Human Immunodeficiency Virus (HIV) Infection: Treatment Overview

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Treatment Overview

The most effective treatment for HIV is highly active antiretroviral therapy (HAART)—a combination of several antiretroviral medicines that aims to control the amount of virus in your body. Other steps you can take include keeping your immune system strong, taking medicines as prescribed, and monitoring your CD4+ (white blood cells) counts to check the effect of the virus on your immune system. If HIV is not treated, it eventually progresses to AIDS, the last and most severe stage of HIV infection. People with AIDS are more likely to develop certain illnesses, called opportunistic infections. Examples include tuberculosis and some cancers. These illnesses are common in people who have weakened immune systems.

Treatment to prevent infection (postexposure prophylaxis)

Health care workers who may be at risk for HIV because of an accidental needlestick or other exposure to body fluids may need medicine to prevent infection.⁵ Medicine may also prevent HIV infection in a person who has been raped or was accidentally exposed to the body fluids of a person who may have HIV.⁶ This type of treatment is usually started within 72 hours of the exposure.

Initial treatment

If you are diagnosed with HIV infection during the initial symptoms of early HIV (acute retroviral syndrome), discuss the use of highly active antiretroviral therapy (HAART) with your doctor. Information about treatment of early HIV from clinical trials is very limited but suggests that treatment of early HIV with antiretroviral medicines may have long-term benefits.⁴ But more studies need to be done.

HAART medicines that are most often used to treat HIV infection include:

• Nucleoside/nucleotide reverse transcriptase inhibitors, such as tenofovir, emtricitabine, lamivudine, and abacavir. These medicines are often combined with other medicines for best results.
• Nonnucleoside reverse transcriptase inhibitors (NNRTIs), such as efavirenz, nevirapine, or etravirine.
• Protease inhibitors (PIs), such as atazanavir, saquinavir, ritonavir, indinavir, nelfinavir, fosamprenavir, lopinavir/ritonavir, tipranavir, or darunavir.
• Fusion and entry inhibitors, such as enfuvirtide and maraviroc.
• Integrase inhibitors, such as raltegravir.

The decision whether to start HAART before your health starts to decline is complicated. Consider the potential benefits and risks of early treatment and discuss all the issues with your doctor before starting HAART.

• Benefits. Early treatment of HIV may:⁴
  • Decrease the severity of early HIV symptoms.
  • Affect the rate at which the disease progresses.
  • Reduce the rate at which the virus multiplies in the body.
  • Preserve immune system function.
  • Lower the risk of drug resistance with complete viral suppression.
  • Reduce the risk of HIV spreading.

    Note:

    Even with early treatment, the risk of HIV transmission still exists. Antiretroviral therapy cannot substitute for prevention measures, such as condom use and safer sex practices.
  • Extend life.⁷
• Risks. Early treatment of HIV may:⁴
  • Cost a lot and cause side effects.
  • Lead to the development of drug resistance to antiretroviral medicines, which may limit future treatment options.
  • Result in the need for continuing therapy indefinitely.
  • Reduce future medication options when HIV disease risk is highest.

If you do not have symptoms of HIV even though you have tested positive for the virus, you and your doctor may simply continue to watch for symptoms to occur. If you do not show any signs of disease and your CD4+ cell count is more than 350 cells per microliter (mcL), you may not require treatment. But during this time you still need regular checkups with a doctor to monitor your viral load and CD4+ cell counts—these tests measure the amount of HIV in your blood and detect how well your immune system is working. For more information, see:

Should I start antiretroviral medicines for HIV infection even though I have no symptoms?

Ongoing treatment

Ongoing treatment for HIV includes regular appointments with your doctor to monitor the amount of virus in your blood (viral load) and CD4+ cell counts. This is done with blood tests taken every 3 to 4 months that show how much virus is in your blood and how it is affecting your immune system.⁴ The results of these tests will help monitor your infection and help you make decisions about starting antiretroviral medicines.

The most effective treatment for HIV infection is antiretroviral medicines called highly active antiretroviral therapy (HAART). HAART is a combination of several antiretroviral medicines that aims to control the amount of virus in your body. It interferes with the ability of the virus to multiply and weaken your immune system.

HAART medicines that are most often used to treat HIV infection include:

• Nucleoside/nucleotide reverse transcriptase inhibitors, such as tenofovir, emtricitabine, lamivudine, and abacavir. These medicines are often combined with other medicines for best results.
• Nonnucleoside reverse transcriptase inhibitors (NNRTIs), such as efavirenz, nevirapine, or etravirine.
• Protease inhibitors (PIs), such as atazanavir, saquinavir, ritonavir, indinavir, nelfinavir, fosamprenavir, lopinavir/ritonavir, tipranavir, or darunavir.
• Fusion and entry inhibitors, such as enfuvirtide and maraviroc.
• Integrase inhibitors, such as raltegravir.

Treatment guidelines suggest the following for people with HIV:⁴

• When considering treatment, experts currently consider your CD4+ cell count and the presence or absence of symptoms much more important than your viral load.
• If your CD4+ cell count is below 350 cells per microliter (mcL), you should begin treatment to stabilize and increase your CD4+ cell count.
• If your CD4+ cell count is more than 350 cells per microliter, treatment may be offered to help keep your immune system healthy and prevent AIDS.
• If treatment is not started, your condition will be monitored with frequent CD4+ cell counts.
• If you have symptoms of HIV or AIDS, you should consider starting treatment, whatever your CD4+ cell count is.
• If you are pregnant, you should be treated to prevent your unborn baby (fetus) from becoming infected with HIV.
• If you also have hepatitis B and are starting treatment for it, you should begin treatment for HIV as well.

