What Is Antiretroviral Therapy For Human Immunodeficiency Virus Infection
Antiretroviral therapy for human immunodeficiency virus infection is a treatment regimen used to reduce the amount of the virus in the body . There is no cure for HIV, but antiretroviral therapy can slow the progress of the infection and reduce the chances of transmission to others.
Many classes of HIV antiretroviral drugs act in different ways to control virus proliferation. Antiretroviral therapy usually is a combination of three or more types of medications that target the virus at different stages of its life cycle. Multiple angles of attack improve the chances of reducing the viral load.
Antiretroviral therapy is started immediately after diagnosis of HIV infection to decrease its risk of progression and transmission. HIV antiretroviral therapy regimen is tailored to suit individual requirements based on several factors that include:
- Other diseases or conditions of the patient
- Potential interactions with other medications of the patient
- Patients tolerance to ART side effects
- Results of viral drug-resistance tests
- Convenience of the regimen
Antiretroviral therapy is a lifelong treatment, but it can keep HIV-infected people healthy and active for many years. It is important to never stop the medication, even if the viral load drops to undetectable levels. If treatment is interrupted, the virus is more likely to mutate and become drug-resistant.
Taking Antiretroviral Treatment With Other Medicines
If you are taking other medications or drugs including: treatments for other health conditions contraception hormonal therapies or use psychoactive drugs, its important that your doctor knows about this. Different drugs can interact, changing the way that they work. This may mean that a drug becomes too strong or that a drug becomes too weak, so that it can no longer control your HIV, prevent pregnancy or treat another health condition. Discuss the medication you take with your healthcare workers so they make sure that the combination is safe and will work well for you.
Generic Antiretrovirals And Multi
In 2017, savings to the U.S. health care system generated by the use of generic drugs and biosimilar products totaled $265 billion, including $40.6 billion and $82.7 billion in savings to Medicaid and Medicare, respectively.27
With substantial improvements in the long-term safety and effectiveness of contemporary ART, a number of regimens and regimen components in Table 6 remain listed beyond their patent protection date and are or will be available as lower-cost generic options. In one study, the savings associated with a transition to a hypothetical lower-cost generic ART could potentially help cover the 20-year, $480 billion projected costs to reach national treatment targets.5
Some research informs the cost impact of using specific generic ARV regimens or regimen components. In a cost-effectiveness analysis conducted before the availability of integrase strand transfer inhibitors , the use of generic efavirenz had an estimated saving of nearly $1 billion, and a regimen with generic EFV was very cost-effective.2 A more recent study describes a 25% reduction in both the wholesale acquisition cost and federal supply schedule cost associated with switching from branded coformulated dolutegravir/abacavir/lamivudine to branded DTG plus generic ABC and generic 3TC.2, 28
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What Is Hiv Infection
HIV infection is caused by a virus that attacks the human immune system. Once the HIV enters the bloodstream, it binds to a kind of receptor on the surface of the T-cells . T-cells are a type of white cells in the blood that help fight infection.
The virus enters the T-cell and replicates itself, destroying the host cell. As a result, the body slowly loses its ability to fight infections.
A person contracts an HIV infection by contact with bodily fluids such as blood, semen, vaginal fluids, or breast milk from an infected person. Primary modes of HIV transmission are:
- Sexual contact
- Sharing needles for injecting drugs
- From mother to the baby during pregnancy, delivery, or breastfeeding
Acquired immune deficiency syndrome occurs in the later stages of an HIV infection. When HIV infection progresses to an extent that a persons immune system becomes too weak to fight off common infections, the person becomes susceptible to certain cancers and tuberculosis.
There are two main types of human immunodeficiency virus, HIV-1 and HIV-2, and each type has multiple groups and strains of virus. Both HIV infections can lead to AIDS, but they are different from each other. HIV-1 is the most common infection found worldwide and referred to as HIV. HIV-2 is found mostly in a small population in West Africa, and in a few people in the US primarily from West Africa.
