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TABLE 28: Indications for isoniazid preventive therapy (provided that there are clinical complications and transmission) and should cover
no tuberculosis symptoms or contra-indications to isoniazid). safer sex practices and address issues related to reproductive
Patient category IPT Duration
Non-pregnant, regardless of CD4 count Indicated 12 months health (i.e. family planning, contraception, condom use and
+
Pregnant women with CD4 count > 350 cells/μL Not indicated N/A pregnancy). Clinicians should check family-planning choices
+
Pregnant women with CD4 count < 350 cells/μL Indicated 12 months at follow-up visits and ensure adequate access to safe and
+
(at high risk for TB) effective contraception. It is important to discuss the concept
+
ART, antiretroviral therapy; CD4 , cluster of differentiation 4; IPT, isoniazid preventive of ‘Undetectable = Untransmittable’ with patients and ensure
therapy; N/A, not applicable; TB, tuberculosis.
that they have a correct understanding of this concept and
receiving IPT, monitoring for neuropathy and hepatitis that ART will only prevent onward transmission if there is
symptoms should be performed. Routine ALT monitoring is optimal adherence with VL suppression.
not indicated, but ALT should be tested if hepatitis symptoms
occur. Active depression, other mental health issues or substance
abuse should be detected actively and treated. A personal
A recent trial of IPT in pregnant women receiving ART, the treatment plan should be formulated for each patient, specifying
TB APPRISE study, showed that IPT resulted in worse drug storage, strategies for missed doses and how to integrate
pregnancy outcomes. However, this was not confirmed in a taking medication into their daily routine. The patient must be
100
larger observational study from the Western Cape, which made aware of scheduling in terms of clinical follow-up.
showed that IPT use was associated with better pregnancy
outcomes, and that incident TB was reduced in women on Disclosure of HIV status (to a partner and/or other household
IPT who had CD4 counts < 350 cells/μL. The duration of members) should strongly be encouraged; it is an important
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+
IPT is now 12 months irrespective of TST status, as outlined determinant of treatment adherence and assists in the
in Table 28. provision of patient-directed support. Disclosure also
identifies exposed contacts for screening and support. This
28. Adherence issue needs to be handled carefully in situations where
disclosure may have harmful consequences, particularly for
Patient readiness for antiretroviral therapy women. The patient should be encouraged to join a support
Key points group and/or identify a treatment ‘buddy’. However, neither
disclosure nor support group participation is a prerequisite
ÿ Each patient commencing ART needs to be prepared for for good adherence and should not be a reason for deferring
treatment before or during early ART period. ART. Clinicians should ensure that they have the contact
ÿ Barriers to adherence (e.g. depression, alcohol use, non- details of each patient and their treatment buddy.
disclosure and food security) and any misconceptions
° Common pitfalls:
about ART must be identified in the preparation for ART
° Delaying ART because the patient has not completed
or during the early period of ART.
three clinic visits or not disclosed his or her HIV
status.
Preparing patients for lifelong ART with good adherence is a
° Not outlining the goals of ART with the patient.
critical component of achieving long-term efficacy and These are to:
preventing treatment resistance. To accommodate ß provide maximal and durable suppression of VL
counselling, traditionally two or three visits are required, ß restore and preserve immune function
staggered closely together, before ART. However, it is now ß reduce HIV-related infectious and non-infectious
considered acceptable to do some of the counselling during morbidity
early ART rather than delaying initiation (same-day initiation ß prolong life expectancy and improve quality of
is described in section 6). Prolonged delays in commencing life
ART should be avoided. Antiretroviral therapy should be ß prevent onward transmission of HIV
delayed only if concerns about adherence are severe enough ß minimise adverse effects of the treatment.
to outweigh the risk of HIV disease progression.
Support and counselling
The patient should be provided with details regarding:
Key points
• the benefits of ART
• that ART is a life-long therapy ÿ Success of ART hinges on how well the tablets are taken;
• the importance of good adherence at least 90%, preferably more, of treatment doses need to
• a list of ART side effects relevant to the drugs they will be taken.
use, including what to do and who to contact if serious ÿ Support should be provided to ensure high levels of
side effects occur treatment adherence.
• viral load monitoring on ART. ÿ None of the commonly used first- and second-line options
have meaningful food restrictions.
The counselling approach should also ensure that the patient ÿ Delayed dosing is rarely a problem; even if out by many
has a good understanding of HIV (the virus, the potential hours, most of the drugs have long half-lives, and patients

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