HIV AIDS medical therapy: Difference between revisions
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==Medical Therapy== | ==Medical Therapy== | ||
Anti-HIV medications (also called antiretrovirals) are grouped into six drug classes according to their mechanism of action. | Anti-HIV medications (also called antiretrovirals) are grouped into six drug classes according to their mechanism of action. | ||
The six classes are as follows: | The six classes are as follows: | ||
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Multidrug regimen has proved to be very beneficial because of reduction in progression to AIDS, opportunistic infections, rate of hospitalizations and deaths. <ref name="pmid16054937">{{cite journal |author=Sterne JA, Hernán MA, Ledergerber B, Tilling K, Weber R, Sendi P, Rickenbach M, Robins JM, Egger M |title=Long-term effectiveness of potent antiretroviral therapy in preventing AIDS and death: a prospective cohort study |journal=Lancet |volume=366 |issue=9483 |pages=378–84 |year=2005 |pmid=16054937 |doi=10.1016/S0140-6736(05)67022-5 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(05)67022-5 |accessdate=2012-02-15}}</ref> | Multidrug regimen has proved to be very beneficial because of reduction in progression to AIDS, opportunistic infections, rate of hospitalizations and deaths. <ref name="pmid16054937">{{cite journal |author=Sterne JA, Hernán MA, Ledergerber B, Tilling K, Weber R, Sendi P, Rickenbach M, Robins JM, Egger M |title=Long-term effectiveness of potent antiretroviral therapy in preventing AIDS and death: a prospective cohort study |journal=Lancet |volume=366 |issue=9483 |pages=378–84 |year=2005 |pmid=16054937 |doi=10.1016/S0140-6736(05)67022-5 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(05)67022-5 |accessdate=2012-02-15}}</ref> | ||
===Anti Retroviral Drug Classes=== | |||
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=== | ===Initiation of ART=== | ||
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Skipping medications makes it easier for drug resistance to develop. HIV can develop resistance to the anti-HIV medications in a person’s current regimen or to other, similar anti-HIV medications not yet taken, limiting options for successful HIV treatment. And drug-resistant strains of HIV can be transmitted to others, too. Although there are many different anti-HIV medications and treatment regimens, studies show that a person’s first regimen offers the best chance for long-term treatment success. Adhering to the regimen from the start will help ensure that the HIV treatment is successful. | Skipping medications makes it easier for drug resistance to develop. HIV can develop resistance to the anti-HIV medications in a person’s current regimen or to other, similar anti-HIV medications not yet taken, limiting options for successful HIV treatment. And drug-resistant strains of HIV can be transmitted to others, too. Although there are many different anti-HIV medications and treatment regimens, studies show that a person’s first regimen offers the best chance for long-term treatment success. Adhering to the regimen from the start will help ensure that the HIV treatment is successful. | ||
===Visit Frequency=== | ===Visit Frequency=== | ||
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Transient increase in the viral load can be present in acute illness and [[vaccination]]s. | |||
===Virologic Failure=== | ===Virologic Failure=== | ||
It is defined either as primary failure to achieve a viral load <50 copies/mL or any sustained recurrence of viremia to >50 copies/mL after initial viral suppression.<ref name="pmid20639566">{{cite journal |author=Thompson MA, Aberg JA, Cahn P, Montaner JS, Rizzardini G, Telenti A, Gatell JM, Günthard HF, Hammer SM, Hirsch MS, Jacobsen DM, Reiss P, Richman DD, Volberding PA, Yeni P, Schooley RT |title=Antiretroviral treatment of adult HIV infection: 2010 recommendations of the International AIDS Society-USA panel |journal=JAMA |volume=304 |issue=3 |pages=321–33 |year=2010 |month=July |pmid=20639566 |doi=10.1001/jama.2010.1004 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=20639566 |accessdate=2012-02-20}}</ref> | It is defined either as primary failure to achieve a viral load <50 copies/mL or any sustained recurrence of viremia to >50 copies/mL after initial viral suppression.<ref name="pmid20639566">{{cite journal |author=Thompson MA, Aberg JA, Cahn P, Montaner JS, Rizzardini G, Telenti A, Gatell JM, Günthard HF, Hammer SM, Hirsch MS, Jacobsen DM, Reiss P, Richman DD, Volberding PA, Yeni P, Schooley RT |title=Antiretroviral treatment of adult HIV infection: 2010 recommendations of the International AIDS Society-USA panel |journal=JAMA |volume=304 |issue=3 |pages=321–33 |year=2010 |month=July |pmid=20639566 |doi=10.1001/jama.2010.1004 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=20639566 |accessdate=2012-02-20}}</ref> | ||
