New Approaches to Using Antiretroviral Therapy for the Management of Hiv Infection

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Abstract
Objective: To review the changes that have occurred in the past 2 years in the management of HIV infection with antiretroviral agents by contrasting the 1994 with the 1996 Guidelines. Data Sources: Conference proceedings, clinical experience of the author and her colleagues, and English-language articles from the body of scientific literature identified via MEDLINE, AIDSLINE, and Current Contents served as data sources. Data Synthesis: Current antiretroviral management strategies include movement away from using zidovudine monotherapy, institution of combination antiretroviral therapy earlier in HIV disease, the use of newer agents such as lamivudine, protease inhibitors (i.e., saquinavir, ritonavir, indinavir), and nonnucleoside reverse transcriptase inhibitors (i.e., nevirapine, delavirdine), prevention of vertical transmission with zidovudine, and use of HIV-1 RNA determinations (viral load) to guide the initiation and alteration of antiretroviral therapy. These strategies represent a dramatic change from the 1994 Guideline, which recommended zidovudine monotherapy in nonpregnant and pregnant individuals whose CD4 cell counts were less than 500 cells/mm3, when many of the newer agents were not available and the assays to determine viral load were strictly investigational. Conclusions: The difference between the 1994 and 1996 Guidelines is substantial. It is likely that within a year's time, newer information on pathogenesis and antiretroviral agents in development will be known and further management strategies will need to be disseminated. Until then, the International AIDS Society — USA Guidelines for 1996 should be followed as the standard of care.