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.

ART Initiation

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?”

ART Adherence and Viral Suppression

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.

Learn more about discussing ART adherence with patients.

Viral Load Monitoring

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.

Regular, Ongoing Care

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.

Learn more about discussing retention in care.

Coinfections

• 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.

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