Treatment

• Highly Active Antiretroviral Therapy (HAART) or Anti-retroviral therapy (ART)
• Other treatments

The principles of treatment include:

• Management by a specialist multidisciplinary team
• Early recognition, treatment and/or prevention of opportunistic infection and tumours
• Treating HIV with combinations of antiviral drugs, usually known as “Highly Active Antiretroviral Therapy (HAART)” or “Antiretroviral Therapy (ART).”

Ongoing clinical care for people with diagnosed HIV infection should be under the supervision of a consultant in a specialist centre. Specialist centres are responsible for the initiation, monitoring and ongoing prescribing of highly active antiretroviral therapy.

The role of the GP varies. It is not uncommon for the GP to be unaware of the diagnosis as some people refuse to allow them to be informed. Frequently, less serious problems for example skin problems, may be treated by the GP, but more serious problems, especially those affecting people with CD4 counts below 200/µl, may require urgent referral.

Highly Active Anti-Retroviral Therapy (HAART) or Anti-Retroviral therapy (ART)

Drug treatment for HIV infection, highly active anti-retroviral therapy (HAART), has resulted in a dramatic increase in life expectancy for people with HIV infection.

There are at least 4 major classes of drugs:

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

Some of the drugs currently available include:

Trade names are not often used for single drug tablets. Trade names of combination tablets are used more commonly and are listed below:

HIV readily mutates in the process of replication so resistance to single drugs develops readily. For this reason these drugs are used in combinations of three or more. Initially treatment is usually with two NRTIs with one NNRTI. The choice of treatment will depend upon the need to minimise side effects while providing an effective combination likely to suppress the virus in the long term. Sometimes tablets containing more than one drug are given in order to aid compliance (treatment adherence).

HIV specialists take a number of factors into account when deciding when to start HAART that include the CD4 count and risk of disease progression. The choice of drugs is determined by a number of factors that include:

• The CD4 count
• Likelihood of resistance
• Drug toxicity
• Drug interactions
• The number of pills that have to be taken
• Lifestyle

Resistance of the virus to HAART is minimised if drug levels are maintained at therapeutic levels. Non compliance increases the risk of drug resistance. Drug resistance once developed is irreversible. There tends to be cross resistance between drug groups and therefore further treatment choices may be limited.

Failure of antiretroviral therapy is not uncommon and an increase in the plasma viral load is a good indicator that therapy is failing. This should prompt a change to a different drug combination. However, the efficacy of therapy tends to decrease with successive drug regimens. One of the most common reasons for treatment failure is poor compliance.

HIV can directly invade brain tissue causing AIDS dementia complex (HIV encephalopathy). Minor cognitive impairment (usually a later feature of the disease) is relatively common in HIV infection and can produce a wide range of neuro-psychiatric disorders. This can now be prevented and / or treated by HAART and has become much less common.

Other treatments

People who have a CD4 count of less than 200/µl are offered prophylaxis (preventative treatment) against pneumocystis. This is usually the antibiotic cotrimoxazole, but some people use dapsone or nebulised pentamidine.

People with a CD4 count of less than 50/µl may be offered prophylaxis against Mycobacterium Avim Complex (MAC), with either azithromycin or rifabutin, but this is only practiced in a few centres in the UK.

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• Side Effects