Post on 16-Jan-2016
transcript
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Introduction to ARV therapy
HAIVN Havard Medical School AIDS
Initiative in Vietnam
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By the end of this session, participants should be able to:Present the goals of ARV therapyOutline ARV drugs used in Viet NamInstruct patients on medication adherenceRecognize common and/ or significant side effects of ARV drugs
Learning objectives
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What are the goals of ARV therapy?
Why do we use ARV drugs knowing they don’t eliminate
HIV?
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Ultimately: Improve patient’s quality of life
Reduce HIV replication in patient:• Reduce viral load• Lessen attack of the virus on the
immune system Create opportunities for the immune
system to recover:• Help increase the number of CD4 cells
Goals of ARV therapy
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Relationship between CD4 count and viral load
Slow: <5,000Fast: 50,000+
HIV RNA (viral load) = Speed of train
CD4 count = Distance to crash
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Prevent the progression from HIV to AIDS
Prevent opportunistic infections Increase survival rate Decrease HIV transmission
Results of decrease in viral load and increase in CD4 count
Effect of ARV
HIV uses CD4 cell as a “factory” to produce HIV
ARV goes into the “factory” and reduces its ability to “produce” HIV
When patient takes ARV, virus production can be minimized
CD4CD4
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Each patient is infected with different strains of HIV
Each strain of HIV is sensitive to some but not all ARV drugs
To achieve the best and the longest effect, patient has to take at least 3 different ARV drugs
Why do we have to combine drugs in treatment?
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Progression to AIDS according to ARV therapy
%
MonthNon therapy Mono therapy
Triple therapyDual therapy
Nucleoside/Nucleotide RTI
AZT / Zidovudine
d4T / Stavudine
3TC / Lamivudine
ddI / didanosine
ABC / Abacavir
TDF / Tenofovir
ARV drugs currently available in Viet Nam
Non-nucleoside RTI
NVP /Nevirapine
EFV / Efavirenz
Protease inhibitors
RTV / Ritonavir
IDV / Indinavir
LPVr / Lopinavir + ritonavir
First line ARV regimens in Viet Nam
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Stavudine (D4T) is no longer recommended as a first line ARV
drug
Lamivudine (3TC)Tenofovir (TDF)Zidovudine (AZT)
Efavirenz (EFV)
Nevirapine (NVP)
Modified and Supplemented from Guidelines for Diagnosis and Treatment of HIV/AIDS,11/2011
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Side effects of ARV
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Side effects can happen when taking ARVs• Usually in the first weeks of therapy• improve over time or with symptomatic
management Side effects can be mild or severe Some side effects relate to dosage
and/or drug interactions
Side effects of ARV (1)
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Common side effects:• Peripheral
neuropathy• Diarrhea• Rash• Nightmare
Uncommon but severe side effects :• Pancreatitis • Bone marrow
suppression • Severe rash • hypersensitivity
Side effects of ARV (2)
Nurse should instruct patients to recognize side effects of ARV
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Some examples of side effects of ARV
Allergy to Nevirapine (1)
rash
Allergy to Nevirapine (2)
Stevens-Johnson syndrome
Allergy to Nevirapine (3)
Stevens-Johnson syndrome
Allergy due to Efavirenz
Hội chứng Stevens-Johnson
Allergy to cotrimoxazole may cause erythematous rash, flat or slightly elevated lesions on the trunk and extremities
Allergy to Cotrimoxazole (1)
Allergy to Cotrimoxazole (2)
Rash
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Adherence
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Adherence means taking the correct medications, in proper doses and on time
To achieve the best effect with ARV therapy, adherence rate is required to be above 95%. • Example: If medications are prescribed
2 times a day, don’t forget more than 2 doses a month.
Adherence
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Assessments of rates of non adherence to treatment range from 20% to 80%, with the average rate of 50%.
Adherence rate in IDUs (40% - 80%) and non-IDUs (30% - 70%) are similar.
Non adherence to ARV therapy is common
Common levels of adherence
Howard AIDS 2002; Ickovics Antiviral Ther 2002; Moss CID 2004
Ad
her
enc
e
Treatment time (month)
100%
0%
0 12 24
Three types of patient’s adherence
Very good adherence
Reduced adherenceNon adherence
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Reason %
Simply forgot or were busy 66%
Not at home 57%
Had a change in daily routine 51%
Slept through dose time 40%
Sick 28%
Sad, sorrowful 18%
Individual problems 14%
Side effects 12%
Common reasons for non adherence to ARV
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Medications interfere with daily life Drinking alcohol or using drugs Sad mood, stress Pessimistic about HIV Treatment is less effective than
desired
Factors influencing non adherence to HIV treatment
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Maximizes inhibition of viral load Reduces drug resistance Increases time of exposure to
effective medication Above all, helps:
• Delay progression to AIDS• Prolong survival• Improve quality of life
Goals of adherence to ARV drugs
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Take medicine on time Maintain regular check up Maintain “healthy lifestyle with HIV”
• Eat healthy food• Exercise regularly• Do not smoke tobacco or drink alcohol
Components of adherence
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Nurse should pay attention to
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Find out attitudes, knowledge and beliefs of the patient by asking questions :About medication generally:
• For example: Did you take medication before? Tell me about that.
About HIV/AIDS:• For example: Can HIV be cured?
Learn about the patient (1)
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About ARV drugs: • Do you know someone who is on ARV
therapy?• How is his/ her health after taking ARVs?• What would happen if you take ARV
drugs? Patient’s desires:
• benefit and cost of treatment• changes in appearance (or not)• side effects
Learn about the patient(2)
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Has patient ha disclosed his / her HIV status to anyone?
Who is the main support person for the patient?• Does s/he know that the patient has HIV?
• What does s/he know about ARV drugs?
Learn about the life circumstances of the patient (1)
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Life circumstance• Have a house?• Is anyone in the family aware of the
patient's diagnosis?• Are there any children at home?
Daily living• work?• child care?
Learn about the life circumstances of the patient (2)
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Instruct patients on ARV therapy purposes
Understand how ARV impacts patients’ lives
Collaborate with physicians and pharmacists in ARV therapy group to give patients the best care
The role of nurses in ARV therapy groups (1)
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Ensure that patients:• understand how to take medicine
before leaving the clinic• have plans to remember to take
medicine Instruct patients on:
• possible side effects• what to do if side effects occur
Give patients and their families a message of: HOPE
The role of nurses in ARV therapy groups (2)
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The goal of ARV treatment is to reduce viral load and increase CD4 count and ultimately to increase quality of life
A 3-drug combination is most effective
The role of nurses is to help patients adhere to treatment to obtain the best results from ARVs
Key points
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Thank you
Question?