据8月6日《美国医学协会期刊》（JAMA）上的一篇文章披露，对最近数据的评估使得有关方面更新了针对成人的人类免疫缺陷病毒（HIV）感染抗逆转录病毒治疗的方针和建议。

纽约哥伦比亚大学的Scott M. Hammer和International AIDS Society–USA Panel在JAMA的有关HIV/AIDS的媒体简报会上向该委员会介绍了这些建议。

Hammer及小组的成员分析了来自过去2年新的实地数据并为抗逆转录病毒治疗的关键领域提供了指导方针，其中包括何时开始治疗、初始疗法的选择、病人监护及在治疗失败时的应对方法。

何时开始抗逆转录病毒的治疗

新的数据及考量支持当CD4 细胞计数下降至低于350/μL之前即开始进行治疗的做法。对CD4 细胞计数在350/μL或以上的病人，病人是否做好接受治疗的准备、药物的相互作用、对病人是否能够坚持既定疗法的挑战、药物毒性及成本等因素皆需在决定是否开始治疗之前给予考虑。

CD4细胞计数的快速下降（即每年超过100/μL）、血浆HIV-1 RNA浓度大于10万拷贝/mL、心血管疾病的风险因子以及同时存在的某些其它疾病（如：同时发生活动性乙型肝炎或丙型肝炎病毒的感染及HIV相关性肾病）都必须在决定是否开始对CD4 细胞计数在350/μl的病人进行治疗时给予考虑。

开始的时候采用什么样的抗逆转录病毒疗法

文章的作者写道，初始的疗法必须个体化，特别是当病患还有其它的同时存在的疾病时尤其是如此，但该疗法应该包括efavirenz 或是一个由ritonavir增进的蛋白酶抑制剂加上2个核苷（或核苷加上核苷酸）逆转录酶抑制剂（nRTIs）。在初始疗法中所建议的nRTIs是tenofovir/emtricitabine 或abacavir/lamivudine的固定剂量组合。疗法的简单程度、药片的数量、病人对药物的耐受程度、病人是否希望怀孕、药物相互作用及病毒对主要药物的抵抗性都可能会影响病人在这两种建议的选项中做出何种选择。

病人的监护

抗逆转录病毒疗法的目标是减少并维持血浆HIV-1 RNA的浓度在低于50拷贝/mL的水平。血浆HIV-1 RNA水平在治疗开始时或在病毒学反应失败时应该进行频繁的监测（例如：在第2、4、8周及此后的每四周时）直至其水平达到化验可检测到的下限之下为止，此后将对病人进行规律性的监测（如每年进行3-4次的监测）。对某些病人需要进行药物抵抗性的基因型测试。在开始对病人进行治疗之前或在随访之前，需要对病人的其它情况进行恰当的评估并对药物的毒性进行监测。

治疗的更改

如果对病人的某种初始的非核苷逆转录酶抑制剂（NNRTI）或以ritonavir-增强的蛋白酶抑制剂为基础的疗法失败的话，需要对此病人给予早期的治疗，理想的情况是使用3种有充分活性的药物。对出现多种药物抵抗性的病例，则应该使用3种活性的药物，只要有可能的话就应该包括使用新类型的药物。

恰当地使用诸如raltegravir（一种整合酶链转移抑制剂）、maraviroc（一种CCR5拮抗剂）及etravirine（一种“第二代”NNRTI）等新的药物加上较老的药物可以帮助病人达到将血浆HIV-1 RNA水平维持在50拷贝/ml的目标，即使这些病人已经有过高度的治疗经验及出现了对多种药物有抵抗性的病毒。

文章的作者写道，尽管人们在HIV感染的治疗上取得了进展，“对该疾病的处理仍然受到药物毒性、病人对既定治疗方案是否能坚持、与药物和HIV感染本身相关的临床表现及耐药性的威胁等的挑战。” （绿谷生物网 ibioo.Com)

JAMA，300(5):555-570，Scott M. Hammer，Paul A. Volberding

Antiretroviral Treatment of Adult HIV Infection

Scott M. Hammer, MD; Joseph J. Eron Jr, MD; Peter Reiss, MD, PhD; Robert T. Schooley, MD; Melanie A. Thompson, MD; Sharon Walmsley, MD; Pedro Cahn, MD; Margaret A. Fischl, MD; Jose M. Gatell, MD, PhD; Martin S. Hirsch, MD; Donna M. Jacobsen, BS; Julio S. G. Montaner, MD; Douglas D. Richman, MD; Patrick G. Yeni, MD; Paul A. Volberding, MD

JAMA. 2008;300(5):555-570.

Context  The availability of new antiretroviral drugs and formulations, including drugs in new classes, and recent data on treatment choices for antiretroviral-naive and -experienced patients warrant an update of the International AIDS Society–USA guidelines for the use of antiretroviral therapy in adult human immunodeficiency virus (HIV) infection.

Objectives  To summarize new data in the field and to provide current recommendations for the antiretroviral management and laboratory monitoring of HIV infection. This report provides guidelines in key areas of antiretroviral management: when to initiate therapy, choice of initial regimens, patient monitoring, when to change therapy, and how best to approach treatment options, including optimal use of recently approved drugs (maraviroc, raltegravir, and etravirine) in treatment-experienced patients.

Data Sources and Study Selection  A 14-member panel with expertise in HIV research and clinical care was appointed. Data published or presented at selected scientific conferences since the last panel report (August 2006) through June 2008 were identified.

Data Extraction and Synthesis  Data that changed the previous guidelines were reviewed by the panel (according to section). Guidelines were drafted by section writing committees and were then reviewed and edited by the entire panel. Recommendations were made by panel consensus.

Conclusions  New data and considerations support initiating therapy before CD4 cell count declines to less than 350/µL. In patients with 350 CD4 cells/µL or more, the decision to begin therapy should be individualized based on the presence of comorbidities, risk factors for progression to AIDS and non-AIDS diseases, and patient readiness for treatment. In addition to the prior recommendation that a high plasma viral load (eg, >100 000 copies/mL) and rapidly declining CD4 cell count (>100/µL per year) should prompt treatment initiation, active hepatitis B or C virus coinfection, cardiovascular disease risk, and HIV-associated nephropathy increasingly prompt earlier therapy. The initial regimen must be individualized, particularly in the presence of comorbid conditions, but usually will include efavirenz or a ritonavir-boosted protease inhibitor plus 2 nucleoside reverse transcriptase inhibitors (tenofovir/emtricitabine or abacavir/lamivudine). Treatment failure should be identified and managed promptly, with the goal of therapy, even in heavily pretreated patients, being an HIV-1 RNA level below assay detection limits.