How HIV Is Treated

A comprehensive guide to treatment options

This article is part of Health Divide: HIV, a destination in our Health Divide series.

Thanks to advances in treatment, people with HIV are living longer, healthier lives than ever before. Although there is still no cure for the disease, HIV is today considered a chronic, manageable condition with numerous medications able to control the infection.

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Understanding HIV and AIDS

Even so, only around 66% of the 1.2 million people living with HIV in the United States are undergoing treatment. Approximately 57% are able to achieve viral suppression needed to stop the disease from progressing.

Fixed-dose combination antiretroviral drug Odefsey (emtricitabine, rilpivirine, tenofovir AF)
The fixed-dose combination drug Odefsey. Gilead Sciences

Background

HIV infects a type of cell called a CD4 T-cell. This is the cell that helps launch the body's immune response. Once the HIV enters a CD4 T-cell, it "hijacks" its genetic machinery and turns it into an HIV-producing factory, churning out multiple copies of itself until the cell eventually dies.

As more and more CD4 T-cells are destroyed, the immune system becomes less and less able to defend the body against otherwise common infections, referred to as opportunistic infections (OIs). Without treatment, the immune defenses are eventually compromised, leaving the body vulnerable to an ever-increasing number of potentially life-threatening OIs.

HIV is treated with a combination of antiretroviral drugs. The drugs work by blocking a stage in the virus' life cycle. Without the means to replicate, the viral population will eventually drop to undetectable levels where it can do the body little harm.

Prior to the introduction of combination antiretroviral therapy in 1996, the average life expectancy for a 20-year-old newly infected with HIV was just 17 years. With today's medications, a typical 20-year-old is expected to live well into their 70s, if diagnosed and treated early.

However, in order to sustain an undetectable viral load, you need to take your medication every day. Unfortunately, some individuals are unable to do so. This is especially true for people who don't have access to adequate or consistent health care. Without viral suppression, you're more likely to infect others, increasing infection rates in their community

Infection Rates Among Black People

According to the Centers for Disease Control and Prevention (CDC), fewer Black people with HIV have sustained viral suppression compared with people of Latin American culture or White people. This accounts in part for why 43% of all new infections are among Black people, despite the fact that Black people only account for 12% of the U.S. population.

Treatment Failure With HIV

Verywell / Julie Bang

How Antiretrovirals Work

Antiretrovirals target specific stages of the virus' life cycle, blocking enzymes or proteins that the virus needs to make copies of itself. Without the means to replicate, the virus can quickly be suppressed to undetectable levels. This not only keeps the immune system intact, reducing the risk of OIs, but also prevents others from getting infected.

Studies have confirmed that having and sustaining an undetectable viral load cuts the risk of infecting others to zero.

The following chart includes antiviral medicines recommended to treat HIV in the United States.

Drug Class Stage(s) Blocked Drug Action Drugs
Entry/attachment inhibitors Viral attachment and fusion Prevents HIV from attaching to and entering the host cell Fuzeon (enfuvirtide) Rubukio (fostemsavir) Selzentry (maraviroc) Trogarzo (ibalizumab)
Nucleoside reverse transcriptase inhibitors (NRTIs) Reverse transcription Blocks an enzyme called reverse transcriptase that translates viral RNA into DNA Emtriva (emtricitabine) Epivir (lamivudine) Retrovir (zidovudine) Viread (tenofovir) Ziagen (abacavir)
Non-nucleoside reverse transcriptase inhibitors (NNRTIs) Reverse transcription Binds to the reverse transcriptase enzyme to prevent its action Edurant (rilpivirine) Intelence (etravirine) Pifeltra (doravirine) Sustiva (efavirenz) Viramine (nevirapine)
Integrase strand transfer inhibitor (ISTI) Integration Blocks the integrase enzyme that the virus uses to integrate the newly formed DNA into the host cell's nucleus Isentress (raltegravir) Tivicay (dolutegravir) Vocabria (cabotegravir)
Pharmacokinetic enhancers ("booster drugs") N/A Boosts the concentration of certain antiretrovirals so they work longer Norvir (ritonavir) Tybost (cobicistat)
Protease inhibitors (PIs) Assembly Blocks an enzyme called protease that promotes the building blocks that are used to assemble new HIV Aptivus (tipranavir) Lexiva (fosamprenavir) Prezista (darunavir) Reyataz (atazanavir)

Combination Therapies

Antiretroviral drugs are used in combination. By blocking more than one stage in the virus' life cycle, the drugs are better able to achieve and sustain viral suppression. HIV drugs used on their own (referred to as monotherapy) cannot do this.

