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HIV treatment

HIV treatment doesn't cure HIV. When successful, it reduces the amount of the virus (your 'viral load') to very low ('undetectable') levels. It's now recommended that everyone diagnosed with HIV starts treatment straight away – regardless of their CD4 count.

You will take a combination of drugs – usually three. Once you start treatment, it is likely you will be taking it for the rest of your life.


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'Undetectable' viral load

HIV treatment works to reduce your viral load to undetectable levels. This means that the level of HIV in your blood is so low, it can’t be detected by the tests used to measure viral load. But it doesn’t mean there is no HIV at all.

With an undetectable viral load, HIV is not able to damage your immune system.


Does an undetectable viral load make me less infectious?

Yes. If you have an HIV negative partner, HIV treatment can also be used as a prevention method.

There is an extremely low risk of you passing on HIV through sex, as long as:

  1. your viral load has been undetectable for the past 6 months,
  2. you are on HIV treatment, and
  3. neither you nor your partner has a sexually transmitted infection (STI).

Successful treatment can also prevent a mother passing HIV to her baby during pregnancy or birth.


How do we know this?

A large study called PARTNER has been looking at over 1,000 gay and straight couples where one partner is HIV positive and one is HIV negative. The study won’t finish until 2017 but early results have shown that where the HIV positive partner had an undetectable viral load and was on treatment, there were no cases of HIV transmission whether they had anal or vaginal sex.

If you have HIV, having untreated STIs could make it more likely that you’ll pass on HIV during condomless sex. But if HIV drugs have made your viral load undetectable then STIs don’t appear to make you more likely to pass on HIV.

It is important to remember that these are preliminary findings so as the study goes on the advice may change, but this is what has been reported so far.

Before you make any decision about not using condoms, get advice from your HIV doctor or nurse practitioner.


When should I start taking HIV treatment?

In the UK, national guidelines set out standards for HIV treatment. They currently recommend that anyone with HIV who is ready to commit to treatment should start it regardless of their CD4 count.


The START study

The UK guidelines have been recently reviewed to reflect the findings of the START study.

This study found that people who delayed treatment until their CD4 count dropped to 350 - which is when people were previously advised to start treatment - had a much higher chance of developing AIDS-related illnesses such as cancers.

More about the START study ››


How does HIV treatment work?

Treatment with anti-HIV drugs is sometimes called combination therapy because people usually take three different drugs at the same time.

It is also known as antiretroviral therapy, or highly active antiretroviral therapy - HAART for short.

HIV treatment does not cure HIV, but it stops the virus from reproducing in your body. It can reduce levels of the virus in the blood to such low levels that it is not able to cause damage to your immune system.

Once you start HIV treatment, it is likely you will be taking it for the rest of your life. 


Types of HIV treatment

Over 25 anti-HIV drugs are now available, in six 'classes' of drugs. Each class works against HIV in a particular way. You will take a combination of drugs – usually three.

Guidelines recommend several combinations. You and your doctor can choose the one best suited to your health needs and lifestyle. The most important thing you can do is take all your drugs in the right way at the right time (known as ‘adherence’).


What types of anti-HIV drugs are available?

You don’t need to know about all the types of drugs, or the details about the drugs you’re on, for you to be able to take your treatment properly.

Your HIV healthcare team will have the specialist knowledge to talk to you about what might work best for you. Making sure you take your treatment as recommended is what’s most important.


The classes of anti-HIV drugs are:

  • Nucleoside reverse transcriptase inhibitors (NRTIs or ’nukes’).
  • Nucleotide reverse transcriptase inhibitors (NtRTIs).
  • Non-nucleoside reverse transcriptase inhibitors (NNRTIs or ‘non-nukes’).
  • Protease inhibitors (PIs).
  • Fusion and entry inhibitors.
  • Integrase inhibitors.

How do I decide what type of HIV treatment to take?

Guidelines developed by the British HIV Association (BHIVA, the organisation for specialist HIV doctors in the UK) set out the medical treatment people living with HIV in the UK should receive.

