HIV/AIDS Treatment

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By Nancy Evans, BS

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• List the stages of HIV/AIDS.
• Describe the antiretroviral therapy (ART) treatment process.
• Discuss the primary coexisting infections of HIV.

The trajectory between infection with HIV and the development of full-blown AIDS can be steep or gradual and may take as long as a decade or more. If the infection is untreated, the average time from HIV infection to death is 10 to 12 years. However, early detection and appropriate medical treatment may extend the lives of those infected and reduce the rates of HIV transmission.

COURSE OF THE DISEASE AND DIAGNOSIS

As the HIV virus suppresses immune function, the infected person becomes more vulnerable to opportunistic infections caused by a wide variety of bacteria, viruses, fungi and other pathogens encountered in daily life. The physical results of these opportunistic infections are called clinical manifestations. For example, the opportunistic infection cytomegalovirus (CMV) often causes the clinical manifestation of blindness in people with AIDS.

Some conditions, called co-factors, can affect the course of disease progression, including age, genetic factors, drug use, smoking, nutrition, and coinfection with hepatitis C virus (HCV) and/or tuberculosis (TB).

Stages of HIV/AIDS

Although the slope of the disease trajectory varies with each individual, HIV/AIDS progresses through five stages:

1. Viral transmission: the initial infection with HIV, also called acute HIV infection. Persons may become infectious to others within days of transmission and before any symptoms appear. Once infected, a person is always infectious to others. During acute HIV infection, high levels of virus circulate in the bloodstream. Symptoms are nonspecific and may include fever, swollen lymph glands, rash, fatigue, and sore throat. This is sometimes called seroconversion syndrome or seroconversion sickness. Initial symptoms resolve in a few weeks but the person remains infectious for life.
2. Seroconversion: the time period from infection to the production of antibodies detectable on an HIV test, usually within 3 to 6 months of transmission.
3. Asymptomatic HIV infection: a variable time period, sometimes 10 years or longer, during which an HIV-infected person has no noticeable signs or symptoms and appears healthy, but can transmit the virus to others. Unless tested for HIV, the person will not be aware of being infected.
4. Symptomatic HIV infection: the stage during which noticeable physical symptoms of HIV are present. The most common symptoms include:
   • Persistent low-grade fever
   • Pronounced weight loss not due to dieting
   • Persistent headaches
   • Diarrhea lasting more than 1 month
   • Difficulty recovering from colds and flu
   • More acute illness than normal
   • Recurrent vaginal yeast infections in women
   • Oral thrush (candidiasis) coating the mouth or tongue
5. AIDS: diagnosis can be made only by a licensed healthcare provider. The diagnosis is based on the result of HIV-specific blood tests and the person’s physical condition. Once diagnosed with AIDS, a person is always considered to have AIDS, even if their health seems to improve. Over time, people with AIDS frequently have a reduced white-blood-cell count and deteriorating health. They also may have a significant amount of virus present in their blood, measured as viral load.

