Antiretroviral Therapy

Treatment of patients with HIV has changed substantially in the past several years due to the introduction of potent antiretroviral agents. In 1996, a decline in the number of new AIDS cases and AIDS-related deaths was seen for the first time since the beginning of the epidemic, attributed in large part to the use of these new medications.2 Extended survival has been linked to dramatic decreases in the incidence of new opportunistic events.

The first antiretroviral agent discovered to have clinical efficacy was zidovudine (AZT) (Retrovir). AZT is a thymidine analog that inhibits HIV replication by interfering with the action of viral RNA-dependent DNA polymerase (reverse transcriptase). This agent is effective in delaying progression to AIDS and decreasing mortality rates for patients with AIDS. These trends are associated with changes in the host immune response demonstrated by increased CD4 cell counts and reduced risks of opportunistic infections. Combination therapy with two nucleoside reverse transcriptase inhibitors and a protease inhibitor results in maximal response of the immune system.28 Eleven antiretroviral agents are currently licensed for use in HIV infection, and this number is likely to increase in the near future.

The goal of antiretroviral therapy is to reduce HIV viremia as much as possible for as long as possible. The best time to start therapy and the best drugs to use are not known with certainty, and treatment strategies will continue to evolve. General guidelines include initiation of antiretroviral therapy in persons with CD4 cell counts of less than 500 cells/pL. However, therapy must be tailored to individual patients with attention to suppression of viral replication, preservation of immune function, drug side effects, drug interactions, and the patient's preference. Education and counseling also constitute an integral part of antiretroviral therapy. For these reasons, decisions regarding initiation of and changes in antiretroviral therapy should always be made in consultation with the primary care physician and an infectious disease consultant.

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