HIV Treatment and Care
Antiretroviral therapy (ART) reduces HIV-related morbidity and mortality at all stages of HIV infection and reduces HIV transmission.1-8 When taken consistently as prescribed, ART can suppress viral load, maintain high CD4 cell counts, prevent AIDS, prolong survival, and reduce risk of transmitting HIV to others, all of which are important treatment goals.9,10 Current treatment guidelines recommend ART for all people with HIV, regardless of CD4 cell count. ART should be started as soon as possible after diagnosis and should be accompanied by patient education regarding the benefits and risks of ART and the importance of adherence to ART.
Health care providers play a crucial role in helping patients initiate ART, including describing the benefits of early initiation of ART, offering and prescribing ART, helping to manage long-term ART use, and providing information on other interventions that can reduce HIV transmission risk.
By engaging patients in brief conversations at every office visit, providers can emphasize the benefits of consistent, long-term adherence to their prescribed ART regimen and the potential consequences of nonadherence. One way health care providers can enhance communication is to ask their patients open-ended questions during their office visits. These questions can help providers better understand the patient’s views, barriers, and ability to adhere to their treatment regimen.
Here are some examples of questions providers can ask patients about initiating ART:
- “What have you heard about HIV medicines?”
- “What are the most important results you hope to get from treatment?”
- “What are your concerns about HIV medicines?”
There are many benefits to ART, including improved health and reduced risk of HIV transmission – but adherence is key!
The success of ART is contingent on adherence to achieve and maintain viral suppression. Data show, however, that not all HIV-positive individuals on ART are virally suppressed, while even fewer maintain viral suppression over time. According to CDC’s national surveillance data, an estimated 60% of persons with diagnosed HIV in the United States in 2015 were virally suppressed.11 Among HIV-positive persons in the United States in HIV clinical care (defined as either receiving HIV medical care or having a CD4 or viral load test within the past year), about 80 percent were virally suppressed at their last test.11,12,13 Also, slightly more than two-thirds of HIV-positive persons in care achieved and maintained viral suppression over 12 months, which means up to one-third (or 1 in 3) did not maintain viral suppression over that time period.12,13
Health care providers can positively impact ART adherence among people with HIV by engaging in regular conversations at every office visit to identify ART adherence barriers, offer adherence support services, and provide information on other interventions that can improve patient adherence and reduce HIV transmission to others.14,15
Here are some examples of questions providers can ask patients to assess their ongoing adherence to ART:
- “How has it been going taking your HIV medicines?”
- “What seems to get in the way of taking your medicines?”
- “Have you missed any doses of your medication and if so, what was going on at that time?”
Once the conversation has started, health care providers may find that patients are encountering barriers to adherence. Below is a list of common barriers and ways providers can address them through routine conversations during patient visits.
|Barrier(s)||Approach to Address the Barrier(s)|
|Patient beliefs and behaviors, such as not taking their medications when they “feel well.”||
|Cognitive or organizational barriers, such as lack of logistic skills and comprehension level.||
|Treatment competence or the overall ability to adhere to a potentially complicated and long-term regimen.||
|Comorbid conditions – such as diabetes, dyslipidemia, hypertension, and viral hepatitis – that may further complicate the treatment plan design and the ability of the patient to adhere to the plan.||
|Regimen-related barriers, including fear of treatment, fear of treatment-related side effects, and confusion about doses.||
|Short-term side effects that can occur when patients start or change ART regimens, such as nausea, fatigue, disturbed sleep or dreaming.||
|Psychosocial barriers, such as mental health issues (e.g., depression, perceived low quality of live), drug or alcohol abuse, negative attitudes or beliefs about HIV, and lack of social support.||
|Structural barriers, such as lack of transportation, housing, childcare, or insurance covering ART and long-term HIV care.||
Plasma HIV RNA viral load should be measured regularly to confirm initial and sustained response to ART. Most patients taking ART as prescribed achieve viral suppression within six months.
