The antiretroviral HIV drugs that are currently available can improve the quality of life of someone infected with HIV, helping them to stay well much longer than they otherwise would. The drugs slow down the replication of HIV within the body, but it must be remembered that they are a treatment and not a cure.
Deciding when to start treatment can be difficult as there is no proven "right" time. There are different views of the benefits of starting HIV treatment earlier or later, though most guidelines recommend not starting treatment until the advanced stages of HIV infection. This is an important decision with long term consequences.
When to start treatment
There are certain tests available that will help determine when to start treatment, in particular the CD4 test and the viral load test.
The CD4 Test
HIV attacks a type of immune system cell called the T-helper cell. This cell carries on its surface a protein called CD4, which HIV uses to attach itself to the cell before gaining entry.
The T-helper cell plays an important part in the immune system by helping to co-ordinate all the other cells to fight illnesses. A major reduction in the number of T-helper cells can have a serious effect on the immune system.
HIV causes many T-helper cells to be damaged or destroyed. As a result, there are fewer cells available to help the immune system to fight illnesses.
The CD4 test measures the number of T-helper cells in your blood. The more cells you have per cubic millimetre of blood, the stronger is your immune system. The stronger your immune system, the better your body can fight illnesses. A low CD4 count does not mean that you will certainly become ill, but it makes it more likely.
Generally treatment is started when the CD4 test shows between 200 to 350 T-helper cells per cubic millimetre of blood, although advice varies slightly between countries.
The Viral Load Test
Viral load refers to the amount of HIV in your blood.
Like the CD4 test, the viral load test can provide important information about the likely course of HIV infection. There are different viral load tests available, which use a variety of techniques to measure the amount of virus. The results of these tests tell you whether your viral load is low, medium or high.
As the immune system becomes increasingly damaged by HIV it becomes susceptible to opportunistic infections. These infections would usually be fought off easily by a healthy immune system, but a low T-helper cell count means opportunistic infections such as PCP (a type of pneumonia) can be life-threatening. If one of these illnesses has become a serious problem then HIV antiretroviral treatment may be advised straight away.
Making a decision
Viral load and CD4 tests can help you to decide whether to start treatment or not. You should talk to your doctor about the results of the tests and what they indicate. The anti-HIV drugs should reduce viral load to below the level of detection of the current tests, and the drugs should also boost CD4 levels.
After considering the results of the tests, you can find out from your doctor about the various HIV drugs and combinations available, and which are suitable, including the positive and negative effects the drugs have.
You should start the treatment only when you are really ready. You need to be committed, since following a drug regime can be quite demanding. Your commitment to the treatment is as important as the drugs themselves. Once the treatment is started, it is likely to be for life. So only start treatment when you feel that you can really be committed to it.
In circumstances where serious opportunistic infections have occurred it is usually recommended to start anti-HIV treatment without delay.
Choosing the best combination
For most people, there are a number of drug combinations available to choose from. There are more than 20 approved drugs belonging to four different groups. It is not always easy to tell which will be the best option, since a combination that suits one person might not suit another.
The first time you use antiretrovirals is when they are most effective. This is why you should try to get the combination right first time and strictly follow the guidelines on taking the therapy.
It is important that the drugs can be taken properly and on time. It is therefore necessary to think ahead about the restrictions and limitations that the drugs may impose on your lifestyle. These are some of the issues that need to be considered and discussed with your doctor:
How effective is the combination?
Some combinations of antiretrovirals are more effective than others. Taking drugs randomly from the different ARV groups may result in a weak combination that doesn’t suppress the HIV infection sufficiently, ending in drug resistance. Also some anti-HIV drugs have harmful effects when used together and should not be combined (an example is stavudine and zidovudine). Always seek advice from a medical professional on the most effective combinations of ARVs.
How many pills are there and how often must they be taken?
