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Initial antiretroviral therapy for HIV


Related Terms
  • Acquired immune deficiency syndrome, acquired immunodeficiency syndrome, AIDS, antibodies, antibody, antiretroviral therapy (ART), antiretrovirals, CD4 cells, CD8 cells, fusion inhibitor, HAART, highly active antiretroviral therapy, HIV, human immunodeficiency virus, immune, immune defense system, immune system, immunocompromised, immunodeficiency, NNRTI, non-nucleoside reverse transcriptase inhibitors, nucleotide reverse transcriptase inhibitor, NRTI, OI, opportunistic infection, PI, protease inhibitor, reverse transcriptase inhibitor, treatment adherence, viral, viral infection, viral load, viral particles, virus, weakened immune system, white blood cells.

  • There is debate among researchers and healthcare professionals over when anti-HIV medications (antiretrovirals) should be started in patients with the human immunodeficiency virus (HIV). Although these medications have been shown to effectively suppress the virus from replicating inside the body, they can also cause severe side effects, including liver damage and neuropathy (nerve damage). Therefore, when patients are diagnosed with HIV, they should discuss the risks and benefits of all treatment options with their healthcare providers.
  • Before beginning treatment, patients must be prepared to follow treatment plans. Some patients may need to take several different pills each day. If drugs are not taken exactly as prescribed on a regular basis, the patient may become resistant to the medication. When this happens, the medication does not effectively suppress the virus. Once a patient is resistant to a drug, the patient can no longer take the drug in the future because it is ineffective. As a result, the patient has fewer treatment options for HIV.
  • In general, most guidelines recommend that antiretroviral therapy (ART) is started when the patient's CD4 cell count is between 200-350 cells per microliter of blood. HIV primarily infects the CD4 cells, which are white blood cells that help coordinate the immune system's response to infections and diseases. Healthy individuals have a CD4 cell count between 600 and 1,200 cells per microliter of blood. The lower the CD4 count, the higher the risk of infection. Patients progress to AIDS (acquired immune deficiency syndrome) when their CD4 cell counts drops below 200 cells per microliter of blood. AIDS patients have the greatest risk of developing life-threatening infections because their immune systems are severely weakened.
  • The results of viral load tests are also taken into consideration. These tests measure the amount of viral particles inside the patient's blood. According to treatment guidelines in the United States, anyone who has a viral load higher than 100,000 copies per milliliter of blood should be offered treatment.
  • Treatment is also recommended if the patient develops an opportunistic infection, such as cytomegalovirus or Pneumocystic jiroveci pneumonia (formerly called Pneumocystis carinii or PCP). Opportunistic infections occur in patients with weakened immune systems and may lead to AIDS.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (

