Combination therapy is the term for using three or more drugs to treat HIV. Treatment works for women, men and children. It works no matter how you were infected with HIV. At some point, most HIV-positive people will need treatment. It is recommended to start treatment before your CD4 count falls below 200.
By Simon Collins from i-Base
What is combination therapy?
Combination therapy is the term for using three or more drugs to treat HIV. It is also called triple or quadruple therapy or HAART (Highly Active Anti-Retroviral Therapy).
HIV drugs are also called ARVs. These drugs work in different ways and at different stages of the HIV life cycle.
Do the drugs really work?
In every country that uses HAART, AIDS-related deaths and illnesses have dropped dramatically.
Treatment works for women, men and children. It works no matter how you were infected with HIV. Whether this was sexually, through IV drug use, or by blood transfusion.
Taking HIV drugs, exactly as prescribed, will reduce the virus in your body to tiny amounts. This then lets your immune system recover and get stronger by itself.
Regular monitoring, using blood tests, will check that the drugs continue to work
• Viral load tests measure the amount of HIV in your blood. Results are given as copies/mL.
• CD4 tests measure how strong your immune system is. Results are given as cells/uL.
uL is an abbreviation for microlitre, a standard measurement for volumes of liquid. The same volume is also called a cubic millimetre which is abbreviated to mm3
Even if you start with a very low CD4 count, you could regain enough of your own immune system for your body to recover from many HIV-related illnesses.
If you use HIV treatment at the right time, and in the right way, you should stay well much longer.
How long will the drugs work?
Combination therapy using at least three drugs has now been used for over ten years. Many of the individual drugs have been studied for even longer.
The length of time that any combination will work depends mainly on you not developing resistance. This depends on getting, and keeping, your viral load to undetectable levels, below 50 copies/mL.
If your viral load stays undetectable, you can use the same combination for many years.
UK guidelines state that getting your viral load below 50 is a main goal when starting treatment.
Does everyone need treatment?
At some point, most HIV-positive people will need treatment. When people will need it though, can vary a lot. HIV infection progresses in different people at very different rates.
• About one third of HIV-positive people will stay well for up to 10 years after infection, even without treatment.
• About 60% will start treatment after 4-5 years.
• 2-3% of people can become ill more quickly and need treatment much earlier.
• 2-3% can go for 15-20 years without treatment.
Whether you need treatment is something you have to discuss with your doctor. This will usually take place over several visits.
When discussing treatment:
• Ask as many questions as possible until you are happy with the answers.
• Get useful information from other sources. This includes the internet, friends, newsletters and phonelines.
Even if you are well, it is a good idea to get to know something about treatment now, before you need it. This is particularly important if your CD4 count is falling, or if you have a high viral load.
When should I start treatment?
When to start treatment is something you and your doctor must discuss together. You are the person who has to take the pills. So you have the choice over whether you start, as well as which drugs you use.
It is recommended to start treatment before your CD4 count falls below 200. Even at this level, there is unlikely to be an urgent need for you to start treatment straight away, if you are not ready.
• Ask your doctor to tell you about the different drugs that you can use. You need to know the good and bad things about each of them.
• Take time to think about what you want to do. Do not feel rushed or pressurised into doing something you don’t understand. If you have only recently been diagnosed HIV-positive, you will need to deal with that first.
Although you may be worried about using treatments, HIV and AIDS is still a very real and life-threatening illness. It is possible to delay treatment until it is too late. Illnesses that can occur at any time when your CD4 count is below 200 can be fatal.
While your CD4 count is above 300 you still have a good immune system. Below 300 you are at a higher risk of infections that cause diarrhoea and weight loss.
If your CD4 count falls below 200, your risk of developing a pneumonia called PCP increases. If it falls below 100, then your risk of serious illnesses increases even further.
A low CD4 count does not mean that you will definitely become ill. It is, however, much more likely. Most of the drugs used to treat these HIV-related illnesses can be more toxic and difficult to take than regular anti-HIV drugs.
Don’t look at the drugs you start with now as a treatment that you will be taking forever. Look at them as something you have to be really committed to for the next couple of years. Take this new aspect of your life more seriously than anything else until you get it right.
Different drugs work at different stages of the HIV life cycle
HIV uses CD4 cells as factories to make hundreds of copies of itself - entry inhibitors and CCR5 inhibitors stop HIV getting into the CD4 cell, nukes & non-nukes (NNRTIs) block one of the main ways HIV reproduces inside the CD4 cell, integrase inhitors stop the virus from integrating into the cell DNA, and protease inhibitors stop any new genetic material from being cut and reassembled into newly infectious HIV..
What about side effects?
Everyone considering HIV treatment worries about side effects. But most people find that, within a few weeks, taking treatment becomes an ordinary and manageable part of their daily life.
• Most side effects are usually mild.
• They can often be reduced with other medication that is easy to use.
• There is only a small risk of serious side effects, and these should be picked up by routine monitoring.
Regular blood tests will check for some side effects. If you have any difficulties make sure your doctor takes these seriously. Nausea and fatigue can be very serious.
Ask your doctor, nurse or HIV pharmacist about the most common side effects of the drugs that you want to use. Ask how likely they are to occur. Ask how many people stop treatment because of them (usually very few). Even rough estimates will give you a good idea of what is involved.
Nausea, diarrhoea and tiredness are the most common general side effects. These often become easier after the first few weeks. This is why you should tell your doctor of any problems.
Ask your doctor or pharmacist for anti-nausea and diarrhoea medications when you first start therapy so you can use these as you need them.
If these medications aren’t effective, ask your clinic for stronger or more effective drugs.
Lipodystrophy
Lipodystrophy refers to changes in blood fat and blood sugar levels. It also includes changes in fat cells and the distribution of body fat.
It is a set of side effects that is a worry for many people who are about to start treatment.
However, most severe cases of lipodystrophy are in people who have used many different drugs, or have used treatment for many years.
Newer drugs used in first-line therapy are less likely to cause these problems. The greater awareness of lipodystrophy today means that you will be monitored carefully. You can change treatment if you get low-level symptoms.
Different drugs may be responsible for fat gain and fat loss. Fat accumulation, to the stomach or breasts and/or across the shoulders, has been more linked to protease inhibitors and NNRTIs. Fat loss, from arms, legs, face and buttocks, has been linked to nucleosides. This is mainly to d4T, and to a lesser extent to AZT.
We do not know what causes lipodystrophy. Lipodystrophy usually, but not always, develops slowly over many months.
Early symptoms may reverse if you switch to different HIV drugs. Exercise and dietary changes can also help.
Careful body measurements by a dietician, by DEXA scan, or photographs can monitor changes.
Other side effects
Regular blood tests will check for other side effects. If you have any difficulties make sure your doctor takes them seriously and does something about it.
Side effects that are more serious occur rarely with most combinations. They also relate to specific drugs. It is important to be aware of those associated with the drugs that you will use before you start treatment.
Because some of these symptoms include rash, nausea and tiredness that are common side effects themselves, it is important that your doctor knows about any difficulty you are having. +
This text is from the i-Base Introduction to Combination Therapy, which also includes sections on adherences, resistance, choice of drugs and your rights as a patient.
For free copies call 0207 407 8488 or request online at: www.i-Base.info
Other guides cover Changing Treatment. Side Effects. Pregnancy. and Hepatitis C coinfection. All guides are also available online.
