Since the mid 1990’s treatment of AIDS has been improved substantially by applying the principles that came out of AIDS-research.
Treatment should be monitored by an AIDS center, if at all possible. This way the patient can be certain that the latest knowledge about AIDS treatment is incorporated into the treatment regimen. The principals of treatment are as follows.
As the HIV virus reprograms the infected cells (CD4 cells, endothelial cells, monocytes and brain cells) to produce new HIV RNA virus copies at a high rate, the treatment is directed against this new RNA virus synthesis. This is done by combining two antiretroviral drugs inhibiting HIV reverse transcriptase with one protease inhibitor, which is directed against HIV protease. A newer class of drugs, integrase inhibitors, has been added to this combination (thanks to en.wikipedia.org for this link) of anti-AIDS drugs known as the “cocktail” against AIDS. Highly active antiretroviral therapy (HAART) is another name for the anti-AIDS cocktail.
It has to be taken regularly in order to gradually starve the HIV virus. Unfortunately, there are many possible treatment failures. Most commonly it is because patients get tired of swallowing pills or of the side-effects, but fail to seek the advice of the treating physician who could switch them to another medication that may be more tolerable. It could also be that resistant strains are developing. The treating physician can monitor for all of this by checking the plasma HIV RNA levels in the blood. Any level of more than 400 copies per milliliter is now accepted by many AIDS experts to mean that treatment needs to be stepped up after fist checking that the patient had taken the medicines regularly (Ref. 1, p. 1321 and Ref. 2, p. 7).
Some drugs directed against HIV
|Generic name:||Brand name:||Comments:|
|Zidovudine||Retrovir||can lead to anemia and low white blood count|
|Lamivudine||Heptovir||side effect :reversible peripheral neuropathy and pancreatitis|
|Stavudine||Zerit||side effect :reversible peripheral neuropathy|
|Indinavir||Crixivan||protease inhibitor; can lead to kidney stones|
|Nevirapine||Viramune||can cause skin rashes|
|Delavirdine||Rescriptor||can cause skin rashes|
|Viread||Tenofovir||Nucleotide Analog Reverse Transcriptase Inhibitor (NRTI), can cause elevated liver enzymes|
If the initial three drug cocktail is not effective in reducing the viral load, then the specialist has several other options of treating. One option is to increase the number of drugs in the cocktail, another to change the drugs to some of the newer drugs that would cover for resistant strains.
The emergence of resistant strains will always be a problem with treatment of AIDS as there is such a huge turnover of viral copies in the beginning of the disease where mutagenesis will create small subpopulations of resistant HIV substrains, particularly in the presence of antiviral drugs. With the introduction of the protease inhibitors there has been a remarkable improvement in survival rates. However, despite the introduction of yet a new class of antiviral drugs in the form of an HIV-1 infusion inhibitor (Fuzeon or T20) it is clear that resistance will likely always remain a limiting factor (Ref. 5). Overall this has led to a 20 to 25% survival advantage, but costs, injection site reactions and the need for twice per day injections by the patient lead to a 10% discontinue rate.
Here is a website that lists the latest on HIV treatment and research: http://www.cdcnpin.org/scripts/hiv/index.asp
The phone number of the CDCNational AIDS Clearinghouse is 1-800-458-5231 (Ref. 2, p.7).
Apart from treatment of the HIV virus the physician must address the multiple possible opportunistic infections. The worst of them might be tuberculosis, which has to be treated like it is listed under this disease. Candidiasis has to be addressed, as does diarrhea from Clostridium difficile or Salmonella. In the case of recurrent genital herpes or herpes zoster the appropriate maintenance antiherpetic antibiotic has to be taken in addition to the anti-AIDS medicine.
Side effects of treatment against AIDS
As important as effective treatment of AIDS is, one cannot overlook the toxic effects of some of the medications that are used to combat this disease. Doctors are always aware of the importance of balancing the benefits of a therapeutic intervention against the negative side effects of it. With AIDS treatment the relationship between benefits and harmful side effects of the medications used to treat is even more important as AIDS treatment can potentially span over several decades and some side effects are quite significant. Also, resistant strains of AIDS are always developing. Protease inhibitors, not long ago thought of as the cure-all for AIDS, turn out to have significant drug side-effects of increasing fatty substances (lipids) in the blood and causing diabetes mellitus. Fusion inhibitors cause damage to body cells that contain large amounts of the energy packs, called mitochondria, such as in liver cells and fat cells. The end result after 18 months of fusion inhibitors is in many patients a starved look as the body fat simply melts away through a process called fat dystrophy. The end results are higher risks of heart attacks and strokes and the need for more medications to attempt to treat these side effects with statins, lipid lowering agents and insulin for diabetes. Clearly, this type of complex therapy is best done in close contact with a University Center that specializes in AIDS treatment. Use this government link (thanks to www.aidsinfo.nih.gov for this link) for access to AIDS information and treatment centers (Ref.5).
Prevention of AIDS
The most important aspect of prevention is to avoid unprotected sex between an HIV infected individual and an uninfected person. The the use of condoms as a barrier method is of some help. Avoidance of anal intercourse is also important because of what was discussed in the introduction to this chapter on AIDS. The use of antiretroviral medications likely will reduce the risk of transmitting HIV, but the proof for this is not yet in. A woman who is diagnosed with AIDS when pregnant has to be treated with zidovudine. Without this the risk of transmitting HIV to the fetus is about 40%, with zidovudine the risk of transmitting HIV to the fetus is about 15% (Ref. 1, p. 1320, and Ref. 2, p. 5).
1. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 163.
2.James Chin et al., Editors: Control of Communicable Diseases Manual, 17th edition, 2000, American Public Health Association.
3.The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 164.
4. Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 7th ed., © 2002 Elsevier : pages 1306-1307.
5. Dr. Marianne Harris: “Fusion Inhibitors: New Class for HIV Tretment”; also: Dr. Joss De Wet: “HIV 2004-Emerging Antiviral Exposure Issues”. The 50th Annual St. Paul’s Hospital Continuing Medical Education Conference for Primary Physicians, Nov. 16 – 19, 2004