What is the treatment for HIV infection

HIV AIDS> Treatment

1. The most important things in a nutshell

If the diagnosis is made early, HIV infection can now be treated in such a way that the onset of AIDS can be delayed for decades or even prevented. The current state of research is antiretroviral therapy (ART, therapy against the retrovirus HIV), a combination therapy of several different drugs. This must always be individually adapted to the patient and requires a good specialist knowledge of the doctor. Therefore, those affected should consult a specialist.

ART inhibits the reproduction of the HI virus, ideally below the detection limit, but it cannot cure the infection. Consistent, continuous, lifelong use of medication is essential. Because of the side effects and the long duration, this is a major challenge for people infected with HIV. If the psychological stress is particularly high, psychotherapy can help.

2. Antiretroviral Therapy (ART)

Antiretroviral therapy (ART) is also known as HAART (highly active antiretroviral therapy), cART (combined ART) or simply “combination therapy”. It was introduced in 1996 and is constantly evolving with medical advances.

Resistant mutations can develop when antiretroviral drugs are given as monotherapy. In order to prevent the development of resistance, several substances are combined with one another in ART therapy. These attack at different points in the HIV life cycle or have a different mechanism of action. The HI viruses can only multiply effectively again when they have become resistant to several active substances at the same time. For the success of the therapy and to prevent resistance, it is extremely important that the therapy is consistently adhered to.

ART has been proven to work only against HIV type 1. For treatment of the infection with HIV-2, which occurs very rarely in Germany, one should contact a recognized HIV specialist. Contact addresses can be found at www.hivandmore.de> Arztsuche.

2.1. Therapy goals

The ART has several goals:

  • Inhibit the multiplication of the HI viruses and thus reduce the viral load in the blood
  • Suppress symptoms of HIV infection
  • Slowing down the progression of the disease, i.e. in the best case improving the immune system
  • Restore cell immunity
  • Reduce inflammation as a result of the chronically active immune system
  • Reduce the risk of infection
  • Enable the person affected to live as normal and long as possible with a good quality of life

2.2. Therapy success

An effective ART should reduce the viral load to 0 or below the laboratory detection limit (less than 20 viral RNA copies per ml of blood). The so-called virus concentration drops quickly at first, then more slowly. The target value “below the detection limit” should be reached after 3 to 4 months, at most after 6 months. If only a few HI viruses are active, the immune system can also recover and the number of T helper cells increases.

Patients with a viral load below the detection limit are no longer considered to be contagious. Nevertheless, HIV-infected people with a low viral load should also follow the recommended protective measures, especially safer sex and safer use (for more information under HIV AIDS> Prevention), because they protect themselves from other infections.

In HIV-infected people, the values ​​of the T helper cells and the HIV-RNA are determined at short intervals after the therapy has been initiated. If ART shows lasting success, control measurements every 3 months or as agreed with the attending physician are sufficient.

ART works better, the fewer symptoms are already present. It is important to take it continuously, as an interruption or discontinuation of the therapy leads to an increase in the viral load or promotes resistance through the restructuring of the genetic information.
In the case of late diagnoses, especially if AIDS has already broken out, the prognoses are significantly worse. Late diagnoses are more common among women.

As before, an HIV infection cannot be cured, which means: HI viruses always remain in the body. There is also no vaccine (yet) against infection with HIV. Nevertheless, the therapy now enables an almost normal life expectancy.

2.3. Combination therapy drugs

ART is a combination of at least 3 different antiretroviral drugs.

The "I" in the abbreviations always stands for "inhibitor". The drugs are divided into different classes. Most work on enzymes that are necessary for the HIV reproductive cycle.

2.3.1. Entry Inhibitors

This group includes 3 different substances or attack sites to prevent the HIV virus from entering the cell. They either block the docking points of the virus with the cell (attachment inhibitors), occupy a second necessary binding site on the target cell (coreceptor antagonists) or prevent the virus and target cell from merging (fusion inhibitors).

