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Antiretroviral Therapy
Background
Potent combination antiretroviral therapy (ART),
consisting of 3 or more antiretroviral drugs (ARVs),
has greatly improved the health and survival rates
of HIV-infected patients in areas of the world with
access to ARVs.
More than 20 individual ARVs are available in the
resource-sufficient world, in addition to several fixeddose
combination preparations. These can be combined
to construct a number of effective regimens for initial
and subsequent therapy. ART is not without limitations,
however. ART does not cure HIV infection and it
requires that multiple medications be taken for very
long periods of time (usually for the duration of life).
It is expensive, may cause a variety of adverse effects
(some severe), requires close adherence to be effective
and to prevent the emergence of resistance, and often
fails (because of the patient’s imperfect adherence or
other factors). The failure of an ARV regimen when
accompanied by drug resistance usually means that
subsequent regimens are less likely to succeed.
Greatly overshadowing the limitations of ART,
however, is the overwhelming evidence that ART saves
lives and improves or restores immune system function.
Mortality and morbidity benefits are particularly
obvious in patients with relatively advanced immune
suppression or with symptoms related to HIV infection.
For asymptomatic patients with relatively high CD4 cell
counts (>350 cells/µL), it is less clear whether or when
to start ART. In deciding when to start ART for any
patient, practitioners must weigh the expected benefits
of ART for that individual (in terms of morbidity and
mortality) against the possible risks (eg, toxicity, drug
resistance, adverse drug interactions).
Although implementing ART is complex, a number
of guidelines from expert panels are available to help
practitioners select effective regimens for particular
patients. The U.S. Department of Health and Human
Services (DHHS) keeps a repository of “living
documents” of frequently updated recommendations
on the use of ARV medications in children, adults
and adolescents, and pregnant women. All clinicians
treating HIV-infected patients should be familiar with
the most current versions of these treatment guidelines.
They are available on the Internet at the AIDSinfo Web
Section 3—Antiretroviral Therapy | 3–1
site “Clinical Guidelines” section (http://aidsinfo.nih.
gov/Guidelines). This chapter frequently references the
Adult and Adolescent ARV Guidelines. (U.S. Department
of Health and Human Services. Guidelines for the
Use of Antiretroviral Agents in HIV-1-Infected Adults
and Adolescents. October 10, 2006. Available online
at aidsinfo.nih.gov/Guidelines/GuidelineDetail.
aspx?GuidelineID=7.)
S: Subjective
Obtain the patient’s history, including the following:
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CD4 cell count history, including nadir
HIV viral load history, including before therapy if
the patient is currently taking ARVs
History of HIV-related conditions
Previous and current ARV regimens, including
regimen efficacy, toxicity, resistance, start and stop
dates
Current medications, including herbal preparations,
supplements, and over-the-counter medications
Medication allergies, intolerances, or prominent
adverse effects
Comorbid conditions (eg, hepatitis C, hepatitis B,
depression)
Occupation and daily schedule
Current and previous substance use, including
alcohol and recreational drugs
Self-assessment of adherence to previous regimens
Desire to start or continue an ARV regimen
Commitment to adherence (see chapter Adherence)
Indicators of ability to adhere to various types of
regimens (eg, once daily, twice daily, every 8 hours,
with or without food) given current life situation
For women of childbearing potential: last menstrual
period, current method of birth control (if any),
current pregnancy status, thoughts on whether or
when to have children
History and review of systems (see chapter Initial
History)