The evolution of antiretroviral therapy (ART) has transformed acute HIV infection into a chronic condition, with the life expectancy of people living with HIV, who initiated ART with CD4 count of ≥500 cells/mm3 being similar to that of the HIV-negative population.1 As such, the treatment goals of ART have also evolved to support life-long health in people living with HIV.
ART regimens are a combination of medicines developed to stop HIV from replicating in the body. ART cannot cure HIV but can help people living with HIV to live longer, healthier lives.2
What is the aim of ART?
ART aims to:2
• Suppress plasma HIV RNA or ‘HIV viral load’ in the body
• Preserve immunologic function
• Reduce the risk of HIV transmission
• Prevent progression to AIDS
• Reduce the risk of comorbidities and prolong the duration and quality of life
When should ART be initiated?
ART should be started as soon as possible after diagnosis, regardless of CD4+ cell count to decrease the time required to achieve virologic suppression and reduce the risk of HIV transmission.3,4
How is an ART regimen selected?
Current guidelines recommend that healthcare professionals consider multiple factors when choosing the most appropriate ART for an individual patient. These factors include, but are not limited to, efficacy, tolerability, comorbidities, risks of drug-drug interactions, ease of adherence and patient’s lifestyle and wishes.3,4
In women, ART selection should also consider reproductive intent, contraceptive use and hormone replacement therapy.4 Similarly, for transgender people, the choice of ART should consider any gender-affirming therapy they may be receiving.4
In general, there are five main considerations to guide HIV management strategies and ART selection:
General assessment: This includes a medical and social history, family history, lifestyle, smoking, drug and alcohol use; all of which might impact ART selection. Genotypic and phenotypic resistance assays might also be included at the point of diagnosis.3,4
Comorbidities: Considerations of the individual’s overall health, including body mass index, bone, kidney, metabolic, cardiovascular, liver and neurological health, are important. Concomitant medications are common with comorbidities and therefore potential drug–drug interactions should be regularly assessed.4
Past regimen tolerability: Tolerability of ART can impact the individual’s wellbeing, lifestyle and adherence. Assessing any past tolerability issues may help inform the choice of ART, especially in the case of switching.3,4
Mental health status: The presence of mental health disorders may negatively impact adherence to ART. Mental health disorders can be exacerbated by the social exclusion and stigma associated with HIV. Regular psychosocial and mental health assessments are essential with a need for focus on the impact of the diagnosis and coping skills, pre-morbid psychosocial issues, and specific effects relating to stigmatisation and discrimination.3-5
Adherence: Good adherence to ART is associated with achieving virologic suppression and should be assessed every 3–6 months following initiation. It is essential that people living with HIV have a thorough understanding of the importance of adherence to prevent the development of drug resistance. Counselling interventions, community resources, family and peer advocates can be utilised and provide education about HIV risk behaviours that impact adherence.3,4,6