CDC AIDS CASE DEFINITION FOR SURVEILLANCE OF ADULTS AND ADOLESCENTS

Source: Zolopa & Katz, 2010.
Definitive AIDS diagnoses with or without laboratory evidence of HIV infection	Candidiasis of esophagus, bronchi, trachea, or lungs Cryptococcosis, extrapulmonary Cryptosporidiosis, chronic intestinal (>1 month duration) Cytomegalovirus disease of an organ other than liver, spleen, or lymph nodes Herpes simplex virus infection causing a mucocutaneous ulcer(s) (>1 month duration) or bronchitis, pneumonitis, or esophagitis of any duration Kaposi’s sarcoma in a patient <60 years of age Lymphoma of the brain (primary) in a patient <60 years old Mycobacterium avium complex or disease caused by M. kansasii, disseminated (at a site other than or in addition to lungs, skin, or cervical or hilar lymph nodes) Pneumocystis jiroveci pneumonia Progressive multifocal leukoencephalopathy Toxoplasmosis of the brain
Definitive AIDS diagnoses with laboratory evidence of HIV infection	Coccidioidomycosis, disseminated (at a site other than or in addition to lungs or cervical or hilar lymph nodes) HIV encephalopathy Histoplasmosis, disseminated (at a site other than or in addition to lungs or cervical or hilar lymph nodes) Isosporiasis with diarrhea (>1 month duration) Kaposi’s sarcoma at any age Lymphoma of the brain (primary) at any age Other non-Hodgkin lymphoma of B cell or unknown immunologic phenotype Any mycobacterial disease caused by mycobacteria other than M. tuberculosis, disseminated (at a site other than or in addition to lungs, skin, or cervical or hilar lymph nodes) Disease caused by extrapulmonary M. tuberculosis Salmonella (non-typhoid) septicemia, recurrent HIV wasting syndrome CD4+ lymphocyte count below 200 cells per microliter or CD4 lymphocyte percentage below 14 percent Pulmonary tuberculosis Recurrent pneumonia Invasive cervical cancer
Presumptive AIDS diagnoses with laboratory evidence of HIV infection	Candidiasis of esophagus: (a) recent onset of retrosternal pain on swallowing; and (b) oral candidiasis Cytomegalovirus retinitis. A characteristic appearance on serial ophthalmoscopic examination Mycobacteriosis: Specimen from stool, normally sterile body fluids or tissue from a site other than lungs, skin, or cervical or hilar lymph nodes, showing acid-fast bacilli of a species not identified by culture Kaposi’s sarcoma: Erythematous or violaceous plaque-like lesion on skin or mucous membrane Pneumocystis jiroveci pneumonia: (a) a history of dyspnea on exertion or nonproductive cough of recent onset (within past 3 months); and (b) chest x-ray evidence of diffuse bilateral interstitial infiltrates or gallium-scan evidence of diffuse bilateral pulmonary disease; and (c) arterial blood gas analysis showing an arterial oxygen partial pressure of <70 mm Hg, or a low respiratory diffusing capacity of <80% of predicted values, or an increase in the alveolar-arterial oxygen tension gradient; and (d) no evidence of a bacterial pneumonia Toxoplasmosis of the brain: (a) recent onset of a focal neurologic abnormality consistent with intracranial disease or a reduced level of consciousness; and (b) brain imaging evidence of a lesion having a mass effect or the radiographic appearance of which is enhanced by injection of contrast medium; and (c) serum antibody to toxoplasmosis or successful response to therapy for toxoplasmosis Recurrent pneumonia: (a) more than one episode in a 1-year period; and (b) acute pneumonia (new symptoms, signs, or radiologic evidence not present earlier) diagnosed on clinical or radiologic grounds by the patient’s physician Pulmonary tuberculosis: (a) apical or miliary infiltrates; and (b) radiographic and clinical response to antituberculous therapy

Multisystem Effects of HIV/AIDS

HIV infection affects more than just the immune system. It also affects the cardiovascular, neurologic, and musculoskeletal systems as well as the body’s basic metabolism. These effects can alter:

• The kind and number of blood cells
• The amount and distribution of fat and muscles in the body
• The structure and function of the brain
• The basic metabolism of the body

HIV-RELATED CONDITIONS

Multisystem effects can lead to many painful or disruptive conditions, including:

• Confusion or dementia
• Vision or hearing loss
• Diarrhea, urinary or fecal incontinence
• Thrush (yeast infections in the mouth)
• Fatigue
• Fever
• Nausea or vomiting
• Painful joints, muscles, or nerve pain
• Difficult breathing
• Chronic pneumonias, sinusitis, or bronchitis
• Loss of muscle tissue and body weight

Dementia is a growing concern as HIV-infected people live longer. Using functional MRI, researchers measured the blood flow in the brains of people with HIV and found signs of premature aging. Whether this effect is the result of the virus or the antiviral drugs—or both—is unclear. However, the evidence of harm raises concern because, by 2015, people over 50 will account for more than half of all AIDS patients (Ances et al., 2010).

HIV/AIDS also increases the risk of certain cancers, four of which are included in the CDC classification of AIDS: Kaposi’s sarcoma, non-Hodgkin’s lymphoma, primary lymphoma of the brain, and invasive cervical carcinoma in women. Recent research shows that in HIV-infected men, antiretroviral therapy has a protective effect against first AIDS-defining cancers (Shiels et al., 2008). Cervical carcinoma seems to be more aggressive in HIV-infected women. Most women with cervical cancer die of that disease rather than AIDS (Zolopa & Katz, 2010).

