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Antiretroviral treatment reduces the multiplication of HIV and this allows the immune system to recover. As a result the patient loses the symptoms and signs of HIV infection and is able to return to a normal lifestyle. Antiretroviral treatment therefore decreases both the morbidity and mortality related to HIV. Antiretroviral treatment is best started at an antiretroviral clinic. Antiretroviral therapy may also be started in a TB clinic for TB patients, at a MOU for pregnant women or in a hospital or hospice for very sick patients.
The main goal of antiretroviral treatment is to get the patient well again.
This is a clinic where antiretroviral treatment is started and managed. Patients are referred to the antiretroviral clinic when they have met the criteria for treatment. An antiretroviral clinic is staffed by doctors and nurses who have had special training in the use of antiretroviral drugs and the management of patients on these drugs.
This is the visit when antiretroviral treatment is started (i.e. commencement visit). Patients should already have been prepared for antiretroviral treatment at one or two screening visits. A decision would already have been made that the patient is ‘treatment ready’ and baseline blood tests done. A final check is made that the patient is fully prepared for treatment. At the first antiretroviral treatment visit the following should be done:
This is a treatment card kept by the patient (similar to the antenatal cards and Road-to-Health cards). It includes all the important information about the patient’s management. Patient-carried cards are a very important tool in helping patients become responsible for their care. It also improves communication between health facilities. Managing HIV infection like any other disease helps to reduce stigma.
Almost all patients are started on the first-line single dose combination tablet of TDF, FTC and efavirenz. Nevirapine may be used instead of efavirenz for patients with psychiatric disorders or other contraindications to efavirenz, e.g. shift workers who would not want to take their medication before starting night shift. All patients who have previously been started on a first-line regimen containing d4T should have the d4T changed to TDF.
Treatment is almost always started with the first-line combination of antiretroviral drugs.
Co-trimoxazole prophylaxis will be continued until the CD4 count is above 200 cells/µl. This usually implies that prophylaxis is continued for at least the first six months of antiretroviral treatment.
Usually patients are seen at the antiretroviral clinic at one, two and three or four months after starting treatment.
Patients who are taking nevirapine have an extra visit two weeks after starting treatment as they need to be assessed for possible side effects and the dose of nevirapine needs to be increased from the starting dose of one tablet daily to one tablet twice daily at this visit.
At every clinic visit. The importance of excellent adherence and support must always be stressed. Patients must have an opportunity to ask questions or discuss problems.
The patient should be counselled at every visit.
Trained lay counsellors and community care workers are very important members of the health team.
Monthly to 3-monthly. A missed visit for medication suggests poor adherence. When medicine is collected, the patient should also be seen by a nurse or counsellor who will assess adherence and ask about side effects. Excellent adherence must be promoted at every visit. The antiretroviral treatment register or electronic database must be updated each time medication is provided.
Creatinine clearance monitoring is done at three, six and twelve months for patients on TDF.
Clinical monitoring without blood tests is adequate for 3TC, efavirenz and d4T provided the patient is clinically well.
Most of the side effects will have cleared by three months. Patients should also be into the routine of taking their antiretroviral drugs regularly. Few problems are expected after three months therefore patients, will then only be seen by a doctor six-monthly. They may collect their medicines every one to three months.
Some antiretroviral clinics are able to follow their patients for six months after starting treatment. However, some patients can be referred back to the HIV clinic sooner or may be enrolled in adherence clubs for long term support during treatment.
With successful treatment patients should start to feel and look well again. Most patients develop a good appetite and gain weight. Associated infections such as thrush and diarrhoea disappear and skin rashes clear up. The clinical response follows the gradual recovery of the immune system. By three months patients should notice a big difference in their general health.
The viral load is a measure of the amount of HIV in the blood. The higher the viral load, the faster HIV is multiplying. Therefore, a high viral load indicates that there is a lot of HIV in the blood (and other body secretions). Viral load is usually expressed as RNA copies/ml (which is the same as copies/ml).
The viral load is a measure of the amount of HIV in the blood.
People with HIV infection can have a viral load ranging from less than 50 copies/ml to several million copies/ml. A viral load of less than 50 copies/ml is regarded as ‘undetectable’.
The viral load is the best indicator of the response of the immune system to antiretroviral treatment. With successful treatment the viral load will steadily drop until it is undetectable. Measuring the viral load is of very little value before antiretroviral treatment is started.
