Zambian HIV Guidelines:: Changing or Stopping ART

	Zambia HIV National Guidelines
	Introduction HIV Counseling and Testing Sexually Transmitted Infections (STIs) General Principles of Antiretroviral Therapy for Chronic HIV Infection in Adults and Adolescents When to Start ARV Therapy for Chronic HIV Infection in Adults and Adolescents Initial Regimen for ARV Therapy Adherence Baseline evaluation and Monitoring Calculations: Ideal Body Weight, Body Mass Index and Creatinine Clearance ARV Therapy for Individuals with Tuberculosis Co-Infection Adverse Effects and Toxicity Immune Reconstitution Inflammatory Syndrome (IRIS) Changing or Stopping ART Treatment Failure Stopping ARV Therapy Post Exposure Prophylaxis Cotrimoxazole Prophylaxis WHO Staging in Adults and Adolescents Nutrition Care and Support Palliative Care in HIV and AIDS
	Guide Editors
	Editor In Chief Joel E. Gallant, MD, MPH Pharmacology Editor Paul Pham, PharmD, BCPS Zambia Guideline Team Peter Mwaba MMed PhD FRCP Alywn Mwinga MMed Isaac Zulu MMed MPH Velepie Mtonga MMed Albert Mwango MBChB Jabbin Mulwanda MMed FCS

Changing or Stopping ART

05-06-2008

Goals in Changing Regimens

Restore patients clinical, immunologic and virologic response when treatment failure occurs
Manage serious toxicities and intolerance
Reduce likelihood of adverse events when certain medical conditions occur (e.g., pregnancy, TB)

Indications for Changing Treatment

Intolerance or unresolved and prolonged side effects
Treatment failure: clinical, immunologic, or virologic as outlined above
Toxicity such as anaemia, peripheral neuropathy, liver or renal abnormalities
Poor adherence: change indicated only to simplify dosing schedule to improve adherence
Active TB: (refer to TB/HIV co-infection)
Pregnancy: if regimen contains EFV
New therapies: may consider change in regimen as new agents with better efficacy and/or lower toxicity become available

Before Changing Therapy for Treatment Failure , Rule Out

Immune reconstitution inflammatory syndrome (IRIS)
Untreated inter-current OIs
Poor adherence: must be corrected and therapy changed only after adherence issues have been addressed (unless change will improve adherence)
Inadequate dosing
Drug interactions resulting in reduced ART blood levels (e.g. NVP + rifampicin)
Poor absorption of drugs due to adverse effects (e.g., nausea/vomiting)
Inter-current infections causing transient decrease in CD4 count (if possible, repeat CD4 to confirm immunologic failure)

Changing ART Due to Toxicity

Footnotes

If creatinine clearance normal
Exclude malaria in endemic areas; severe anemia (grade 4) defined as Hb <6.5 g/dl
Neutrophil count <500/mm³ (grade 4)
e.g. persistent hallucinations or psychosis
Extensive rash with desquamation, angioedema, or reaction resembling serum sickness; or rash with constitutional findings (e.g. fever, oral lesions, blistering, facial oedema or conjunctivitis); Stevens-Johnson syndrome can be life-threatening. For life-threatening rash, substitution with EFV not recommended, although has been reported in small number of patients in Thailand without recurrence of rash.

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