It is recommended that everyone living with HIV be on antiviral treatment, and as soon as possible after diagnosis, according to the HIV treatment guidelines from the U.S. Department of Health and Human Services (DHHS).
The scientific evidence for HIV treatment is so strong that DHHS recommends starting therapy on the same day an HIV diagnosis is received.
Treatment helps keep people healthy and keeps AIDS at bay, among other benefits. It can even prevent the transmission of HIV to sex partners.
All HIV medications are listed in alphabetical order here.
Many of the drugs on the list are rarely used by themselves because they are instead taken as part of a co-formulation with other meds. For example, Emtriva is usually used by way of Descovy or Biktarvy. Descovy itself (two drugs in one pill) is usually used by way of a single-tablet regimen (See below).
What does HIV treatment do?
The goal of therapy is to suppress the amount of virus (called “viral load”) to an undetectable level. This means that the amount of virus in your blood is so low, it cannot be detected by viral load tests. Undetectable viral load will help keep you healthy; the sooner you start therapy, the less damage the virus can do to your immune system so you’ll stay healthier longer. It also means you can’t transmit HIV to your partner through sex (see sidebar). HIV treatment should also raise the number of your CD4+ T cells, a measure of the immune system.
Tests to take before starting HIV therapy
People should be tested for STIs, hepatitis B and C virus, and HIV drug resistance. These conditions and their treatment may affect the HIV medications that can be taken.
Rapid Start
Going on treatment when receiving an HIV diagnosis is called “rapid start” or “rapid ART.” “ART” stands for “antiretroviral therapy” (since HIV is a retrovirus). Rapid ART is also known as “same-day ART” and “treatment upon diagnosis.”
With the rapid ART strategy recommended by DHHS, treatment can begin while awaiting test results.
Only three HIV medications qualify for use as rapid ART under DHHS and International AIDS Society-USA guidelines. They are:
- Biktarvy
- Tivicay + TAF or TDF + FTC or 3TC (basically, Tivicay plus Descovy or Truvada)
- People living with HIV who have used Apretude (for PrEP) should use boosted darunavir (Prezista or Prezcobix) + TAF or TDF + FTC or 3TC for rapid start. Symtuza alone meets those requirements.
What does HIV treatment consist of?
HIV therapy is made up of medications from at least two drug classes. HIV drugs are called “antiretrovirals” (ARVs).
A single-tablet regimen (STR) consists of two or more ARVs from at least two drug classes, and form a complete HIV treatment taken by itself.
Cabenuva is a complete regimen that is given as two long-acting injections every two months (or monthly).
A fixed-dose combination (FDC) combines two or more ARVs in one pill but is not a complete regimen.
STRs are widely used by people taking HIV treatment for the first time (called “treatment naïve”), but they are not for everybody, including some people who are treatment-experienced or have multi-drug resistance.
Medications that are approved by the U.S. Food and Drug Administration (FDA) for highly-treatment experienced individuals (and recommended as such by DHHS) include Rukobia, Selzentry, Sunlenca and Trogarzo. Prezista and Prezcobix are also frequently used as part of that mix.
Treatment-experienced individuals may need to switch therapy due to side effects or drug resistance. Some treatment-experienced people, however, do well with medications that are easier to take, such as Biktarvy or Juluca, both of which are STRs.
HIV treatment is based on considerations such as health status (for example, kidney or liver disease) and lifestyle. See considerations for therapy in the DHHS guidelines.
What is drug resistance?
If treatment is not taken correctly or is unable to completely suppress the virus, it might mutate (make changes in its viral genetic structure). This can make therapy less effective or even ineffective. This drug resistance occurs mostly through missed doses. Fortunately, many of the widely used HIV drugs today have a high barrier to resistance, are easier to take, and have few if any side effects. However, it is better to avoid missing doses. Drug resistance may lead to the need for more complicated therapy (such as more pills).
Drug names
Medications generally have three names. For example, Epivir is a brand name, lamivudine is the generic name and 3TC is the shortened form of its chemical name.