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Integrative therapies
  • Note: Integrative therapies should not replace antiretroviral therapy (ART) in HIV patients. Patients should consult their healthcare providers before taking any herbs or supplements because they may interact with treatment. Patients should not take St. John's wort because it may interact with HIV treatment.
  • Unclear or conflicting scientific evidence:
  • Aloe vera: Clear gel from the pulp of Aloe vera leaves has been used on the skin for thousands of years to treat wounds, skin infections, minor burns, and other skin conditions. Although aloe has been suggested as a possible treatment for HIV, further research is needed before a firm conclusion can be made.
  • Avoid if allergic to aloe or other plants of the Liliaceae family (garlic, onions, tulips). Avoid injecting aloe. Do not apply to open skin, surgical wounds, or pressure ulcers. Avoid taking by mouth with diarrhea, bowel blockage, intestinal diseases, bloody stools, or hepatitis. Avoid with a history of irregular heartbeat (arrhythmia), electrolyte imbalances, diabetes, heart disease, or kidney disease. Avoid taking by mouth if pregnant or breastfeeding.
  • Antineoplastons: Antineoplastons are substances found in human blood and urine. A small preliminary study reported increased energy and weight in patients with HIV, as well as a decreased number of opportunistic infections and increased CD4 cell counts. These patients were treated with antineoplaston AS2-1. However, this evidence cannot be considered conclusive. Currently, there are drug therapy regimens available for HIV with clearly demonstrated effects (highly active anti-retroviral therapy) and patients with HIV are recommended to consult with their physicians about treatment options.
  • Avoid if allergic or hypersensitive to antineoplastons. Use cautiously with high medical or psychiatric risk. Use cautiously with an active infection due to a possible decrease in white blood cells. Use cautiously with high blood pressure, heart conditions, chronic obstructive pulmonary disease, liver disease/damage, or kidney disease/damage. Avoid if pregnant or breastfeeding.
  • Beta sitosterol: Beta-sitosterol is found in plant-based foods, such as fruits, vegetables, soybeans, breads, peanuts, and peanut products. It is also found in bourbon and oils (such as olive oil, flaxseed, and tuna). Due to data that suggest immune modulating effects of beta-sitosterol and beta-sitosterol glucoside, these sterols have been studied in combination in the treatment of HIV. Larger populations of patients with HIV should be evaluated in randomized controlled trials to draw any conclusions.
  • Avoid if allergic or hypersensitive to beta-sitosterol, beta-sitosterol glucoside, or pine. Use cautiously with asthma or breathing disorders, diabetes, primary biliary cirrhosis (destruction of the small bile duct in the liver), ileostomy, neurodegenerative disorders (like Parkinson's disease or Alzheimer's disease), diverticular disease (bulging of the colon), short bowel syndrome, celiac disease, and sitosterolemia. Use cautiously with a history of gallstones. Avoid if pregnant or breastfeeding.
  • Bitter melon: Laboratory studies have shown that a protein in bitter melon called MAP30 may have antiviral activity. However, this has not been studied in humans. Further research is needed before a firm conclusion can be made.
  • Avoid if allergic to bitter melon or members of the Curcurbitaceae (gourd or melon) family. Avoid ingesting bitter melon seeds. Avoid with glucose-6-phosphate dehydrogenase deficiency. Use cautiously with diabetes, glucose intolerance, or with hypoglycemic agents due to the risk of hypoglycemia. Avoid if pregnant or breastfeeding.
  • Chiropractic: Chiropractic care focuses on how the relationship between musculoskeletal structure (mainly the spine) and bodily function (mainly nervous system) affects health. There is not enough reliable scientific evidence to conclude the effects of chiropractic techniques on CD4 cell count or quality of life in patients with HIV/AIDS.
  • Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders, or migraines. Use cautiously with the risk of tumors or cancers. Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis, or arthritis. Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data.
  • Coenzyme Q10: Coenzyme Q10 (CoQ10) is produced by the body and is necessary for basic functioning of cells. CoQ10 levels decrease with age. There is limited evidence that natural levels of CoQ10 in the body may be reduced in people with HIV/AIDS. There is no reliable scientific research showing that CoQ10 supplements have any effect on this disease.
  • There are currently no documented cases of allergy associated with Coenzyme Q10 supplements, although rash and itching have rarely been reported. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use cautiously with a history of blood clots, diabetes, high blood pressure, heart attack, or stroke. Use cautiously with anticoagulants (blood thinners), antiplatelet drugs, blood pressure drugs, blood sugar drugs, cholesterol drugs, or thyroid drugs. Avoid if pregnant or breastfeeding.
  • DHEA: DHEA (Dehydroepiandrosterone) is a hormone that is secreted by the adrenal glands. Although some studies suggest that DHEA supplementation may be beneficial in patents with HIV, results from different studies do not agree with each other. There is currently not enough scientific evidence to recommend DHEA for this condition, and other therapies are more proven in this area.
  • Avoid if allergic to DHEA. Avoid with a history of seizures. Use cautiously with adrenal or thyroid disorders. Use cautiously if taking anticoagulants, or drugs, herbs or supplements for diabetes, heart disease, seizures, or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.
  • Flaxseed: Flaxseed and flaxseed oil/linseed oil are rich sources of the essential fatty acid alpha-linolenic acid (omega-6). While flaxseed has been used to treat HIV, no strong evidence supports its use and no recommendation can be made without further research.
  • Flaxseed has been well tolerated in studies for up to four months. Avoid if allergic to flaxseed, flaxseed oil, or other plants of the Linaceae family. Avoid with prostrate cancer, breast cancer, uterine cancer, or endometriosis. Avoid ingestion of immature flaxseed pods. Avoid large amounts of flaxseed by mouth and mix plenty of water or liquid. Avoid flaxseed (not flaxseed oil) with a history of esophageal stricture, ileus, gastrointestinal stricture, or bowel obstruction. Avoid with a history of acute or chronic diarrhea, irritable bowel syndrome (IBS), diverticulitis, or inflammatory bowel disease (IBD). Avoid topical flaxseed in open wounds or abraded skin surfaces. Use cautiously with a history of a bleeding disorder or with drugs that increase the risk of bleeding (such as anticoagulants and non-steroidal anti-inflammatories). Use cautiously with high triglyceride levels, diabetes, mania, seizures, or asthma. Avoid if pregnant or breastfeeding.
  • Healing Touch: Healing touch (HT) is a combination of hands-on and off-body techniques to influence the flow of energy through a person's biofield. Data from small preliminary studies are insufficient to support any recommendations for or against the use of HT in HIV/AIDS. Studies of better design are needed before any conclusions can be reached.
  • HT should not be regarded as a substitute for established medical treatments. Use cautiously if pregnant or breastfeeding.
  • L-carnitine: L-carnitine may be beneficial in AIDS treatment by increasing proliferation of mononuclear cells and increasing CD4 counts. Additional study is needed to make a firm recommendation.
  • Avoid if allergic or hypersensitive to carnitine. Use cautiously with peripheral vascular disease, high blood pressure, alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.
  • Meditation: Various forms of meditation have been practiced for thousands of years throughout the world, with many techniques originating in Eastern religious practices. A common goal is to attain a state of "thoughtless awareness" of sensations and mental activities occurring at the present moment. More studies are needed to establish how meditation may be useful as an adjunctive therapy in HIV/AIDS patients.
  • Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professionals before starting a program of meditation and they should explore how meditation may or may not fit in with their current treatment plans. Avoid with a risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and it should not be used as the sole approach to illnesses.
  • Melatonin: Melatonin is a neurohormone produced in the brain. There is a lack of well-designed scientific evidence to recommend for or against the use of melatonin as a treatment for AIDS. Melatonin should not be used in place of more proven therapies and patients with HIV/AIDS should be treated under the supervision of their healthcare professionals.
  • Based on available studies and clinical use, melatonin is generally regarded as safe in recommended doses for short-term use. There are rare reports of allergic skin reactions after taking melatonin by mouth. Use cautiously with bleeding disorders, seizure disorders, or if taking drugs that increase the risk of bleeding.
  • Mistletoe: Once considered a sacred herb in Celtic tradition, mistletoe has been used for centuries for high blood pressure, epilepsy, exhaustion, anxiety, arthritis, vertigo (dizziness), and degenerative inflammation of the joints. Treatment of HIV patients with mistletoe has been done in Europe since the beginning of the AIDS epidemic. Treatment seems to be tolerable with minimal side effects reported. Mistletoe may assist in inhibiting disease progression. However, not all mistletoe preparations have shown equal effects. Further study is needed before a firm conclusion can be made.
