Number of pills and frequency of dosage

Some Combinations – FDC (Fixed Dose Combination)

Some combinations - especially those involving a protease inhibitor - require swallowing many pills throughout the day, which some people find hard to do. The size of the pills can also be an issue. One option for reducing the pill burden may be to take a FDC (fixed dose combination), which combines two or more drugs in a single tablet or capsule.

Food restrictions

There are a few drugs, particularly protease inhibitors, which have to be taken with food to improve absorption rates. Some other drugs have to be taken on an empty stomach. There may be a need for lifestyle changes to accommodate the medication.

Side-effects

Side effects are the undesired effects of a drug, which can range from mild irritations to serious health problems. Common side effects should be taken into consideration when choosing a combination. It is also important to consider existing medical conditions that may be worsened by some antiretrovirals. IRIS is an illness that occurs for a small minority of patients soon after treatment is started. Continuing antiretroviral treatment has more information.

Drug interactions

When choosing a combination the interactions between other drugs should be taken into consideration. Interactions can occur between antiretrovirals and non- HIV pharmaceutical and recreational drugs. More information can be found in continuing antiretroviral treatment.

Special handling requirements

Storage can be an issue as some anti-HIV drugs have to be kept below a certain temperature to last long term. Ritonavir, for example, must be refrigerated.

Drug resistance

In some countries a drug resistance test can be carried out before treatment is started in order to determine whether the HIV is already resistant to any of the drug classes. If available the test is recommended for those who have contracted HIV from someone who is already taking treatment.

  Preparing for adherence

The term adherence means taking the drugs exactly as prescribed, on time, and following any dietary restrictions. If the treatment instructions are not followed, it is likely that the drugs will not be absorbed properly in the body. This can have serious short- and long-term consequences, such as an increase in viral load and a greater risk of developing drug resistance.

Adhering to the drug regimen can often be difficult, due to side effects or the frequency of dosage. Sometimes lifestyles changes are needed. Doctors should be able to offer advice if someone is experiencing adherence difficulties.

Pregnancy and treatment

Many studies have shown that antiretroviral drugs can be used during pregnancy. The drugs can be used to reduce a woman's viral load effectively below detection. This also greatly reduces the risk of the baby becoming infected.

Find out more about HIV and pregnancy.

 

Treatment for children

The progression of HIV in children is monitored through viral load and CD4 tests, as with adult treatment, but because the CD4 and viral load levels vary in children (especially between ages 1 to 4) they must be treated on an individual basis. CD4 counts in children are generally much higher than in adults, and change with the child’s age. This means that adult guidelines on when to start antiretroviral treatment do not apply.

HIV more susceptible to Opportunistic Infection

Opportunistic infections

As the immune system becomes increasingly damaged by HIV it is more susceptible to opportunistic infections. These infections would usually be fought off by a healthy immune system, but a low CD4 cell count means opportunistic infections such as PCP (a type of pneumonia) can be life-threatening. If one of these illnesses becomes a serious problem, antiretroviral treatment may be advised immediately.

Making a decision

Treatment should only be started once the person is ready. A lot of commitment is needed, since following a drug regime can be quite demanding and in most circumstances, the treatment will have to be taken for life.

Once it is decided that treatment should be started, doctors will advise of the various HIV drugs and combinations available and which might be most suitable.

Choosing the best combination

In the developed world, there are a number of drug combinations available to choose from. There are more than 20 approved drugs belonging to five groups. It is not always easy to tell which will be the best option, since a combination that suits one person might not suit another.

The first combination of drugs that a person is given is called first line therapy. For treatment in resource-poor countries, the World Health Organisation recommends a first line regimen of one NNRTI and two NRTIs, such as AZT or tenofovir combined with 3TC or FTC. American guidelines recommend one NNRTI or a PI combined with two NRTIs.

The effectiveness of the drugs depends heavily upon taking them exactly as prescribed. Therefore when choosing a combination, it is important to think about how the drugs may affect lifestyle. The combination must be right the first time, as antiretrovirals are most effective in people who have not had any treatment before.

The following issues need to be considered before starting treatment:

The effectiveness of the combination

Some combinations of antiretrovirals are more effective than others. Taking drugs randomly from the different ARV groups may result in a weak combination that doesn’t suppress the HIV infection sufficiently, ending in drug resistance. A few drugs have harmful effects when used together and should not be combined (an example is stavudine and zidovudine).

