Zambian HIV Guidelines:: General Principles of Antiretroviral Therapy for Chronic HIV Infection in Adults and Adolescents

	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

Guidelines>Zambia HIV National Guidelines>

General Principles of Antiretroviral Therapy for Chronic HIV Infection in Adults and Adolescents

05-06-2008

Introduction

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.

Goals of Therapy

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

General principles of ART

Use of combinations of at least 3 ARV drugs
Maximize adherence to ARV regimen
Rational sequencing of ARV drugs
Avoid resistance

Prerequisites for administration of ART

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

Indications for Consultation with or referral to an HIV specialist

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

Highly Active Antiretroviral Therapy (HAART)

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

General Points

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.

Who should prescribe HAART?

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

Contacts

Help

Acknowledgments

Abbreviations