HIV/AIDS Warning: You are not logged in. Your IP address will be publicly visible if you make any edits. If you log in or create an account, your edits will be attributed to your username, along with other benefits.Anti-spam check. Do not fill this in! === Antiviral therapy === [[File:Stribild bottle Dutch labeling.jpg|thumb|alt=A white prescription bottle with the label Stribild. Next to it are ten green oblong pills with the marking 1 on one side and GSI on the other.|''[[Stribild]]'' – a common once-daily ART regime consisting of [[elvitegravir]], [[emtricitabine]], [[tenofovir]] and the booster [[cobicistat]]]] <!--What it is --> Current ART options are combinations (or "cocktails") consisting of at least three medications belonging to at least two types, or "classes", of [[antiretroviral]] agents.<ref name=WHOTx2010Pg19>{{cite book |title=Antiretroviral therapy for HIV infection in adults and adolescents: recommendations for a public health approach |year=2010 |publisher=World Health Organization |isbn=978-92-4-159976-4 |pages=19–20 |url=http://whqlibdoc.who.int/publications/2010/9789241599764_eng.pdf |url-status=live |archive-url=https://web.archive.org/web/20120709184257/http://whqlibdoc.who.int/publications/2010/9789241599764_eng.pdf |archive-date=July 9, 2012 }}</ref> There are eight classes of antiretroviral agents (ARVs), and over 30 individual drugs: nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase, inhibitors (NNRTIs), protease inhibitors (PIs), integrase strand transfer inhibitors (INSTIs), a fusion inhibitor, a CCR5 antagonist, a CD4 T lymphocyte (CD4) post-attachment inhibitor, and a gp120 attachment inhibitor. There are also two drugs, ritonavir (RTV) and cobicistat (COBI) which can be used as pharmacokinetic (PK) enhancers (or boosters) to improve the PK profiles of PIs and the INSTI elvitegravir (EVG).<ref name=":1">{{cite web |date=March 23, 2023 |title=HIV Clinical Guidelines: Adult and Adolescent ARV - What's New in the Guidelines |url=https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/whats-new |access-date=December 1, 2023 |website=clinicalinfo.hiv.gov |archive-date=November 26, 2023 |archive-url=https://web.archive.org/web/20231126215220/https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/whats-new |url-status=live }}</ref> Depending on the guidelines being followed, initial treatment generally consists of two nucleoside reverse transcriptase inhibitors along with a third ARV, either an integrase strand transfer inhibitor (INSTI), a non-nucleoside reverse transcriptase inhibitor (NNRTI), or a protease inhibitor with a pharmacokinetic enhancer (also known as a booster).<ref name=":1"/> <!--When to start --> The World Health Organization and the United States recommend antiretrovirals in people of all ages (including pregnant women) as soon as the diagnosis is made, regardless of CD4 count.<ref name=WHO2015Tx/><ref name="IAS2014">{{cite journal|vauthors=Marrazzo JM, del Rio C, Holtgrave DR, Cohen MS, Kalichman SC, Mayer KH, Montaner JS, Wheeler DP, Grant RM, Grinsztejn B, Kumarasamy N, Shoptaw S, Walensky RP, Dabis F, Sugarman J, Benson CA|date=July 23–30, 2014|title=HIV prevention in clinical care settings: 2014 recommendations of the International Antiviral Society–USA Panel|journal=JAMA|volume=312|issue=4|pages=390–409|doi=10.1001/jama.2014.7999|pmc=6309682|pmid=25038358}}</ref><ref name=DHHS2013>{{cite web |title=Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents |url=http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf |website=Department of Health and Human Services |access-date=January 3, 2014 |page=i |date=February 12, 2013 |url-status=live |archive-url=https://web.archive.org/web/20161101202407/https://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf |archive-date=November 1, 2016 }}</ref> Once treatment is begun, it is recommended that it is continued without breaks or "holidays".