FL: HIV, 3 unitsPage 8 of 14

6. Clinical Management of HIV

When their immune system is suppressed, people have weaker defenses against the wide variety of bacteria, viruses, fungi, and other pathogens that are present almost everywhere. The opportunistic diseases and infections associated with HIV infection comprise any of the infections that are part of the AIDS-defining classification and the AIDS indicator conditions discussed earlier. The original case definition of HIV infection was based on the clinical symptoms seen in men. In 1993 the CDC revised the classification system for HIV infection and expanded the case definition for AIDS to include invasive cervical cancer, obviously a condition found only in women. Since 1993 scientists have reported further differences in the way that HIV affects men, women, and children.

Initial Evaluation

Each HIV-infected patient initially entering into care should have a complete medical history, physical examination, laboratory evaluation, and counseling. The purpose is to confirm the presence of HIV infection, obtain appropriate baseline historical and laboratory data, ensure patient understanding about HIV infection and its transmission, and initiate care. The initial evaluation also should include introductory discussion on the benefits of antiretroviral therapy (ART) for the patient’s health and to prevent HIV transmission. Baseline information then is used to define management goals and plans (DHHS, 2013).

The CD4+ T-cell count (or CD4 count) serves as the major clinical indicator of immune function in patients who have HIV infection. It is one of the key factors in determining the urgency of antiretroviral therapy (ART) initiation and the need for opportunistic infection prophylaxis. it is also the strongest predictor of subsequent disease progression and survival according to clinical trials and cohort studies (DHHS, 2013).


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 are used in combination. Each one targets 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, called highly active antiretroviral therapy (HAART).

HAART is made up of several different kinds of medications:

  • Nucleoside reverse transcriptase inhibitors (NRTIs)
  • Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
  • Protease inhibitors
  • Fusion inhibitors
  • Integrase inhibitors
  • Entry inhibitors
  • Combination drugs

The addition of new drugs to combination therapy has contributed to a decline in morbidity and mortality in those infected with HIV and AIDS; it has also added to the cost of HAART. A Canadian study, which analyzed healthcare costs in HIV-infected patients during 1995 to 2002, noted a substantial increase in healthcare expenditures per patient per month since the advent of HAART (Sendi and Gafni, 2003). However, when other factors are taken into consideration—such as increased productivity due to a longer lifespan—the increased cost of HAART appears to be offset by other societal gains.

In 2003 the lack of access to HIV/AIDS treatment was declared a global health emergency and world leaders set a goal of universal access to HAART by 2010. The World Health Organization (WHO) estimates that, globally, 2 million AIDS patients in developing countries were receiving HAART in December of 2006, a more than fivefold increase since 2001. However, this number is only about 26% of the estimated 7.1 million people needing HAART. Even the lowest price—US $142 per person per year for the first-line HAART regimen—remains out of reach for many patients in resource-limited settings. Because large-scale treatment began only recently in many developing countries, little is known about the long-term costs of drugs for AIDS treatment (Nunn et al., 2007).

As patients receive HAART for longer periods, AIDS case management has become more complex. Over time new antiretrovirals have emerged, offering therapeutic improvements with fewer pills. Although the prices of some new second-line antiretrovirals (ARVs) have also declined in some countries, second-line treatment is nearly always more expensive than first-line treatment because of the high costs associated with developing new technologies and the monopoly prices innovator companies enjoy during patent terms. As treatment scales up globally, many AIDS patients now receiving first-line therapies will need therapeutic alternatives. The cost of second- and third-line AIDS treatment and access to the latest ARV therapies is therefore a problem of global public health concern (Nunn et al., 2007).

Many studies have demonstrated that better outcomes are achieved in HIV-infected outpatients cared for by a clinician with HIV expertise. Appropriate training and experience, as well as ongoing continuing education, are important components for optimal care. Primary care providers without HIV experience, such as those who provide service in rural or underserved areas, should identify experts in the region who will provide consultation when needed (DHHS, 2013).

HIV and Viral Hepatitis Co-Infection

People infected with HIV are often at risk for viral hepatitis; about one-third are co-infected with either HBV or HCV, which can cause long-term illness and death. More people living with HIV have HCV than HBV. Viral hepatitis progresses faster and causes more liver-related health problems among people with HIV than among those who do not have HIV. Although drug therapy has extended the life expectancy of people with HIV, liver disease—much of which is related to HCV and HBV—has become the leading cause of non-AIDS-related deaths in this population (CDC, 2013d).

To prevent co-infection for those who are not already infected with HBV, the Advisory Committee on Immunization Practices recommends universal HBV vaccination of high-risk patients (including those who have multiple sex partners; gay, bisexual, and other men who have sex with men [MSM]; injection drug users; and those who are exposed to blood at their jobs) with HIV infection or AIDS (CDC, 2013d).

Co-infection with viral hepatitis may also complicate the treatment and management of HIV infection. Because viral hepatitis infection is often serious in people with HIV infection and may lead to liver damage more quickly, CDC recommends that all people with HIV infection be tested for HBV and HCV. The CDC also recommends that everyone born during the period 1945–1965 should be tested at least once for HCV, no matter what their HCV risk (CDC, 2013d)

HIV/HBV and HIV/HCV co-infections can be effectively treated in many people, but treatment is complex and people with co-infection should look for healthcare providers with expertise in the management of both HIV infection and viral hepatitis (CDC, 2013d).