ART Guidelines

ART Guidelines


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  • ABBREVIATIONS
    /r ritonavir-boosted
    3TC lamivudine
    ABC abacavir
    ADR adverse drug reaction
    AKI acute kidney injury
    ALT alanine transaminase
    ANC antenatal care
    ART antiretroviral therapy
    ARV antiretroviral
    AST aspartate transaminase
    ATV atazanavir
    ATV/r ritonavir-boosted atazanavir
    AZT zidovudine
    bd twice daily
    CD4+ cluster of differentiation 4
    CM cryptococcal meningitis
    CNS central nervous system
    CrAg cryptococcal antigen
    CrCl creatinine clearance rate
    CSF cerebrospinal fluid
    CTX cotrimoxazole
    d4T stavudine
    ddI didanosine
    DILI drug-induced liver injury
    DNA deoxyribonucleic acid
    DRV darunavir
    DRV/r ritonavir-boosted darunavir
    DTG dolutegravir
    eGFR estimated glomerular filtration rate
    ELISA enzyme-linked immunosorbent assay
    ETR etravirine
    FBC full blood count
    FTC emtricitabine
    GI gastrointestinal
    Hb haemoglobin
    HBsAg hepatitis B surface antigen
    HBV hepatitis B virus
    HIV human immunodeficiency virus
    ICU intensive care unit
    INH isoniazid
    INR international normalised ratio
    InSTI integrase strand transfer inhibitor
    IPT isoniazid preventive therapy
    IRIS immune reconstitution inflammatory syndrome
    LAM lipoarabinomannan
    LDL-C low-density lipoprotein cholesterol
    LFT liver function test
    LP lumbar puncture
    LPV lopinavir
    LPV/r ritonavir-boosted lopinavir
    MDRD modification of diet in renal disease
    MTCT mother-to-child transmission of HIV
    MVC maraviroc
    NGT nasogastric tube
    NNRTI non-nucleoside reverse transcriptase inhibitor
    NRTI nucleoside reverse transcriptase inhibitor
    NTDs neural-tube defects
    NtRTI nucleotide reverse transcriptase inhibitor
    NVP nevirapine
    OI opportunistic infection
    PAS p-aminosalicylic acid
    PCR polymerase chain reaction
    PI protease inhibitor
    PI/r ritonavir-boosted protease inhibitor
    PMTCT prevention of mother-to-child transmission of HIV
    PPIs proton pump inhibitors
    PrEP pre-exposure prophylaxis
    QTc corrected QT interval
    RAL raltegravir
    RCTs randomised controlled trials
    RIF rifampicin
    RFB rifabutin
    RNA ribonucleic acid
    RPV rilpivirine
    RTV or /r ritonavir
    sCr serum creatinine
    sCrAg serum cryptococcal antigen
    TAF tenofovir alafenamide
    TAM thymidine analogue mutation
    TB tuberculosis
    TB-IRIS tuberculosis immune reconstitution inflammatory syndrome
    TBM tuberculosis meningitis
    TC total cholesterol
    TDF tenofovir disoproxil fumarate
    TG triglycerides
    TST tuberculin skin test
    UDP uridine 5’-diphospho
    ULN upper limit of normal
    VL viral load
    WHO World Health Organization
    WOCP women of childbearing potential








    Adherence
    Patient readiness for antiretroviral therapy
            Key points
     
    • Each patient commencing ART needs to be prepared for treatment before or during the early ART period.
    • Barriers to adherence (e.g. depression, alcohol use, non-disclosure or food security) and any misconceptions about ART must be identified in the preparation for ART or during the early period of ART.


    Preparing patients for lifelong ART with good adherence is a critical component of achieving long-term efficacy and preventing treatment resistance. To accommodate counselling, traditionally two or three visits were required, staggered closely together, before ART. However, it is now considered acceptable to do certain of the counselling during early ART rather than delaying initiation (same-day initiation is described in Module 6). Prolonged delays in commencing ART should be avoided. ART should be delayed only if concerns about adherence are severe enough to outweigh the risk of HIV disease progression.