Rapid Art Initiation Is Safe
In the San Francisco study discussed above , 89.7% of patients used integrase strand transfer inhibitor -containing regimens and 12.8% used protease inhibitor-containing regimens. The predominant INSTI-based regimen was dolutegravir plus emtricitabine/tenofovir disoproxil fumarate. The clinic did not have any cases of major resistance mutations to the prescribed ART regimen, and no regimen switches were made because of resistance. Two patients had their regimens changed because of rash, and in 10 cases, the regimen was simplified to a single-tablet regimen.
Of 149 patients initiating ART through a program in New York City, only 1 required a regimen change because of subsequently detected resistance .
Rapid ART initiation is safe. Most designated regimens for rapid ART initiation are the same regimens that are recommended as initial treatment in the existing NYSDOH, International Antiviral SocietyUSA, and DHHS guidelines. These regimens are well-tolerated and effective, and the likelihood of drug resistance is low based on the current prevalence of drug resistance .
References
Amanyire G, Semitala FC, Namusobya J, et al. Effects of a multicomponent intervention to streamline initiation of antiretroviral therapy in Africa: a stepped-wedge cluster-randomised trial. Lancet HIV 2016 3:e539-e548.
CDC. Understanding the HIV care continuum. 2018
NYCDHMH. HIV surveillance annual report, 2017. 2018
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Patients Cured Of Hiv Infection
The so-called “Berlin patient” has been potentially cured of HIV infection and has been off of treatment since 2006 with no detectable virus. This was achieved through two bone marrow transplants that replaced his immune system with a donor’s that did not have the CCR5 cell surface receptor, which is needed for some variants of HIV to enter a cell. Bone marrow transplants carry their own significant risks including potential death and was only attempted because it was necessary to treat a blood cancer he had. Attempts to replicate this have not been successful and given the risks, expense and rarity of CCR5 negative donors, bone marrow transplant is not seen as a mainstream option. It has inspired research into other methods to try to block CCR5 expression through gene therapy. A procedure zinc-finger nuclease-based gene knockout has been used in a Phase I trial of 12 humans and led to an increase in CD4 count and decrease in their viral load while off antiretroviral treatment. Attempt to reproduce this failed in 2016. Analysis of the failure showed that gene therapy only successfully treats 11-28% of cells, leaving the majority of CD4+ cells capable of being infected. The analysis found that only patients where less than 40% of cells were infected had reduced viral load. The Gene therapy was not effective if the native CD4+ cells remained. This is the main limitation which must be overcome for this treatment to become effective.
What Are The Components Required To Implement This Program
A successful ART program requires all of the following:
- Diagnosis. A means for testing individuals to identify those in need of treatment. In the case of ART, diagnosis consists of more than merely testing an individual for HIV/AIDS. This is because when the disease is far enough along, the toxicity of the drugs may outweigh the benefits of starting treatment.5
- Distribution. A method for distributing the drugs to those who need them.
- Drugs. Antiretroviral drugs can be costly.
- Patient adherence to drug regimen. ART consists of a relatively complex drug regimen to which patients must strictly adhere.6 And because ART does not cure HIV/AIDS,7 patients must adhere to the regimen as long as they remain alive.
- Monitoring of the patient’s response to treatment. ART may cause negative side effects in a patient.8 In addition, laboratory monitoring may be needed for purposes of noticing decreased efficacy or the development of resistance.9
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Enhancing Healthcare Team Outcomes
The management of HIV patients is best with an interprofessional team that includes clinicians, mid-level practitioners, ID specialists, pharmacists,s and infectious disease nurses. The pharmacist should verify the chosen regimen, check for drug interactions, verify dosing, and assumes responsibility for patient counseling. Nursing can make an initial assessment of treatment effectiveness and, particularly, patient compliance. Nursing also must participate in patient education because improper compliance can lead to disastrous therapeutic failure. All healthcare team members must press the point of compliance when they have the opportunity, and any concerns about the regimen or compliance require communication to the treating physician.
