Treating HIV/AIDS

HIV/AIDS is treated with antiretroviral treatment (ART) and medication that helps to keep opportunistic infections (diseases that occur in people with suppressed immune systems) under control.

Without treatment, almost everyone with HIV will get AIDS. ART isn't a cure, but it can control the virus so that you can live a longer, healthier life and reduce the risk of transmitting HIV to others.

The goals of ART treatment are to:

  • Consistently suppress the viral load (the amount of concentration of HIV in your blood)
  • Keep your immune system as strong as possible
  • Reduce your risk of HIV-related infections
  • Improve your quality of life and make you live as long as possible
  • Prevent you from passing the virus on to others
  • Minimise the side effects related to your treatment

ART involves taking a daily combination of HIV medicines, called an HIV regimen. These HIV medicines prevent the virus from multiplying (making copies of itself), which reduces the amount of HIV in the body.

Having less HIV in your body gives your immune system a chance to recover and fight off infections and cancers. It also allows you to remain symptom-free for longer. 

ART is recommended for anyone who has HIV, without delay, regardless of how long they’ve had the virus or how healthy they are. If left untreated, HIV will attack the immune system and eventually progress to AIDS.

ART is strongly advised when the CD4 count is less than or equal to 350 cells per mm3, or if you have an AIDS-defining illness, irrespective of your CD4 count.

Certain groups of people, such as children under the age of five, those with HIV and TB and those with HIV and hepatitis, should receive ART as soon as possible. 

If you feel unsure about taking the medicines, talk to your doctor or clinic nurse about your concerns. It might also help to talk to someone else who is using ART.

Factors to consider when starting ART:

  • Your medication must be taken for the rest of your life to control the HIV infection. 
  • Treating HIV/AIDS usually requires a fairly complex medication regimen. The main first-line regimen (tenofovir/emtricitabine/efavirenz) consists of one single tablet to be taken at the same time every day. For those who aren’t able to take this regimen, or who have failed this regimen, the number of pills increase. Fortunately, more and more combination tablets are increasingly available, which makes taking ART easier. 
  • The tablets must be taken at the correct times of day or they won’t work properly. The more doses you miss, the greater the chance of viral mutations and drug resistance, so make sure to take your medication exactly as prescribed. It’s important to not miss doses. Write down exactly how you should take your medicine to help you remember. There’s support available at health facilities to assist with taking pills. Find out from your doctor what this entails. 
  • The medicines often have unpleasant side effects such as nausea and headache. Speak to your doctor or clinic nurse if you’re unsure of how to deal with them. 
  • It may be necessary to change your treatment over the course of your life. You therefore have to be motivated and dedicated to taking your treatment as directed. Be open and honest with your clinic doctor or nurse. 
  • Remember that the virus can never be completely eradicated from your body. A reservoir of infected cells will always remain, even if the virus can’t be detected in your blood. Currently, doctors can only test for 40 virus copies in the blood; if less copies are present, tests won’t pick up the virus.
  • Tell someone you trust that you’re on ART. Ask them to remind you to take your medication every day, to join you when you visit your clinic or doctor, and to help you if you experience unpleasant side effects.  
  • Tell  to your doctor about your risk for other diseases as a result of taking ART (e.g. diabetes type 2) and find out what you can do to lower your risk.
  • Don’t ever skip a clinic or doctor’s visit, and try to go to the same facility every time. The facility will keep a medical record, helping you to track your progress. 

PrEP, PEP and the race to find an HIV vaccine
If you’re HIV-negative but at ongoing risk of being exposed to HIV, it’s worth learning more about pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP).
You might also be interested to know if researchers are making progress in developing an HIV vaccine.

Pre-exposure prophylaxis (PrEP)
Prophylaxis refers to the prevention or protective treatment of disease. The WHO now recommends that people who are at substantial risk of getting HIV infection should be offered preventative antiretroviral treatment (ART), called pre-exposure prophylaxis (PrEP). 

High-risk groups include sex workers, men who have sex with men, adolescents or adults engaging in condomless sex, or the HIV-negative partners of those who are HIV-positive. A drug called Truvada (a combination of emtricitabine and tenofovir disoproxil fumarate, which is licensed in South Africa for this purpose) can reduce the risk of contracting HIV by at least 90% if taken every day. 