    The patient should be provided with details regarding:

    • the benefits of ART
    • that ART is life-long therapy
    • the importance of good adherence
    • a list of ART side-effects relevant to the drugs that the patient will use, including what to do and who to contact if serious side-effects occur
    • VL monitoring on ART.


    The counselling approach should also ensure that the patient has a good understanding of HIV (the virus, the potential clinical complications and transmission), and should cover safer-sex practices and address issues related to reproductive health (i.e. family planning, contraception, condom use and pregnancy). Clinicians should check family-planning choices at follow-up visits and ensure adequate access to safe and effective contraception. It is important to discuss the concept of 'Undetectable = Untransmittable' with patients and to ensure that they have a correct understanding of this concept and that ART will only prevent onward transmission if there is optimal adherence with VL suppression.

    Active depression, other mental health issues or substance abuse should be detected actively and treated. A personal treatment plan should be formulated for each patient, specifying drug storage, strategies for missed doses and how to integrate taking medication into their daily routine. The patient must be made aware of scheduling in terms of clinical follow-up.

    Disclosure of HIV status (to a partner and/or other household members) should strongly be encouraged; it is an important determinant of treatment adherence and assists in the provision of patient-directed support. Disclosure also identifies exposed contacts for screening and support. This issue needs to be handled sensitively in situations where disclosure may have harmful consequences, particularly for women. The patient should be encouraged to join a support group and/or identify a treatment ‘buddy.’ However, neither disclosure nor support group participation are prerequisites for good adherence, and should not be a reason for deferring ART. Clinicians should ensure that they have the contact details of each patient and their treatment buddy.

    Common pitfall: Delaying ART because the patient has not completed three clinic visits or not disclosed their HIV status.

     

    Common pitfall: Not outlining the goals of ART with the patient. These are to:
    • Provide maximal and durable suppression of VL.
    • Restore and preserve immune function.
    • Reduce HIV-related infectious and non-infectious morbidity.
    • Prolong life expectancy and improve quality of life.
    • Prevent onward transmission of HIV
    • Minimise adverse effects of the treatment.

    Support and counselling
            Key points
     
    • Success of ART hinges on how well the tablets are taken; at least 90%, preferably more, of treatment doses need to be taken.
    • Support should be provided to ensure high levels of treatment adherence.
    • None of the commonly used first- and second-line options have meaningful food restrictions.
    • Delayed dosing is rarely a problem; even if out by many hours, most of the drugs have long half-lives, and patients should be encouraged and supported to take their dose once they remember to do so in these instances.
    • Disclosure is not a prerequisite for ART.
    • Heavy alcohol use may affect adherence and may potentiate ART hepatotoxicity and other hepatic pathology; however, responsible alcohol use is not prohibited in patients established on or starting ART.


    The patient should be informed about the benefits of ART and that side-effects are usually minor and transient, or manageable. The patient should be given a treatment plan, specifying the drugs to be used (with names and details including the appearance of each drug, when and how they are to be taken, and a brief indication of anticipated side-effects and toxicity).

    The causes of poor adherence are often complex and linked to social issues. Common causes are outlined in Table 29.

     

    Tip: To best view this table, zoom in or rotate your mobile device into landscape orientation.

    TABLE 29: Possible reasons for poor adherence.
    Individual Provider Medication
    Depression

    Alcohol or sub­stance use

    Non-disclosure

    Inadequate treat­ment literacy

    Adolescence

    Following pregnancy

    Food security

    Work-related issues (shift work)

    Social problems (stigma and poor social support networks)
    Stock-outs

    Inaccessible clinics (both in place and time)

    Poor communication (not patient-centred)
    High pill burden

    Frequent dosing (> once per day)

    Adverse effects
    Common pitfall: Not informing patients of the benefits of ART. This includes not only reduced mortality and morbidity, but also prevention of HIV transmission.
    Common pitfall: Not informing patients that side-effects are usually minor and transient, or manageable.
    Common pitfall: Not advising patients on how to deal with delayed dosing.
    Common pitfall: Not providing patients with a treatment plan specifying the drugs to be used.