  • Avoid if allergic or hypersensitive to mistletoe or to any of its constituents. Anaphylactic reactions (life threatening, shock) have been described after injections of mistletoe. Avoid with acute, highly febrile, inflammatory disease, thyroid disorders, seizure disorders, or heart disease. Use cautiously with diabetes, glaucoma, or with cholinergics.
  • Prayer/distant healing: Prayer can be defined as a "reverent petition," the act of asking for something while aiming to connect with God or another object of worship. Limited study of prayer in patients with AIDS reports fewer new AIDS-related illnesses and hospitalizations. However, due to methodological problems, these results cannot be considered conclusive.
  • Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and it should not delay the time it takes to consult with a healthcare professional or receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches and require an open dialog between patients and caregivers.
  • Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional. The patient will explore thoughts, feelings, and behaviors to help with problem solving. Psychotherapy, especially supportive psychotherapy, may reduce depression in HIV-positive patients. It may also help with treating substance abuse when used in combination with prescription medicine. Supportive-expressive group therapy may also have concomitant improvements in CD4 cell count and viral load. More research is needed in this area, especially to determine the best type of psychotherapy.
  • Psychotherapy cannot always fix mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases symptoms may get worse if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression.
  • Relaxation therapy: Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. Mental health and quality-of-life improvements have been seen in preliminary studies of HIV/AIDS patients. These findings suggest the need for further well-controlled research.
  • Avoid with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and it should not delay the time to diagnosis or treatment with more proven techniques.
  • Selenium: Selenium is a mineral found in soil, water, and some foods. Selenium supplementation has been studied in HIV/AIDS patients, and some reports associate low selenium levels with complications, such as cardiomyopathy. It remains unclear if selenium supplementation is beneficial in patients with HIV, particularly during antiretroviral therapy.
  • Avoid if allergic or sensitive to products containing selenium. Avoid with history of non-melanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.
  • Shiitake: Shiitake mushrooms were originally grown on natural oak logs found in Japan. Today, they are available in the United States. These mushrooms are large, black-brown, and have an earthy rich flavor. Based on preliminary studies, lentinan may increase CD4 counts and may qualify in future multi-drug studies in HIV patients. Further well-designed studies are needed to confirm these results. Side effects have been reported and more proven therapies are recommended at this time.
  • Avoid if allergic or hypersensitive to shiitake mushrooms. Avoid if pregnant or breastfeeding.
  • Thymus extract: Thymus extracts for nutritional supplements are usually derived from young calves. Preliminary evidence found no improvement in HIV progression to AIDS or immunostimulation, although some immunological activity was noted in a non-randomized controlled trial. Additional study is needed in this area.
  • Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy or hormone therapy. Avoid with thymic tumors, myasthenia gravis (neuromuscular disorder), or untreated hypothyroidism. Avoid if pregnant or breastfeeding. Thymic extract increases human sperm motility and progression.
  • Traditional Chinese medicine (TCM): Traditional Chinese medicine (TCM) is a broad term that refers to many different treatments and traditions of healing. They share a common heritage of technique or theory rooted in ancient Chinese philosophy (Taoism) that dates back over 5,000 years. TCM herbs are a popular complementary therapy in HIV/AIDS. However, study results conflict. More studies are needed before the potential benefits of TCM herbs in HIV/AIDS can be established.
  • Chinese herbs can be potent and may interact with other herbs, foods, or drugs. Consult a qualified healthcare professional before taking. There have been reports of manufactured or processed Chinese herbal products being tainted with toxins or heavy metal or not containing the listed ingredients. Herbal products should be purchased from reliable sources. Avoid ma huang, which is the active ingredient in ephedra. Avoid ginseng if pregnant or breastfeeding.
  • Turmeric: Turmeric is a perennial plant native to India and Indonesia that is often used as a spice in cooking. Several laboratory studies suggest that curcumin, a component of turmeric, may have activity against HIV. However, reliable human studies are lacking in this area.
  • Avoid if allergic or hypersensitive to turmeric (curcumin), yellow food colorings, or plants belonging to the Curcuma or Zingiberaceae (ginger) families. Use cautiously with a history of bleeding disorders, immune system deficiencies, liver disease, or gallstones. Use cautiously with blood-thinners (e.g. warfarin). Use cautiously if pregnant or breastfeeding.
  • Vitamin A: Vitamin A is a fat-soluble vitamin that is derived from two sources: retinoids and carotenoids. Retinoids are found in animal sources (such as liver, kidney, eggs, and dairy products). Carotenoids are found in plants like dark or yellow vegetables and carrots. The role of vitamin A in the prevention, transmission, or treatment of HIV is controversial and not well established. A clear conclusion cannot be formed based on the available scientific research.
  • Avoid if allergic or hypersensitive to vitamin A. Vitamin A toxicity can occur if taken at high dosages. Use cautiously with liver disease or alcoholism. Smokers who consume alcohol and beta-carotene may have an increased risk for lung cancer or heart disease. Vitamin A appears safe in pregnant women if taken at recommended doses. Use cautiously if breastfeeding because the benefits or dangers to nursing infants are not clearly established.
  • Zinc: Zinc formulations have been used since ancient Egyptian times to enhance wound healing. Patients with HIV/AIDS, especially in those with low zinc levels, may benefit from zinc supplementation. Some low quality studies cite reduction in infections, enhanced weight gain, and improved immune system function, including increased CD4 and CD8 cells. However, other low quality studies conflict with these findings. Further research is needed before a conclusion can be drawn.
  • Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. While zinc appears safe during pregnancy in amounts lower than the established upper intake level, caution should be used since studies cannot rule out the possibility of harm to the fetus.
  • Fair negative scientific evidence:
  • Ozone therapy: Ozone molecules are composed of three oxygen atoms. Ozone exists high in the earth's atmosphere and absorbs radiation from the sun. Reports of using ozone for medicinal purposes date to the late 19th Century. Laboratory studies have shown the HIV virus to be sensitive to ozone, but no high-quality human studies exist. A preliminary study measured the safety and effectiveness of ozone-treated blood in the treatment of HIV infection and immune disease. Ozone therapy was not shown to enhance immune activation or diminish the HIV virus.
  • Autohemotherapy, a therapy in which blood is withdrawn from the body, infused with ozone, then replaced into the body, has been associated with transmission of viral hepatitis and with a possible case of dangerously lowered blood cell counts. Insufflation of the ear carries a risk of tympanic membrane ("ear drum") damage and colon insufflation may increase the risk of bowel rupture. Consult a qualified health professional before undergoing any ozone-related treatment
  • St John's wort: St. John's wort is a perennial herb that is commonly found in many parts of the world, including eastern North America and the Pacific coast. Anti-viral effects of St. John's wort have been observed in laboratory studies, but were not found in one human study. Multiple reports of significant adverse effects and interactions with drugs used for HIV/AIDS, including protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs), suggest that patients being treated for HIV/AIDS should avoid this herb. Therefore, there is evidence to recommend against using St. John's wort in the treatment of patients with HIV/AIDS.
  • Avoid if allergic or hypersensitive to plants in the Hypericaceaefamily. Rare allergic skin reactions like itchy rash have been reported. Avoid with immunosuppressant drugs (such as cyclosporine, tacrolimus, or myophenic acid). Avoid with non-nucleoside reverse transcriptase inhibitors or protease inhibitors. Avoid with organ transplants, suicidal symptoms, or before surgery. Use cautiously with a history of thyroid disorders. Use cautiously with drugs that are broken down by the liver, with monoamine oxidase inhibitors (MAOI) or selective serotonin reuptake inhibitors (SSRIS), digoxin, or birth control pills. Use cautiously with diabetes or with a history of mania, hypomania, or seasonal affective disorder. Avoid if pregnant or breastfeeding.

