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HIV 2 – Treatment

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Where are we with HIV treatment in 2020?

Treating HIV early keeps people living with HIV alive, healthier and reduces the spread of HIV. For this reason, and in line with World Health Guidelines, South Africa has a ‘test-and-treat-all’ policy, making all populations and age groups eligible for treatment regardless of CD4 count.1a

With approximately 7.5 million people (of all ages) in South Africa living with HIV at the end of 2019, there is still an enormous need to create awareness and improve access to effective medicines for all.2a,3a

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How is HIV treated?

There is no cure for HIV, but treatment with HIV medicines, called antiretroviral therapy (ART), can slow or prevent HIV from advancing from one stage to the next. HIV medicines help people live longer, healthier lives.4a

People on antiretroviral therapy take a specific combination of HIV medicines every day, called an ART regimen.4b HIV medicines are grouped into different drug classes according to how they fight HIV.4b

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Goals of HIV treatment

It is important to know that antiretroviral therapy cannot cure HIV but does help people with HIV live longer, healthier lives. HIV medicines also reduce the risk of HIV transmission (spread to others).4c

  • One of the main goals of treatment is to reduce a person’s viral load to an undetectable level. People with HIV who maintain an undetectable level of virus in their blood have no risk of transmitting HIV to their HIV-negative partner through sex.4c
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What are the benefits of HIV treatment?

All people living with HIV are eligible to be provided with lifelong treatment, regardless of age, clinical status or CD4 count, including children, adolescents and adults, and pregnant and breastfeeding women.1b,5a

Treatment can offer the following benefits to patients:4a,c,6a

  • slow down the progression of HIV through the stages
  • prevent HIV from advancing from one stage to the next
  • help people with HIV live longer, healthier lives
  • reduce the risk of transmission to HIV-negative people

Without treatment, HIV infection advances in stages, getting worse over time.4d

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Deciding on treatment for each patient

The World Health Organisation and National guidelines recommends ART for all people with HIV as soon as possible after diagnosis without any restrictions of CD4 counts.1a,6b

There are certain steps that must be taken to decide on appropriate therapy for each individual patient, these are:1c

  1. Determine the timeframe for starting treatment
  2. Decide on first- or second-line treatment
  3. Choose the drugs in the regimen
  4. Provide education to encourage adherence to medication

In some instances, treatment will not be started immediately after diagnosis. Special screening (testing) will be done to find out if a patient has tuberculosis (TB) or any other chronic condition or infection that may affect the type of medication that can be prescribed.1d

For example, if a patient is found to have TB at the time of testing for HIV, antiretroviral therapy will only be started after a minimum of 2 weeks after starting TB treatment when a person is stable on the TB treatment.1e For further information on HIV and co-infection with TB, read here: https://private.medinformer.co.za/health_subjects/hiv-8-tuberculosis-tb/

Starting daily antiretroviral therapy as soon as possible after diagnosis and staying on treatment are essential for keeping HIV under control, which benefits individual health and prevents HIV transmission to others.7a

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Did you know?

Because of antiretrovirals, HIV infection has transformed from an almost uniformly fatal infection into a manageable chronic condition!7

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Different types of HIV medicines

HIV medicines are grouped into different classes according to how they fight HIV.4 There are currently 5 main classes of antiretrovirals in South Africa.8

Some HIV medicines are available in fixed-dose combinations which means there is more than one medicine combined into one tablet. This reduces the burden of multiple pills and may improve treatment adherence.8

The following table lists the names of the medicines (active ingredients) and their unique identifying abbreviation.8 This information is quite complex and if you have any questions relating to specific medicines, please ask your healthcare professional

*Ritonavir is used in combination with a Protease Inhibitor (/r)in order to improve efficacy.8

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What is new in HIV treatment?