Overwhelming data shows that HAART can improve survival and reduce the risk of opportunistic infections. Thus, healthcare workers need to understand these medications because of their effectiveness and the potential adverse effects that can occur. When in doubt about HAART, a consultation with an infectious disease expert is the recommended approach.
Only with a complete “all in,” collaborative interprofessional team approach can ART have its best chance for therapeutic success while minimizing adverse events.
Where Are These Art Centres Located
In order to make treatment more accessible ART centres are located in medical colleges, district hospitals and non-profit charitable institutions providing care, support and treatment services to PLHA. A PLHA network person at each of the ART centre facilitates access to care and treatment services at these centres. ART centres also provide counselling and follow up on treatment adherence and support through community care centres.
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Benefits Of Statin Use For Cv Disease
Statins competitively inhibit hydroxy-3-methylglutaryl coenzyme A reductase impairing cholesterol biosynthesis and decreasing hepatic cholesterol concentrations , . These actions result in decreased cholesterol in plasma and cell membranes, explaining their widespread use in the primary and secondary prevention of CVD. Statins also have anti-inflammatory effects by decreasing circulating concentrations of pro-inflammatory cytokines, improving endothelial function, and stabilizing coronary plaques .
The Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults was released by the American College of Cardiology/American Heart Association in November 2013, to replace the outdated Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults , . The new guidelines eliminated LDL-cholesterol targets, and created 4 groups of patients that could benefit most from statin therapy: patients with atherosclerotic cardiovascular disease , patients with LDL-C 190 mg/dL, patients age 4075 years with diabetes mellitus and LDL-C of 70-189 mg/dL without ASCVD, and patients age 4075 years with LDL-C of 70-189 mg/dL and an estimated 10 year ASCVD risk of 7.5% without ASCVD or diabetes mellitus. Based on these changes, statin therapy is now recommended for a much larger percentage of the general patient population.
It’s Not The Same As An Art Class
People often wonder how an art therapy session differs from an art class. Where an art class is focused on teaching technique or creating a specific finished product, art therapy is more about letting clients focus on their inner experience.
In creating art, people are able to focus on their own perceptions, imagination, and feelings. Clients are encouraged to create art that expresses their inner world more than making something that is an expression of the outer world.
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What Hiv Medicines Are Included In An Hiv Treatment Regimen
There are many HIV medicines available for HIV treatment regimens. The HIV medicines are grouped into seven drug classes according to how they fight HIV.
The choice of an HIV treatment regimen depends on a person’s individual needs. When choosing an HIV treatment regimen, people with HIV and their health care providers consider many factors, including possible side effects of HIV medicines and potential drug interactions.
What Is The Treatment For Hiv
The treatment for HIV is called antiretroviral therapy . ART involves taking a combination of HIV medicines every day.
ART is recommended for everyone who has HIV. ART cannot cure HIV, but HIV medicines help people with HIV live longer, healthier lives. ART also reduces the risk of HIV transmission.
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Baseline Laboratory And Resistance Testing
All patients with a reactive HIV test result should undergo the baseline laboratory testing listed in Box 2, below. For discussion of baseline testing, see the NYSDOH AI guideline Selecting an Initial ART Regimen > ART-Initiation Laboratory Testing. It is not necessary to wait for these test results before initiating ART.
| Box 2: Baseline Laboratory Testing Checklist |
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References
Abdool Karim SS, Naidoo K, Grobler A, et al. Timing of initiation of antiretroviral drugs during tuberculosis therapy. N Engl J Med 2010 362:697-706.
Boulware DR, Meya DB, Muzoora C, et al. Timing of antiretroviral therapy after diagnosis of cryptococcal meningitis. N Engl J Med 2014 370:2487-2498.
Ford N, Migone C, Calmy A, et al. Benefits and risks of rapid initiation of antiretroviral therapy. AIDS 2018 32:17-23.