In September 2017, the Higher Education and Training HIV & AIDS (HEAIDS) national programme also announced that Truvada will be made available to university and college students across South Africa. 

If you’re using Truvada to limit your risk of getting HIV, it’s important to use the drug in combination with other safer sex practices (e.g. using a condom). Make sure you still get tested for HIV every three months and talk to your doctor or clinic nurse if you experience any side effects. 

You should also remember that PrEP becomes effective only after 7-20 days of taking the medicine. It takes around 7 days for the drug to reach rectal tissue, and around 20 days for the drug to reach tissues of the cervix and vagina. 

PrEP should be taken for as long as you’re considered “high risk” and must be continued for 28 days after your last potential HIV exposure. It shouldn’t be taken if you think you may be HIV-positive (for example, if you’re still in the window period) or definitely are HIV-positive. Tests will be carried out before starting PrEP to ensure that you’re HIV-negative. 

Post-exposure prophylaxis
In the context of HIV, post-exposure prophylaxis (PEP) refers to ART that’s given to someone to help prevent HIV infection after being exposed to the virus.

Healthcare workers who are accidentally exposed to HIV through, for example, a needle-prick accident, should start taking ART as soon as possible after the incident, but no later than 72 hours after exposure. 

The drugs must be taken for 28 days and you should see your doctor every two weeks, six weeks and three months after the exposure for HIV testing. Tests for hepatitis B and C, as well as syphilis, should also be done. 

PEP isn’t needed if the source patient was HIV-negative. It’s also contraindicated if you’re HIV-positive. If this is the case, you should be on ART.

From analysing thousands of accidental exposures in healthcare workers, it’s been calculated that even though the risk of getting HIV infection from such an accident is quite low (0.3% of cases), taking ART reduces the risk of infection by about 80%.

The South African Government now also funds ART in the context of rape and women who have been raped should start ART as soon as possible.

Note that PEP may be difficult to obtain outside of large hospitals. If you’ve been raped, you can get in touch with a rape centre in your area or ask the local police to point you to a facility where you’ll be assisted. 

A doctor or clinic nurse will assess your risk of HIV infection before starting treatment with PEP. 

The race to find a vaccine
The first HIV vaccine clinical trial kicked off in Maryland, USA, in 1987.

Since then, numerous experimental vaccine trials have been conducted but none have proven effective. The first-ever vaccine to show efficacy was tested during the RV144 trial in 2009. 

The trial consisted of over 16,000 participants in Thailand who received a combination of two vaccines – AIDSVAX and ALVAX. These vaccines were based on HIV strains commonly circulating in Thailand.

A total of six injections were given over six months and participants were followed up for three years. The vaccine lowered the rate of HIV infection by 31% when compared to a placebo. It was the first vaccine trial to appear effective. 

There are two vaccine trials currently running in South Africa: HVTN702 is testing a vaccine to protect against the subtype C HI virus prevalent in southern African populations. The vaccine used in this trial is a modified version of the vaccine used in the RV144 trial.

It started in late 2016 and results are expected in 2020. The HVTN702 trial is a phase III trial, which means that, if successful, the drug qualifies to be licensed for medication.  

A new vaccine trial was launched in 15 sites across South Africa at the end of 2017. The HVTN705 study involves a mosaic vaccine that targets different strains and sub-types of HIV-1.

It will be tested on 2,600 HIV-negative women between the ages of 18 and 35 who are at risk of HIV infection. Results are expected in 2021 but, even if the trial is successful, further studies will be required. It could take several years before a vaccine becomes available.

Other preventative methods on the horizon
Other preventative methods that are in the research pipeline include vaginal rings, gels and tablets that release antiretroviral medication to reduce the risk of getting HIV from others. None of these have been approved for use as yet. 

The US National Institutes of Health (NIH) have also recently launched a trial to test a preventative injection of a drug called cabotegravir. The trial will establish whether a two-monthly injection will reduce the risk of contracting HIV.  

Some 3,200 women in southern and eastern Africa, including South Africa, are participating in the trial. Half of the women will take Truvada, while the other half will receive the injection every few months. The study will run for three years and will then assess which group has fewer HIV infections. 

