When should treatment start?
The Norwegian Association for Infection Medicine has published guidelines for the treatment of HIV positive people. Last issued in 2018, these guidelines recommend that all newly diagnosed with a HIV infection should as soon as possible be referred to a specialist and start treatment (ART) immediately regardless of CD4 cell count or symptoms. The person with HIV should be involved in the decision to begin treatment.
What should be done before treatment starts?
Once treatment has started, it must continue. If treatment is to be successful, it must be taken as specified by the doctor and without interruption. Good advice before treatment starts:
- It is very important to become familiar with how the medication should be taken, e.g., how often should it be taken and if it should be taken with or without food. Daily routines may need to be changed to take the medicines as prescribed.
- Learn about side effects and how they can be tackled. They can be bothersome at first, so medical leave of absence or help from others may be necessary. Do not discontinue treatment due to side effects without first consulting the doctor handling the treatment.
- Discuss with the doctor what can be done if it is difficult to follow the treatment schedule.
Today, there are a number of different registered HIV medicines and new ones are in development. Progress in recent years has meant that fewer tablets and fewer doses need to be taken daily. HIV treatment consists of combination therapy with multiple medications. When treatment begins, medicines are selected from four different classes:
- Nucleoside/nucleotide reverse transcriptase inhibitors (NRTI)
- Non-nucleoside reverse transcriptase inhibitors (NNRTI)
- Protease inhibitors (PI)
- Integrase inhibitors (INSTI)
How do the medicines work?
HIV treatment aims to prevent the reproduction of the virus and thus the attack on the white blood cells (immune cells). The virus needs several biochemical processes to enable it to penetrate the white blood cells, multiply and then exit the cells to infect new ones. HIV medication prevents or disturbs these processes.
HIV treatment exploits different attack strategies to prevent HIV from multiplying. Some medicines block the virus from the immune cells and others destroy or prevent the virus production within immune cells, or prevent them from leaving in a form where they can attack new cells.
Risk of mutation and resistance development
HIV can multiply quickly and create new “versions” of the virus which differ slightly from the original, known as mutation. In practice, this means that an HIV positive person will eventually have many different variants of the virus, but none are produced in large enough quantities to overtake the majority of the original virus.
When starting treatment, the original virus will be blocked by HIV medicine. When the treatment only uses a single drug, a mutation could be formed that can withstand it. The mutated virus will escape the “blockade” created by the HIV drug. The viruses will continue to multiply and with time will overtake the original virus. Treatment will no longer work and this is called resistance.
The same can happen when two drugs are taken simultaneously, but the risk of resistance development is less. The more medicines are administered, the less risk there is for resistance development. Therefore a “cocktail” of several drugs is often given simultaneously. In recent years, fewer daily doses have been needed.
The goal of treatment is to find a combination of drugs that reduces viral load to below detectable levels and keeps it there. Then the risk of new mutations and resistance is small.
The correct use of HIV medicine will usually be very effective in preventing the production of new viruses and reduce the risk of HIV mutations. However, this requires that the virus will constantly be “bombarded” with drugs that interfere with the reproduction process. Therefore, it is vital to take HIV medicine according to a rigid schedule and in the right dose every day.
Side effects of treatment
The side effects of HIV medicine can vary from one drug to another and from person to person. With many of the current HIV drugs it is possible to find a treatment that provides minimal side effects for the individual. Side effects of HIV medicine may be considered problematic or may only be detected in blood sample checks. They include:
Bothersome, but mostly harmless side effects such as headache, muscle and joint pain, diarrhoea and nausea, dizziness, vivid dreams and a slight yellow tinge to the eyeballs. These are most pronounced during the start of treatment and will usually disappear after some time.
Side effects that can damage organs such as bone marrow, kidneys, liver and pancreas.
Side effects that influence fatty acid metabolism. This may increase the risk of cardiovascular disease and diabetes. In addition, the HIV infection itself may increase the risk of such diseases.
It is therefore important to have routine checks, both to monitor the effect of treatment and to assess any side effects. Medicine used against other diseases than HIV can have effects that heighten or impair the effects of HIV medicine, and HIV medicine can also affect treatment for other diseases. The doctor who is responsible for the treatment of the HIV positive person will ask what other medicines are being taken. This also applies to some herbal remedies and stimulants, which could have unexpected effects when combined with HIV medicine.
