Office of Overseas Programming & Training Support (OPATS)

Treatment AdherenceHIV Care, Support, and Treatment

Antiretroviral Therapy (ART)

ART dramatically improves the quality of life of PLHIV and restores hope–Patients gain weight, are less fatigued,

feel better, are often able to return to work–Slows or stops progression of illness

Joseph Jeune, a farmer in Haiti, before and after treatment for HIV/AIDS and TB co-infection

Access to ART

While access to HIV treatment has increased by 63 percent from 2009 to 2011, only 54 percent of people eligible for HIV treatment in low and middle-income countries were on ART in 2012

Care and Treatmentin the pre-ART Period Critical to identify HIV-infected persons early

and enroll in care and support services After diagnosis, but before ART, regular clinic

visits and care and support services are vital– For clinic checkups (prophylaxis, screening,

treatment for OIs, to monitor progression, etc.)– For education in self-care and living positively to

stay healthy and maintain strong immune system– To meet psychosocial needs (support groups, etc.)

Eligibility for ART

Prompt and timely initiation of ART results improved quality of life and reduced mortality

Eligibility for ART is determined at the clinic – When CD4 thresholds are reached (and other

criteria) – And before OIs contribute to poor outcomes

CD4 Count

The major lab indicator of immune function in PLWHIV

Key factor in determining:– Urgency of antiretroviral therapy (ART) initiation– Need for prophylaxis for opportunistic infections

Strongest predictor of subsequent disease progression and survival

Clinical Exams for ART Eligibility

Medical history Physical exam: WHO clinical

staging and disease classification Laboratory tests: CD4 count, Viral

load, OI screening (including TB)

Country-specific ART Eligibility Criteria: South Africa Example Adults: CD4 count <350 cells/mm OR clinical

staging 3 and 4 (WHO) OR patient with TB Infants and children: All children under 5,

irrespective of CD4 cell count Fast tracking ART initiation: Children under 1,

CD4 cell count <200 cells/mm, clinical staging 4, women who are pregnant or breastfeeding, patients with TB and CD4 cell count <50 cells/mm

ART: How It Works

ART uses a combination of at least three ARVs– This combination suppresses the HIV virus and

stops the virus from multiplying– With less virus, the immune system becomes

stronger, resists infections, and the person gets sick less often

NOTE: ART does not completely destroy the virus or cure the disease and ART can reduce, but not eliminate the risk of HIV transmission. People on ART can still transmit the virus to others.

ARV Drugs

The combination of three drugs reduces the likelihood of the virus developing resistance

First, second, and third-line therapies are different combinations of ARV drugs– First-line: Usually standard, but doctor may adjust if

patient is pregnant or if person has TB– Second-line: Prescribed if first-line does not work or if

there are side effects– Third-line: National guidelines, based on funding,

sustainability, and ART access

Successful Treatment with ARVs

Must be taken daily for remainder of patient’s life to continually suppress the virus– Must be taken at specific times of day, under

specific conditions– Must be carefully stored– Must take 95 percent or higher of scheduled doses– Most effective when patients are well-nourished

If ARVs are NOT taken correctly, benefits are rapidly reversed, virus may become resistant

Predicted and observed risk of viral control according to the longer interval of treatment discontinuation,

POSOVIR and REACH cohorts

Side Effects of ARVs

All medicines can cause side effects, including ARVs. Most common with ARV:– Headaches, nausea, diarrhea, skin rashes, tingling

sensations, tiredness, nightmares or anxiety, and changes in body

Vary in severity (minor/major), duration, and start; some manageable by patient

Can interfere with treatment adherence, lessen quality of life, or cause long-term health conditions

ART and TB Treatment

PLHIV more susceptible to TB; TB most common cause of death of PLHIV

A doctor must decide how to treat both diseases in people with both TB and HIV

Some ARVs cannot be used at the same time as some TB drugs; thus, a doctor will prescribe a special first-line ARV drug combination for patients with TB

Treatment Adherence

The ability to start, manage, and maintain a given medication regimen at the times, frequencies, and under specific conditions as prescribed by a health care provider

MORE than just taking drugs– Patient attends all scheduled clinical care visits,

follow-up appointments and monitoring, lab tests– Patient practices recommended behaviors (diet,

limiting use of alcohol)

The Importance of Treatment Adherence Suboptimal adherence– Treatment failure– Limited future treatment options (second-

line therapy much more expensive, often unavailable)– Increased risk of HIV transmission to others– Increased mortality

Care and Support is Vital for Treatment Adherence

ART Initiation and Patient Readiness ART initiation involves a partnership

between PLHIV and the health system–Critical to involve patient in decision–Requires adequate preparation and

support–Requires commitment from patient

Patient Preparation for ART

Counseling– To identify barriers and solutions

Training– Treatment literacy

Patient Assessment – Beliefs, attitudes, mental health

Identification of social support– Help with disclosure, socioeconomic situation

Development of a treatment plan

Barriers to Treatment Adherence

Individual FactorsSystem FactorsCommunity FactorsMedication Factors

Despite Barriers, Treatment Adherence Can Be Achieved Adherence is feasible in low-resource settings– 77 percent of patients in Africa achieved adequate

treatment adherence (defined as taking 95 percent of prescribed pills) compared with just 55 percent in North American settings

Good adherence has been shown within key populations, including sex workers and People Who Inject Drugs