Deciding to Begin Anti-retroviral Therapy

Deciding when to start antiretroviral therapy is both challenging and personal. The decision should be made in partnership with an experienced, trusted doctor. It’s important to be well informed about both the benefits and the risks of antiretroviral therapy before starting it.
Many people live a long time without symptoms of HIV and without using anti-HIV therapy. Making a decision about treatment isn’t something that has to be done right away after you learn you have HIV.
Antiretroviral therapy requires a long-term commitment to taking many pills or medicines as prescribed. Some of these medicines must be taken several times a day. Others have special requirements such as being taken with food – or several hours before or after meals.
Anti-HIV drugs are powerful. They have side effects that must be considered. Finally, the longer a person is on antiretroviral therapy, the more likely it is that drug resistance will develop. (This means that a drug is no longer effective in fighting HIV).
When deciding to start anti-HIV therapy, you should take into consideration:

• Viral load levels (the amount of HIV in the blood)
• CD4 cell counts. If a person’s CD4 cell count is 200 or below, most doctors would recommend anti-HIV therapy, even if there were no other symptoms of disease. Therapy should be considered if the CD4 cell count is below 350 or falling fast
• General health status. Are there symptoms of HIV-related disorders or recurring health conditions that aren’t responding to treatment?
• Your own feelings about anti-HIV therapy
• Your commitment to taking the medications as prescribed for the rest of your life.
• The impact on your quality of life
• The risk of the disease getting worse (progressing)

Treating HIV/AIDS

Since 1987, when the first antiretroviral drug was approved for treating HIV, many life-extending advances have been made in the drug therapy used to treat HIV/AIDS. That first drug, azidothymidine (AZT), is now one of more than 22 drugs that have been approved by the U.S. Food and Drugs Administration (FDA) to fight AIDS-related conditions.
There are four classes of antiretrovirals:

 

• Nucleoside reverse transcriptase inhibitors (NRTIs)
• Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
• Protease inhibitors
• Fusion inhibitors

The first three classes work by interfering with the process by which the HIV replicates itself inside a cell. The fourth works by preventing HIV from getting into the cell in the first place.
In highly active antiretroviral therapy (HAART), three or more drugs from different classes are combined to fight the virus. Combining drugs makes them more effective. This also means that you have to take many drugs at different times of day. Some need to be taken with food, some on an empty stomach. Some may interfere with other drugs you need to take.
It is important to take the drugs as the doctor prescribed every day to be as effective as possible. Each drug regimen is tailored to the individual. Just because you know someone on a particular regimen doesn’t mean that it’s the regimen you should be on.
Antiretroviral drugs neither cure HIV/AIDS nor prevent it from being spread to other people.
Antiretrovirals are powerful drugs and can cause side effects. It is important to be as well informed as possible about the drugs you are taking. Talk to your doctor if you have side effects that are unpleasant or don’t go away over time.
Over the course of treatment, the combination of drugs being used may need to be changed. Changes in a drug program are usually done when:

• CD4 counts or viral load tests show the virus isn’t being controlled
• Side effects become a problem
• One or more drugs are no longer effective against the virus. This is called drug resistance.

Sometimes a doctor will stop treatment for two weeks or more and then restart it. This may be done because of side effects, drug resistance or pregnancy. Stopping antiretroviral therapy should only be done under a doctor’s supervision.

Side Effects of Anti-retroviral Therapy

Anti-HIV drugs do cause side effects. Just because a drug has side effects doesn’t mean that everyone who takes it will have those effects. And just because a drug has side effects, doesn’t mean it shouldn’t be taken.
What these facts do mean, however, is that you should know and watch out for possible side effects.
Taking drugs the way they are prescribed helps keep side effects low. When side effects do happen, it is usually in the first two to four weeks after starting a particular drug. Many side effects go away on their own as the body adapts to the medicines.
Common side effects from anti-HIV drugs include:

• Changes in how fat is distributed around the body (lipodystrophy)
• Damage to organs, especially the liver and kidneys, which are responsible for how the body metabolizes energy and drugs and filtering out toxins from the body
• High blood sugar
• High cholesterol levels
• Lactic acidosis, which is a condition involving the energy producing elements of cells

Drug Interactions

Because HAART involves taking several drugs, and because a person may be taking drugs for other infections at the same time, there is a risk of the various drugs interacting badly with each other.

This doesn’t mean that the drugs shouldn’t be taken. It does mean that adjustments sometimes need to made to the therapy plan. Dosages may need to be changed to adapt to these interactions. It’s important to tell your health care providers about all the drugs you are taking in order to prevent drug interactions.

Drug Resistance

One of the concerns about anti-HIV therapy over the long term is the virus’ ability to change (mutate) so that an anti-HIV drug no longer affects it. This is called drug resistance.

Often when drug resistance happens with one anti-HIV drug, the virus will resist all drugs in that class of anti-HIV drug. This is known as cross-resistance. Drug resistance is more likely to occur with some classes of anti-HIV drugs than others.

For this reason, antiretroviral therapy usually includes drugs from several different classes. If the virus can resist one drug, it can still be held in check by the other drugs from other classes. If resistance develops, a doctor may change the drugs being used.

In some cases, it’s possible to measure whether a person with HIV will be likely to resist a specific drug. This can sometimes be helpful in making treatment decisions.

Ongoing Monitoring During Treatment

Anyone with HIV will need to have tests to monitor his or her condition over time. These monitoring tests check for CD4 cell count levels, viral load and blood levels of various chemicals and enzymes that measure the body’s response to anti-HIV therapy.

It is important to get these tests as your doctor recommends them. They help keep the virus under control and avoid the more significant side effects of anti-HIV treatment.

During antiretroviral therapy, the goal is to get the viral load so low it cannot be detected by a blood test. Viral load tests today measure as few as 20 copies of the virus.

There are several different viral load tests. Some consistently report higher viral loads than others. It’s important to have tests done at the same lab and using the same test, so that results are consistent.