Objective New information warrants updated recommendations for the 4 central issues
in antiretroviral therapy: when to start, what drugs to start with, when to
change, and what to change to. These updated recommendations are intended
to guide practicing physicians actively involved in human immunodeficiency
virus (HIV)– and acquired immunodeficiency syndrome (AIDS)–related
Participants In 1995, physicians with specific expertise in HIV-related basic science
and clinical research, antiretroviral therapy, and HIV patient care were invited
by the International AIDS Society-USA to serve on a volunteer panel. In 1999,
others were invited to broaden international representation. The 17-member
panel met regularly in closed meetings between its last report in 2000 and
April 2002 to review current data. The effort was sponsored and funded by
the International AIDS Society-USA, a not-for-profit physician education organization.
Evidence and Consensus Process The full panel was convened in late 2000 and assigned 7 section committees.
A section writer and 3 to 5 section committee members (each panel member served
on numerous sections) identified relevant evidence and prepared draft recommendations.
Basic science, clinical research, and epidemiologic data from the published
literature and abstracts from recent (within 2 years) scientific conferences
were considered by strength of evidence. Extrapolations from basic science
data and expert opinion of the panel members were included as evidence. Draft
sections were combined and circulated to the entire panel and discussed in
a series of full-panel conference calls until consensus was reached. Final
recommendations represent full consensus agreement of the panel.
Conclusions Because of increased awareness of the activity and toxicity of current
drugs, the threshold for initiation of therapy has shifted to a later time
in the course of HIV disease. However, the optimal time to initiate therapy
remains imprecisely defined. Availability of new drugs has broadened options
for therapy initiation and management of treatment failure, which remains
a difficult challenge.