Adjustments to Treatment

People who are receiving antiretroviral medications should have a baseline viral load and CD4 count done and regular evaluations during treatments. If the viral load increases and CD4 count decreases, the treatment regimen may need to be adjusted. In that case, the physician will evaluate 3 factors to determine what adjustments need to be made:
· Adherence: Refers to how closely a person follows the medication regimen. If someone is unable to follow the regimen, treatment may need to be adjusted to give medication in fewer doses or fewer pills.
· Tolerability: Refers to side effects caused by the medications. If a particular drug is causing a very difficult side effect, a different medication may be prescribed.
· Medication interactions: Refers to drug reactions to other medicines a person may be taking. Since some drug reactions can have a negative effect on the efficacy of antiretroviral treatment, these reactions need to be identified, so treatment can be adjusted.
Non-occupational Post-exposure prophylaxis (nPEP)
In January 2005, the CDC issued guidelines for non-occupational post-exposure prophylaxis (nPEP). The recommendations cover those exposed to HIV from rapes, accidents or isolated episodes of drug use or unsafe sex. The previous recommendation (1996) had recommended prophylactic treatment only for health care workers accidentally exposed on the job.
The nPEP regimen is intended for people seeking care within 72 hours of exposure to blood, genital secretions (semen and vaginal fluids), or other potentially infectious body fluids of a person of unknown HIV status, if a positive HIV status would pose a substantial risk of transmission. In many cases, the HIV status may be known, but, for example, a condom may break, exposing someone to infected semen. The recommended drug regimen is a 28-day course of highly active antiretroviral therapy (HAART).
No recommendation is made if the exposure was more than 72 hours prior to seeking treatment. People who receive nPEP should receive counseling and be scheduled for followup testing at 4-6 weeks, 3 months, and 6 months after exposure, to determine if HIV infection has occurred. Additional testing for sexually transmitted diseases, hepatitis B and C, and pregnancy should also be offered. Patients need instruction about the signs and symptoms of HIV infection.
Health care workers who incur accidental needle pricks will also be treated with this regimen of drugs. A case control study of health care workers who had needlestick injuries showed that prompt initiation of treatment with zidovudine was associated with an 81% decrease in the risk of acquiring HIV. A number of international studies have shown that nPEP results in almost 100% protection from HIV.
This protocol is not recommended for people who continually or repeatedly engage in high-risk behavior, because they would essentially have to be on the drug regimen fulltime. Because people seeking treatment may not know their own HIV status, it is recommended that all who are candidates for nPEP be tested for HIV, preferably with an FDA-approved rapid test kit that provides results within an hour prior to initiating therapy.