<ref name=Deut2010/> Many people are diagnosed only after treatment ideally should have begun.<ref name=Deut2010/> The desired outcome of treatment is a long-term plasma HIV-RNA count below 50 copies/mL.<ref name=Deut2010>{{cite journal |vauthors=Vogel M, Schwarze-Zander C, Wasmuth JC, Spengler U, Sauerbruch T, Rockstroh JK |title=The treatment of patients with HIV |journal=Deutsches Ärzteblatt International |volume=107 |issue=28–29 |pages=507–15; quiz 516 |date=July 2010 |pmid=20703338 |pmc=2915483 |doi=10.3238/arztebl.2010.0507}}</ref> Levels to determine if treatment is effective are initially recommended after four weeks and once levels fall below 50 copies/mL checks every three to six months are typically adequate.<ref name=Deut2010/> Inadequate control is deemed to be greater than 400 copies/mL.<ref name=Deut2010/> Based on these criteria treatment is effective in more than 95% of people during the first year.<ref name=Deut2010/> <!--Benefit --> Benefits of treatment include a decreased risk of progression to AIDS and a decreased risk of death.<ref>{{cite journal |vauthors=Sterne JA, May M, Costagliola D, de Wolf F, Phillips AN, Harris R, Funk MJ, Geskus RB, Gill J, Dabis F, Miró JM, Justice AC, Ledergerber B, Fätkenheuer G, Hogg RS, Monforte AD, Saag M, Smith C, Staszewski S, Egger M, Cole SR |title=Timing of initiation of antiretroviral therapy in AIDS-free HIV-1-infected patients: a collaborative analysis of 18 HIV cohort studies |journal=The Lancet |volume=373 |issue=9672 |pages=1352–63 |date=April 2009 |pmid=19361855 |pmc=2670965 |doi=10.1016/S0140-6736(09)60612-7}}</ref> In the developing world, treatment also improves physical and mental health.<ref>{{cite journal |vauthors=Beard J, Feeley F, Rosen S |title=Economic and quality of life outcomes of antiretroviral therapy for HIV/AIDS in developing countries: a systematic literature review |journal=[[AIDS Care]] |volume=21 |issue=11 |pages=1343–56 |date=November 2009 |pmid=20024710 |doi=10.1080/09540120902889926|s2cid=21883819 }}</ref> With treatment, there is a 70% reduced risk of acquiring tuberculosis.<ref name=WHOTx2010Pg19/> Additional benefits include a decreased risk of transmission of the disease to sexual partners and a decrease in mother-to-child transmission.<ref name=WHOTx2010Pg19/><ref>{{cite journal |vauthors=Attia S, Egger M, Müller M, Zwahlen M, Low N |title=Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis |journal=AIDS |volume=23 |issue=11 |pages=1397–404 |date=July 2009 |pmid=19381076 |doi=10.1097/QAD.0b013e32832b7dca|s2cid=12221693 |doi-access=free }}</ref> The effectiveness of treatment depends to a large part on compliance.<ref name=Deut2010/> Reasons for non-adherence to treatment include poor access to medical care,<ref>{{cite journal |vauthors=Orrell C |title=Antiretroviral adherence in a resource-poor setting |journal=Current HIV/AIDS Reports |volume=2 |issue=4 |pages=171–76 |date=November 2005 |pmid=16343374 |doi=10.1007/s11904-005-0012-8|s2cid=44808279 }}</ref> inadequate social supports, [[mental illness]] and [[drug abuse]].<ref>{{cite journal |vauthors=Malta M, Strathdee SA, Magnanini MM, Bastos FI |title=Adherence to antiretroviral therapy for human immunodeficiency virus/acquired immune deficiency syndrome among drug users: a systematic review |journal=Addiction |volume=103 |issue=8 |pages=1242–57 |date=August 2008 |pmid=18855813 |doi=10.1111/j.1360-0443.2008.02269.x |url=https://www.arca.fiocruz.br/handle/icict/1377 |access-date=August 31, 2021 |archive-date=October 28, 2021 |archive-url=https://web.archive.org/web/20211028225006/https://www.arca.fiocruz.br/handle/icict/1377 |url-status=live }}</ref> The complexity of treatment regimens (due to pill numbers and dosing frequency) and [[adverse effect]]s may reduce adherence.