{"id":1330,"date":"2011-01-11T18:04:39","date_gmt":"2011-01-11T23:04:39","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=1330"},"modified":"2015-06-04T15:24:08","modified_gmt":"2015-06-04T19:24:08","slug":"revised-dhhs-guidelines-and-some-thoughts-on-guidelines-in-general","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/revised-dhhs-guidelines-and-some-thoughts-on-guidelines-in-general\/2011\/01\/11\/","title":{"rendered":"Revised DHHS Guidelines, and Some Thoughts on Guidelines in General"},"content":{"rendered":"<p><img loading=\"lazy\" decoding=\"async\" class=\"alignright size-full wp-image-1331\" title=\"blizzard of 78 boston\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2011\/01\/blizzard-of-78-boston1.jpg\" alt=\"blizzard of 78 boston\" width=\"377\" height=\"207\" \/>As another major snow storm <a href=\"http:\/\/boston.cbslocal.com\/2011\/01\/11\/the-storm-is-nearing\/\" target=\"_blank\">barrels in on us<\/a>, you might have time over the next 24-48 hours to make some hot chocolate, throw some logs on the fire, and read the spanking-new 2011 Department of Health and Human Services (DHHS) HIV Treatment Guidelines, just posted <a href=\"http:\/\/www.aidsinfo.nih.gov\/Guidelines\/GuidelineDetail.aspx?MenuItem=Guidelines&amp;Search=Off&amp;GuidelineID=7&amp;ClassID=1\" target=\"_blank\">here<\/a> on the AIDSinfo web site.<\/p>\n<p>(Disclosure: I&#8217;m on the Guidelines panel &#8212; opinions that follow are mine, and do not represent the panel.)<\/p>\n<p>There are no major changes &#8212; befitting a relatively quiet era in HIV treatment &#8212;\u00a0but here are a few highlights:<\/p>\n<ul>\n<li>Frequency of CD4 determinations can be decreased in stable patients who are virologically suppressed, down to every 6-12 months. \u00a0This makes abundant sense for multiple reasons: \u00a01) high variability with higher counts; 2) no proven strategy for managing decreases in CD4 with virologic suppression; 3) reduces potential anxiety for unanticipated results; 4) saves money.<\/li>\n<li>Virologic failure criterion has been shifted to a confirmed viral load &gt; 200 cop\/mL; this is in response to the higher rates of lower level viremia using the newer assays. \u00a0I&#8217;ve written about this a <a href=\"http:\/\/blogs.nejm.org\/?s=taqman&amp;fulltext=taqman&amp;x=0&amp;y=0&amp;searchPointer=This+Blog\" target=\"_blank\">couple of times<\/a> &#8212; it takes some time learning not to panic for a viral load of &#8220;121&#8221; or even better, &#8220;49&#8221;, but it can be done.<\/li>\n<li>Some minor tweaks on the &#8220;what to start&#8221; section.<\/li>\n<li>Timing of ART initiation with TB updated to reflect results from <a href=\"http:\/\/aids-clinical-care.jwatch.org\/cgi\/external_ref?access_num=20181971&amp;link_type=MED\" target=\"_blank\">SAPiT<\/a> and <a href=\"http:\/\/pag.aids2010.org\/Abstracts.aspx?AID=17091\" target=\"_blank\">CAMELIA<\/a> studies.<\/li>\n<li>A new format for adverse event tables.<\/li>\n<\/ul>\n<p>Some other points worth mentioning: \u00a01) The whole operation could not happen without the incredible coordination and support of \u00a0Alice Pau, PharmD, from the NIH; 2) the PDF is 166 pages long, a major test for even industrial-strength staplers; and 2) An HTML version is in the works.<\/p>\n<p>And in case you haven&#8217;t had enough of Guidelines recently, here&#8217;s a <a href=\"http:\/\/archinte.ama-assn.org\/cgi\/content\/short\/171\/1\/18\" target=\"_blank\">somewhat critical review<\/a> of the IDSA Guidelines &#8212; the ones <a href=\"http:\/\/blogs.nejm.org\/index.php\/thursday-thienamycins\/2011\/01\/06\/\" target=\"_blank\">I praised earlier in the week<\/a>. \u00a0The complaint? \u00a0Not enough recommendations backed by &#8220;Level I&#8221; evidence, i.e., a randomized clinical trial.<\/p>\n<p>Well, I for one remain a fan of these IDSA Guidelines, and for the following reason: \u00a0Patient care is frequently a chaotic, messy business, and the expectation that all clinical scenarios will be addressed by prospective randomized trials is invariably going to be disappointed.<\/p>\n<p>So even though we would like to have an evidenced-based approach to every decision, <em>it&#8217;s never going to happen<\/em>.<\/p>\n<p>Which means that getting a bunch of smart, experienced, and detail-obsessed clinicians together to decide what&#8217;s best is pretty darn valuable, if you ask me.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>As another major snow storm barrels in on us, you might have time over the next 24-48 hours to make some hot chocolate, throw some logs on the fire, and read the spanking-new 2011 Department of Health and Human Services (DHHS) HIV Treatment Guidelines, just posted here on the AIDSinfo web site. (Disclosure: I&#8217;m on [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[4,5,8],"tags":[77,273,486,630],"class_list":["post-1330","post","type-post","status-publish","format-standard","hentry","category-hiv","category-infectious-diseases","category-patient-care","tag-antiretroviral-therapy","tag-dhhs-guidelines","tag-idsa-guidelines","tag-mrsa"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/1330","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=1330"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/1330\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=1330"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=1330"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=1330"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}