HIV and AIDS Treatment

When to start antiretroviral treatment

Before a person starts treatment it is recommended that a basic clinical assessment should be carried out. This should include determination of existing medical conditions (such as hepatitis, TB, pregnancy, injecting drug use and major psychiatric illness), assessment of current medications (including traditional and herbal medications), weight measurement, and assessment of patient readiness for therapy. If AZT is being considered then a haemoglobin measurement should be taken, and a pregnancy test should be taken if EFV is being considered.

The CD4 test

Where available, the CD4 test is used to determine when a person should start treatment.

HIV attacks a type of immune system cell called the T-helper cell. This cell carries on its surface a protein called CD4, which HIV uses to attach itself before gaining entry to the cell.

The T-helper cell plays an important part in the immune system by helping to co-ordinate all the other cells to fight illnesses. A major reduction in the number of T-helper cells can have a serious effect on the immune system. HIV causes many T-helper cells to be damaged or destroyed; as a result, there are fewer cells available to help the immune system.

A CD4 test measures the number of T-helper cells (in a cubic millimetre of blood). Someone uninfected with HIV normally has between 500 and 1200 cells/mm³. In a person infected with HIV the CD4 count declines over a number of years. Treatment is generally recommended when the CD4 test shows fewer than 350 cells/mm³.^{1 2 3 4} However, guidelines vary slightly between countries and these are constantly debated.

When the CD4 count reaches the recommended level to start treatment, other factors may also be taken into account, such as viral load and opportunistic infections. More information about viral load monitoring is available in continuing antiretroviral treatment.

WHO clinical staging of HIV disease

The World Health Organisation (WHO) has a method of describing the different stages of HIV disease based on clinical symptoms, known as the WHO staging system for HIV disease. The WHO 2009 treatment guidelines state that where CD4 testing is unavailable, the WHO staging system should be used to determine whether to start treatment. Where a patient is showing signs of WHO clinical stages 3 or 4 they should start treatment and if they are showing signs of stages 1 and 2 they should not start treatment. In places where CD4 tests are available, the WHO recommend that treatment is started if the CD4 count is 350 cells/mm³ or below, regardless of the WHO clinical stage.

The Living Proof Project

Introduction of Project

The introduction of antiretroviral treatment in 1996 revolutionized the treatment of HIV/AIDS, adding decades of life to people living with the disease. Access to treatment has expanded dramatically over the past decade as a consequence of an unprecedented global effort to combat HIV/AIDS, but intensified efforts in prevention are still needed to reverse the course of the pandemic.

Global Progress

Funding for HIV/AIDS in low- and middle-income countries increased from a mere $300 million (U.S.) in 1996 to $13.6 billion (U.S.) in 2008, the highest level to date.1 In addition, several new institutions were created to coordinate and finance global efforts to combat the pandemic:

• The Joint United Nations Programme on HIV/AIDS (UNAIDS) was launched in 1996 to strengthen the U.N. response to the pandemic. It coordinates the HIV/AIDS activities of 10 U.N. organizations, provides strategic information, and advocates for a greater political and financial commitment to control HIV/AIDS.

• The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) was established in 2002 as an innovative financing mechanism to raise and disburse funding to countries in need. As a partnership representing public and private stakeholders, the Global Fund uses a demand-driven, performance-based model. Countries can apply for grants to finance their response to HIV/AIDS, whereas continued financing is dependent on achievement of targets. By March 2009, the Global Fund had committed $11.9 billion (U.S.) to 136 countries for HIV/AIDS prevention, treatment, and care programs.

• The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), established in 2003 by the U.S. government, represents the largest investment by any nation to combat a single disease in history. PEPFAR contributed $25 billion.

(U.S.) between 2004 and 2009 to address the global HIV/AIDS pandemic. Around 80 percent of this funding was channeled to 15 focus countries, with much of the remainder (16 percent) channeled through the Global Fund. In May 2009, U.S. President Barack Obama asked Congress to appropriate $63 billion (U.S.) between 2010 and 2015 for global health, including $51 billion (U.S.) to address HIV/ AIDS, tuberculosis, and malaria.3 If approved by Congress, a substantive portion of this funding will be channeled through PEPFAR for HIV/AIDS efforts.

Symptomatic stage of HIV infection (AIDS)

Symptomatic Stage HIV Infection


HIV infects the immune system sells called T-helpers (very important white blood cells involved in identifying different infections).

As HIV infection propagates in the body the immune system is undermined. The common infections that are easy treated or self-recovered in healthy people can become life-threatening in HIV infected ones. In most patients pneumonia is observed (caused by Pneumocystis carinii) followed by other additionalinfections and Kaposi’s sarcoma.


