June 25, 2008
The goal of antiretroviral therapy is to prevent HIV from replicating (making more copies of itself). The antiretroviral drugs that are currently available belong to four classes: nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), and entry inhibitors.
Each class of antiretroviral drugs fights HIV in a unique way. NRTIs (such as AZT and tenofovir) and NNRTIs (including Sustiva and nevirapine) interfere, in different ways, with the production of reverse transcriptase, a protein the virus must use in order to replicate. PIs (such as Kaletra and saquinavir) interfere with HIV's use of the protease enzyme, another component essential to its replication. Finally, the entry inhibitor Fuzeon prevents HIV from entering cells and making more copies of the virus.
Highly active antiretroviral therapy (HAART) combines three or more drugs from among the four classes (e.g., two NRTIs and one PI). This is very important, because the virus in an HIV-positive person's body can change after exposure to antiretroviral medications and become resistant to certain drugs, making those drugs less effective for that particular person. A treatment regimen that involves taking medications from more than one class at a time has a built-in safety net: if the virus becomes resistant to a drug from one class, then drugs from the other classes can continue to fight the virus.
In addition, some drugs are now combined in one pill; for example, Combivir, Trizivir, Epzicom, and Truvada combine two or more NRTIs in a single pill. As a result, some treatment regimens require patients to take as few as four pills per day, making it easier for HIV-positive people to adhere to their drug regimens.
HAART has been credited with significantly improving the length and quality of life for many people living with HIV/AIDS. In addition, new drug classes and medications to fight HIV are currently being developed so that people with drug-resistant HIV have more treatment options.
In addition, the U.S. Department of Health and Human Services (DHHS) issues guidelines for the medical management of HIV infection and issues surrounding HIV infection, including treatment in adults, adolescents, and children. Learn more about these guidelines. (http://aidsinfo.nih.gov/Guidelines/Default.aspx?MenuItem=Guidelines).
Project Inform -- a national HIV treatment organization based in San Francisco -- also provides excellent information and materials on a range of HIV treatment issues. In addition, these treatment links can also help you better understand your treatment options and make informed choices about your HIV care.
It is important for people who are HIV positive to seek regular care from a physician. Such care will provide you with important information about the progression of your disease and will assist you in deciding whether to start taking antiretroviral medications.
The first step in getting care for HIV/AIDS is to choose a physician. Obviously, it is best to find a doctor who is familiar with treating HIV disease. Doctors who don't specialize in HIV treatment are not likely to keep up with rapidly changing developments in drug therapies and treatment strategies.
It is always okay to get a second opinion if you have doubts about a doctor's approach to treating HIV. In fact, some people "interview" several doctors before making a permanent selection.
Your overall health and HIV disease progression are reflected in the health of your immune system. HIV impairs immune function by infecting certain white blood cells -- called CD4 cells -- that normally help keep the immune system working. HIV uses CD4 cells as a tool to replicate, or make copies of itself: the virus enters the CD4 cell, gives it "instructions" for making more HIV instead of helping the immune system, and finally destroys the CD4 cell. When CD4 cells are lost, the immune system is weakened.
Even for an HIV positive person who is asymptomatic (without symptoms), it is very important to monitor the immune system in order to make the best choices about treatment. Two tests are used to monitor immune health:
Another important diagnostic tool is resistance testing, which helps determine whether an HIV-positive person's specific virus is resistant to certain anti-HIV medications, rendering those medications ineffective for that person. With this knowledge, the individual and his or her physician can avoid those medications when customizing a treatment regimen. There are two different resistance tests:
Other tests and general diagnostic tools, such as CBC (complete blood count), help physicians gain more information about how the immune system is responding, in terms of both disease progression and treatment.
People with health insurance can usually get most of these tests through private doctors, clinics, or hospitals. For people without health insurance, programs at community clinics and county public health departments often provide some or all of these tests at reduced cost or free of charge.
