Monitoring Of Patients Who Are Receiving Haart
Routine laboratory monitoring should be done approximately every 3 months to determine whether the patient has asymptomatic abnormalities. Monitoring laboratory tests include complete and differential blood counts and measurement of electrolyte, creatinine, liver transaminase, bilirubin and amylase levels. Patients should also be monitored at regular intervals for dyslipidemia, diabetes, and lipoaccumulation or lipoatrophy. This laboratory work should include determination of total cholesterol, LDL cholesterol, HDL cholesterol, triglyceride and fasting blood glucose levels. Patients should be asked about and examined for changes in fat distribution. Imaging tests, such as abdominal CT to detect visceral fat, are not recommended for routine monitoring.
NRTIs have few interactions with other medications. Clinically significant interactions usually involve additive toxicity or problems with drug absorption
What Side Effects Might I Have From My Hiv Medicine
The HIV virus can cause heart, kidney, bone, liver, bone marrow, and metabolic problems. These problems can also be side effects of medicines for HIV . Side effects can also occur because of interactions between ART and other medicines that you take. It is important to talk with your doctor about these issues, because the benefits and risks of ART need to be balanced.
Below is a list of some common side effects of ART. If you are taking one of these medicines and are worried about side effects, talk with your doctor before you stop taking your medicine. Stopping can cause dangerous resistance.
|Weight loss in arms, legs, and face||Stavudine, zidovudine, tenofovir, abacavir, emtricitabine , lamivudine|
The Group Of Teenagers
A study in teenagers by Kim et al in 2014 indicates a large variability, ranging from an adherence rate above 7085% in young people from Africa/Asia to only 5060% in those from Europe and North America. In this group ART discontinuation is frequent. The relevance of the teenagers group is extremely important for the subsequent evolution of HIV, as this group represents over 40% of the new HIV infections and the most active population in what concerns sexual transmission. Lack of ARV adherence of this group is worrying and is based on factors that act simultaneously at this age: the fear of disclosure and social stigma, low social support, inadequate communication and education, the entry in various delinquent or inappropriate social groups, the lack of a motivation and the depression related to living with HIV/AIDS.
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Daily Pattern To Side
There can be a daily pattern to side-effects, linked to the time you take your medicines and also to the processing of the drug by your body. It might be possible to minimise the inconvenience that this causes by adjusting the time at which you take your medicines. For example, efavirenz can cause dizziness and other psychological side-effects. Many people overcome these by taking their daily dose of the drug just before going to bed.
“Your doctor can usually do something about side-effects, so it makes good sense to mention any that youre experiencing.
The Group Of Elderly People
Elderly represents an increasing population in the following years. In some areas this group has already reached 50% of the local HIV population and is predicted to rise in the following years. In a study by Johnson et al 7080% of the analyzed population displayed an adherence rate above 90% while other reports indicated overall adherence rates up to 87% . The use of recreational drugs and alcohol has been shown to lower the adherence below 70% . The screening for these risk factors should not be neglected in this population. Furthermore, poly-pharmacy and depression frequently found in older patients have a negative effect on ARV implementation lowering the adherence throughout time. Therefore, individual differences should not be neglected despite the preliminary favorable data on adherence in this group.
Highly Active Antiretroviral Therapy
In 1996, highly active antiretroviral therapy was introduced for people with HIV and AIDS. HAART â often referred to as the anti-HIV “cocktail” â is a combination of three or more drugs, such as protease inhibitors and other anti-retroviral medications. The treatment is highly effective in slowing the rate at which the HIV virus replicates itself, which may slow the spread of HIV in the body. The goal of HAART is to reduce the amount of virus in your body, or the viral load, to a level that can no longer be detected with blood tests.
Interventions For Preventing Treatment Discontinuation
All interventions applied in this phase intend to encourage the patient and to offer an adequate moral, social, and family support to prevent the patient’s discontinuation of ART. Furthermore, the treating physician is responsible for observing various health-care related causes of the decrease of adherence and for establishing appropriate treatment . Unfortunately, some of the obstacles and particularly those related to financial constraints cannot be easily solved and could cause treatment discontinuation .
Recent debates stress the need to implement monotherapy in restricted HIV populations or to prevent HIV infection through harm reduction programmes. Suppositions that the high efficiency of modern therapy can be attained even with lower adherence rates such as 80% are unconfirmed and the emerging risks from generalized such concepts remain unknown.
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Adverse Effects Observed With More Than 1 Insti
Several studies have concluded that INSTIs , particularly dolutegravir , lead to greater weight gain than other classes of antiretrovirals, but the mechanism and clinical significance are unclear. Dolutegravir-associated weight gain appears to be more pronounced when dolutegravir is combined with tenofovir alafenamide than with tenofovir DF . Available data also suggest wight gain is a complication in persons taking bictegravir-tenofovir alafenamide-emtricitabine.