<ref name="pmid21406048">{{cite journal |vauthors=Nachega JB, Marconi VC, van Zyl GU, Gardner EM, Preiser W, Hong SY, Mills EJ, Gross R |title=HIV treatment adherence, drug resistance, virologic failure: evolving concepts |journal=Infectious Disorders Drug Targets |volume=11 |issue=2 |pages=167–74 |date=April 2011 |pmid=21406048 |pmc=5072419 |doi=10.2174/187152611795589663}}</ref> Even though cost is an important issue with some medications,<ref>{{cite journal |vauthors=Orsi F, d'Almeida C |title=Soaring antiretroviral prices, TRIPS and TRIPS flexibilities: a burning issue for antiretroviral treatment scale-up in developing countries |journal=Current Opinion in HIV and AIDS |volume=5 |issue=3 |pages=237–41 |date=May 2010 |pmid=20539080 |doi=10.1097/COH.0b013e32833860ba|s2cid=205565246 }}</ref> 47% of those who needed them were taking them in low- and middle-income countries {{as of|2010|lc=y}},<ref name="UN2011Ten">UNAIDS 2011 pg. 1–10</ref> and the rate of adherence is similar in low-income and high-income countries.<ref>{{cite journal |vauthors=Nachega JB, Mills EJ, Schechter M |title=Antiretroviral therapy adherence and retention in care in middle-income and low-income countries: current status of knowledge and research priorities |journal=Current Opinion in HIV and AIDS |volume=5 |issue=1 |pages=70–77 |date=January 2010 |pmid=20046150 |doi=10.1097/COH.0b013e328333ad61|s2cid=7491569 }}</ref> <!--Adverse effects --> Specific adverse events are related to the antiretroviral agent taken.<ref name=Montessori2004/> Some relatively common adverse events include: [[HIV-associated lipodystrophy|lipodystrophy syndrome]], [[dyslipidemia]], and [[diabetes mellitus]], especially with protease inhibitors.<ref name=M121/> Other common symptoms include diarrhea,<ref name=Montessori2004>{{cite journal |vauthors=Montessori V, Press N, Harris M, Akagi L, Montaner JS |title=Adverse effects of antiretroviral therapy for HIV infection |journal=Canadian Medical Association Journal |volume=170 |issue=2 |pages=229–38 |date=January 2004 |pmid=14734438 |pmc=315530}}</ref><ref name="Burgoyne2008">{{cite journal |vauthors=Burgoyne RW, Tan DH |title=Prolongation and quality of life for HIV-infected adults treated with highly active antiretroviral therapy (HAART): a balancing act |journal=[[Journal of Antimicrobial Chemotherapy]] |volume=61 |issue=3 |pages=469–73 |date=March 2008 |pmid=18174196 |doi=10.1093/jac/dkm499|doi-access=free }}</ref> and an increased risk of [[cardiovascular disease]].<ref>{{cite journal |vauthors=Barbaro G, Barbarini G |title=Human immunodeficiency virus & cardiovascular risk |journal=The Indian Journal of Medical Research |volume=134 |issue=6 |pages=898–903 |date=December 2011 |pmid=22310821 |pmc=3284097 |doi=10.4103/0971-5916.92634 |doi-access=free }}</ref> Newer recommended treatments are associated with fewer adverse effects.<ref name=Deut2010/> Certain medications may be associated with [[birth defect]]s and therefore may be unsuitable for women hoping to have children.<ref name=Deut2010/> <!--In children --> Treatment recommendations for children are somewhat different from those for adults. The World Health Organization recommends treating all children less than five years of age; children above five are treated like adults.<ref name=WHOCARV2013>{{cite web |title=Summary of recommendations on when to start ART in children |url=https://www.who.int/hiv/pub/guidelines/arv2013/art/WHO_CG_table_7.4.pdf?ua=1 |website=Consolidated ARV guidelines, June 2013 |format=PDF |date=June 2013 |url-status=live |archive-url=https://web.archive.org/web/20141018175301/http://www.who.int/hiv/pub/guidelines/arv2013/art/WHO_CG_table_7.4.pdf?ua=1 |archive-date=October 18, 2014 }}</ref> The United States guidelines recommend treating all children less than 12 months of age and all those with HIV RNA counts greater than 100,000 copies/mL between one year and five years of age.