(BlackDoctor.org) — If you’re newly diagnosed with HIV or about to start HIV treatment, you may still be haunted by the old specter of gaunt AIDS patients and few treatment options.
HIV/AIDS is still here and it is still a serious disease. But the picture for patients in the U.S. today is very different than it was 30, 15, or even five years ago.
“Life expectancy has improved dramatically,” says Babafemi O. Taiwo, MBBS, an internist and assistant professor in the division of infectious diseases at Northwestern University’s Feinberg School of Medicine in Chicago. “For many patients, it can be close to that of uninfected persons.”
The treatment that is making this era so much more hopeful is called highly active antiretroviral therapy, or HAART. HAART is a potent combination of at least three active antiretroviral medications (ARVs). HAART is popularly called the “AIDS cocktail” because of its mix of drugs.
AIDS Cocktails: The Benefits of HAART
The goal of AIDS cocktails today is to reduce the virus in the blood (viral load) so it is no longer detected. Though AIDS cocktails aren’t a cure, they are a very effective treatment. They can delay progression to AIDS, help rebuild and maintain the immune system, and reduce complications.
Today HIV medications are available with fewer short- and long-term side effects.
And taking more than one drug helps prevent drug resistance. This means the drugs will keep working longer because they continue to be effective against HIV.
“Patients who were previously considered untreatable because of multidrug resistance have become treatable,” Taiwo says. That’s because people have not developed resistance to drugs in the new classes, and the drugs are stronger in overcoming resistance. “It’s hard to find patients who truly have no antiviral options, whereas that was common just five to seven years ago,” says Taiwo.
“With multiple options now available, we don’t think there is any excuse for a patient to be failing therapy or to have a detectable viral load if we manage things correctly,” says Monica Gandhi, MD, MPH, associate professor of medicine in the divisions of HIV/AIDS and infectious diseases at the?University of California in San Francisco and director of the HIV Consult Service at San Francisco General Hospital.
HIV Medications: How HAART Works
Initial treatment against HIV targets three key enzymes — reverse transcriptase, protease, and integrase. These are all needed for the virus to make copies of itself. Different classes of drugs target different enzymes and prevent them from functioning:
• Nucleoside or nucleotide reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs)
• Protease inhibitors (PIs)
• Integrase inhibitors
The FDA has approved several of these medications, which can be taken in various combinations and schedules (regimens). In addition, other HIV medications — such as fusion or entry inhibitors, which block HIV’s entry into a cell — may be part of treatment.
Preferred HAART Regimens to Use for Initial HIV Treatment
Researchers are always looking at which regimens work best, have the fewest side effects, last longest, and are easiest to use. At the end of 2009, the Department of Health and Human Services (DHHS) published preferred initial treatment regimens, based on findings from studies.
With the new department’s recommendations, the previous “backbone” or “anchor drugs” for the NRTI component of triple regimens has changed. Abacavir ( Ziagen) and lamivudine ( Epivir, 3TC) were bumped down. This is partly due to a link between recent abacavir use and increased heart attack risk. With higher viral loads, it was also found to be less effective than the drugs tenofovir (Viread) and emtricitabine ( Emtriva). According to Gandhi, this change has stirred some controversy because of concerns about tenofovir’s potential impact on kidneys and bones. Lamivudine can cause serious liver damage and lactic acid buildup in the bloodstream.
Because of the variety of improved options, it’s no longer advised to take breaks from a treatment that causes severe side effects (“drug holidays” or intermittent therapy). “This is associated with increased mortality from all causes, not just from HIV,” Ghandi says. Instead, people can now switch to a different regimen.
Alternative regimens can also be effective and well tolerated by some patients. But they can have disadvantages when compared with preferred regimens. The list of preferred HAART regimens will likely continue to change over time.
But here are the current regimens for initial treatment preferred by the Department of Health and Human Services.
