Human Immunodeficiency Virus (HIV) (cont.)
Eric S. Daar, MD
Dr. Daar received his undergraduate degree from UCLA and medical degree from Georgetown University School of Medicine. He completed an internship and residency in internal medicine at Cedars-Sinai Medical Center and his clinical and research fellowship in infectious diseases at Cedars-Sinai Medical Center and UCLA.
In this Article
- Human immunodeficiency virus (HIV) facts
- What is the history of HIV, and when was HIV discovered? HIV vs. AIDS
- What tests are used in the diagnosis of HIV?
- How is HIV spread (transmitted)?
- What are symptoms and signs of HIV infection and AIDS in men, women, and children?
- What happens after an exposure to the blood or genital secretions of an HIV-infected person?
- What laboratory tests are used to monitor HIV-infected people?
- What are HIV treatments and medications? What are the key principles in managing HIV infection?
- When should antiviral therapy be started?
- What is the initial therapy for HIV?
- What are nucleoside and nucleotide analogue reverse transcriptase inhibitors (NRTIs)?
- What are nonnucleoside analogue reverse transcriptase inhibitors (NNRTIs)?
- What are protease inhibitors?
- What are fusion inhibitors?
- What is a CCR5 antagonist?
- What is an integrase strand transfer inhibitor?
- What HIV drugs are in development?
- What are side effects of HIV therapy?
- What happens if the patient's viral load increases while on HIV therapy?
- What are the risks of missing doses or stopping antiviral therapy?
- Should patients with the flu- or mono-like illness of primary HIV infection be treated?
- What about treatment for HIV during pregnancy?
- What can be done for people who have severe immunosuppression?
- What is the future for HIV-infected individuals with regards to treatment simplification and cure research?
- What is in the future for preventing HIV transmission?
- HIV-AIDS FAQs
- Find a local Infectious Disease Specialist in your town
When should antiviral therapy be started?
Guidelines for starting antiviral therapy have been proposed by panels of experts from several groups, including the DHHS (http://www.aidsinfo.nih.gov) and IAS-USA. There are similar guidelines for treatment throughout Europe and by the World Health Organization for treatment in resource-limited countries. Until recently a recommendation supporting the start of therapy in those with CD4 cells greater than 500 cells was based upon evidence that ongoing viral replication, even in the setting of high CD4 cell counts, may be associated with damage to the brain, kidneys, heart, and possibly even liver. Along with this rationale, it was clear that newer regimens were easy to take, including a growing number of one-pill-per-day options, with minimal side effects. Another compelling argument that can be made for early therapy is the ability to reduce the risk of transmission to uninfected partners. A study called HPTN 052 demonstrated that amongst couples where one person is HIV-infected and the other is not, those who were on antiretroviral therapy were 96% less likely to transmit HIV to their uninfected partner than those not on treatment. Finally, a large study was recently reported that demonstrated unequivocally that starting therapy even with a CD4 cell count of greater than 500 cells/mm3 was associated with less risk of disease progression than waiting until CD4 cells were less than 350 cells/mm3. This study was called the START study and demonstrated a major reduction in disease progression with early therapy with virtually no increased risk for side effects. Based upon START, HPTN 052 and other accumulated data, currently all major guidelines around the world, including those of the World Health Organization recommend that antiretroviral therapy be initiated in all HIV-infected patients at the time of diagnosis. It is worth noting that these recommendations for universal treatment of HIV-infected patients will be limited by resources available for antiviral treatment in resource-limited countries.
Before starting treatment, patients must be aware of the short- and long-term side effects of the drugs, including the fact that some long-term complications may not be known. Patients also need to realize that therapy is a long-term commitment and requires consistent adherence to the drugs. In addition, clinicians and patients should recognize that depression, feelings of isolation, substance abuse, and side effects of the antiviral drugs can all be associated with the failure to follow the treatment program.
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