Your Essential Guide to HIV Therapy

Though recent advances in antiretroviral therapy have been nothing short of astonishing—affording people with HIV normal to near-normal life expectancy—there remain significant gaps in treatment among people living with HIV in the United States.

In fact, of the nearly 1.2 million Americans living with HIV today, fewer than one in four are able to achieve complete viral suppression, which is key to treatment success.

This is a major problem. Without the means to achieve and sustain an undetectable viral load, people with HIV are at greater risk of HIV-related and non-HIV-related illnesses as well as the premature development of drug resistance.

In the end, HIV therapy is ultimately about more than just pills. It's about finding the tools to effectively manage your disease in partnership with your healthcare provider. It's about taking charge and normalizing HIV in your life so that you can control the disease rather than the disease controlling you.

It all starts with education and by asking yourself the right questions.

What Are Antiretrovirals?

Antiretroviral drugs do not cure HIV. Rather, they work by blocking a stage in the virus's replication cycle, either by binding to a protein or inhibiting an enzyme needed to complete the cycle. Without the means to do so, the virus will drop to undetectable levels where it can do the body little harm.

For antiretroviral therapy to work, several drugs are combined to block different stages of replication. To ensure that the concentration of medication in your blood remains at a steady state, you need to take the pills routinely and as prescribed (referred to as a treatment adherence).

When starting treatment, it is important to learn the names of your drugs—both the brand name (like Viramune) and the chemical name (like nevirapine)—and to ask your healthcare provider about possible side effects and drug interactions. By doing so, you can participate more actively in your treatment decisions and know when to act if a problem occurs.

What Drugs Do I Start With?

A special panel organized by the U.S. Department of Health and Human Services oversees the HIV treatment guidelines in the United States. The group, comprised of healthcare providers, scientists, and public health officials, regularly updates their recommendations based on emerging science.

In most cases, a newer class of drugs called integrase inhibitors are included in the first-line treatment of HIV due to their efficacy, ease of use, durability, and low risk of side effects.

Even so, not everyone starts with the same drugs. Before prescribing treatment, your practitioner will perform tests to "profile" your virus and determine if it has any drug-resistant mutations that might limit the effectiveness of a drug. This typically involves a blood test referred to as genetic resistance testing.

Based on the findings and the DHHS recommendations, your healthcare provider can tailor treatment for you as an individual. In some rare cases, integrase inhibitors may not be a viable option and an alternative drug may be used.

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What Causes HIV Resistance?

HIV drug resistance can develop naturally as your virus mutates in response to the medications you take. With that said, the resistance tends to develop slowly over the course of many years and requires multiple mutations before significant resistance occurs.

If drug resistance occurs early, such as within a year or two, it is more likely than not to be the result of poor adherence. Unless the virus is completely suppressed with uninterrupted therapy, drug-resistant variants can "escape" and gradually grow in numbers until they become the predominant type.

When this occurs, your drugs will not work as effectively. In some cases, the mutations you develop may even reduce the effectiveness of other antiretroviral drugs you've never been exposed to.

How Much Adherence Is Enough?

As a rule, people on antiretroviral therapy have long been advised to maintain greater than 95% adherence to sustain viral suppression. This translates to roughly 15 non-consecutive missed doses per year (or little more than one missed dose per month).

For some, this may seem a daunting task. But things have changed in recent years as more and more combination drugs are being released, allowing many people to take one pill daily rather than multiple drugs several times a day.

Single-pill therapies not only translate to improved adherence rates but also have been shown to significantly reduce the risk of severe illnesses and hospitalization compared to multi-pill antiretroviral therapy.

Furthermore, newer HIV drugs have improved pharmacokinetics (drug activity) and are more "forgiving," meaning that you can miss a dose without undue concern about resistance. Some studies have even shown that newer drugs like tenofovir and integrase inhibitors are able to sustain viral suppression with 85% adherence.

With that said, antiretroviral therapy consists of multiple drugs each with different half-lives, and adjusting the adherence threshold with each regimen is not only impractical but may end up causing excessive "slippage" in your routine pill-taking.

What Happens If A Treatment Fails?

When the drugs you take no longer work, you are said to have treatment failure. By definition, treatment failure is declared when you are unable to maintain a viral load of fewer than 200 copies per milliliter (mL) despite adherence to treatment. On top of that, the viral elevation must persist over several consecutive readings within the course of six months or sooner.

When failure is first suspected, your healthcare provider will assess whether you have any adherence problems and try to correct them in order to preserve the current treatment.

If that doesn't help, your practitioner will once again profile your virus. In addition to genetic resistance testing, your healthcare provider may order a phenotypic test in which the virus is directly exposed to all available antiretrovirals to see which ones work best.

A Word From Verywell

If you test positive for HIV, you need to start treatment as soon as possible. The longer you delay, the further your immune function can drop (as measured by the CD4 count). If the CD4 count drops below 200—the diagnostic definition of AIDS—your chances of complete immune recovery may also be decreased.

By starting treatment early, you not only stand a good chance of living a normal lifespan but will reduce your risk of serious HIV-associated and non-HIV-associated illness by more than half.