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}}</ref> | }}</ref> | ||
==NIH Recommendations== | ==NIH Recommendations== | ||
===NIH Recommendations:Treatment-Naive Patients=== | ===NIH Recommendations:Treatment-Naive Patients=== | ||
Revision as of 20:56, 1 October 2014
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HIV AIDS medical therapy On the Web |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]
Overview
The primary goal of antiretroviral therapy (ART) is to reduce HIV-associated morbidity and mortality. This goal is best accomplished by using effective ART to maximally inhibit HIV replication, as defined by achieving and maintaining plasma HIV RNA (viral load) below levels detectable by commercially available assays. Durable viral suppression improves immune function and quality of life, lowers the risk of both AIDS-defining and non-AIDS-defining complications, and prolongs life. Based on emerging evidence, additional benefits of ART include a reduction in HIV-associated inflammation and possibly its associated complications.
Medical Therapy
Anti-HIV medications (also called antiretrovirals) are grouped into six drug classes according to their mechanism of action. The six classes are as follows:
- Non-nucleoside reverse transcriptase inhibitors (NNRTIs).
- Nucleoside reverse transcriptase inhibitors (NRTIs).
- Protease inhibitors (PIs).
- Fusion inhibitors.
- CCR5 antagonists.
- Integrase inhibitors.
Multidrug regimen has proved to be very beneficial because of reduction in progression to AIDS, opportunistic infections, rate of hospitalizations and deaths. [1]
Anti Retroviral Drug Classes
| Drug Name | Dose |
|---|---|
| Nucleoside Reverse Transcriptase Inhibitors (NRTIs) | |
|
300 mg BID or 600 mg once daily |
|
400 mg once daily In combination with TDF: 200 mg once daily |
|
200 mg once daily |
|
250-300 mg BID |
|
150 mg BID or 300 mg once daily |
|
>60 kg: 40 mg BID <60 kg: 250 mg BID |
| 300 mg once daily | |
| Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) | |
|
600 mg once daily |
|
200 mg BID |
|
200 mg once daily for 14 days, then 200 mg BID or 400 mg once daily |
|
25 mg once daily |
| Protease Inhibitors (PIs) | |
|
400 mg once daily In combination with TDF: 300 mg + RTV 100 mg once daily In combination with EFV: 400 mg + RTV 100 mg once daily |
|
800 mg/d |
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1400 mg BID or 700 mg + RTV 100 mg BID In combination with EFV: 700 mg + RTV 100 mg BID or 1400 mg + RTV 300 mg once daily |
|
800 mg q8h |
|
400 mg/100 mg BID or 800 mg/200 mg once daily |
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1250 md BID or 750 mg TID |
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100-400 mg/d q12-24h |
|
1000 mg BID |
|
500 mg BID |
| Integrase Inhibitors | |
|
50 mg q12-24h |
|
150 mg once daily |
|
400 mg BID |
| Fusion Inhibitor | |
|
90 mg SQ BID |
| CCR5 Antagonist | |
|
150-600 mg BID |
| Adapted from Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. [2] | |
Goals of Therapy
DHHS ART Guidelines present the following goals for therapy:
- Durable suppression of HIV viral load ( to <50 cells/mL ).
- Restoration of normal CD4 cell count.
- Prevention of transmission of the disease.
- Prevention of building of drug resistance.
- Improvement in quality of life of the patient.
Uncontrolled viremia causes inflammation and immune activation, which has an overall effect on cardiovascular, renal and hepatic systems. Controlling viremia also controls these effects.
Anti Retroviral Therapy (ART)
- Current optimal HAART options consist of drug combinations consisting of at least three drugs belonging to at least two classes of antiretroviral agents.
