Treatment of HIV Infection and AIDS

Robert Yarchoan Samuel Broder

Since the identification of the acquired immunodeficiency syndrome (AIDS) as a new entity in 1981, dramatic changes have occurred in therapy for this disease and its related disorders. In 1984, therapy was either entirely supportive or directed at a bewildering array of infectious and oncologic complications. The identification of human immunodeficiency virus (HIV) as the causative agent of AIDS and the elucidation of its life cycle have enabled the development of specific antiretroviral therapy, and such therapy is now recognized as being the cornerstone of treatment for HIV infection and AIDS. Substantial advances have been made over the past several years. At least 13 antiretroviral drugs are now approved belonging to three major classes: nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors (PIs) (Table 418-1).

It has also been shown that these drugs are particularly effective if used in combination regimens that effectively suppress HIV replication.

The physician treating HIV-infected patients thus has a wide array of active regimens to chose from; and although none is curative, the use of these drug regimens has substantially improved the outlook for HIV-infected patients. At the same time, however, these recent developments have increased the complexity of therapy, and it has been shown that the experience of physicians in treating AIDS has a direct bearing on their patients' survival. It is thus essential that physicians setting out to treat HIV-infected individuals have a good understanding of the issues involved.

In this section, the principles underlying the therapy for HIV infection, the drugs used, the approaches now being used, and the limitations of these approaches are discussed. It should be noted, however, that this is an extremely rapidly moving field and that physicians treating HIV-infected patients should make a particular effort to stay informed of new developments.