Preferred NNRTI-Based Regimen
Medications: efavirenz ( Sustiva)+tenofovir (Viread)+emtricitabine (Emtriva) also available as a 3-drug combination pill ( Atripla). Note: Complera is another 3-drug combination pill taken once daily. Complera is a combination of Truvada (which combines the nucleoside reverse transcriptase inhibitors Emtriva and Viread) and the non-nucleoside reverse transcriptase inhibitor Edurant.
Efavirenz has always been a preferred HIV medication due to its potency, effectiveness, and durability — even when compared to PIs, Gandhi says. She adds that its impact on blood fats, such as cholesterol, is limited. Another advantage is that it can be taken with two other drugs in one-pill-a-day regimen. “But adherence must be essentially perfect,” Gandhi says. This means you must take it exactly as prescribed or you are more likely to become resistant to it.
Preferred PI-Based Regimens
• Atazanavir ( Reyataz) boosted with low-dose ritonavir + tenofovir (Viread) + emtricitabine (Emtriva). Tenovir and emtricitabine are also available as a combination pill ( Truvada).
• Darunavir ( Prezista) boosted with low-dose ritonavir (once daily) + tenofovir + emtricitabine
If you are relatively careful about taking medication as directed, a protease-based regimen could last you a very long time. “These are very durable, potent regimens that have the ability to last patients their entire lives,” Ghandi says.
Atazanavir/ritonavir has long been a favorite PI in terms of tolerability, effectiveness, and once-daily dosing. Because darunavir/ritonavir also has these features, it has also come into play the last three years, Gandhi says. But it also has an advantage over atazanavir/ritonavir in terms of drug interactions.
Darunavir can be given with antacids, and atazanavir really can’t. “For all those reasons, it’s gaining in popularity and is incredibly potent,” Ghandi says.
A preferred regimen for pregnant women is lopinavir ( Kaletra) boosted with low-dose ritonavir (twice daily) + zidovudine (AZT, Retrovir, ZDV) + lamivudine(3TC, Epivir). Zidovudine and lamivudine are also available as a combination pill ( Combivir).
Preferred Integrase-Based Regimen
Medications: Raltegravir ( Isentress) + tenofovir + emtricitabine
The only example in its class of integrase inhibitors, raltegravir has also done well since approval, according to Gandhi. But in “head-to-head” trials with efavirenz, it appears to not be quite as effective. “It has great advantages in terms of tolerability — it causes very few side effects — but its disadvantage over the other three is that it is currently a twice-a-day drug,” Gandhi says.
Getting the Right HIV Treatment: How to Talk to Your Doctor
Which HIV/AIDS cocktail you and your doctor choose depends on factors such as:
• Your lifestyle
• Your viral load
• The status of your immune system (CD4 count)
• If you have resistance to any drugs (which can be checked before you begin a regimen)
• Other conditions you have
• Other medications you’re taking
“Become educated about the preferred options,” Taifo says. “Each is unique, with its own set of advantages and disadvantages. Some are taken in a combination once-a-day pill. Others follow a different, more involved schedule. Some cause minimal side effects. Others are more likely to cause noticeable or long-lasting complications. When your doctor prescribes a regimen, ask, ‘Why this one, of all the options? Make sure your doctor understands who you are — your family history, your risk for heart disease, your preferences,'” Taifo says. “These all can be factors in the selection of a regimen.”
Enhancing the Effectiveness of AIDS Cocktails
“All these regimens work — they work if patients take them,” Taiwo says. This is the most critical thing to understand, he adds: Resistance to HIV medications doesn’t just happen and is unlikely if you take your HIV/AIDS cocktail as directed. But it can happen if you end up with too little medication in your blood and uncontrolled infection. Then it also becomes a public health issue because resistant strains can be passed to others, as well.
“Those who do best are almost obsessive about their medications,” Taiwo says. “They incorporate it into their lifestyle and accept it as a way of life — they do very well.”
What seemed inconceivable not that long ago is eminently possible today. You can take HIV cocktails for a long time and live a good life.