  • Children born to HIV-infected mothers typically take zidovudine by mouth every six hours for six weeks after birth. This helps reduce the risk of the baby acquiring HIV.
  • Treatment plans for children younger than 13 vary considerably, depending on the patient's weight, age, and overall health. Combination therapy with at least three drugs, including a protease inhibitor or non-nucleoside reverse transcriptase inhibitor plus a nucleoside reverse transcriptase inhibitor is recommended for initial therapy in children. When healthcare providers prescribe treatments, they must consider the formulations of the drugs. Some drugs are available in liquid or powder form, making it easier for young children to take. Many antiretrovirals like zidovudine/lamivudine (Combivir®) are available as combination pills, which make it easier for children and their caretakers to follow treatment plans.
  • The guidelines for antiretroviral treatment among adolescents (13-17 years old) are the same as for adults. In emergency situations, or if parental involvement is impossible or could cause harm, and if the adolescent patient can adhere to treatment regimens, a minor can consent to treatment without parental involvement. However, communication with legal guardians should be encouraged in all patients who are younger than 18 years old and need to make healthcare decisions.

  • If a pregnant woman is diagnosed with HIV, antiretroviral therapy usually begins after the first trimester (14-34 weeks into pregnancy), when the fetus is less susceptible to harmful side effects of the drug. Antiretroviral therapy has been shown to significantly reduce the risk of the mother passing the infection to her baby.
  • Combination antiretroviral therapy with zidovudine (Retrovir®) and other antiretrovirals is the standard treatment prescribed to prevent HIV-infected pregnant women from passing the virus onto their children. Zidovudine is considered the most effective antiretroviral at preventing HIV transmission from mother to child. The exact combination and dosage varies among patients, depending on their overall health and severity of their HIV infections. The newborn typically receives oral zidovudine every six hours for six weeks after birth.
  • Zidovudine may also be prescribed alone to prevent transmission from an HIV-infected pregnant woman to her baby. Treatment is usually started after 28 weeks of pregnancy in women who have low levels of HIV in the blood and who are concerned about the side effects antiretrovirals may have on the baby. A single dose of nevirapine (Viramune®) and zidovudine is then taken during labor to reduce the chance of transmission during vaginal delivery.
  • However, taking the zidovudine alone is typically less effective at reducing the viral load than combination therapy with other antiretrovirals. Taking only one antiretroviral also increases the risk of developing drug resistance. Once drug resistance occurs, the particular drug can no longer suppress the virus, even if it is taken in the future.
  • In general, efavirenz (Sustiva®), stavudine (Zerit®), hydroxyurea (Droxia® or Hydrea®), and the oral liquid formulation of amprenavir (Agenerase®) should not be taken during pregnancy because they may cause harm to the fetus.

