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Antiretroviral treatment (ART) is best started when a patient’s immune function begins to decrease. This is indicated by either one or both of the following:
Antiretrovirals should also be started in all pregnant or breastfeeding women to prevent mother to child transmission of the virus.
Antiretroviral treatment should preferably be started before a patient’s immune system begins to fail.
The 2014 South African treatment guidelines recommend that antiretroviral treatment should be started when the patient reaches clinical stage 3 or 4 disease.
All pregnant and breastfeeding women and all patients with Hepatitis B or TB should start ART irrespective of their CD4 count.
Antiretroviral treatment should be started when stage 3 or 4 is reached.
Antiretroviral treatment should be started when the CD4 count falls below 500 cells/µl, even if the clinical stage is still 1 or 2. The aim of antiretroviral treatment is to prevent the CD4 count dropping further.
Yes. Both the clinical stage of HIV infection and the CD4 count should be considered when deciding on whether to start antiretroviral treatment or not. Either the clinical stage of HIV infection (e.g. stage 3 or 4) or the CD4 count (e.g. below 500 cells/µl) may be used as an indication to start treatment. Therefore, treatment is indicated in a patient who is stage 2 but with a CD4 count below 500 cells/µl. Similarly, treatment should be started in all stage 4 patients even if their CD4 count is still above 500 cells/µl.
Both the clinical stage of HIV infection and the CD4 count are used as independent indicators for starting antiretroviral treatment.
Yes. It is a major decision to start antiretroviral treatment as these patients will have to take drugs every day for the rest of their life. The patients must be fully counselled and given time to consider all the implications. Their opinion is very important and they must agree before treatment is started. They must understand the implications, the benefits and the side effects. Patients must be prepared and ready to start antiretroviral treatment. Treatment will fail if the patient is not ready and willing to start.
Patients must be fully informed and willing to start antiretroviral treatment.
Patients should have a CD4 count below 500 cells/µl or stage 3 or 4 disease plus a readiness and commitment to lifelong treatment. Therefore both medical and psychosocial factors are important in deciding when a patient should start antiretroviral treatment.
Both medical and personal factors must be considered before starting antiretroviral treatment.
The nurse at the HIV clinic or general primary-care clinic, if an HIV clinic is not available. As the decision to start antiretroviral treatment is often complex, and as patient preparation is so important, this assessment should be done at an antiretroviral clinic if possible. All HIV clinics should know the criteria for patient referral. Patients should not be referred for antiretroviral treatment before the criteria are met.
Patients should be sent to the antiretroviral clinic with a full referral letter. A standardised referral letter is helpful. Send the latest CD4 count if available. An appointment should be made. The patient must be told the venue, date and time of the appointment. Keeping appointments is a good index of patient reliability.
Patients who meet the criteria for treatment should be referred to the antiretroviral clinic.
The multidisciplinary team at the antiretroviral clinic. The team consists of the doctor, nurse, counsellor and community care worker.
All the important management decisions should be made by a multidisciplinary team.
The patient is referred back to their local clinic with a letter providing the reasons why the patient has not been accepted for antiretroviral treatment. The local clinic should follow these patients and refer them again to the antiretroviral clinic when the criteria (stage 3 or 4 or CD4 count below 500 cells/µl) have been met. Any psychosocial problems identified during screening should be addressed. Patients should be provided with counselling to encourage disclosure so that they can obtain social support.
No. However, psychosocial considerations (emotional, family and community problems) are very important when a patient is being assessed for antiretroviral treatment. Antiretroviral treatment is likely to fail if there are major psychosocial problems. Therefore, provided antiretroviral treatment is not urgently required for clinical reasons, it may be postponed until the psychosocial problems have been addressed.
Psychosocial problems are useful in predicting whether treatment is likely to be successful or not.
Antiretroviral treatment is postponed (deferred) if:
Treatment however should not be delayed if the patient has a CD4 count below 100 cells/µl, has Stage 4 disease, is pregnant or breastfeeding or has drug-resistant TB. In these instances extra counselling support should occur during the first weeks of treatment.
Starting too early when a patient is not treatment ready may lead to:
Poor adherence and drug resistance will decrease the chances of a good response to antiretroviral treatment when it is really needed.
Patients may die of the complications of HIV infection if antiretroviral treatment is started too late. Therefore, the correct timing of starting treatment is very important and is a balance between the risks of poor adherence, drug resistance and side effects if started too early, and the risk of serious illness if started too late. If antiretroviral treatment is started too late (e.g. with a CD4 count below 100 cells/µl) the immune system may have been so badly damaged that full recovery is no longer possible.
The timing of starting antiretroviral treatment is a balance between the risks of starting too early and the dangers of starting too late.
Usually two to four weeks. During this time the patient is prepared for the start of antiretroviral treatment.
It usually takes two to four weeks to prepare a patient for antiretroviral treatment.
