Do I really need to start HIV treatment immediately?

The recommendation that treatment be started by all U.S. residents living with HIV, regardless of their CD4 cell count, is based on three major goals: To treat HIV before the virus has had a chance to cause serious damage to the immune system; to reduce the risk of non-AIDS-related diseases, such as those typically associated with aging, that are becoming increasingly common among people living with HIV; and to reduce the risk of transmitting the virus to others. Here's a more detailed look at the potential benefits of early treatment, along with the possible risks:


Potential Benefits

•Keep your CD4 count high and possibly prevent irreversible damage to the immune system.

•Decrease your risk of certain HIV-related health problems that can sometimes occur in people with high CD4 counts, including tuberculosis, non-Hodgkin's lymphoma, Kaposi's sarcoma, peripheral neuropathy, cancers and pre-cancers caused by human papillomavirus (HPV), and mental deficits seen in some people with HIV such as difficulty thinking and reasoning (neurocognitive problems).

•Decrease your risk of serious health problems that occur more frequently in HIV-positive people, such as cardiovascular disease, kidney disease, liver disease, neurological complications and various non-AIDS-related cancers and infections.

•Reduce your risk of transmitting HIV to others—several studies have confirmed an association between undetectable viral loads and a greatly reduced risk of transmitting the virus, notably during sexual activity and pregnancy. One clinical trial in particular (HPTN 052), involving mixed-status heterosexual couples, found that treating HIV-positive people with ARV drugs reduces the risk of transmitting the virus to HIV-negative sexual partners by 96 percent.


Potential Risks

•Risk developing treatment-related side effects, including long-term side effects that haven't yet been discovered.

•Risk developing HIV drug resistance, resulting in loss of future treatment options.

•Less time for you to learn about HIV and its treatment, and less time to prepare for adherence to therapy.

•Premature use of treatment before the development of more effective, less toxic and/or better studied combinations of HIV drugs.

•Increased risk of transmitting drug-resistant HIV to others if you have a detectable viral load while on treatment.


Unfortunately, we do not yet have data from a well-designed clinical trial comparing the benefits and risks of starting HIV treatment early—particularly when the CD4 count is above 500—with the benefits and risks of waiting to start treatment until the CD4 count falls below 350 or 500. In other words, while the majority of DHHS guidelines panelists believe, based on their expert opinions, that treatment should be recommended for all people living with HIV, regardless of their CD4 cell count, research will be necessary to determine, once and for all, if the benefits of early treatment clearly outweigh the risks.

Preferred Regimens

 

NNRTI-Based Regimen

 

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Atripla (efavirenz + tenofovir + emtricitabine)

PI-Based Regimen (in alphabetical order)

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Prezista (darunavir) and low-dose Norvir (ritonavir) and Truvada (tenofovir + emtricitabine)

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Reyataz (atazanavir) and low-dose Norvir (ritonavir) and Truvada (tenofovir + emtricitabine)

Integrase Inhibitor-Based Regimen

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Isentress (raltegravir) and Truvada (tenofovir + emtricitabine)

*Preferred Regimen for Pregnant Women

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Kaletra (lopinavir/ritonavir) twice-daily and Combivir (zidovudine + lamivudine)

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Women in the first trimester of pregnancy or likely to become pregnant should not use Sustiva.

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People on high dose proton pump inhibitors (PPIs) for acid reflux, equivalent to more than 20 mg of Prilosec (omeprazole), should not use Reyataz/Norvir.

Tenofovir, one of the active ingredients in Truvada, should be used with caution in people with signs of kidney disease.

Alternative Regimens

 

NNRTI-Based Regimen (in alphabetical order)

•

Complera (rilpivirine + tenofovir + emtricitabine)

Edurant (rilpivirine) and Epzicom (abacavir + lamivudine)

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Sustiva (efavirenz) and Epzicom (abacavir + lamivudine) or Combivir (zidovudine + lamivudine)

PI-Based Regimens (in alphabetical order)

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Kaletra (lopinavir/ritonavir) [once or twice daily] and Epzicom (abacavir + lamivudine) or Truvada (tenofovir + emtricitabine)

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Lexiva (fosamprenavir) low-dose Norvir (ritonavir) [once or twice daily] and Epzicom (abacavir + lamivudine) or Truvada (tenofovir + emtricitabine)

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Prezista (darunavir) and low-dose Norvir (ritonavir) and Epzicom (abacavir + lamivudine)

•

Reyataz (atazanavir) and low-dose Norvir (ritonavir) and Epzicom (abacavir + lamivudine)

Integrase Inhibitor-Based Regimen

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Stribild (elvitegravir + cobicistat + tenofovir + emtricitabine)

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Isentress (raltegravir) and Epzicom (abacavir + lamivudine)

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Complera or other Edurant-based regimens should be used cautiously by people living with HIV with viral loads in excess of 100,000 copies.

