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HIV and AIDS
Initial Antiretroviral Therapy in Treatment-naïve Patients
a report by
Andrzej Horban and Piotr Pulik
Hospital of Infectious Diseases, Warsaw
The European Aids Clinical Society (EACS) advocates that optimal • confirmation of HIV-antibody-positive testing;
antiretroviral therapy (ART) and care are elements in the European • complete blood count, transaminase level, alk phosphatase, calcium
response to the needs of HIV-infected patients, whatever their phosphate, creatinine, calculated creatinine clearance, fasting blood
origin, mode of infection or socioeconomic status. There are glucose and panel of lipids for everybody under European guidelines
international guidelines provided by independent international (under DHHS guidelines these tests apply if the patient is at risk of
research organisations such as the International AIDS Society (IAS) US cardiovascular diseases or is ART-naive);
Panel or the EACS or headed by official US governmental • urine analysis, also for protein and sugar;
organisations such as the Department of Health and Human Services • antibody tests for toxoplasma, cytomegalovirus (CMV), hepatitis A, B
(DHHS). Clinical knowledge is improving all the time, so guidelines are and C and syphilis;
revised and updated as often as possible. Two sets of guidelines – • other sexually transmitted infection screening for Chlamydia
from the EACS and the DHHS – have been updated recently. The most trachomatis and Neisseria gonorrhoeae, if appropriate;
important issues are: • cervical smear (for women);
• plasma HIV RNA;
• how best to manage naïve patients to find the point at which ART • CD4 absolute count (in European guidelines also the percentage and
should be applied; optional CD8 with the percentage);
• when to initiate ART;
• which drugs should be used as first-line regimens;
• the criteria for effective treatment; and
• how to treat pregnant women. As the most influential factor on the
duration of the first and most important
The Management of Newly Diagnosed
HIV-infected Naïve Patients
regimen is psychological condition, a
Each patient entering care should undergo a complete medical
complete assessment should be made.
history and physical examination. European guidelines recommend
paying attention to height, weight, body mass index (BMI)
and blood pressure. As the most influential factor on the duration
of the first and most important regimen is psychological • for patients with HIV RNA >1,000copies/ml, genotypic resistance
condition, a complete assessment should be made. In some testing and, in Europe, determination of HIV subtype – if genotypic
countries, intravenous drug abusers are the biggest group of testing is not available it is advised that a sample of blood is stored;
patients so substance abuse should be reduced. For those who US guidelines advise considering repeated testing at the beginning of
cannot stop taking illegal drugs,harm-reduction programmes antiretroviral treatment; and
should be recommended. For opioid users, a methadone • both guidelines recommended HLA*B5701 determination before
maintenance programme is strongly recommended as part of the introducing abacavir; if this is impossible, use of abacavavir is allowed
prevention tool to diminish the spread of HIV infection. after counselling.
The following laboratory tests should be performed during the
preliminary visit: Depending on serology results, hepatitis A and B vaccinations are
recommended. Pneumococcal vaccination should be offered. For
asymptomatic patients not receiving ART, a complete blood count,
Andrzej Horban is Head of the AIDS Diagnosis and
CD4 count and the percentage and plasma HIV RNA should be
Therapy Centre of the Infectious Diseases Hospital in
Warsaw, Poland. He is President of the Polish AIDS
performed at least every six months. US guidelines advise measuring
Society, a member of the Executive Committe of the CD4 count every three to six months. European guidelines advise
European AIDS Clincal Society and a Member of the Board
measuring alanine transaminase (ALT), aspartate aminotransferase
of Council of the International AIDS Society (IAS). He is
also a member of the Steering Committee of EuroSIDA,
(AST) and fasting lipids at least once a year. The physical examination
NEAT and EHR. Dr Horban has been involved in many
is recommended at least once a year, but in my opinion it should take
international clinical trials.
place on every visit to the centre. If not yet performed, genotyping is
E:
ahorban@zakazny.pl
recommended before treatment begins. Other laboratory parameters
should be added according to the selected regimen.
40 © TOUCH BRIEFINGS 2007
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