When to start treatment
  • General: Once a patient is diagnosed with HIV, a healthcare provider will perform a CD4 and viral load test by taking a sample of blood. The results of these tests, along with the patient's overall health, are taken into account when a treatment plan is developed.
  • Treatment with antiretroviral drugs is an effective way to prevent or slow the progression to AIDS and it has been shown to reduce the risk of infections. However, medications are costly, sometimes difficult to take, and may cause significant side effects. For these reasons, it may be advisable to delay initiating treatment until CD4 counts and viral load indicate that treatment is warranted.
  • It is ultimately the patient's choice when to begin treatment. Patients should make an educated decision after discussing the potential health risks and benefits of treatment with their healthcare providers and loved ones. The patient must be committed to follow treatment regimens to ensure the safety and effectiveness of therapy.
  • CD4 cell count test: The CD4 cell count test, which is performed every three to six months after diagnosis, is a blood test that measures the number of CD4 T-cells per microliter of blood. Healthy adults who are HIV-negative typically have 600-1,200 CD4 cells per cubic millimeter of blood. HIV-positive patients have lower counts because the virus infects and destroys these cells. In general, antiretroviral therapy is usually started when the patient's CD4 cell count is 200-350 cells per microliter of blood.
  • Viral load test: A viral load test measures the number of copies of HIV per milliliter of blood. A low viral load is about 200-500 copies per milliliter of blood. A high viral load can be anywhere from 5,000-1,000,000 or more copies. A high viral load indicates that HIV is replicating and the disease will most likely progress quicker than if the viral load is low. According to treatment guidelines in the United States, anyone who has a viral load higher than 100,000 should be offered treatment. However, some physicians may recommend treatment with lower viral counts, depending on the patient's CD4 cell count and overall health.
  • Opportunistic infection: If an HIV patient develops an opportunistic infection (OI), which is an infection that occurs in patients who have weakened immune systems, antiretroviral therapy (ART) is usually started. Opportunistic infections are a sign that the HIV infection is worsening. Treatment can help suppress the virus, which subsequently boosts the body's immune system helping it to fight off the infection.

