Page 39 - HIV/AIDS Guidelines

Treatment Goals (Last updated March 27, 2012; last reviewed March 27, 2012)

Eradication of HIV infection cannot be achieved with available antiretroviral (ARV) regimens even when
new, potent drugs are added to a regimen that is already suppressing plasma viral load below the limits of
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detection of commercially available assays. This is chiefly because the pool of latently infected CD4 T cells
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is established during the earliest stages of acute HIV infection and persists with a long half-life, despite
prolonged suppression of plasma viremia. 3-7 Therefore the primary goals for initiating antiretroviral therapy
(ART) are to:

• reduce HIV-associated morbidity and prolong the duration and quality of survival,
• restore and preserve immunologic function,
• maximally and durably suppress plasma HIV viral load (see Plasma HIV RNA Testing), and

• prevent HIV transmission.
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ART has reduced HIV-related morbidity and mortality 8-11 and has reduced perinatal and behavior-associated
transmission of HIV. 13-17 HIV suppression with ART may also decrease inflammation and immune activation
thought to contribute to higher rates of cardiovascular and other end-organ damage reported in HIV-infected
cohorts. (See Initiating Antiretroviral Therapy.) Maximal and durable suppression of plasma viremia delays
or prevents the selection of drug-resistance mutations, preserves CD4 T-cell numbers, and confers substantial
clinical benefits, all of which are important treatment goals. 18-19

Achieving viral suppression requires the use of ARV regimens with at least two, and preferably three, active
drugs from two or more drug classes. Baseline resistance testing and patient characteristics should guide
design of the specific regimen. (See What to Start: Initial Combination Regimens for the Antiretroviral-
Naive Patient.) When initial suppression is not achieved or is lost, rapidly changing to a new regimen with at
least two active drugs is required. (See Virologic and Immunologic Failure.) The increasing number of
drugs and drug classes makes viral suppression below detection limits an appropriate goal in all patients.

Viral load reduction to below limits of assay detection in an ART-naive patient usually occurs within the first
12–24 weeks of therapy. Predictors of virologic success include:

• high potency of ARV regimen,
• excellent adherence to treatment regimen, 20
• low baseline viremia, 21

3 22
• higher baseline CD4 count (>200 cells/mm ), and
• rapid reduction of viremia in response to treatment. 21,23
Successful outcomes are usually observed, although adherence difficulties may lower the success rate in
clinical practice to below the 90% rate commonly seen in clinical trials. 24

Strategies to Achieve Treatment Goals
Achieving treatment goals requires a balance of sometimes competing considerations, outlined below.
Providers and patients must work together to define individualized strategies to achieve treatment goals.

Selection of Initial Combination Regimen

Several preferred and alternative ARV regimens are recommended for use. (See What to Start.) Many of
these regimens have comparable efficacy but vary to some degree in dosing frequency and symmetry, pill

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents D-1

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