Torok ME, Yen NT, Chau TT, et al. Timing of initiation of antiretroviral therapy in human immunodeficiency virus associated tuberculous meningitis. Clin Infect Dis 2011 52:1374-1383.
WHO. Guidelines for managing advanced HIV disease and rapid initiation of antiretroviral therapy. 2017
Benefits And Risks Of Art
Lead authors: Asa Radix, MD, MPH, and Noga Shalev, MD, with the Medical Care Criteria Committee, updated October 2021
| RECOMMENDATION |
Benefits and Risks of ART
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Antiretroviral therapy refers to the use of pharmacologic agents that have specific inhibitory effects on HIV replication. The use of fewer than three agents is not recommended for initiating rapid treatment. These agents belong to six distinct classes of drugs: the nucleoside and nucleotide reverse transcriptase inhibitors , the non-nucleoside reverse transcriptase inhibitors , the protease inhibitors , the fusion inhibitors , the CCR5 co-receptor antagonists, and the integrase strand transfer inhibitors . See all commercially available antiretroviral drugs that are approved by the U.S. Food and Drug Administration for the treatment of HIV/AIDS.
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Change In Terminology Is About More Than Semantics
Antiretroviral therapy is used to treat HIV and is comprised of a combination of drugs that block different stages in the virus’ replication cycle. By doing so, the virus can be suppressed to undetectable levels where it can do the body little harm.
The effectiveness of the combination antiretroviral therapy was first reported by researchers in 1996 at the International AIDS Conference in Vancouver, who dubbed the approach HAART .
Today, the term HAART is less commonly used and has largely been supplanted in the medical literature by the simplified ART . The change in terminology is about more than just semantics it reflects a shift in the goals and benefits of HIV therapy and a step away from what HAART historically implied.
Immediate Antiretroviral Therapy Initiation On The Day Of Hiv Diagnosis
Since individuals may fail to engage in care between the initial HIV diagnosis and the time ART is prescribed, some groups have proposed rapid ART initiation on the same day of HIV diagnosis as a strategy to increase ART uptake and engagement in care and to accelerate the time to ART-mediated viral suppression. Rapid ART initiation also has the potential to reduce the time during which people with newly diagnosed HIV can transmit HIV. The rapid ART initiation strategy is supported by randomized controlled trials that were performed in resource-limited settings outside of the United States27-29 and observational trials in the United States that included both immediate initiation of ART 30-32 and rapid ART initiation .32,33 The results from some of these studies are discussed below.
There are many differences between health care in southern Africa and Haiti and in the United Statesincluding differences in the health care systems, structural barriers to engagement in care, underlying HIV and tuberculosis epidemics, and ART regimens usedthat limit the generalizability of the findings of the results from the studies described above. These studies, however, suggest that same-day initiation of ART is feasible and could potentially improve clinical outcomes.
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Cost Sharing In The United States
Prescription drug pricing in the United States involves complex systems with varying requirements for mandatory and voluntary discounts, rebates, and reimbursement rates, and much of the pricing information is confidential. Prices can vary depending on the state, purchaser, type of public or private insurance coverage in use, and number of generic competitors to branded drugs . Therefore, providers may find it difficult to navigate payer cost-containment practices, including formulary restrictions, prior authorization requirements, and patient cost-sharing arrangements, such as copayments , coinsurance , and insurance deductible payments.
Maximum allowable copayments on prescription drugs covered by Medicaid can vary by family income, but they are usually nominal. For commercial insurers, cost sharing generally is subject to maximum payment rules under the Affordable Care Act . Manufacturer cost-sharing assistance programs are available for most brand-name ARV products but may be restricted by pharmacy and by state. Manufacturer copay assistance also may be subject to copay accumulator programs implemented by insurers pharmacy benefit managers , whereby manufacturer payments do not count toward a patients deductible or out-of-pocket maximum.