Continual research takes place to discover new ARV options with better tolerability and efficacy, offering patients improved quality of care.5b,7b Since 2019, a new regimen has been preferred.1g To improve the lives of people living with HIV a new regimen called ‘TLD’ is now preferred.9a,b A TLD regimen offers patients:9a,c

  • 3 medicines in 1, with a new drug called Dolutegravir (DTG)
  • one pill, taken once-a-day
  • rapidly suppresses the HIV virus
  • unlikely to have resistance
  • less side effects
  • smaller tablet – making it easier to take

TLD is recommended by the World Health Organisation for first-line treatment of HIV. It can also be used in second-line and third-line treatment of HIV.5b,9b

TLD is manufactured and supplied by several pharmaceutical companies and comes in different colours, shapes and sizes – all contain the same ingredients.9e

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Is TLD recommended for everyone?

Each HIV regimen is chosen according each person’s individual needs.10a TLD can be taken by any person over the age of 10 and over 35kg in weight.1h Pregnant women and those planning for pregnancy have a choice and should discuss the benefits and potential risks of TLD with their healthcare provider to make an informed choice.9d

TEE is another alternative first-line ART regimen.1i,9d Speak to your healthcare professional about which may be best for you.

 

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When would a patient require a switch of therapy from first-line to second-line options?

A person may have to be switched onto ‘second-line treatment’ if the current medications they are on are not working well enough to keep the viral load low.1j

Together with an increased viral load on repeated occasions, declining CD4 and/or increased opportunistic infections will confirm that the medication will need to be changed.1j

A ‘failure’ of medication is sometimes caused by suboptimal treatment adherence.1j Before switching, the reasons for medication ‘failure’ will be assessed. These include:1k

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Targets and milestones of the National HIV Programme

90|90|90

South Africa is committed to achieving 2020 targets of:1

  • having 90% of people living with HIV know their status
  • 90% of those diagnosed initiated on HIV treatment, and
  • 90% of those on treatment being virally suppressed.

To accelerate progress towards these targets, we have seen the introduction of a new antiretroviral medicine called Dolutegravir (DTG), which will offer patients:1

  • improved efficacy
  • a high barrier to resistance
  • good tolerance
  • improved health outcomes

There are many factors that are considered when your doctor chooses an HIV treatment regimen, including if there are other diseases or conditions that the person may have, whether they may be pregnant, possible side effects or interactions they may experience, as well as the suitability of the regimen to the patient.1,10 Can the patient swallow tablets? Are they able to follow the instructions? The best regimen for a person depends on their individual needs.10

Medical References

  1. National Consolidated Guidelines for the management of HIV in adults, adolescents, children and infants and prevention of mother-to-child transmission. South African National Department of Health, February 2020.
  2. World Health Organisation (WHO). Number of people (all ages) living with HIV Estimates by country [Last updated 09.07.2020]. Available from: https://apps.who.int/gho/data/view.main.22100?lang=en Last accessed August 2020.
  3. Joint United Nations Programme on HIV/AIDS (UNAIDS) Data 2017.
  4. AIDSinfo, National Institutes for Health (NIH). HIV Overview. Available from: https://aidsinfo.nih.gov/understanding-hiv-aids/fact-sheets/ Last accessed August 2020.
  5. World Health Organisation (WHO) HIV-AIDS Key Facts; [July 6, 2020]. Available from: https://www.who.int/news-room/fact-sheets/detail/hiv-aids Last accessed August 2020.
  6. World Health Organisation (WHO). HIV/AIDS Topics; [Last updated June 16, 2020]. Available from: https://www.who.int/hiv/topics/treatment/en/ Last accessed August 2020.
  7. National Institutes for Allergy and Infectious Diseases (NIAID), National Institutes for Health (NIH). HIV treatment. Available from: https://www.niaid.nih.gov/diseases-conditions/hiv-treatment Last accessed August 2020.
  8. Meintjes G, Moorhouse MA, Carmona S, et al. Adult antiretroviral therapy guidelines 2017. S Afr J HIV Med 2017;18(1):a776. https://doi.org/10.4102/ sajhivmed.v18i1.776.
  9. TLD poster. South African National Department of Health. Available at: http://www.health.gov.za/index.php/component/phocadownload/category/613-a1-poster Last accessed August 2020.
  10. AIDSINFO, National Institutes for Health (NIH). HIV Treatment: The Basics [Last reviewed March 2, 2020]. Available from: https://aidsinfo.nih.gov/understanding-hiv-aids/fact-sheets/21/51/hiv-treatment–the-basics Last accessed August 2020.
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