These guidelines recommend that everyone with HIV, regardless of their CD4 count, starts taking treatment. This usually includes three anti-HIV drugs and is often called combination therapy. Often two or more of these drugs are combined in one tablet to reduce the number of pills you need to take.

For people who have not been on HIV treatment, it’s recommended you start on a combination containing two NRTIs and either a ritonavir-boosted protease inhibitor, an NNRTI, or an integrase inhibitor.

The preferred NRTIs for starting HIV treatment are emtricitabine and tenofovir (available combined in a pill called Truvada). These drugs are also available combined with efavirenz in a pill called Atripla, combined with rilpivirine in a pill called Eviplera or combined with elvitegravir and cobicistat in a pill called Stribild. Two other NRTIs, lamivudine and abacavir (combined in a pill called Kivexa), are an alternative for some people.

In addition, you will need to take a third drug.

The guidelines recommend that this is one of the following: atazanavir (Reyataz), darunavir (Prezista), raltegravir (Isentress), dolutegravir (Tivicay)rilpivirine (Edurant) or elvitegravir (Vitekta). Atazanavir and darunavir are boosted with another protease inhibitor, ritonavir (Norvir) to increase their levels in the body. Elvitegravir is boosted by a drug called cobicistat (Tybost) and is usually prescribed in the combination pill called Stribild. An alternative third drug to the preferred options is efavirenz (Sustiva).


What if I'm resistant to the prescribed medication?

If you have taken HIV treatment before, your doctor will need to look at your treatment history and the results of a test for drug resistance, to decide about the most suitable combination of drugs for you to take.

There are now a number of anti-HIV drugs that work against virus that is resistant to other drugs. The recommended options for people who are resistant to the three main classes of drugs - NRTIs, NNRTIs and protease inhibitors - are:

These drugs are most effective when used in combination with another drug which is active against HIV. Your doctor will look at your previous drug history and do a resistance test to find out which would work best for you.

If you are resistant to only one class of drugs, the options may be slightly different and your doctor will advise you.

Thanks to these drugs, an undetectable viral load is now achievable for nearly everyone.

We have published a full list of HIV medication available for UK patients.


What if I have another illness or a co-infection?

You may have a co-infection (such as hepatitis B or C or tuberculosis) or another illness such as cardiovascular disease, HIV-related cancerchronic kidney disease or HIV associated neurocognitive impairment.

In these situations your doctor may need to tailor your antiretroviral treatment or treat your other condition before starting your HIV treatment. This will be explained to you by the clinicians looking after you.


More on HIV treatment:


Next: When to start HIV treatment? ››

 

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The Information Standard: Certified member

This article was last reviewed on 16/5/2016 by Anna Peters

Date due for the next review: 16/5/2019

Content Author: Kerri Virani

Current Owner: Kerri Virani

More information:

BHIVA guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2015, Writing Group: Duncan Churchill Chair Laura Waters Vice Chair N Ahmed, B Angus, M Boffito, M Bower, D Dunn, S Edwards, C Emerson, S Fidler, †M Fisher, R Horne, S Khoo, C Leen, N Mackie, N Marshall, F Monteiro, M Nelson, C Orkin, A Palfreeman, S Pett, A Phillips, F Post, A Pozniak, I Reeves, C Sabin, R Trevelion, J Walsh, E Wilkins, I Williams, A Winston

No one with an undetectable viral load, gay or heterosexual, transmits HIV in first two years of PARTNER study, NAM, Aidsmap, Gus Cairns, 4/3/14

START trial finds that early treatment improves outcomes for people with HIV, NAM, Aidsmap, Gus Cairns, 27/5/15

New British guidelines recommend treatment for everyone living with HIV, NAM, Aidsmap, Keith Alcorn, 24/6/15

START trial provides definitive evidence of the benefits of early HIV treatment, NAM, Aidsmap, Liz Highleyman, Produced in collaboration with hivandhepatitis.com, 21/7/15