Follow-up during treatment
Treatment is monitored by measuring the viral load in the blood and CD4 cells and resistance testing of viruses. If severe side effects arise, the drug combinations can be altered so that treatment is better tolerated.
The goal of treatment is a viral load of less than 500 virus copies/ml after 12 weeks and less than 50 virus copies / ml after 24 weeks. Development of resistance is usually caused by medicines not being taken as directed by the doctor.
What if we/I want a child?
HIV positive people have good prospects for a long life. This makes the desire to have a child feasible when the father and / or mother are HIV positive. Despite advances in HIV treatment, there are still several obstacles and dilemmas linked to conception, pregnancy and birth. Treatment reduces the risk of transmission from mother to child
What if the man has an HIV infection and the woman does not?
A man with HIV-infection who are on successful treatment poses a very small risk of infected the women who can then become pregnant. This small risk can be additional reduced by using a method to wash” the virus out of the semen, and the woman can then be artificially inseminated.
What if the woman has HIV infection and the man does not?
The risk of a woman on successful treatment passing the infection to the man is considered very small. If the woman is not on successful treatment, there is a less than 2 % risk that the child could become infected during pregnancy or birth. Assisted reproduction (IVF) for couples where one or both are HIV infected is available in Norway.
Some couples may consider adoption as an option. There are strict requirements for the adoption applicant’s physical and mental health to ensure the child has a safe home with adequate resources for long-term care. The countries that release children for adoption also place requirements on who can be adoptive parents. Some countries state clearly that HIV positive adoption applicants will not be approved. Consideration for the child’s best interests is crucial in the approval process.
Treatment during pregnancy
Worldwide, many women with HIV infection become pregnant and give birth. Transmission from mother to child occurs either during pregnancy, during birth or through breastfeeding. A man cannot transmit HIV directly to the foetus. This can only happen when the mother is infected.
The risk of transmission from an untreated mother to child during pregnancy, childbirth and breastfeeding is approximately 30%. This risk can be reduced to less than 2 % with successful antiviral treatment of the mother during pregnancy and the child in the first weeks after birth. If the pregnant woman is under successful treatment, a vaginal birth will normally be attempted. In other situations, a Caesarean section may become necessary.
It is not recommended to breastfeed the child even if the woman is being successfully treated and the child is receiving prophylactic treatment. There are several combinations of HIV medication that can be used during pregnancy. These depend on the availability of monitoring and control for the mother. In Norway, HIV treatment of pregnant women usually starts at week 12 to 20 of pregnancy, or as soon as possible if HIV diagnosis is made after week 20.
Treatment of the child will start immediately after birth and continue for six weeks.
When do we/I know if a child is infected?
When a child is born, antibodies are transferred from the mother. The standard HIV test that detects antibodies will initially give a positive result. In a child who is not infected, the antibodies will gradually disappear from the blood by two years of age. Testing the child’s blood for viruses earlier with a PCR test will give a good indication of whether or not the child is infected. The first sample is taken a few weeks after birth. If there have been three negative PCR tests by 4-6 months of age, infection can be ruled out and the monitoring can stop.
Children born with HIV infection
It is important with early diagnosis so that HIV treatment may be continued beyond six weeks and adjusted to the child’s needs. Treatment and follow-up of a child with HIV must take place at a hospital and by specialists with sound knowledge of children with HIV infection. As for adults, the effect of treatment is good.
Preventive treatments (PEP and PREP) of HIV
Preventive treatment after risk of transmission (PEP)
This treatment is often referred to as post-exposure prophylaxis (PEP). The risk of contracting HIV following exposure can be greatly reduced by immediately starting treatment with HIV medicine. PEP should only be used in cases where the source person is known to be HIV positive and where there has been a risk situation for HIV transmission.
Treatment usually lasts for four weeks. PEP can be used when other preventive measures have failed or with unexpected events such as a split condom. PEP should be started as soon as possible if there is an indication for such treatment and within 48 hours after the risk situation occurred.
Preventive treatment before risk of transmission (PREP)
Studies have shown that HIV medicine can also help prevent HIV transmission to the partner if the medicine is taken before a possible infection situation arises. This is called pre-exposure prophylaxis (PrEP). Use of PrEP as prevention does not remove the need for other preventive measures such as using a condom. When using PrEP, a dose of HIV medicine is taken daily or intermittent. The drugs are free of charge.