ARV AND ADHERENCE

MICHAEL OKUMU
HAART/ART
• Highly active antiretroviral therapy(HAART) is a treatment regimen
comprising a combination of three or more antiretroviral drugs.
• Also called antiretroviral therapy( ART) or combined antiretroviral
therapy (cART)
GOALS OF ARVs
 Reduce morbidity and mortality
 Improve the quality of life
 Reduce plasma viral RNA load/amount of virus in the body
 Prevent transmission of HIV to others
 Improve immune function
IMPROVING PATIENT EVALUATION,
TREATMENT PREPARATION AND ADHEREANCE
• Providing comprehensive and accurate information prior to ART
initiation.
• Group counselling of newly diagnosed patient using pamplets, audio-
visual aids.
• Task shifting/sharing to train lay providers for counselling, treatment
preparation and literacy.
• Orientation of new patients to the HIV care process and introducing
them to the multidisciplinary team
IMPROVING EVALUATION AND
TREATMENT PREPARATION CONT,
• Efficiently conducting enrolment, clinical evaluation, investigations,
initial patient education and counselling on the same day.
• Increasing the number of healthcare providers in the
multidisiciplinary team with counselling skills through mentoring.
• Implementing family care models and other tailored services( child
and adolescent friendly clinics) to facilitate disclosure and reduce
stigma
CLINICAL EVALUATION FOR PLHIV
• History and physical examination
• Baseline laboratory investigations
BASELINE LABORATRY
INVESTIGATIONS
HIV SPECIFIC
 Confirm and document positive test result
 CD4 cell count
 Viral load
 Serum Cryptococcal antigen(sCrAG) for all adults with CD4 counts<
100 cell/µL
OTHER BASELINE LABORATORY TESTS
• Hemoglobin ( HB) level
• Pregnancy status for all women of reproductive age
• Urinalysis for proteins and glucose
• Cretinine
• RPR(syphillis test)
• Hepatis B surface antigen( HBsAg)
• Hepatitis C antibody test-for injection drug users
• ALT( Liver function tests)
ART TREATMENT PREPARATION
HIV EDUCATION AND COUNSELLING
All patients/caregivers must be provided with enough information to
make informed choice about ART initiation and adherence.
Content of HIV education and adherence counselling include
 HIV-transmission, importance of testing
 Viral load-meaning, how often it is tested, meaning of VL levels
 CD4 cell-how CD4 is affected by HIV
 ART-meaning, benefits. duration of treatment
ART PREPARATION CONT
HIV EDUCATION AND COUNSELLING
 Treatment failure
 ART side effects
 Adherence to treatment
 Other medications-CPT, IPT
 Nutrition-role of nutrition in the immune system
 Follow up-frequency of visits
 ART readiness assessment
ART THERAPY IN
ADULTS/ADOLESCENCE
• Eligibility-All individuals with confirmed HIV infection are eligible for
ART, irrespective of CD4 cell levels, WHO clinical stage, age, pregnancy
or breastfeeding status, co-infection status, risk group or any other
criteria