There are varying opinions on when is the best time to begin HIV treatment; however, the federal Centers for Disease Control and Prevention (CDC) recommends starting highly active antiretroviral therapy (HAART) if you have a history of opportunistic infections (OIs) or other severe symptoms of HIV disease, or if your CD4 count is lower than 200/mm3. The CDC also suggests that you may want to consider starting HAART if your CD4 count is lower than 350/mm3 and your viral load is greater than 100,000 copies/mL, even if you are not experiencing symptoms of HIV disease. Preventive treatment (prophylaxis) against Pneumocystis carinii pneumonia and other OIs is recommended when CD4 count indicates severe immune suppression.
Treatment is a personal choice and when or if you start can depend on a variety of other health issues. It is helpful to find a doctor you trust who can help you determine what treatment strategy makes the most sense for you.
These treatment links can help you make informed decisions about starting antiretroviral therapy.
HIV positive people with suppressed immune systems may experience illnesses that are not usually seen (or do not cause symptoms) in people with healthy immune systems; these illnesses are called "opportunistic infections" (OIs). Some of the most common OIs include:
Many OIs can be prevented or treated successfully. This has substantially increased the longevity and quality of life for people living with HIV/AIDS. The U.S. Department of Health and Human Services (DHHS) issues guidelines for the medical management of HIV infection and issues surrounding HIV infection, including treatment and prevention of OIs. To learn more about these guidelines for treating OIs, go to www.projectinform.org/info/ois/index.shtml or www.aidsinfo.nih.gov/guidelines/.
Clinical trials test drugs that are promising but have not yet been proven effective. Each new drug must go through several phases of clinical trials to determine toxicity (whether the drug is harmful) and efficacy (whether the drug is effective).
Most clinical trials have strict eligibility rules. Eligibility criteria often include viral load, CD4 count, current or previous symptoms and opportunistic infections, antiretroviral drugs taken in the past and current drug regimen.
It is important for people who choose to participate in a clinical trial to feel fully informed about the trial and comfortable with its rules, as well as with the physicians and researchers who are carrying it out. Participants should also know they have the right to leave a clinical trial at any time and for any reason.
Learn more about clinical trials at http://aidsinfo.nih.gov/ClinicalTrials/ClinicalTrial.aspx?menuItem=ClinicalTrials or www.aidsmeds.com/lessons/clinicaltrials.htm, or by reading this BETA article.
Many HIV-positive people believe contemporary or "Western" medicine is most appropriate for treating illness. Others feel that "alternative" medicine is more appropriate, or that it complements Western treatments. Complementary and alternative approaches include herbal or Chinese medicine, holistic medicine, spirituality, body work, relaxation techniques, and many others. For some, a combination of Western and alternative approaches helps the body fight toxicity and immune suppression.
Natural approaches to wellness are as diverse as each person's cultural background, life experience, and individual metabolism. As with other treatment considerations, it is best to seek advice from a doctor you trust. Also, be sure to inform your doctor of any alternative medicines or supplements (including vitamins and herbs) you are taking, as these may affect how your body responds to a particular anti-HIV medication.
With HIV disease, the immune system is under great stress. Eating a balanced diet that includes a variety of foods can help strengthen the immune system and maintain optimum body weight. A balanced diet is based on selecting foods from the four basic food groups: proteins, fruits and vegetables, breads and grains, and dairy products.
People with HIV disease are encouraged to eat a balanced diet high in protein and calories, which the immune system requires to fight illness. Most people with symptoms of HIV disease need up to 3,500 calories per day. They may also have one and a half to two times the normal protein requirement of other people -- as much as 130 grams per day. For an overview of nutrition for people with HIV, read this Winter 2006 BETA article.
Because some AIDS-related conditions affect the ability to eat and some treatments have dietary restrictions, it is important to consult a physician and an HIV-knowledgeable dietitian to ensure adequate nutrition. The Association of Nutrition Services Agencies provides nutrition education for people with HIV/AIDS at www.aidsnutrition.org.