Thursday, October 8, 2015

Hospital test worth Rs 200 can rule out heart attacks|||-Dr Prafulla Kerkar, said that the British findings need to be validated using large multi-centric studies.

Hospital test worth Rs 200 can rule out heart attacks

Hospital test worth Rs 200 can rule out heart attacks
The test measures the level of troponin proteins in the blood. These proteins are released when the heart muscle has been damaged, like during a heart attack. (Image for representation)
MUMBAI: Ruling out a heart attack or distinguishing it from acidity-related chest discomfort got a bit easier.

A British study, being published in the medical journal Lancet on Thursday morning, shows that a high sensitivity blood marker test done as soon as the patient gets into a hospital emergency room can provide the answer. "Heart attacks can be ruled out in two-thirds of people attending the emergency department,'' said the Lancet report about the high sensitivity troponin I marker test.

READ ALSO:
7 tests to diagnose heart diseases




In Indian hospital emergency rooms, this test has been available for about a year at prices ranging from Rs 200 to Rs 500, depending on the type of hospital and the kind of bed. "We have been doing this test twice —when the patient is brought in with chest pain and after three hours. The graph helps us establish with 99% accuracy whether or not the patient is suffering from or has suffered a heart attack,'' said Dr Barnali Das of Kokilaben Hospital.

But British scientists, led by Dr Anoop Shah from the University of Edinburgh, say that the test needs to be done only once—immediately on admission—to firmly answer the heart-attack-or-not question.



"Until now there was no quick way to rule out a heart attack within the emergency department," said Dr Shah in a press release put out by Lancet. "We have identified a cardiac troponin concentration (less than 5 nanogram per decilitre) below which patients are at very low risk of heart attack either during the admission or in the ensuing 30 days.'' The study's findings could dramatically reduce unnecessary hospital admissions and "provide substantial cost savings for healthcare providers".

"Emergency rooms are busy places. If we can reduce the number of hours a patient spends in the ER, it will be helpful,'' said Dr Das, who has just completed a study of 200 patients on the high sensitive troponin I test.

The test measures the level of troponin proteins in the blood. These proteins are released when the heart muscle has been damaged, like during a heart attack. "The more damage there is to the heart, the greater the amount of troponin there will be in the blood. Even a slight increase in the troponin level will often mean there has been some damage to the heart. Very high levels of troponin are a sign that a heart attack has occurred,'' said the Lancet report.

Dr Prafulla Kerkar, who heads the cardiology department of civic-run KEM Hospital in Parel, said that the British findings need to be validated using large multi-centric studies.

Wednesday, October 7, 2015

Tiny DNA 'machine' could cut HIV diagnosis cost

Tiny DNA 'machine' could cut HIV diagnosis cost
Tiny DNA 'machine' could cut HIV diagnosis cost (Getty Images)
Researchers have designed and synthesised a nanometer-scale DNA "machine" that can make the process of detecting the antibodies that can help with the diagnosis of infectious and auto-immune diseases such as rheumatoid arthritis and HIV much cheaper.

Their new approach promises to support the development of rapid, low-cost antibody detection at the point-of-care, thereby eliminating the treatment initiation delays.

"One of the advantages of our approach is that it is highly versatile," said senior co-author of the study Francesco Ricci from University of Rome Tor Vergata in Italy.

"This DNA nanomachine can be in fact custom-modified so that it can detect a huge range of antibodies, this makes our platform adaptable for many different diseases," Ricci said.

The binding of the antibody to the DNA machine causes a structural change (or switch), which generates a light signal.

The sensor does not need to be chemically activated and is rapid - acting within five minutes - enabling the targeted antibodies to be easily detected, even in complex clinical samples such as blood serum.

"Our modular platform provides significant advantages over existing methods for the detection of antibodies," professor Alexis Vallee-Belisle from University of Montreal in Canada noted.

"It is rapid, does not require reagent chemicals, and may prove to be useful in a range of different applications such as point-of-care diagnostics and bioimaging," Vallee-Belisle said.

"Another nice feature of our this platform is its low-cost," professor Kevin Plaxco of the University of California, Santa Barbara, US, pointed out.

"The materials needed for one assay cost about 15 cents, making our approach very competitive in comparison with other quantitative approaches," Plaxco said.

The findings were detailed in the journal Angewandte Chemie.

Tuesday, October 6, 2015

Treatment Decisions for HIV: Entire Section

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Treatment Decisions for HIV: Entire Section

Treatment Decisions

HIV is a virus that can multiply quickly in your body and damage your immune system. Even though no cure exists for HIV infection or the later stage of HIV disease known as AIDS, there are many different drugs that can greatly slow down the damage done by the HIV virus and allow the immune system to recover. Treatment allows people to live longer and healthier lives, and helps prevent transmission of HIV to sex partners. Most people who take medicine for their HIV infection can now expect to live healthy lives for many years.
Without treatment, HIV can make your immune system very weak. Your immune system is what allows your body to fight off infections and cancers. When it is weakened, you will have a hard time staying well.
Deciding to take anti-HIV drugs is a very personal choice, and one that cannot be made alone. It is important to talk with your VA health care provider, who can help you make a wise, appropriate decision.
This lesson can help you decide:
  • Whether to start therapy
  • What drugs to take
  • Whether to continue therapy