Elevated Serum Creatinine
Dolutegravir and bictegravir causes a predictable modest increase in serum creatinine and a decrease in estimated creatinine clearance due to inhibition of active tubular secretion of creatinine via blockade of the organic cation transporter 2 . In the kidney, OCT2 is an uptake transporter located on the basolateral membrane of renal proximal tubular cells, and it plays a role in transporting creatinine from the peritubular capillary blood cells into the renal tubular cells . Inhibition of OCT2 by dolutegravir causes more creatinine to remain in the bloodstream and an increase in serum creatinine. Iohexol clearance studies have shown that dolutegravir-related changes in serum creatinine do not reflect a reduction in true renal glomerular function. Continued increases in serum creatinine after 2 to 3 months or an increase significantly greater than 0.2 mg/dL should prompt evaluation for a source of elevated creatinine other than bictegravir or dolutegravir.
Safety Laboratory Monitoring In Persons Taking Antiretroviral Therapy
All persons with HIV who initiate antiretroviral therapy should have laboratory studies performed at the initial visit, before initiating or changing a regimen, and as regular monitoring for long-term safety once a regimen is initiated. If abacavir or any abacavir fixed-dose combination is used in the regimen, baseline HLA-B*5701 testing should be performed. The following summarizes key baseline and safety laboratory studies recommended for individuals taking antiretroviral therapy .
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The Treatment Of Depression
At least half of HIV patients suffer from depression according to a large study on 1,713 patients . Depression is a strong risk-factor for non-adherence according to numerous studies . The use of anti-depressives could significantly improve the adherence to ART even in complex ARV regimens . A close collaboration with a psychiatric service and psychotherapy sessions are therefore needed in all HIV patients irrespective of age or risk group.
What Are Antiretroviral Drugs
The main treatment for HIV is a class of drugs called antiretrovirals. These drugs dont cure HIV, but they can reduce the amount of virus in the body of someone living with HIV. This keeps the immune system strong enough to fight off disease.
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Interruption Of Antiretroviral Therapy
Interruption of ART is usually safe if all drugs are stopped simultaneously, but levels of slowly metabolized drugs may remain high and thus increase the risk of resistance. Interruption may be necessary if intervening illnesses require treatment or if drug toxicity is intolerable or needs to be evaluated. After interruption to determine which drug is responsible for toxicity, clinicians can safely restart most drugs as monotherapy for up to a few days.
Interventions To Increase The Adherence To Art
Adherence is a complex and dynamic process. As in other chronic diseases, patients with HIV experience difficulties to achieve and maintain a high adherence indefinitely. It is for this reason that the health-care provider should acknowledge that no patient can display a perfect adherence. A permanent monitoring of the patient’s adherence is required at all times. Medical staff should not rush discussions on adherence even in patient’s known to be compliant as it is never too late for the patient to become non-adherent.
The main issues that need to be established when monitoring drug adherence include:
– rapid identification of non-adherent patients
– establishing the causes
– finding the adequate solutions
Addressing these points requires the development of a dedicated multidisciplinary team involving the doctor and the patient, the pharmacist, the psychologist and other close relatives or friends.
Below are described the most notable interventions that could improve adherence in HIV-infected patients.
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Adherence To A Treatment Plan
Antiretroviral drugs must be taken at the right time and in the right way for them to work properly. Taking these medications the way a healthcare professional has prescribed is called adherence.
Sticking to a treatment plan isnt always easy. Antiretroviral drugs can cause side effects that can be severe enough to make some people stop taking them.
But if a person with HIV skips doses of these drugs, the virus can start copying itself in their body again. This could cause HIV to become resistant to the drugs. If that happens, the drug will no longer work, and that person will be left with fewer options to treat their HIV.
Read on to learn more about antiretroviral drug side effects, and how to manage them and stick to a treatment plan.
Antiretroviral Drug Side Effects And Management
HIV drugs have improved over the years, and serious side effects are less likely than they used to be. However, HIV drugs can still cause side effects. Some are mild, while others are more severe or even life threatening. A side effect can also get worse the longer a drug is taken.
Its possible for other medications to interact with HIV drugs, causing side effects. Other health conditions can also make the side effects from HIV drugs worse. For these reasons, when starting any new drug, people with HIV should talk with a healthcare professional and pharmacist about all the other medications, supplements, or herbs theyre taking.
In addition, if any new or unusual side effects occur, people with HIV should contact a healthcare professional. They should do this even if theyve been on the medication for a long time. It can take months or years to start reacting to a drug.
For serious side effects, a healthcare professional might make sure that its the medication and not another factor thats causing the symptoms. If the drug is to blame, they might switch treatment to another antiretroviral drug. However, switching treatments isnt easy. They need to be sure that the new treatment will still work and that it wont cause even more severe side effects.
Here are some of the more common side effects from antiretroviral drugs and tips for managing them.
Loss of appetite happens when you have a decreased desire to eat.
Examples of drugs that may cause it:
What might help:
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Interventions During The Implementation Phase
The implementation phase has received the most intense analysis regarding the adherence. During this period the patient experiences various psychological and social barriers as well as obstacles related to the costs of the treatment , difficulties to abandon various habits and to adapt to ART side effects.
Social interventions of this period need to be tailored to individual needs providing support to combat stigma and promoting a positive approach to living with HIV. Careful planning of the medical visits is also important so as to ensure a permanent feedback between the patient and the treating physician. Interdisciplinary consults and indicated treatments could also prevent or reduce various side-effects and alleviate the patient’s anxiety. Social support, food security or the cash plus care system are particularly relevant in poor countries .
