Over the Counter Choices:

Over the Counter Choices:

There are no over the counter products recommended for the treatment of HIV infection. There are products that can be used to treat some of the symptoms of HIV infection and to manage some of the side effects of HIV drug therapy. There are also products available for nutrition, safe sex, skin care, hair loss, wasting syndrome - maintaining body mass and building muscle, immune system enhancement, liver cleansing, nausea & vomiting, constipation, sexual performance, wound healing, diabetes and lipodystrophy.

Prescription Choices:

The standard for therapy in treatment of HIV disease is now combination therapy that targets 2 different enzymes. Treatments that consist of 2 to 4 drugs have halted viral replication, preserved immune function, and decreased the likelihood of developing drug-resistant mutations. Evaluation of viral load is the accepted method for judging the effectiveness of drug therapy. The drugs used in the treatment of HIV disease are nucleoside analog reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, and protease inhibitors.

There are many other prescription medications available for the treatment of AIDS related infections. These medications fall into many different classes like antivirals, antineoplastics, antifungals, immune modulators, antibacterials, appetite stimulants, antimicrobials, and antiprotozoals. These medications are often taken with the other medications to treat HIV disease.

Clinical stages of HIV infection

The American health authority CDC (Center for Disease Control and Prevention) defines 3 clinical stages of the disease and 3 immunological categories. According to the CDC definition HIV can only be diagnosed with a confirmed HIV positive test.

Stage A covers both the acute HIV illness and the subsequent clinical latency.The acute HIV illness arises 3-6 weeks after infection for 50-70% with flu type symptoms: fever, skin eruptions, throat inflammation, muscular pains, lymph node swelling, headache, and nausea.
During clinical latency there are no further complaints although some people have continuous Lymphadenopathie in the shoulders, back or neck. The clinical latency can last for many years.

Stage B consists of disease symptoms prior to stage C (AIDS), which further weakens the immune system. Usually these symptoms accompany a general worsening of health. In addition to long lasting (a month plus) symptoms such as fever, night sweats and weight loss, many other infections such as candida infections of the mouth and throat or viral illnesses like belt rose occur.

Stage C is the final phase of the HIV infection, the actual AIDS illness. It is the collapse of the immune system. The pattern of the AIDS illness is unmistakable although individual symptoms may vary. Diverse infections and cancers are common, as are fungal infections of the esophagus and special forms of pneumonia (Pneumocystis carinii Pneumonia), also common are virus illnesses (i.e. retinal inflammation CMV-Retinitis), parasite infection (i.e. Toxoplasmosis that causes brain abscesses), rare cancer forms (e.g. Kaposisarkom, Lymphdrüsensarkom, brain tumors) as well as neurological illnesses (among other things HIV dementia) and strong weight loss (Wasting syndrome).



The defense system defends against the HIV infection (blue curve). But the HIVs (red curve) attack, infiltrate, and destroy them. During the first weeks the human defense system wins the first battle (decrease of the viruses), but eventually the HIVs overwhelm the immune system and the infected person dies. The concentration of the CD4+ helper cells is a good indicator of the condition of the human defense system, and is used nowadays as a measure of HIV infections.

HOW DOES RESISTANCE DEVELOP?

HOW DOES RESISTANCE DEVELOP?

HIV usually becomes resistant when it is not totally controlled by drugs someone is taking. However, more people are getting infected with HIV that is already resistant to one or more ARVs.

The more that HIV multiplies, the more mutations show up. These mutations happen by accident. The virus doesn’t "figure out" which mutations will resist medications.

Just one mutation can make HIV resistant to some drugs. This is true for 3TC (Epivir) and the non-nucleoside reverse transcriptase inhibitors (NNRTIs). However, HIV has to go through a series of mutations to develop resistance to other drugs, including most protease inhibitors.

The best way to prevent resistance is to control HIV by taking strong ARVs. If you miss doses of your medications, HIV will multiply more easily. More mutations will occur. Some of them could cause resistance.

If you have to stop taking any ARV, talk to your health care provider. You may have to stop some drugs sooner than others. If you stop taking drugs while the virus is under control, you should be able to use them again.

TYPES OF RESISTANCE

There are three types of resistance:

• Clinical resistance: HIV multiplies rapidly in your body even though you’re taking ARVs.
• Phenotypic resistance: HIV multiplies in a test tube when ARVs are added.
• Genotypic resistance: The genetic code of HIV has mutations that are linked to drug resistance.

Clinical resistance shows up as a higher viral load, lower CD4 count, or opportunistic infections (see Fact Sheet 500). Laboratory tests can measure phenotypic and genotypic resistance.

PHENOTYPIC TESTING

A sample of HIV is grown in the laboratory. A dose of one ARV is added. The growth rate of the HIV is compared to the rate of wild type virus. If the sample grows more than normal, it is resistant to the medication.

Phenotypic resistance is reported as "fold" resistance. If the test sample grows twenty times as much as normal, it has "20-fold resistance".

Phenotypic tests cost about $800. It used to take over a month to get the results. New phenotypic tests are somewhat quicker.

GENOTYPIC TESTING

The genetic code of the sample virus is compared to the wild type. The code is a long chain of molecules called nucleotides. Each group of three nucleotides, called a "codon", defines a particular amino acid used to build a new virus.

Mutations are described by a combination of letters and numbers, for example K103N. The first letter (K) is the code for the amino acid in the wild type virus. The number (103) identifies the position of the codon. The second letter (N) is the code for the "changed" amino acid in the mutant sample.

Genotypic testing costs about $250. Results come back in about two weeks.

VIRTUAL PHENOTYPE

This test is really a method of interpreting genotypic test results. First, genotypic testing is done on the sample. Phenotypic test results for other virus samples with a similar genotypic pattern are taken from a database. These matched samples tell you how the virus is likely to behave. The virtual phenotype is faster and less expensive than a phenotypic test.

CROSS-RESISTANCE

Sometimes a mutant version of HIV is resistant to more than one drug. When this happens, the drugs are called "cross-resistant". For example, most HIV that is resistant to nevirapine (Viramune) is also resistant to efavirenz (Sustiva). This means that nevirapine and efavirenz are cross-resistant.

Cross-resistance is important when you change medications. You need to choose new drugs that are not cross-resistant to drugs you’ve already taken.

We do not totally understand cross-resistance. However, many drugs are at least partly cross-resistant. As HIV develops more mutations, it gets harder to control. Take every dose of your ARVs according to instructions. This reduces the risk of resistance and cross-resistance. It saves the most options for changing medications in the future.

PROBLEMS WITH RESISTANCE TESTING

Resistance tests are not available everywhere. They are expensive. However, they are becoming more common, faster and cheaper.

The tests aren’t good at detecting "minority" mutations (less than 20% of the virus population.) Also, they work better when the viral load is higher. If your viral load is very low, the tests might not work. Tests usually cannot be run if the patient’s viral load is less than 500 to 1,000 copies per ml.

Test results can be difficult to understand. Drugs that should work according to the tests sometimes don’t work, and vice versa. Sometimes genotypic and phenotypic tests give conflicting results for the same patient. Some mutations can "reverse" or reduce resistance to some medications.

Recent research suggests that a genotypic resistance test should be done for every patient before they start taking ARVs. This saves money by avoiding putting someone on ARVs that will not work for them.