Significant progress has been made in the management of HIV-1 disease since 1987, when the first antiretroviral agent, zidovudine, was released. Four classes of antiretrovirals are currently used for the treatment of HIV-1: nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), and fusion inhibitors (FIs). A combination of two NRTIs with one NNRTI or PI comprises the standard antiretroviral treatment regimen, also known as highly active antiretroviral therapy (HAART). As of the beginning of 2007, 22 agents have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of HIV-1 (Table 97.1). The goal of antiretroviral treatment is to achieve maximal viral suppression and thus preserve the immune function of the patient and delay the clinical progression of HIV-1 disease. Treating HIV-infected patients requires commitment from both the caregiver and the patient, perpetual counseling and support, and judicial use of the available diagnostic and therapeutic tools by the clinician. Measurement of plasma HIV-1 RNA levels (viral load, VL) and CD4+ cell count is routinely used to monitor therapy. With the new ultrasensitive polymerase chain reaction (PCR) methods, reliable detection of 50 viral copies/mL or more can be accomplished. Failure to achieve undetectable levels of plasma HIV-1 RNA may suggest incomplete compliance, drug resistance, or unfavorable pharmacokinetics.

In this chapter the following topics are discussed: treatment initiation, antiretroviral drugs, recommended first-line antiretroviral regimens, and management of HIV infection during pregnancy.