The viral DNA migrates to the nucleus of the cell where it is spliced into the host
DNA with the help of the integrase enzyme. Once combined, the HIV DNA is
called the provirus and is duplicated each time the cell divides. The protease
enzyme assists in the assembly of a new form of the viral particles.
Patients with HIV undergo Highly Active Antiretroviral Therapy (HAART)
that uses antiretroviral medications designed to slow or inhibit reverse tran-
scriptase and protease enzymes. The Food and Drug Administration approved
the first reverse transcriptase (RT) inhibitor in 1987. The first protease inhibitor
was approved in 1995. No integrase inhibitors have been approved as yet.
HAART decreases the viral load to undetectable levels, thereby preserving
and increasing the number of CD4+ T cells. HAART also prevents resistance to
disease and keeps the patient in good clinical condition and prevents secondary
infections and cancer.
The patient must adhere to HAART therapy as the virus becomes resistant
and the antiretroviral agents lose their therapeutic effect. In addition, patients
must avoid opportunistic infections and aggressive prophylaxis and treatment of
opportunistic infections that do occur is recommended. Nutritional therapy,
complementary therapy, and supportive care are also necessary.
Antiretroviral therapy is offered to patients who have less than 500 CD4+ T
cells mm^3 or whose plasma HIV RNA levels are greater than 10,000 copies/mL
(B-DNA assay) or 20,000 copies/mL (R-PCR assay). Therapy should be consid-
ered for all HIV-infected patients who have detectable HIV RNA in plasma.
There are risks and benefits to early initiation of antiretroviral therapy in the
asymptomatic HIV-infected patient.Potential Benefits- Control of viral replication and mutation
- Reduction of viral burden
- Prevention of progressive immunodeficiency
- Maintenance of the normal immune system
- Reconstruction of the normal immune system
- Delay in the progression to acquired immunodeficiency syndrome and
prolongation of life - Decreased risk of selection of resistant virus
- Decreased risk of drug toxicity
- Possible decreased risk of viral transmission
Potential Risks- Reduction in quality of life from adverse drug effects
- Inconvenience of taking the regimen of medications
(^318) CHAPTER 17 Immunologic Agents