Combination therapy also reduces the risk of HIV drug resistance. With monotherapy, strains of the virus can mutate or begin to vary, which results in the single drug being ineffective against the strain. If the variant strain is drug-resistant, it can continue to multiply and eventually become the predominant strain. This can lead to a condition known as "treatment failure," in which the drugs no longer work effectively.

To simplify dosing and improve adherence, the drugs are often co-formulated into a single tablet. There are currently 22 different fixed-dose combination drugs approved by the U.S. Food and Drug Administration (FDA), some of which are all-in-one therapies requiring only one pill per day.

Brand Name Contents
Atripla 600mg efavirenz + 200mg emtricitabine + 300mg tenofovir disoproxil fumarate
Biktarvy 50mg bictegravir + 200mg emtricitabine + 25mg tenofovir alafenamide
Cabenuva 400-600mg cabotegravir + 600-900mg rilpivirine
Cimduo 300mg emtricitabine + 300mg tenofovir disoproxil fumarate
Combivir 300mg zidovudine + 150mg lamivudine
Complera 25mg rilpivirine + 200mg emtricitabine + 300mg tenofovir disoproxil fumarate
Descovy 200mg emtricitabine + 25mg tenofovir alafenamide
Delstrigo 100mg doravirine + 300mg lamivudine + 300mg tenofovir disoproxil fumarate
Dovato 50mg dolutegravir + 300mg lamivudine
Epzicom 600mg abacavir + 300mg lamivudine
Evotaz 300mg atazanavir + 150mg cobicistat
Genvoya 150mg elvitegravir + 150mg cobicistat + 200mg emtricitabine + 10mg tenofovir alafenamide
Juluca 50mg dolutegravir + 25mg rilpivirine
Kaletra 200mg lopinavir + 50mg ritonavir
Odefsey 25mg rilpivirine + 200mg emtricitabine + 25mg tenofovir alafenamide
Prezcobix 800mg darunavir + 150mg cobicistat
Symtuza 800mg darunavir + 150mg cobicistat + 200mg emtricitabine + 10mg tenofovir alafenamide
Symfi 600mg efavirenz + 300mg lamivudine + 300mg tenofovir disoproxil fumarate
Symfi Lo 400mg efavirenz + 300mg lamivudine + 300mg tenofovir disoproxil fumarate
Stribild 150mg elvitegravir +150mg cobicistat + 200mg emtricitabine + 300mg tenofovir disoproxil fumarate
Triumeq 600mg abacavir + 50mg dolutegravir + 300 mg lamivudine
Truvada 200mg emtricitabine + 300mg tenofovir disoproxil fumarate

Treatment Guidelines

The HIV treatment guidelines in the United States are overseen by the Department of Health and Human Services (DHHS). The DHHS panel of experts issues specific recommendations on how to treat HIV in adults, children, and pregnant people.

Delayed Diagnoses in Black People

People who delay treatment almost invariably have worse outcomes. Black people with HIV are more likely to present with an AIDS defining illness due to delay in diagnosis. Misconceptions about HIV drugs, distrust in the public health system, decreased access to healthcare systems, poverty, stigma and other structural barriers all contribute to these delays.

Starting Treatment

Integrase inhibitors are the ideal drug for most people newly diagnosed with HIV (due to their ease of use, low risk of side effects, and overall durability and effectiveness). In December 2019, the HHS reaffirmed integrase inhibitors as the preferred class of drugs for the first-line treatment of HIV.

All five preferred, first-line therapies include an integrase inhibitor as part of combination therapy.

