Why, when, how – combined therapy

What is a combined therapy?

Combined therapy, triple therapy or HAART (Highly Active Anti Retroviral Therapy) are terms used for three or more different drugs to treat HIV.

Once it penetrates organism, HIV attacks CD4 cells and uses them as factories to make hundreds of its own copies. CD4 are among the main cells of our immune system, meaning that HIV attacks the defence (immune) system of an organism.

Drugs that consist combined therapy work in different ways and different phases of HIV life cycle, aiming at preventing viral multiplication and protect the body defence system.

Do drugs work?

In each country where combined therapy is used (HAART) significant drop is noted in number of death cases and HIV/AIDS related diseases, regardless to gender, age or way of transmission.

Taking drugs in treatment of HIV, strictly following the manner prescribed by a doctor will result in meaningful reduction of viral load in your body.

Regular blood tests (special tests) serve to check drug activity.

•Tests for measuring the quantity of the viral load - PCR test, viral load test
•CD4 tests check the strength of your immune system - the number of CD4 lymphocytes in blood/ml is measured

Even in case you have small number of CD4 cells at the beginning of the treatment, with the aid of immune system may grow strong again so to make large number of serious conditions retreat. By using anti-HIV therapy in the right time and in the right way you will remain healthy for a lot longer then you would be in case you would not use therapy at all.

How long will the drugs work?

Combined therapy consists of at least three drugs and is used for over six years now. A large number of those drugs have also been individually tested over the longer period of time.

Will and for how long respective drug combination work depends mostly from the fact whether viral drug resistance will develop. It is highly unlikely for it to happen if a number of below 50 viral copies per ml is reached and maintained.

In case the quantity of the virus remains in the 50 copies limit, you can use the same drug combination for years.

Should everyone use combined therapy?

Majority of HIV positive persons shall need therapy at a certain stage of the infection but the right moment when they might use it depends on various factors.

The conditions of symptom free HIV infection to disease stage (AIDS) transfer may take different pace, in some persons very fast while on others much slower.

Approximately one third of HIV positive persons shall remain healthy up till 10 years, even without using the therapy. About 60% shall commence treatment in the period of 4 to 5 years upon HIV infection. A small percentage of persons may, due to ill medical condition start using therapy much sooner, while in some person's stage without disease signs may last from 15 to 20 years.

Commencing with therapy is something you need to discuss with your medical professional. In case the number of your CD4 is lowering or the level of virus grows in your organism it is highly important to find out facts about therapy. Even in the case you feel well subjectively it would not you're your getting information about treatment or showing an interest. This usually requires several separate visits to your medical professional.

• Ask as many questions as you wish until you are completely satisfied with the answers. As well, you may rely for useful tips from your friends, specialised phone lines or information obtained from the magazines or from the Internet.

When is the right time for me to begin with therapy?

This is something you should consult with your doctor. As you will be the one taking pills, it is your choice whether and when to start, as well which ones out of available drugs will be used. In order to make the right decision, it is essential you learn as much as possible about the therapy.

• Ask your doctor about the different drugs you may use - their good and bad effect.
• Give yourself some time to think about it. Do not rush with a decision and do not feel forced to do something you do not understand all too well. This specifically relates to those who were confirmed their HIV status recently and who need time to deal with the situation.

In general, it is recommended for the therapy to take place before the CD4 count falls under the number of 300, and especially while the number is still above 200. Yet, even in these cases, there is no urgent need to commence the therapy right away if you yourself o not feel ready.

When the number of your CD count is above 300 your immune system works quite well but the risks exists to develop infections that result in diarrhoea and weight loss. In case your CD4 cells drop below 200, specific pneumonia called pneumocystis pneumonia may occur (pneumocystis carine pneumonia). In case your CD4 count should drop below 100, the risk from other severe diseases increases more.

Low CD count in a patient does not translate to a certain disease; it only implies that the probability is higher. Aside from that, lots of drugs used in treating opportunistic infections (symptomatic therapy) may prove to be more toxic and harder to sustain that regular anti-HIV drugs.