2.3.2. Reverse transcriptase inhibitors (RTI)

Nucleoside reverse transcriptase inhibitors (NRTIs), also known as nucleoside analogs, were the first HIV drugs. The conversion of the HIV-RNA (genetic material of the HI virus) into DNA by the enzyme reverse transcriptase is a step necessary for the virus to multiply. NRTIs are “wrong” building blocks that are modeled on natural cell building blocks (nucleoside analogs). Instead of the “correct building blocks”, they are built into the new DNA and cause the DNA chain to be broken.

NNRTIs (non-nucleoside reverse transcriptase inhibitors) are synthetically produced substances that bind directly to the enzyme reverse transcriptase and thus prevent nucleoside binding and molecule chaining.

2.3.3. Integrase Inhibitor (INI)

The HIV virus needs the enzyme integrase to integrate its converted DNA into the DNA of the human cell. Integrase inhibitors prevent this.

2.3.4. Protease inhibitors (PI)

The enzyme protease enables new HI viruses to be built from protein components. Protease inhibitors block this process so that only harmless virus particles are produced. The effect of the protease inhibitors is increased (“boosted”) by a low dose of 2 other drugs: either ritonavir (PI / r) or cobicistat (PI / c).

2.3.5. combination

The common combination therapies currently consist of 2 NRTI + 1 NNRTI + 1 INI or boosted PI.

Monotherapies, i.e. therapies only with NRTI or NNRTI, are no longer considered to be indicated today. Dual therapy approaches without an NRTI component are also no longer recommended today.

The exact composition of the drug combination varies from person to person and is based on the patient's living situation as well as any other infections, diseases and side effects. Tried and tested fixed combinations are usually prescribed, i.e. several drugs in one tablet. They have the advantage that they are easier to take. If that does not work, e.g. because the dose does not fit, a component is not tolerated, a resistance or another disease is present, the individual substances are prescribed.

2.4. Technical information guideline

The German and Austrian AIDS societies jointly publish the “German-Austrian guidelines for antiretroviral therapy for HIV infection”. These guidelines are updated regularly due to the rapid changes in therapeutic knowledge. Download from www.awmf.org> search term: "HIV".

3. Start of therapy

Because of the side effects and interactions, the start of ART is sometimes delayed. However, due to increasingly tolerable drugs, treatment begins earlier and earlier, as it has been shown that starting therapy earlier improves the prognosis. However, the development of viral resistance and the long-term side effects of HIV drugs must be weighed against the benefits of starting therapy early.

 

There are several factors that can help you decide whether to start therapy or to wait:

  • complaints
  • Number of helper T cells
  • Viral load (number of viruses in the blood)

 

Treatment is generally recommended if the T helper cell count is below 200 / microliter. If the person concerned has symptoms such as persistent tiredness and weakness or prolonged diarrhea, therapy should be started earlier.

 

Additional criteria for starting therapy early (with a number of T helper cells between 350 and 500 / microliter of blood) can also be:

  • Pregnancy (for details see HIV AIDS> Family Life Travel)
  • Hepatitis B in need of therapy
  • Chronic hepatitis C
  • Older age (from 50 years)
  • High cardiovascular risk
  • Rapid decrease in the number of T helper cells
  • Immunosuppression in chemotherapy, radiotherapy, autoimmune diseases, or transplantation
  • Lowering the risk of transmission

 

The individual professional associations currently give slightly different recommendations for starting therapy, but these always have to be coordinated individually. In order not to miss the right time to start therapy, it is important that those affected are regularly examined by a doctor who specializes in HIV.

4. Consistent medication intake

Most HIV drugs must be taken once or twice a day to be effective and to avoid the development of resistance. The application must be consistent and lifelong. Therapy breaks may only take place in close consultation with a specialist doctor. This requires good cooperation and a lot of discipline on the part of the patient. For this reason, the person affected should take the time to consider whether he understands the need to start therapy and is willing to consistently adhere to it.

Taking medication is also a challenge because severe side effects often occur, especially at the beginning. Then many patients who have not yet felt any symptoms of the infection feel worse with the therapy than without it. However, the long-term prognosis is considerably better with ART, so a rapid start of therapy is recommended.