HHS Preferred First-Line Regimens (December 2019)
Option 1 Biktarvy (bictegravir + emtricitabine + tenofovir alafenamide
Option 2 Triumeq (abacavir + dolutegravir + lamivudine)
Option 3 Tivicay (dolutegravir) plus Descovy (emtricitabine + tenofovir alafenamide) OR Tivicay (dolutegravir) plus Cimduo (lamivudine + tenofovir disoproxil fumarate)
Option 4 Isentress (raltegravir) plus Descovy (emtricitabine + tenofovir alafenamide) OR Isentress (raltegravir) plus Cimduo (lamivudine + tenofovir disoproxil fumarate)
Option 5  Dovata (dolutegravir + lamivudine)

Prior to starting treatment, a healthcare provider will order tests to understand the variation of the virus. This involves a blood test, called genetic resistance testing, that can identify mutations associated with drug resistance. Based on the number and types of mutations you have, the test can predict which drugs will work most effectively for you.

A healthcare provider will also order baseline CD4 count and viral load tests. The CD4 count measures the number of CD4 T-cells in a sample of blood and is used as a general measurement of your immune strength. The baseline viral load allows your healthcare professional to monitor how well you are responding to treatment based on the number of viruses in your blood.

Changing Treatment

Treatment failure is most often the result of a lack of adherence to medication regimen but can also occur naturally over time as drug-resistant mutations slowly develop. You can also "inherit" a drug-resistant strain.

If treatment is failing, your healthcare provider will again profile your virus to see which drugs it is sensitive to. In addition to genetic resistance testing, another test—called phenotypic testing—may be ordered. This involves directly exposing the virus to all available antiretrovirals to see which ones work best.

Based on the results of these tests and recommendations from the HHS, your healthcare provider can select the best combination of drugs for you.

Treatment Failiure Among Black People

Studies have shown that Black people in the United States are 1.7 times more likely to experience treatment failure than Whites. Although the disparity is largely driven by social factors—including high rates of poverty, a lack of access to health care, and stigma—it is also possible that biological factors, such as metabolism and tolerability, may play a role.

Lifestyle

Managing HIV is about more than just pills. It is also important to manage any issues in your life that can affect your adherence or increase your risk of OIs. Because you only see your healthcare provider occasionally, it is up to you to manage your health over the long term. The choices you make can directly impact your health.

Adherence

One of the key ways to ensure long-term adherence is to remain linked to HIV-specific care. This means seeing your healthcare provider one to three times yearly to get your blood checked and prescriptions refilled.

If you can't and find your current drug regimen difficult, speak with your doctor. In some cases, your doctor may be able to switch you to a once-daily, all-in-one tablet.

Viral Suppression Among Black People

Black people with HIV have the lowest rate of viral suppression, with only 51% able to achieve an undetectable virus. Moreover, Black men who have sex with men (MSM) are 60% less likely to have an undetectable viral load than White MSM. The combination of poverty and homophobia contributes to this disparity.

General Health

HIV cannot be managed in isolation. It requires a holistic approach to avoid HIV-associated illnesses as well as non-HIV-associated illnesses that are the most common causes of death in people living with HIV today.

In the United States, people with HIV are more likely to die from heart disease, cancer, and liver disease than from HIV itself. Because HIV places the body under persistent inflammation, these diseases often occur 10 to 15 years earlier than in the general population.

If you have HIV, you need to adhere to the same general health recommendations as everyone else. This includes:

Accessing Healthcare Among Black Males

Around 77% of Black people newly diagnosed with HIV are linked to health care. Of these, only 3 of every 5 Black heterosexual males between the ages of 13 and 24 or 45 and 54 receive care. HIV stigma and conspiracy theories keep many of these men from seeking treatment.

Over-the-Counter (OTC) Therapies

Over-the-counter (OTC) medications have no effect on HIV infection. Even though some manufacturers will market their products as "immune boosters," they ultimately do nothing to treat the infection or alter the course of the disease.

With that said, there are OTC medications that are sometimes used to relieve symptoms of the disease or side effects of treatment. These include:

  • Capsaicin: Applied topically to the skin, these medications are derived from chili peppers and are thought to relieve symptoms of peripheral neuropathy in some people.
  • Antioxidant supplements: Long-term HIV infection can increase the concentration of free radicals that cause harm to tissues and cells. There is some evidence, albeit scant, that antioxidant supplements like CoQ10 and L-carnitine can help neutralize free radicals (although there is no evidence they can either prevent or treat HIV-associated illnesses).
  • Calcium and vitamin D: Long-term HIV infection is associated with bone mineral loss. Although it is unclear if calcium or vitamin D supplements can reduce the risk of HIV-associated fractures, they may be a reasonable option for people with HIV who have osteoporosis.