Classes of drugs
A growing number of drug classes are being used to treat HIV. These drugs work against the virus in different ways and at different points in the growth cycle. 

There are currently five classes of drugs available in South Africa:

Class of drug

Generic name

Function

Nucleoside and nucleotide reverse transcriptase inhibitors (NRTIs)

Zidovudine (AZT), emtricitabine (FTC), lamivudine (3TC), tenofovir (TDF), abacavir (ABC), stavudine (d4t), didanosine (ddI)

These mimic the normal building blocks of DNA. They inhibit the viral enzyme (reverse transcriptase) that allows the virus to convert its RNA genome into DNA.

Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

Nevirapine, efavirenz (EFV), rilpivirine, etravirine (ETR), delavirdine (DLV)

These alter the site where reverse transcriptase needs to bind and directly inhibit its action.

Protease inhibitors (PIs)

Indinavir (IDV), saquinavir (SQV), lopinavir (LPV), atazanavir (ATV)

These handicap the viral enzyme (protease) that allows young viruses to mature to the state in which they can infect new cells.

Entry inhibitors

Maraviroc (MCV), enfuvirtide (T20)

These prevent the virus from gaining entry into the cell by blocking various receptor molecules.

Integrase inhibitors; also called integrase strand transfer inhibitors (InsTI)

Raltegravir (RAL), dolutegravir 
(DTG) 

These prevent the viral DNA from being incorporated into the cells’ DNA.

Combination therapy 
If you’re HIV-positive, you’ll receive a combination of three or more antiretroviral drugs that target different steps in the virus’s replication cycle. This is known as or highly active antiretroviral therapy (HAART). 

A combination of drugs is prescribed because the HIV virus very quickly becomes resistant to a single drug (monotherapy). The drug becomes ineffective and can’t be used for ongoing treatment. These days a combination of three drugs (triple therapy) is used. A combination of two drugs (dual therapy) is generally no longer recommended.  

In South Africa, fixed-dose combination antiretroviral drugs (a combination of two or more active drugs in a single pill) is now used as the first line of treatment in people with HIV. This means that, if you’re HIV-positive, you can take just a single pill once a day instead of three or more pills several times a day.

For example, the pill could combine tenofovir (TDF), emtricitabine (FTC) and efavirenz (EFV). Note, however, that fixed-dose combination pills aren’t suitable for everyone.

Regardless of the ART you’re on, your doctor or nurse will monitor your side effects, look for evidence of a response to the therapy (i.e. they’ll check to see if your CD4 cell count is increasing, which indicates a recovering immune system), and keep an eye on the presence of opportunistic infections. 

There’s a slightly higher risk for opportunistic infections in the weeks following the start of ART, as your immune system recovers and turns to attack the invaders in the body. This is known as immune reconstitution inflammatory syndrome (IRIS) and could involve the sudden, unexpected flare-up of a previously undiagnosed condition or the worsening of a previously treated disease as a result of ART.

When to start treatment
On 1 September 2016, South Africa adopted the World Health Organization’sConsolidated Guidelines on the Use of Antiretroviral Drugs, which state that all people who are diagnosed with HIV are immediately eligible for antiretroviral therapy (ART), regardless of their CD4 count.

South Africa was also among the first countries in Africa to formally adopt the WHO Universal Test and Treat (UTT) Guidelines, which support the UNAIDS 90-90-90 targets of 2020. The aim is to ensure that 90% of all people living with HIV know their status; that 90% of people with diagnosed HIV infection receive sustained ART; and that 90% of all people receiving ART have viral suppression.

These steps are supported by research studies that showed that early use of ART keeps HIV-positive people alive and healthy, while reducing their risk of transmitting the virus to their partners. So, it’s best to start treatment as soon as possible after the diagnosis was made.

Managing opportunistic infections
If you’ve tested positive for HIV, a thorough medical examination should be done to evaluate your current state of health. As other sexually transmitted infections (STIs) and TB are often present in HIV-positive people, additional screening tests must be done. If you have any other infections, these must be treated straightaway.

Severe opportunistic infections need to be treated before ART can be started. If your CD4 count is very low (less than 350 cells per mm3), your doctor will start prophylaxis for Pneumocystis jiroveci (PJP). This organism can cause life-threatening lung disease. The drug used is co-trimoxazole and is usually taken until the CD4 count rises to above 350 cells per mm3. 