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Complera or Edurant should not be taken if proton pump inhibitors (PPIs) for acid reflux are also being used.

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People who test positive for HLA-B*5701, a genetic mutation that greatly increases the risk of a serious allergic reaction to Ziagen, should not use Ziagen.

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People at high risk for cardiovascular disease should use Epzicom with caution, as they may be at greater risk of heart attacks.

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People who start treatment with viral loads greater than 100,000 should use Epzicom with caution, as they may be at greater risk of early treatment failure.

•

Once daily Kaletra is not recommended for pregnant women

Acceptable Regimens [and Acceptable Regimens but More Definitive Data are Needed]

 

NNRTI-Based Regimen (in alphabetical order)

 

•

Edurant (rilpivirine) and Combivir (zidovudine + lamivudine)

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Sustiva (efavirenz) and Combivir (zidovudine + lamivudine)

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Virumune (nevirapine) and Combivir (zidovudine + lamivudine) or Epzicom (abacavir + lamivudine) or Truvada (tenofovir + emtricitabine).

PI-Based Regimen

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Kaletra (lopinavir/ritonavir) [once or twice daily] and Combivir (zidovudine + lamivudine)

•

Lexiva (fosamprenavir) and low-dose Norvir (ritonavir) [once or twice daily] and Combivir (zidovudine + lamivudine)

•

Prezista (darunavir) and low-dose Norvir (ritonavir) and Combivir (zidovudine + lamivudine) [More definitive data needed.]

•

Reyataz (atazanavir) [without Norvir (ritonavir)] and Epzicom (abacavir + lamivudine) or Combivir (zidovudine + lamivudine)

•

Reyataz (atazanavir) and low-dose Norvir (ritonavir) and Combivir (zidovudine + lamivudine)

Integrase inhibitor-Based Regimen

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Isentress (raltegravir) and Combivir (zidovudine + lamivudine) [More definitive data needed.]

Entry Inhibitor-Based Regimen

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Selzentry (maraviroc) and Combivir (zidovudine + lamivudine)

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Selzentry (maraviroc) and Truvada (tenofovir + emtricitabine) or Epzicom (abacavir + lamivudine) [More definitive data needed.]

•

Viramune should not be used in people with moderate to severe liver disease (Child-Pugh score B or C)

•

Women with a CD4 count greater than 250 and men with a CD4 count greater than 400 before starting treatment should not use Viramune.

•

Viramune and the abacavir in Epzicom can both cause hypersensitivity (allergic) reactions. They should be used together with caution.

•

The zidovudine in Combivir can affect the bone marrow's ability to produce new red and white blood cells. It can also cause fat loss in the face and limbs (lipoatrophy) and, rarely, a buildup of lactic acid in the blood and fatty liver disease.

•

Kaletra plus Combivir is the preferred regimen for pregnant women.

•

Norvir-boosted Reyataz is preferred over unboosted Reyataz, but can be used when Norvir boosting is not possible.

•

Tropism testing is required before Selzentry can be used. Only people who's virus uses only the CCR5 coreceptor on CD4 cells will benefit from Selzentry.

Regimens that may be acceptable but shoud be used with caution

 

PI-Based Regimen

•

Invirase (saquinavir) + low-dose Norvir (ritonavir) and Truvada (tenofovir + emtricitabine)

•

Invirase (saquinavir) + low-dose Norvir (ritonavir) and Epzicom (abacavir + lamivudine) or Combivir (zidovudine + lamivudine) [More definitive data needed.]

•

Norvir-boosted Invirase was linked to abnormal heart rhythms is a study of HIV-negative volunteers. Heart testing (electrocardiograms) should be conducted before starting Norvir-boosted Invirase; the drug is not recommended for people with certain heart rhythm abnormalities.

