HIV Treatments and Medications

Before there was Covid-19, there was HIV/AIDS. Caused by an RNA virus similar to coronavirus, HIV/AIDS swept around the globe in the 1980s. Fortunately, the virus was not as easy to catch as Covid-19, but it was fatal to everyone who caught it in those first years of the pandemic. In the decades since, however, science has made great leaps in treating the virus. Although HIV has resisted a cure, HIV medicines can keep the virus under control as a chronic, latent infection. Today, patients with HIV live nearly as long as patients without the infection.

What is HIV?

HIV, or human immunodeficiency virus, infects the body’s immune system. The virus attacks a specific type of white blood cell called the CD4 T lymphocyte. Also called “helper” T-cells, CD4 lymphocytes recognize foreign invaders and sound the alarm to the rest of the immune system to go on the attack.

HIV is spread through sexual fluids (either semen or vaginal fluid), blood, and breast milk. In pregnant women, HIV can infect a baby through the placenta or during labor and delivery. However, the overwhelming majority—67% of HIV infections—are sexually transmitted. Unprotected sex is the single greatest risk factor for HIV infection, but other significant risk factors include untreated STIs, intravenous drug use, blood transfusions, and working in occupations that involve potential exposure to other people’s blood.

As an HIV infection progresses, the amount of CD4 T lymphocytes in the bloodstream decreases, weakening the immune system. Eventually, the body loses the ability to fight off infections and tumors, a condition called HIV Acquired Immune Deficiency Syndrome, or HIV/AIDS. Untreated, most HIV infections will progress to AIDS in ten years. Once AIDS develops, most patients who are untreated usually pass away from infections or cancer within two years.

An HIV infection is not curable but can be managed as a chronic illness with medications called antiretroviral drugs. HIV belongs to a family of viruses called retroviruses. These viruses store their genetic information in RNA and use an enzyme called reverse transcriptase to translate this information into DNA. This newly formed DNA then merges with the cell DNA of a different organism to create copies of the virus. Antiretroviral therapy (ART) can target this process and prevent HIV from evolving into AIDS, but it requires a lifelong commitment to daily treatment.

Even when an HIV infection does not progress to AIDS, patients can experience serious complications due to long-term infections or the effects of antiretroviral therapy. Patients with long-term HIV infection may experience some form of neurological problem, cognitive impairment, or dementia (although the incidence of HIV dementia has decreased by almost 50% with the use of treatment). Heart disease, liver disease, and kidney disease are also major complications and some of the leading causes of death in patients with long-term HIV infection.

For all these reasons, prevention is considered the best treatment for HIV and AIDS. While about 38 million people worldwide are infected with HIV, widespread education and active prevention measures have reduced new infections in the United States to less than 39,000 per year.

How is HIV diagnosed?

HIV infection is primarily identified through a blood or saliva test, but a thorough medical history, physical exam, and other tests are necessary to determine the stage of the disease and the appropriate treatment.

HIV infection passes through four stages: primary infection, chronic HIV infection, symptomatic HIV infection, and AIDS. These stages are distinguished primarily by symptoms, opportunistic infections, the amount of virus in the body, and declining levels of CD4 cells in the bloodstream.

In some people, primary infection occurs one to four weeks after exposure to HIV and typically lasts for no longer than two weeks, though it can drag on for a few months in rare cases. Flu-like symptoms may be experienced, including fever, sore throat, headache, muscle pain, joint pain, and swollen lymph nodes.

Primary infection is followed by a long, latent HIV infection that can last for several years. During this period, there are typically no symptoms at all. This is followed by symptomatic HIV infection, when the weakened immune system makes the body more vulnerable to infections. Symptoms may include persistently swollen lymph nodes, fatigue, fever, involuntary weight loss, shingles (a viral infection), yeast infections of the mouth (oral thrush), and pneumonia.

Full-blown AIDS is marked by serious, multiple infections that are usually not found in healthy people. In addition, severe symptoms such as involuntary weight loss, chronic diarrhea, fever, fatigue, weakness, cognitive impairment, and Parkinson’s-like symptoms characterize this last stage of HIV infection.

Blood or saliva tests identify the virus or antibodies, but a thorough blood test is required to determine the stage of the disease. Several measures need to be taken:

• Viral load. This test measures the amount of HIV in the blood. Viral load is often the most reliable predictor of HIV/AIDS progression.

• Viral drug resistance. This test identifies strains of HIV that are resistant to some antiretroviral drugs.

• CD4 cell count. This test measures the blood concentration of CD4 T lymphocytes, the white blood cells the virus infects and kills. The normal count is 500 to 1200 CD4 cells per cubic millimeter of blood. Symptomatic HIV typically occurs when CD4 counts fall below 500, and AIDS occurs when CD4 counts drop below 200.