<ref name=DHHS2014>{{cite web |title=Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection |url=http://aidsinfo.nih.gov/contentfiles/lvguidelines/pedarv_recsonly.pdf |website=Department of Health and Human Services, February 2014 |date=March 2014 |url-status=live |archive-url=https://web.archive.org/web/20150914053159/https://aidsinfo.nih.gov/contentfiles/lvguidelines/pedarv_recsonly.pdf |archive-date=September 14, 2015 }}</ref> The [[European Medicines Agency]] (EMA) has recommended the granting of marketing authorizations for two new antiretroviral (ARV) medicines, [[rilpivirine]] (Rekambys) and [[cabotegravir]] (Vocabria), to be used together for the treatment of people with human immunodeficiency virus type 1 (HIV-1) infection.<ref name="EMA PR">{{cite press release | title=First long-acting injectable antiretroviral therapy for HIV recommended approval | website=[[European Medicines Agency]] (EMA) | date=October 16, 2020 | url=https://www.ema.europa.eu/en/news/first-long-acting-injectable-antiretroviral-therapy-hiv-recommended-approval | access-date=October 16, 2020 | archive-date=October 17, 2020 | archive-url=https://web.archive.org/web/20201017014521/https://www.ema.europa.eu/en/news/first-long-acting-injectable-antiretroviral-therapy-hiv-recommended-approval | url-status=live }} Text was copied from this source which is © European Medicines Agency. Reproduction is authorized provided the source is acknowledged.</ref> The two medicines are the first ARVs that come in a long-acting injectable formulation.<ref name="EMA PR"/> This means that instead of daily pills, people receive intramuscular injections monthly or every two months.<ref name="EMA PR"/> The combination of Rekambys and Vocabria injection is intended for maintenance treatment of adults who have undetectable HIV levels in the blood (viral load less than 50 copies/ml) with their current ARV treatment, and when the virus has not developed resistance to a certain class of anti-HIV medicines called non-nucleoside reverse transcriptase inhibitors (NNRTIs) and integrase strand transfer inhibitors (INIs).<ref name="EMA PR"/> [[Cabotegravir/rilpivirine|Cabotegravir combined with rilpivirine]] (Cabenuva) is a complete regimen for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in adults to replace a current antiretroviral regimen in those who are virologically suppressed on a stable antiretroviral regimen with no history of treatment failure and with no known or suspected resistance to either [[cabotegravir]] or [[rilpivirine]].<ref name="FDA PR">{{cite press release | title=FDA Approves First Extended-Release, Injectable Drug Regimen for Adults Living with HIV | website=U.S. [[Food and Drug Administration]] (FDA) | date=January 21, 2021 | url=https://www.fda.gov/news-events/press-announcements/fda-approves-first-extended-release-injectable-drug-regimen-adults-living-hiv | access-date=January 21, 2021 | archive-date=January 21, 2021 | archive-url=https://web.archive.org/web/20210121213203/http://www.fda.gov/news-events/press-announcements/fda-approves-first-extended-release-injectable-drug-regimen-adults-living-hiv | url-status=live }} {{PD-notice}}</ref><ref>{{cite news | title=F.D.A. Approves Monthly Shots to Treat H.I.V. | first=Apoorva | last=Mandavilli | website=[[The New York Times]] | date=January 21, 2021 | url=https://www.nytimes.com/2021/01/21/health/hiv-cabenuva.html | access-date=January 22, 2021 | archive-date=January 22, 2021 | archive-url=https://web.archive.org/web/20210122000724/https://www.nytimes.com/2021/01/21/health/hiv-cabenuva.html | url-status=live }}</ref> Summary: Please note that all contributions to Christianpedia may be edited, altered, or removed by other contributors. If you do not want your writing to be edited mercilessly, then do not submit it here. You are also promising us that you wrote this yourself, or copied it from a public domain or similar free resource (see Christianpedia:Copyrights for details). Do not submit copyrighted work without permission! Cancel Editing help (opens in new window) Discuss this page