Potential Areas for Future Revisions

In future revisions, reflecting changes in the management and care of HIV infection will be important. Areas of particular concern for future assessments include long-term adverse events of treatment, newly emerging clinical manifestations of HIV infection, and consequences of nonadherence and resistance to antiretroviral therapies. SSA ought to monitor these issues and others that may potentially be added to the HIV Infection Listings as appropriate.

First, the long-term impacts of HIV and its treatment are still largely unknown because HIV disease did not become a chronic, manageable infection until combination antiretroviral therapies were widely introduced in the mid-1990s. Identifying all the effects from antiretroviral therapies could take many years as people use established and new combinations of them. Adverse effects of treatment with the potential to prevent people from performing daily activities will continue to evolve and may need to be addressed in the HIV Infection Listings.

Second, as discussed in previous chapters, HIV infection affects multiple body systems. With the evolution into a chronic disease with improved longevity, new disease conditions may arise that could cause severe impairments. For example, the impact of HIV on increasing risk of cardiovascular disease was not recognized until recently, and the impact of HIV infection on neurocognitive function with long-term survival is largely unknown. It is also possible that some impairments may also lessen or even disappear over time as new therapies are developed.

Finally, because HIV is perpetually replicating and evolving, complications of nonadherence and resistance is another issue to consider in future revisions of the HIV Infection Listings. Resistance can result from a number of causes, such as nonadherence and individual pharmacodynamics, which can lead to severe adverse health outcomes similar to those that occurred before widespread use of combination antiretroviral therapy. As the nature of treatment evolves, new patterns of resistance are likely to emerge. Transmitted resistance may also become an important factor to consider due to its potential to reduce treatment options.

Revision Process

SSA will need to create HIV Infection Listings that are both flexible enough and broad enough to reflect advances in HIV therapy. Although additions and revisions to the Listings will likely be needed, removal of some sublistings may also become necessary. The Listings also will need periodic revision to add, remove, or modify criteria to maintain its currency.

The committee understands that a process is in place for SSA to revise all the listings. This process typically involves evaluating an entire body sys-



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