# Treatment methods for HIV and AIDS
The treatment of HIV has changed dramatically over the past decades. Where HIV once quickly led to AIDS and death, it is now a chronic condition for many people that can be well controlled. This tab describes the treatments applied during different stages of HIV infection.
Antiretroviral therapy (ART)
The cornerstone of HIV treatment is antiretroviral therapy: medicines that prevent the virus from multiplying. This therapy is usually given as a combination of at least three different medicines from different classes, because otherwise the virus can quickly develop resistance.
ProveniIncluded in official guidelines, or approved by EMA or FDA
Antiretroviral agents work by attacking different parts of the virus. Some block the enzyme reverse transcriptase (which the virus needs to establish itself in cells), others block integrase (which allows the virus to work in DNA) or protease (needed to make new virus particles). A third type inhibits the virus from entering cells.
When ART works well, the amount of virus in the blood (viral load) drops below the detection limit. This does not mean the virus is gone — it remains in reservoir sites in the body — but it no longer multiplies and the immune system can recover. People with an undetectable viral load can no longer transmit HIV to their sexual partners (the principle 'U=U', undetectable equals untransmittable).
Side effects of ART vary greatly depending on the medicine and the individual. Common side effects include headache, fatigue, nausea and diarrhea, especially at first. Some medicines can cause metabolic changes (such as altered fat storage or effects on blood sugar and blood fats). These side effects usually decrease after a few weeks. A healthcare provider can adjust the combination if side effects are bothersome or not tolerable.
Pre-exposure prophylaxis (PrEP)
ProveniIncluded in official guidelines, or approved by EMA or FDA
PrEP is prevention for people who are HIV-negative but at high risk of infection (for example due to unprotected sex with multiple partners or with an HIV-positive partner whose viral load is not undetectable). PrEP consists of daily intake of antiretroviral medicines, or in some cases an injection given every two months.
PrEP works by preventing the virus from establishing itself in cells. Studies show that PrEP is effective in preventing HIV infection when used regularly. Side effects are usually mild, similar to what can occur at the beginning of ART.
Recent studies also examine the cost-benefit of PrEP in different settings, including online availability through pharmacies in resource-limited countries.
Post-exposure prophylaxis (PEP)
ProveniIncluded in official guidelines, or approved by EMA or FDA
PEP is emergency care after possible exposure to HIV — for example after unsafe sex, a needle stick injury with contaminated material, or an accident in healthcare personnel. PEP consists of antiretroviral medicines that should be started as soon as possible after exposure, ideally within a few hours and certainly within 72 hours.
PEP works by stopping the virus before it can establish itself in the body. Studies show that PEP is effective when given quickly. Treatment usually lasts 28 days. Side effects may occur, but are usually temporary.
Treatment of opportunistic infections
When the immune system is severely weakened (usually when the number of CD4 cells drops below certain numbers), there is a risk of so-called opportunistic infections: infections with pathogens that a healthy immune system normally can control. This occurs especially in advanced AIDS. These infections are treated with medicines targeted at the specific pathogen.
Pneumocystis pneumonia (PCP)
ProveniIncluded in official guidelines, or approved by EMA or FDA
This causative fungus can cause severe pneumonia. Standard treatment is an antibiotic-like substance, often combined with corticosteroids to counteract inflammation. Side effects may include rash, liver irritation and other symptoms.
Tuberculosis in combination with HIV
ProveniIncluded in official guidelines, or approved by EMA or FDA
Tuberculosis (TB) is a common opportunistic infection in people with advanced HIV. TB is treated with a standard combination of anti-TB drugs for several months. In HIV-TB coinfection, careful timing of when to start ART and how it combines with TB drugs must be considered, as these can affect each other.
Recent research shows that bacterial load and inflammatory response in HIV-TB coinfection are associated with mortality outcomes, and that age plays a role.
Cytomegalovirus (CMV) and other viral infections
ProveniIncluded in official guidelines, or approved by EMA or FDA
CMV can cause problems in the eye (retinitis), gastrointestinal tract and nervous system. This is treated with antiviral medicines. Other herpesviruses can also reactivate; these are countered with medicines such as aciclovir or valaciclovir.
