Management and Counseling for persons with HIV infection

John A. Bartlett

Treatment advances in human immunodeficiency virus (HIV) disease have dramatically changed the management of chronically infected persons. Advances in three areas have contributed to these successes: (1) an improved understanding of the dynamic nature of HIV replication and its implications for treatment, (2) the technology to measure HIV RNA levels with an understanding of their correlation with prognosis in untreated and treated persons, and (3) the availability of an expanding number of antiretroviral agents with increased potency. These advances have resulted in profound virologic suppression in treated patients with an associated improvement in clinical outcomes and survival. However, despite these treatment advances, significant gaps remain in our understanding of the strategies needed to guide treatment initiation, and when to change a failing regimen.

Coincident with these treatment advances, persons with HIV infection in the United States are increasingly impoverished, more likely to abuse drugs, and have less access to health care. The use of complex antiretroviral regimens has created a scheduling challenge for many patients, and the success of therapy is absolutely dependent on patient adherence. Therefore, health care providers must carefully assess the resources and commitment of persons beginning antiretroviral therapy, design a highly potent and convenient regimen for individual patients, optimize adherence through patient preparation and education, and continually reassess the entire process in a patient on treatment. Significant questions remain unanswered regarding the durability of successful antiretroviral therapy, the potential infectivity of persons on treatment, and the optimal management of treatment failure. These uncertainties may make counseling difficult because individual patients may experience emotional extremes in periods of treatment successes and failures.