The AIDS symptoms include persisting infections, such as candidosis, tuberculosis, cytomegalovirus infection, herpes, toxoplasmosis and other that are called opportunistic infections. These infections are the most frequent reasons of the patients’ heavy conditions. But not only. HIV infection is often associated with other sexually transmitted infections. Combination of HIV with other sexually transmitted infections is more life-threatening than each of them separately. Almost every infection is possible with its worst manifestation.
Other consequences of the immune system depression are cancer tumors. The most frequent is Kaposi’s sarcoma; others are lymphomas and carcinomas. Kaposi’s sarcoma found in people younger than 60 years together with positive HIV tests (for HIV antibodies and for low T-helpers) indicates AIDS as well as brain lymphoma.


There can be intermittent acute conditions and improvements in the course of HIV infection. Different patients demonstrate different AIDS symptoms in different target organs: lungs, nervous system, intestine etc. But the earliest symptom is swollen/enlarged lymph nodes, especially if it lasts more than 2 months without visual reasons. When making diagnose it is taken into account epidemiological data: it is very likely to be HIV infection if Kaposi’s sarcoma or lymphoma are found in homosexualists, drug addicts, people with irregular sexual contacts.

Treatment for the infections or cancer is not effective here as the underlying reason is HIV virus to destroy immune system.

HIV virus also destroys central nervous system. The most dangerous and frequent symptom is progressive dementia as a result of cortical atrophy of the brain. This symptom is found in about 50% of the AIDS patients. Many medical specialists believe that brain disorders, dementia in most cases may develop in each HIV infected human. The autopsy of people who died because of AIDS showed that 2/3 of them had brain atrophy.

It is supposed that in adults nervous activity disorders may occur even after 20 – 30 years after initial infection and that average duration of the latent period for progressive dementia is 15 years. There are also reported brain blood vessels damage, meningitis. The patients suffer from head aches, eye vision deterioration.
HIV virus propagation in the brain sells leads to the loss of short-term memory, incoordination, muscle weakness, speech and psychics disorders. The brain damage not always is associated with immune deficit.
The earliest and the strongest brain disorders are observed in children, especially with fetal or natal infection.
  
Official AIDS Diagnosis


Officially AIDS diagnosis is confirmed by different criteria in different countries. At the latest stage HIV infection often develops into the hard disease at which the patient even cannot get up on his own and do simple daily routine. The family members usually should take care of him/her. It is possible to be very ill with HIV but not to have an AIDS diagnosis.

Ways of getting infected

People usually get infected from other infected people sexually. Other possible ways are through the blood, before or during the birth and through breast feeding.

It should be noted that HIV infection is not very much contagious. You cannot as easy get infected as with, say respiratory or intestinal infections. HIV is not transferred during usual communications with infected people. It is unlikely to be infected if you come into contact with sweat, tears, urine, saliva (unless if blood is present in it).

The best way of preventing HIV infection when having sexual intercourse is usage of condoms. Use it in all cases when you are not 100% sure that your sex partner is not infected. It is recommended to limit the number of sexual partners and do not reuse injection needles, share razors and other personal things that may come into contact with the blood.

Care should be taken to prevent a baby infection from the infected mother.

Initial stage of HIV infection

Initial HIV/ AIDS Symptoms

Most of the serious scientists believe AIDS is caused by HIV virus. HIV infection is very insidious, because the virus penetration into the human body and reproduction in most cases does not cause any specific AIDS symptoms at the beginning. HIV test is the only reliable way to determine HIV status. HIV virus affects the immune system and the central nervous system. That’s why at much later stage the infected person suffers from diverse symptoms connected with poor functioning of these systems.

So the initial HIV/ AIDS symptoms are implicit. For example, in a few weeks after the infication the body temperature may increase slightly (99.5 – 100.4°F) accompanied by enlarged lymph nodes, sore throat, red spots on the skin, sometimes diarrhea.

These AIDS symptoms are often neglected and thought they are caused by slight flu or intestinal disorder. Even not each HIV infected person has these symptoms; in those who do have the AIDS symptoms they last for a short time. But if the symptoms are really caused by HIV infection their disappearance means the infection is propagating in the body.

Asymptomatic stage of HIV infection

This stage is characterized by large amount of HIV virus in the peripheral blood. Immune system produces antibodies and cytotoxic lymphocytes in response. Such immune response is called seroconversation. HIV antibody test may be negative if done before producing large amount of antibodies in the body.

