Goals of antiretroviral therapy in people living with HIV
Antiretroviral therapy (ART) regimens are a combination of HIV medicines that stop the virus from replicating in the body. ART cannot cure HIV, but helps people living with HIV (PLHIV) to live longer, healthier lives.2
ART aims to2:
• Durably suppress plasma HIV RNA or ‘HIV viral load’, ideally <50 copies/mL; the person with HIV viral load <50 copies/mL is also called ‘undetectable’
• Restore and preserve immunologic function (preserve or improve the CD4+ T-cell count)
• Reduce the risk of HIV transmission
• Prevent progression to AIDS
• Reduce the risk of comorbidities and prolong the duration and quality of life
When to start ART?3,4
ART should be started as soon as possible after diagnosis or even immediately to decrease the time required to achieve virological suppression and reduce HIV transmission risks.
How is an ART regimen selected for an individual patient?
Current guidelines recommend that healthcare professionals consider multiple factors when choosing the most appropriate ART for an individual patient.3,4 These factors include, but are not limited to, efficacy, tolerability, comorbidities, risks of drug-drug interactions, ease of adherence and patient’s lifestyle and wishes.3,4
In women, ART selection should also consider reproductive intent, contraceptive use and hormone replacement therapy.4,5 For transgender people, the choice of ART should also consider any gender-affirming therapy they may be receiving.4
The following assessments usually help guide HIV management strategies and ART selection:
This incorporates a medical and social history, family history, lifestyle, smoking, drug and alcohol use. Genotypic and phenotypic resistance assays to assess HIV viral strains and select treatment strategies are also included.
When choosing ART, considerations of the individual’s overall health, including body mass index, bone, kidney, metabolic, cardiovascular, liver and neurological health, are important. Concomitant medications and the potential for drug–drug interactions should be regularly assessed.
Past regimen tolerability3,4
Tolerability of ART can impact the individual’s wellbeing, lifestyle and adherence. Assessing any past tolerability issues may help inform the choice of ART.
Mental health status3,4,5
The presence of mental health disorders may negatively impact adherence to ART and increase risk-taking behaviours. Mental health disorders can be exacerbated by the social exclusion and stigma associated with HIV.
Regular psychosocial and mental health assessments are essential and focus on the impact of the diagnosis and coping skills, premorbid psychosocial issues, and specific effects relating to stigmatisation and discrimination.
Adherence to ART is associated with achieving virological suppression and should be assessed every 3–6 months. 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.