Viral load is the best indicator of the success of antiretroviral treatment.
The viral load is expressed as copies/ml or a log value. The log value is preferred if the change in viral load is determined. If the viral load drops by 1 log the number of copies/ml will fall by a factor of 10. Similarly a 2 or 3 log drop means that the number of viral copies has decreased 100 or 1000 fold respectively. The log value will fall by 0.3 if the number of viral copies is halved.
Log values are used to measure changes in viral load.
If the response to antiretroviral treatment is good the viral load should fall by 1 log within six weeks. (See 5-25.)
These are transient (short-lived) increases in the viral load of patients who are being successfully treated. They may be caused by an acute infection or an immunisation. Therefore, it is important that the viral load is not measured when the patient is ill.
Viral loads should be measured once at 4 to 6 months and again 12 months after starting treatment and every 12 months thereafter. The CD4 count should be measured at 12 months after starting treatment and if less than 200cells/µl should be repeated at 6 monthly intervals until two consecutive CD4 counts are above 200cells/µl .
The CD4 count should increase. People with CD4 counts below 200 cells/µl may expect an increase of 80% or more.
The viral load should be undetectable (less than 50 copies/ml).
An undetectable viral load.
An undetectable viral load is the best indicator of successful treatment.
If the treatment is successful with an undetectable viral load by six months, the patient should be followed at the ART clinic and seen every three months. The CD4 count and viral load should be measured 12-monthly to determine whether the treatment has remained successful or not. Adherence should be supported at every clinic visit.
For many years. Provided drug adherence is excellent, viral resistance is unlikely to develop and a long-lasting response to multi-drug treatment can be expected (15 to 20 years with excellent adherence).
Antiretroviral treatment can be successful for many years.
The feature of treatment failure after six months on antiretroviral therapy is a viral load above 1000 copies/ml.
Progression of the clinical disease with further development of HIV-associated infections or malignancies despite antiretroviral treatment should always suggest treatment failure.
These patients and their management must be carefully reviewed before a change in treatment is made. Treatment failure may be due to poor adherence or may occasionally occur in spite of excellent adherence.
Always repeat the viral load measurement before considering a change in regimen.
Yes. If first-line treatment including nevirapine in a woman has failed, despite excellent adherence, make sure that she was not given nevirapine for the prevention of mother-to-child transmission of HIV. Previous exposure to nevirapine is not a contraindication to standardised first-line treatment. However, treatment of patients who have been exposed to any antiretroviral drugs before must be discussed with an antiretroviral expert before starting treatment.
Change from first-line to second-line treatment. The choice of the second-line combination depends on the drugs used in first line treatment.
If first line treatment consisted of TDF, 3TC or FTC plus efavirenz, change to a second-line regimen of AZT, 3TC and lopinavir/ritonavir. If AZT is contraindicated due to severe anaemia (Hb below 8g/dL), abacavir may be used in its place.
If first line treatment consisted of d4T or AZT plus 3TC and efavirenz, change to a second-line regimen of TDF, 3TC and lopinavir/ritonavir.
The schedule of visits is the same as that for the first-line combination with a commencement visit followed by visits at one, two and three or four months. Patients are then seen again at six months followed by three-monthly visits.
Patients receiving AZT should have a baseline Hb and differential white count or FBC before the start of treatment followed by a repeat test at three and six months, as AZT may suppress the bone marrow.
Patients on lopinavir/ritonavir should have a baseline fasting blood glucose, cholesterol and triglyceride measurement. This should be repeated at three months.
Resistance to protease inhibitors is rare and raised viral loads in these patients on second-line treatment are most often due to poor adherence. If failure is due to poor adherence, every effort must be made to improve it.
Patients with proven good adherence on second-line may be eligible for third-line treatment. These patients should be referred to an infectious-diseases clinic or specialist for resistance testing and consideration for third-line treatment, provided they have been on a protease-inhibitor (PI) containing regimen for at least a year and have not achieved viral suppression.
As PI resistance is uncommon and resistance testing is expensive, Western Cape ART guidelines recommend resistance testing in public-sector patients on second-line after at least two years of second-line treatment with three viral loads above 1000 copies/ml taken 8 to 12 weeks apart.
Patients who are not eligible for third-line treatment should remain on the second-line combination even if the viral load is high, as antiretroviral therapy has been shown to be effective at maintaining the patient’s CD4 counts even with viral loads up to 10000 copies/ml.
