Human Immunodeficiency Virus (HIV) Treatment

  • Treatment

    HIV treatment has been revolutionized since 1996 with the development of protease inhibitors, a type of highly active antiretroviral therapy (HAART). Prior to 1996, only AZT was available, and it only slightly prolonged life. Since the newer types of medication that effectively fight the virus for many years have become available, life expectancy for people with HIV has soared. The newer drugs are taken in combination to best fight the virus. Newer versions of the drugs may require only 1 or 2 combination pills/day. People taking HAART require frequent monitoring and blood draws, and must do their best to take their medication as prescribed without missing a single dose. Most doctors start patients with HIV infection on HAART when their CD4 is about 300-350 cells per mL; this approach does vary, however. Choosing the best combination pill (s) for you is complex and should be individualized. If you have HIV, you should talk to your doctor about available options. People with HIV who develop opportunistic infections require proper treatment. It is important for you to discuss any unusual symptoms that might require care with your doctor.

    In severe cases late in the course of the disease, people living with HIV may need urgent care for respiratory failure or severe neurological complications. Urgent care is most commonly required in the later stages of HIV disease when the immune system becomes so weakened that infections are difficult to keep under control. Acute respiratory failure accounts for between 50% and 75% of HIV-related intensive care admissions, and often involves the use of mechanical respirators. A patient experiencing respiratory failure may go to the emergency room initially, but in many cases will end up in an intensive care unit for a prolonged period of time.

    Late-stage HIV infection can cause deterioration in neurological function, and may result in lethargy, coma, seizures, and respiratory failure. Many patients who are admitted for neurological symptoms require mechanical ventilation; many die from profound coma.

    Good nutrition is critical for people living with HIV. Chronic infection with HIV increases a person's metabolism, requiring a high intake of calories just to maintain existing weight. At the same time, many people living with the virus lose their appetite, or experience illnesses that can cause diarrhea or reduce the ability of the intestines to absorb nutrients. Most physicians recommend high-protein, low-fat, nutrient-rich diets with fresh fruits, vegetables, and whole grains. Small, frequent, regular meals are easier to digest than less frequent, larger meals.

    Physical exercise can improve the health of people living with HIV. Several studies suggest that exercise may improve the health of the immune system by raising CD4 counts and reducing the number of opportunistic infections. If you have symptomatic HIV disease or are recovering from an HIV-related illness, check with your physician before starting a new exercise program.

    Your doctor is the best source of information on the drug treatment choices available to you.

    Maintaining good mental health is important for people living with HIV. Depression, anxiety, and stress are common among HIV-positive people. Signs of depression occur in an estimated 20% to 40% of people living with the virus, which is of particular concern because people who are depressed often stop taking their medication.

    If you are experiencing signs of depression (e.g., fatigue, loss of appetite, loss of interest in your work or leisure activities), your doctor or counselor may be able to help. In addition, depressed people should not take efavirenz, as it has been associated with a risk of suicide.

    Treatment for substance abuse can improve the health of people living with HIV. Putting an end to alcohol, cocaine, heroin, and other drug abuse can both improve overall health and strengthen the immune system. If you smoke cigarettes, quitting can improve stamina, restore lung function over time, and reduce the risk of certain infections associated with HIV. Quitting can also reduce the risk of smoking-related illnesses such as emphysema and lung cancer.

    If you are diagnosed with HIV, talk to your doctor about the vaccinations you should receive to help prevent infectious diseases. Current recommendations include vaccination against pnuemonia, hepatitis B, and yearly flu shot. If your CD4 count drops below 200 cells per mL, your doctor will prescribe medication that can help prevent opportunistic infections. Subsequently, if your CD4 count falls below 100, your doctor will prescribe additional drugs to help prevent infections for which you are susceptible. Intravenous drug users who simultaneously take HIV medication have a risk of adverse drug interactions that can put them at risk for suicide. Therefore, substance abuse treatment is especially important for HIV-positive individuals.

    Acupuncture, herbal remedies, spiritual approaches, homeopathy, and non-FDA-approved drugs are sometimes used by people with HIV. Because HIV infection is a disease for which conventional medicine has no cure, many people with the virus seek out alternative treatments. Although some remarkable examples of success have been reported, few alternative therapies have been studied in rigorously controlled clinical trials.

    Children with HIV have special needs. The fundamental goals of HIV treatment are the same for children as for adults, but the treatment plan must be customized for each child's developmental stage and immune status.

    The rate at which children metabolize drugs changes as they grow and their organs mature. Therefore, a physician must closely monitor how the metabolism of the drugs changes in the child over time, and modify therapy accordingly.

    Children, and especially infants, have less developed immune systems than do adults, putting them at a greater risk for rapid disease development. In addition, blood tests that measure the progression of the disease are not very accurate for infants. Despite the adverse events and unknown long-term effects, however, early aggressive therapy is recommended for infants.

    Infants cannot swallow the pills that are sometimes the only available form for a given HIV medication. Very young children also have problems taking their drugs, as the drugs often taste unpleasant, or must be taken in pill form. Therefore, doctors must be vigilant when treating children with HIV.

    Older adults are often an invisible at-risk population for HIV infection. More than 10% of new AIDS cases in the U.S. each year occur in people over the age of 50; however, few screening or prevention programs are targeted to older adults. As a result, most older adults infected with the virus are first diagnosed at later stages of the disease.

    It is important for people over the age of 50 to continue to protect themselves from HIV infection. Even though pregnancy is no longer a concern after menopause, condom use is important because it can reduce the risk of contracting the virus or other sexually transmitted diseases.

    Most people infected with HIV will go on to develop AIDS, but new drug treatments can slow the progression. An estimated 95% to 100% of people infected with HIV will go on to develop AIDS, but the time from infection to late-stage disease varies widely. Before the availability of effective treatments, a person with HIV had a 1% to 2% chance of developing AIDS within the first few years of infection, increasing by 5% each year thereafter. By 10 to 11 years postinfection, most people with HIV had already developed AIDS. The availability of effective drugs and drug combinations may improve this outlook.

    Prevention of and treatment for infections has increased the lifespan of people with AIDS. In the early stages of the epidemic, most people died within two years of developing AIDS. Most often they died because of resulting infections, and not because of the virus itself. Aggressive prevention, treatment, and suppression of infections has improved both the quality and quantity of life of people living with AIDS. Today, HIV infection is a chronic disease, and although not curable, is treatable.

    Ongoing research may lead to effective vaccines and more effective treatments. Scientific research has already had a dramatic impact on the lives of people living with HIV. For example, since the introduction of protease inhibitors (one type of HAART) in 1996, the number of deaths and AIDS-related hospitalizations has declined significantly. In 1997 alone, 44% fewer people with AIDS died than in 1996. Ongoing research into the molecular biology of HIV infection holds the promise of more effective treatments and the potential for effective vaccines to either prevent or treat HIV infection.

    During the asymptomatic phase of HIV, your physician will want to see you several times a year to monitor the progression of your disease. Every 3 to 4 months, your physician will want to perform a physical exam and laboratory tests to monitor the progression of your disease. Follow-up will be more frequent when starting or changing drug therapies. Laboratory testing will generally include CD4 counts and HIV RNA viral load testing, as well as standard blood tests to determine the health of your liver, kidneys, and other organs.

    During symptomatic HIV disease, follow-up will depend on your particular symptoms, infections, and stage of disease.

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I'm Shereen A. Gharbia, PharmD. Welcome to PDR Health!

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