Your provider will talk with you and together you will come up with a personal treatment plan. You may find it easier to understand your plan if you learn about the different drugs available and what they do.
What kinds of drugs are available?
HIV drugs are also called antiretroviral drugs or antiretrovirals (ARVs). A whole treatment regimen is called antiretroviral therapy, or ART. The ARVs work because they attack the HIV virus directly--they cripple the ability of the virus to make copies of itself. Usually an ART regimen consists of 3 different medicines from at least 2 classes (types) of drugs. This is because it takes a powerful combination of medicines to suppress the HIV virus.
There are 5 main classes of HIV drugs:
- Nucleoside Reverse Transcriptase Inhibitors (NRTIs or "nukes")
- Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs or "non-nukes")
- Integrase Inhibitors
- Protease Inhibitors (PIs)
- Entry Inhibitors
Each group attacks HIV in its own way and helps your body fight the infection. Most of these drugs come as tablets or capsules. Several of these drugs may be combined into one tablet to make it easier to take your medications. These are known as fixed-dose combinations or single tablet regimens.
The following is a short description of how each group of drugs works.
Nucleoside Reverse Transcriptase Inhibitors (nucleoside analogues, NRTIs or nukes)
When the HIV virus enters a healthy cell, it attempts to make copies of itself. It does this by using an enzyme called reverse transcriptase. The NRTIs work because they block that enzyme. Without reverse transcriptase, HIV can't make new virus copies of itself.
Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs, non-nukes, or non-nucleosides)
These drugs also prevent HIV from using reverse transcriptase to make copies of itself, but in a different way.
Protease Inhibitors (PIs)
(pronounced "pro-tee-ase")
Once HIV has infected a cell and made copies of itself, it uses an enzyme called protease to process itself correctly so it can be released from the cell to infect other cells. These medicines work by blocking protease.
Integrase Inhibitors
This class of anti-HIV drugs works by blocking an enzyme (HIV integrase) that the virus needs in order to insert copies of itself into human DNA.
Chemokine Coreceptor Antagonists (CCR5)
To infect a cell, HIV must bind to two types of molecules on the cell's surface. One of these is called a chemokine coreceptor. Drugs known as chemokine coreceptor antagonists block the virus from binding to the coreceptor.
Entry Inhibitors
The entry inhibitors that are currently available work in different ways, by preventing HIV from entering the CD4 T cell, blocking HIV from binding to the CD4 receptor, or blocking HIV from binding to a coreceptor.
Multi-class drug combinations
There are a number of combination tablets that include drugs from two different groups in a complete HIV drug regimen. A patient prescribed one of these combinations typically takes only one tablet, once a day. You and your provider can decide whether these drug combinations are right for you.
Which drugs should you take?
Now that you have learned a little about the types of drugs that are available and how they work, you may be wondering how your provider will know which treatment you should take.
HIV drugs are used in combination with one another in order to get the best results. The goal is to get the viral load as low as possible (to levels that are undetectable by standard laboratory tests) for as long as possible.
HIV drugs do different things to the virus — they attack it in different ways — so using combinations works better than using just one by itself. Combinations usually include three antiretroviral drugs. Except in very special circumstances, anti-HIV drugs should never be used one or two at a time. Using only one or two drugs at a time can fail to control the viral load and let the virus adapt (or become resistant) to the drug. Once the virus adapts to a drug, the drug won't work as well against the virus, and maybe it won't work at all.
There is no one combination of HIV drugs that works best for everyone. Each combination has its pluses and minuses.
So, how will your provider know which combination to choose? You and your provider can consider the options, keeping certain things in mind, such as possible side effects, the number of pills you'll need to take, and how the drugs interact with each other and with other medications you may take.
Sticking to Your Medicines (Adherence)
"Adherence" refers to how well you stay on your treatment plan--whether you take your medications exactly as your provider tells you.
If you follow your provider's instructions, the HIV drugs will work well to lower the amount of virus in your blood. Taking your drugs correctly increases your likelihood of success.
But, if you miss doses, or don't follow a regular schedule, your treatment may not work, and the HIV virus may become resistant to the medicines.
Before you start a treatment plan, you should:
- Get your provider to write everything down for you: names of the drugs, what they look like, how to take them (for example, with food or not, with other medications or not), and how often to take them. This way, you'll have something to look at in case you forget what you're supposed to do.
- With your provider's help, develop a plan that works for you.
Pop question: True or false. Missing doses and not following a regular schedule can lessen the effect of your HIV medication.
Answer: TRUE. Missing doses and not following a regular schedule can lessen the effect of your HIV medication. It is very important that you stay on your treatment plan and follow your provider's instructions for taking your medicine.
Questions to ask about each drug
One of the most important things you can do to make sure you take your medicine correctly is to talk with your medical provider about your lifestyle, such as your sleeping and eating schedule. If your provider prescribes a drug, be sure and ask the following questions (and make sure you understand the answers):
- What dose of the drug should be taken? How many pills does this mean?
- How often should the drug be taken?
- Does it matter if it is taken with food, or on an empty stomach?
- Does the drug have to be kept in a refrigerator?
- What are the possible side effects of the drug?
- What should be done to deal with the side effects?