Taking HIV treatment
Getting to and staying undetectable requires adherence: taking your medication as prescribed (for example, with or without food) and not missing doses. Discuss any concerns with your doctor, nurse or pharmacist. Reach out for support at your local HIV organization or support network. That includes housing and job opportunities if you need them. Anti-stigma efforts are also important for HIV care.
IRIS
Individuals with a weak immune system who go on HIV therapy may develop something called IRIS, which stands for “immune reconstitution inflammatory syndrome.” It is rarely seen now thanks to people starting treatment as soon as possible when diagnosed, which helps the immune system stay healthy. IRIS was generally seen with less than 100 T cells and a history of AIDS-defining opportunistic infections (OIs). Notify your doctor right away of any symptoms so that you can be treated as needed. The immune system is actually getting stronger.
Checking in with your providers
You can play an active role in your health care by talking to your doctor, nurse practitioner or other provider. Clear and honest communication can help you both make smart choices about your health. It’s important to be honest and upfront about your symptoms even if you feel embarrassed or shy. Have an open dialogue—ask questions to make sure you understand your diagnosis and treatment. While ARV regimens are usually well tolerated, each ARV can have side effects. Some may be serious. Each person is different; you and your health care provider can decide which drugs to use.
Going on treatment when receiving an HIV diagnosis is called “rapid start” or “rapid ART.” “ART” stands for “antiretroviral therapy”.
Here are a few tips that can help you talk with your provider to make the most of your appointment:
- Write down a list of questions and concerns before your appointment.
- Consider bringing a close friend or family member with you.
- Take notes about what the provider says, or ask a friend or family member to take notes for you.
- Learn how to access your medical records, so you can keep track of test results, diagnoses, treatment plans and medications, and prepare for your next appointment.
- Ask for the provider’s contact information and their preferred method of communication.
- Remember that nurses and pharmacists are also good sources of information.
Pricing
As one HIV specialty pharmacist likes to say, drug pricing is like the sticker price on a car. Much of it depends on the negotiation.
The Average Wholesale Price (AWP) on each drug page is a way to compare the cost of drugs. It is not what you would pay if you were to pay the full retail price. (That’s why AWP’s commonly referred to as “ain’t what’s paid.”) The 2023 Positively Aware HIV Drug Guide used prices listed in Micromedex’s Red Book guide.
In her comments on the drug pages, Dr. Melanie Thompson refers to the Wholesale Acquisition Cost (WAC).
The AWP is “an estimate of the price retail pharmacies pay for drugs from their wholesale distributor.” WAC is “an estimate of the manufacturer’s list price for a drug to wholesalers or other direct purchasers, not including discounts or rebates. This price is defined by federal law.”
The drug cost-sharing and patient assistance program charts (beginning on page 70) include information on how to access programs that can help cover all or part of the costs of many of these medications.
More information online
U.S. HIV treatment guidelines from DHHS
HIV treatment guidelines from the International AIDS Society-USA
iasusa.org/resources/guidelines
HIV drug interactions calculator
Successful HIV treatment stops sexual transmission of the virus
Individuals on successful HIV therapy are unable to pass the virus on to their sex partners. This is called “treatment as prevention,” or TasP. It means being on HIV antiretroviral treatment (ART) and undetectable with less than 200 copies for at least six months. It also goes by “undetectable equals untransmittable,” or U=U.
PEP and PrEP: HIV prevention medications
PEP and PrEP are not HIV treatment, but are HIV medications used by HIV-negative people to prevent infection with the virus.
PEP stands for “post-exposure prophylaxis” and is taken for 28 days following a potential exposure to the virus; PEP must be started within 72 hours after a possible exposure.
PrEP stands for “pre-exposure prophylaxis” and is taken before a potential exposure to the virus.
Prophylaxis means “preventative.”
Apretude is used as one injection given every two months. Descovy for PrEP and Truvada for PrEP are taken as one tablet daily. (They may also be used as four tablets a week or even just around the time of sex, depending upon the guidelines followed.)