A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

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A Guide to Primary Care of People with HIV/AIDS Chapter 4: Prevention of HIV in the Clinical Care Setting 4 28 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
A Guide to Primary Care of People with HIV/AIDS Chapter 5: Antiretroviral Therapy Chapter 5: Antiretroviral Therapy THE PRINCIPLES OF ANTIRETROVIRAL THERAPY (ART) What are the goals of therapy? The overall objective of treatment for HIV disease, as with treatment for many other infectious diseases, is to control the putative agent with antimicrobial agents while providing other appropriate therapies for HIV-related complications. The single most important goal of HIV antiretroviral therapy is to reduce the HIV viral load to as low as possible for as long as possible. The 5 other goals of antiretroviral therapy (ART) are to • Prevent HIV-associated complications • Avoid the long-term and short-term adverse drug reactions associated with antiretroviral agents • Prevent HIV transmission • Avoid HIV resistance • Preserve HIV treatment options THE PRINCIPLES OF ANTIRETROVIRAL THERAPY (ART) WHEN TO START THERAPY WHAT TO START WHEN TO CHANGE THERAPY WHAT TO CHANGE TO RESISTANCE TESTING KEY POINTS SUGGESTED RESOURCES CASES Does antiretroviral therapy work? Treatment recommendations have evolved greatly since zidovudine (AZT), a nucleoside, was first tested in 1986. The strategy was revolutionized in 1996-97 with the introduction of protease inhibitors (PIs) and then subsequently non-nucleoside reverse transcriptase inhibitors (NNRTIs). Combined with AZT and other nucleosides (see Table 5-1), the result was potent combination ART (also referred to as highly active antiretroviral therapy, or HAART) that had an immediate and dramatic impact on the prognosis for HIV infection, in fact one of the most impressive changes in any disease since the introduction of penicillin in the 1940s. Within 2 years there was a 60%-80% decrease See Glossary of Antiretroviral Drugs on page viii and the Pocket Guide John G. Bartlett, MD in mortality, AIDS rates, and hospitalizations for HIVassociated complications. Nevertheless, this treatment was also associated with some disappointments: there is still no cure for HIV infection, many of the patients given ART develop serious side effects, and drug resistance causes many patients to eventually have virologic failure so that longterm benefit may be difficult to sustain. Also, adherence has been shown to be critical to treatment success, and the level of adherence required is among the stiffest for the treatment of any disease in medicine. WHEN TO START THERAPY What are the criteria for starting therapy? The decision to start therapy, like most medical decisions, depends on the risk-to-benefit ratio of treatment. ART is given to control HIV replication and the consequent immune dysfunction, but therapy is also associated with the development of some substantial side effects and the risk of developing resistance that would limit future options. The reduction in CD4 cells is the pivotal event of HIV disease that renders the patient susceptible to the unique opportunistic infections (OIs) and tumors that have come to be known as AIDSdefining diagnoses (see Table 5-2). The patient becomes vulnerable to these diseases when the CD4 cell count decreases from normal levels (500-1500 cells/mm 3 ) to
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