There is debate among researchers and healthcare professionals over when anti-HIV medications (antiretrovirals) should be started in patients with the human immunodeficiency virus (HIV). Although these medications have been shown to effectively suppress the virus from replicating inside the body, they can also cause severe side effects, including liver damage and neuropathy (nerve damage). Therefore, when patients are diagnosed with HIV, they should discuss the risks and benefits of all treatment options with their healthcare providers.
Before beginning treatment, patients must be prepared to follow treatment plans. Some patients may need to take several different pills each day. If drugs are not taken exactly as prescribed on a regular basis, the patient may become resistant to the medication. When this happens, the medication does not effectively suppress the virus. Once a patient is resistant to a drug, the patient can no longer take the drug in the future because it is ineffective. As a result, the patient has fewer treatment options for HIV.
In general, most guidelines recommend that antiretroviral therapy (ART) is started when the patient's CD4 cell count is between 200-350 cells per microliter of blood. HIV primarily infects the CD4 cells, which are white blood cells that help coordinate the immune system's response to infections and diseases. Healthy individuals have a CD4 cell count between 600 and 1,200 cells per microliter of blood. The lower the CD4 count, the higher the risk of infection. Patients progress to AIDS (acquired immune deficiency syndrome) when their CD4 cell counts drops below 200 cells per microliter of blood. AIDS patients have the greatest risk of developing life-threatening infections because their immune systems are severely weakened.
The results of viral load tests are also taken into consideration. These tests measure the amount of viral particles inside the patient's blood. According to treatment guidelines in the United States, anyone who has a viral load higher than 100,000 copies per milliliter of blood should be offered treatment.
Treatment is also recommended if the patient develops an opportunistic infection, such as cytomegalovirus or Pneumocystic jiroveci pneumonia (formerly called Pneumocystis carinii or PCP). Opportunistic infections occur in patients with weakened immune systems and may lead to AIDS.
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If a pregnant woman is diagnosed with HIV, antiretroviral therapy usually begins after the first trimester (14-34 weeks into pregnancy), when the fetus is less susceptible to harmful side effects of the drug. Antiretroviral therapy has been shown to significantly reduce the risk of the mother passing the infection to her baby.
Combination antiretroviral therapy with zidovudine (Retrovir®) and other antiretrovirals is the standard treatment prescribed to prevent HIV-infected pregnant women from passing the virus onto their children. Zidovudine is considered the most effective antiretroviral at preventing HIV transmission from mother to child. The exact combination and dosage varies among patients, depending on their overall health and severity of their HIV infections. The newborn typically receives oral zidovudine every six hours for six weeks after birth.
Zidovudine may also be prescribed alone to prevent transmission from an HIV-infected pregnant woman to her baby. Treatment is usually started after 28 weeks of pregnancy in women who have low levels of HIV in the blood and who are concerned about the side effects antiretrovirals may have on the baby. A single dose of nevirapine (Viramune®) and zidovudine is then taken during labor to reduce the chance of transmission during vaginal delivery.
However, taking the zidovudine alone is typically less effective at reducing the viral load than combination therapy with other antiretrovirals. Taking only one antiretroviral also increases the risk of developing drug resistance. Once drug resistance occurs, the particular drug can no longer suppress the virus, even if it is taken in the future.
In general, efavirenz (Sustiva®), stavudine (Zerit®), hydroxyurea (Droxia® or Hydrea®), and the oral liquid formulation of amprenavir (Agenerase®) should not be taken during pregnancy because they may cause harm to the fetus.
Children born to HIV-infected mothers typically take zidovudine by mouth every six hours for six weeks after birth. This helps reduce the risk of the baby acquiring HIV.
Treatment plans for children younger than 13 vary considerably, depending on the patient's weight, age, and overall health. Combination therapy with at least three drugs, including a protease inhibitor or non-nucleoside reverse transcriptase inhibitor plus a nucleoside reverse transcriptase inhibitor is recommended for initial therapy in children. When healthcare providers prescribe treatments, they must consider the formulations of the drugs. Some drugs are available in liquid or powder form, making it easier for young children to take. Many antiretrovirals like zidovudine/lamivudine (Combivir®) are available as combination pills, which make it easier for children and their caretakers to follow treatment plans.
The guidelines for antiretroviral treatment among adolescents (13-17 years old) are the same as for adults. In emergency situations, or if parental involvement is impossible or could cause harm, and if the adolescent patient can adhere to treatment regimens, a minor can consent to treatment without parental involvement. However, communication with legal guardians should be encouraged in all patients who are younger than 18 years old and need to make healthcare decisions.