Research has also shown that HIV infection is associated with a five-fold increase in the incidence of Hodgkin’s disease. Anal dysplasia and squamous cell carcinoma have also been associated with HIV infection in both men and women, many of whom are also infected with HPV. Dysplasia can progress quickly to invasive cancer in patients with compromised immune systems; therefore, some experts recommend anal Papanicolau swabs in HIV patients.

ANTIRETROVIRAL THERAPY

Antiretroviral therapy (ART) has become the gold standard for treatment of HIV/AIDS. People with HIV may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia.

ART Drugs

Antiretroviral drugs are administered in “cocktails” of three or more, a treatment referred to as antiretroviral therapy (ART). (ART is also sometimes referred to as highly active antiretroviral therapy, or HAART.) The primary goal of ART is to reduce HIV-associated morbidity and mortality by suppressing the individual’s viral load to below detectable levels.

Antiretroviral treatment of people with HIV continues to prove complex, controversial, dynamic, and expensive. These drugs do not constitute a “cure” for HIV/AIDS. If therapy is discontinued, viral load will increase. Even during treatment, the virus is replicating and the person remains infectious to others.

Initiating ART

In 1996, tests to measure an individual’s viral load became available, providing objective criteria for treatment decisions. Following are treatment recommendations by the Panel on Antiretroviral Guidelines for Adults and Adolescents (2009):

• Antiretroviral therapy should be initiated in all patients with history of an AIDS-defining illness or with a CD4+ T-cell count <350 cells/mm.
• Antiretroviral therapy should also be initiated in the following groups of patients regardless of CD4 T-cell count:
  • Pregnant women
  • Patients with HIV-associated nephropathy
  • Patients coinfected with HBV when treatment is indicated
• Antiretroviral therapy may be considered in all patients with CD4 T-cell counts between >350 and 500 cells/mm. (See detailed guidelines on the AIDSinfo website listed under “Resources” at the end of the course.)
• Patients initiating ART should be willing and able to commit to lifelong treatment and should understand the benefits and risks of therapy and the importance of adherence. Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy based on clinical and/or psychosocial factors.

Treatment Goals and Guidelines

Once ART has begun, CDC recommends these goals of therapy:

• Maximal and durable suppression of viral load
• Reduction of HIV-related morbidity and prolonging survival
• Improvement in quality of life
• Restoration and/or preservation of immunologic function
• Prevention of HIV transmission

Treatment guidelines are revised frequently based on ongoing research findings. The most up-to-date information can be found online at http://aidsinfo/nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

HEALTHCARE MAINTENANCE OF HIV-INFECTED INDIVIDUALS

Condition	Healthcare Maintenance
Source: Zolopa & Katz, 2010.
All HIV-infected individuals	CD4 counts every 3–6 months Viral load tests every 3–6 months and 1 month following a change in therapy PPD (to screen for tuberculosis) INH for those with positive PPD and normal chest x-ray RPR or VDRL (to screen for syphilis) Toxoplasma IgG serology Hepatitis serologies: hepatitis A antibody, hepatitis B surface antigen, hepatitis B surface antibody, hepatitis B core antibody, hepatitis C antibody Cytomegalovirus IgG serology Pneumococcal vaccine Inactivated influenza vaccine in season Hepatitis A vaccine for those without immunity to hepatitis A Tetanus/diphtheria vaccine Hepatitis B vaccine for those who are HB surface antigen and antibody negative. Haemophilus influenzae B vaccination Papanicolaou smears every 6 months for women Consider anal swabs for cytologic evaluation yearly for patients with history of receptive anal intercourse
HIV-infected individuals with CD4<200 cells/μL	P jiroveci prophylaxis
HIV-infected individuals with CD4<75 cells/μL	M avium complex prophylaxis
HIV-infected individuals with CD4<50 cells/μL	Consider CMV prophylaxis
PPD = purified protein derivative; INH = isonicotinic acid hydrazide (isoniazid); RPR = rapid plasma regain; VDRL = Venereal Disease Research Laboratories; IgG = immunoglobulin G; HBsAb = antibody to the hepatitis B surface antigen; CMV = cytomegalovirus

TREATMENT EFFICACY

The efficacy of ART can be measured by plasma HIV RNA testing. Four to six months after treatment begins, there should be no detectable virus (<50 copies/mL). Treatment failure at this point may be due to nonadherence, inadequate potency of drugs, suboptimal levels of antiretroviral agents, viral resistance, or other factors not completely understood.

