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May 3rd, 2014

The Top Items from the Revised DHHS HIV Treatment Guidelines

A sparkling, shiny new revision of the DHHS HIV Treatment Guidelines was released this week (thanks Alice Pau!), and provides plenty to read and think about — 285 pages, if you’re counting.

A few ways to navigate this gargantuan effort more efficiently — the What’s New section, the recommendations summarized here, and the tables here.

But if you want the Monarch Notes/CliffsNotes version (clearly an analogy soon to be as outdated as dial phones, fax modems, and 8-track tapes), here’s one perspective (mine, not the panel’s) on the most important changes:

  • After two years of virologic suppression, frequency of CD4 monitoring reduced — and for those with CD4 > 500, it’s now “optional.” Everyone knows it makes no sense to modify treatment based on CD4 results alone in their patients on suppressive therapy, so it’s liberating to have this now formalized in treatment guidelines. Soon quality improvement programs, ADAPs, and others (patients?) will stop nagging us for CD4s in these situations. By the way, “optional” means “if it makes you and/or your patient feel better to check it, go ahead and do so.” It doesn’t mean that there are new guidelines for what to do with the results when the CD4 comes back 840, or 570, or 750, or 1001. And that’s because you should do nothing.
  • More recommended initial regimens! As per the late 2013 update, there are now seven recommended regimens — the “core four” from 2009 (TDF/FTC + EFV, or ATV/r, or DRV/r, or RAL), plus the three other integrase options:  TDF/FTC + EVG/c or DTG, and ABC/3TC + DTG. And now there’s an entirely new category for those with HIV RNA < 100,000, CD4 > 200, which for me predominantly exists for TDF/FTC/RPV. (ABC/3TC + EFV and ATV/r are also in there.) In fact, there are so many recommended regimens that the “preferred” term has been dropped, the alternative options relatively few in number (4), and many drugs (ZDV, FPV, MVC, SQV, NVP) no longer recommended at all. Makes sense to retire them, right? Why would you ever choose one of these for initial therapy in 2014?
  • The “Regimen Simplification” section is now called, “Regimen Switching in the Setting of Viral Suppression.” That’s a much better title, and not only that, the entire section has been extensively revised. If you read the PDF versus the HTML version and are looking for the yellow highlighting showing what has changed in this section, it’s intentionally left out when so much is altered — too distracting.
  • A whole new section on cost considerations. Gingerly treading into these potentially contentious waters, the section mentions cost sharing, prior authorizations, generic ART, lab testing (again), and the wholesale prices of various ART components.

Plenty more in there, of course. Now get reading!

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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