General Principles of Antiretroviral Therapy for Chronic HIV Infection in Adults and Adolescents
Taking antiretroviral therapy (ART) requires long-term commitment from patient. Correct and consistent use required for drugs to be effective. Antiretroviral drugs (ARVs) have side effects that can make them difficult for some patients to take. Thus the decision about when to start therapy is an important one. Treating too early may lead to unnecessary toxicity and premature drug resistance; treating too late can increase risk of morbidity, mortality, and treatment failure.
- Reduction of viral load (VL) as much as possible for as long as possible
- Restoration and/or preservation of immunologic function
- Improvement of quality of life
- Reduction of HIV-related illness and death
- Possible reduction in transmission to others
- Use of combinations of at least 3 ARV drugs
- Maximize adherence to ARV regimen
- Rational sequencing of ARV drugs
- Avoid resistance
- Appropriate drugs available
- Drug supply can be sustained
- Basic clinical and lab measures used to determine need for treatment
- Basic clinical and lab measures available to monitor for toxicity
- Patient understands importance of adherence
- Health care providers trained in use of ART
- Before initiating or changing ART in
Pregnant women or women at risk for pregnancy with CD4 counts 250-350
- Patients co-infected with viral hepatitis
- Patients with ALT/AST >5-fold the upper limits of normal range
Co-infection with TB if on non-EFV regimen
- Failure or inability to tolerate second-line therapy or when on other PI-based regimen
- Severe or life-threatening adverse reactions
- Before restarting ART after severe or life-threatening adverse reactions
- Inability to tolerate therapy despite change in regimen
- Asymptomatic patient wishing to start ART with no CD4 count available or with CD4 >200
HAART: a combination of at least 3 drugs: namely, any of the following 3 combinations
- 2 nucleoside reverse transcriptase inhibitors (NRTIs) + 1 non-nucleoside reverse transcriptase inhibitor (NNRTI)
- 2 NRTIs + 1 protease inhibitor (PI)
- 3 NRTIs
- Goal of HAART: to reduce VL to undetectable levels.
- HAART must be taken for life.
Adherence vital to prevent emergence of resistance.
- HAART indicated for any patient who meets Zambian National Guideline eligibility criteria.
- All patients must have confirmed HIV serology and should access counselling services.
- HAART complements treatment and prophylaxis of opportunistic infections.
- HAART not an emergency; must be initiated after proper treatment preparation.
- In case of post exposure prophylaxis (PEP), prophylaxis should be initiated as soon as possible (ideally within 2 hours of exposure).
- In PMTCT, more urgent prophylaxis needs to be considered to minimize risk of perinatal transmission.
Health care providers fulfilling following requirements:
- Legally recognized to prescribe in Zambia
- Trained in HIV/AIDS management
- Have access to sustainable drug supply and facilities to monitor therapy
- Participate in continuous medial education in use and monitoring of ART