Starting antiretroviral treatment is never an emergency. But sometimes the indication to start may be urgent and treatment should not be unnecessarily delayed. Wherever possible, patients must be fully prepared before treatment is started and this always takes time. Preferably do not rush the decision or force patients who are well to start antiretroviral treatment before they are ready. Patients must show a commitment to take their medication correctly and follow instructions. However, in some cases the preparation may need to be as fast as possible, e.g. pregnant and breastfeeding women or patients with CD4 counts below 100cells/µl or stage 4 disease.
Starting antiretroviral treatment becomes urgent when the patient is demented or very weak and ill. In many of these cases the patient will die if treatment is delayed until they are fully prepared.
The decision to start antiretroviral treatment usually is not an emergency and must not be rushed.
If the treatment is begun before the patient is ready to start treatment, there will almost certainly be poor adherence. The success or failure of antiretroviral treatment often depends on whether the patients have been well prepared or not. One of the main reasons for treatment failure and poor co-operation from patients is inadequate preparation.
Inadequate preparation is an important cause of poor co-operation and treatment failure.
It is very important that HIV patients take their correct medication on time every day. Poor adherence to taking medicine correctly leads to HIV resistance to one or more of the antiretroviral drugs being used. This reduces the drug options later in the course of the illness. Taking the first regimen of antiretroviral drugs correctly is the best chance the patient has to be healthy and well for many years.
Excellent drug adherence is extremely important for the successful management of AIDS.
Usually two treatment readiness visits are needed, followed by the final visit when treatment is started.
Usually two visits are needed to fully assess a patient for antiretroviral treatment.
This is best done by the multidisciplinary staff of the health centre where antiretroviral treatment is started. The doctor, nurse, counsellor, and pharmacist all play an important role in preparing a patient for antiretroviral treatment. Sometimes patients are referred for special treatment readiness classes.
Patients need to attend a treatment readiness programme.
The patient needs to:
The patient needs to understand antiretroviral treatment (‘patients must know their meds’). It is particularly important that the patient accepts that excellent adherence is essential and understands that resistance is dangerous, and that failure of treatment and resistance are usually due to poor adherence.
Patients need to know about the drugs they will be taking.
The patient may need help in accepting their HIV status and the importance of antiretroviral treatment. They may also have difficulty disclosing their HIV status and finding someone who can support them. All patients preparing for antiretroviral treatment should be encouraged to join a support group. Patients need an opportunity to talk about their fears and concerns. Counselling empowers patients to make the best decisions for themselves and take control of their lives. It helps them understand, accept and make choices.
Disclosure and support are needed for successful treatment.
Co-trimoxazole provides protection against pneumocystis pneumonia, toxoplasmosis, many bacterial infections and some causes of chronic diarrhoea.
Two single-strength tablets daily (i.e. 80/400 mg). The commonest side effect is a maculopapular rash. Continue the co-trimoxazole if the rash is mild. Stop immediately if the rash is severe or blistering, the mucous membranes are involved, or the patient becomes ill with fever.
Yes, as patients who are not adherent to prophylactic co-trimoxazole will probably not adhere to antiretroviral treatment. Patients should bring their unused tablets to each clinic visit. These should be counted to assess adherence. If all the tablets needed have not been taken, the patient should be counselled to find out why adherence is poor. The advantages and importance of excellent adherence must again be stressed.
Adherence to co-trimoxazole is a good indicator of adherence to antiretroviral treatment.
A home visit is very helpful to assess the home circumstances and family support, and whether the patient has provided the correct contact and social details. A reliable home address is essential and a telephone contact number is useful. A home visit also helps to determine whether the patient has disclosed his/her HIV status.
This is usually done by a lay counsellor who has taken on the role of community care worker or home based carer.
Some lay counsellors are on antiretroviral treatment themselves. They have a personal understanding of what it means to have HIV infection and successfully adhere to treatment. As a result, these lay counsellors are good role models for patients starting antiretroviral treatment.
Lay counsellors undergo careful training which provides them with the knowledge and skills to function in their new role as counsellors and educators. Without lay counsellors, most antiretroviral clinics would not be able to function. They are essential members of the treatment team as they know the community well, usually speak the patients’ home language and help to maintain close contact between patients and the clinic.
Lay counsellors promote a healthy lifestyle and often follow up the patient once antiretroviral treatment is started. Tracing patients that fail to collect their medicines regularly or miss a clinic appointment is an important function.
Lay counsellors are valuable members of the treatment team.
A personal counsellor is a great advantage if it is possible to have one. Often the success of antiretroviral treatment depends on the help and support of a lay counsellor. The counsellor should develop a special, caring relationship with the patient. They can perform the home visit, meet the patient at each clinic visit and act as the contact between the patient and the clinic team.
It is a great advantage if each patient can have a personal counsellor.
The second visit is usually arranged for one to two weeks after the first visit. During this time the patient has had time to consider the implications of antiretroviral treatment. The following should be done at the second assessment visit:
The second visit is followed by a multidisciplinary team discussion.
