Page 119 - HIV/AIDS Guidelines

Treatment for Recent but Nonacute HIV Infection or Infection of Undetermined
Duration

In addition to patients with acute HIV infection, some HIV clinicians also recommend consideration of
therapy for patients in whom seroconversion has occurred within the previous 6 months (CIII). Although the
initial burst of viremia among infected adults usually resolves in 2 months, rationale for treatment during the
2- to 6-month period after infection is based on the probability that virus replication in lymphoid tissue is still
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not maximally contained by the immune system during this time. In the case of pregnancy, use of a
combination ARV regimen to prevent MTCT of HIV is recommended (AI). For nonpregnant patients the
current guidelines have provided a rationale for recommending initiation of ART in ART-naive patients with
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CD4 count between 350 and 500 cells/mm as well as a recommendation to consider therapy for those with
CD4 count >500 cells/mm . (See Initiating Antiretroviral Therapy.) Although these recommendations are
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primarily based upon data from patients with chronic infection, the potential benefit of early treatment on
immune recovery and on attenuation of the pathologic effects of viremia-associated inflammation and
coagulation could apply to those with early HIV infection as well. Based upon all of these considerations it is
reasonable that clinicians share with patients the potential rationale for initiating ART during early HIV
infection and offer treatment to those who are willing and able to commit to lifelong treatment.

Treatment Regimen for Acute or Recent HIV Infection

If the clinician and patient have made the decision to initiate ART for acute or recent HIV infection, the goal
of therapy is to suppress plasma HIV RNA levels to below detectable levels (AIII). Data are insufficient to
draw firm conclusions regarding specific drug combinations to use in acute HIV infection. Potential
combinations of agents should be those used in chronic infection. (See What to Start.) However, because
clinically significant resistance to PIs is less common than resistance to NNRTIs in ART-naive persons, an
RTV-boosted PI-based regimen should be used if therapy is initiated before drug-resistance test results are
available (AIII). If resistance test results or resistance pattern of the source virus are known, this information
should be used to guide the selection of the ARV regimen.

Patient Follow-up
Testing for plasma HIV RNA levels and CD4 count and toxicity monitoring should be performed as
described in Laboratory Testing for Initial Assessment and Monitoring While on Antiretroviral Therapy (i.e.,
HIV RNA at initiation of therapy, after 2–8 weeks, then every 4–8 weeks until viral suppression, then every
3–4 months thereafter) (AII).
Duration of Therapy for Acute or Recent HIV Infection

The optimal duration of therapy for patients with acute or recent HIV infection is unknown, but ongoing
clinical trials may provide relevant data regarding these concerns. Difficulties inherent in determining the
optimal duration and therapy composition for acute or recent infection (and the potential need for lifelong
treatment) should be considered when counseling patients prior to initiation of therapy. Patients need to know
that there are limited data regarding the benefits of stopping treatment, whereas strong data from studies in
patients with chronic HIV infection show that stopping ART may be harmful. 21

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents I-3

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