• Symptomatic therapy is a term that implies drugs for treatment of the diseases that follow HIV infection but do have effect on the HIV itself. These drugs take effect on other causes that have exploited the weakness of the body defence system and attacked it. In the first line those drugs include antibiotics, antimycotic drugs, antiretroviral drugs, drugs against diarrhoea, increased bodily temperature...

You may doubt using the therapy but HIV and aids are very dangerous and we should fight them because they are life threatening. There is always the possibility to prolong the onset of therapy usage, but it should not be commenced too late. The diseases that might appear every moment when your immune system is weakened can prove to be life threatening.
Researches made just prove the importance of commencing the therapy before the CD4 count drops below 200.

Is therapy recommended equally to men and women?

There are certain differences in HIV manifestation in women and men. One of them is that with the same amount of CD4 cells women may have lower viral quantity in blood then men. Some researches on this topic have shown that women tend to be more prone to developing diseases than men with the same CD4 count, which may be the reason for them to commence therapy sooner then men. However, the supporting evidence is not as strong to be taken into consideration in everyday practice.

One study done in US shows that viral load in blood varies depending the menstrual cycle stage. Maybe a good idea for you and your doctor would be to keep track about viral load over the cycle and take those data into consideration the next time you take the blood tests.

What about the pregnancy?

Researches have shown that HIV infection in women may be successfully treated over the course of pregnancy. Thus, if the viral load drops to uncountable, the risk of transferring the HIV to your child reduces. Make sure you consult your doctor in regards to therapy if you are pregnant or plan to become pregnant.

How is therapy used in population of children?

General principles of applying the therapy in HIV positive children are similar to those in adults. Yet, there are several important differences and this is the reason children should be prescribed those dosages calculated specifically for them. Aside from that, there are specially adjusted forms of rugs for children in the shape of syrup and solutions so that administering therapy would be easier.

Is age a significant factor in adults?

It is discovered that combined therapy may reactivate an important part of your immune system called TIMUS. Earlier it was perceived that timus ceases its work in the adolescence period (till the age of 21).

An interesting research on this topic has shown that timus may be reactivated in people in their 30es, HIV positive and using combined therapy. This revelation has not been explored to its full and made clear but may imply that earlier commencing the therapy, in 20es and 30es carries with it the potential of using this opportunity.

In any case, as the person grows older, defence system grows old as well and functions worse. People above the age of 50 bear increased risk from further worsening of health caused by HIV and all the arguments that speak on behalf of commencing the therapy become more important as we grow older.

We reiterate, researches on this topic still are far away from final conclusion.

Drugs, age and hart conditions, including blood vessels conditions

Risk factors for heart condition and blood vessel conditions are: age (especially above the age of 45 in men and 55 in women), gender (male), low physical activity, family history of heart conditions, high blood pressure, smoking and diabetes. It is important to accentuate the high level of triglycerides and cholesterol in blood, which might occur, as side effect of using the combined therapy.

Earlier researches show that good results of treatment generally effect lowering the risk of developing heart conditions that usually occur due to administering anti-HIV therapy. This is why, before commencing the therapy a thorough estimation of your cardio vascular system should be made, and later your lifestyle in order to lower the risk of heart disease to the least possible level. For example, if you are a 45 years old male, smoker and not so physically active, it would be better to postpone commencing the therapy until you are able to change some of your habits and lifestyle. Additional incentive at given situation may be the results of your blood tests - high viral load and low CD4 count.

Early diagnosis and primary infection

Some persons discovering their infections as recent as in six months time may decide to commence therapy immediately regardless to the viral load and CD4 count. Persons administering the therapy over the course of a six months time have preserved part of an immune system that specifically react to HIV and which is usually damaged in persons not using the therapy (except for in those where infection progresses slowly. Unfortunately, the scientist were not able to support these findings to enable this discovery be applied for the purposes of health preservation, and this option is researched continually.

It is necessary to set the balance between potential benefits on one side and side effects including drug resistance of the therapy on the other. Likewise, from the medical point of view, you might not need therapy for the period of time but this is definitively a topic to be discussed with your doctor.

