All people with HIV should start lifelong antiretroviral treatment as soon as they are diagnosed. It is currently the only form of treatment for HIV.
The ultimate aim of HIV treatment programmes is to ensure that people with HIV are virally suppressed.
HIV care supports people to take their HIV medication every day (treatment adherence) and monitors levels of HIV in the body to check that treatment is working.
Testing, treatment and care join together to form the HIV treatment cascade. A treatment cascade is effective when all the separate elements work well and the links between them are strong.
The main aim of HIV treatment programmes is to ensure that people with HIV are virally suppressed. This is when the level of HIV in the body is so low it is undetectable in tests. If someone is virally suppressed they are likely to be in good health. They will also not be able to pass HIV on to others. That’s why expanding access to antiretroviral treatment (ART) is also important for preventing HIV (a strategy called ‘treatment as prevention’).
Effective treatment programmes provide patient-centred care – services that meet the needs and fit into the lives of the people on treatment. HIV care supports people to take their HIV medication every day (treatment adherence) throughout their life. It also monitors people’s viral load to check that treatment is working.
Testing, diagnosis, starting treatment, adherence support, viral monitoring and viral suppression make up the HIV treatment cascade (or care continuum). The treatment cascade is at its most effective when all the separate elements work well and the links between them are strong.
To end the AIDS epidemic by 2030, all countries are aiming for 95% of people diagnosed with HIV to be on treatment by 2025. As of 2020, 87% were. This is equivalent to 73% of all people with HIV on treatment, as not everyone with HIV is aware of their status.
Certain groups, particularly people who are criminalised and discriminated against (for example sex workers or men who have sex with men), struggle to access treatment, despite being more vulnerable to HIV than others. In some regions, men, children and young people also struggle to access treatment.
The World Health Organization (WHO) recommends ‘treat all’ (also known as ‘test and treat’). This means people who are diagnosed with HIV should be offered immediate treatment, regardless of the level of HIV in their body. This should be done on the same day as diagnosis if possible or within seven days.
If a lack of resources makes it impossible to offer test and treat, treatment should be prioritised for people with severe or advanced HIV.
The HIV treatment cascade sets out the steps of care that people with HIV go through from initial diagnosis to achieving viral suppression.
Testing and diagnosis: The first step in the treatment cascade is to ensure that people who have HIV can access testing (including counselling) and get diagnosed.
Linking to treatment: HIV testing services should closely link to treatment services. Ideally, the two things should be offered together. If testing and treatment services are provided separately, people newly diagnosed with HIV might not start treatment or they might delay it.
Immediate treatment: People should be encouraged to start ART immediately, although they should never be forced to do this. Providing immediate treatment is the best way to for people with HIV to become virally suppressed as quickly as possible.
HIV care: adherence support: This means helping people to take their HIV medication every day as prescribed. This should be patient-centred with a focus on understanding and meeting patient needs. The most effective forms of care are often community-based and peer led (see Adherence section below).
HIV care: viral load monitoring: This is important for checking that HIV treatment is working and for identifying when treatment is failing. If viral load testing is not available, CD4 count tests should be used instead. If someone is on treatment but it is not working (i.e. their viral load is increasing), they should be given extra support. They might also need to change to a different type of ART (called second- or third-line treatment). If someone remains on failing treatment for too long, they are at risk of developing drug-resistant HIV (see below).
Viral suppression: This must be maintained by taking treatment as prescribed, with adherence support if needed, and regular viral load monitoring. These should be done within six months of starting treatment, at 12 months, then every 12 months after that if someone is stable on ART.
The WHO recommends people are given once-a-day ART regimens, which combine several drugs in one pill. These are easier to remember to take than multiple pills. They also have fewer side-effects.
Despite this, many people on HIV treatment, struggle with adherence and leave care. There are lots of reasons for this, such as:
HIV stigma
other stigma and discrimination, such as homophobia
concerns about confidentiality
the cost of treatment (in some places)
treatment side effects
difficulties taking lifelong daily medication (also known as pill burden)
lack of food (ART should not be taken on an empty stomach)
the financial and time costs of attending appointments
waiting times in clinics
moving to a different area
legal difficulties (for example, being criminalised or not having the correct migration papers or ID card)
unsupportive or abusive partners and family
other personal priorities.
There are lots of ways to make it easier for people with HIV to stay on treatment. These include:
support from peer counsellors
support using mobile phone messages
reminder devices, such as alarms and treatment apps
cognitive behavioural therapy
behavioural skills training
providing financial support to travel to clinics or free transport
food and nutrition support, including cash transfers, for people on low incomes.
People who have been on treatment for a stable length of time and have suppressed viral loads might need less support but may benefit from easier access to their medication through:
multi-month refills (between three to six months)
making refills available from community pick-up points, not just clinics
treatment clubs, where a group of people with HIV take it in turns to go to a clinic to pick up the group’s treatment refills.
If someone with HIV is on treatment but is not taking their medication consistently, they can develop drug-resistant HIV.
This is when HIV makes changes (mutations) to its genetic make-up meaning that it becomes resistant to certain antiretrovirals, or classes of antiretrovirals. These mutations can make copies of themselves, which increases the level of HIV in the blood (the viral load). When this happens, treatment is failing. If someone’s viral load is high enough, they may also pass drug resistant-HIV on to others.
A class of antiretrovirals called non-nucleoside reverse-transcriptase inhibitors (NNRTIs) are particularly likely to cause drug-resistant HIV. For this reason, the WHO recommends that countries use Dolutegravir (or DTG) as the preferred regimen (first treatment option) for all people with HIV. DTG is faster at suppressing HIV, has a higher genetic barrier to resistance, and fewer side effects.
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