HIV therapy today

There are now over 20 antiretroviral drugs available. These drugs have been shown to work and can mean a much longer and healthier life for people with HIV. Indeed, many doctors now think that with good HIV treatment and care a person with HIV could live a more or less normal lifespan.

In order to get the maximum benefit from anti-HIV therapy it’s important to have a doctor who knows what they are doing and to have a good relationship with your doctor.

Experienced doctors provide better care and there is good evidence showing that patients at bigger HIV clinics  and/or those that see doctors who look after a lot (>50-100) patients have better care and maybe an improved prognosis.

The experience of your doctor is becoming increasingly important. They must be skilled at providing anti-HIV treatment and care, and also aware of the new issues that are increasingly becoming a feature of HIV medicine such as those related to ageing.

Illness related to the long-term side-effects of anti-HIV treatment, as well as long-term minor immune suppression and the natural ageing process are now important causes of illness and death in people with HIV and doctors need to be able to recognise and appropriately treat them. Such problems include heart disease, kidney and liver disease, dementia and cancers.

Thanks to the success of anti-HIV treatment many people infected with the virus are now surviving into older age.

Doctors need to think about the illnesses of ageing – such as heart disease and dementia – in their HIV-positive patients. It is also important that clinical trials are designed to look at the effectiveness and safety of anti-HIV drugs in older patients.

When is the best time to start anti-HIV treatment?

It is currently recommended that anti-HIV treatment should be started by people who are ill because of HIV and by those with a CD4 cell count between 200 – 250. A CD4 cell count at this level indicates that a person has a very real risk of developing a serious, potentially life-threatening opportunistic infection.

But some doctors now think that there are good reasons for treatment to be started earlier: when a person has a CD4 cell count of around 350. They point to evidence showing that people who started treatment at this time did better on HIV treatment in the long-term.

Information from a study designed to look at the safety and benefits of treatment interruptions also showed the value of starting treatment at higher CD4 cell counts. This study was called the SMART study, and it was stopped early after it was shown that people who interrupted their treatment were more likely to become ill. People in the study were randomly divided to either take their HIV drugs all the time, or to interrupt their HIV therapy when their CD4 cell count was above 350 (provided they had an undetectable viral load), starting again when it fell to 200 – 250.

When the researchers from the study looked at their results in more detail they found that it wasn’t just HIV-related illnesses that occurred more frequently in the treatment interruption arm. They also found that serious illnesses like heart, liver and kidney disease occurred more often in those taking treatment breaks.

They think that this is because these patients spent longer at low CD4 cell counts – between 200 – 350, and that this increased general inflammation and the risk of serious illnesses.

Which drugs to start with?

Treatment guidelines say that the first combination of anti-HIV drugs a person takes should include two NRTI drugs plus either an NNRTI or a ritonavir boosted protease inhibitor.

Many people start treatment with a combination that includes the NNRTI efavirenz (Sustiva). This is because it is easy to take and has relatively few side-effects although if this combination does not work then the consequences due to resistance tend to be greater than if you start with a boosted protease inhibitor based regimen, which I personally prefer.

Long-term HIV treatment

Doctors have become a lot better at treating people who’ve taken a lot of anti-HIV drugs in the past and have drug resistant HIV. The use resistant tests to find drugs with the best chance of success, and the development of new, more potent ritonavir-boosted protease inhibitors like tipranavir (Aptivus) and darunavir (Prezista), and drugs from new classes, like CCR5 inhibitors and integrase inhibitors, mean that many treatment experienced people can get undetectable viral loads and experience good increases in their CD4 cell count.

Several types of anti-HIV drugs have been developed that work against HIV before they enter human cells. One of these groups of agents is called CCR5 inhibitors, and the first of these drugs, maraviroc was recently approved for use by people who’ve taken a lot of anti-HIV drugs before and have drug resistant virus. Clinical trials have shown that the drug can be produce good results in such patients. For maraviroc to work you have to have virus that has the CCR5 co-receptor on its surface – doctors test people for this before prescribing the drug.

Doctors wanted to see how safe and effective maraviroc was in people new to anti-HIV therapy. A study presented to the Sydney conference found maraviroc-treated patients were slightly less likely than those taking efavirenz to get their viral load to undetectable levels – the goal of anti-HIV treatment.

The other major advance has been the arrival of integrase inhibitors and the one available for doctors now is called raltegravir. These drugs act to prevent the virus genetic material being incorporated into the cell nucleus and thereby preventing new virus particle being produced by the infected cell. This first-in-class seems to be safe and very effective although it must be used with other agents as resistance can develop to it relatively easily.

Another developing area of research is genetics. Tests are already been used to see if people have a gene that is associated with a severe allergy to abacavir (Ziagen).

About 10% of people newly infected with HIV have contracted a drug-resistant strain of the virus. It is important to carry out resistance tests on people who are newly diagnosed and on those about to start treatment for the first time to make sure that the most appropriate drugs are used.