PCP HIV AIDS Toolkit/Biology of HIV AIDS/Handout D: Antiretrovirals
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.
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 cell. Drug-related issues that influence their use include the following:
- All ARVs are still costly, even with recent dramatic price reductions, when compared to sexually transmitted disease (STD) or tuberculosis (TB) drugs, for example. However, many resource-poor countries are benefiting from worldwide efforts, such as the President's Emergency Plan for AIDS Relief (PEPFAR), and the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund), to expand drug availability.
- Side effects of the drugs are common and need to be clinically monitored. Side effects may lead to stopping or changing the drug, or making lifestyle or diet changes.
- HIV can easily become resistant to ARVs, hence the need to combine different kinds of ARVs to treat patients.
- Some 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 and careful monitoring of the patient.
- Many ARVs 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).
- ARVs must be taken for a lifetime 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 ARV therapy is crucial for effective results, and lessens the chance that HIV will become resistant to ARVs. The following are issues from the client's perspective that should be considered and incorporated in planning:
- Starting ARVs is a commitment to lifelong medication and entails enduring an 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 ARVs should be discussed at the start of treatment.
- Continuous drug information and counseling by the health-care provider is important for adherence.
- There should be links between drug treatment, home-based care, and palliative care.
- ARVs may create a false hope of safety among users and may result in increased high-risk behavior. Services should include ongoing counseling about the need to continue protective action for clients and their sexual partners.
- ARVs are neither a cure nor a preventive tool. Information and education for communities and society on the realities of ARV use should also be in place.
The Health Systems
To optimize the benefits of ARVs for greatly reduced morbidity, mortality, and improved quality of life, the following need to be addressed simultaneously:
- Training health teams (doctor, nurse, counselor, pharmacist, laboratory staff) in both the public and private sectors, with regular updates on treatment and care options.
- Reorganizing services to integrate HIV care in outpatient departments and at health centers to allow for space, privacy, and time and links with tuberculosis Directly Observed Therapy (TB-DOT) and sexually transmitted infection (STI) programs.
- 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.
- Expanding and integrating quality voluntary counseling and testing into health systems as an entry point to prevention and care.
- 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.
- Communicating to the public at large on the benefits and risks of ARV treatment.
- Strengthening and scaling up comprehensive care programs (management of opportunistic infections, preventive therapies, TB-DOT, home care, palliative care, social support) to accommodate ARV use and continue to care for a majority of patients not on ARVs.
- 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 PLWA. All efforts need to be made to ensure that patients can adhere and health systems can accommodate these new interventions.
What can Peace Corps Volunteers do?
Volunteers can play an important role in ARV programs by helping to educate PLWA, family, friends and other care givers about ARV compliance, benefits and risks of ARV treatment, and strengthening prevention programs that are closely linked to care and treatment activities that include ARVs. Volunteers can also advocate and facilitate the points outlined above to strengthen in-country systems for the management and distribution of ARVs.
- 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. Geneva: WHO, 2000.
- National Minority AIDS Council. http://www.nmac.org
- The Body: The Complete HIV/AIDS Resource. http://www.thebody.org
- AIDSinfo: HIV/AIDS Information from the U.S. Department of Health and Human Services. http://www.hivatis.org
- Johns Hopkins AIDS Service. http://www.hopkins-aids.edu
This fact sheet is based on information summarized from Family Health International ARV Fact Sheet, www.fhi.org (accessed May 8, 2007).
- Family Health International. ‚ÄúSafe and Effective Introduction of Antiretroviral (ARV) Drugs for HIV/AIDS.‚Äù http://www.fhi.org/en/HIVAIDS/pub/fact/introarv.htm (accessed March 12, 2007).