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Initiating Therapy
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There is currently no medication that will cure HIV. However, with good medical care, many patients are able to remain healthy for long periods of time and lead productive lives, including attending school and holding a job. Without treatment, however, the virus will continue to multiply and, as it does so, it will weaken the immune system. Once the immune system is weakened to a certain critical point, you or your child will be more likely to develop potentially life-threatening infections. Children who maintain a close relationship with their doctor and who have strong family and friend support have a very good chance at achieving and maintaining a healthy lifestyle. Although antiretroviral medications are usually necessary at some point to control the progression of HIV disease, these medications can be difficult to use and have significant side effects. This requires that your child be scheduled for a clinic visit appointment every 1-3 months. Occasionally more frequent visits will be necessary when first starting or when making any medication changes. The decision to start treatment in a child with HIV is difficult and requires thought and commitment by the patient, family, and doctor. Babies with HIV who are less than 1 year of age require immediate treatment. This is because small babies and children have immature immune systems and are therefore at much greater risk of developing life-threatening illnesses. Infants also have much higher viral loads and poor control of the HIV in their body. They often require treatment with 3 medications and very frequent monitoring by the doctor. Sometimes, children are diagnosed when they are preschoolers or teenagers. They may have had HIV since birth and their mother's HIV status was likely unknown if she was not screened before giving birth. Often the mother's HIV infection is not diagnosed until the child becomes ill and the diagnosis is made on the child. Also, some older children and teenagers do become infected at an older age and may not be diagnosed until they have been HIV positive for a period of time. In these children, the decision to begin medications will be based on many factors. In a child who is HIV positive, is over 1 year of age, but has no symptoms of disease, the decision to treat is based on several factors including T4 count, viral load, and a readiness of the patient and family to commit to therapy. This decision is made carefully because treatment can result in many different side effects. The child and family must be ready and willing to work through these and the doctor and care team must be prepared to support the child and family in this process. Some children have HIV infection that is slowly progressing. These children are termed as "slow-progressors". They have no symptoms of being sick and their immune systems remain healthy in spite of the HIV. In the few children who do fit this pattern, the decision to treat may be delayed until the disease progresses. The medical team may decide not to treat a patient who is in a situation where they will not be able to maintain the medication schedule as long as the child is not suffering from the symptoms of the disease. Treatment will be required in any child with: illness from their disease, a low CD4 count or a high viral load. While the acceptable levels of immune function and viral load vary with age, generally the lowest acceptable CD4 count in an older child or teenager is 350 cells and any viral load over 35,000 to 50,000 is often the most allowed before starting therapy. Once the decision is made to begin treatment, it is critical that children are compliant with the schedule, which means taking every dose of every medicine at the scheduled time. This is critical to maintaining the effectiveness of the medications and the long term health of the child. Skipping doses of medication can cause the virus to become resistant to the medication.When that occurs, the drugs will no longer control the progress of the HIV disease and the immune system will be weakened and eventually destroyed. Resistance to one medicine may result in resistance to other medications, even some the child has never taken before. This is called cross resistance. This limits the medication options available in future treatment. Treatment with antiretroviral medications is called HAART. This stands for Highly Activated Antiretroviral Therapy. It is an aggressive approach at attacking HIV from different sides at the same time. This is done by using combinations of medications in groups of 2-7. Treatment of HIV disease using one medication or monotherapy is rarely recommended in children or adults. Each medication works differently in controlling the HIV. Once treatment begins, it is extremely important to be compliant and take all the medications as prescribed. Studies have shown that resistance to the medications can occur quite easily. Antiretrovirals taken less than 100% of the time can lead to resistance. If the HIV sees medications on and off or sees them one at a time, it may figure out how the medicine works and change itself in some way to become resistant. Another important part of being compliant is keeping all scheduled appointments with your doctor. This allows the care team to evaluate how effectively the medications are controlling the HIV. This is determined by talking to your child and family, by performing an examination on your child, and monitoring blood tests. Side effects and compliance will be evaluated at each visit. It is critical that your child and family be considered a part of the care team and are able to discuss your concerns with the rest of the care team openly. We hope to provide support, resources, and encouragement as each family struggles with road blocks to maintaining a healthy lifestyle. To help ensure a child's compliance, we try to start medications that are effective but with the least side effects, that fit into busy schedules, and that are tolerable in taste. Patients and families are encouraged to call for information and support at any time but particularly in the first few weeks of starting therapy when side effects may be at the worst. Once therapy is started, blood will be drawn at 3 to 4 week intervals. This will help monitor the effectiveness of the medication as well as side effects on other body organs. The maximum effect of the medications on the HIV viral load will generally be seen after 8-16 weeks of therapy. The goal is to reach an undetectable level, but this is achieved in only about 50% of patients. The other half may not reach undetectable but may have their HIV viral load decreased to a point where it does not weaken the immune system as quickly. It is also important to remember that an undetectable viral load does not mean the virus is cured and that levels may go up and down slightly from one measurement to the next. If the medications are effective, it may take months or even years to see the CD4 count increase to higher levels. The viral load may not decrease with medications or it may decrease for a period of time but then go back up to very high levels. The cause of this will need to be determined. There are generally four reasons the viral load will be high:
Not being compliant with the HIV medications will cause resistance to quickly occur, but even the most compliant people will eventually develop resistant virus over time. It is also important to know that other medications may interfere with the antiretrovirals and change the way they work in the body. This may require an adjustment of the dose. Please inform the care team of any other medications including over the counter drugs your child is taking on a regular basis or even every once in a while. If you are given a prescription or over the counter medication by another care provider, please check with the care team to make sure it will not interact with the antiretrovirals before you start to take the new medication. [Keywords:HIV] |
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