Cryptococcus meningitis
ProveniIncluded in official guidelines, or approved by EMA or FDA
This life-threatening meningitis is caused by a fungus. Treatment consists of antifungal medicines, given intravenously and later orally, for several months. This is a serious infection with substantial side effects from the medicines.
Recent research examined postmortem diagnostic methods for TB meningitis in HIV patients in Zambia.
Treatment of HIV-related cancers
Kaposi sarcoma
ProveniIncluded in official guidelines, or approved by EMA or FDA
This is a cancer of blood vessel-forming tissue, strongly associated with the virus HHV-8 (human herpesvirus 8), especially when the immune system is severely weakened. The first stage of treatment is usually starting or optimizing ART to allow the immune system to recover. When this is insufficient, chemotherapy or local treatments (injection into the tumour or radiation) are used.
Recent research describes the broad spectrum of Kaposi sarcoma and HHV-8-related Castleman disease, including new diagnostic and therapeutic approaches.
Lymphomas and cervical cancer
ProveniIncluded in official guidelines, or approved by EMA or FDA
HIV-positive persons have increased risk of non-Hodgkin lymphoma and cervical cancer. These are treated with standard chemotherapy or surgery, similar to non-HIV patients, although possible interactions with ART and immune system status must be taken into account.
Treatment of coinfections
Hepatitis B and C
ProveniIncluded in official guidelines, or approved by EMA or FDA
Many HIV-positive people also have hepatitis B or C. For hepatitis B there is now effective treatment with antiviral agents; for hepatitis C, medicines are available that in most cases lead to complete cure. ART and hepatitis treatment must be well coordinated.
Recent research in India shows that coinfection with hepatitis B or C is fairly common among newly diagnosed HIV patients.
Tuberculosis
See above under opportunistic infections.
Other sexually transmitted infections
ProveniIncluded in official guidelines, or approved by EMA or FDA
HIV-positive persons more often get other sexually transmitted infections (chlamydia, gonorrhoea, syphilis). These are treated with antibiotics according to standard regimens. Screening tests are recommended to detect these infections early.
Immune reconstitution inflammatory syndrome (IRIS)
ProveniIncluded in official guidelines, or approved by EMA or FDA
IRIS can occur when ART is started and the immune system begins to recover. The immune system reacts suddenly strongly to pathogens or antigens that were already present. This can cause symptoms such as fever, swollen lymph nodes and inflammation. IRIS is managed by continuing ART, sometimes supplemented with corticosteroids to moderate inflammatory reactions.
Recent research described Pneumocystis-related IRIS as a self-limiting condition.
Support of the immune system
Vaccination
ProveniIncluded in official guidelines, or approved by EMA or FDA
When the immune system has recovered sufficiently (usually a CD4 count above a certain threshold), vaccination is recommended against infections that pose extra risk for HIV-positive people: influenza, pneumococci, HPV (to limit cervix and other cancer risk), hepatitis A and B (if not immune), and COVID-19.
Recent research examined the immune response to COVID-19 boosters in nursing home residents.
Additional prevention
ProveniIncluded in official guidelines, or approved by EMA or FDA
Prophylaxis (preventive medicines) is given when the CD4 count drops below certain limits, to prevent opportunistic infections. Typical examples are medicines against PCP, toxoplasmosis, TB and MAC (Mycobacterium avium complex). These are stopped when the immune system has recovered sufficiently through ART.
Supportive care
ProveniIncluded in official guidelines, or approved by EMA or FDA
In addition to antiretroviral drugs, treatment includes regular monitoring (blood tests for viral load, CD4 cell count and organ function), management of side effects, guidance on medication adherence, psychological support, and treatment of comorbidities such as heart disease, diabetes and bone disease. Recent research pointed to higher prevalence of atrial fibrillation among adults with HIV in certain regions.
Research into new treatments
Various new approaches are being investigated:
- **Long-acting injectables**: Antiretroviral drugs that need to be administered less frequently (for example once a month or every two months) are under development and some have already been approved.
- **Gene therapy**: Experimental approaches in which the immune system is modified to better fight HIV.
- **Curative strategies**: Research into possible cure focuses on eliminating viral reservoirs or changing the immune system so it can control the virus without medication. This is still highly experimental.
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_This information never replaces a doctor's judgment. Always discuss your situation with your own healthcare provider._