Latest Treament for HIV-Aids - Coursework Example

Human immunodeficiency virus infection (HIV) is in the forefront of untreatable infectious disorder epidemiology and is contemplated a serious health problem. The treatment for HIV/AIDS has undergone many transformations over human history from its established fact of deadly fatal disease to current status of manageable infection. Antiretrovirals or ARVs are the medications which are used against HIV to treat the condition by prevention of its progress by reducing active HIV load in the body. Nucleoside/Nucleotide Reverse Transcriptase Inhibitors and Non-Nucleoside Reverse Transcriptase Inhibitors are widely available drugs in most countries, against fusion/entry inhibitors and integrase inhibitors which are often restricted to countries having sound financial condition. Expensive drugs from the class of protease inhibitors are not generally used as first line treatment due to cost, pill burden and adverse drug reactions. The recent drugs like Maraviroc, Raltegravir, and Etravirine are FDA approved in 2007-2008 are indicators of positive steps towards HIV battle. Antiretroviral treatment has made major breakthrough in prevention of mother-to-child transmission (MTCT) of HIV. MTCT rate fell from 25% to 8% in a decade by standard dosage regimen of zidovudine during pregnancy, during labor (delivered intravenously to the mother), and postnatal period (syrup formulation delivered to the newborn) for 6 weeks. Zidovudine medication and Cesarean section method of delivery reduced MTCT to 2% only. The synergistic relationships between western medicines (used by doctors) and traditional healers could have significant impact for the prevention and treatment of HIV/AIDS in underdeveloped and developing countries. Introduction Human immunodeficiency virus (HIV) or retrovirus is uncommon type of virus that causes acquired immune deficiency syndrome (AIDS) disease. HIV infection is in the forefront of untreatable infectious disorder epidemiology and is contemplated a serious health problem. The treatment for HIV/AIDS has undergone many transformations over human history from its established fact of deadly fatal disease to current status of manageable infection. In AIDS our immune system is hampered reducing body’s ability to fight against diseases. As the global environment is changing at fast pace, the paths of disease transmission are also varying and therefore, offering more challenges when international control and prevention is concerned. To control HIV infection two important tools are: knowledge of epidemiology, and good management. The control of HIV infection has posed ongoing varied problems. In commissioning and contracting for this contagious disease, several management issues have to be considered. Technical and financial amenities should be used by the developed countries to prevent resurgence of this infectious disease. The people who do not want to follow preventive education are the most vulnerable to risk factors. To reduce the enormous global burden and long-term goal of better control of this communicable disease, there is a need for international surveillance. The people should be aware of the fact that HIV infected individual might be able to lead normal life in the future, if properly treated. Antiretrovirals Antiretrovirals or ARVs are the medications which are used against HIV to treat the condition by prevention of its progress by reducing active HIV load in the body, and keeping immune system as fit as possible but can not cure the problem itself. There are around 20 antiretroviral drugs approved or licensed by the U.S. Food and Drug Administration (FDA) indicated for treating HIV and AIDS, but are not available in every country. There are five categories of antiretroviral drugs depending upon their mechanism of action on HIV. Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTI): These nucleosides analogues are approved in 1987 by FDA to inhibit HIV replication and include drugs like Abacavir (Ziagen, ABC), Didanosine (Videx, dideoxyinosine, ddI), Emtricitabine (Emtriva, FTC), Lamivudine (Epivir, 3TC), Stavudine (Zerit, d4T), Tenofovir (Viread, TDF), Zalcitabine (Hivid, ddC), Zidovudine (Retrovir, ZDV or AZT). To lower the pill burden and increase effectiveness of the therapy the drugs could be administered in following combination Combivir (Zidovudine and Lamivudine), Trizivir (Zidovudine, Lamivudine and Abacavir), Epzicom (Abacavir and Lamivudine) and Truvada (Tenofovir and Lamivudine). Protease Inhibitors (PI): These drugs are first introduced in 1995 and include drugs like Amprenavir (Agenerase, APV), Atazanavir (Reyataz, ATV), Fosamprenavir (Lexiva, FOS), Indinavir (Crixivan, IDV), Lopinavir (Kaletra, LPV/r), Ritonavir (Norvir, RIT), Saquinavir (Fortovase,Invirase, SQV). Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI): These drugs are first approved by FDA in 1997 for blocking HIV for infecting new cells and usually used with other drugs. NNRTs include Delvaridine (Rescriptor, DLV), Efravirenz (Sustiva, EFV), Nevirapine (Viramune, NVP). Fusion Inhibitors or entry inhibitors: These drugs are first approved in 2003 for the prevention of HIV entry into the cells and include drugs like Enfuvirtide also known as Fuzeon or T-20. Integrase inhibitors: FDA approved first integrase inhibitor Raltegravir (Isentress) is introduced in 2007 to inhibit HIV enzyme and prevent new infections. These miracle drugs are becoming increasingly ineffective due to their misuse, overuse as well as underuse, inconsistent prescribing practices, and patient’s noncompliance. Evolution and mutation of notorious viruses is a strategy used by these viruses to adapt to environmental circumstances and make them superbugs. These survived superbugs in antiviral environment are referred as resistant pathogens. They proliferate rapidly and give rise to new generation of resistant viruses. Therefore single drug therapy fails to fight against invading superbugs. This gives rise to widespread antiretroviral drug resistance. Combination drug therapy approach is useful against such resistant pathogens. Highly Active Antiretroviral Therapy (HAART) is the most aggressive approach introduced in 1996 to fight against HIV. This anti-HIV "cocktail" strategy uses mixture of three or more medications such as protease inhibitors and other anti-retroviral drugs to slow own spread of HIV in the body by widespread inhibition of HIV replication. These therapy reduces the HIV load in the body to such an extent that blood tests are not able to detect the presence of HIV (UCSF Medical Center, May 8, 2007). This treatment is recommended for nonpregnant individuals having CD4 cell count below 350/µL (RITA, 41, 2008). NRTIs and NNRTIs are widely available drugs in most countries, against fusion/entry inhibitors and integrase inhibitors which are often restricted to countries having sound financial condition. Expensive drugs from the class of protease inhibitors are not generally used as first line treatment due to cost, pill burden and adverse drug reactions (AVERT, Introduction to HIV and AIDS drug treatment, July 01, 2009). The factors which play important role in antiretroviral management include right start for the initiation of therapy in terms of time and initial regimen, best combination approach for the individual, monitoring the patient for the compliance and effectiveness of therapy and introduction of approved novel drugs (maraviroc, raltegravir, and etravirine) for the patient if not responding to initial therapy (Hammer et al., 2008). The patient should receive the treatment prior his/ her CD4 cell count drops to 350/µL. High plasma viral load (eg, >100 000 copies/mL) and rapidly declining CD4 cell count (>100/µL per year) are indicators for immediate start for the antiretroviral therapy. Personalised treatments are necessary depending upon the presence of comorbidities like active hepatitis B or C virus coinfection, cardiovascular disease risk, and HIV-associated nephropathy, risk factors for progression to AIDS and non-AIDS diseases, and patient’s willingness for the treatment. The pretreated patient having undetectable HIV viral load should also be managed properly for any future treatment failures (Hammer et al., 2008). In addition to this the interaction between oral contraceptives and antiviral drugs should be considered while deciding the dosage for the patient (RITA, 2008, p. 45). The developing countries like China, UNAIDS has reported that within the span of four years from 2003 to 2007 the HIV infected population dropped by 140, 000. Costlier antiretroviral therapy was not easily available before 2003 in China. Then the Chinese government took cautious steps to introduce several care and prevention programs like China CARES (China Comprehensive AIDS Response) in 2003, a community-based HIV treatment, etc. Chinese government delivered free antiretroviral medications first line therapy of zidovudine (or stavudine) + lamivudine + nevirapine) (WHO CHINA, 2005) in rural areas to 37,497 AIDS infected population including 771 HIV positive children. Other restricted free of charge medicines contain combinations of zidovudine + lamivudine (Combivir®) and of efavirenz (WHO CHINA, 2005). Also, Chinese government is promoting use of condoms through education, advertising, and free distribution to prevent spread of HIV especially in sex workers, migrating workers, gay population having sex etc (Zaccagnini, June 17, 2009). To prevent HIV transmission to child from mother zidovudine is given from 28 weeks and during labor and a single dose of nevirapine