Specific drugs or regimens that should NOT be taken when starting therapy for the first time

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Trizivir (zidovudine/lamivudine/abacavir)

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Trizivir (zidovudine/lamivudine/abacavir) plus Viread (tenofovir)

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Ziagen (abacavir) plus Videx EC (didanosine)

•

Ziagen (abacavir) plus Viread (tenofovir)

•

Prezista (darunavir) used without Norvir (ritonavir)

•

Rescriptor (delavirdine)

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Videx/Videx EC (didanosine) + Viread (tenofovir)

•

Fuzeon (enfuvirtide)

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Intelence (etravirine)

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Crixivan, either with or without Norvir (ritonavir)

•

Viracept (nelfinavir)

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Norvir (ritonavir) as sole protease inhibitor

•

Invirase (saquinavir) used without Norvir (ritonavir)

•

Aptivus (tipranavir)

•

Zerit (stavudine) plus Epivir (lamivudine)

 

Understanding Drug Resistance & The Tests to Measure It

Above all, it is important that you take the correct dose of your medications every time you're supposed to take them, exactly as prescribed by your health care provider or recommended by your pharmacist. This is called treatment adherence—you need to take your medications correctly if they are to keep you healthy. To learn more about treatment adherence, click here:

 

Understanding Drug Resistance

Introduction

The widespread availability of antiretroviral therapy has made the fight against HIV a great deal easier. But like a horse without a rider, these medications can't go the distance alone. Working closely with your doctor, you'll need to choose and monitor your treatment carefully. This is because of obstacles that can arise before and during treatment—one of the most important is HIV drug resistance.


Fortunately, we now know a lot about how to reduce the risk of drug resistance and treat drug-resistant virus. We also have access to important technologies that look for drug-resistant virus and help us make important treatment decisions. These drug-resistance tests have become a routine part of HIV care.


This lesson explains what drug resistance is and how drug-resistance tests work, including the role they play in improving the success of antiretroviral therapy.

 

In Potential Vaccine Breakthrough, Antibody Response Outwits HIV

A new discovery could prove a major stepping-stone toward developing an effective HIV vaccine. In South Africa, two women’s immune systems reacted to changes in HIV cells by producing potent “broadly neutralizing antibodies” that could kill 88 percent of HIV found throughout the world. The study, published October 24 in Nature Medicine and highlighted in a news release by the University of the Witwatersrand in Johannesburg, was conducted by the Centre for the Aids Programme of Research in South Africa (CAPRISA) consortium. The researchers found that, after infection, the two women’s immune systems initially produced less potent antibodies that pressured the virus to cover a key point of its surface with sugar, or “glycan.” This position on the cell became an Achilles’ heel, prompting the development of broadly neutralizing antibodies that effectively targeted the site. This scientific know-how could prove crucial to what CAPRISA scientists envision as a sequential series of vaccinations that would mimic this co-evolution between HIV and the body’s immune response—but without the actual presence of the virus—and result in the creation of broadly neutralizing antibodies

Understanding Drug Resistance & The Tests to Measure It

Above all, it is important that you take the correct dose of your medications every time you're supposed to take them, exactly as prescribed by your health care provider or recommended by your pharmacist. This is called treatment adherence—you need to take your medications correctly if they are to keep you healthy. To learn more about treatment adherence, click here:

 

Understanding Drug Resistance

Introduction

The widespread availability of antiretroviral therapy has made the fight against HIV a great deal easier. But like a horse without a rider, these medications can't go the distance alone. Working closely with your doctor, you'll need to choose and monitor your treatment carefully. This is because of obstacles that can arise before and during treatment—one of the most important is HIV drug resistance.


Fortunately, we now know a lot about how to reduce the risk of drug resistance and treat drug-resistant virus. We also have access to important technologies that look for drug-resistant virus and help us make important treatment decisions. These drug-resistance tests have become a routine part of HIV care.


This lesson explains what drug resistance is and how drug-resistance tests work, including the role they play in improving the success of antiretroviral therapy.

 

In Potential Vaccine Breakthrough, Antibody Response Outwits HIV

A new discovery could prove a major stepping-stone toward developing an effective HIV vaccine. In South Africa, two women’s immune systems reacted to changes in HIV cells by producing potent “broadly neutralizing antibodies” that could kill 88 percent of HIV found throughout the world. The study, published October 24 in Nature Medicine and highlighted in a news release by the University of the Witwatersrand in Johannesburg, was conducted by the Centre for the Aids Programme of Research in South Africa (CAPRISA) consortium. The researchers found that, after infection, the two women’s immune systems initially produced less potent antibodies that pressured the virus to cover a key point of its surface with sugar, or “glycan.” This position on the cell became an Achilles’ heel, prompting the development of broadly neutralizing antibodies that effectively targeted the site. This scientific know-how could prove crucial to what CAPRISA scientists envision as a sequential series of vaccinations that would mimic this co-evolution between HIV and the body’s immune response—but without the actual presence of the virus—and result in the creation of broadly neutralizing antibodies

 potent narcotic that had not been filled in months and for which there was no obvious need. He declined to fill it.

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