Deciding whether to start therapy

HIV drugs are very important in keeping people healthy over the years. For people who are sick from HIV, they can be lifesavers. Effective treatment stops or slows the progression of HIV. In recent years, scientists have learned a lot about the benefits of treatment even for persons whose immune systems appear to be functioning relatively well. Thus, in general, HIV drugs are recommended for ALL people with HIV infection, whether they are sick or well.
For people whose immune systems are weaker, starting treatment is urgent. Even for people whose immune systems are still relatively strong, it is important to consider starting HIV medications. More and more studies show that starting treatment early may be the most effective way to prevent long-term consequences of HIV. And, treatment dramatically reduces the risk of passing HIV infection to sex partners (or injection drug use partners); for pregnant women, it greatly reduces the chance of infecting the fetus.
However, there are reasons some people may not start taking HIV treatment right away. For one thing, the medications must be taken correctly every day or the virus may become resistant to drugs. That means the virus may change in a way that makes the drug no longer work. The most common cause of drug resistance is not taking medications correctly every day. So, people need to be ready to commit to taking the medications every day (we call this "adherence"). Also, HIV medicines, like any other drugs may cause side effects in some people. But for most people the newer HIV drugs are quite tolerable. In addition, the current drug regimens usually are simple and compact (between 1 and 3 pills per day).
So, as we said earlier, treatment of HIV is recommended for all people with the infection. In terms of exactly how quickly to start the drugs, these are some of the main things to consider:
  • Symptoms of HIV disease (also called your clinical status, or how well you feel)
  • Your CD4 count and viral load
  • Whether you have certain other medical conditions that may be helped by HIV treatment
  • Whether you can and will stick to your treatment plan (adherence)
  • Whether you have sex partner(s) who are HIV-negative and may be at risk of becoming infected through you.
We will look at each of these more closely.

Symptoms (clinical status)

"Clinical status" refers to how well you are doing in general, including how well you feel. Your doctor will look at whether you have symptoms of HIV disease. These symptoms are signs that HIV is weakening your immune system, and include things such as weight loss, chronic fevers, and opportunistic infections. (Opportunistic infections--also called OIs--are infections that happen in someone with a damaged immune system.)

CD4 count and viral load

Even though you may not feel it, when you have HIV, the virus and your immune system are at war with each other. The virus is trying to multiply as fast as it can, and your body is trying to stop it. Two tests, the CD4 count and the HIV viral load, help you and your health care provider know how strong your immune system is, and know whether it is keeping HIV under control.
CD4 cells play a major role in helping your immune system work properly. HIV causes disease by killing off CD4 cells. It does this by infecting the cells and turning them into virus factories, a process that kills the cell. A test called the CD4 count can tell you how many CD4 cells you have. The higher the number, the better. The test, however, doesn't tell you if those CD4 cells are working properly.
The viral load test indicates how much of the HIV virus is present in your blood, and how fast it is multiplying. The higher the viral load, the faster HIV is infecting and killing your CD4 cells. The lower the viral load, the better.
Your health care provider will look at these two things carefully. People whose CD4 count is low, and people whose viral load is high, are more likely to get sick sooner than people with a high CD4 count and low viral load.
CD4 count and viral load tests usually are done every 3 months. Results can help you and your health care provider decide how urgent it is to start anti-HIV drugs. The U.S. Department of Health and Human Services makes general recommendations regarding when HIV-positive people should start taking HIV drugs. These are not firm rules, just guidelines. These guidelines recommend HIV drugs for everyone, no matter how high or low their CD4 count is. However, they say that HIV treatment is especially important if your CD4 count is lower, or if you have symptoms. The lower the CD4, the more important it is to start treatment quickly.

Whether you have certain other medical conditions that may be helped by HIV treatment

Starting HIV drugs may be particularly important for people with certain other medical conditions. For example, your doctor will recommend HIV therapy if you are pregnant or plan to become pregnant, if you have kidney disease that is caused by HIV, or if you have hepatitis B or hepatitis C.

Whether you can and will stick to your treatment plan (adherence)

It is very important to start drug therapy only when you are ready to make a strong commitment to sticking to a drug therapy plan (or regimen). With an HIV drug regimen, you will need to take pills every day!
In order for the drugs to work and keep working, you must carefully follow the directions for taking them. If you're not sure you can do this, you might need help in finding ways to stick to the plan.
If you are wondering whether you should start taking drugs for HIV, you should sit down and talk with your provider as soon as possible. Depending on your specific needs, your provider can come up with a personal treatment plan for you.

Risk of transmitting HIV to sex partners

HIV therapy has been shown to reduce the risk of transmitting HIV to uninfected sex partners. Thus, if you have a sex partner who is HIV negative, you may consider starting HIV treatment both to protect and improve your own health and to prevent transmission to partners.

Deciding what drugs to take

Once you and your provider have decided that you should start taking drugs for HIV, he or she will come up with a personal treatment plan for you. You will find it easier to understand your plan if you learn about the different drugs available and what they do.
Print out these questions to ask your doctor when you start to discuss particular drugs.

What kinds of drugs are available?

Anti-HIV drugs are also called antiretroviral drugs or antiretrovirals (ARVs). They work because they attack the HIV virus directly. The drugs cripple the ability of the virus to make copies of itself.
There are 6 main classes of anti-HIV drugs:
  • Nucleoside Reverse Transcriptase Inhibitors (NRTIs or "nukes")
  • Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs or "non-nukes")
  • Protease Inhibitors (PIs)
  • Integrase Inhibitors
  • Chemokine Coreceptor Antagonists (CCR5 Antagonists)
  • Fusion or Entry Inhibitors
Each group attacks HIV in its own way and helps your body fight the infection. Most of these drugs come as tablets or capsules. Several of these drugs may be combined into one tablet to make it easier to take your medications. These are known as fixed-dose combinations.
The following is a short description of how each group of drugs works and the names of the individual drugs.
Note: The names of drugs are long and sometimes hard to pronounce. Don't worry! You can always come back and read this again, and you can talk to your VA doctor about questions you have.

