Guias Art Jama 2012

REVIEW

Antiretroviral Treatment of Adult HIV Infection
2012 Recommendations of the International Antiviral Society–USA Panel
Melanie A. Thompson, MD Judith A. Aberg, MD Jennifer F. Hoy, MBBS, FRACP Amalio Telenti, MD, PhD Constance Benson, MD Pedro Cahn, MD, PhD Joseph J. Eron Jr, MD Huldrych F. Gunthard, MD ¨ Scott M. Hammer, MD Peter Reiss, MD, PhD Douglas D. Richman, MD GiulianoRizzardini, MD David L. Thomas, MD Donna M. Jacobsen, BS Paul A. Volberding, MD drug was approved 25 years ago, improvements in the potency, tolerability, simplicity, and availability of antiretroviral therapy (ART) have resulted in dramatically reduced numbers of opportunistic diseases and deaths where ART is accessible.1 New data show that viral suppression due to ART results in decreased humanimmunodeficiency virus (HIV) transmission on individual2 and population levels1 and that, when used consistently by HIVuninfected persons, ART also may provide protection against HIV infection.3-5 Together, these developments have translated into newly articulated viCME available online at www.jamaarchivescme.com and questions on p 413. Context New trial data and drug regimens that have become available inthe last 2 years warrant an update to guidelines for antiretroviral therapy (ART) in human immunodeficiency virus (HIV)–infected adults in resource-rich settings. Objective To provide current recommendations for the treatment of adult HIV infection with ART and use of laboratory-monitoring tools. Guidelines include when to start therapy and with what drugs, monitoring for response and toxiceffects, special considerations in therapy, and managing antiretroviral failure. Data Sources, Study Selection, and Data Extraction Data that had been published or presented in abstract form at scientific conferences in the past 2 years were systematically searched and reviewed by an International Antiviral Society–USA panel. The panel reviewed available evidence and formed recommendations by fullpanel consensus. Data Synthesis Treatment is recommended for all adults with HIV infection; the strength of the recommendation and the quality of the evidence increase with decreasing CD4 cell count and the presence of certain concurrent conditions. Recommended initial regimens include 2 nucleoside reverse transcriptase inhibitors (tenofovir/emtricitabine or abacavir/lamivudine) plus a nonnucleosidereverse transcriptase inhibitor (efavirenz), a ritonavirboosted protease inhibitor (atazanavir or darunavir), or an integrase strand transfer inhibitor (raltegravir). Alternatives in each class are recommended for patients with or at risk of certain concurrent conditions. CD4 cell count and HIV-1 RNA level should be monitored, as should engagement in care, ART adherence, HIV drug resistance, andquality-of-care indicators. Reasons for regimen switching include virologic, immunologic, or clinical failure and drug toxicity or intolerance. Confirmed treatment failure should be addressed promptly and multiple factors considered. Conclusion New recommendations for HIV patient care include offering ART to all patients regardless of CD4 cell count, changes in therapeutic options, and modificationsin the timing and choice of ART in the setting of opportunistic illnesses such as cryptococcal disease and tuberculosis.
JAMA. 2012;308(4):387-402 www.jama.com

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INCE THE FIRST ANTIRETROVIRAL

sions of the “beginning of the end of AIDS.”6 This revision of the International Antiviral (formerly AIDS) Society–
Author Affiliations: AIDS Research Consortium of Atlanta, Atlanta, Georgia (DrThompson); New York University School of Medicine (Dr Aberg) and Columbia University College of Physicians and Surgeons (Dr Hammer), New York, New York; The Alfred Hospital and Monash University, Melbourne, Australia (Dr Hoy); University Hospital of Lausanne, Lausanne, Switzerland (Dr Telenti); University of California San Diego School of Medicine (Drs Benson and Richman) and Veterans Affairs San...