1st August 2023

Management

Antiretroviral therapy

The first line treatment for established HIV infection is antiretroviral therapy (ART). ART directly targets the underlying pathophysiology by limiting viral replication and has drastically changed the management of HIV. The goal of treatment is to reduce viral load to undetectable levels.

There are five classes of ART drugs, which are categorised by their mechanism. Examples are listed in the table below, along with common side effects, and the most frequently used drugs highlighted in bold.

Due to the tendency of the HIV virus to mutate, drug resistance is high, so ART is typically given as combination therapy of three or more drugs to reduce resistance. Typically, regimens consist of two nucleoside reverse transcriptase inhibitors (NRTI), with either a non-nucleoside reverse transcriptase inhibitor (NNRTI) or a protease inhibitor (PI). Integrase inhibitors (II) and entry inhibitors (EI) are newer drugs with less long-term evidence available in regard to side effects. They are more expensive than the first line treatments, so they are generally reserved for resistant infections.

Current guidance states that ART should be started as soon as the infection is confirmed, as early treatment is a key positive prognostic factor.

Table 1: Classes and side effects of antiretroviral therapy (ART)

Monitoring

Disease monitoring consists of CD4 count and HIV viral load. The two are linked – a falling CD4 count is associated with a rising HIV viral load and is indicative of disease progression. A falling CD4 count may also suggest a lack of treatment adherence.

Monitoring blood tests for patients on ART include FBC, U&Es, LFTs, lipid profiles and glucose levels to assess for toxicity. Regular reviews of therapeutic compliance and monitoring for the development of any complications is also indicated, with specialist services available to facilitate this.

Patients with CD4 counts below 200 are most at risk of opportunistic infections (see AIDS and Other Complications).

Patient education and support

HIV is a chronic illness that has the potential to cause significant morbidity and a variety of complications, and remains associated with social stigma. As such, education and support are crucial aspects of management. Specialist services exist nationwide, through which patients can access specialist medical care, but also support groups and other forms of psychosocial input to help them live with their disease.

It is crucial that patients with HIV are educated on the risk of infections and fully immunised. Patients with HIV should also not receive live attenuated vaccines. Information on sexual health, and in particular, barrier methods of contraception to reduce transmission risk, is key.