Nucleoside Reverse Transcriptase Inhibitors (NRTIs or nukes)

The first group of antiretroviral drugs is the nucleoside reverse transcriptase (pronounced "trans-krip-tase") inhibitors (NRTIs).
NRTIs were the first type of drug available to treat HIV. They remain effective, powerful, and important medications for treating HIV when combined with other drugs. They are better known as nucleoside analogues or "nukes."
When the HIV virus enters a healthy cell, it attempts to make copies of itself. It does this by using an enzyme called reverse transcriptase. The NRTIs work because they block that enzyme. Without reverse transcriptase, HIV can't make new virus copies of itself.
The following is a list of the drugs in the NRTI class:
  • Emtriva® (emtricitabine)
  • Epivir® (3TC, lamivudine)
  • Retrovir® (AZT, zidovudine)
  • Videx-EC® (ddI, didanosine)
  • Viread® (tenofovir)
  • Zerit® (d4T, stavudine)
  • Ziagen® (abacavir)
Several of the NRTI drugs may be combined into one tablet to make it easier to take your medications. These drugs are known as fixed-dose combinations:
  • Combivir® (Retrovir + Epivir)
  • Epzicom® (Epivir + Ziagen)
  • Trizivir® (Retrovir + Epivir + Ziagen)
  • Truvada® (Viread + Emtriva)

Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs or non-nukes)

The second type of antiretroviral drugs is the non-nucleoside reverse transcriptase inhibitors (NNRTIs). These drugs are sometimes called non-nucleosides or "non-nukes."
These drugs also prevent HIV from using reverse transcriptase to make copies of itself, but in a different way.
These NNRTIs are available:
  • Edurant® (rilpivirine)
  • Intelence® (etravirine)
  • Rescriptor® (delavirdine)
  • Sustiva® (efavirenz)
  • Viramune® (nevirapine)

Protease Inhibitors (PIs)

The third group of drugs is the protease (pronounced "pro-tee-ase") inhibitors (PIs).
Once HIV has infected a cell and made copies of itself, it uses an enzyme called protease to process itself correctly so it can be released from the cell to infect other cells. These medicines work by blocking protease.
Nine PIs are available:
  • Aptivus® (tipranavir)
  • Crixivan® (indinavir)
  • Invirase® (saquinavir)
  • Kaletra® (lopinavir + ritonavir combined in one tablet)
  • Lexiva® (fosamprenavir)
  • Norvir® (ritonavir)
  • Prezista®(darunavir)
  • Reyataz® (atazanavir)
  • Viracept® (nelfinavir)
Many PIs are recommended or approved for use only with another drug that "boosts" their effect. One of these is low-dose Norvir®, the other is a non-HIV drug called Tybost® (cobicistat).
Several combination tablets that include a "booster" plus a PI are:
  • Evotaz® (Reyataz® + Tybost®)
  • Prezcobix® (Prezista® + Tybost®)
  • Kaletra® (lopinavir + Norvir®)

Integrase Inhibitors

This class of anti-HIV drugs works by blocking an enzyme (HIV integrase) that the virus needs in order to splice copies of itself into human DNA.
  • Isentress® (raltegravir)
  • Tivicay® (dolutegravir)
  • Vitekta® (elvitegravir)
    (Note: Vitekta must be "boosted" with a pharmacokinetic enhancer, either Tybost® or Norvir®.)

Chemokine Coreceptor Antagonists (CCR5)

To infect a cell, HIV must bind to two types of molecules on the cell's surface. One of these is called a chemokine coreceptor. Drugs known as chemokine coreceptor antagonists block the virus from binding to the coreceptor.
  • Selzentry® (maraviroc)

Fusion or Entry Inhibitors

The fusion or entry inhibitors work by stopping the HIV virus from getting into your body's healthy cells in the first place.
Only one fusion inhibitor is available at present, and it needs to be injected:
  • Fuzeon® (enfuvirtide, T-20)

Multi-class drug combinations

At present there are four options that combine drugs from two different groups into a complete HIV drug regimen. A patient prescribed one of these combinations takes only one tablet, once a day. Despite the convenience, these combination tablets are not for everyone--each has specific possible side effects or dosing requirements that should be considered. You and your doctor can decide whether these drug combinations are right for you.
  • Atripla® (Sustiva + Emtriva + Viread)
  • Complera® (Edurant + Emtriva + Viread)
  • Stribild® (Vitekta + Tybost + Emtriva + Viread)
  • Triumeq® (Tivicay + Epzicom + Ziagin)

Which drugs should you take?

Now that you have learned a little about the types of drugs that are available and how they work, you may be wondering how your VA health care provider will know which medicines you should take.
Anti-HIV drugs are used in combination with one another in order to get the best results. The goal is to get the viral load as low as possible (to levels that are undetectable by standard laboratory tests) for as long as possible.
Anti-HIV medicines do different things to the virus--they attack it in different ways--so using the different drugs in combination works better than using just one by itself. Combinations usually include three antiretroviral drugs. Except in very special circumstances, anti-HIV drugs should never be used one or two at a time. Using only one or two drugs at a time can fail to control the viral load and let the virus adapt (or become resistant) to the drug. Once the virus adapts to a drug, the drug won't work as well against the virus, and maybe it won't work at all.
There is no one combination of HIV medications that works best for everyone. Each combination has its pluses and minuses.
When drugs are used together, the therapy is called combination therapy [or antiretroviral therapy (ART)].

Combination therapy

So, how will your health provider know which combination to choose? You and your VA provider can consider the options, keeping certain things in mind, such as possible side effects, the number of pills you'll need to take, and how the drugs interact with each other and with other medications you may take.
Print out these questions to ask your doctor if you are considering combination therapy.

Why must you stay on the treatment plan?