Complementary and Alternative Medicine (CAM)

There are no complementary or alternative therapies that can take the place of antiretroviral therapy. With that said, sometimes people with HIV will turn to alternative medicine to better manage symptoms or relieve side effects.

To avoid interactions and other possible harms, speak with your healthcare provider before adding any complementary or alternative therapy to your treatment plan.

Medical Marijuana

Medical marijuana has long been used to treat pain, reduce nausea, and stimulate appetite in people with HIV. Even so, evidence is lacking as to whether cannabis in any form offers real benefits. A few studies have suggested that THC (the psychoactive ingredient of marijuana) may provide short-term relief of peripheral neuropathy when smoked.

Yoga and Meditation

HIV is associated with high rates of stress, anxiety, and depression, particularly in communities where HIV is stigmatized. These emotions can affect your ability to adhere to treatment. Yoga, meditation, and other mind-body therapies cannot overcome these issues on their own but may help manage stress and anxiety as part of an overall treatment plan.

Some studies suggest that mindfulness meditation can help minimize chronic pain caused by peripheral neuropathy, in part by reducing the anxiety that heightens the sensation of pain.

A Word From Verywell

Without question, the benefits of HIV therapy outweigh any potential risks. It can increase life expectancy and prevent the transmission of the virus to others. Treatment can also reduce the risk of severe HIV-associated and non-HIV-associated illness by as much as 72% if started early, according to research published in the New England Journal of Medicine.

HIV testing can be conducted confidentially. If you test positive and need treatment, there are many federal, state, and institutional programs that can help pay for your treatment and care.

Frequently Asked Questions

  • How is HIV treated?

    HIV is treated with a combination of antiretroviral drugs. Antiretrovirals work by blocking different stages in the virus' life cycle to prevent the virus from making copies of itself that can go on to infect more of your immune cells.

  • What are the goals of HIV treatment?

    The primary goal is to reduce the viral population to undetectable levels. This prevents disease progression and dramatically reduces the risk of opportunistic infections and death.

  • How are HIV treatments chosen?

    HIV mutates continuously and has a multitude of variations. A genetic resistance test can determine the characteristics of an individual’s specific virus and identify which antiretrovirals would be most effective. The test may be accompanied by phenotyping, a process by which a sample of a virus is exposed to each antiretroviral to see which ones work best.

  • What happens if you stop HIV treatment?

    When you stop antiretroviral therapy, the viral number will rebound. In the end, antiretrovirals don’t kill HIV; they simply suppress the virus and keep it from destroying your immune system. If you stop and start treatment, the virus also has a greater chance of developing drug-resistant mutations, making your drugs less effective.

  • Are all antiretroviral therapies taken once daily?

    Until recently, that was the case. But in 2021, the FDA approved a combination therapy called Cabenuva, which can be given monthly or every two months. The combination of two different injectable antiretrovirals, cabotegravir and rilpivirine, has proven to be just as effective in suppressing HIV as once-daily oral options.

  • What other treatments are used in people with HIV?

    For severely immunocompromised people, prophylactic (preventive) drugs may be prescribed to avoid opportunistic infections like toxoplasmosis, tuberculosis, pneumocystis pneumonia, and others. Vaccination for hepatitis A, hepatitis B, human papillomavirus (HPV), influenza, pneumococcal disease, and shingles are recommended for everyone with HIV.

  • Can HIV be treated without antiretrovirals?

    No. Antiretrovirals are the only treatments that can block viral replication and prevent disease progression. There are no "immune boosters," supplements, or endorsed medical procedures that can "cure" HIV or alter the course of the disease in any way.

  • How long can you live if you are treated for HIV?

    If diagnosed and treated early, people with HIV can enjoy near-normal to normal life expectancy. Even people with advanced HIV can benefit from medication by preventing opportunistic infections.

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