Therapeutic Options for HIV Infection

Treatment of HIV infection has seen dramatic developments since the start of the epidemic over thirty-five years ago. Since the advent of highly active antiretroviral therapy (HAART), HIV infection has gone from being a terminal illness with the inevitable development of AIDS to a now-treatable chronic condition with infected individuals living a ‘normal’ and healthy lifestyle when tested early and engaged in care. Antiretroviral therapy (ART) has become simpler with minimal pill burden and fewer side effects. In the UK ART can only be prescribed by a HIV specialist ensuring the patient is engaged in care and under regular monitoring and follow up. HIV infection affects the immune system through depletion of CD4 T-lymphocytes. There are several goals and aims of treating HIV infection. The main function of ART is to prevent HIV viral replication, which in turn reduces viral load (VL) and depletion of CD4 cells thereby preventing the development of AIDS and eventual mortality. HIV infection induces a pro-inflammatory state, which is associated with several conditions especially in late presenters. Common conditions include cardiovascular disease including cardiomyopathy, increased risk of venous thromboembolism due to a hypercoagulable state, HIV-associated nephropathy, disorders of the central nervous system, bone disorders, various dermatological conditions, and acceleration of ageing. Timely initiation of ART can help reduce and reverse such conditions. Studies demonstrate early initiation of ART and maintaining a suppressed VL minimizes the risk of onward sexual transmission of HIV. Though barrier protection is always advised in serodiscordant couples, recent studies support the reduced risk of transmission in virologically suppressed serodiscordant sexual couples, which has led to changes in post-and pre-exposure prophylaxis guidelines and enabling serodiscordant couples to conceive naturally. All HIV positive women should be initiated on ART and virologically suppressed ideally prior to conception. It is now routine practice in the UK and many parts of the world to perform HIV testing during pregnancy. If tested positive during pregnancy ART should be initiated and, depending on the stage of pregnancy and the VL, a Caesarean section may be necessary and the neonate may require prophylactic ART.