"Adherence" refers to how well you stay on your treatment plan--whether you take your medications exactly as your VA health care provider tells you.
If you follow your provider's instructions about how to take your medicine, the anti-HIV drugs will work well to lower the amount of virus in your blood. Taking your drugs correctly increases your likelihood of success.
But, if you miss doses, or don't follow a regular schedule, the level of the drug in your body goes up and down. When drug levels are low, the virus then has the opportunity to make copies of itself more rapidly. That increases your viral load.
Following your treatment schedule also helps to prevent drug resistance. If you miss a dose, the virus may make new and different types of itself that the drug can no longer combat.
It's challenging for some patients to stick to their HIV drug treatment plan. Most plans involve taking several pills every day, and some of the drugs have unpleasant side effects.
Pop question: True or false. Missing doses and not following a regular schedule can lessen the effect of your HIV medication.
Answer: TRUE. Missing doses and not following a regular schedule can lessen the effect of your HIV medication. It is very important that you stay on your treatment plan and follow your doctor's instructions for taking your medicine.

Questions to ask about each drug

One of the most important things you can do to make sure you take your medicine correctly is to talk with your doctor about your lifestyle, such as your sleeping and eating schedule. If your doctor prescribes a drug, be sure and ask the following questions (and make sure you understand the answers):
  • What dose of the drug should be taken? How many pills does this mean?
  • How often should the drug be taken?
  • Does it matter if it is taken with food, or on an empty stomach?
  • Does the drug have to be kept in a refrigerator?
  • What are the side effects of the drug?
  • What should be done to deal with the side effects?
  • How severe do side effects have to be before a doctor is called?
During every visit to your doctor, you should talk about whether you are having trouble staying on your treatment plan. Studies show that patients who take their medicine in the right way get the best results: their viral loads stay down, their CD4 counts stay up, and they feel healthier.

Tips for staying on your treatment plan

Before you start a treatment plan, you should:
  • Get your health care provider to write everything down for you: names of the drugs, what they look like, how to take them (for example, with food or not, with other medications or not), and how often to take them. This way, you'll have something to look at in case you forget what you're supposed to do.
  • With your provider's help, develop a plan that works for you.
Quick Tips: Adherence
  • Get a pillbox and fill it at the beginning of each week.
  • Take your medicine at the same time each day. (Use a watch with an alarm or get a beeper.)
  • Get a medication "diary" or notebook. In it, you can write the names of your drugs, and then check off each dose as you take it. (See the "Resources" section for a sample diary.)
  • Plan ahead for changes in your normal routine (for example, if you will be out all day, or if you're going on vacation).
  • Make sure you always have enough medicine! Call your VA provider or pharmacist if you are running low.
It is important that you tell your provider right away about any problems you are having with your treatment plan. Keeping a medication diary can help you remember any problems you have.

Deciding whether to continue HIV therapy

Now that you've gone over some of the things you should think about before starting HIV drug therapy, let's look at some of the things you will need to know once you are taking the medicine. These involve drug interactions and drug side effects.

What are drug interactions?

Your anti-HIV medications can be affected by other medicines, including other prescription drugs you are taking and drugs you buy over the counter at a pharmacy. Even herbal therapies, nutritional supplements, and some things found in common foods can affect your HIV medicines.
When one drug affects how another drug behaves, this is called a drug-drug interaction. For example, when taken together, some drugs become less effective or cause side effects.
When something in food affects how a drug behaves, it is called a drug-food interaction. For example, grapefruit juice, taken at the same time as certain drugs, can boost the amount of these drugs in your bloodstream to an undesirable level. Everyone taking anti-HIV drugs needs to be very careful about these interactions. Luckily, many of these interactions are well known to your provider, and can be managed.
Your VA health care provider can give you a list of drugs and foods to avoid, depending on what kind of medicine you are taking. Ask for this information for each drug that you are taking.
Also, be sure that you tell your doctor about every single medication, drug, supplement, and herb you are taking--whether you got them by prescription or not.

What are side effects?

Medicines can cause changes (or effects) in the body. Some effects, like making you feel better, are the ones that you want and expect to happen. Other effects are ones that you don't want or don't expect. The effects that you don't want or expect are called side effects.
Almost all medicines may have side effects in some people. Some people take aspirin for a headache, but it gives them an upset stomach. The upset stomach is a side effect of the aspirin. Not all side effects are unpleasant, though. Even the side effects that make you feel sick aren't always bad. Some side effects mean that your medicine has started to work.
Your provider will try to prescribe anti-HIV medicines that fight the HIV virus in your body without causing unpleasant side effects.

How do you deal with side effects?

Some side effects can be hard to deal with. One way to cope with them is to know what to watch out for and have a plan to deal with problems that come up.
That's why you need to talk to your VA provider about the risk of side effects from different drugs, before you start therapy.
At the beginning of any treatment, you go through a period of adjustment--a time when your body has to get used to the new drugs you're taking. Sometimes you'll have headaches, an upset stomach, fatigue, or aches and pains. These side effects may go away after a few weeks or so.
If you notice any unusual or severe reactions after starting or changing a drug, report the side effects to your provider immediately.
More information is available in the Side Effects Guide.

How do you know if the drugs are working?

After you've started taking medicine for your HIV, your health care provider will look at how much HIV virus is in your bloodstream (your viral load) to see how well the drug therapy is working. If the medicines are working, your viral load goes down. You will have less of the virus in your bloodstream. A very important goal of treatment is to reduce the viral load to "undetectable" levels, and to keep it there. "Undetectable" means the viral load is too low to measure using standard laboratory tests.
Other ways you and your provider can see if the drugs are working are:
  • Your CD4 count. This number should stay the same or go up if your drugs are working.
  • Your health checkups. Your treatment should help keep you healthy and help you fight off infections and diseases.

Should you ever take a 'holiday' from the drugs?

In general, taking a "drug holiday" from your anti-HIV medicine for reasons other than a severe reaction to medications may be harmful to your health. Having said that, your doctor may suggest that you temporarily stop your antiretroviral drugs for certain specific reasons. Be sure to talk with your VA health care provider about this issue if you have questions about it. How you stop taking your anti-HIV drugs safely can be a complicated process.
Remember, just skipping doses without your doctor's instructions is dangerous, and you should never change your treatment plan without talking with your doctor.

