HIV Module 3

The third module deals with treatment of HIV, drugs used and care to be given to HIV patients.

When to start HIV Treatment.

           Drugs against HIV (HAART) Highly Active Antiretroviral Treatment) are not emergency drugs and need not be initiated on the same day of HIV diagnosis or in a casualty or without adequate preparation. If the infected individual has TB, then TB has to be treated first and not HIV. HIV drugs can be administered after a week or two. The drugs currently used for treating HIV come in the form of pills and need to be taken at the same time daily without fail. So the individuals who need treatment should be given adequate counselling and should be mentally well prepared before starting the treatment. The person should have the will power to take the pills everyday for lifelong without fail. If the drug dose in the blood remains adequate round the clock, HIV cannot multiply uncontrollably in the body. So to control HIV in one’s body, all one needs is to ensure that the pill is taken daily at the same time: Tenofovir, Lamivudine and Efavirenz are the three drugs commonly used and they are combined into a single pill.

Drugs used against HIV.

First line treatment.

First line drugs are used to start treatment for the first time in HIV infected individual. Mainly two groups of drugs are used as first line drugs. It was observed that single drugs are not effective in the long run and hence a combination of three drugs is being used for treatment. The two groups of antivirals used are NRTI- Nucleoside Reverse Transcriptose Inhibitors- and NNRTI- Non Nucleoside Reverse Transcriptose Inhibitors. Tenofovir, Lamivudine Zidovudine and Stavudine belong to NRTI group. Nevirapine, Epavirenz etc belong to NNRTI group. Usually the combination pills consist of two drugs from NRTI group and one from NNRTI group. The selection of drugs is done after considering the health status and laboratory blood results of the individual. In those individuals who regularly take the medication, a rise in CD4 value, increase in body weight and general well being can be observed within few months time. This healthy status can be maintained for a long period with regular medication and follow up visits.

Second line treatment.

           After years of the first line treatment, some patients reach a point were the drugs are not effective any longer. This can be observed usually after 10 to 15 years of treatment but rarely it occurs earlier too. The high CD4 level starts falling in their case. Diseases related to immune suppression reappear. This stage is called “First line treatment failure”. it can happen due to various reasons. If the person has missed his daily pills for even one or two days, the drug levels in his blood can drop and HIV can gain strength. Gradually, this may lead to drug resistance of the virus. Such resistant virus, if transmitted to another individual cannot be suppressed and would result in an early first line treatment failure in him/her. This is why doctors and counsellors involved in HIV care emphasise very much on regular medications and adherence to timely drugs.

            First line treatment failure should be confirmed by laboratory tests. In failed cases, HIV viral load test shows viral copies in thousands or lakhs. In such confirmed cases, second line drugs are initiated without delay. Second line drugs include Protease Inhibitor group in addition with NRTI group. A different drug from NRTI group which was not used before in the same individual is included in the second line drug. This is because the virus might already have acquired resistance against the drugs used earlier. Zidovudine (NRTI) and the protease inhibitors like Lopinavir, Atazanavir and Ritonavir are used in second line treatment. These drugs are also administered as one or two pills taken daily at a fixed time.

           Regular laboratory tests need to be done at fixed intervals after the initiation of treatment. This is to find out if there are any side effects experienced by the individual. Haemoglobin, kidney function tests (RFT) and liver function tests are to be done at regular intervals to monitor side effects. CD4 tests are done every 6 months to assess the effect of the drug and evaluate the progress of health of the individual. 

           Second line treatment might also fail after several years of treatment, and this is because HIV slowly attains resistance to these drugs.Third line of drugs is now available in the market. There are many HIV infected individuals leading normal lives performing all kind of jobs without any health issues for 10 to 20 years on first and second line treatment.

Initiation of HIV treatment,

           In the past, drugs were not administered if the CD4 count was above 500 cells. But the latest guidelines by WHO instruct treatment to be given to HIV positive individuals irrespective of CD4 counts. Early initiation of treatment in HIV infected children can ensure their normal growth and optimum health.

Treatment of HIV related diseases.

            Other illnesses resulting from the HIV induced immune suppression, should also receive timely treatment. TB, Pneumonia, Fungal and Protozoal infections and Cancer should be detected and treated along with HIV drug administration. Nutritious diet, multi vitamin tablets, regular execrcise and positive thinking may have beneficial effects on HIV infected individuals. On the contrary, smoking, tobacco, alchohol, drugs etc can worsen HIV related health issues.

           Next module will be about recommended preventive measures for protecting individuals from HIV infections.