Key concepts

0 The treatment goals for HIV infection are to maximally and durably suppress HIV replication, avoid the development of drug resistance, restore and preserve immune function, prevent opportunistic infections, and minimize adverse effects.

01 HIV RNA plasma concentrations and CD4+ T-cell counts are used to assess risk of progression to AIDS (or risk for opportunistic infection) and to monitor efficacy and durability of treatment.

Effective and complete treatment of HIV infection involves a multidisciplinary approach, which includes pharmacists, clinicians, social workers, and others.

O1 Treatment with two nucleoside reverse transcriptase inhibitors (NRTIs) and either a nonnucleoside reverse transcriptase inhibitor (NNRTI) or a ritonavir-boos-ted protease inhibitor (PI) is the mainstay of initial treatment for HIV infection.

All patients with HIV infection relapse if medication is withdrawn. Therefore, long-term maintenance treatment is required.

® Eventually, HIV becomes resistant to current medication therapy. To prolong this time to resistance, both strict adherence to the drug regimen and avoidance of deleterious drug interactions is critical.

The majority of antiretroviral medications are metabolized by the cytochrome P-450 enzyme system (CYP). Therefore, it is important to review patient medication profiles for drugs that may interact with antiretroviral drugs.

® Most antiretroviral medications cause acute and chronic adverse effects. Patients should be closely monitored for these toxicities so that interventions can occur quickly.

The acquired immune deficiency syndrome (AIDS) was first recognized in 1981, and described in a cohort of young homosexual men with significant immune deficiency. Since then, human immunodeficiency virus type 1 (HIV-1) has been clearly identified as the major cause of AIDS^HIV-2 is much less prevalent than HIV-1, but also causes AIDS. HIV primarily targets CD4+ lymphocytes, which are critical to proper immune system function. If left untreated, patients experience a prolonged asymptomatic period followed by rapid, progressive immunodeficiency. Therefore, most complications experienced by patients with AIDS involve opportunistic infections and cancers.

HIV is primarily transmitted by sexual contact, by contact with blood or blood products, and from mother to child during gestation, delivery, or breast-feeding. The prevalence and incidence ofHIV is rising globally, and to date there are no treatments which eradicate HIV from the body. Combinations of potent antiretroviral agents (called highly active antiretroviral therapy, or HAART) can suppress HIV replication to undetectable levels, delay the onset of AIDS, and prolong survival. However, there are a number of drug-induced, long-term toxicities that challenge effective patient management. This chapter will address HIV treatment options and challenges, and give practical suggestions for patient management.

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