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Guidelines for HIV/AIDS Diagnosis and Treatment
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Guidelines for HIV/AIDS Diagnosis and Treatment

Christina Mattina
These guidelines provide an overview of the current recommendations surrounding HIV/AIDS diagnosis, treatment, and complications.
TREATMENT
Antiretroviral Therapy
The primary treatment for HIV is antiretroviral therapy (ART), which has been shown to improve survival rates and immune system function, decrease the risk of complications, and reduce the likelihood of HIV transmission.7

Therapy typically consists of a regimen of 3 or more antiretroviral (ARV) drugs. In the US, there are over 20 individual ARVs in 6 classes, which can be combined in a regimen tailored to each individual patient.7,8 The formulation of these regimens will depend on the patient’s comorbidities and disease stage, potential side effects, and possible interactions with the patient’s concomitant medications.8

ART works by inhibiting HIV replication so as to lower the viral load of HIV RNA in plasma, which then “delays or prevents the selection of drug-resistance mutations, preserves or improves CD4 T lymphocyte (CD4) cell numbers, and confers substantial clinical benefits.”8 Effective ART can also reduce the risk of HIV transmission to sexual partners by more than 96% by lowering the viral load. Complete eradication of HIV infection cannot be achieved with ART, so therapy must be continued to achieve viral suppression. Viral suppression below assay detection limits generally occurs within the first 12 to 24 weeks of therapy. Predictors of success include low baseline viral load, high potency of the ARV regimen, and stringent patient adherence, which is more likely if the regimen is both tolerable and convenient.

Several guidelines agree that ART should be initiated in all people with HIV, but there are some conditions that increase the urgency of treatment initiation:
  • Pregnancy7,8
  • AIDS-defining conditions, including HIV-associated dementia and AIDS-associated malignancies7,8
  • Acute opportunistic infections7,8
  • Lower CD4 counts (<200 cells/mm3 [7,8]; <350 cells/mm3 [9])
  • Severe or advanced HIV clinical disease (WHO stage 3 or 41)9
  • HIV-associated nephropathy7,8
  • Acute/early infection7,8
  • HIV/hepatitis B virus coinfection7,8
  • HIV/hepatitis C virus coinfection7,8
  • Rapidly declining CD4 counts (eg, >100 cells/µL/year)7
  • Higher viral loads (eg, >100,000 copies/mL)7
Note: 1 cubic millimeter (mm3) = 1 microliter (µL) = 0.001 milliliter

Adherence Support
Experts unanimously agree that patient adherence to the ART regimen is essential to achieving viral suppression and, therefore, better clinical outcomes and survival. Adherence is second only to CD4 cell count as a predictor of HIV progression to AIDS and death.7 Average ART adherence in the United States is about 70%.7 Because adherence is so central to therapy success, numerous guidelines offer suggestions on how to develop individual support plans for each patient during every stage of the care continuum.
  • Before treatment: establish trusting relationship with patient7; ensure patient readiness to begin treatment7,8; identify potential barriers to successful medication adherence7,8; provide mental health and substance abuse resources if necessary7,9
  • Regimen selection: involve patient in selection of regimen7,8; tailor regimen to patient’s circumstances8; consider a fixed-dose combination or a once-daily regimen9
  • Access: provide resources to obtain prescription drug coverage7; use patient prescription assistance programs8
  • Adherence tools: reminder devices8,9; pill boxes7,8; visual aids like planners and calendars7; text messaging9
  • Community resources: peer counselors8,9; visiting nurses, community workers, family members, treatment navigators8; adherence clubs9
  • Behavioral interventions: positive reinforcement of successes7,8; motivational interviewing8; behavioral skills training9; health literacy support7
  • Assessment: assess adherence at every clinic visit7,8; identify reasons for nonadherence7; follow up on missed visits8; confirm adherence via pharmacy refill records, pill counts, and viral load monitoring9

The CDC has also compiled a list of specific interventions that have strong evidence supporting their efficacy. These include programs that administer ART in methadone clinics, interventions to help serodiscordant couples (1 HIV-positive and 1 HIV-negative partner) manage adherence together, and text messaging reminders for young adults.10



 
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