Treatment of HIV: Guide to Modern HIV Management

Introduction: HIV Treatment Today

The HIV virus cannot be eliminated by the body, therefore once infected, it results in lifelong infection.

There is currently no cure for HIV, but HIV regimen (usually with 3 HIV medicines from 2 different classes combined into one pill taken once a day) known as antiretroviral therapy (ART) is available to suppress HIV replication to undetectable level in order to prevent damage to the immune system, lowers the risk of disease progression to AIDS and transmission to others. HIV infection is no longer considered a death sentence, it is a chronic but manageable illness. With effective treatment, people with HIV can live a long and healthy life.

Understanding Antiretroviral Therapy (ART)

What is ART?

Antiretroviral therapy (ART) involves using a combination of HIV medicines to treat HIV infection. People on ART take a combination of HIV medications every day as prescribed by their healthcare provider.

How ART Works:

Suppresses viral replication: Prevents HIV from multiplying
Increases CD4 cell count: Helps rebuild the immune system
Reduces viral load: Can achieve undetectable status
Prevents disease progression: Reduces risk of opportunistic infections
Prevents HIV transmission: Undetectable = Untransmittable (U=U)

Current HIV Treatment Guidelines

When to Start Treatment

Current guidelines recommend starting ART:

Immediately after diagnosis regardless of CD4 count
As soon as possible after HIV diagnosis
During acute HIV infection for better long-term outcomes

Treatment Goals

Maximal and durable suppression of viral load
Restoration and preservation of immunological function
Improved quality of life
**Reduction of HIV-related morbidity and mortality
Prevention of HIV transmission

HIV Medication in HK

There are several classes of HIV medicine (REF5), each targeting a different pathway in the HIV replication cycle, which includes:

Nucleoside reverse transcriptase inhibitors (NRTIs) – Block reverse transcriptase
Non-nucleoside reverse transcriptase inhibitors (NNRTIs) – Bind to reverse transcriptase
Protease inhibitors (PIs) – Block protease
Fusion inhibitors – Block HIV from entering CD4 cells
CCR5 antagonists – Block CCR5 co-receptors
Integrase strand transfer inhibitors (INSTIs) – Block integrase
Attachment inhibitors – Bind to gp120 protein
Post-attachment inhibitors – Block CD4 receptors
Pharmacokinetic enhancers – Increase the effectiveness of HIV medicine

HIV replication cycle.

Credit: https://www.niaid.nih.gov/diseases-conditions/hiv-replication-cycle

Undetectable = Untransmittable (U=U)

The PARTNER (Partners of People on ART – A New Evaluation of the risks) study and the Opposite Attract study were carried out to assess the risk of HIV transmission to the HIV-negative partner from their HIV-positive partner on ART with undetectable HIV viral load. The results show that none of the HIV-negative partners contracted HIV from their HIV-positive partners despite regular unprotected (condomless) sex. However, not everyone on ART can achieve and maintain an undetectable viral load. So, it is crucial for people living with HIV to take their medicine every day and monitor their viral load regularly.

Managing Side Effects and Complications

Common Side Effects:

Initial side effects: Nausea, headache, dizziness, diarrhea (often temporary)
Long-term considerations: Bone density, kidney function, cardiovascular health
Metabolic changes: Lipid abnormalities, insulin resistance

Management Strategies:

Symptom-specific treatments
Timing adjustments (taking with food or at bedtime)
Medication switches when necessary
Supportive care and lifestyle modifications

Special Considerations in HIV Treatment

Treatment in Special Populations

Pregnancy: ART to prevent mother-to-child transmission
Children and adolescents: Age-appropriate formulations and dosing
Older adults: Managing comorbidities and polypharmacy
Co-infections: TB, hepatitis B and C management
Renal or hepatic impairment: Adjusted regimens

Drug Interactions

Common interactions: With other medications, supplements, and recreational drugs
Important to discuss: All medications with healthcare providers
Regular review: Of complete medication list