| Therapy HIV infection, as assessed by the CD4 count and viral load, can
proceed from the acute syndrome (or virus dissemination), through clinical latency and, ultimately, opportunistic
infections and death. Specific guidelines on when to initiate antiretroviral therapy have been established and are
updated on an annual basis. 20 |
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Combination therapy is considered the standard of care, and there are more than 1800 possible combinations. The goal of antiretroviral therapy is choosing a regimen that minimizes development of viral resistance to drugs while developing a long-term treatment strategy. |
| Treatment should be offered to all patients with acute HIV syndrome, those within six months of HIV seroconversion, and all patients with symptoms consistent with HIV infection. Medical intervention should also be offered in asymptomatic HIV-infected persons with CD4 T-cell counts less than 350/mm3 or HIV RNA levels greater than 55,000 if done by RT-PCR. Therapy might be safely deferred for patients at low risk of progression (i.e. low plasma HIV RNA level and high CD4 count), specifically those not committed to adhering to a complex regimen; these patients should be monitored closely. 21 Symptomatic patients, including those with AIDS, thrush or unexplained fever, should be treated regardless of CD4 count or HIV RNA level. Once the decision is made to initiate therapy, the goal should be maximal and prolonged suppression of viral load, restoration and/or preservation of immunologic function, improvement of quality of life, and reduction in HIV-related morbidity and mortality. |
Guidelines for using
antiretroviral therapy:
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Guidelines for
starting antiretroviral therapy:
Source:Yeni PG, et al. Antiretroviral therapy for adult HIV Infection in 2002: Updated recommendations of the International AIDS Society-USA panel. JAMA 2002; 288(2):222-235. |
Factors influencing the decision to initiate early therapy include the goal of maximally suppressing viral replication, preserving immune function, prolonging health and life, decreasing the risk of drug resistance through early suppression of viral replication with potent therapy, and decreasing drug toxicity by treating the healthier patient. Disadvantages to earlier therapy in the asymptomatic patient includes the potential adverse effects of the drugs on quality of life, the potential risk of developing drug resistance despite early initiation of therapy, the potential for limiting future treatment options due to cycling of the patient through the available drugs during early disease, the risk of dissemination of virus resistant to antiretroviral agents, the unknown durability of effect of the currently available therapies, and the long term toxicity of some drugs, such as lipodystrophy, glucose intolerance, lactic acidosis, hepatic steatosis and osteonecrosis. Hence, the decision to begin therapy in the asymptomatic patient must be made in the setting of careful counseling and education. Factors that must be considered are: the willingness of the patient to begin treatment, the risk of disease progression as determined by the level of plasma HIV RNA and CD4 count, and the likelihood, after counseling, of adherence to the prescribed treatment regimen. 20 Structured treatment interruptions outside of a controlled trial setting cannot be recommended at this time. 21 Combination therapy is superior to monotherapy and should always be applied, including cases involving pregnant women. Viral resistance develops fairly readily to any single drug, particularly to lamuvidine. 20 More drugs used in combination are more effective, but intolerance and drug-drug interactions make using more than four drugs simultaneously difficult in most circumstances. Regimens should be selected to minimize the risk of developing resistance, using maximal doses, following food requirements and appropriate timing of doses. Assessment of compliance, interactions with other drugs and underlying medical problems need to be considered on a continuous basis. |