Did You Know. . .

People with HIV who take HIV medicine as prescribed and get and keep an undetectable viral load (or stay virally suppressed) won’t transmit HIV to their sexual partners.

Before 1996 there were three medications available to treat HIV. These drugs were used singly and were of limited benefit. Researchers in 1996 discovered that taking combinations of these and newer medications dramatically reduced the amount of HIV (viral load) in the bloodstream of a person infected with HIV. Two or three different medications were used in combination, each one targeting a separate part of the virus and its replication.

The reduction of deaths from AIDS in the United States has been primarily attributed to this combination therapy. Originally known as highly active antiretroviral therapy or HAART, this treatment is simply referred to now as ART (antiretroviral therapy).

4.1 ART (Antiretroviral therapy)

Antiretroviral therapy (ART) is recommended for all people with HIV, regardless of CD4 cell count. It 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 adhering to ART. People with HIV who are aware of their status should be prescribed ART and, by achieving and maintaining an undetectable (<200 copies/mL) viral load, can remain healthy for many years.

ART is available globally and the number of people with access to it is increasing every year. In 2023, of the nearly 40 million people with HIV, 30.7 million of them were on ART (Benisek, 2024).

ART reduces HIV-related morbidity and mortality at all stages of HIV infection and reduces HIV transmission. ART is known to reduce levels of multiple markers of immune activation and inflammation. Mortality associated with uncontrolled HIV replication at higher CD4 counts is believed to be due to immune activation and an inflammatory milieu that promotes progression of end-organ disease.

ART reduces the chances of transmitting HIV to others. Three landmark studies have shown that treatment prevents sexual transmission of HIV. Evidence shows that taking ART as prescribed can help achieve an undetectable viral load. When maintained, an undetectable viral load prevents transmission of HIV through sex. This is known as treatment as prevention.

4.1.1 Treatment Types

All people with HIV should take HIV treatment, no matter how long they've had HIV or how healthy they are. If you delay treatment, HIV will continue to harm your immune system and increase your chances of transmitting HIV to others, getting sick, and developing AIDS.

There are two types of HIV treatment: pills and shots.

Pills are recommended for people just starting HIV treatment. There are many FDA-approved single pill and combination medicines available.

HIV treatment shots are long-acting injections given once a month or once every other month, depending on your treatment plan.

Shots may be right for you if you are an adult with HIV who

• has had an undetectable viral load (or has achieved viral suppression) for at least three months,
• has no history of treatment failure, and
• has no known allergy to the medicines in the shot.

You’ll need to visit your provider regularly to receive your shots. Tell your health care provider as soon as possible if you've missed or plan to miss an appointment for your shot.

4.2 HIV Drug Resistance

Did You Know. . .

Viral load suppression—the goal of HIV treatment—significantly contributes to preventing the emergence of HIV drug resistance. When viral load suppression is achieved and maintained, drug-resistant HIV is less likely to emerge (WHO, 2024).

With so many people on HIV medications, drug resistance has been increasing. HIV drug resistance can be either acquired or transmitted. Transmitted drug resistance means that the virus that originally infected the person was already drug resistant. The prevalence of this type is 9.3%.

Acquired drug resistance can happen for several reasons. One is if a person does not take their medications consistently according to instructions, allowing the virus to replicate at the same time. Another is when a person’s body does not absorb the drugs properly or other drugs the person is taking interfere with the HIV medications.

There is a third type of resistance known as pretreatment HIV drug resistance. This is not common but can happen as a result of a baby being given drugs to prevent perinatal transmission who becomes infected anyway, or when a patient was taking pre-exposure prophylaxis (PrEP) to prevent HIV but still became infected. If a patient is drug resistant, testing can be done to gather information to determine adjustments to be made (Benisek, 2024; WHO 2024).

4.3 Prevention Strategies

There are now more options than ever before to reduce the risk of acquiring or transmitting HIV. Using medicines to treat HIV, using medicines to prevent HIV, using condoms, having only low-risk sex, only having partners with the same HIV status, and not having sex can all effectively reduce risk. Some options are more effective than others. Combining prevention strategies may be even more effective. But in order for any option to work, it must be used correctly and consistently (CDC, 2022).