If your CD4 count drops to below 100 cells per mm3, a CrAG screen will be done to identify and provide treatment for cryptococcal infection. If you have a positive CrAg screen, you need to be evaluated for symptoms of cryptococcal meningitis and then treated with amphotericin B with fluconazole, or only fluconazole if there’s no evidence of meningitis. 

If you’re co-infected with active TB, and you have a CD4 count of less than 50 cells per mm3, you should be treated for TB first and then ART must be initiated within two weeks. If your CD4 count is over 50 cells per mm3, ART should be started as soon as it’s tolerated. This is typically between two and eight weeks of starting TB treatment.

If you have TB or cryptococcal meningitis, and you’re not using ART yet, ART must wait until four to six weeks after the meningitis has been treated. If there isn’t any evidence of TB, you can be put on isoniazid (an antibiotic) to reduce your risk of getting this infectious disease. 
ART and mother-to-child transmission (MTCT)

If you’re pregnant and become HIV-positive, you can reduce your risk of infecting your baby by starting ART immediately. This is also the case if you become HIV-positive during breastfeeding. 

If you’re diagnosed as being HIV-positive during the delivery of your baby, you should receive a single dose of nevirapine (NVP), a single dose of tenofovir and emtricitabine (Truvada) as well as zidovudine (AZT) every three hours during labour. If you’re delivering by C-section, a single dose of NVP and Truvada is sufficient. This will reduce the risk of HIV transmission to your baby. 

You’re also eligible for lifelong ART after your baby is born. The treatment should be initiated straightaway to reduce the risk of transmission.

All babies whose mothers were on ART for more than four weeks before delivery need to be given NVP at birth, and then daily for six weeks. This may be extended to 12 weeks if you started ART less than four weeks prior to delivery, if you weren’t using ART before delivery, or if tests are positive within 72 hours of delivery. 

If you’re diagnosed with HIV while you’re breastfeeding, your baby should receive NVP and AZT immediately. He or she should also be tested for HIV. If tests are negative, AZT can be discontinued and NVP continued for 12 weeks. 

If you’re HIV-positive, HIV testing in your baby should be done at birth, at 10 or 18 weeks depending on how long NVP was given, at 18 months, and 6 weeks after breastfeeding has stopped. If you’re worried, visit your doctor sooner rather than later to have your baby tested. 

Your baby should also be given nevirapine at birth, and then every day for six weeks. Thereafter, an HIV PCR test will be done to determine the ongoing management of your little one. 

ART and mother-to-child transmission (MTCT)
If you’re pregnant and become HIV-positive, you can reduce your risk of infecting your baby by starting ART immediately. This is also the case if you become HIV-positive during breastfeeding. 

If you’re diagnosed as being HIV-positive during the delivery of your baby, you should receive a single dose of nevirapine (NVP), a single dose of tenofovir and emtricitabine (Truvada) as well as zidovudine (AZT) every three hours during labour. If you’re delivering by C-section, a single dose of NVP and Truvada is sufficient. This will reduce the risk of HIV transmission to your baby. 

You’re also eligible for lifelong ART after your baby is born. The treatment should be initiated straightaway to reduce the risk of transmission.

All babies whose mothers were on ART for more than four weeks before delivery need to be given NVP at birth, and then daily for six weeks. This may be extended to 12 weeks if you started ART less than four weeks prior to delivery, if you weren’t using ART before delivery, or if tests are positive within 72 hours of delivery. 

If you’re diagnosed with HIV while you’re breastfeeding, your baby should receive NVP and AZT immediately. He or she should also be tested for HIV. If tests are negative, AZT can be discontinued and NVP continued for 12 weeks. 

If you’re HIV-positive, HIV testing in your baby should be done at birth, at 10 or 18 weeks depending on how long NVP was given, at 18 months, and 6 weeks after breastfeeding has stopped. If you’re worried, visit your doctor sooner rather than later to have your baby tested. 

Your baby should also be given nevirapine at birth, and then every day for six weeks. Thereafter, an HIV PCR test will be done to determine the ongoing management of your little one. 