Patients whose treatment fails despite careful adherence to the regimen should have their regimen changed. A thorough drug treatment history plus drug resistance testing should guide the design of the new regimen.

Patients who are cared for by clinicians with expertise in HIV/AIDS have better outcomes—in mortality, rate of hospitalizations, compliance with guidelines, cost of care, and adherence to medication regimens—than those cared for by less-experienced providers. Expertise is defined in terms of the number of patients actually managed. The DHHS panel recommends HIV primary care by a clinician with at least 20 HIV-infected patients and preferably at least 50 HIV-infected patients.

Many new medications for HIV/AIDS are in clinical trials. Patients experiencing drug resistance may be appropriate candidates for drugs still in trials. Physicians without extensive experience in treating HIV/AIDS are strongly urged to consult with specialists in this area when considering clinical trials for their patients.

MEASURING QUALITY OF CARE

The clinical management of HIV/AIDS is complex, comprising several major concerns. In 2010, a national multiagency collaboration consisting of the National Committee for Quality Assurance (NQA), American Medical Association (AMA), Health Resources and Services Administration (HRSA), Infectious Diseases Society of America (IDSA), and HIV Medicine Association (HIVMA) endorsed 17 measures for quality of HIV care (see below). All healthcare practitioners can use these benchmarks to assess the management of patients with HIV.

TREATMENT COMPLIANCE

Successful treatment not only requires the patient to have significant financial resources but also the ability to understand and comply with a complex regimen.

Unfortunately, many of the patients with the greatest need for treatment lack the necessary financial resources to make treatment a reality. However, patient demographics, such as race/ethnicity, sex, age, and socioeconomic status, do not predict who will adhere to a treatment regimen. Research in Africa among the poorest populations showed 90% adherence, as compared to 70% in the United States (McNeil, 2003).

ART Complications

Discontinuing or interrupting ART may become necessary due to factors such as serious drug toxicity, intervening illness, surgery, or unavailability of medications. Although unplanned short-term interruption of therapy may be unavoidable, planned interruption is no longer recommended. Interrupting therapy increases the risk of AIDS-related complications, declining CD4 counts, and other non-AIDS-related complications such as heart attack and liver failure.

While extending and improving lives of people with HIV, long-term use of some of these drugs increases the risk of liver problems, high cholesterol, stroke, heart disease, osteoporosis, diabetes, pancreatitis, neuropathy, and skin rashes. Some of the skin rashes can be life-threatening, such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), which are two different forms of the same kind of skin rash. TEN may involve as much as 30% of the total body skin area. Both these severe rashes must be treated by a physician.

Antiretroviral drugs may also interact with other drugs used to treat opportunistic infections. For example, researchers reported that using oral erythromycin while taking protease inhibitors increased the risk of sudden death from cardiac causes (Ray et al., 2004). As patients live longer with HIV/AIDS, many develop drug-resistant strains of the virus, which further complicates treatment.

Drug Resistance Testing

Use of multi-drug ART by many people over time has allowed drug-resistant strains of the virus to develop. These drug resistant strains have been found in those receiving ART as well as in patients who have never received ART, which limits their treatment options at the outset.

Experts predict that drug-resistant infections are about to spike in developed countries. One recent study suggests that drug resistance will increase by about 30% in the next 3 to 5 years in San Francisco (Smith et al., 2010). Treating drug-resistant HIV requires a constantly changing cocktail of expensive new drugs, and adherence to such a complex regimen can be difficult for many patients. If drug resistance increases in developing countries, treatment would be unsustainable.

Experts recommend that pretreatment drug resistance testing be done in persons with acute or chronic HIV infection and when changing antiretroviral regimens after drugs cease to be effective (treatment failure). Resistance testing helps clinicians better predict viral response to newly initiated therapy.