- How severe do side effects have to be before a provider is called?
During every medical visit you should talk about whether you are having trouble staying on your treatment plan. Studies show that people who take their medicine in the right way get the best results: their viral loads stay down, their CD4 counts stay up, and they feel healthier.
Tips for staying on your treatment plan
Before you start a treatment plan, you should:
- Get your health care provider to write everything down for you: names of the drugs, what they look like, how to take them (for example, with food or not, with other medications or not), and how often to take them. This way, you'll have something to look at in case you forget what you're supposed to do.
- With your provider's help, develop a plan that works for you.
Other challenges you might have while on HIV therapy
Now that you've thought about adherence and some of the other factors you should consider before starting HIV drug therapy, let's look at some of the other things you will need to know once you are taking the medicine. These involve drug interactions and drug side effects.
What are drug interactions?
Your HIV medications can be affected by other medicines, including other prescription drugs you are taking and drugs you buy over the counter at a pharmacy. Even herbal therapies, nutritional supplements, and some things found in common foods can affect your HIV medicines.
When one drug affects how another drug behaves, this is called a drug-drug interaction. For example, some drugs become less effective or cause side effects when they are taken with certain other drugs.
When something in food affects how a drug behaves, it is called a drug-food interaction. For example, grapefruit juice, taken at the same time as certain drugs, can boost the amount of these drugs in your bloodstream to an undesirable level. Everyone taking HIV drugs needs to be very careful about these interactions. Luckily, many of these interactions are well known to your provider and can be managed.
Your provider can give you a list of drugs and foods to avoid, depending on what treatment you are taking. Ask for this information for each drug that you are taking.
Also, be sure that you tell your provider about every single medication, drug, supplement, and herb you are taking--whether you got them by prescription or not.
How do you deal with side effects?
Some side effects can be hard to deal with. One way to cope with them is to know what to watch out for and have a plan to deal with problems that come up.
That's why you need to talk to your provider about the risk of side effects from different drugs, before you start therapy.
At the beginning of any treatment, you go through a period of adjustment--a time when your body has to get used to the new drugs you're taking. Sometimes you'll have headaches, an upset stomach, fatigue, or aches and pains. These side effects may go away after a few days or a few weeks.
If you notice any unusual or severe reactions after starting or changing a drug, report the side effects to your provider immediately.
How do you know if the drugs are working?
After you've started taking drugs for HIV, your provider will look at how much HIV virus is in your bloodstream (your viral load) to see how well the drug therapy is working. If the drugs are working, your viral load goes down. You will have less of the virus in your bloodstream. A very important goal of treatment is to reduce the viral load to below the level that can be counted by laboratory tests, and to keep it there. This sometimes is called an "undetectable" level of HIV.
Other ways you and your provider can see if the drugs are working are:
- Your CD4 count. This number should stay the same or go up if your drugs are working.
- Your health checkups. Your treatment should help keep you healthy and help you fight off infections and diseases.
Should you ever take a 'holiday' from the drugs?
Taking a "drug holiday" from your HIV treatments for reasons other than a severe reaction to medications may be harmful to your health. Having said that, your provider may suggest that you temporarily stop your antiretroviral drugs for certain specific reasons. Be sure to talk with your provider about this issue if you have questions about it. How you stop taking your HIV drugs safely can be a complicated process.
Remember, just skipping doses without your provider's instruction is dangerous; you should never change your treatment plan without talking with your provider.
Should you ever switch the drugs you're taking?
You should never change the drug plan you're on without talking with your provider. This is a very important decision and one that must be made with your provider.
There are a few reasons that your provider may suggest you change your medicines. There may be a fixed-dose combination pill that could simplify your therapy. Or your treatment may not be working well enough and you may need different medicines. Or you may have side effects that are bothering you, or lab tests that show signs of ill effects from the HIV drugs (this is called drug toxicity).
Before changing medicines, you and your provider should talk about:
- All the HIV drugs you have taken before and the ones you haven't taken
- Any drug resistance your HIV virus may have
- Possible side effects of the new medicines
- How well you will be able to follow the new drug treatment plan
Always be sure to talk with your provider about any changes in your drug treatment.
If the viral load is undetectable, can you stop treatment?
No! Having a viral load below levels that laboratory tests can measure (an "undetectable" viral load) tells us that the HIV drugs are working. An undetectable viral load doesn't mean the HIV virus is gone from your body, though. Even though the virus is not detected in the blood, it is still present in other parts of your body, such as the lymph nodes, brain, and reproductive organs. If you stop treatment, the virus will start reproducing again and your viral load will increase, putting your health at risk.
What if your treatment isn't working?
Sometimes the HIV medications don't work. This may occur because the drugs don't completely stop the virus from reproducing. As the virus makes copies of itself, changes (or mutations) sometimes occur. These changes may result in a new strain of the virus that is resistant to the action of the drugs. If your providers think this has happened, they will do a blood test (called a resistance test, genotype, or phenotype) that can help show which drugs the virus has become resistant to. This can help identify other drugs that might still work against your virus.
If a person has a strain of HIV that is resistant to most or all available drugs, that person may want to consider joining a clinical trial that is testing new drugs that have not yet been approved by the U.S. Food and Drug Administration (FDA).