Following the second visit the patient must be assessed for readiness for antiretroviral treatment by a multidisciplinary team. This is done by the whole treatment team and not just one person. All the available information must be ready for the discussion (clinical assessment, results of the two educational and counselling sessions and a home visit report if possible). This is the final check that the patient is fully prepared for treatment.
Patients who are ready for treatment should be given an appointment to start their antiretroviral treatment.
The treatment plan is the formal guide to the patient’s future management. Each patient must be fully aware of their own treatment plan. Usually the treatment plan is given to each patient as a printed form.
It is essential that each patient has a clearly understood treatment plan.
If patients are not treatment ready yet and are clinically well, the start of antiretroviral treatment may be postponed until they are ready and all the requirements have been met.
The baseline CD4 count has usually been done before the patient is referred for treatment consideration and, therefore, need not be repeated. If the CD4 count was not measured, this should be done at the screening visit.
Special blood tests depending on the likely side effects of the specific drugs being used:
Other routine baseline blood tests:
They should be asked to continue their co-trimoxazole prophylaxis and be given an appointment for their next visit in one to two weeks when antiretroviral treatment will begin.
Once it is agreed that antiretroviral treatment should be started, the drug regime and doses must be decided on and the drugs should be ordered from the pharmacy. It is helpful to have a system which maintains a close check on medication collected.
A patient who has had symptomatic HIV infection for the past year is referred to an antiretroviral clinic for treatment. Her CD4 count is 150 cells/µl and she has been clinically graded as stage 4. She is unhappy about starting treatment as she does not want to disclose her HIV status to her partner and family. She has a chronic cough.
Yes, as her CD4 count is below 500 cells/µl. This indicates that her immune function is depressed and she is at high risk of contracting an opportunistic infection unless she receives antiretroviral treatment.
Yes. Stage 4 HIV infection (i.e. AIDS), with or without a low CD4 count, is a criteria for treatment. She therefore meets both the immunological and clinical criteria for treatment.
No, as she has psychosocial problems. She is not happy about starting treatment and has not disclosed her status to either her partner or family.
No, but she should be counselled and be helped to become ‘treatment ready’. Without disclosure, support and a firm commitment to daily medication, she will almost certainly not succeed with antiretroviral treatment.
Yes, as she has a CD4 count above 50 cells/µl she should start antiretroviral treatment 2 to 8 weeks after starting treatment for tuberculosis.
A patient who meets both the medical and psychosocial criteria for treatment attends his first screening visit. He is very keen and wants treatment to start immediately.
No. It is always important to make sure that the patient is well prepared before starting treatment. Starting antiretroviral treatment is not an emergency.
A careful history should be taken and a full physical examination done to confirm that all the criteria for treatment have been met. Counselling and education sessions must be arranged and co-trimoxazole started.
All the members of the multidisciplinary team play a role. Individual counselling is important. Pamphlets, videos and posters are helpful. A group education course may be available.
He must know what drugs are to be taken, the dose and timing of treatment, and the side effects. He must ‘know his drugs’. The importance of excellent adherence must be stressed at every meeting. He must be aware of the risks and advantages of treatment.
It prevents many of the infections associated with HIV. It is also a measure of the patient’s willingness to take regular medication. A ‘pill count’ assesses whether all doses have been taken. Taking all his co-trimoxazole tablets as prescribed suggests he will also adhere to antiretroviral treatment.
For successful treatment drug adherence must be excellent.
After the first screening appointment a home visit is arranged. This is done by a community care worker. The community care worker discovers that the patient is drinking heavily over weekends.
To help assess the home circumstances, especially disclosure and support. It is also important to confirm the home address and contact phone number.
Usually there are not enough professional counsellors to do all the home visits. Therefore community care workers or home based carers often perform this function. They are well trained and employed by the clinic.
They sometimes are HIV positive and well managed on antiretroviral treatment. As a result they have personal experience of the problems of HIV management. They come from the local community and have a good understanding of the social circumstances. Usually the community care worker can speak the patient’s home language. The community care worker is a good role model for the patient starting antiretroviral treatment.
Yes, if uncontrolled. So would untreated active depression or drug abuse. These problems would need to be successfully managed before treatment could start. Discovering this problem stresses the importance of a home visit.
They help with counselling and education. Lay counsellors keep close contact between patients and the clinic. They help promote a healthy lifestyle with a positive outlook.
A patient attends the screening visit. After she is seen by the doctor, blood samples are taken. She is assessed for treatment readiness and told to return to the clinic for treatment readiness classes.
A CD4 count is done if this has not already been checked. Additional blood tests are done depending on the drugs to be used:
When they are willing to accept that treatment is for life and excellent adherence is the key to successful treatment. They must understand how to take their medication correctly and know what side effects to expect. They should also be able to attend clinic regularly, have preferably disclosed their HIV status and have good home support.
The multidisciplinary team. The decision should not be taken by the doctor alone.