HIV drug resistance testing also should be performed:

• To assist in selecting active drugs when changing antiretroviral regimens in cases of virologic failure
• When managing suboptimal viral load reduction

In cases of virologic failure, drug resistance testing should be performed while the patient is taking his or her drugs or within 4 weeks of discontinuing therapy.

Two types of resistance assays are used: genotypic and phenotypic assays. Genotypic assays detect drug resistance mutations in the viral genes, while phenotypic assays measure a virus’s ability to grow in different concentrations of antiretroviral drugs. Genotypic assays take 1 to 2 weeks and phenotypic assays, 2 to 3 weeks. A genotypic assay is generally recommended for patients who have never had antiretroviral therapy. Genotypic resistance testing also is recommended for all pregnant women prior to initiation of therapy and for those entering pregnancy with detectable HIV RNA levels while on therapy.

Treatment Recommendations for Women

Current recommendations for pregnant women are to start antiviral therapy during the second trimester. Those women who seek perinatal care after the second trimester should start treatment as soon as possible thereafter.

Therapy should be individualized for each woman based on her history of HIV antiretroviral therapy (past or current use or never used) as well as possible coinfection with HBV and/or HCV. Choice of therapy regimen also should consider not only the effectiveness of drug treatment for maternal disease but also possible teratogenic effects of the drugs on the infant. For example, efavirenz (EFV) should be avoided during the first trimester of pregnancy, and no pregnant woman should be offered regimens containing nelfinavir (NFV).

Public Health Service guidelines emphasize that combination drug regimens—rather than zidovudine (ZDV) alone—are considered the standard of care both for treatment of maternal HIV infection and for prevention of perinatal HIV transmission. Clinical trial results indicate that antiretroviral prophylaxis to prevent perinatal transmission of HIV should be offered to all HIV-infected women, regardless of CD4 cell count (Panel on Treatment of HIV-Infected Pregnant Women, 2010).

Specific detailed guidelines for the antepartum, intrapartum, and postpartum treatment of HIV-infected women of childbearing age and treatment of their infants evolve rapidly. Practitioners are advised to consult the most recent information on the CDC’s AIDSinfo website (Panel on Treatment of HIV-Infected Pregnant Women, 2010).

Smoking cessation is important for all women receiving ART because it interferes with the therapy’s effectiveness. A large, 8-year study of women showed that those who smoked were more likely than nonsmokers to die during the study period. Smokers also had higher viral loads and lower CD4 counts. They also were more likely to be diagnosed with an AIDS-related illness such as wasting syndrome or non-Hodgkin’s lymphoma (Feldman, 2006).

According to the Office of Women’s Health (2009), women taking antiviral drugs may have different side effects than men on the same drugs. This may be because women are generally smaller than men and have a higher body-fat content and different hormones. For example, ritonavir (Norvir, RTV) causes more nausea and vomiting in women but less diarrhea than in men.

Some women with HIV, especially those with a low CD4 count, experience irregular or long menstrual periods. Others may also experience early menopause and are more likely to have rashes, fat buildup, and problems with their pancreas and liver. However, more research is needed before treatment doses can change, and more clinical trials need to be done that include higher numbers of women.

Women with HIV may suffer discrimination by prescribing physicians. A study of HIV-infected patients in 10 U.S. cities showed that women were less likely than men to receive prescriptions for the most effective treatments for HIV infection (McNaghten et al., 2004).

OTHER MEDICATIONS AND THERAPIES

In addition to ART, people with HIV/AIDS may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia. Some of these medications may have serious interactions with ART, so prescribing physicians need to be familiar with all ART medications, as well as with their potential toxicities, when administered with other drugs.

Some people with HIV supplement their prescription drugs with vitamins, acupuncture, massage, yoga, meditation, herbs, naturopathic remedies, and other complementary therapies. People who turn away from prescription HIV medications and choose only herbs, vitamins, and other supplements are said to be using alternative therapies. Many of these remedies have not been studied to see if they offer any real benefit.