HIV and breastfeeding
Although babies can be infected with HIV through breast milk – and the use of formula milk has long been advocated in HIV-positive mothers with HIV-negative babies – this guideline recently changed. 

Research has shown that a combination of exclusive breastfeeding and ART can significantly reduce the risk of HIV transmission from mother to child. Note, however, that there are still risks involved. Talk to your doctor and/or nurse to make sure you follow the correct steps to keep your child healthy.

WHO furthermore recommends that all mothers, regardless of their HIV status, practise exclusive breastfeeding for the first six months of their child’s life. This means that you should not give your baby any other liquids or foods during this time. After six months, you can start giving your baby complementary foods, but you should continue with supplemental breastfeeding for at least one year. 

Note that infants of mothers who are failing second- or third-line HIV regimens should not be breastfed.

Follow-up visits
If you’re HIV-positive, you should visit your doctor or clinic regularly so that the progress of HIV can be managed. Your healthcare team will also diagnose and treat other infections and keep your treatment regimen up to date. 

Your doctor will check your CD4 count before you start ART, and then every six months until your viral load is suppressed. Once your viral load is suppressed, your CD4 will be checked annually. 

Viral load monitoring in women who aren’t pregnant is usually done within six months of starting ART, and then every six months until viral suppression is achieved. After that, it’s measured annually. In instances where viral suppression hasn’t been achieved, the viral load will need to be monitored more frequently. Pregnant women and children have different monitoring intervals.

Note that regular dental examinations are also necessary, because HIV can increase your risk of dental problems (e.g. gum disease).

Adherence to treatment
Taking your medicines exactly as prescribed is extremely important if you’re HIV-positive.

Your ART will fail completely if you don’t take it correctly and consistently. Research shows that, if ART is taken with more than 95% adherence, it’s 81% effective. If adherence is less than 70%, it’s only 6% effective. That’s a dramatic difference.

Drug resistance is one of the major problems in people who don’t take their medication as prescribed. This occurs when the drugs can’t protect the CD4 cells anymore and the virus starts to infect the cells. Note that drug resistance doesn’t mean that the HIV-positive person develops resistance, but that the virus develops ways to resist the drugs, and so the drugs no longer work.

Common barriers to treatment adherence include substance abuse, fear of disclosure of HIV status, stigma, depression, forgetfulness and suspicions about ART. Talk to your doctor or clinic nurse if, for whatever reason, you find it hard to adhere to your drug regimen. 

Your healthcare team also needs to monitor any side effects. Some of the more serious side effects of ART include:

Lipodistrophy (change in body fat distribution)
Osteoporosis
High cholesterol
Metabolic disturbances (e.g. insulin resistance, diabetes)
Stephens-Johnson syndrome, a severe skin reaction linked to the use of nevirapine 

Complementary and alternative treatments
Some people seek alternative treatment for HIV from traditional healers, or try alternative forms of medicine like dietary supplements and herbal remedies. 

Traditional medicines haven not been empirically proven to cure HIV and the role of traditional healers in South Africa has been controversial, largely because traditional medicine was promoted as a cure for AIDS and an alternative to ART by the government until 2008. 

Likewise, some dietary supplements claim to boost the immune system or counteract the side effects of HIV medication. In many instances, good-quality research hasn’t been done to prove the supplement’s safety or efficacy in people with HIV.

Supplements that may be helpful include:

  • Acetyl-L-carnitine. Researchers have used acetyl-L-carnitine to treat nerve pain in people with diabetes. It may also ease nerve pain linked to HIV if you have a deficiency.
  • Whey protein. Early evidence suggests that whey protein, a cheese by-product, can help some people with HIV gain weight. Whey protein also appears to reduce diarrhoea and increase CD4 counts.

Supplements that may be dangerous include:

  • St. John's wort. This common remedy can reduce the effectiveness of several types of anti-HIV drugs by more than half.
  • Garlic supplements. Although garlic itself may help strengthen the immune system, garlic supplements interact with several anti-HIV drugs and reduce their ability to work. Eating garlic every now and then appears to be safe, although the herb does interact with saquinavir.
  • African potato (Hypoxis hemerocallidea). A study that looked at the safety and efficacy of the African potato extract in HIV-positive people was terminated early due to the severe bone marrow suppression that resulted after eight weeks of taking the supplement.
  • Ginkgo biloba. This herbal supplement is widely used to improve concentration, memory, dementia and depression. It can, however, interact with the metabolism of the antiretroviral drug efavirenz (EFV). Don’t use ginkgo biloba if you’re on ART.

