Transcript Goals of ARV therapy

Introduction to ARV
therapy
HAIVN
Havard Medical School AIDS
Initiative in Vietnam
1
Learning objectives
By the end of this session, participants
should be able to:
 Present the goals of ARV therapy
 Outline ARV drugs used in Viet Nam
 Instruct patients on medication
adherence
 Recognize common and/ or
significant side effects of ARV drugs
2
What are the goals of ARV
therapy?
Why do we use ARV drugs
knowing they don’t eliminate
HIV?
3
Goals of ARV therapy


Ultimately: Improve patient’s quality
of life
Reduce HIV replication in patient:
• Reduce viral load
• Lessen attack of the virus on the
immune system

Create opportunities for the immune
system to recover:
• Help increase the number of CD4 cells
4
Relationship between CD4 count and
viral load
HIV RNA (viral load) = Speed of train
Slow: <5,000
Fast: 50,000+
CD4 count = Distance to crash
5
Results of decrease in viral load
and increase in CD4 count




Prevent the progression from HIV to
AIDS
Prevent opportunistic infections
Increase survival rate
Decrease HIV transmission
6
Effect of ARV



HIV uses CD4 cell as
a “factory” to produce
HIV
ARV goes into the
“factory” and reduces
its ability to
“produce” HIV
When patient takes
ARV, virus production
can be minimized
CD4
Why do we have to combine drugs
in treatment?



Each patient is infected with different
strains of HIV
Each strain of HIV is sensitive to
some but not all ARV drugs
To achieve the best and the longest
effect, patient has to take at least 3
different ARV drugs
8
Progression to AIDS according to ARV
therapy
30
25
20
% 15
10
5
0
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15
Non
therapy
Non
therapy
Mono
therapy
Mono
therapy
Dual
therapy
Dual
therapy
Triple
therapy
Triple
therapy
Month
9
15
ARV drugs currently available in
Viet Nam
Nucleoside/
Nucleotide RTI
AZT / Zidovudine
Protease inhibitors
RTV / Ritonavir
IDV / Indinavir
d4T / Stavudine
LPVr / Lopinavir
+ ritonavir
3TC / Lamivudine
ddI / didanosine
Non-nucleoside RTI
ABC / Abacavir
NVP /Nevirapine
TDF / Tenofovir
EFV / Efavirenz
First line ARV regimens in Viet Nam
Lamivudine (3TC)
Tenofovir (TDF)
Zidovudine (AZT)
+ Efavirenz (EFV)
Nevirapine (NVP)
Stavudine (D4T) is no longer
recommended as a first line ARV
drug
Modified and Supplemented from Guidelines for Diagnosis and Treatment of
HIV/AIDS,11/2011
Side effects of ARV
12
Side effects of ARV (1)

Side effects can happen when taking
ARVs
• Usually in the first weeks of therapy
• improve over time or with symptomatic
management


Side effects can be mild or severe
Some side effects relate to dosage
and/or drug interactions
13
Side effects of ARV (2)

Common side
effects:
• Peripheral
neuropathy
• Diarrhea
• Rash
• Nightmare

Uncommon but
severe side
effects :
• Pancreatitis
• Bone marrow
suppression
• Severe rash
• hypersensitivity
Nurse should instruct patients to recognize side
effects of ARV
14
Some examples of
side effects of ARV
15
Allergy to Nevirapine (1)
rash
Allergy to Nevirapine (2)
Stevens-Johnson syndrome
Allergy to Nevirapine (3)
Stevens-Johnson syndrome
Allergy due to Efavirenz
Hội chứng Stevens-Johnson
Allergy to Cotrimoxazole (1)

Allergy to
cotrimoxazole may
cause
erythematous
rash, flat or
slightly elevated
lesions on the
trunk and
extremities
Allergy to Cotrimoxazole (2)
Rash
Adherence
22
Adherence


Adherence means taking the correct
medications, in proper doses and on
time
To achieve the best effect with ARV
therapy, adherence rate is required
to be above 95%.
• Example: If medications are prescribed
2 times a day, don’t forget more than 2
doses a month.
23
Non adherence to ARV therapy is
common


Assessments of rates of non
adherence to treatment range from
20% to 80%, with the average rate
of 50%.
Adherence rate in IDUs (40% - 80%)
and non-IDUs (30% - 70%) are
similar.
24
Common levels of adherence
Three types of patient’s adherence
Very good
adherence
Adherence
100%
Reduced
adherence
Non adherence
0%
0
12
24
Treatment time (month)
Howard AIDS 2002; Ickovics Antiviral Ther 2002; Moss CID 2004
Common reasons for non adherence
to ARV
Reason
%
Simply forgot or were busy
66%
Not at home
57%
Had a change in daily routine
51%
Slept through dose time
40%
Sick
28%
Sad, sorrowful
18%
Individual problems
14%
Side effects
12%26
Factors influencing non adherence to HIV
treatment





Medications interfere with daily life
Drinking alcohol or using drugs
Sad mood, stress
Pessimistic about HIV
Treatment is less effective than
desired
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Goals of adherence to ARV drugs




Maximizes inhibition of viral load
Reduces drug resistance
Increases time of exposure to
effective medication
Above all, helps:
• Delay progression to AIDS
• Prolong survival
• Improve quality of life
28
Components of adherence



Take medicine on time
Maintain regular check up
Maintain “healthy lifestyle with HIV”
• Eat healthy food
• Exercise regularly
• Do not smoke tobacco or drink alcohol
29
Nurse should pay
attention to
30
Learn about the patient (1)
Find out attitudes, knowledge and
beliefs of the patient by asking
questions :
 About medication generally:
• For example: Did you take medication
before? Tell me about that.

About HIV/AIDS:
• For example: Can HIV be cured?
31
Learn about the patient(2)

About ARV drugs:
• Do you know someone who is on ARV
therapy?
• How is his/ her health after taking
ARVs?
• What would happen if you take ARV
drugs?

Patient’s desires:
• benefit and cost of treatment
• changes in appearance (or not)
• side effects
32
Learn about the life circumstances
of the patient (1)


Has patient ha disclosed his / her HIV
status to anyone?
Who is the main support person for the
patient?
• Does s/he know that the patient has HIV?
• What does s/he know about ARV drugs?
33
Learn about the life circumstances
of the patient (2)

Life circumstance
• Have a house?
• Is anyone in the family aware of the
patient's diagnosis?
• Are there any children at home?

Daily living
• work?
• child care?
34
The role of nurses in ARV therapy
groups (1)



Instruct patients on ARV therapy
purposes
Understand how ARV impacts
patients’ lives
Collaborate with physicians and
pharmacists in ARV therapy group to
give patients the best care
35
The role of nurses in ARV therapy
groups (2)

Ensure that patients:
• understand how to take medicine
before leaving the clinic
• have plans to remember to take
medicine

Instruct patients on:
• possible side effects
• what to do if side effects occur

Give patients and their families a
message of: HOPE
36
Key points



The goal of ARV treatment is to
reduce viral load and increase CD4
count and ultimately to increase
quality of life
A 3-drug combination is most
effective
The role of nurses is to help patients
adhere to treatment to obtain the
best results from ARVs
37
Thank you
Question?
38