Adherence is the degree to which patients take their antiretroviral drugs correctly.
Excellent adherence is taking all the pills correctly every day. With excellent adherence, 95% of all doses must be taken (i.e. 19 out of 20 doses). This means that not more than three doses can be missed in a month. It is also important that the doses are taken at the same time each day. Taking all the drugs at the correct dose and at the correct time each day is very important if antiretroviral treatment is going to be successful. Antiretroviral treatment can suppress the viral load reliably only if adherence is excellent.
Not more than three doses a month should be missed.
Excellent adherence is the key to treatment success.
Poor adherence is missing doses or taking doses at the wrong time. Any adherence of less than 95% is not good enough (i.e. poor). Even adherence of 80 to 95% may be inadequate.
Every effort must be made to ensure excellent adherence. Without excellent adherence the progression of HIV will not be stopped.
Poor adherence increases the risk of treatment failure and drug resistance.
The history given by the patient is an unreliable method of assessing adherence. Better methods include:
A simple card for recording each dose on a daily basis helps promote and assess excellent adherence.
Note that excellent adherence does not correlate with gender, education level, socio-economic class or cultural background. Adherence can be excellent even in poor, under-developed communities.
Excellent adherence must be promoted before treatment is started and then promoted continually at every clinic visit. Patients must be encouraged to take an active and responsible role in their treatment.
Patients must be ready and prepared before starting antiretroviral treatment.
Adherence can be improved if the clinic provides a more caring service.
A good, caring service by the clinic improves adherence.
It is very important to find out why doses have been missed and how adherence can be improved.
It is important to find out why doses are missed.
If a dose is not taken at the correct time, it can still be safely taken when remembered. It is better to take the dose late than not at all.
Yes. If the patient vomits up the pills or tablets, the dose should be taken again immediately. Vomiting more than one hour after the medication is probably not important.
Taking ddI with meals results in poor absorption. Therefore ddI is always taken well before or well after a meal.
No, there are differences. With the DOT programme (Direct Observation of Therapy) the responsibility for taking the anti-TB medication is shared between the patient and a supporter in the community. This has only had limited success due to the difficulty in finding reliable and motivated supporters. In the HIV programme, patients are motivated and helped to take responsibility for their own treatment. Although family and community support is still important, the main responsibility for taking the medication correctly every day is placed on the patients themselves.
However, in patients who are unable to maintain excellent adherence in spite of help and support, a DOT system, where the responsibility for taking antiretroviral drugs is given to another reliable person (a ‘treatment partner’), may be useful.
It is hoped that the media and the general community will help in reminding people on antiretroviral treatment to take their medication. Reminders could be given over the radio or on television. As HIV is a national problem, it is important that the whole nation helps to make sure that there is excellent adherence to antiretroviral treatment in order to reduce the risk of HIV drug resistance and the further spread of HIV.
A national adherence programme is urgently needed.
Drug resistance in HIV occurs when the multiplication of HIV is not blocked completely by a particular drug combination. Drug resistance will lead to treatment failure.
Yes. The development of resistance to one or more antiretroviral drugs will reduce the chance of successful treatment to the individual. It will also increase the risk of other people in the community acquiring HIV infection which is resistant to those drugs. This can be disastrous to both the patient and the community.
Drug resistance can be disastrous to both the patient and the community.
Excellent adherence to antiretroviral treatment is the best way of avoiding drug resistance.
Yes. Patients who have previously been given antiretroviral drugs (‘non-naive patients’) must be carefully assessed by an antiretroviral expert before one of the standard drug combinations is started. There is concern that nevirapine used in the prevention of mother-to-child transmission (PMTCT) may cause later drug resistance to nevirapine in mother or infant.
If HIV becomes resistant to one drug in a class it is often also resistant to some or all the drugs in the same class. This is called cross-resistance (i.e. HIV is resistant to drugs across a drug class). This is particularly common for ‘non-nucs’. If patients are resistant to nevirapine there is a high chance that they will also be resistant to efavirenz. Drug resistance between classes is uncommon.
Treatment failure is diagnosed when antiretroviral treatment fails to produce and maintain an adequate suppression of the viral load. There are two forms of treatment failure.
