First, some basics. HIV infects cells of the immune system and destroys or impairs their function. Over time, the immune system progressively deteriorates. Eventually, this leads to acquired immune deficiency syndrome, or AIDS. And because our immune systems are essential to protect us from developing life-threatening infections and cancers, HIV treatment, also known as antiretroviral (ARV) therapy, is essential to our survival.
ARV therapy blocks the ability of HIV to multiply, or replicate, inside immune system cells. Once HIV replication is halted, immune system cells—notably CD4 cells (also called T cells), which help organize the immune system’s response to infections and cancers—are able to live and do their jobs. And the longer ARV therapy is able to stop HIV replication and keep the number of CD4 cells high, the greater the chance of disease-free survival.
In terms of deciding if and when to start treatment, there is no one right or wrong answer—it’s different for each person living with HIV. “Some patients think that if they look and feel healthy, they don’t have to be on meds, which is not necessarily true,” states Kimberly Y. Smith, MD, MPH, an HIV specialist at Rush University Medical Center in Chicago. Starting meds, she says, depends on a number of things, including the number of CD4 cells (CD4 count) and amount of virus (viral load) in your blood. “If you’re tired a lot and have conditions like skin rashes, recurrent yeast infections and chronic diarrhea,” she says, “regardless of your CD4 count, I am definitely going to suggest starting HIV treatment.”
Though many health care providers have strong ideas about when treatment should be started (see the pullout poster), remember that it’s you who needs to take the medications—not your doctor. In turn, it’s important that you’re mentally prepared to begin therapy, which, generally, must be taken for life and exactly as recommended. So don’t be afraid to speak up if you’re feeling rushed to begin ARV therapy—you and your provider can work through any concerns and reservations together.
If you start treatment, but your viral load doesn’t remain undetectable, your CD4 count continues to fall or you find that the side effects are unmanageable, then you might have to switch to a new regimen. And just as there are different med options for those starting ARVs for the first time, there are also options for those needing to switch.
Knowing your options, and the differences between them, will help you have a productive conversation about treatment with your health care provider. The following is a breakdown of the five different classes of HIV drugs—each one prevents HIV from replicating at a different stage in its life cycle:
- Entry inhibitors (EIs)
- Integrase inhibitors (INIs)
- Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs, or nukes)
- Non-nucleoside reverse transcriptase inhibitors (NNRTIs, or non-nukes)
- Protease inhibitors (PIs)
HIV meds are taken in combination because one drug is not enough. If you were only to take one or even two HIV meds, HIV could quickly outsmart the meds and your virus could develop resistance to the drugs, which would mean you’d be taking them in vain and not controlling HIV. It takes a team of meds from different classes to control HIV. Standard treatment (often called HAART, or highly active antiretroviral therapy) combines at least three meds. For first-time treatment takers, this often involves two nukes, plus either an INI, a non-nuke or a PI.
When choosing a regimen, ask your health care provider these questions:
- Potency: Is the combo powerful enough to fight my virus and keep my viral load undetectable?
- Safety: What kind of short- and long-term side effects will the meds have on my overall health?
- Convenience: How many pills must I take, and how many times a day?
- Works well with others: Do they interact with other meds I’m taking?
Be sure to tell your doctor about all over-the-counter, prescription and recreational drugs you’re taking so he or she can warn you about any potentially dangerous drug interactions.
“If you can, make sure that your doctor is calling in [all] your prescriptions to the same pharmacy,” advises M. Keith Rawlings, MD, the medical director of the Peabody Health Center in Dallas and president of Integrated Minority AIDS Network Inc. “That way [your pharmacist] has all of your med information and can watch for drug interactions.”
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