Should you ever switch the drugs you're taking?

You should never change the drug plan you're on without talking with your health care provider. This is a very important decision and one that must be made with your VA health care provider.
If you are following your drug therapy plan correctly (taking the right medicines in the right amount at the right time), but the treatment is not working well enough, your provider may consider switching your medicines.
Your provider also may want to change your medicine if you have side effects that are bothering you or if your lab tests show signs of ill effects of the HIV drugs (this is called drug toxicity).
Before changing medicines, you and your VA provider should talk about:
  • All the anti-HIV drugs you have taken before and the ones you haven't taken
  • Any drug resistance your HIV virus may have
  • The strength of the new drugs that your provider recommends
  • Side effects that may go along with the new medicines
  • How well you will be able to follow the new drug treatment plan
Always be sure to talk with your provider about any changes in your drug treatment.

What if the viral load is undetectable?

If your HIV viral load becomes undetectable (doesn't show up on tests), can you stop treatment?
Having an undetectable viral load tells us that the anti-HIV medications are working. An undetectable viral load doesn't mean the HIV virus has been eradicated from your body, though. Even though the virus is undetectable in the blood, it is still hidden in other parts of your body, such as the brain, reproductive organs, and lymph nodes. If you stop treatment, the virus will start reproducing again and your viral load will increase, putting your health at risk.

What if your treatment isn't working?

Sometimes the HIV medications don't work. This may occur because the drugs don't completely stop the virus from reproducing. As the virus makes copies of itself, changes (or mutations) sometimes occur. These changes may result in a new strain of the virus that is resistant to the action of the drugs. Sometimes, your provider can do a blood test (called a resistance test, genotype, or phenotype) that can help show which drugs the virus has become resistant to. This can help identify other drugs that might still work against your virus.
Even if a virus is resistant to most or all available drugs (this is very rare), some people can still stay healthy by continuing to take a combination of drugs. Therefore, you should discuss the situation with your doctor rather than just stop taking your medications.
If a person has a strain of HIV that is resistant to most or all available drugs, that person may want to consider joining a clinical trial that is testing new drugs that have not yet been approved by the U.S. Food and Drug Administration (FDA). See Clinical Trials.

Resources

Tips and Tools

Questions to Ask Your Doctor

Web Resources



HIV test and testing prerequsites

Dec 28, 2010
Sir, I just have 2 concerns that I am putting forward to you: 1.Is there any restriction / preparation for HIV testing like empty stomach or full stomach or 2 hours after taking food or water or is it that any body can go /walk any time and do the testing ? 2.I have tested HIV 2 times on 2 different methods and they are as follows :
The first report is: Rapid Screening test for HIV 1 and 2 antibodies HIV 1 NON-Reactive. HIV 2 NON-Reactive Method Immunochromatography. Kit used HIV TRI DOT LotNo. HTD 091024
Note : All reactive samples should be cross checked with a different ELISA system and /or Western B lot test for information. Remarks:
The second report is : Detection of HIV p24 antigen and antibodies to HIV type 1 and/or HIV type 2- Result: Non-Reactive (0.19) Chemilluminescent Microparticle immunoassay (CMIA)(Architect, Abbott)
(This is a screening test and there may be false positive and false negative results in a small percentage of cases for various reasons.) Interpretation: - <1.0: Non-Reactive >/=: Reactive Is the above two method of tests(Rapid test and CMIA) is sufficient or should it be tested in a ELISA or any other method ?

Response from Dr. McGowan

Thank for your question.
No there is no dietary restriction on when an HIV test can be done. the test measures antibodies against the virus that develop over weeks. The P24 test is a direct measure of part of the virus circulating in the blood, likewise it's detection would not be affected by eating.
Since both screeing are negative this should be very reassuring.


Hiv Testing Preparation

Here's a taste of what TheBody.com has to offer on this topic:
Ask the Experts

Preparation for HIV TestThe Body: Rick Sowadsky M.S.P.H., C.D.S, Answers to Safe Sex Questions

Rick, Is it advisable to avoid eating for a certain number of hours before taking an HIV antibody test? Usually, doctors will tell patients to take a conventional set of blood tests on an empty stomach; I was wondering if the same caution correctly...
Rick Sowadsky, M.P.H.

Response from Rick Sowadsky, M.P.H.

Nevada State Health Division AIDS Program
...test) will not affect the test results. Inaddition, taking drugs like sleeping pills will also not affect this test. So if you tested negative, that indicates that no antibodies were found. Aslong as it was more than 6 months after your last... Read more »

HIV test and testing prerequsites

Sir, I just have 2 concerns that I am putting forward to you:1.Is there any restriction /... Read more »

Starting, Monitoring & Switching HIV Treatment

An HIV-positive South African woman holding her ARV drugs
An HIV-positive South African woman holding her ARV drugs
The success of antiretroviral treatment for someone living with HIV depends on:
  • Starting treatment at the right time
  • Choosing the right combination of antiretroviral drugs
  • Monitoring the effectiveness of the treatment.

