Considerations prior to initiating antiretroviral therapy
- John G Bartlett, MD
John G Bartlett, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — HIV; Pulmonary Infections
- Professor Emeritus
- Johns Hopkins University School of Medicine
At the time of the introduction of potent combination antiretroviral therapy (ART) in 1996, there was a "hit hard and hit early" approach to treatment . However, when the toxicities and resistance of chronic ART became apparent and complicated dosing regimens thwarted adherence, the pendulum swung back to withholding therapy in patients with relatively preserved CD4 cell counts.
Advances in HIV therapy in the last decade have shifted the risk-benefit ratio to earlier treatment. The institution of effective ART can reduce HIV-related morbidity and mortality and decrease HIV transmission. HIV treatment guidelines from the United States Department of Health and Human Services (DHHS) and the International Antiviral Society-USA (IAS-USA) panels now recommend antiretroviral treatment in all patients with HIV infection, regardless of CD4 cell counts [2,3]. The strength of evidence supporting this recommendation varies by the pretreatment CD4 cell count.
This topic will address issues related to the evaluation of the chronically infected HIV-seropositive patient prior to starting therapy and other specific considerations that may influence treatment decisions in the individual patient. Indications for initiating ART in the chronically infected HIV-infected patient, relative efficacy of different regimens, patient evaluation, and laboratory monitoring are discussed elsewhere. (See "Patient monitoring during HIV antiretroviral therapy" and "Selecting antiretroviral regimens for the treatment-naïve HIV-infected patient" and "When to initiate antiretroviral therapy in HIV-infected patients".)
Issues related to the initiation of HIV therapy in the patient with acute HIV infection are discussed elsewhere. (See "Acute and early HIV infection: Treatment".)
PATIENT EVALUATION PRIOR TO INITIATION OF ANTIRETROVIRAL THERAPY
A patient’s readiness to adhere to lifelong chronic therapy must be assessed prior to treatment initiation, although the urgency to start antiretroviral therapy (ART) is greater in patients with advanced immunocompromise. Certain patient considerations and comorbidities will also affect selection of specific antiretroviral medications.
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- PATIENT EVALUATION PRIOR TO INITIATION OF ANTIRETROVIRAL THERAPY
- Psychosocial evaluation
- Physical exam
- Patient education
- LABORATORY TESTING
- General laboratories
- HIV resistance testing
- HIV tropism assay
- Screening for tuberculosis
- Genetic testing for risk of abacavir hypersensitivity
- MEDICATION CONSIDERATIONS WHEN CHOOSING ANTIRETROVIRAL THERAPY
- PATIENT CONSIDERATIONS WHEN CHOOSING ANTIRETROVIRAL THERAPY
- Methadone recipients
- Ethanol abuse
- Chronic viral hepatitis
- Cardiovascular disease
- - Dyslipidemia
- - Risk of myocardial infarction
- Renal insufficiency
- Postmenopausal women
- Immune status
- Baseline level of viremia
- Patients with tuberculosis infection
- Patients with depression
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS