HIV treatment goes by many names: combination therapy, antiretroviral therapy (ART), highly active antiretroviral therapy (HAART) and HIV meds, to name just a few.

HIV treatment involves taking a combination of drugs—usually three or more—every day to keep you healthy. Although many people take just one pill once a day, that pill contains several different drugs.

With many HIV drugs and many combinations available, you are likely to find a treatment that works for you, with minimal or no side effects.

Ultimately, effective HIV treatment and care allows people with HIV to live full and healthy lives.

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HIV treatment keeps you healthy by suppressing the amount of HIV in your blood.

When left untreated, HIV infects CD4 cells and other types of cells in the body. It uses these cells to make millions of copies of itself, which then go on to infect other cells. This process, called viral replication, eventually damages your immune system, lowers your CD4 count and leaves you vulnerable to serious infections and diseases. The goal of HIV treatment is to stop this process and reduce your viral load.

How does it do this? There are several different groups, or classes, of drugs and each class attacks the virus in a different way. Your treatment will include drugs from different classes, to fight the virus on different fronts.

Soon after a person starts taking HIV treatment, viral replication slows down dramatically. The assembly line for producing more HIV essentially slows to a crawl. Since very few new copies of the virus are now being created, the amount of HIV in your body—your viral load—drops. Most people’s viral loads fall to undetectable levels within three to six months of starting treatment.

Suppressing HIV in this way allows your immune system to regain its strength. Your CD4 count rises, the risk of serious infections drops, and any symptoms of HIV infection that you may have experienced diminish or disappear.

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For the sake of your own sense of well-being and the success of your treatment, it is important to be prepared—practically, mentally and emotionally.

Before starting treatment, your healthcare provider will recommend blood tests to check for drug resistance and hypersensitivity. He or she will ask you about other drugs and supplements you are taking, to help ensure that the drugs you take all play well together. The HIV drugs you and your doctor decide on will also be influenced by other health conditions you may have.

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Drug resistance refers to HIV that is resistant to certain HIV drugs and stops those drugs from working properly. Drug-resistant forms of HIV can sometimes be transmitted from person to person—so a person who has never taken HIV medications before can become infected with drug-resistant HIV. A person’s HIV can also change and become drug-resistant. If a person who is on treatment misses doses, the virus can mutate and become resistant to the medication.

All people living with HIV should have a resistance test done before they start treatment, and, in most cases, before switching to a new treatment. Resistance testing can identify medications that may not work against the HIV in your body. Drug-resistance testing can help you and your doctor determine which medicines to include in your HIV treatment regimen.

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You may be allergic, or hypersensitive, to certain drugs. For example, some people are hypersensitive to abacavir (Ziagen, ABC, also found in Kivexa, Trizivir and Triumeq). A simple blood test, done before you start treatment, can determine whether you’re likely to have a potentially dangerous reaction to abacavir. If your test result is positive, you can cross that drug off your list of choices. If your test result is negative, a reaction is still possible but the risk is low.

Ask your doctor about the signs of a hypersensitivity reaction so that you can seek medical help should you have such a reaction to abacavir or another HIV drug.

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When one drug alters the effect of another drug—intensifying the side effects or producing new side effects or making the drug less effective—this is known as a drug interaction. It is important to choose HIV medications that do not interact with other drugs you take.

Talk to your doctor(s) and pharmacist about all the different drugs you’re taking—including prescription drugs, over-the-counter drugs, street drugs, herbal and nutritional supplements—so they can advise you about possible interactions. In some cases, there are drugs that cannot be used together. In other cases, it may be possible to use certain drugs together provided you make certain adjustments (for example, change the time when you take one of them).

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Be sure to let your doctor know…

• if you have any risk factors for cardiovascular disease (such as smoking, high cholesterol levels, obesity, a parent or sibling who has had heart disease, or you use street drugs such as cocaine or amphetamines) because HIV and some HIV medications can increase your risk of heart disease. A good combination for you will avoid these drugs.
• if you have hepatitis B or C or other liver problems, kidney injury, tuberculosis, depression or other mental and emotional health issues, as certain drugs may not be recommended.

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With the newer HIV medications, many people experience no side effects whatsoever. Plus, we now know that the sooner you are diagnosed with HIV and the sooner you begin HIV treatment (in other words, the shorter the time between infection and starting treatment), the less likely you are to experience major side effects from your medications.

Still, side effects are to some extent the luck of the draw: You may get them, you may not. If you do experience side effects, they may go away in a short time on their own or you may be able to manage them with an over-the counter treatment, such as acetaminophen for headaches or an antihistamine for rashes. Each drug in your HIV combination is associated with various side effects, some more common and some very rare, but that doesn’t mean you will experience all or any of them.

Ask your doctor about the most common side effects for the drugs in your combination. Discuss ways you might be able to minimize some of these side effects, should you experience them. Pharmacists are also a good source of information.

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If you experience side-effects:

If your HIV treatment is successfully suppressing your viral load but you experience side effects, talk with your doctor about what you’re experiencing.

Many side effects disappear after a few days or weeks. Others can be managed through over-the-counter medications or by changing the time of day when you take your drugs. Your doctor and pharmacist will likely have suggestions. Your doctor may suggest changing your treatment to one that will hopefully give you fewer side effects or none at all.

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HIV treatments can be very simple: Many people need to take just one pill a day to keep their virus under control. But one thing that hasn’t changed is the reality that HIV treatment is a lifelong commitment that requires taking medication every day, exactly as prescribed. This is called adherence.

Your treatment will only work if you take it each and every day. Sticking to your pill-taking schedule is important because these drugs leave the body quickly and you need to have a certain amount of HIV medication in your blood to keep the virus suppressed. If you miss taking too many pills and develop resistance to these drugs, they will no longer be able to control your HIV. While there are other combinations that might work for you, it’s best to keep your current treatment working for as long as possible.

Your doctor and pharmacist should be able to help you adhere to your pill-taking schedule, so be sure to discuss this with them.

Here are some tips you might find useful:

• Take your medication at the same time(s) each day.
• Set the alarm on your cell phone or watch to remind you to take your pills. This can be especially useful when you are travelling. Or carry a small medication “beeper” (talk to your pharmacist about getting one). There are also many apps out there that can remind you it’s pill time.
• Keep your medications near your bed, in a kitchen cupboard you open frequently or somewhere you are likely to see them and remember to take them.
• Keep a small supply of medications in places you frequently visit—at your family’s or partner’s house, and possibly at your workplace.
• If you’re taking a trip, plan ahead. Pack the number of pills you’ll need for the time you will be away plus a few extra doses in case your plans change. When flying, always take your pills and your prescription carry-on. Do not pack them in your checked luggage. If your luggage were to get lost, you’d be without your meds.
• Use plastic pill boxes (“dosettes”) for storing a week’s worth of your pills. Some pharmacies will package your pills in blister packs according to your daily dosing schedule.
• Make sure you don’t run out of your medications.
• Talk to other people living with HIV and learn from their experiences.
• Develop a network of people who can support you and help remind you to take your medications.

If you are having trouble taking your drugs as prescribed, don’t be afraid to ask for help. Maybe you’re feeling down and depressed, maybe you travel a lot, maybe your life isn’t so stable these days or you use substances, or maybe it is not safe to keep your pills out in the open in your home… These things can all affect your adherence. Or maybe you just find it hard to remember your meds every day! You are not the only one. Talk to your doctor, nurse or pharmacist and to people at your local HIV organization to figure out how they can support you.

Adherence can be challenging! Missing an occasional dose is not the end of the world, so don’t panic. Do the best you can to get back on track: You’ll keep your drug combination working for as long as possible and do yourself the most good in the long run.

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Regular visits with your doctor to monitor your health are part of living with HIV. At these visits, you can ask questions and talk about any changes in your body that you may be experiencing. Your doctor may do a physical exam to follow up on specific issues.

You will also get blood drawn at the lab every few months, particularly in the first year of treatment. Your blood will be tested for several things. Two important blood tests will be done to measure your viral load and your CD4 count. Other routine tests can spot potential health issues even if you have no noticeable symptoms.

How you’re feeling – Every time you see your doctor, tell him or her how you have been feeling, especially if you have noticed anything new or unusual. This can also include changes in your mood and mental health: If you’ve been feeling down or depressed, say so. Your doctor will probably follow up with some questions.

Your viral load – Your viral load is the amount of HIV in your blood. A viral load test measures the amount of HIV in a sample of blood. The results are reported as the number of copies of HIV genetic material (called RNA) in a millilitre of blood (copies/ml—a millilitre is about the size of a pea). Without treatment, a person’s viral load can be as high as millions of copies/ml.

The standard tests in Canada can measure levels as low as 40 to 50 copies/ml. Below this level, your virus is considered undetectable. (There are more sensitive viral load tests, but these are used only in specialized labs and in some clinical trials.)