If the side effects are too severe, other medications must be switched to. Since the drugs act in the body at different speeds and for different lengths of time, the discontinuation or conversion must also be carefully planned by the specialist so that there is no unwanted break in therapy.

Therapy breaks may only take place in close consultation with a specialist doctor. If the tablets are not taken regularly, their blood levels drop and the HIV viruses can multiply again. In addition, resistances can develop, which lead to the viral load increasing despite taking the medication again, because the viruses no longer react to the medication. Cross-resistance often occurs, i.e. if a drug in one group no longer works, this usually also applies to all other drugs in the group. The treatment options are considerably limited if resistance develops. To prevent this, patients should inform themselves carefully in advance and consistently follow the doctor's recommendations. This is the only way to effectively suppress the replication of the virus and thus also the destruction of the T helper cells and prevent therapy failure. Therapy failure means that the virus count increases again and at some point AIDS breaks out. According to information from the Robert Koch Institute, the most common reason for therapy failure is incorrect medication intake. Patients should therefore inform themselves carefully here and consistently adhere to the recommendations of the doctor.

5. Treatment of opportunistic infections and diseases

HIV weakens the immune system, which is why HIV-infected people can be severely affected by diseases or infections that the immune system of healthy people defends against. For examples of opportunistic infections, see HIV AIDS> General.

Where available, preventive measures should be taken against opportunistic diseases and infections.

Opportunistic infections and illnesses need treatment. In doing so, however, interactions with the drugs used in HIV therapy must often be taken into account, which is why one should only consult doctors with the appropriate specialization for these diseases.

6. Side effects

ART drugs can have various, sometimes severe, side effects.

A distinction is made between acute side effects, which occur at the beginning of therapy and usually disappear again after 2 to 4 weeks, and long-term side effects, which often only become noticeable after years and occur gradually.

Depending on the substance group, go to the acute side effects gastrointestinal complaints such as bloating, stomach problems, nausea and diarrhea as well as rashes, headaches and increased liver values.

To the Long term side effects include nerve disorders (polyneuropathy), fat distribution disorders such as lipodystrophy with the breakdown of fatty tissue in the face, buttocks, arms, legs and accumulation on the stomach and neck (bull's neck), increased blood sugar, changes in fat metabolism with an increase in cholesterol / triglycerides and thus an increased risk of heart diseases -Circulatory system.

7. Interactions

Paying attention to interactions is particularly important in HIV patients, as at least 3 drugs are usually used in the context of ART alone. In addition, there are often concomitant medications and dietary supplements, possibly also medication for opportunistic infections.

Interactions can lead to drugs having a stronger (poisoning) or weaker (undesired therapy break) effect than planned. If several doctors are treating, it is important to ensure that everyone is informed about the entire range of intake.

Since it is often difficult to make predictions and the organism reacts very differently from person to person, the drug level is sometimes determined (so-called TDM - Therapeutic Drug Monitoring). An analysis of the drug concentrations in the blood is carried out.

Continuously updated, English-language specialist information on interactions with HIV drugs is available on the website provided by the University of Liverpool at www.hiv-druginteractions.org.

8. Psychotherapy

The shock of the diagnosis, the knowledge that you are suffering from an incurable disease, an uncertain course, problems in your professional and private life, constant pressure to adhere to therapy, discrimination, side effects of medication and the deterioration of the overall condition can be very stressful for those affected .

For many, the diagnosis changes the life situation and life planning, hardly anyone just continues to live as before: Fear, sadness, guilt or shame can play a role. Help is provided by self-help groups, contact details under HIV AIDS> Addresses, and advice centers.

Anyone who feels permanently stressed should not be afraid to seek psychotherapeutic treatment. It does not have to be prescribed and up to 4 trial sessions are possible, see psychotherapy for more information.

9. Who can help?

The advice centers of the German Aidshilfe provide addresses of specialized practices, contact at www.aidshilfe.de> Advice. Most are only available in larger cities. However, because of the better long-term prognosis, one should not shy away from the path.

10. Related links

Guide to HIV and AIDS

HIV AIDS

HIV AIDS> General

HIV AIDS> Age and Care

HIV AIDS> Rehabilitation

HIV AIDS> Family Life Travel