Treatment goals

Management of chronic HIV infection is not unlike that of other chronic illness such as diabetes, cardiovascular disease and viral hepatitis.1 People living with HIV (PLHIV) should be active participants in their health management and require an understanding of the HIV infection, management and treatments.

The health care professional (HCP) has a role in facilitating the individual’s understanding of the various aspects of HIV, empowering self-management skills and facilitating their health literacy.

Ideally, a management plan is negotiated that includes mutual goals for therapeutic intervention within a long term, comprehensive management plan to achieve ongoing viral suppression, maintenance of immune function, lifelong good health and prevention of onward transmission of HIV infection within an agreed timeframe.1

Goals of antiretroviral therapy

The goal of antiretroviral therapy (ART) is suppression of HIV replication to below the detection limits of clinical assays, and suppression at <50 copies/mL is the widely accepted target for ART success.2,3

Maximal and durable viral suppression:

  • Preserves CD4 T-cell numbers.3
  • Delays or prevents viral resistance.4
  • Decreases inflammation and immune activation thought to contribute to higher rates of cardiovascular and other end-organ damage.5
  • Reduces perinatal and behaviour-associated onward transmission of HIV.6

Important considerations when selecting an ART regimen

The most appropriate ART regimen is one based upon assessment of the ease of adherence, tolerability and efficacy, according to current guidelines. The wishes, context, lifestyle, comorbidities and other medication of PLHIV ought to influence significantly the choice of the initial ART regimen. In women, it is important that ART selection consider reproductive intent, contraceptive use and hormone replacement therapy.3

Information from the following assessments will guide ongoing management and treatment decisions:

General assessment.1

This incorporates a medical and social history, which includes family history, relationship status, drug and alcohol history, smoking history and sexual history. Genotypic and phenotypic resistance assays to assess viral strains and select treatment strategies are also included.

Regimen side effects.3

Consider how side effects with ART regimens could impact on lifestyle and any tolerability or toxicity issues experienced with previous regimens in the short and long term.

Comorbidities.1

Consider the individual’s overall health, including weight, oral and dental health, skin, pelvic and a general systems examination. Consider bone, kidney, metabolic, cardiovascular, and liver health together with signs and/or symptoms of neurocognitive impairment. Concomitant medications and the potential for drug-drug interactions should be regularly assessed.

Education.1,3

It is essential that PLHIV have a thorough understanding of the importance of adherence to prevent the development of drug resistance. Counselling interventions, community resources, family and peer advocates can be utilised to provide education about HIV risk behaviours and to support adherence.

Mental health status.1

The presence of mental health issues may negatively impact adherence to ART, poor diet/reduced exercise, social withdrawal, and increased risk taking. Therefore, psychosocial and mental health assessments at the initial consult are essential and focus on the impact of the diagnosis and coping skills, pre-morbid psychosocial issues, and specific effects relating to stigmatisation and discrimination.

Treatment guidelines

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Regimen Selection

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