Therapies such as yoga, meditation and massage can help reduce stress and enhance quality of life. However, herbs and other “natural” remedies may also interact with prescription medication. For example, St. John’s wort has major interactions with HIV medications. Therefore, people on HIV medications need to tell their physician, pharmacist, and social worker about all other supplements and nonprescription drugs they take.

COEXISTING INFECTIONS

Infections that are commonly found in HIV-positive patients include a number of other sexually transmitted diseases, TB, and hepatitis. Coexisting infections may increase the risk of transmission of HIV and make its treatment more complex.

Tuberculosis

Mycobacterium tuberculosis (M. tuberculosis, or TB) is the most common and most deadly coexisting infection for HIV-positive individuals. Likewise, the spread of HIV/AIDS has helped fuel the TB epidemic. The CDC estimates that TB is the cause of death for 1/3 of people with HIV worldwide. Any HIV-infected person with a diagnosis of TB should be reported as having TB and AIDS.

According to the CDC (2009d):

• People with HIV and untreated latent TB infection are much more likely to develop active TB disease during his or her lifetime than someone without HIV infection.
• Among people with latent TB infection, HIV infection is the strongest known risk factor for progressing to active TB disease.
• Any HIV-infected person with a diagnosis of TB should be reported as having both TB and AIDS.

TB TRANSMISSION

TB is transmitted by airborne droplets from people with active pulmonary or laryngeal TB during coughing, sneezing, or talking. When these infected droplets are inhaled, the bacteria enter the bloodstream and lymphatic system, and circulate throughout the body.

Most of the bacteria settle in the lungs, where they multiply and may cause pneumonia-like symptoms. This process is called primary infection and in most cases resolves by itself within 4 to 12 weeks, after which a latent state of TB develops. Nine out of 10 people with latent TB never experience subsequent disease and are not infectious to others. The only evidence of TB infection is a positive tuberculin skin test.

In 10% of infected individuals, the TB infection undergoes reactivation at some point, causing active TB disease. Progression to active disease and obvious symptoms (cough, weight loss, and fever) usually occurs within the first 2 years after infection but may occur at any time.

TB TESTING AND TREATMENT

All people infected with HIV should be tested for TB and, if infected, begin complete therapy as soon as possible to prevent active TB disease. HIV-infected persons with either latent TB infection or active TB disease can be effectively treated. The first step is to ensure that HIV-infected persons are tested for TB. The second step is to help those infected with TB to get proper treatment and prevent rapid progression from latent TB infection to active TB disease.

Treatment of HIV/TB coinfected patients involves a complex 6- or 9-month multidrug regimen. All these drugs have significant side effects, which can lead to nonadherence and development of MDR TB, which is much more difficult to treat successfully. Coinfected individuals are at increased risk of developing active TB disease, and their anti-HIV medications must be carefully orchestrated to coincide with the TB regimen. Ideally, this complex care involves experts in the management of both tuberculosis and HIV disease (CDC, 2007).

Hepatitis

Hepatitis is inflammation of the liver that may be caused by drugs and toxic agents or by one of several viruses, including hepatitis A, B, C, D, and others. People who are HIV-positive are at risk for hepatitis A, B, and C infection. Hepatitis A is transmitted by fecal/oral route, usually by contamination of water or food due to poor sanitation. Hepatitis B (HBV) and C (HCV) are transmitted by the blood and body fluids of an infected person.

HIV-infected people should be tested for both A and B viruses, and if they test negative, should receive vaccines against both. However, there is no vaccine for HCV.

Those who receive hepatitis B vaccine should be tested for antibodies to hepatitis B surface antigen (antiHBs) 1 to 2 months after completion of the primary series of hepatitis B vaccine. Those who fail to respond should be revaccinated with up to three additional doses.