Starting HIV treatment

In order to decide whether or not a person living with HIV should start treatment, clinical tests will determine the stage of HIV infection and their readiness for antiretroviral drug (ARV) treatment.
The average person is recommended to start treatment when their CD4 count drops below 500 cells/mm3. This is in line with the most recent World Health Organisation (WHO) Treatment Guidelines which increased the eligibility from under 350 to under 500 cells/mm3. 1
People who have a CD4 cell count higher than 350 cells/mm3 are typically healthy and do not show any symptoms. Health professionals are concerned that people in this situation will feel complacent about adhering to taking treatment for a virus that is not yet making them ill.
However, many people report the desire to stay healthy, and to reduce the chance of HIV transmission to others as the main reasons why they are keen to start antiretroviral treatment early. A rural HIV clinic in Uganda found that between 95 and 98 percent of their patients with a CD4 cell count above 350 cells/mm3 achieved excellent adherence and viral suppression within 48 months. 2
Starting treatment early significantly reduces the likelihood of onwards HIV transmission - known as ' treatment as prevention'. It also delays the onset of AIDS-related illnesses, and morbidity and mortality in general. These findings were a result of the HPTN 052 study (completed in 2011), which showed that early initiation of treatment has both health and prevention benefits. 3
The WHO 2013 guidelines also have recommendations for if there are complications. They say ARV treatment should be initiated immediately regardless of CD4 count for patients who are: pregnant or breastfeeding, have active tuberculosis (TB), have severe and chronic HBV liver disease, are HIV-positive in a serodiscordant relationship, or a child under 5 years of age. 4
The WHO guidelines have also been summarised and adapted to resource-rich areas. 5

The CD4 test

Usually, the CD4 test is used to determine when a person should start HIV treatment.
HIV attacks a type of immune system cell called the T-helper cell. The T-helper cell plays an essential part in the immune system by helping to co-ordinate all the other cells to fight illnesses. HIV damages and destroys T-helper cells. A major reduction in the number of T-helper cells can have a serious effect on the immune system.
CD4 testing at Saint Francis hospital in Katete, Zambia
CD4 testing at Saint Francis hospital in Katete, Zambia
A CD4 test measures the number of T-helper cells (in a cubic millimetre of blood) which is known as a CD4 count. Someone who is not infected with HIV normally has between 500 and 1200 cells/mm3. In a person infected with HIV, the CD4 count often declines over a number of years.
HIV treatment is now recommended when the CD4 test shows fewer than 500 cells/mm3, as stated in the World Health Organization (WHO) 2013 guidelines. 6 This will vastly increase the number of people eligible for treatment by 9.2 million, forming a challenge for resource-limited countries. 7 As of 2011, most but not all resource-limited countries had been administering ART to patients with a CD4 count of 350 cells/mm3 or less. However some are only able to start treatment at less than 200 cells/mm3, which was what the WHO's 2006 guidelines recommended. (See Universal access to AIDS treatment for more information).
Some countries may have treatment guidelines which differ from WHO recommendations. For example, although USA treatment guidelines state that treatment should be initiated for all patients with a CD4 count <350 cells/mm3 they had also been recommending treatment for patients with a CD4 count between 350 and 500 cells/mm3 before WHO did.

WHO clinical staging

However the resources needed to measure the CD4 count are not available everywhere, in which case, a recommendation is made based on the person’s clinical stage. This describes the different stages of HIV disease based on clinical symptoms. WHO recommend not starting treatment until the advanced stages of HIV infection because it is an important decision with long-term consequences. The decision also depends on the person; children and pregnant women have different guidelines. See our Treatment for Children page, and our HIV and Pregnancy page.
Where a patient is showing signs of stage 1 and 2 they should not start treatment. However, if they are showing signs of WHO clinical stages 3 or 4 they should start treatment. Clinical stages 3 and 4 are identified by the emergence of certain opportunistic infections (such as PCP) and cancers, which a healthy immune system would normally fight off.
Read more about the Stages of HIV Infection.

Basic clinical assessment

Before a person starts treatment, a basic clinical assessment should also be carried out. This assessment determines, for example, existing medical conditions (such as hepatitis, TB, pregnancy, injecting drug use and major psychiatric illness), whether or not the individual is currently taking medications (including traditional and herbal HIV medications), their weight measurement, and a patient's readiness for therapy. Treatment should only be started once the person is ready. A lot of commitment is needed, since following a drug regime can be quite demanding and in most circumstances, the treatment will have to be taken every day for life.
Once it is decided that treatment should be started, doctors will give advice about the various HIV drugs and combinations available and which might be most suitable.

Choosing the best combination of antiretroviral drugs

There are a number of issues which need to be considered when choosing a combination of antiretroviral drugs. The first combination of drugs that a person takes is called first-line therapy. In order for HIV treatment to be effective, patients should take a combination of three drugs.
Antiretroviral drugs attack the ability of HIV to infect healthy cells in five different ways and are therefore divided into five different classes. The WHO 2013 guidelines recommend an antiretroviral combination that consists of two drugs from the Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs) class and one drug from the Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) class. 8

Transmitted HIV drug resistance

If possible, a test should be carried out to make sure that a person doesn’t have a strain of HIV that is already resistant to a certain class of drug. If a person’s strain of HIV is resistant to a class of drug, taking that type of drug may be ineffective or at worse, harmful as it may lead to failure of the treatment to work effectively. This type of drug resistance is known as ‘transmitted drug resistance’ because it has been passed from one person to another.
  • Acquired drug resistance
Acquired HIV drug resistance refers to when HIV mutates after it has become established in  the body into a form that can no longer be treated with the current course of antiretroviral drugs. This can be as a result of poor adherence, interruptions in treatment, and the use of ineffective drugs or faulty drug combinations. 9
Around 1 in 10 people living with HIV in Europe and America are infected with a type of HIV that is already resistant to at least one class of antiretroviral drug before treatment is started. 10 It is thought that the number of Europeans infected with a drug-resistant strain of HIV has risen by 35 percent since 2003. 11