Treatment regimens
  • General: Antiretrovirals are the most effective when they are taken for the first time. The specific combination and doses of antiretrovirals are tailored to individual patients. There are currently four classes of antiretrovirals: protease inhibitors (PIs), nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and fusion inhibitors. Each of these medications disrupts a different cycle of HIV's replication. The most effective treatment for HIV is a combination of antiretrovirals from at least two different classes of drugs. This form of treatment is called highly active antiretroviral therapy (HAART).
  • Highly active antiretroviral therapy (HAART): The U.S. Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents has provided recommendations for initial treatment of HIV. According to these guidelines, patients should take one nucleoside reverse transcriptase inhibitor [tenofovir/emtricitabine (Truvada®) or zidovudine/lamivudine (Combivir®)] along with either one non-nucleoside reverse transcriptase inhibitor [efavirenz (Sustiva®)] or a combination of two protease inhibitors [atazanavir (Reyataz®) plus ritonavir (Norvir®); fosamprenavir (Lexiva®) plus ritonavir (Norvir®); or lopinavir/ritonavir (Kaletra®)].
  • Altering treatment: If the drugs are effective, the viral load will drop to less than 400 copies per microliter of blood within the first six months of treatment. Within one year, the number of viral copies will decline to less than 50 copies. If patients do not experience such decreases in their viral loads, alternative dosages or different medications may be prescribed.
  • Treatment may also need to be changed if the patient experiences severe side effects or if the antiretrovirals interact with medications to treat other medical conditions, such as diabetes or depression.
  • Side effects: Side effects of antiretrovirals vary depending on the specific drug treatment. In general, some of the most common side effects of antiretrovirals include dizziness, confusion, fatigue, headache, difficulty sleeping, nausea, vomiting, and diarrhea. Long-term side effects may cause serious medical problems, including liver damage and changes in metabolism such as abnormal lipid and glucose metabolism. These conditions may cause changes in the body shape due to loss and/or accumulation of body fat.

Adhering to treatment
  • In order for anti-HIV drugs to work correctly, they must be taken exactly as prescribed. Skipping doses or not taking the medications correctly can cause the amount of an antiretroviral drug to decrease in the bloodstream. If the drug level becomes too low, HIV can begin reproducing more quickly. The faster HIV reproduces, the more mutations occur, including those that may be resistant to drugs.
  • According to several studies, HIV patients must be more than 95% adherent to their treatment plans in order for them to remain effective. This means that missing more than one dose a month could decrease the drug's ability to treat HIV. Healthcare providers evaluate the effectiveness of treatment by measuring the patients' CD4 cell counts.
  • Patients may benefit from treatment reminders such as pillboxes, beepers, or timers.

Copyright © 2011 Natural Standard (

The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

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