The introduction of antiretroviral drugs as part of HIV clinical care has made AIDS more of a manageable chronic illness with restored economic productivity and social functioning. But these effects have been seen only in settings where resources were available to make the drugs affordable and there are health service capacities to optimize their sustained, safe and effective use. There are multiple requirements for such an effect that can be grouped into three areas: (1) the drugs, (2) the client, and (3) the health system. Persons living with HIV/AIDS (PLHA) play a crucial role in the design and implementation of antiretroviral (ARV) drug introduction into HIV/AIDS prevention and care programs.
Antiretroviral Drugs
A dramatic reduction in viral load (the level of virus in the blood) with resulting arrest in immune damage is achieved by combining at least three drugs from the various classes of antiretroviral drugs into a "cocktail." This three-drug cocktail is called "Highly Active Antiretroviral Therapy" (HAART). Each class of anti-HIV drugs attacks the virus at a different stage of replication while is it growing in the human host lymphocyte cell. The common classes of drugs currently on the market are the nucleoside reverse transcriptase inhibiters such as zidovudine (AZT), lamivudine (3TC), abacavir; the non-nucleoside reverse transcriptase inhibitors such as nevirapine and efavirenz; and the protease inhibitors such as indinavir, ritonavir and lopinavir. Drug-related issues that influence their use include the following:
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All ARVs are still costly, even with recent dramatic price reductions, when compared to STD or TB drugs, for example.
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Side effects of the drugs are common and need to be clinically monitored. Side effects may lead to stopping or changing the drug, or changing life style to reduce alcohol intake in case of liver toxicity.
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HIV can easlity become resistant to ARVs, hence the need to combine different classes of ARVs to treat patients.
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Most of the ARVs interact with other drugs commonly used in the treatment of opportunistic diseases such as tuberculosis and fungal infections. This requires adjusting the dosage of the drugs or the discontinuing ARVs while taking other medication.
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Most of the ARVs currently available have strict medication schedules or storage requirements although medical advances are developing new drugs and drug combinations to make them easier to take with fewer side effects. The protease inhibitors, for example, require a very strict time regimen to be effective (e.g., indinavir every eight hours on an empty stomach). Some require refrigeration (e.g., ritonavir, lopinavir). Others need precautions to avoid severe side effects (indinavir, for example, requires at least 1 _ litres of water a day to avoid kidney stones; efavirenz can cause insomnia with chaotic dreams, requiring it to be taken only at night). Pregnant women should not use efavirenz.
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ARV must be taken lifelong if AIDS is to be a manageable chronic illness. It requires a lifelong relationship between client and the health team.
The Client on ARV
Adherence (also called compliance or concurrence) to the complex and lifelong ARV medication is the key to sustained effectiveness and less of a chance that HIV will become resistant to ARVs. In general, regimens without protease inhibitors are easier to take. Other regimens require taking medication once or twice a day, and do not require strict timing, an empty stomach or large fluid intake. The following are issues from the client's perspective that should be considered and incorporated in planning:
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Starting ARVs is committing to lifelong medication and entails enduring the almost universal initial period of unpleasant side effects. It also requires identifying financial resources necessary for regular medical visits, costs of laboratory tests and treatment costs. The self-discipline and financial burden associated with ARV should be discussed at the start of treatment.
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Continuous drug information or even drug counseling by the care provider and pharmacist is essential to improved adherence.
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Emotional support for clients on ARV remains a cornerstone of care. Issues of when, how and to whom to disclose need to be carefully planned.
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Treatment failure is common and when there are no alternatives to the initial ARV regimen, there must be support to ensure continuation of care and referral to palliation and home care.
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ARV may create false hope of safety among users and result in increased high risk behavior. Although it is biologically plausible that effective use of ARV would reduce viral loads in vaginal fluids and semen–and as a result reduce sexual transmission–no studies have demonstrated this at the population level. Services have to ensure ongoing counseling about the need to continue protective action and information on the effects of ARV for clients and their sexual partners.
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Information and education for communities and society on the realities of ARV use should also be in place. ARVs are neither a cure nor a preventive tool per se. The media will have a key role to play in educating the public. PLHA play an effective role in community education.
The Health Systems
To optimize the benefits of ARV for greatly reduced morbidity, mortality and improved quality of life, the following need to be addressed simultaneously:
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Training health teams (doctor, nurse, counselor, pharmacist, laboratory staff) in both the public and private sectors, with regular updates on treatment and care options.
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Reorganizing services to integrate HIV care in outpatient departments and at health centers to allow for space, privacy and time and linkages with TB-DOTS and STI programs
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Strengthening rapid registration of new drugs and drug procurement and management systems to ensure continuous availability of the drugs and avoidance of pilferage and misuse.
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Expanding and integrating quality VCT into health systems as an entry point to prevention and care.
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Strengthening and upgrading laboratory facilities. Although viral load measurements may not be essential for safe and effective use, CD4 counts or cheaper alternatives are needed to help providers and clients decide together when to start and when to switch or stop treatment. There needs to be laboratory monitoring for potential side effects.
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Communicating to the public at large on the benefits and risks of ARV treatment.
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Strengthening and scaling up comprehensive care programs (management of opportunisitic infections, preventive therapies, TB-DOTS, home care, palliative care, social support) to accommodate ARV use and continue to care for a majority of patients not on ARV.
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Strengthening prevention programs to link closely with care and ARV treatment programs and reinforce the need for prevention as a primary goal within and beyond the health sector.
In summary, the good news is that ARVs are becoming a welcome addition to greatly improve the quality of life of many more PLHAs. All efforts need to be made to ensure that patients can adhere and health systems can accommodate these new interventions.
Resources
- Panel on Clinical practices for treatment of HIV infection. Guidelines for the use of Antiretroviral Agents in HIV-infected Adults and Adolescents. U.S. Department of Health and Human Services and the Henry J. Kaiser Foundation, January 2000.
- World Health Organization, International AIDS Society and UNAIDS, Safe and Effective Use of Antiretroviral Treatments in Adults with Particular Reference to Resource Limited Settings. WHO/HSI/2000.04. Geneva:WHO, 2000.
- http://www.nmac.org
- http://www.thebody.org
- http://www.hivatis.org
- http://www.hopkins-aids.edu