Before diagnosing treatment failure it is important to repeat the viral load measurement after two to three months. The diagnosis of treatment failure is confirmed if the viral load remains high or increases further. Sometimes the viral load will be increased at the time of the first measurement but falls with the second measurement. Transient rises in the viral load are called ‘blips’. They are not uncommon, especially if there has been a viral or bacterial infection, or the patient has recently been immunised. Therefore, always repeat the viral load after two to three months before diagnosing treatment failure.
There are a number of causes:
Poor adherence is by far the commonest cause of treatment failure.
Poor adherence is the commonest cause of treatment failure.
The cause of the high viral load must be determined as far as possible, and actively managed, before the viral load measurement is repeated. It is important that the treatment regime should not be changed until a careful assessment is done and all the options considered. The second measurement of the viral load is usually done two to three months after the first measurement.
The treatment regimen should not be changed in haste.
This is the interference of one drug with another drug. Common examples of drug interaction are:
Using either the first- or second-line combinations for antiretroviral treatment avoids drug combinations which compete with each other.
Rifampicin, used in the treatment of TB, increases the rate at which some antiretroviral drugs are broken down by the liver. As a result, these drugs may not act adequately because their blood levels are too low.
Higher than normal doses of ‘PIs’ are needed if used together with rifampicin.
Peripheral neuropathy is a side effect of INH (isoniazid) as well as d4T and ddI. Therefore, the risk of peripheral neuropathy is greater if either d4T or ddI are used together with INH.
Due to drug interactions with both PIs and NNRTIs, many commonly used antiepileptic medications cannot be used with ART. Patients on phenytoin, phenobarbital and carbamazepine should have their medication changed to sodium valproate (epilim) or lamotrogine before starting ART. The changeover of treatment should occur gradually to avoid precipitating siezures.
Sodium valproate or lamotrogine are the antiepileptic medications of choice for patients starting ART.
This is when antiretroviral treatment is stopped for a short period (a temporary interruption).
Causes of drug interruptions are:
If only one antiretroviral drug is stopped there is a danger that resistance will develop to the remaining drugs. Therefore, it is best to stop all the antiretroviral drugs if drug interruption cannot be avoided. When stopping a regimen containing a ‘non-nuc’ the ‘nucs’ should be continued for one week after stopping the ‘non-nuc’. This is because the ‘non-nuc’ remains for a longer period in the body than the ‘nucs’ and the continuation of the ‘nucs’ therefore ensures that the patient continues to receive triple therapy until the ‘non-nuc’ has been eliminated. This is referred to as ‘covering the tail of the “non-nuc”’. This decreases the chance of the patient developing resistance to the ‘non-nuc’.
The same or another antiretroviral drug combination should be started as soon as possible. Never interrupt treatment if it can be avoided.
It is essential to stop all drugs and not just the one drug believed to be causing a problem.
All drugs must be stopped immediately. Never stop only one drug. The whole drug combination must be assessed. Either of the following may be done:
This is an unexpected clinical deterioration which occurs soon after antiretroviral treatment is begun. Functional immune recovery starts within weeks of beginning antiretroviral treatment. An inflammatory response to HIV-associated infections was not possible before antiretroviral treatment was started as the immune system was too suppressed. As the immune system recovers, the body may develop an inflammatory response to any of the following:
Up to a third of patients starting antiretroviral treatment develop a mild immune reconstitution syndrome which does not require treatment. Rarely the immune reconstitution syndrome is serious and very rarely may be life threatening.
It usually presents with fever and a worsening of the patient’s symptoms after starting antiretroviral treatment. All cases of severe immune reconstitution inflammatory syndrome must be urgently referred to an antiretroviral clinic. The immune reconstitution inflammatory syndrome usually presents abruptly within two weeks to a month after antiretroviral treatment is started. Consider immune reconstitution inflammatory syndrome in anyone who is not thriving after six weeks of antiretroviral treatment.
The immune reconstitution inflammatory syndrome presents suddenly and unexpectedly with clinical deterioration in the patient’s condition soon after antiretroviral treatment is started.
Patients with a CD4 count below 100 cells/µl when antiretroviral treatment is started.
Tuberculosis is the commonest cause of the immune reconstitution syndrome in South Africa. The immune reconstitution inflammatory syndrome presenting with TB is less common if TB is treated for at least a month before starting antiretroviral treatment. Immune reconstitution inflammatory syndrome is not caused by treatment failure, side effects or drug interactions.
