Guidelines for managing HIV infection

The goal is maximal suppression of HIV replication for as long as possible

The medical management of HIV infection and AIDS has finally been rewarded with some success, witnessed by falls in AIDS associated deaths in industrialised countries, fewer opportunistic infections, and fewer admissions for HIV infection.1 2 What constitutes optimal practice, however, remains a topic of debate. Two widely publicised sets of guidelines on antiretroviral treatment have appeared over the past year, one from the International AIDS Society in the United States,3 and the other from the British HIV Association.4 While their emphasis was different, the recommendations were broadly similar.

The guidelines agreed on the need for regular monitoring of HIV-1 plasma RNA (“viral load”) and for using antiretroviral treatment in people with low CD4 lymphocyte counts or symptomatic disease. The British guidelines were less prescriptive and placed less emphasis on introducing treatment for people with CD4 cell counts >300x10⁶/l and high viral load.4 Both guidelines endorsed combinations of nucleoside analogues such as zidovudine and didanosine (AZT/ddI), zidovudine and zalcitabine (AZT/ddC), or zidovudine and lamivudine (AZT/3TC) as first line treatments and discussed indications and options for switching treatments.3 4

Practice in many quarters, however, has moved beyond these guidelines.5 6 Many doctors now use triple therapy including a protease inhibitor …