Drug interactions

Interactions between certain antiretroviral drugs and other drugs, both pharmaceutical and recreational, can alter the effectiveness of antiretroviral therapy. Interactions may lower the amount of antiretroviral drugs absorbed, allowing low level HIV replication to occur, which may increase the risk of drug resistance and thereby lead to treatment failure.
Drug interactions are often a concern amongst older people living with HIV, as there is a higher chance they will be taking other medications for age-related illnesses.
ARVs may interact with the following types of drugs:
Other antiretrovirals: An ongoing study has found that Invirase (saquinavir) when combined with Norvir (ritonavir) may cause an abnormal heart rhythm by affecting the heart's electrical signals. 12 Symptoms can range from lightheadedness to an abnormal heartbeat with the possibility that more severe side effects will develop such as ventricular fibrillation. 13 This has been found from preliminary data and a review of these findings are ongoing.
Other pharmaceutical drugs: Some other pharmaceutical drugs may cause side effects or decrease the effectiveness of some antiretroviral drugs. For example, it is not recommended that protease inhibitors be taken with drugs such as Cafergot and Migranal, which are used to treat migraine headaches. 14 Women living with HIV taking oral contraceptives and/or hormone replacement therapy need to talk to their doctor about possible drug interactions.
Herbal and complementary treatments: Garlic capsules, for example, stop saquinavir - a protease inhibitor - from working properly. 15
Drugs for treating opportunistic infections: For example the tuberculosis treatment rifabutin should usually not be used with the protease inhibitor saquinavir or the NNRTI delavirdine. 16
Recreational drugs: Minimal research has been carried out on the relationship between recreational drugs (such as ecstasy, cocaine and amphetamines) and antiretroviral drugs, as many recreational drugs are illegal. However, as most recreational drugs and antiretroviral drugs are broken down in the liver, they may interact and result in serious clinical consequences. Laboratory experiments and case studies have found that the interaction between some recreational drugs and some antiretrovirals results in increased toxicity which increases the risk of potentially fatal side effects such as respiratory depression. However, this has not been determined for all recreational and antiretroviral drugs. The safest action is not to mix these drugs with antiretroviral drugs at all.
HIV infected injecting drug users who are taking opioid substitution therapy (such as methadone or bureprenorphine) may be at increased risk of intensified side effects. 17 Another risk is that certain antiretrovirals reduce the concentration of the drug substitution therapy leading to withdrawal symptoms. 18 However, the effects vary considerably depending on the opioid substitution agent and the antiretroviral drugs taken. 19 20
The University of Liverpool maintains an up-to-date chart of drug interactions.

Number of pills

An HIV-positive man sitting at home before taking his antiretroviral drugs
An HIV-positive man sitting at home before taking his antiretroviral drugs
Some combinations - especially those involving a protease inhibitor - require swallowing many pills throughout the day, which some people find hard to do. The size of the pills can also be an issue. WHO now recommends taking an FDC (fixed dose combination), which combines two or more drugs in a single tablet or capsule. This eases the treatment regimen and makes treatment adherence more likely.

Food restrictions

There are a few drugs, particularly protease inhibitors, which have to be taken with food to improve absorption rates. If taken on an empty stomach, some drugs can be extremely painful to take. In areas where there is no regular access to food therefore, taking these drugs may be unfeasible. However, some other drugs have to be taken on an empty stomach.

Storage requirements

Storage can be an issue as some HIV drugs have to be kept below a certain temperature to last long term. The older version of ritonavir, for example, must be refrigerated.

Monitoring HIV treatment

Once a person starts HIV treatment, it is essential that they adhere to their treatment. The patient will need to be monitored by a doctor to make sure that the treatment is working for them.

Adherence

The term adherence means taking the drugs exactly as described. This includes taking all of the medication at the right time and exactly as the directions state. It also means ensuring that there will be no interactions with other drugs being taken.
Anything below 95 percent adherence has been associated with increases in viral load and drug resistance. Therefore adherence to antiretroviral treatment is extremely important. This means missing no more than one dose a month, if taking antiretroviral drug treatment once a day.

Viral load monitoring

Viral load refers to the amount of HIV in the blood. If the viral load is high, T-helper cells tend to be destroyed more quickly. Therefore, the aim of antiretroviral treatment is to keep the viral load as low as possible. Treatment monitoring is now recommended to be based on viral load, rather than CD4 count, because it provides greater accuracy of test results. 21
The current WHO treatment guidelines recommend that a viral load test is carried out at 6 months after treatment begins, at 12 months, and then every year. If the treatment is working effectively the viral load will drop to an undetectable level – below 50 copies/ml. 22 Ideally this will happen within 24 weeks of starting treatment, but for some it can take 3 to 6 months. On the other hand, some people never reach undetectable in which case alternative regimens can be started if necessary.
Viral load testing is costly and rather complicated, resulting in its limited use in many resource-poor areas. Some solutions to the cost and logistical issues have been put forward:
  • Dried blood spot testing – tests dried samples of blood for any trace of HIV. Dried blood is easier to transport to laboratories than fresh blood samples, which is of importance in rural areas with limited infrastructure.
  • Pooled samples – mixes a blood sample from five different people and tests its viral load; this reduces the need for five different tests which overcomes some of the cost barriers to scaling-up viral load testing. If the combined average viral load is less than 1000 copies/ml then all patients have a low viral load; above 1000 copies/ml means treatment is failing for at least one patient. In this case all will need individual viral load tests to confirm the person/people with a higher viral load.
  • Follow the viral load cascade – follow up viral load tests with appropriate treatment and care, re-tests, and second-line therapy if necessary. This reduces the number of patients lost along the care continuum, and prevents the need for unnecessary re-testing. 23 24
Video of HIV STATUS? Undetectable

Structured Treatment Interruptions (STIs)

A Structured Treatment Interruption (STI) or 'drug holiday' is when someone stops taking antiretroviral treatment temporarily. UK and American treatment guidelines do not recommend taking planned treatment breaks unless under clinical trial settings. Studies have shown that some types of STI have been associated with an increased risk of HIV disease progression. 25 26

Side effects

Side effects occur when the drugs affect the body in ways other than those intended. Most of the antiretroviral drugs have known side effects, but this does not mean that everyone who takes the drugs will experience them. Some people only experience mild side effects and find them easily manageable. But for some the side effects occur so strongly that they have to consider alternative drugs.
Read more about side effects.