HIV infection may be present imperceptibly up to 10-12 years: this time usually passes from HIV infection till AIDS development if no treatment is undertaken.

Sometimes the infection gives a notice of itself by increasing some lymphatic nodes: posterior cervical, infraclavicular, sometimes anterior cervical, axillary, inguinal. In this case it is recommended to get tested not only for the diseases that are manifested by the lymph nodes enlargement (there are plenty of them, for example the lymph nodes enlargement may be a single symptom of lymphogranulomatosis) but also for HIV infection. Other AIDS symptoms may include constant fatigue, loss of the appetite, night sweating, quick weight loss, diarrhea, persistent coughing and mouth ulcers.

The level of HIV virus in the peripheral blood drops to low level. Nevertheless the patient is infectious and HIV antibodies can be detected by antibody test. There is another test to measure HIV RNA in the body and it is usually positive during this asymptomatic stage.

Estimated rates of new HIV Infection by graph

Show new HIV infection by graphically

It should be noted that the new incidence estimate does not represent an actual increase in the numbers of HIV infections, but reflects a more accurate way of measuring new infections. A separate CDC historical trend analysis published as part of this first analysis suggests that the annual number of new infections was never as low as 40,000 and that it has been roughly stable since the late 1990s.

The analyses published in the JAMA article are the first of many that will be published using data from this new system. Visit this site often to monitor emerging information on HIV incidence in the United States.

AIDS Dot Map

Map about AIDS

Of the various types of thematic maps, choropleth maps are the most common and easily interpreted. With a choropleth map one uses a sequence of shades, colors or patterns to assign values/classes using predefined areal units (politically-defined area or administrative units--census areas or zip codes). Here we are using dot maps, as they provide an easily understood pattern of relative AIDS density.

In this series of county-based dot-density maps, the data used are estimated AIDS cases by county, for the 50 US states, Washington D.C. and Puerto Rico, cumulative through 2007. The mapped data excludes cases where the county of residence at AIDS diagnosis is unknown (but these cases are accounted for in the title of each map where the cumulative number is provided). The dot size and value remain constant through time; each dot represents 50 cases of AIDS by county. In other words, if by 2005 a particular county hasn’t reported more than 49 cumulative cases of AIDS, then that county would not have a dot associated with it -- it doesn’t mean that county doesn’t have any cases of AIDS, only that it doesn’t have 50 or more. Additionally, if a county has between 50 and 99 cases of AIDS, it receives 1 dot. In several areas the dots begin to coalesce as time passes. Assigning one dot to every 100 cases was considered, but left many areas of the US erroneously under-represented. Finally, the dots are randomly placed inside the counties.

Data source 

HIV Incidence and Case Surveillance Branch, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention. Data have been adjusted for reporting delays. Data are presented for AIDS cases reported to CDC through June 2007. All data are provisional. 

While the content is in the public domain and no copyright restriction applies, we do ask that users preserve the slides in their current format and cite CDC as the source.

 In August 2008, CDC published the first national HIV incidence (new infections) estimates using new technology and methodology that more directly measure the number of new HIV infections in the United States. The first analyses, published in the August 6, 2008 issue of the Journal of the American Medical Association (JAMA), showed that in 2006, an estimated 56,300 new HIV infections occurred - a number that is substantially higher than the previous estimate of 40,000 annual new infections.

State-by-State HIV infection and AIDS Data

HIV infection and Aids Data

• Provides state-by-state information about new and cumulative AIDS diagnoses, AIDS diagnosis rates, persons living with an AIDS diagnosis, AIDS deaths, diagnoses of HIV infections, HIV testing statistics and policies, additional AIDS-related state policies, Ryan White funding and funding for HIV prevention, and AIDS Drug Assistance Programs, including budget, client, and expenditure data from the Kaiser Family Foundation.

International Statistics

For the most up-to-date information on international HIV infection and AIDS statistics.

For current statistics on the number of reported AIDS cases in North, Central, and South America. Which is the regional office for the Americas of the World Health Organization at 525 23rd Street, N.W., Washington, D.C. 20037, telephone: 202-861-4346.

Deaths of Persons with an AIDS Diagnosis

Deaths of Person with an Aids diagnosis in USA

In 2007, the estimated number of deaths of persons with an AIDS diagnosis in the United States and dependent areas was 18,089. In the 50 states and the District of Columbia, this included 17,613 adults and adolescents, and 6 children under age 13 years.

The cumulative estimated number of deaths of persons with an AIDS diagnosis in the United States and dependent areas, through 2007, was 597,499. In the 50 states and the District of Columbia, this included 571,453 adults and adolescents, and 4,931 children under age 13 years.