Some combinations – especially those involving a protease inhibitor – require swallowing many pills throughout the day, which some people find hard to do. The size of the pills can also be an issue. One option for reducing the pill burden may be to take an FDC (fixed dose combination), which combines two or more drugs in a single pill, capsule or tablet. One of the last developments in this field is the approval of the one pill once daily (Atripla from Gilead Sciences), which combines tenofovir with emtricitabine.
Are there any food restrictions?
Some drugs, particularly protease inhibitors, have to be taken with food to improve absorption rates. Also some drugs impose food restrictions. There may be a need for lifestyle changes to accommodate the medication.
What are the possible side-effects?
Side effects are the undesired effects of a drug, which can range from mild irritations to serious health problems. Common side effects should be taken into consideration when choosing a combination. It is also important to consider existing medical conditions that may be worsened by some anti-HIV drugs.
Are drug interactions an issue?
When taking other drugs, food supplements or alternative therapies it’s important to check with a doctor that they will not interfere with anti-HIV medication. Some substances can reduce absorption rates and so increase the risk of drug resistance developing.
Are there any special handling requirements?
Storage can be an issue as some anti-HIV drugs have to be kept below a certain temperature to last long term. Ritonavir, for example, must be refrigerated.
Preparing for adherence
The term adherence means taking the drugs exactly as prescribed, on time and following any diet restrictions. Adherence can be difficult and may require changes to your lifestyle. Developing a routine can help you to keep up with your daily treatment regime.
It is important to concentrate on getting used to the treatment. Give yourself some time and space to get it to work.
If the treatment instructions are not followed, it is likely that the drugs will not be absorbed properly in the body. This will have serious short- and long-term consequences. It will allow viral load to increase. It will also increase the likelihood of the HIV developing drug resistance. This will reduce the overall benefits from the drugs in the future.
Issues such as side effects and frequency of dosage can compromise adherence. Contact your doctor for advice if your having problems with adherence.
Pregnancy & treatment
Many studies have shown that anti-HIV drugs can be used during pregnancy. The drugs can be used to reduce a woman’s viral load effectively below detection. This also greatly reduces the risk of the baby becoming infected.
Treatment for children
Newborn children with HIV may have a significantly higher viral load than adults because their immune systems are immature. The progression of HIV in children can be rapid if not treated. Studies have shown that HAART is very effective in suppressing the virus in children, but it must be administered in the correct dosage. CD4 counts in children are generally much higher than in adults, and change with the child’s age, meaning that adult guidelines on when to start antiretroviral treatment do not apply.
The progression of HIV in children is monitored through viral load and CD4 tests, as with adult treatment, but because the CD4 and viral load levels vary in children (especially between ages 1 to 4) they must be treated on an individual basis. It is harder to apply guidelines on starting treatment to children than to adults.
Issues to consider with children taking antiretroviral therapy
Adherence to treatment can be a problem because of side effects, pill burdens, swallowing difficulties, unpleasant tasting medications, or food requirements.
Depending on the age of the child, adult supervision is usually needed to ensure the medication is taken consistently and correctly.
Other medicines may interfere with the antiretrovirals; consult you doctor before using other medications.
With younger children some medicines have to be taken as a syrup, which may require refrigeration.
When a child is born with HIV, some guidelines recommend they should receive cotrimoxazole until their viral load is suppressed, to prevent opportunistic infections such as PCP.
Children with tuberculosis (TB) may have to postpone antiretroviral treatment temporarily whilst taking TB treatment, as the drugs can have negative interactions.
There are more antiretroviral drugs available for adults than there are for children because of the way some of them react negatively with a growing child’s immune system. Children are given combination treatment based on body surface area (calculated by measuring height and weight) or sometimes on weight alone. As a child grows the dosage increases, as does the number of treatment options.
Fixed-dose combinations are not recommended for children because the amounts of each drug in one tablet cannot be tailored to suit an individual. A child may at times have to take a higher dosage than an adult because their metabolism processes the drugs more quickly.
Note: This information is cross-posted and slightly adapted from AVERT.org in order to emphasize some aspects refering particulary to Moldova. For more details, visual adds, updated information and primary sources, please visit AVERT.org web page.