Spanish GESIDA/National AIDS Plan recommendations for antiretroviral therapy in HIV-infected adults in the year 2002

OBJECTIVE. To provide an update of recommendation on antiretroviral treatment (ART) in HIV-infected adults. METHODS. These recommendations have been agreed by consensus by a committee of the Spanish AIDS Study Group (GESIDA) and the National AIDS Plan. To do so, advances in the physiopathology of AIDS and the results on efficacy and safety in clinical trials, cohort and pharmacokinetics studies published in biomedical journals or presented at congresses in the last few years have been reviewed. Three levels of evidence have been defined according to the data source: randomized studies (level A), case-control or cohort studies (level B) and expert opinion (level C). Whether to recommend, consider, or not to recommend ART has been established for each situation. RESULTS. Currently, ART with combinations of at least three drugs constitutes the treatment of choice in chronic HIV infection. In patients with symptomatic HIV infection, initiation of ART is recommended. In asymptomatic patients initiation of ART should be based on the CD4+/muL lymphocyte count and on the plasma viral load (PVL): a) in patients with CD4+ lymphocytes < 200 cells/muL, initiation of ART is recommended; b) in patients with CD4+ lymphocytes between 200 and 300 cells/muL, initiation of ART should, in most cases, be recommended; however, it could be delayed when the CD4+ lymphocyte count remains close to 350 cells/muL and the PVL is low, and c) in patients with CD4+ lymphocytes > 350 cells/muL, initiation of ART can be delayed. The aim of ART is to achieve an undetectable PVL. Adherence to ART plays a role in the durability of the antiviral response. Because of the development of cross-resistance, the therapeutic options in treatment failure are limited. In these cases, genotypic analysis is useful. Toxicity limits ART. The criteria for ART in acute infection, pregnancy and postexposure prophylaxis and in the management of coinfection with HIV and hepatitis C and B virus are controversial. CONCLUSIONS. The current approach to initiating ART is more conservative than in previous recommendations. In asymptomatic patients, the CD4+ lymphocyte count is the most important reference factor for initiating ART. Because of the considerable number of drugs available, more sensitive monitoring methods (PVL) and the possibility of determining resistance, therapeutic strategies have become much more individualized.