offer some musings on regimen simplification and the care of HIV-infected adolescents.

Specific changes to the recommendations for initial treatment include the following:

• Once-daily ritonavir-boosted darunavir (800 mg, plus 100 mg of ritonavir) is now included among the "preferred" PI components of initial treatment, thanks to its good performance in the ARTEMIS head-to-head trial against lopinavir/ritonavir (AIDS Clin Care Aug 11 2008).
  
• Lopinavir/r (a "preferred" PI component) can now be dosed either once daily or twice daily.
  
• Coformulated abacavir/3TC has been demoted from a "preferred" NRTI combination to an "alternative" one because of data suggesting that it may be insufficiently potent in patients with high viral loads (AIDS Clin Care Sep 15 2008). Other data have linked the use of abacavir to increased risk for myocardial infarction (AIDS Clin Care Sep 11 2008), and the new guidelines suggest that the drug be used cautiously in patients with cardiac risk factors.
  
• The combination of ddI, FTC, and unboosted atazanavir has demonstrated poor efficacy in some studies, as has the combination of tenofovir, FTC (or 3TC), and nevirapine. Both regimens have been flagged as ones to avoid or to use only with caution.
  

For a complete list of the preferred and alternative components of initial regimens, see Table 1.

The guidelines also feature a new section on regimen simplification that describes a variety of ways to alleviate pill burden and forestall cumulative drug toxicity in successfully treated patients who are taking outmoded regimens. An expanded section on HIV-infected adolescents considers the challenge of transitioning them to adult HIV clinics.

Comment: These new guidelines have incorporated most of the year’s pertinent clinical data in record time. Refreshingly, they now also address some perplexing issues (such as regimen simplification), even though too few data are available for actual recommendations to be set forth. Equally impressive is the new format of these guidelines. Tables are now integrated into the text, and the ranking of data and recommendations has been streamlined, making them far easier to read than were previous versions.

— Abigail Zuger, MD

Published in Journal Watch HIV/AIDS Clinical Care November 6, 2008

Citation(s):

Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Nov 3 , 2008. (http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf)

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