A thorough physical and history are necessary to get a full picture of the medical situation. Other blood tests, urine tests, or imaging may be necessary to properly diagnose other infections or cancers requiring treatment. Neuropsychological tests may be used to identify any cognitive or emotional impairment.

HIV treatment options

The primary goal of HIV treatment is to reduce the viral load to undetectable levels and increase CD4 cell counts. This can only be accomplished through antiretroviral medications, though associated infections or cancers will require separate treatments.

Antiretroviral therapy (ART)

A combination of antiretroviral drugs is used at all stages of an HIV infection to reduce the amount of HIV in the body. Called highly active antiretroviral therapy (HAART), combination drug therapy helps prevent HIV from developing into AIDS.

Prophylaxis

People who are exposed or may be exposed to the virus may also be put on highly active antiretroviral therapy to prevent HIV infection. Pre-exposure prophylaxis (PrEP), intended for people at high risk for infection, involves taking one tablet (Truvada) every day. Post-exposure prophylaxis (PEP), intended for people who may have been exposed to the virus, is a four-week regimen of three antiretroviral drugs.

Prevention

The best treatment for HIV is to avoid getting or spreading the infection. HIV prevention involves limiting the number of sexual partners, wearing a condom during sex, and using clean needles when taking intravenous (IV) drugs. HIV-negative individuals with active sex lives or risky behaviors should regularly undergo HIV testing. People with an HIV infection should inform partners about their HIV-positive status before having sex. Reducing the viral load in the body also helps prevent the spreading of the infection, so HIV-positive individuals should rigorously adhere to their treatment regimen.

HIV medications

Highly active antiretroviral therapy (HAART) is the foundation of HIV and AIDS treatment. It requires taking two or more drugs every day for a lifetime to prevent HIV from progressing to AIDS. If started early enough, people infected with HIV can enjoy a lifespan nearly equal to that of people without HIV.

Antiretroviral drugs

Antiretroviral drugs work by attacking the virus at various stages in its lifecycle. Some drugs prevent the virus from making copies of its genetic material. Other drugs interfere with the virus’s ability to attach to or enter CD4 cells. Additionally, certain drugs can prevent the virus from making new viral particles.

Most antiretroviral therapies involve two, three, or more drugs across two or more drug classes. These include

• Nucleoside reverse transcriptase inhibitors (NRTIs) such as Viread (tenofovir disoproxil fumarate), Ziagen (abacavir), Epivir (lamivudine), and Emtriva (emtricitabine) interrupt the virus’s ability to form a complete copy of its genetic material by blocking the enzyme (reverse transcriptase) needed to make this copy.

• Non-nucleoside reverse transcriptase inhibitors (NNRTIs) such as Sustiva (efavirenz) and Edurant (rilpivirine) interfere with the process the virus uses to create copies of its genetic material.

• Protease inhibitors such as Prezista (darunavir), Norvir (ritonavir), and Reyataz (atazanavir) prevent the virus from making proteins that form the building blocks of virus particles.

• Integrase inhibitors such as Tivicay (dolutegravir). Isentress (raltegravir), and Vitekta (elvitegravir) prevent the virus from entering CD4 cells.

• Fusion inhibitors are a class of drugs with a single representative, Fuzeon (enfuvirtide). This drug prevents viral particles from attaching to CD4 cells, fusing with the cell’s outer membrane, and injecting genetic material into the cell.

• CCR5 antagonists are represented by a single drug, Selzentry (maraviroc) blocks the virus’s ability to attach to a molecule called CCR5 on the outside of CD4 cells so that the virus can’t enter.

• Post-attachment inhibitors are represented by a single drug, Trogarzo (ibalizumab-uiyk) is a synthetic antibody that attaches to the CD4 receptor and prevents the virus from entering CD4 cells.

Pharmacokinetic enhancers

Also called a CY3PA inhibitor, Tybost (cobicistat) is prescribed along with antiretroviral drugs to increase their effectiveness. CY3PA inhibitors block the body’s ability to metabolize drugs, increasing the concentration and availability of antiretroviral drugs in the bloodstream.

What is the best medication for HIV?

HIV medications are always used in regimens of two or more drugs at a time. Many factors determine the appropriate individualized antiretroviral therapy regimen: the stage of the infection, viral load, CD4 cell count, the virus’s resistance to drugs, possible side effects, the presence of hepatitis infection, pregnancy, as well as liver or kidney problems. For this reason, there is no “best” medication for HIV, only the most appropriate combination of drugs for a person’s medical situation.

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Best medications for HIV