Significant challenges facing HIV practitioners.

The care of patients with HIV infection has become possibly the most rewarding and yet most challenging specialty in medicine. The advances over the past 10–15 years have been extraordinary and probably are unrivaled by those for the treatment of any other contemporary disease. However, treatment-related decisions are complex, and the penalties for mistakes are harsh. There are now 24 antiretroviral drugs, with 2 new agents introduced in 2007. PubMed lists 16000 articles about HIV treatment that have been published within the past year. It is becoming impossible to keep up. This supplement to the Journal of Infectious Diseases discusses 5 areas that are central to HIV care and that are characterized by especially challenging issues. Authoritative reviews are provided regarding the management of initial therapy, failed therapy, adherence issues, hepatic coinfection, and neurological complications. Martin S. Hirsch [1] reviews the lat-est information about when to start an-tiretroviral therapy (ART) during chronic infection, as well as the drugs to use and whether to start therapy during primary infection and what to use in the initial regimen. He also addresses the value of new and investigational therapies for treatment naive patients. Joseph J. Eron [2] examines issues related to treatment-experienced patients, such as when to change therapy, what to change to, the use of resistance testing, and when to use or await new agents. Eron also presents the mounting evidence against the use of structured treatment interruptions , primarily on the basis of the results of the Strategies for Management of Antiretroviral Therapy study [3, 4]. The most common cause of viral rebound is suboptimal adherence to ART. David R. Bangsberg [5] summarizes his work showing the distinctive differences in virologic and resistance outcomes based on patterns of adherence to nonnucleoside reverse-transcriptase inhibitor (NNRTI), protease inhibitor (PI), and boosted-PI regimens. He also addresses methods for the detection of declining adherence before viral rebound and in time to prevent HIV resistance. Of particular importance is understanding that the commonly quoted " 95% rule " [6] is correct only for unboosted PIs with a short half-life, such as nelfinavir. Specifically, adherence demands are much less restrictive with NNRTI and boosted-PI regimens [7]. With the advent of increasingly effective ART, liver disease due to chronic hepatitis B virus (HBV) and/or hepatitis C virus (HCV) infection has become the second most common cause of death among persons with HIV infection [8]. The management of HIV …