COMPARISON CHART OF HIV, HBV, AND HCV

	HIV	HBV	HCV
Source: Washington State Department of Health, 2007.
Transmission by:
Blood	Yes	Yes	Yes
Semen	Yes	Yes	Rarely (more likely if blood present)
Vaginal fluid	Yes	Yes	Rarely (more likely if blood present)
Breast milk	Yes	No (but may be transmitted if blood is present)	No (but may be transmitted if blood is present)
Saliva	No	No	No
Target in the body	Immune System	Liver	Liver
Risk of infection after needlestick exposure to infected blood	0.5%	1–31%	2–3%
Vaccine available	No	Yes	No

HEPATITIS B

Hepatitis B (HBV) can cause chronic liver disease or liver cancer, which makes vaccination essential to prevention. HBV vaccine is relatively inexpensive for infants and children and commonly administered to most infants before their first birthday. It is critical that infants whose mothers are HBV positive receive the vaccine; otherwise, they have a 90% chance of developing the disease. Adult doses of HBV vaccine cost about $150 per person, which may explain why most adults are not vaccinated against HBV.

Symptoms of HBV may vary. Some people may feel fine and look healthy; others may have only mild symptoms, such as loss of appetite, extreme fatigue, abdominal pain, jaundice (yellowing of the eyes and skin), joint pain, malaise, dark urine, nausea or vomiting, and skin rashes. Still others may experience more severe symptoms and may be incapacitated for weeks or months. Long-term complications may also occur, including chronic hepatitis, recurring liver disease, liver failure, or cirrhosis (chronic liver damage).

Risk factors for HBV include:

• Being born in areas with a high prevalence of HBV (China, Southeast Asia, Africa, the Pacific Islands, the Middle East, South America, and Alaska)
• Sharing injection paraphernalia
• Having sexual intercourse with an infected person or with multiple partners
• Men having sex with men
• Occupational exposures that involve contact with blood or body fluids, such as in a healthcare setting or prison
• Sharing personal care items such as razors or toothbrushes with an infected person
• Being on kidney dialysis
• Getting a tattoo or body piercing with equipment contaminated with the blood of someone infected with HBV

There are no medications available for recently acquired (acute) HBV infection. There are antiviral drugs available for the treatment of chronic HBV infection, but they are not always effective.

HEPATITIS C

Hepatitis C (HCV) is the most common chronic bloodborne infection in the United States and a leading cause of chronic liver disease. HCV was discovered in the late 1980s, although it was probably being spread for decades prior to that. The CDC (2009) estimates that 3.2 million Americans have been infected with HCV, many of them from blood transfusions, and half of them do not know they are HCV-positive. (Since 1992, all blood donations in the United States have been tested for HCV.) People infected with HCV may have no symptoms for decades. When symptoms do appear, they are similar to those of HBV (see above).

An estimated one third of HIV-positive people in the United States are also infected with HCV. Incidence is even higher among HIV-positive injection drug users (IDUs) (50%–90%). Coinfection with HIV and HCV is associated with higher titers of HCV, more rapid progression to HCV-related liver disease, and increased risk for cirrhosis of the liver.

Liver disease from chronic HCV is now one of the leading causes of death among people living with HIV. Individuals coinfected with HIV and HCV should restrict alcohol consumption and if possible avoid alcohol altogether because of potential liver damage.

The U.S. Public Health Service/Infectious Disease Society of America guidelines recommend that all HIV-infected persons be screened for HCV infection.

Coinfected patients also need to consult their health professional before taking any new medications, including over-the-counter (OTC), alternative/complementary, or herbal medicines, because of their possible effects on the liver. Those receiving ART may also be at risk for drug-induced liver injury (DILI) and should be carefully monitored.

In coinfected patients with lower CD4 counts (<200 cell/mm³), it may be preferable to initiate antiretroviral therapy and delay HCV therapy until CD4 counts increase. Patients receiving or considering therapy with ribavirin should avoid didanosine, stavudine, and zidovudine. Antiretroviral agents with the greatest risk of DILI should be used with caution (Public Health Service Task Force, 2009).

CONCLUSION

Although there is no cure for HIV infection, there are treatment options that can help people living with HIV experience long and productive lives. Antiretroviral therapy (ART) for the treatment of HIV infection has improved steadily since the advent of potent combination therapy in 1996. New drugs have been approved that offer new mechanisms of action, improvements in potency and activity even against multidrug-resistant viruses, dosing convenience, and tolerability.

Because the science evolves rapidly, therapeutic options and preferences are continually changing. Treatment guidelines are updated frequently and are available on the AIDSinfo website at http://www.aidsinfo.nih.gov.