It is recommended that all patients with early HIV infection begin antiretroviral therapy (ART) as soon as possible; initiation of ART soon after the initial HIV infection may be associated with a greater chance of immune reconstitution to normal or near-normal CD4+ lymphocyte levels. The goals of ART include durable suppression of HIV viral load to less than 50 copies/mL, restoration of immune function (as indicated by the CD4+ lymphocyte count), prevention of HIV transmission, prevention of drug resistance, and improvement in quality of life. ART regimens for treatment-naive patients are composed of a “base” medication and a “backbone” regimen. The base is either an integrase strand transfer inhibitor, a nonnucleoside reverse transcriptase inhibitor (NNRTI), or a protease inhibitor (PI). The backbone typically consists of 2 nucleoside reverse transcriptase inhibitors (NRTIs). Treatment is based on adverse-effect profiles, comorbidities, potential drug interactions, results of drug resistance testing, virologic efficacy, allergy history, pregnancy status, pill burden, and dosing frequency.
ART has been shown to dramatically reduce the HIV viral load, increase CD4+ lymphocyte counts, delay disease progression, reduce the number of opportunistic infections, decrease the number of hospital admissions, and prolong survival. Some statistics show up to an 82% decline in the number of opportunistic infections in patients on ART. These advantages translate into improved survival and enhanced quality of life for HIV-infected patients.
A small percentage of the population appears to be naturally immune to HIV infection. These persons have defective genes for CCR5, a surface receptor that HIV requires to attach to T lymphocytes. Also, approximately 50% of long-term survivors of HIV infection are heterozygous for the CCR5 defect. This finding has led to speculation concerning the possibilities for genetic therapy, in which anti-HIV genes could be “injected” into a patient’s chromosomes with a harmless viral vector.
Pre-exposure prophylaxis (PrEP) with tenofovir-emtricitabine can be considered in high-risk individuals. When taken consistently, and when used in combination with condoms and other preventive methods, PrEP can reduce the risk of HIV infection in high-risk patients. For post-exposure prophylaxis (PEP), ART is taken within 72 hours after possible exposure to HIV. Efforts continue to develop a safe and effective HIV vaccine.
Günthard HF, Saag MS, Benson CA, et al. Antiretroviral drugs for treatment and prevention of HIV infection in adults: 2016 Recommendations of the International Antiviral Society—USA panel. JAMA. 2016; 316(2):191–210.
World Health Organization. Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection: Recommendations for a Public Health Approach. 2nd ed. Geneva, Switzerland: World Health Organization; 2016.
Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.