• Timing-ART should be started in all patients as soon as possible-

preferably within 2 weeks of confirmation of HIV status
SPECIAL CONSIDERATIONS IN TIMING
OF ART INITIATION
• Pregnancy and breastfeeding-consider initiation on the same day.
• Infants less than 2 months-consider initiation on same day as
enrollment.
• Patients with strong motivation to start ART immediately-Consider as
soon as they meet the readiness criteria
• Patients with newly diagnosed TB-Defer ART until tolerating anti-TBs
• Patients with cryptococcal menengitis-Defer ART for 4 weeks to
complete treatment for menengitis
SPECIAL CONSIDEARTIONS IN TIMING
FOR art
 Patients for whom adherence will be challenging-start ART a soon as
support systems are in place
 ALL OTHER PATIENTS-START ART WITHIN 2 WEEKS OF HIV
DIAGNOSIS
CLASSES OF ART
 Nucleoside/Nucleotide reverse transcriptase inhibitors( NRTIs)
 Non-nucleoside reverse transcriptase inhibitors( NNRTIs)
 Protease inhibitors( PIs)
 Intergrase strand transfer inhibitors(InSTIs)
 Fusion inhibitors( FIs)
 Chemokine receptor antagonist(CCR antagonist)
CHANGING/SUBSTITUTING ARTs
CHANGING ARTs DUE TO ADVERSE DRUG REACTIONS
 All patients are education on ART associated drug reactions
 Once on ART for several months, ADRS are unlikely
 Most common reactions that require substitution include anemia,
liver damage, kidney damage, hyperbilirubinemia
MONITORING AND CHANGING ARTs
CHANGING ARTS DUE TO DRUG-DRUG INTERACTIONS
 Some common drugs have specific drug-drug interactions that may
require dose adjustments or substitutions of the ARV or other
interacting drug.
 Common medications that interact with specific ARTs include anti-
convulsants, anti-TBs, some antihypertensive
MONITORING AND CHANGING ARTs
CHANGING ARTs DUE TO TREATMENT FAILURE
Viral load is the test of choice in monitoring response to ART and
identifying treatment failure. Carried out at 6 and 12 months after
initiating or changing ART and every 12 months if below 1000
copies/ml.
Clinical -Suspected when a new or recurrent HIV associated condition
indicating severe immunodeficiency(WHO stage III/IV) develops after at
least 6 months on ART. Should be confirmed viral load test.
MONITORING AND CHANGING ARTs
TREATMENT FAILURE
Virologic
Defined by a persistently high viral load ≥ 1000 copies/ml ( two viral
loads measured within a 3 month interval with adherence support
between measurements) after at least 6 months of using ART
For pregnant and breastfeeding women, persistently high viral load( 2
viral load tests after 1-month interval with adherence support between
measurement) should be considered treatment failure after 6 months
of using ART
ADHERENCE SUPPORT AND
COUNSELLING
• Adherence-The whole process from choosing, starting. managing and
maintaining a given therapeutic regimen to control HIV from
replicating and to improve function of the immune system
• Non-adherence-The discontinuation or cessation of part or whole of
the treatment such as dose missing, under dosing/overdosing and
drug holiday
• Adherence support is key in for the wellbeing and good health
outcomes since HIV affects every aspect of an individuals life.
STANDARD ADHERENCE SUPPORT
INTERVENTIONS
STRUCTURAL INTERVENTIONS
 Explore aspects of clients life that may affect adherence
 Use multidisciplinary team approach
 Engage peer educators
 Formalizing a system for providng health talks and treatment literacy
classes for clients
 Linking patients to community based resources-Community support
groups, CBOs, groups supporting income generating activities.
ADHERENCE SUPPORT
INTERVENTIONS CONT
HIV EDUCATION AND COUNSELLING
• Remind client how ART works and need for adherence
• Discuss a treatment plan
• Discuss the use of alcohol and how it affects adherence
• Maintain non-judgemental attitude towards children, establish trust
with caregivers
ADHERENCE SUPPORT
INTERVENTIONS CONT
DISCLOSURE AND STIGMA
 Respect patient privacy and confidentiality
 Discuss the role of disclosure to close family members/trusted friends
in promoting adherence
 Offer to facilitate disclosure
 For children/adolescents, discuss age appropriate disclosure with the
caregiver and offer to support
 Conduct stigma assessment and support appropriately
ADHERENCE SUPPORT
INTERVENTIONS CONT
TREATMENT SUPPORTER
Encourage identification of a treatment supporter to provide
encouragement and support
Invite the supporter at least once to adherence counselling sessions
Obtain consent from patient to contact the supporter if needed
SMS REMINDER SYSTEM
Enroll to automated SMS reminder system
Ensure the system and messages maintain privacy and confidentiality
ADHERENCE SUPPORT INTERVENTION
SUPPORT GROUP
 Link the patient to a psychosocial support group and other
community-based support mechanisms.
 Deveop population specific support groups when possible-children
clubs, youth groups.
REASONS FOR NON-ADHERENCE
 Forgetting
 Regimen complexity
 Side effects
 Substance abuse
 Fear of medications
 Denial of the need for treatment
HOW TO PROMOTE ADHERENCE-
GENERAL
 Counselling
 Patient participation in plan of care
 Don’t rush ARVs, to ensure patient is ready
 Information, education, communication on ARVS-drug info, side
effects and what to do incase they occur.
 Use of fixed dose combinations(FDC) where possible
 Sustainable, continuous supply of drugs
 Treatment buddy
HOW TO PROMOTE ADHERENCE-
GENERAL
 Improving capacity of support groups to sustain patient education and
adherence.
 Consistent adherence messages offered by different healthcare
workers.
 Keeping an organized appointment diary-ensures patients don’s miss
appointments and drugs