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Choosing a treatment that’s right for you

By Paromita Pain

It’s been more than 30 years since HIV/AIDS was first identified. While no longer a death sentence, being diagnosed with HIV and starting treatment can be scary. Today there are more than 25 antiretroviral medications that are used either singly or in combination as part of HIV treatment protocols. When started early, these medications can help limit or slow down the destruction of the immune system and can slow the progression of the HIV infection to AIDS-defining illnesses, helping  a long and fulfilling life with HIV.

So what are your treatment options and how do you choose the right one? We talked to a panel of HIV experts from the Keck School of Medicine of the University of Southern California to help you know what to expect during treatment — from how treatment works and what your medical costs will be like to tips for dealing with treatment side effects.

Our expert panel:

• Suraiya Rasheed, Ph.D, FRCPath. Professor of Pathology, USC Keck School of Medicine and Director, Laboratory of Viral Oncology and AIDS Research at the Cancer Research Laboratory
• Joel W. Hay, PhD, Professor, Clinical Pharmacy and Pharmaceutical Economics & Policy, USC School of Pharmacy and the Schaeffer Center for Health Policy and Economics
• Marvin E. Belzer, MD, Associate Professor of Clinical Pediatrics, USC Keck School of Medicine and Director, Division of Adolescent Medicine, Children’s Hospital Los Angeles

Q: What constitutes an HIV diagnosis? When exactly does treatment start?

Dr. Rasheed: AIDS is the disease caused by a virus called HIV (or the Human Immunodeficiency Virus). If the virus is allowed to replicate without any treatment, then the disease may progress to AIDS. However, with the advent of multidrug treatments, the incidence of AIDS has been reduced significantly as the virus level (virus load) goes down. In most cases HIV disease progresses by causing the death of CD4 positive cells (cells that are critical for fighting infection and maintaining immunity), treatment must be started when the number of CD4 cells are highThe very first step towards choosing a treatment regimen starts with a confirmation of whether the patient is HIV positive. Usually the ELISA test checks for the HIV antibodies and then the Western Blot test is done to check if the patient has HIV-specific proteins and the viral load is determined by the amount of HIV-RNA.detected in the blood The virus load indicates how fast the HIV is replicating. It’s best to start treatment immediately after HIV-infection is confirmed. The sooner an HIV-infected person is treated the faster the virus can be prevented from spreading to different parts of the body.

Q: What should I know before starting treatment?

Dr. Rasheed: The most important factor in successfully treating HIV-disease is drug adherence or compliance — you must stick to your drug regimen — and understand that these are not medicines you can take for week or a month and then stop. Treatments are usually for long-term since there is no complete cure yet. So start treatment when you are sure that you will be able to take your drugs and know how and when they should be taken.

Drugs used to treat HIV are called antiretroviral drugs. They include: protease inhibitors (PIs), fusion or entry inhibitors, integrase inhibitors, non-nucleoside reverse transcriptase inhibitors (NNRTIs), and nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs). Each destroys the virus in different ways. Fusion or entry inhibitors and integrase inhibitors are now being  used in the United States.

Using antiretroviral drugs as a treatment plan is called antiretroviral therapy (ART). A combination of two groups of antiretroviral drugs is called combination therapy. Combining three or more groups of drugs is known as highly active antiretroviral therapy (HAART).Some of the medicine combinations need to be taken with food. Following your doctor’s instructions helps the body use the medication more effectively.

Understanding how drugs work to kill HIV is important. When HIV infects healthy cells responsible for maintaining health and immunity in our bodies, it becomes a part of those cells. The various combination treatments available today kill most of the virus present in the blood (outside of the infected cells), but do not remove the integrated HIV in the chromosomal DNA. Scientists are still trying to find out a good combination of drugs that would eliminate both cell-associated and cell-free HIV from the body.Treating HIV-diseases is complicated because a significant number of HIV-infected individuals are also infected with other pathogenic viruses such as Hepatitis B,C and D and in addition acquire many opportunistic infections such as TB, other bacteria and fungi. In US, TB and other infections are also  treated while adjusting dosages of ART to help suppress the HIV infection and bolster CD4 cell count to help build immunity.

Doctors check frequently to see how patients are responding to the prescribed treatment protocol. If after a month the viral load shows no signs of decreasing or shows higher viral load then the drug combinations are changed. Often many combinations are tried before a patient starts responding satisfactorily to a combination. Medications are so sophisticated now that patients tolerate combinations well with minimal side effects.

Q: What are the popular medications used in treatment?

Dr. Rasheed: Depending on the viral load (amount of HIV) in the blood, patients may need to take just one pill. Since 2006, a drug called Atripla, a combination of three anti-HIV drugs [Viread (generic name tenofovir disoproxil fumarate), Emtriva (generic name emtricitabine) and Sustiva (or Stocrin in Europe, generic name efavirenz)] can be taken once daily. Then you have Truvada (a combined NRTI comprised of emtricitabine and tenofovir) which is also a single pill that works against HIV infections.

In addition, the drug Viramune (generic name nevirapine), a type of NNRTI, is also used for  treating HIV infections.

For persons seeking care less than 72 hours after nonoccupational exposure to blood, genital secretions, or other potentially infectious body fluids of a person known to be HIV infected, when that exposure represents a substantial risk for transmission,] the CDC recommends a 28-day course of highly active antiretroviral therapy (HAART). [However, the efficacy of this drug regimen] is yet to be ascertained.

Q: Does medication for HIV/AIDS differ by age groups?

Dr. Belzer: Medication does differ a little bit by groups, but we don’t group based so much on the concepts of age but rather body development and sexual maturity indexes define care. Children and teenagers metabolize medication faster so dosages have to be adjusted accordingly. Some medications cause birth defects so we are careful not to use them on young women who are pregnant or wanting to get pregnant.

Q: Is there a choice about when one should start treatment? Should treatment be started immediately after diagnosis?

Dr. Rasheed: Yes, there is a choice. While it is recommended to start the treatment as soon as HIV infection  is diagnosed, no doctor can force patients to start treatment. Patients start when they are ready. The sooner you start the better it is to prolong lifespan and stay healthy. Some disadvantages to starting therapy late involve greater intolerance to side effects and drug resistance.

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