Transcript 03.02 Initiating and monitoring ART

Module 3: Management of
Patients on Antiretroviral Therapy
Unit 2: Initiation and Monitoring
of ART in Adults and Adolescents
Objectives
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Explain the principles of successful
antiretroviral therapy (ART)
Explain ART combinations that are used
and the rationale for use of national
standardized ART regimens
Explain drug and non-drug related
considerations prior to initiating ART
Objectives
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Explain when ART should be initiated and
who should be started on ART
Describe when to change or stop ART
Describe type of monitoring employed in
ART management
Goals of ART
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1. Maximal suppression of HIV
replication
2. Restoration and preservation of
immune function
3. Improved Quality of Life
4. Reduction of HIV related
Morbidity and Mortality
1. Suppression of HIV Replication
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ARVs must be taken in combination of
at least 3 drugs
Strict adherence to treatment is of the
upmost importance
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<95% adherence allows the rapid
development of viral resistance
Poor adherers do badly
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Fail treatment much earlier
2. Immune Reconstitution
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ART prevents CD4 destruction by HIV
CD4 cell count can recover
Improved function of CD4 cells
CD4 cells are central to the immune system
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So there is improved overall function of the immune
system
It takes from 6 to 8 weeks for this to become
evident clinically
3. Improvement of QOL
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Decreased hospitalizations
Decreased risk of illnesses
Increased general well-being
Reversal of weight loss
Ability to return to work
Take-home Messages
about ART
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Not an emergency treatment
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Treat opportunistic infections first
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OI’s cause >90% of morbidity in HIV
>90% of OI’s are simple to treat
ART is only one part of HIV Care
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Benefits take 6 to 8 weeks
Should not be initiated while an inpatient
All who require ART should first be on CPT first
Optimize nutrition
Take-home Messages
about ART
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Adherence counselling essential
Patients should be able to demonstrate an
understanding of:
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Importance of strict adherence
Their ability to afford drugs long term
Life-long treatment, monthly follow-up
The Kenyan National Guidelines should be followed
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“If you don’t agree with them, campaign for a
change rather than ignoring them!”
Rationale Behind
Standardized ARV Therapy
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Success of TB treatment program
Simplicity of prescribing
Preservation of certain ARV’s on a
population level
Simple sequencing of 1st to 2nd line
Increased efficiency in drug procurement
Cost and availability of FDC’s
Standard 1st Line Regime
for Adults and Adolescents
Lamivudine
+
Stavudine
+
Nevirapine
or
Lamivudine
+
Stavudine
+
Efavirenz
Standard 2nd Line Regime
for Adults and Adolescents
Zidovudine
+
or
Didanosine
+
Lopinavir/Ritonavir
Zidovudine
+
Didanosine
+
Nelfinavir
For Patients on Non-standard
1st line Regimes…
1st Line
2nd Line
D4T+ddI+NNRTI
AZT+3TC+LPV/r
AZT+3TC+ABC
NNRTI+LPV/r+d4T
AZT+3TC+PI
NNRTI+ABC+ddI
A note on Fixed Dose
Combinations (FDC’s)
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WHO Approved FDC’s are available for:
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Advantages
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d4T/3TC/NVP
D4T/3TC
AZT/3TC
Decreased pill burden
Increased adherence
Mono or duo-therapy not possible
Lower cost
Simplify stock control and forcasting
GoK has chosen these for the National roll-out
When to Start ART in Adults and
Adolescents
Where CD4 testing available
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WHO II & III when CD4 < 200/mm3
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WHO stage IV irrespective of CD4 level
When to Start ART in Adults and
Adolescents
Where CD4 Testing Unavailable
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WHO II when total lymphocyte count
<1200/mm3
WHO III & IV regardless of total
Lymphocyte count
Guidance on Clinical Criteria
CD4 levels are not “hard and fast” rules
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A sick, deteriorating patient with a CD4 of 210
should not be excluded from ART if otherwise able
and keen to begin
A very well, stable patient with a CD4 of 180 could
reasonably opt for close follow up and deferral of
ART to a later date
Pregnancy and ART
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Not a contraindication ART
In general, best to defer to after the
first trimester (after organogenesis)
EFV contraindicated
ART greatly decreases vertical
transmission
Also allows mother to remain well to
care for her child
Monitoring of ART (1)
ART is monitored using:
 Clinical information
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Body Weight
Signs and symptoms
Past and present medical history
Physical examination
End Points in
Clinical Monitoring
Look for:
 Decrease or disappearance of
symptoms
 Increase in body weight
 Decrease in frequency and severity of
OIs
Monitoring of ART (2)
ART is monitored using:
 Laboratory Parameters
Minimum - HIV Test, Hb, pregnancy test
Standard - FBC, SGPT/ALT, Creatinine
Desirable - CD4
Optional/Ideal - Viral Load
Schedule of
Laboratory Monitoring
Test
Baseline
CD4
X
X
X
X
X
X
FBC
Creatinine
Pregnancy
SGPT/ALT
Urinalysis
1-2
months
6
months
12
months
18
months
24
months
X
X1
X
X1
X1
X1
X
X1
X1
X
X1
X
X
X
X1
X
X
X
X
X
X1
X
X
X1: If clinically indicated
X1
X
X1