Should I start antiretroviral medicines for HIV infection even though I have no symptoms?

HIV: Taking antiretroviral therapy

Lifestyle choices that can help keep your immune system strong include:

• Quit smoking. People with HIV are more likely to have a heart attack or get lung cancer.^{1 2} Cigarette smoking can increase these risks even more. For more information, see the topic Quitting Tobacco Use.
• Limit your use of alcohol. Abuse of alcohol increases the rate of HIV progression. For more information, see the topic Alcohol Abuse and Dependence.
• Eat a healthy, balanced diet. Getting adequate protein and calories may help your immune system fight the HIV infection and improve your overall health. For more information, see the topic Healthy Eating.
• Exercise regularly to reduce stress and help you feel better. For more information, see the topic Stress Management.
• Do not use drugs. Intravenous (IV) drug use also increases the risk of HIV progression, though the reasons for this are not clear. The use of IV drugs makes it more difficult to follow a treatment plan and increases the risk of transmitting HIV to others. Abuse of marijuana, cocaine (crack), and other drugs also can cause HIV to progress more rapidly.

Learning how to live with HIV infection may also keep your immune system strong, while also preventing the spread of HIV to others.

• Learn more about HIV to actively share in health care decisions.
• Join a support group to share information and emotions relating to HIV.
• Practice safe sex. Use condoms whenever you have sex.
• Learn how to handle food properly to prevent the spread of food-borne infections. For more information, see the topic Food Poisoning and Safe Food Handling.

Counseling is another treatment that can improve your quality of life while you are living with HIV. It can help you manage anxiety and depression, which commonly occur with an HIV diagnosis. For more information, see the topics Anxiety and Depression.

If your partner has HIV:

• Provide emotional support. Don't be afraid to discuss the disease. Often, people with HIV need to talk.
• Protect yourself against HIV infection and other infections by not sharing needles or having unprotected sex.
• Protect your partner with HIV from other infections by staying away from him or her when you are sick.

Treatment if the condition gets worse

As HIV progresses to an established or late stage, treatment with three or more antiretroviral medicines (highly active antiretroviral therapy, or HAART) may be needed. The decision to treat your HIV infection with HAART is based on your:

• General health.
• CD4+ counts.
• Ability to follow your medicine schedule as prescribed, which is essential for successful treatment of HIV.

Treatment guidelines suggest the following for people with HIV:⁴

• When considering treatment, experts currently consider your CD4+ cell count and the presence or absence of symptoms much more important than your viral load.
• If your CD4+ cell count is below 350 cells per microliter (mcL), you should begin treatment to stabilize and increase your CD4+ cell count.
• If your CD4+ cell count is more than 350 cells per microliter, treatment may be offered to help keep your immune system healthy and prevent AIDS.
• If treatment is not started, your condition will be monitored with frequent CD4+ cell counts.
• If you have symptoms of HIV or AIDS, you should consider starting treatment, whatever your CD4+ cell count is.
• If you are pregnant, you should be treated to prevent your unborn baby (fetus) from becoming infected with HIV.
• If you also have hepatitis B and are starting treatment for it, you should begin treatment for HIV as well.

Should I start antiretroviral medicines for HIV infection even though I have no symptoms?

HIV: Taking antiretroviral therapy

When HIV has progressed to AIDS, treatment is recommended.⁴

Measuring the effectiveness of medicine therapy

Your doctor will measure the effectiveness of your medicine treatment plan by monitoring your CD4+ cell count and viral load.

Treatment failure

If your viral load does not drop as expected, or your CD4+ cell count starts to fall, your doctor will try to identify why the medicines are not working.

There are two main reasons that treatment fails:

• The HIV has become drug-resistant. The medicines no longer effectively control virus multiplication nor protect the immune system. Tests can determine whether drug resistance has occurred. You may need a different combination of medicines.
• You did not take your medicine as prescribed. If you have difficulty taking the medicines exactly as prescribed, talk with your doctor.

Even though HIV treatment is now more successful at prolonging life, when HIV progresses to AIDS, certain types of severe infections develop that can lead to death. Left untreated, AIDS is often fatal within 18 to 24 months after it develops. Death may occur sooner in people who rapidly progress through the stages of HIV or in young children.

Many important end-of-life decisions can be made while you are active and able to communicate your wishes. For more information, see the topic Care at the End of Life.

What To Think About

Denial, fear, and depression are common reactions to a diagnosis of HIV. Don't be afraid to ask for the emotional support you need. If your family and friends are unable to provide you with support, a professional counselor can help.

Treatment options for HIV are changing often, and experts debate which treatment is best. Talk to your doctor about the treatment that may be best for you.

Alternative and complementary treatments for HIV need to be carefully evaluated. Some people with HIV may use these types of treatment to help with fatigue and weight loss caused by HIV infection and reduce the side effects caused by HAART. Some alternative treatments for HIV or other illnesses (such as St. John's wort) may interfere with your HIV medicines. It is important to discuss alternative treatments with your doctor before trying them.

If you are a caregiver of a person whose HIV has progressed, the following information may help you:

• How to provide good home care, such as giving medicines and learning what to do in case of an emergency
• Taking care of yourself, such as sharing your frustrations with others who share a similar experience

Last updated:	May 08, 2008
Author:	Maria G. Essig, MS, ELS
Reviewed By:	Caroline S. Rhoads, MD - Internal Medicine, Peter Shalit, MD, PhD - Internal Medicine
Editors:	Susan Van Houten, RN, BSN, MBA, Tracy Landauer