for the mother at the beginning of labor and to the infant within 72 hours of birth (WHO CHINA, 2005). In 2004, State Food and Drug Administration (SFDA) has approved Chinese herbal traditional medicine Tangcaopian in HIV patients to boost immunity and treat HIV related clinical manifestations like muscle weakness, coughing, fever and skin rash etc (Hepeng, April 20, 2004). While in developing regions like Western and Central Europe, it was estimated that around 800,000 were infected with HIV which is comparatively less than countries in Asia and sub-Saharan Africa. Combination antiretroviral treatment was introduced in the mid-1990s, still due to late diagnosis, injection drug use, gay people’s sex, sex workers and migratory workers HIV infection is still considered as a challenging epidemic. For preventing HIV/AIDS from mother-to-child-transmission European countries are most successful as compared to other regions by adopting strategies like routine test of HIV for pregnant women, easy access to antiretroviral drugs to HIV infected pregnant women, and prevention of breast feeding (Spink, June 02, 2009). Prenatal and post natal care for HIV patient In 2002 it has been reported that, within a span of decade HIV infected babies rate dropped from 2000 to 300. Antiretroviral treatment has made major breakthrough in prevention of mother-to-child transmission (MTCT) of HIV. MTCT rate fell from 25% to 8% in a decade by standard dosage regimen of zidovudine (ZFV or AZT) during pregnancy, during labor (delivered intravenously to the mother), and postnatal period (syrup formulation delivered to the newborn) for 6 weeks (RITA, 2008, p. 41). AZT and Cesarean section method of delivery reduced MTCT to 2% only. The women who are on HAART therapy before pregnancy can continue the same treatment strategy except for nelfinavir and efavirenz to avoid teratogenic effects in newborns. The pregnant women who are diagnosed with HIV infection should initiate therapy of zidovudine and lamivudine with lopinavir/ritonavir after first trimester. Still, in developing and underdeveloped countries like Uganda, not recommended inexpensive nevirapine is used during antenatal care in pregnant women exhibiting CD4 T-cell counts > 250 copies/mL and also during labor as a single dose to reduce vertical MTCT. Precautions should be taken to avoid nevirapine resistance and virologic failure by taking care of 6 months gap after the peripartum dose. NRTI therapy containing abacavir/zidovudine/lamivudine is recommended for pregnant women having low VLs, (e.g., ≥1,000 copies/mL) and high CD4 T-cell counts (RITA, 2008, p. 42). The pregnant women suffering from or prone to HIV infection should have routine check up of CD4 T-cell count once in three months, viral load (VL) after every two months after initial tests of commencing the HIV therapy (2 to 6 weeks), and genotyping for resistance. In addition to this, complete blood counts and liver function tests also should be carried out to check the adverse events of administered antiretroviral drugs. In the United States, during the delivery of HIV positive woman the recommended practice is as follow: administration of intravenous zidovudine (2 mg/kg loading dose over the first hour and then a 1 mg/kg dose every hour until delivery), avoidance of a fetal scalp electrode, refrain from use of vaccum or forceps for the delivery, and prohibit the artificial rupture of membranes. Postpartum hemorrhage should not be treated with methergine to avoid interaction with PIs or with the NNRTIs leading to vasoconstriction. Pregnant women having HAART treatment and VLs < 1000 copies/mL might undergo vaginal delivery otherwise Cesarean section is recommended at 38 weeks of gestation (RITA, 2008, p. 43). Due to novel treatment strategies and prevention measures adopted HIV-infected women could deliver a normal healthy child if proper precautions are taken. Recent trends and future antiretroviral drugs Due to unmet challenges offered by HIV/AIDS, there is a strong need for safe and effective improved drug therapy. The challenges comprise of the development of novel drug entities with novel mechanisms of action or modified action. New combination therapy containing integrase inhibitor Raltegravir is highly active against resistant HIV pathogens which has successfully reduced the viral load to undetectable levels (ScienceDaily, July 30, 2008). Recently approved drug and future antiretroviral drugs are shown in Table 1. (AVERT, Introduction to HIV and AIDS drug treatment, July 01, 2009). Table 1 Recently approved drug and future antiretroviral drugs Drug class Recently approved Phase III Phase II Entry inhibitor (CCR5) Maraviroc (Aug. 2007) Vicriviroc PRO 140 Entry inhibitor (CD4) TNX-355 Integrase inhibitor Raltegravir (Oct. 2007) Elvitegravir Maturation