Late HIV diagnosis and low CD4 count

Some persons discover their HIV status only when they become ill or admitted into hospital. This often requires initiating the therapy immediately (especially in cases when DC4 count drops below 100).

For people who discovered their HIV status when CD4 count became extremely low, in case they use the therapy carefully and in prescribed manner, you might expect success. Viral load will drop and the CD4 count will rise to safer level.

What about side effects?

Lots of people are worried about therapy due to side effects. However, in majority of persons, already after several weeks the therapy becomes an integral way of life, easily sustained and controlled.

•Lots of side effects are usually very mild.
• Using special, easy to use drugs may reduce occurrence of side effects
•The risk from serious side effects is small and can be early detected in regular doctor check-ups.
•The benefits from anti-HIV therapy is much more significant and larger than consequences of side effects.

Ask your doctor or nurse about common side effects of those drugs you intend to use. Ask about the probability for the side effects to appear and about he number of persons terminating their therapy because of them. Even rough estimation shall provide the overall picture of drugs.

Feeling of nausea, diarrhoea and fatigue are most common side effects although they retract after the first couple of days or weeks of using the therapy. Ask your doctor to immediately, with the therapy prescribe anti nausea and diarrhoea drugs so that you may use them when they become necessary.

Lipodystrophy

Lipodystrophy grasps changes in content of the bodily adipose tissue (lipids) and sugar in blood, and implies changes in distribution of adipose tissue in the adipose tissue cells and other bodily parts.

Lipodistrophy presents the series of side effects that present potential problem in lots of people contemplating the commencing of therapy.

Most severe cases of lipodystrophy may occur in persons using various drugs or have used therapy in many years. The caution concerning lipodystrophy nowadays means that your therapy shall be closely monitored and can be altered in case of low adipose tissue concentration in your blood. More importantly, new drugs used in first line therapy are less likely to cause side effects, lipodystrophy included.

Various drugs may cause gain and loss of weight. Accumulating adipose tissue around the belly and chest and/or shoulder area most likely occurs in using protease inhibitors and non-nucleoside Reverse Transcriptase Inhibitor. Loss of adipose tissue in the area of arms, legs, face and hips most frequently occurs as consequence of administering nucleoside (most often d4T, and to some extent AZT).

The cause that sets off lipodystrophy is still vague. It usually takes several months to develop the symptoms and sometimes they might occur in persons not using the therapy.

In case you change your drug combination on time change nutrition habits or exercise rhythm the symptoms may go away and your body restores its previous shape.

Weight has to be checked regularly so that your doctor could be aware of all the changes.

It is important to report to your doctor about all of the changes you notice on your body.

Other side effects

Side effects of more serious nature rarely occur in using majority of combinations and are related solely to certain drugs. It is important you are familiar with consequences which are the result of taking certain drug become you start therapy.

Peripheral neuropathy may be very serious and painful and generally progresses slowly. In case you develop early symptoms (numbness, tingling in arms, legs back) you may ask your doctor to change the drug that caused it. Changing drugs that cause such condition ddC, ddI, d4T, ritonavir or to a less extent 3TC) is better solution than covering the symptoms with pain relief drugs).

 

What is the best drug combination?

There is no correct answer to this question due to the fact that some drugs suit some people while others find it hard to bear them. You have to establish with certainty that:

•You are using the combination strong enough to lead to lowering viral load below 50 copies. In some cases, this implies using combination of more that three drugs.
•Your body handles therapy well and you follow daily routing of administering therapy and obey the dietary restrictions in nutrition.

Your doctor shall inform you about the best combination for you. Inquire about daily dosages size of the pills and side effects, which will assist you in selecting the combination to use with ease. If you have previously administered anti-HIV drugs, this will have effect on successfulness of your next therapy.

Can I change the therapy?

In case the combination you have chosen is too strong, or side effects have not diminished or disappeared after the first couple of weeks, you may change the drug or drugs toughest to bear especially if this is your first drug combination, you have multiple choices. There is no need to suffer hard and complicated side effects.

