Acquired Immune Deficiency Syndrome (HIV Infection)

Acquired Immune Deficiency Syndrome (HIV Infection) – Treatment Options

Introduction
Acquired Immune Deficiency Syndrome (AIDS) is the advanced stage of infection caused by the Human Immunodeficiency Virus (HIV). HIV progressively weakens the immune system, particularly CD4+ T lymphocytes, predisposing patients to opportunistic infections, malignancies, and systemic complications. Modern treatment focuses on lifelong suppression of viral replication through combination antiretroviral therapy (ART), management of opportunistic infections, and preventive strategies to enhance survival and quality of life.

1. Antiretroviral Therapy (ART)

• General principles:

  • Lifelong therapy for all HIV-infected individuals, regardless of CD4 count.

  • Aim: Suppress HIV RNA to undetectable levels, restore immune function, and reduce transmission.

  • Standard regimens typically combine 2 nucleoside reverse transcriptase inhibitors (NRTIs) + 1 integrase strand transfer inhibitor (INSTI) or, in certain cases, a boosted protease inhibitor (PI) or non-nucleoside reverse transcriptase inhibitor (NNRTI).

• Common regimens:

  • Tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF) + emtricitabine (FTC) or lamivudine (3TC) + dolutegravir (DTG) or bictegravir (BIC).

  • Abacavir (ABC) + lamivudine (3TC) + dolutegravir (DTG), if HLA-B*5701 negative.

• Other classes:

  • Protease inhibitors (atazanavir, darunavir) (with ritonavir or cobicistat boosting).

  • NNRTIs (efavirenz, rilpivirine, doravirine).

  • Entry inhibitors (maraviroc, ibalizumab) and fusion inhibitors (enfuvirtide) for resistant cases.

2. Prophylaxis and Treatment of Opportunistic Infections

• Pneumocystis jirovecii pneumonia (PCP): Prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) if CD4 < 200 cells/µL.

• Toxoplasmosis: TMP-SMX prophylaxis if CD4 < 100 cells/µL and IgG positive.

• Mycobacterium avium complex (MAC): Azithromycin or clarithromycin prophylaxis if CD4 < 50 cells/µL.

• Tuberculosis (TB): Isoniazid preventive therapy in endemic regions; full anti-TB treatment if active disease.

• Fungal infections: Fluconazole for recurrent oropharyngeal candidiasis.

• Cytomegalovirus (CMV): Ganciclovir or valganciclovir in active CMV disease.

3. Management of HIV-Associated Malignancies

• Kaposi’s sarcoma, non-Hodgkin lymphoma, cervical cancer: Managed with ART plus chemotherapy or radiotherapy as indicated.

4. Supportive and Preventive Care

• Vaccinations: Inactivated vaccines (influenza, pneumococcal, hepatitis A and B, HPV) as per guidelines; live vaccines generally avoided in severe immunosuppression.

• Nutritional support: Adequate caloric intake, correction of deficiencies.

• Psychological support: Counseling to address stigma, depression, and adherence challenges.

• Monitoring: Regular CD4 count, HIV viral load, renal and hepatic function, and ART-related toxicities.

5. Lifestyle and Preventive Measures

• Safe sexual practices and use of condoms.

• Avoidance of needle sharing; harm reduction programs for IV drug users.

• Adherence to ART as the single most important determinant of long-term outcomes.

• Regular screening for comorbidities (cardiovascular disease, kidney disease, bone health).

6. Multidisciplinary Care

• Infectious disease specialists for ART initiation and adjustments.

• Oncologists for HIV-associated cancers.

• Psychiatrists and psychologists for mental health support.

• Social workers and community programs for adherence, stigma reduction, and social support.