The frequency of viral load testing depends on several factors. Current guidelines recommend viral load monitoring as follows: 16
- With initiation of ART (before initiation and within 2 to 4 weeks after treatment initiation, followed by 4 to 8 week intervals until the levels become undetectable)
- After ART modification due to suboptimal response (within 2 to 4 weeks after treatment modification, followed by 4 to 8 week intervals until the levels become undetectable)
- After ART modification due to toxicity or need for regiment simplification (within 4 to 8 weeks after changing therapy)
- In patients on a stable, suppressive ART regimen (every 3 to 4 months, or every 6 months if virally suppressed for more than 2 years, to confirm durable viral suppression)
- In patients with suboptimal response (frequency depends on clinical circumstances)
Patients may experience a temporary increase or “blip” in their viral load, defined as viral loads transiently detectable at low levels. These blips usually go back down by the next viral load test. Patients who are using viral suppression as their primary prevention method and experience a blip may benefit from using other prevention strategies until their viral load is undetectable again. These prevention strategies could include condoms and pre-exposure prophylaxis (PrEP) for HIV-negative partners.
Keeping patients in regular care improves their health and reduces their risk of HIV transmission to others. The benefits of ongoing care can include addressing and supporting ART adherence, maintaining decreased viral load and increased CD4 count, lowering rates of progression to AIDS, decreasing rates of hospitalization, and improving overall health.17-19
Poor retention in HIV care is more common in people who have substance use disorders, serious mental health problems, unmet socioeconomic needs such as housing, food, or transportation, limited financial resources or health insurance, or schedules that complicate adherence to HIV medication.
There are several effective approaches to help patients stay in HIV care, improve medication adherence, achieve viral suppression, and improve health outcomes:
- Clinic-wide marketing (such as posters and brochures) and support (customer service training of patient-facing staff) to promote attending scheduled visits and provide patients a welcoming and courteous experience.20,21
- A designated staff person, often referred to as a patient navigator, to focus on retention, adherence, and re-engagement efforts. The patient navigator can help with appointments, referrals, system navigation, service coordination, and transportation.21
- “Data to Care” approaches which use clinic and public health data to identify patients in need of retention, reengagement, or adherence support services to improve patient’s health outcomes, including achieving viral suppression (Note – the effectiveness of data to care strategies is variable and privacy concerns must be adequately addressed).22-24
- Providing medication adherence support for patients in care, either starting HIV treatment or struggling with adherence
- Providing retention and reengagement support for out-of-care persons or patients at risk of falling out of care (e.g., missed a care visit, experiencing barriers to care engagement)
- Local or state health department or local community-based organizations can help providers and HIV medical clinics by integrating their existing prevention services within the HIV care clinic to provide the support services patients need to improve engagement and adherence in HIV care.
- STD preventive services are an essential component of HIV prevention and care. Providers should engage patients in regular conversations about STDs, including review of sexual history and STD symptoms, at every visit. Patients with HIV should be screened for STDs at least annually, and more frequently if they or their sexual partners have multiple or anonymous sex partners. Certain STDs can increase HIV viral load and genital HIV shedding, which may increase the risk of sexual and perinatal HIV transmission. Correct and consistent condom use should be advised to prevent STDs and can reduce HIV transmission risk in those with an STD or unsuppressed viral load. Learn more about STD treatment and care.
- People with HIV are also at risk for a variety of opportunistic infections such as TB and hepatitis virus. These risks can be reduced by viral suppression and a number of other prevention behaviors.
- Also refer to Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIVexternal icon developed by CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Disease Society of America (HIVMA/IDSA), and other experts in infectious disease.
- INSIGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med. Jul 20 2015;373(9):795-807. PubMed abstractexternal icon.
- TEMPRANO ANRS Study Group, Danel C, Moh R, et al. A trial of early antiretrovirals and isoniazid preventive therapy in africa. N Engl J Med. Aug 27 2015;373(9):808-822. PubMed abstractexternal icon.
- Kitahata MM, Gange SJ, Abraham AG, et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med. Apr 30 2009;360(18):1815-1826. PubMed abstractexternal icon.
- Mofenson LM, Lambert JS, Stiehm ER, et al. Risk factors for perinatal transmission of human immunodeficiency virus type 1 in women treated with zidovudine. Pediatric AIDS Clinical Trials Group Study 185 Team. N Engl J Med. Aug 5 1999;341(6):385-393. PubMed abstractexternal icon.
- Wood E, Kerr T, Marshall BD, et al. Longitudinal community plasma HIV-1 RNA concentrations and incidence of HIV-1 among injecting drug users: prospective cohort study. BMJ. 2009;338:b1649. PubMed abstractexternal icon.
- Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. Aug 11 2011;365(6):493-505. PubMed abstractexternal icon.
- Reynolds SJ, Makumbi F, Nakigozi G, et al. HIV-1 transmission among HIV-1 discordant couples before and after the introduction of antiretroviral therapy. AIDS. Feb 20 2011;25(4):473-477. PubMed abstractexternal icon.
- O’Brien WA, Hartigan PM, Martin D, et al. Changes in plasma HIV-1 RNA and CD4+ lymphocyte counts and the risk of progression to AIDS. Veterans Affairs Cooperative Study Group on AIDS. N Engl J Med. Feb 15 1996;334(7):426-431. PubMed abstractexternal icon.
- Garcia F, de Lazzari E, Plana M, et al. Long-term CD4+ T-cell response to highly active antiretroviral therapy according to baseline CD4+ T-cell count. J Acquir Immune Defic Syndr. Jun 1 2004;36(2):702-713. PubMed abstractexternal icon.
- Cohen MS, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011;365(6):493-505. PubMed abstractexternal icon.
- Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2015pdf icon. HIV Surveillance Supplemental Report 2017;22(No. 2).
- CDC. Behavioral and clinical characteristics of persons receiving medical care for HIV infection—Medical Monitoring Project, United States, 2014 Cycle (June 2014–May 2015)pdf iconpdf icon. HIV Surveillance Special Report 17.
- Marks G, Patel U, Stirratt MJ, et al. Single viral load measurements overestimate stable viral suppression among HIV patients in care: Clinical and public health implications. J Acquir Immune Defic Syndr 2016;73:205-12. PubMed abstractexternal icon.
- Parsons JT, Golub SA, Rosof E, Holder C. Motivational interviewing and cognitive-behavioral intervention to improve HIV Medication adherence among hazardous drinkers: a randomized controlled trial. J Acquir Immune Defic Syndr. Dec 01 2007;46(4):443-450. PubMed abstractexternal icon.
- Bogart LM, Mutchler MG, McDavitt B, et al. A randomized controlled trial of rise, a community-based culturally congruent adherence intervention for black Americans living with HIV. Ann Behav Med. Apr 21 2017. PubMed abstractexternal icon.
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Clinical Guidelinesexternal icon (section C-7). DHHS.
- Avnish Tripathi, Eren Youmans, James J. Gibson, and Wayne A. Duffus. AIDS Res Hum Retroviruses. June 2011, 27(7): 751-758. PubMed abstractexternal icon.
- Giordano TP. Retention in HIV care: what the clinician needs to know. Top Antivir Med. 2011;19(1):12-16. PubMed abstractexternal icon.
- Mizuno Y, Zhu J, Crepaz N, Beer L, et al. Receipt of HIV/STD prevention counseling by HIV-infected adults receiving medical care in the United States. AIDS. 2014;28(3):407-415. PubMed abstractexternal icon.
- Gardner LI, Marks G, Craw JA, et al. A low-effort, clinic-wide intervention improves attendance for HIV primary care. Clin Infect Dis. Oct 2012;55(8):1124-1134. PubMed abstractexternal icon.
- Higa, D. H., Crepaz, N., Mullins, M. M., & the Prevention Research Synthesis Project. (2016). Identifying best practices for increasing linkage to, retention, and re-engagement in HIV medical care: Findings from a systematic review, 1996-2014external icon. AIDS and Behavior, 20(5), 951-966. PubMed abstractexternal icon.
- Bove JM, Golden MR, Dhanireddy S, Harrington RD, Dombrowski JC. Outcomes of a clinic-based surveillance-informed intervention to relink patients to HIV care. J Acquir Immune Defic Syndr. Nov 01 2015;70(3):262-268. PubMed abstractexternal icon.
- Sena AC, Donovan J, Swygard H, et al. The North Carolina HIV Bridge Counselor Program: outcomes from a statewide level intervention to link and reengage HIV-infected persons in care in the South. J Acquir Immune Defic Syndr. Sep 01 2017;76(1):e7-e14. PubMed abstractexternal icon.
- Udeagu CC, Webster TR, Bocour A, Michel P, Shepard CW. Lost or just not following up: public health effort to re-engage HIV-infected persons lost to follow-up into HIV medical care. AIDS. Sep 10 2013;27(14):2271-2279. PubMed abstractexternal icon.