Elements of HIV Prevention include:

• Antiretroviral Therapy (ART)
• Pre-Exposure Prophylaxis (PrEP)
• Post-Exposure Prophylaxis (PEP)
• Treatment as Prevention
• Condoms
• Medical Male Circumcision

The six prevention strategies above have undergone significant study and their effectiveness in some or many situations has been demonstrated and details are available on the CDC website (CDC, 2022). As noted throughout this class all of the following have a role in HIV prevention in many scenarios.

• HIV Testing/Counseling
• Education/Behavior Modification
• STI Treatment
• Blood Supply Screening
• Microbicides
• Treatment/Prevention of Drug/Alcohol Abuse
• Clean Syringes

No one prevention option works all the time with every target group, but each one has shown, and continues to show, frequent measurable success with many groups. Used together, they have made significant headway against HIV.

As a concept and a strategy, treating HIV-infected people to improve their health and to reduce the risk of onward transmission—sometimes called treatment as prevention—refers to the personal and public health benefits of using ART to continuously suppress HIV viral load in the blood and genital fluids, which decreases the risk of transmitting the virus to others. The practice has been used since the mid-1990s to prevent mother-to-child, or perinatal, transmission of the virus.

Treatment alone won’t solve the global HIV epidemic, but it is an important element of a multi-pronged attack that includes prevention efforts, wise investment of resources, greater access to screening and medical care, and involvement by everyone—local, state, and federal government; faith-based communities; and private groups and individuals. Providing treatment for people who are living with HIV infection must be the first priority and, in order to get treatment, one must be aware of the need. Thus, testing and identification of those with HIV infection becomes the critical entry point into the medical care system for both treatment and prevention.

4.4 Vaccine

There is currently no vaccine available that will prevent HIV infection. However, scientists around the world, with support from the National Institutes of Health (NIH), are working to develop one. Work on an HIV vaccine can be traced back three decades to before the first HIV vaccine clinical trial at the National Institutes of Health in 1987. Discouraging as that timeframe may sound, it takes a great deal of time to do the work needed to create a vaccine, and HIV provides some unique challenges (NIAID, 2024, 2014; HIV.gov, 2024a).

HIV is a very complex, highly changeable virus, and it is different from other viruses because the human immune system never fully gets rid of it. Most people who are infected with a virus, even a deadly one, recover from the infection, and their immune systems clear the virus from their bodies. Once cleared, an immunity to the virus often develops. But humans do not seem to be able to fully clear HIV and develop immunity to it. The body cannot make effective antibodies and HIV actually targets, invades, and then destroys important cells that the human body needs to fight disease. So far, no person with an established HIV infection has cleared the virus naturally, and this has made it more difficult to develop a preventive HIV vaccine.

4.5 Pre-Exposure Prophylaxis (PrEP)

Pre-exposure prophylaxis (or PrEP) is medicine taken to prevent getting HIV and it is highly effective for preventing HIV when taken as prescribed.

• PrEP reduces the risk of getting HIV from sex by about 99%.
• PrEP reduces the risk of getting HIV from injection drug use by at least 74%.

PrEP is less effective when not taken as prescribed. Since PrEP only protects against HIV, condom use is still important for protection against other STDs. Condom use is also important to help prevent HIV if PrEP is not taken as prescribed.

PrEP is for adults and adolescents without HIV who may be exposed to HIV through sex or injection drug use. PrEP may be an option to help protect pregnant people and their babies from getting HIV while trying to get pregnant, during pregnancy, or while breastfeeding.

PrEP can help protect you if you don’t have HIV and any of the following apply to you:

You have had anal or vaginal sex in the past 6 months and you

• have a sexual partner with HIV (especially if the partner has an unknown or detectable viral load),
• have not consistently used a condom, or
• have been diagnosed with a sexually transmitted disease in the past 6 months.

You inject drugs and you

• have an injection partner with HIV, or
• share needles, syringes, or other drug injection equipment (for example, cookers).

You have been prescribed PEP (post-exposure prophylaxis) and you

• report continued risk behavior, or
• have used multiple courses of PEP.

You may choose to take PrEP, even if the behaviors listed above don’t apply to you.