Among the methods addressed directly to the patient we mention: patient education on HIV course and adherence to ART, positive thinking, technological reminders and HIV support groups organized by hospitals involved in HIV management. Vulnerable groups must be a permanent target of these interventions.
Estimates Of Adherence According To Assessment Method
As shown in Table 1, we found 32 studies that reported data that estimated antiretroviral adherence among pediatric populations. They were published between 1999 and 2005, with 69% of the studies based in the United States. Sample sizes ranged from 10 to 262 , and participants were from 3 months to 24 years of age. Most participants were infected perinatally, but behaviorally infected individuals and those infected by contaminated blood products also were included in some studies.
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Significant Antiretroviral Adverse Effects
Antiretroviral therapy can have a wide range of adverse effects on the human body . Common but mild adverse effects occurring early in most antiretroviral regimens include gastrointestinal effects such as bloating, nausea and diarrhea, which may be transient or may persist throughout therapy.6 Other common nuisance adverse effects are fatigue and headache caused by AZT and nightmares associated with EFV. Several uncommon but more serious adverse effects associated with antiretroviral therapy, including AZT-associated anemia, d4T-associated peripheral neuropathy, PI-associated retinoid toxicity and NNRTI-associated hypersensitivity reactions, are treated according to accepted therapy for these conditions in patients not receiving HAART. However, the subtle and serious nature of other adverse effects lactic acidosis, hepatic steatosis, hyperlactatemia, hepatotoxicity, hyperglycemia, fat maldistribution, hyperlipidemia, bleeding disorders, osteoporosis and skin rash warrant more detailed discussion.
Fig. 1: Adverse effects of antiretroviral therapy. In some cases, only a certain drug causes the effect . Photo: Chesley Sheppard
Evaluations Of Strategies To Improve Haart Adherence
Many studies of factors related to adherence also suggest strategies for improving HAART adherence, but few of these studies have been subject to empirical examination. We found 7 studies that focused on the evaluation of interventions to enhance antiretroviral medication adherence among pediatric populations, all of which were conducted in the United States. As described below, only 1 involved a randomized, control trial51 the other reports presented primarily descriptive data on small samples.5257
Gigliotti et al52 studied a DOT intervention, primarily to determine if prolonged elevation of VL could be attributable to poor adherence. They identified 6 perinatally infected children aged 3.3 to 11.5 years with elevated VLs for periods of months to years and for whom suboptimal adherence was suspected. DOT was administered in the hospital for 4 children and at an HIV programsponsored summer camp for the other 2 children. DOT of 4 to 8 days lowered the VLs of all 6 of these heavily drug-experienced children with advanced HIV, exceeding a 90% decrease in 4 of them. Surprisingly, as few as 4 days of DOT resulted in a 70% drop in VL.
In addition to these 7 published reports of study evaluations, we found 2 ongoing trials of adherence interventions, both of which were sponsored by the Centers for Disease Control and Prevention.
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Recommendations For Improving Adherence
Our review of the empirical literature on the efficacy of HAART-adherence interventions for pediatric populations located only 7 published studies, of which only 1 was a randomized, controlled trial. These studies provided some support for the utility and efficacy of DOT, a 12-week educational program, GT placement, and nursing home visits. However, most findings were based on pilot studies with very small samples, and adherence to the intervention itself was often problematic. The findings suggest that more intensive interventions are required to produce efficacious outcomes and that 1-time interventions in the absence of ongoing education and support may be insufficient. Overall, they exemplify the barriers that are often encountered in this challenging work. Although clinicians commonly assume that certain medications or regimens are easier to tolerate than others or rely on drug holidays to reinvigorate adherence efforts, the literature is sparse and inconsistent regarding the treatment-related factors that affect adherence. Many of these interventions have become clinical lore and require additional scrutiny.
Discussing The Concept Of Adherence To Art
Initiation – the moment when the patient takes the first dose of a prescribed medication
Discontinuation – the moment at which the patient stops taking the prescribed medication
Implementation – the extent to which a patient’s actual dosing corresponds to the prescribed dosing regimen, from initiation until the last dose.
Medication persistence defined as the length of time on regimen before discontinuation was considered as an important aspect of adherence.
The concept of adherence to ART is of a paramount importance for HIV treatment. This also results from its inclusion in the HIV treatment cascade and care continuum, a framework developed beginning with 2013 which consists of five main steps: Diagnosis,Linkage to care,Retention in care,Adherence to ART and Viral suppression .
There are 4 major factors that could influence the various phases related to ART adherence:
– the selected ARV drug, which could lead to various side effects and various restrictions, ultimately impacting the patient’s schedule and the possibility of taking other needed medicines
– the doctor devotion including the time dedicated to counseling, information and establishing a trusting relationship
– the patient– in terms of patient’s understanding, will to fight HIV and to accept ART along with its advantages and disadvantages
– the social and family backgroundable to persuade the patient to continue ART or, on the contrary, to reject or discriminate the patient
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