IMPORTANT: Always speak to your doctor before taking any supplements or herbal remedies.

HIV/AIDS and your medical aid
If you’re on a medical aid, you can get cover for ART. Benefits may differ from one medical scheme to the next, so it’s best to speak directly to your scheme to find out what you’re covered for. 

Remember, if you’re HIV-positive, you still qualify to join a medical scheme, but you must declare your status. It will be considered a pre-existing condition and subject to certain restrictions.

If you’re not on medical aid, you can still get treatment privately through your doctor or hospital, although this is expensive. 

If you can’t afford private care, you can register at a public health facility. Contact the National AIDS Helpline (toll-free on 08 000 123 22) for details of the nearest treatment site.

HIV/AIDS: When to see your doctor
When you first start treatment for HIV, you may suffer from headaches, an upset stomach, fatigue, or aches and pains. These side effects vary from person to person: for some, they're mild and usually go away after a few days. But they can last up to a month for others. 

Before you start antiretroviral treatment (ART), speak to your doctor about potential side effects so that you know what to look out for. 

Don’t stop taking your HIV medication even if you’re struggling with side effects, as this could lead to drug resistance and make the virus harder to treat. First contact your doctor or healthcare provider. They’ll advise you on how to cope with the side effects, or you may be able to change your treatment regimen. Note that many of the newer HIV medications have fewer side effects.

If your symptoms don’t get better, or if you experience any unusual or severe reactions after starting or changing a drug, let your doctor or healthcare provider know immediately. Also get in touch with your doctor if you become pregnant.

Remember that it’s better to be safe than sorry. Everyone is different and we all respond to medication in different ways. If you’re worried about anything, rather call your doctor or healthcare practitioner and get advice. They’re there to help and guide you.

HIV/AIDS and keeping your immune system healthy
If you’re HIV-positive, you should do everything in your power to keep your immune system healthy. You should aim to keep your viral load as low as possible and your CD4 cell count as high as possible.

Take the following actions:

  • Sleep more than 7 hours a night and rest often.
  • Exercise regularly – choose something you enjoy and try to exercise most days of the week.
  • Manage your stress levels and maintain a positive attitude.
  • Follow a healthy, balanced diet: eat lots of fruit and vegetables, wholegrains, low-fat/fat-free dairy, legumes, whole-grains and low-fat protein foods (e.g. lean chicken and eggs). Cut your sugar and salt intake.
  • Talk to your doctor, nurse or pharmacist about taking vitamin and mineral supplements.
  • Avoid recreational drugs.
  • Drink only moderately (if at all).
  • Don’t smoke.
  • Visit your doctor or clinic regularly to keep an eye on your CD4 count and viral load.
  • Take your antiretroviral treatment (ART) exactly as prescribed.

How to prevent the progression from HIV to AIDS
Generally speaking, if you’re HIV-positive, there could come a time when your body’s immune system becomes so weak that you can no longer fight off opportunistic infections. This is when HIV progresses to AIDS.

The good news is that, as long as you take your ART daily and maintain a healthy lifestyle, you’re unlikely to progress to the AIDS stage of the disease. The treatment can halt the progress of the disease and allow your immune system to rebuild itself.

AIDS as such isn’t a disease – it merely describes the stage when HIV has progressed to such an extent that the body’s CD4 count drops below 200 cells per mm3. ART can raise the CD4 count again to above 500 cells per mm3. It’s essential that you follow your doctor’s instructions on taking these drugs, as they can and do save lives. 

Monitoring both your CD4 count and viral load are essential to ensure that you’re healthy, that the HIV isn’t progressing, that the virus isn’t multiplying, and that you’re not at increased risk of opportunistic infections. It’s important to regularly visit your healthcare facility for these routine tests.  

Read more
Preventing HIV/AIDS

Reviewed by Dr Pooja Balani, MBBS (UK). Medical Technical Advisor at the Southern African HIV Clinicians Society. March 2018.

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