inhibitor Bevirimat NNRTI Etravirine (Jan. 2008) Rilpivirine NRTI Apricitabine KP-1461 Racivir Elvucitabine The advantages of both western medicine and traditional therapy Past western medicines and new emerging treatment research areas would always have great contributions in the intervention of HIV/AIDS. Cost factor for the treatment is a major attribute when the economic background of any country is considered. Restricted financial resources limit the use of costlier western medicine treatment policies and procedure in countries like sub-Saharan Africa. Conventional healers like herbal medicines which are used traditionally for the treatment of HIV/AIDS could play major role in underdeveloped as well as developing countries. The synergistic relationships between western medicines (used by doctors) and traditional healers could have significant impact for the prevention and treatment of HIV/AIDS. For example, in South Africa, traditional therapies are well known, easily acceptable, communicable and reachable to all the people in the community since such healers are well trusted by the population. Herbs like Aloe vera, St. Johnswort, echinacea, licorice, woody wine and ginseng are used as herbal medicines for HIV/AIDS to reduce the debilitating infections. The herbs like astragalus, echinacea, and ginkgo are used as immunity boosters in AIDS. Deglycyrrhizinated licorice acts as soothing agent for ulcers accompanying in AIDS (Life Positive Foundation, Natural Treatment for HIV-AIDS, 2008). Therefore, education, training and use of such traditional medicines with innovative approaches should be an integral part of the primary health care model along with costlier antiretroviral treatment drugs in the battle against HIV (Liverpool et al., 2004) especially in developing and underdeveloped countries. Conclusion Despite the developments made in prevention, diagnosis, and treatment, HIV infection remain a significant public health problem worldwide. Treatment should able to provide virologic, immunologic, and clinical advantages with minimal side effects, toxicity, drug resistance to lead normal life in the future. Restricted financial resources limit the use of costlier western medicine treatment policies and procedure in countries like sub-Saharan Africa. Therefore, education, training and use of traditional herbal medicines with innovative approaches should be an integral part of their primary health care model along with costlier antiretroviral treatment drugs in the battle against HIV. Due to novel treatment strategies and prevention measures adopted HIV-infected women could deliver a normal healthy child if proper precautions are taken and right HIV medications are given. The coordinated efforts of local, state, and federal action with synergistic national as well as global strategy and availability of ample resources can deliver dramatic reduction in HIV/AIDS cases at the end of this century. References University of New South Wales. "New Therapy For HIV Treatment." ScienceDaily 30 July 2008. 25 March 2004 . http://www.sciencedaily.com/releases/2008/07/080729133622.htm Hammer, S. M., Eron, J. J., Reiss, P., Schooley, R. T., Thompson, M. A., Walmsley, S., Cahn, P., Fischl, M. A., Gatell, J. M., Hirsch, M. S., Jacobsen, D. M., Montaner, J. S. G., Richman, D. D., Yeni, P. G. & Volberding, P. A. “Antiretroviral Treatment of Adult HIV Infection 2008 Recommendations of the International AIDS Society–USA Panel” JAMA. 300.5 (2008):555-570. August 6, 2008 Liverpool, J., Alexander, R., Johnson, M., Ebba, E. K., Francis, S. & Liverpool, C. “Western Medicine and Traditional Healers: Partners in the Fight Against HIV/AIDS”. Journal Of The National Medical Association 96.6, (2004): 822-825. UCSF Medical Center by health care specialists. Last updated May 8, 2007 HIV/AIDS. http://www.ucsfhealth.org/adult/medical_services/infect/hiv/medications.html AVERT. Introduction to HIV and AIDS drug treatment. Last updated July 01, 2009 http://www.avert.org/treatment.htm AVERT. New Antiretroviral AIDS drug. Last updated July 01, 2009 http://www.avert.org/new-aids-drugs.htm Zaccagnini, M. AVERT, HIV and AIDS in China, Last updated June 17, 2009. http://www.avert.org/aidschina.htm Life Positive Foundation. Natural Treatment for HIV-AIDS. 2008. http://www.lifepositive.com/Body/body-holistic/AIDS/natural-treatment-for-aids.asp World Health Organization. China: summary country profile for HIV/AIDS treatment scale-up [Online]. 2005 http://www.who.int/hiv/HIVCP_CHN.pdf Hepeng, Jia. China approves traditional medicine for AIDS patients. 20 April 2004. http://www.scidev.net/en/news/china-approves-traditional-medicine-for-aids-patie.html Spink, G. AVERT, HIV and AIDS in Western and Central Europe, Last updated June 02, 2009. http://www.avert.org/aids-europe.htm Read More