Long-term management of antiretroviral therapy

Rohan Bopage1, Deborah Couldwell1, Mark Boyd2

  1. Western Sydney Sexual Health Centre, Sydney, New South Wales
  2. University of Adelaide, Adelaide, South Australia

Last reviewed: June 2021


Long term management of HIV infection encompasses the following broad objectives:

  • Prevention of HIV disease progression and associated mortality and morbidity;
  • Restoration and preservation of immunologic function;
  • Prevention of antiretroviral drug resistance;
  • Prevention of HIV transmission to others (Treatment as prevention);
  • Minimisation of antiretroviral drug-related adverse effects, intolerances and drug-drug interactions (DDIs) with concurrent medications;
  • Monitoring and prevention of long-term antiretroviral drug-related toxicity;
  • Maintenance and improvement of quality of life of people with HIV infection (PWH).

HIV infection is now a chronic manageable condition with antiretroviral therapy (ART). However, eradication of HIV infection cannot be achieved with current ART regimens, so treatment is life-long, with the main goal of achieving and maintaining plasma HIV RNA levels that are below the lower limits of detection (LLOD) of currently used laboratory assays i.e. “undetectable viral load”.

ART has reduced HIV-related morbidity and mortality at all stages of HIV infection and has reduced HIV transmission. A high level of adherence to prescribed treatment is essential for optimal outcomes. This level of adherence is beyond that generally necessary for the effective management of many chronic medical conditions. As HIV replication is error-prone, mutations that confer resistance to particular antiretroviral drugs or classes of drugs arise unless viral replication is maximally suppressed. Medication adherence has been demonstrated to be the most important prognostic factor in treatment success. Therefore, patient engagement and commitment to his or her treatment plan is fundamental to the successful long-term management of HIV infection. (Refer to later discussion on Retention in care)

The foundations of the relationship between health professionals and PWH built in the early days and months following a new diagnosis of HIV infection is crucial, and includes a number of principles: having the person with HIV infection feel supported and reassured about their long-term prognosis and other concerns about how HIV may impact their life; developing an understanding of what HIV is and how it causes disease; how antiretroviral drugs work and the goals of treatment, including an understanding of fundamental goals such as establishing and maintaining control of viral replication and recovery of immune function. Before treatment starts, we recommend that clinicians engage in specific discussions about how HIV medication will fit into the person’s daily routine. For instance, it is useful to help PWH identify the most suitable time to ingest medications and discuss strategies to aid adherence. In the case of adherence to treatment, prevention is better than cure, as once established, patterns of non-adherence and disengagement may be difficult to change.