Living Longer With HIV Therapy
By R. Morgan Griffin
The use of highly active antiretroviral therapy (HAART), a "cocktail" of medications, has completely changed the prognosis for people with HIV. It has allowed many to live relatively normal lives, working and raising families without any signs of illness. However, HAART is not a cure for HIV, and its beneficial effects can come at a cost. Those who have been recently diagnosed with HIV should learn what to expect from a life dependent on antiretroviral medications.
It is impossible to give a general prognosis for people with HIV, because the disease is dependent on so many variables. Several things may influence how long you will live, including the following:
- Your state of health before you began treatment and your viral load and CD4 cell count when you were diagnosed
- Whether you have been diagnosed with full-blown AIDS
- What, if any, opportunistic infections you develop
- What medications you take
- Whether you can tolerate side effects to your medications
- How faithfully you adhere to your medication regimen
- Whether or not the virus that infects you has become resistant to some of the medications used to treat it
Although no one can say for certain what your prognosis will be, HAART has greatly improved the odds for people with HIV. HAART is quite effective in boosting the body's immune response and in diminishing viral load to undetectable levels. For many, HAART has prolonged life indefinitely, and until a more permanent cure is discovered, it will remain the primary treatment for HIV.
Admittedly, HAART is not the final answer to HIV. Experts are not sure just how long the treatment will be effective against the virus. The increase in drug-resistant strains of HIV and the manifestation of serious HIV-related illnesses despite HAART could both pose a serious threat to infected people. Because of HAART's enormous costs, its benefits are also not available to everyone. Globally, more than 85 percent of HIV-positive patients do not have access to HAART, because they live in resource-poor countries and cannot afford to pay for the medications. However, this is changing, as the prices of medications have dropped and the political will to improve access to HAART has dramatically increased. Several global initiatives are underway to rapidly expand access to HAART worldwide.
Even though HAART can keep the effects of the virus at bay, living with HIV is still not easy. As people live longer as a result of HAART, experts are focusing on the serious side effects of these powerful antiretroviral drugs. For some patients, the hardest aspect of HIV is tolerating side effects to the very medications that prevent the disease from worsening. These side effects include nausea, diarrhea, lipodystrophy syndrome (fat accumulations, often in the neck or abdomen), weakened bones, anemia, increased cholesterol levels, peripheral neuropathy (a kind of nerve damage) and diabetes. The effects vary from person to person. Although some patients find the side effects unbearable, others tolerate them more easily. If you experience any side effects to HAART, be sure to tell your doctor. He or she may be able to adjust some of your medications and hopefully lessen the ill effects.
HAART is usually effective at lowering viral levels and boosting the body's defenses enough to prevent most opportunistic infections. Most serious opportunistic infections typically occur only when a person's CD4 cell count has declined below a certain level — 200 cells per microliter or lower — but some can occur in any HIV-infected patient.
In order to prevent exposure to dangerous opportunistic infections, your doctor may suggest that you avoid travel to parts of the world where certain pathogens are common. If you do travel to a resource-poor country, it is extremely important that you are fastidious in your choices of food and beverages to minimize your risk of developing diarrhea from parasites such as Cryptosporidia. These infections can cause severe symptoms, and they are often difficult to treat in immunocompromised patients.
In addition, you should avoid cramped and poorly ventilated areas, such as prisons and health care facilities, to decrease your risk of tuberculosis exposure — especially in countries with high rates of tuberculosis. If you have not been exposed to certain infections, your doctor may also recommend caution in caring for your pets. For example, if you haven't been exposed to toxoplasmosis, you will need to take special precautions when changing your cat's litter box.
Although the danger of opportunistic infections has diminished as a result of HAART, concurrent infection with hepatitis B and especially hepatitis C is emerging as a serious threat to people with HIV.
People who started HAART late, or who are not able to tolerate it, may need to be treated for opportunistic infections or may need to take secondary preventive measures.
The schedule for taking HIV medications has become less complicated over the years, but it is still demanding. Studies have indicated that about one-third of people taking HAART have missed a dose within the past three days.
A typical regimen of HAART often includes:
- One nonnucleoside reverse transcriptase inhibitor (such as efavirenz or nevirapine) or one or two protease inhibitors (such as indinavir, nelfinavir, ritonavir, lopinavir, atazanavir, amprenavir fosamprenavir or tipranavir)
- Two nucleoside reverse transcriptase inhibitors (such as stavudine, didanosine, lamivudine, zidovudine, emtricitabine or abacavir) or one nucleoside inhibitor and one nucleotide inhibitor (currently tenofovir is the only drug in this class)
- A fusion inhibitor (enfuvirtide or T20) may be added to the drug regimen for people with highly resistant virus; this medication is given by subcutaneous injection (injection placed just beneath the skin).
Most of these medicines need to be taken from one to four times daily. Some also have requirements about what other drugs they are taken with and whether they should be taken with food or on an empty stomach. You may also have to take additional medications to treat or prevent opportunistic illnesses. Because of the complexity of the drug regimen, experts recommend using weekly or daily pillboxes and timers or pagers to keep track of when to take your doses.
Doctors and researchers still debate exactly when HAART should be first administered, but the general consensus is that treatment should be offered to all patients who have symptoms related to HIV. Treatment should also be considered for all asymptomatic patients who have a CD4 cell count below 350 cells per microliter or a high viral load. Treatment should definitely be started before the CD4 cell count drops below 200, because at that point survival rates drop significantly in untreated patients.
Although it may seem logical to start therapy as soon as you have been diagnosed with HIV, experts have become more conservative about using HAART and suggest that there are significant benefits to waiting. Putting off the medication reduces the amount of time you will suffer from potential side effects. In addition, the longer you take HAART, the greater your risk of developing a resistant strain of the virus. Hence, waiting allows you to ration the available antiretroviral medications and delay the possible development of resistant strains of the virus.
If you have several doctors, you must make certain that they all understand the regimen of medications you are taking. Some medications for opportunistic infections can interact dangerously with HAART, such as rifampin or rifabutin for tuberculosis.
An emerging problem for people taking HAART is the development of drug-resistant strains of HIV. Although resistant strains can develop for many reasons, they often occur in patients who skip doses or who fail to take their medication properly. Once you are diagnosed, your doctor may test you — by genotyping or phenotyping — to see whether the virus in your body is resistant to any medications. This way, he or she can decide how best to treat you.
Resistant strains of HIV are treated by salvage therapy, in which doctors use combinations of alternative antiretroviral medications. Although this can work, the first set of medications is usually the most effective. It is possible to develop a strain of HIV that is resistant to all available medications. It is vitally important, for this reason, to take your medications as your doctor instructs.
Remember that, as bleak as things may look now, HIV can be treated. Antiretroviral medications often allow people to stay healthy indefinitely. Researchers are also working on new drugs — nucleoside reverse transcriptase inhibitors, protease inhibitors and entirely new classes of medications that will hopefully be easier to take, cause fewer side effects and fight resistant strains of HIV.
Keep in mind that your prognosis, in part, also depends on what you do. Make sure to see your doctors for check-ups, regularly monitor your CD4 cell counts and viral load, eat well, exercise and get plenty of rest. And make sure to take your medications. Your life depends on it.
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