Your viral load is the most important measure of whether or not your treatment is working. The main goal of treatment is to reach an undetectable viral load as soon as possible and to keep it that way.

An “undetectable” viral load does not mean that there is no HIV in your body. It means that the amount of HIV in your blood is too low to measure using routinely available tests. If you miss doses, stop taking your treatment or if the HIV in your body becomes resistant to your antiretroviral drugs, your viral load will once again become detectable (that is, greater than 40 or 50 copies/ml). In this case, you may need to change your treatment.

Your CD4 count – Your CD4 count is one measure of how strong your immune system is—that is, how well you are able to fight off infections. CD4 counts generally drop as HIV does more damage to your immune system and they go up as your immune system regains its strength with treatment.

A normal CD4 count in a healthy HIV-negative person is generally somewhere between 500 and 1,500 cells. The sooner you start treatment, the more likely your CD4 count is to stay high or increase to a high level.

Generally, you should get your CD4 count checked every three to six months. CD4 counts are measured in cells per cubic millimetre (cells/mm³—a cubic millimetre is about the size of a pinhead).

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HIV treatment should bring down your viral load to an undetectable level and it should increase your CD4 count.

Your viral load should become undetectable and it should stay there. For most people, it takes three to six months, though for some people it takes less time and for others it can take longer. Some people see occasional blips in their viral load. A “blip” is when your viral load becomes detectable at a very low level on one test and then becomes undetectable again on the next test. A single blip is not cause for alarm, but two detectable measurements in a row may be a sign that your treatment is no longer working. Certainly it is a signal that you and your doctor should talk about why this might be happening.

If your CD4 count had already dropped when you were diagnosed with HIV, it will probably take more time for your CD4 counts to rise than it takes for your viral load to drop. Once HIV is successfully suppressed, your immune system should rally and your CD4s increase.

Your healthcare team can help make your pill-taking schedule manageable, and if you experience side effects, they should be able to help you deal with them.

Many people who felt ill as a result of HIV begin to feel better after starting treatment. And their health improves. People on treatment often feel more confident about their health, their sex lives and as people living with HIV.

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In a word: Don’t! HIV treatment is an ongoing, lifelong necessity. This is because HIV can stay inside infected cells of the body for a very long time and the whole process of HIV replication speeds up once treatment is stopped.

If for some reason you need to stop treatment for a limited period, your doctor can advise you how to do this so that drug resistance does not develop.

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Sometimes you may have to, or simply want to, change your HIV treatment. This could be for any number of reasons:

• Sometimes treatment doesn’t succeed in controlling HIV—a person’s viral load does not drop to an undetectable level or it does drop but then climbs back up to a detectable level.
• A person can’t stand some aspect of the treatment—usually a side effect—even though their CD4 count and viral load are both good.
• A newer HIV treatment with fewer side effects and an easier dosing schedule has become available.

You will need to work with your doctor to make the necessary changes to your treatment. Don’t stop any medications without talking it over with your doctor first. Suddenly stopping any drug could have consequences you don’t expect, including your HIV becoming drug-resistant.

Your viral load is the best way to know whether your HIV treatment is working. If your treatment is successful, your viral load should drop to an undetectable level and stay there. If your viral load remains detectable six months after starting HIV treatment, this may mean that your treatment is not working. Or, if you’ve been on treatment for a while with an undetectable viral load and then your viral load becomes detectable and stays that way, it’s likely that your treatment has stopped working.

You and your doctor will have to find out why your treatment isn’t working. The most common reason, though not the only one, is that too many doses are being missed. You will also need to know whether your virus has developed resistance to one or more of the drugs you are taking.

Resistance tests can detect changes in the virus and predict which drugs are most likely to work for you.

If these tests show that you have drug-resistant virus, you and your doctor will need to pick a new combination, one that has the highest chance of controlling the virus in your body. For your next combination to be effective, you will need to identify which drugs are no longer working and replace them with drugs that will work against the virus. Ideally, the new combination should contain three fully effective drugs. Your doctor’s expertise in these situations is crucial.

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Some people take the “if it ain’t broke, why fix it?” approach to their HIV treatment. Others are looking for increased convenience and a treatment that fits well with their lifestyle. So, your HIV treatment may be working perfectly and you may be experiencing no side effects but you have heard about a new treatment that sounds easier to take or better in some way than your current one.

Talk to your doctor about new treatments you are hearing about and ask about new developments in treatment. Your doctor can help you decide whether it makes sense for you to change medications and can tell you how to go about switching treatments to avoid developing resistance.

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