Lots of persons use one drug combination up till the moment when viral load drips below 50 and then switch to other, simpler to handler therapy.

Can I take a break with using the therapy?

Interruptions in using the therapy have caused significant attention. Primarily in terminological way, but expressions used such as "therapy break" or SIT, short for strategic/structured interruption in therapy, have not succeeded in explanation of the term.

Therapy interruption may assist persons where resistance to available drugs is developed and is administered in cases when an option for other possible therapy does not exist. Then, interruption in therapy should not be longer then two months. One of recent researches has shown that interruption in duration of four months has caused more severe damages than those caused by therapy without interruption.

• Break in using the therapy is not recommended. In period of couple of months, viral load in your blood may be restored from undetectable to several thousand of copies and taken back to the level where it was when the therapy started. Each therapy interruption carries alongside the risk of drug resistance.
•Interruption may be justified solely by large CD4 count or occurrence of complicated side effects.
•In case you wish to make a break in using the therapy it is necessary to discuss this with your doctor. Usually all of the drugs used in combination are dropped at the same time, but some of them need to be stopped with earlier than others.

What does it imply to be without experience in regards to therapy?

This term is used for persons never to have used any of the anti-HIV drugs. This situation is perceived as very specific because it implies that each of the available drugs may reach best results and together with doctor right combination of drugs should be found.

Anti-HIV drugs have most effect on your body once you start using them first which is why it is necessary to make sure everything is in its best shape. It is better to prolong the onset of a strong therapy combination then use weaker combination for which it is less likely to be successful in the first phase.

What else do I need to know?

Researches related to anti-HIV therapy are in progress, so that perception about the ways of administering is often changed. Therapy recommended by your doctor may be different than the one recommended 6 to 12 months ago for new drugs be discovered, others become available and we learn new facts about the existing ones. Especially the researches related to drug resistance present the most important part of information.

• Always ask about everything you do not understand all too well. You will be able to assume responsibility for your decisions.

Why the therapy does not always bring good results?

Some people will not find therapy being successful completely. There are several explanations:

•Combination may not be strong enough
•You may already be insensitive to one or more drugs in your combination for the virus is resistant to them
•Daily schedule of drug administration may be hard to follow (even if you skip only one dosage per week)
•Dietary regime may be too hard to handle
•Maybe one or more drugs do not reach blood stream sufficiently - there are huge individual differences among people
•Side effects may be severe

None of the researches done on the drugs shows 100% successfulness. However, with good doctor and close monitoring of the drug administration everyone involved in the therapy programme for the first time reached undetectable viral load (below 50 copies).

Percentage of success in persons using second or third therapy combination usually is less to the success of those starting the therapy for the first time.

Main determinants guiding the doctors in setting the successfulness of the therapy are influence of treatment to the viral load and CD4 count in your blood. Some persons may never reach undetectable viral load in their blood, but still remain healthy and feel good for many years. There are always more ways to which an individual may react to therapy than can be explained here.

If undetectable viral load cannot be reached maybe there is resistance to other drugs but you can still benefit from prolonging the therapy. Some new drugs to be produced and available in the future may also be useful to you.

In case you need new drug for completing new combination try to, together with your doctor be introduced with the latest research.

Do drugs present cure?

Current drugs are therapy but unfortunately they do not provide complete cure for they stop further advancement of HIV and allow your immune system to restore itself, but you will still remain HIV positive.

In persons using combined therapy and viral load is below 50 copies over several years still there is small quantity of HIV present in the body. Usually it is situated in "dormant" or "sleepy" cells.

Drugs and researches related to therapy bring us closer to finding the cure in the future. Latest drugs may be easier to administer and more effective which speaks on behalf of probability to live to be old age rather than to die of aids related complications.

Aside from that, it may mean you will still be present once the cure is found and this is goal worthwhile.

Do not think about the drugs you are commencing now as a life long therapy. Observe them as something that needs your devotion for the next couple of years. Devote yourself to this new part of your life more serious than anything else you have done, and in time this kind of relation will become common and normal.