The disease causing the inflammation must be diagnosed and treated. Avoid stopping antiretroviral treatment if at all possible. The patient may need to be referred to an HIV specialist.
Immune reconstitution inflammatory syndrome is not an indication to stop antiretroviral treatment.
Some patients become anxious and depressed despite a good response to treatment because they face a lifetime of taking drugs for a chronic disease. A similar problem is seen with patients suffering from other chronic medical conditions such as diabetes and epilepsy. These patients need additional counselling and support. This problem can usually be avoided by good preparation before treatment is started.
Unfortunately some antiretroviral drugs are expensive. If the state does not provide a free service, patients have to buy their own drugs. Expense is one of the reasons that antiretroviral treatment is not made available to all patients who need it. It is hoped that more cheaper generic drugs will be produced for poor countries.
A patient who is ‘treatment ready’ attends her first treatment visit. She is clinically well with a CD4 count of 146 cells/µl and has a good understanding of the treatment but is concerned about side effects as she works as a locum nurse and sometimes does night duties.
After a pill count (of co-trimoxazole) and meeting with the counsellor to discuss the importance of excellent adherence, a final assessment is made by a clinician. This is followed by a visit to the pharmacist to collect the first month’s supply of medication.
Patients are almost always started on the first-line combination (3TC or FTC, TDF and either nevirapine or efavirenz). Co-trimoxazole prophylaxis will also be continued until the patients CD4 count is above 200cells/µl.
3TC, TDF and nevirapine. Most patients would start on a fixed dose combination tablet of TDF, FTC and efavirenz but as this patient does shift work, efavirenz is not the best option as it often causes drowsiness.
Routine visits should occur at monthly intervals with an extra visit at two weeks for patients receiving nevirapine.
Because the dose of nevirapine should be started at 1 tablet once daily and increased to 1 tablet twice daily at two weeks.
At the routine visits the patients are weighed and clinically examined. A history is taken for adherence, side effects or other problems and the patient is counselled. A pill count is done, routine blood samples are taken and one month’s supply of medication is given.
A patient attends all his routine visits for the first four months. He feels well and all his symptoms and signs of illness gradually disappear. He has no side effects from the antiretroviral treatment.
At six months after starting treatment. However, he should immediately return to the antiretroviral treatment clinic if he experiences side effects or has other problems.
Every one to three months. These visits should be used to assess and promote excellent adherence.
By measuring the CD4 count and viral load as well as finding out whether the clinical signs of HIV have disappeared.
The viral load should be measured at four or six months after starting treatment. Completing the first viral load earlier allows time for an adherence intervention if the viral load is raised, potentially reducing the risk of resistance. The viral load should be undetectable if treatment is successful. The CD4 count should be measured after one year on treatment if the CD4 count at the start of treatment was greater than 200 cells/µl. If the CD4 count at the start of treatment was less than 200 cells/µl, it should be measured at 6 monthly intervals until it is above 200 cells/µl on two occasions. This is to guide prophylactic treatment with co-trimoxazole or fluconazole, both of which are stopped when the CD4 count is above 200 cells/µl.
An undetectable viral load.
If the antiretroviral treatment has been successful the patient may be seen every three months. However, he should continue to collect his medication regularly. His CD4 count and viral load should be measured at one year on treatment and he should continue to have a viral load test every year.
A patient who was started on a first line regimen of TDF, FTC and efavirenz is still ill after antiretroviral treatment for six months. Her CD4 count remains below 200 cells/µl and her viral load is above 1000 copies/ml.
Possible antiretroviral treatment failure.
It is important to establish whether adherence has been excellent or poor. If adherence is poor, every effort must be made to improve it. The viral load should then be measured again after two to three months. If it remains high the patient has failed antiretroviral treatment and treatment should be stopped until the patient has been fully prepared to start a second-line treatment regimen.
If the viral load remains high in spite of excellent drug adherence, the patient should be switched to a second-line regimen of AZT, 3TC and Aluvia without interrupting treatment. The HIV is probably resistant to the first-line drugs.
The same as first-line treatment with visits every month until 4 months followed by a visit at six months and then every three months thereafter if treatment is successful.
Before treatment is started an Hb with differential white count (or a FBC), glucose, triglyceride and cholesterol tests are done for baseline values.