Immune Reconstitution Inflammatory Syndrome (IRIS)

IRIS is an illness that occurs for a small number of patients soon after treatment is started. It is caused by an excessive response by the recovering immune system to opportunistic infections that were already present, but were previously dormant and not producing symptoms. Although the symptoms of IRIS are often mild, occasionally they can be life threatening. Generally those who have a severely damaged immune system before starting antiretroviral treatment are more at risk of developing IRIS. 27
IRIS does not indicate that treatment is failing. Usually the best response to IRIS is to continue treatment; the symptoms normally disappear within a few weeks. In cases involving severe opportunistic infections, such as cryptococcal meningitis or tuberculosis, it may be necessary to stop antiretroviral therapy whilst the infection is treated. 28

Switching treatment

First-line ART

First-line ART is the combination of drugs given to a HIV-positive person who has not taken antiretroviral drugs (ARVs) before. The first-line regimen typically consists of two NRTIs and one NNRTI.
Some people on ART will develop a 'failure of therapy'. This means first-line ART is no longer effective as the HIV strain has become resistant to the course of drugs. This can occur as a result of drug resistance, poor adherence, poor drug absorption or a weak drug combination.​ Increased viral load or a HIV-related illness are signs of treatment failure.
Where viral load testing is available, some healthcare professionals recommend switching to second-line ART as soon as the viral load starts to rise, although this could reduce the number of treatment options more quickly. Others recommend monitoring the trend of the viral load before making the decision to change. However, this approach may increase the risk of developing resistance to certain drugs, which can limit future treatment options.
Where viral load testing is not available, the WHO staging system - which determines the stage of HIV infection based on clinical symptoms - may be used instead.
Combined with clinical judgement, the following table can guide the decision of whether to switch treatment.
Treatment failure criteriaWHO Stage IWHO Stage IIWHO Stage IIIWHO Stage IV
Clinical (CD4 testing unavailable)Do not switchDo not switchConsider switchingSwitch
CD4 failure (viral load testing unavailable)
  • Do not switch
  • repeat CD4 test in three months
  • Do not switch
  • repeat CD4 test in three months
Consider switchingSwitch
CD4 failure and viral load failureConsider switchingConsider switchingSwitchSwitch

Second-line ART

Second-line ART uses two NRTIs and one protease inhibitor (PI) drug together. Second-line ART is stronger than first-line ART but requires someone to take more ARVs, adjust their diet, and may have more side-effects. If second-line ART fails, third-line ART may have to be used.

Third-line ART

Third-line ART uses drugs such as etravirine (ETV), darunavir (DRV) and raltegravir (RAL). However, the costs are significantly higher than those for both first and second-line ART, which may reduce access in resource-poor countries.​ 29

Drug resistance

Antiretroviral drugs slow the replication of HIV in the body. However the drugs cannot stop the replication completely, so some HIV is able to survive despite ongoing HIV treatment.
When HIV replicates it often makes slight mistakes, so each new generation of HIV differs slightly from the one before. These tiny differences in the structure of HIV are called mutations. Some of the mutations occur in the parts of HIV that are targeted by antiretroviral drugs. So although there is some HIV that continues to be attacked by the drugs, there are other strains of HIV that are less likely to be affected. This HIV is called drug resistant HIV, and it is able to replicate unaffected by the drugs.
When someone has drug resistant HIV, the amount of HIV in the blood rises and the risk of the person becoming ill increases. Drug resistance is one of the main reasons why antiretroviral treatment fails. If resistance develops, usually the drug regimen needs to be changed.

Cross-resistance

Resistance to some ARVs can limit future treatment options. If HIV is resistant to one drug, it will sometimes be resistant to similar drugs in the same group. This is called cross-resistance and it means that some antiretroviral drugs will not work even if they have not been used before.

Avoiding and detecting resistance

There are certain things that can be done to reduce the risk of developing drug resistant HIV.
  • Ensuring that the drug combination is strong to begin with will lessen the risk of resistance developing. This usually means taking a combination of 3 or 4 drugs.
  • Taking medication exactly as prescribed is a very important part of avoiding resistance. Missing doses or not taking them on time lowers the amount of antiretroviral chemicals in the body, which means the virus is not properly suppressed. The virus is then able to replicate faster, increasing the chance of it becoming resistant.
  • Regular viral load testing is also important as the results can indicate whether a drug resistant strain of HIV is developing. If the drug combination is working, the viral load should be undetectable. An increasing viral load can be a sign of growing drug resistance.

Salvage treatment

Salvage therapy is the term often used to describe the treatment for those who are resistant to drugs in the three original drug classes. In this situation it may be difficult to find a drug regimen that suppresses the viral load to undetectable.
Many people start their salvage therapy with a much higher viral load than when they started previous HIV treatments. This puts more pressure on the new combination to work. Each combination used lessens the chance of maintaining a low viral load because of the possibility of developing resistance to the drugs. The choice of new treatment should always depend on what caused the previous one to fail.
The introduction of two additional classes of drugs since 2003 (fusion or entry inhibitors and integrase inhibitors) has meant that there are more alternative combinations for those who were running out of treatment options.

HIV transmission and antiretroviral drugs

Although antiretroviral drugs suppress HIV they do not eliminate the risk of HIV transmission completely, even when the viral load is undetectable. Antiretroviral treatment cannot make HIV disappear from the blood completely.
Read our treatment as prevention page as to find out more about the effect of antiretroviral treatment on reducing the risk of HIV prevention.
Unprotected sex between two HIV positive people is not a risk-free activity; there are many different strains of HIV and it is possible to become infected with a different strain more than once, which can complicate treatment. Those taking antiretroviral drugs should take as much care to minimise the risk of HIV transmission as they did before starting the treatment.