When Did HAART Become ART?

Change in acronym is more than just semantics

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ART is the acronym commonly used today to describe HIV antiretroviral therapy. Previous to this, doctors and scientists would use the term cART (combination antiretroviral therapy) and previous to that the popular term HAART (highly active antiretroviral therapy),

The changes over the years reflect more than just fashion. Rather, they are a real attempt by public health official to re-frame how we communicate the effectiveness of HIV therapy to the public at large.

No longer do we try to convince users that the drugs are "highly active," since they actually more than that. Today, the drugs allow for a normal quality of life and life span, while newer one-pill options make the use of the term "combination" all the more redundant.

Understanding ART

Whatever the acronym used, the term implies the use of three or more antiretroviral drugs, either taken individually or in fixed-dose combinations. The aim of therapy is to ensure the suppression of HIV to undetectable" levels (meaning that the virus is not gone but is simply beneath detection levels).

As opposed to single-drug or dual-drug therapy, the combination of three or more active drugs is known to effectively suppress the variety of resistant HIV that can exist within a viral population. Essentially, if one drug is unable to suppress a certain viral mutation, the others will likely be able to do so.

High levels of drug adherence are needed in order to maintain therapeutic drug levels in the blood. If these levels fall beneath the therapeutic threshold, resistant strains are provided an opportunity to thrive. The larger these resistant populations, the less effective the drugs will be in suppressing HIV, eventually leading to viral rebound and treatment failure.

Since 2009, the term cART supplanted the more commonly known HAART. While the terms are essentially interchangeable, HAART was largely considered inadequate in describing the empirical effectiveness of combination therapy.

Subsequently, ART was considered more appropriate given the likelihood that combination therapy will change in the coming years. As proof of this, Juluca (rilpivirine plus dolutegravir), the first dual drug combination, was approved by the U.S. Food and Drug Administration in 2018 for the treatment of HIV without a third antiretroviral agent.

Classes of ART

There are currently five classes of antiretroviral drug, each of which inhibit a specific stage in the HIV life cycle:

  • Entry inhibitors 
  • Nucleoside reverse transcriptase inhibitors
  • Non-nucleoside reverse transcriptase inhibitors
  • Integrase inhibitors
  • Protease inhibitors

Other classes of antiretrovirals are being investigated, while newer-generation drugs aim to improve tolerability, reduce adverse effects and simplify dosing for those on therapy.

To this end, an increasing number of fixed-dose combination (FDC) drugs are now available, combining two or more drug into a single pill or tablet. Some, including Atripla ((tenofovir + emtricitabine + efavirenz), Triumeq (abacavir + lamivudine + dolutegravir) and Stribild (tenofovir + emtricitabine + elvitegravir + cobicistat) offer all-on-one formulations for simplified, daily dosing.

Future of ART

With advances in HIV drug developments, ART is now being employed as a means to reverse infection rates in high prevalence HIV populations. The strategy, known as treatment as prevention, has been shown to reduce the risk of transmitting HIV by suppressing viral activity to undetectable levels. In doing so, the risk of transmission is reduced by as much as 96 percent.

By ensuring widespread distribution of antiretroviral drugs, the so-called "community viral load" (the median viral load within a community) can be reduced to levels where the likelihood of transmission is significantly dropped.

Scientists are now exploring the development of long-lasting antiretroviral agents, some of which may require monthly or even quarterly drug dosing.

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