After treatment has been started an Hb and differential should be done at months three and six to screen for anaemia, which is a common side effect of AZT. Fasting glucose, cholesterol and triglyceride should be measured at three months. These tests screen for metabolic abnormalities caused by lopinavir/ritonavir (Aluvia).
A patient on antiretroviral treatment admits to poor adherence. He is sent to the treatment counsellor to discuss the importance of excellent adherence.
Taking less than 95% of doses. Even moderate adherence, when between 80 and 95% of doses are taken, is not satisfactory. The goal must be to take all doses at the correct time.
Antiretroviral treatment is likely to fail and there is a high chance of HIV resistance to the antiretroviral drugs.
Link the time for the dose with a particular radio or TV programme or an activity, e.g. cleaning his teeth. An alarm clock can be used or a supporter could remind him or send a cellphone message.
Because it restricts the choice of drugs which are likely to be effective. If both the first- and second-line combinations fail, patients with good adherence and resistance to protease inhibitors may be eligible for third-line treatment.
It makes HIV more difficult to treat. Others may become infected with a strain of HIV resistant to one or more drugs. Therefore it is in the interest of the whole community that patients take their antiretroviral treatment correctly.
By excellent adherence and always using combinations of at least three antiretroviral drugs.
Three weeks after starting antiretroviral treatment a patient becomes unwell with fever and severe cough. The patient had been reasonably well during the weeks before starting treatment despite having a very low CD4 count.
Immune reconstitution inflammatory syndrome (IRIS). Patients with a very low CD4 count at the start of antiretroviral treatment are at high risk of this condition.
Tuberculosis. With fever and cough this patient probably has the immune reconstitution inflammatory syndrome due to TB. This can sometimes be prevented if the TB treatment is started before starting antiretroviral treatment.
This is an inflammatory reaction which develops when the patient’s immune system starts to recover. Before treatment is started, the immune system is too suppressed (weakened) to respond to an infection such as TB. The treatment therefore ‘unmasks’ an infection that previously had been ‘hidden’.
It usually gets better if antiretroviral treatment is continued provided that the underlying cause is also treated. Immune reconstitution inflammatory syndrome is not an indication to stop antiretroviral treatment.
Provided their adherence is excellent, they can remain well with a good quality of life for many years. Many patients on ART will have a normal life expectancy.
The fact that they have a chronic illness and must remain on treatment for life. The price of antiretroviral drugs may also be high in the private sector. These difficulties should be discussed with the treatment counsellor.
|Medicine||Timing of doses||Possible side-effects|
|1. TDF (Tenofovir) 300mg daily||24 hours||Kidney damage|
|2. 3TC (lamivudine) 300mg daily or FTC (emtricitabine) 200mg daily||24 hours||Diarrhoea, headache|
|3. Efv (Efavirenz) 600 mg daily||24 hours||Skin rash (allergy), vivid dreams, dizziness, sleep changes in first four weeks|
Most side effects get better after one to two months of treatment.
Where possible, prescribe as a fixed dose combination tablet of TDF, FTC and Efavirenz as a once daily tablet (e.g. Atripla or Odimune one tablet daily).
If first-line treatment was TDF, FTC or 3TC and efavirenz or nevirapine, prescribe:
|Medicine||Timing of doses||Possible side-effects|
|1. AZT (Zidovudine) 300 mg twice daily||12 hours||Numbness or pain in the feet, abdominal pain, hepatitis, acidosis|
|2. 3TC 150mg twice daily||12 hours||Diarrhoea, headache|
|3. LPV/r (Lopinavir + ritonavir) 400/100 twice daily (Aluvia 2 tablets twice daily)||12 hours||Skin rash (allergy), hepatitis|
TDF should be continued in second-line treatment in patients with Hepatitis B (HepB surface antigen positive). Second-line treatment would then consist of three nucs, namely TDF, AZT, 3TC and LPV/r.
If first-line treatment was AZT or d4T, 3TC and efavirenz or nevirapine (i.e. old first line), prescribe:
|Medicine||Timing of doses||Possible side-effects|
|1. TDF 300 mg once daily||24 hours||Kidney damage|
|2. 3TC 150mg twice daily||12 hours||Diarrhoea, headache|
|3. LPV/r (Lopinavir + ritonavir) 400/100mg twice daily (Aluvia 2 tablets twice daily)||12 hours||Skin rash (allergy), hepatitis|
Most side effects get better after one to two months of treatment.