Deaths of persons with an AIDS diagnosis may be due to any cause.

Estimated numbers resulted from statistical adjustment that accounted for delays in reporting to the health department (but not for incomplete reporting) and missing risk factor information, where appropriate. Because of delays in reporting of deaths, data are only available through the end of 2007. The exclusion of data from the most recent year allows at least 18 months for deaths of persons with an AIDS diagnosis to be reported.
Totals include persons of unknown race/ethnicity. Because totals for the estimated numbers were calculated independently of the values for the subpopulations, the subpopulation values may not equal the totals.

Persons Living with an AIDS Diagnosis

Persons living with an AIDS diagnosis at the end of 2007

At the end of 2007, the estimated number of persons living with an AIDS diagnosis in the United States and dependent areas was 470,902. In the 50 states and the District of Columbia, this included 458,686 adults and adolescents, and 908 children under age 13 years.


Estimated numbers resulted from statistical adjustment that accounted for delays in reporting to the health department (but not for incomplete reporting) and missing risk factor information, where appropriate.

Because of delays in reporting of deaths, data are only available through the end of 2007. The exclusion of data from the most recent year allows at least 18 months for deaths to be reported and for these persons to be removed from calculations of persons living with an AIDS diagnosis.

Totals include persons of unknown race/ethnicity. Because totals for the estimated numbers were calculated independently of the values for the subpopulations, the subpopulation values may not equal the totals.

AIDS Diagnoses by Top 10 States/Dependent Areas

10 States dependent areas reporting

The 10 states or dependent areas reporting the highest number of AIDS diagnoses in 2008 were:

State/Dependent Area	# of AIDS Diagnoses, 2008
California	4,835
Florida	4,766
New York	4,571
Texas	2,924
Georgia	1,908
Maryland	1,557
New Jersey	1,527
Pennsylvania	1,402
Illinois	1,305
North Carolina	1,157

 

State/Dependent Area	# of Cumulative AIDS Diagnoses Through 2008*
	Adults or Adolescents	Children (<13)	Total
New York	190,363	2,390	192,753
California	159,606	687	160,293
Florida	116,041	1,571	117,612
Texas	76,674	396	77,070
New Jersey	53,756	801	54,557
Georgia	38,054	245	38,300
Pennsylvania	37,842	375	38,217
Illinois	37,592	288	37,880
Maryland	35,395	330	35,725
Puerto Rico	32,057	406	32,463

AIDS Diagnoses by Transmission Category

AIDS diagnoses transmission category 

Six common transmission categories are male-to-male sexual contact, injection drug use, male-to-male sexual contact and injection drug use, heterosexual contact, mother-to-child (perinatal) transmission, and other (includes blood transfusions and unknown cause).

Following is the distribution of the estimated number of AIDS diagnoses among adults and adolescents by transmission category in the 50 states and the District of Columbia. A breakdown by sex is provided where appropriate.

Transmission Category	Estimated # of AIDS Diagnoses, 2008
	Adult and Adolescent Males	Adult and Adolescent Females	Total
Male-to-male sexual contact	17,758	-	17,758
Injection drug use	3,555	2,256	5,811
Male-to-male sexual contact and injection drug use	1,704	-	1,704
Heterosexual contact	4,301	7,112	11,413
Other	225	199	424

Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. Includes hemophilia, blood transfusion, perinatal exposure, and risk not reported or not identified.

 

Transmission Category	Cumulative Estimated # of AIDS Diagnoses, Through 2008*
	Adult and Adolescent Males	Adult and Adolescent Females	Total
Male-to-male sexual contact	513,138	-	513,138
Injection drug use	183,052	84,339	267,391
Male-to-male sexual contact and injection drug use	74,155	-	74,155
Heterosexual contact	68,546	120,039	188,585
Other	13,083	7,426	20,509

From the beginning of the epidemic through 2008. Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. Includes hemophilia, blood transfusion, perinatal exposure, and risk not reported or not identified.

The distribution of the estimated number of  AIDS diagnoses, among children in the 50 states and the District of Columbia, by transmission categories was:

Transmission Category	Estimated # of AIDS Diagnoses, 2008	Cumulative Estimated # of AIDS Diagnoses Through 2008**
Perinatal	34	8,577
Other***	6	773

The term "children" refers to persons under age 13 years at the time of diagnosis.  From the beginning of the epidemic through 2008. Includes hemophilia, blood transfusion, and risk not reported or not identified.