1

Introduction to ARV therapy

HAIVN Havard Medical School AIDS

Initiative in Vietnam

2

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

3

What are the goals of ARV therapy?

Why do we use ARV drugs knowing they don’t eliminate

HIV?

4

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

5

Relationship between CD4 count and viral load

Slow: <5,000Fast: 50,000+

HIV RNA (viral load) = Speed of train

CD4 count = Distance to crash

6

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

8

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?

9

15

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

+

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

12

Side effects of ARV

13

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)

14

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

15

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

22

Adherence

23

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

24

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

26

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

27

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

28

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

29

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

30

Nurse should pay attention to

31

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)

32

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)

33

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)

34

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)

35

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)

36

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)

37

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

38

Thank you

Question?