[National consensus document by GESIDA/National Aids Plan on antiretroviral treatment in adults infected by the human immunodeficiency virus (January 2011 update)]

Abstract

The update of these adult antiretroviral treatment (cART) recommendations has been carried out by consensus of a panel consisting of members of the Grupo de Estudio de Sida (Gesida, AIDS Study Group) and the Plan Nacional sobre el Sida (PNS, Spanish AIDS Plan) who have reviewed the antiretroviral efficacy and safety advances in clinical trials, cohort and pharmacokinetic studies published in medical journals (PubMed and Embase), or presented in medical scientific meetings. Three levels of evidence were defined according to the data source: randomized studies (level A), cohort or case-control studies (level B), and expert opinion (level C). The decision to recommend, consider or not to recommend antiretroviral treatment (ART) was established by consensus in each situation. The current treatment of choice for HIV infection is the combination of three drugs. Combined ART is recommended in patients with symptomatic HIV infection, and guidelines on this treatment in patients with an opportunistic type C infection are included. In asymptomatic patients, initiation of ART is recommended on the basis of CD4 lymphocyte counts, plasma viral load and patient co-morbidities, as follows: a) therapy should be started in patients with CD4 counts <350 cells/μL; b) Therapy should be recommended when CD4 counts are between 350 and 500 cells/μL, except when CD4 are stabilized, there is low plasma viral load, or the patient not willing; c) Therapy could be deferred when CD4 counts are above 500 cells/ μL, but should be considered in cases of cirrhosis, chronic hepatitis C, hepatitis B fulfilling treatment criteria, high cardiovascular risk, HIV nephropathy, viral load > 100,000 copies/ mL, proportion of CD4 cells < 14%, in people aged >55 years, and in cases of discordant serological sexual couples in order to reduce transmission. cART should include 2 reverse transcriptase inhibitor nucleoside analogues (AN) and a non-analogue reverse transcriptase inhibitor (NN) or 2 AN and a ritonavir boosted protease inhibitor (PI/ r), but other combinations are possible. The panel has consensually selected and prioritized some drug combinations, some of them co-formulated. The objective of cART is to achieve an undetectable viral load. Adherence to therapy plays an essential role in maintaining antiviral response. Therapeutic options are limited after cART failures, but undetectable viral load maybe possible with resistance genotypic studies. Adverse events are a decreasing problem of cART, where the benefits exceed the possible harm. cART in acute HIV infection, in women, pregnancy and prevention of mother to child transmission, and pre- and post-exposure prophylaxis are commented on. Management of hepatitis B or C co-infection is also commented on.