- Typical regimens consist of:
- Two nucleoside analogue reverse transcriptase inhibitors (NARTIs or NRTIs) PLUS
- Either a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor (NNRTI).
- In treatment-naive patients, four drug regimen is not found to be more efficacious than three-drug regimens and is associated with more adverse events.[3][4]
- Antiretroviral therapy should be initiated in the following patient populations:
- Patients with history of an AIDS-defining illness or with a CD4 count of less than 350/µL.
- Pregnant women with HIV infection.
- Patients with HIV associated nephropathy.
- Patients with HIV and hepatitis B virus (HBV) coinfection who require treatment for HBV infection.
- Fusion inhibitors (eg, enfuvirtide) are not approved for treatment-naive patients.
- Treatment failure is defined by the following factors:
- Virologic failure: which is defined as suboptimal viral suppression or loss of suppression (>50 HIV-1 RNA copies/mL).
- Immunologic failure : which is defined as failure to achieve or maintain CD4 cell count recovery despite effective viral suppression.
- Development of new opportunistic infections or neoplasms despite apparent CD4 count recovery.
Anti Retroviral Regimens
▸ Click on the following categories to expand treatment regimens.
|
Recommended Regimens ▸ NNRTI-Based Regimen ▸ PI-Based Regimen ▸ INSTI-Based Regimen Alternative Regimens ▸ PI-Based Regimen ▸ INSTI-Based Regimen
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Monitoring CD4 and Viral Load
| Scenario | CD4 Monitoring | Viral Load Monitoring |
|---|---|---|
| Before receiving ART | Yes | Yes |
| While receiving ART | 3 month after initiation of ART | 2-4 weeks after initiation of ART, then every 4-8 weeks |
| ART regimen is modified due to drug toxicity | Will depend on previous CD4 counts | 4-8 weeks after modification of regimen |
| ART regimen is modified due to virologic failure | Every 3-6 months | 2-4 weeks after initiation of ART, then every 4-8 weeks |
| During the first 2 years of ART | Every 3-6 months | Every 3-4 months |
| While on ART with detectable viremia (>200 copies/mL) | Every 3-6 months | Every 3 months |
| Change in clinical status (new HIV clinical symptom or initiation of interferon, chronic systemic corticosteroids, or antineoplastic therapy) |
Will depend on the clinical scenario | Every 3 months |
| Adapted from Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. [2] | ||
References
- ↑ Sterne JA, Hernán MA, Ledergerber B, Tilling K, Weber R, Sendi P, Rickenbach M, Robins JM, Egger M (2005). "Long-term effectiveness of potent antiretroviral therapy in preventing AIDS and death: a prospective cohort study". Lancet. 366 (9483): 378–84. doi:10.1016/S0140-6736(05)67022-5. PMID 16054937. Retrieved 2012-02-15.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 "Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents, AIDS info 2014".
- ↑ Shafer RW, Smeaton LM, Robbins GK, De Gruttola V, Snyder SW, D'Aquila RT, Johnson VA, Morse GD, Nokta MA, Martinez AI, Gripshover BM, Kaul P, Haubrich R, Swingle M, McCarty SD, Vella S, Hirsch MS, Merigan TC (2003). "Comparison of four-drug regimens and pairs of sequential three-drug regimens as initial therapy for HIV-1 infection". N. Engl. J. Med. 349 (24): 2304–15. doi:10.1056/NEJMoa030265. PMID 14668456. Retrieved 2012-02-16. Unknown parameter
|month=ignored (help) - ↑ Puls RL, Srasuebkul P, Petoumenos K, Boesecke C, Duncombe C, Belloso WH, Molina JM, Li L, Avihingsanon A, Gazzard B, Cooper DA, Emery S (2010). "Efavirenz versus boosted atazanavir or zidovudine and abacavir in antiretroviral treatment-naive, HIV-infected subjects: week 48 data from the Altair study". Clin. Infect. Dis. 51 (7): 855–64. doi:10.1086/656363. PMID 20735258. Retrieved 2012-02-16. Unknown parameter
|month=ignored (help)