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Treatment Adherence
HIV Care, Support, and Treatment
Office of Overseas Programming &
Training Support (OPATS)
Antiretroviral Therapy (ART)
 ART dramatically improves the
quality of life of PLHIV and restores
hope
–Patients gain weight, are less fatigued,
feel better, are often able to return to
work
–Slows or stops progression of illness
Joseph Jeune, a farmer in Haiti, before and after
treatment for HIV/AIDS and TB co-infection
Access to ART
 While access to HIV treatment has
increased by 63 percent from 2009
to 2011, only 54 percent of people
eligible for HIV treatment in low and
middle-income countries were on
ART in 2012
Care and Treatment
in the pre-ART Period
 Critical to identify HIV-infected persons early
and enroll in care and support services
 After diagnosis, but before ART, regular clinic
visits and care and support services are vital
– For clinic checkups (prophylaxis, screening,
treatment for OIs, to monitor progression, etc.)
– For education in self-care and living positively to
stay healthy and maintain strong immune system
– To meet psychosocial needs (support groups, etc.)
Eligibility for ART
 Prompt and timely initiation of ART
results improved quality of life and
reduced mortality
 Eligibility for ART is determined at the
clinic
– When CD4 thresholds are reached (and other
criteria)
– And before OIs contribute to poor outcomes
CD4 Count
 The major lab indicator of immune function in
PLWHIV
 Key factor in determining:
– Urgency of antiretroviral therapy (ART) initiation
– Need for prophylaxis for opportunistic infections
 Strongest predictor of subsequent disease
progression and survival
Clinical Exams for ART Eligibility
 Medical history
 Physical exam: WHO clinical
staging and disease classification
 Laboratory tests: CD4 count, Viral
load, OI screening (including TB)
Country-specific ART Eligibility
Criteria: South Africa Example
 Adults: CD4 count <350 cells/mm OR clinical
staging 3 and 4 (WHO) OR patient with TB
 Infants and children: All children under 5,
irrespective of CD4 cell count
 Fast tracking ART initiation: Children under 1,
CD4 cell count <200 cells/mm, clinical staging
4, women who are pregnant or breastfeeding,
patients with TB and CD4 cell count <50
cells/mm
ART: How It Works
 ART uses a combination of at least three ARVs
– This combination suppresses the HIV virus and
stops the virus from multiplying
– With less virus, the immune system becomes
stronger, resists infections, and the person gets
sick less often
 NOTE: ART does not completely destroy the virus or
cure the disease and ART can reduce, but not
eliminate the risk of HIV transmission. People on ART
can still transmit the virus to others.
ARV Drugs
 The combination of three drugs reduces the
likelihood of the virus developing resistance
 First, second, and third-line therapies are
different combinations of ARV drugs
– First-line: Usually standard, but doctor may adjust
if patient is pregnant or if person has TB
– Second-line: Prescribed if first-line does not work
or if there are side effects
– Third-line: National guidelines, based on funding,
sustainability, and ART access
Successful Treatment with ARVs
 Must be taken daily for remainder of patient’s
life to continually suppress the virus
– Must be taken at specific times of day, under
specific conditions
– Must be carefully stored
– Must take 95 percent or higher of scheduled
doses
– Most effective when patients are well-nourished
 If ARVs are NOT taken correctly, benefits are
rapidly reversed, virus may become resistant
Predicted and observed risk of viral control according
to the longer interval of treatment discontinuation,
POSOVIR and REACH cohorts
Side Effects of ARVs
 All medicines can cause side effects, including
ARVs. Most common with ARV:
– Headaches, nausea, diarrhea, skin rashes, tingling
sensations, tiredness, nightmares or anxiety, and
changes in body
 Vary in severity (minor/major), duration, and
start; some manageable by patient
 Can interfere with treatment adherence,
lessen quality of life, or cause long-term
health conditions
ART and TB Treatment
 PLHIV more susceptible to TB; TB most
common cause of death of PLHIV
 A doctor must decide how to treat both
diseases in people with both TB and HIV
 Some ARVs cannot be used at the same time
as some TB drugs; thus, a doctor will prescribe
a special first-line ARV drug combination for
patients with TB
Treatment Adherence
 The ability to start, manage, and maintain a
given medication regimen at the times,
frequencies, and under specific conditions as
prescribed by a health care provider
 MORE than just taking drugs
– Patient attends all scheduled clinical care visits,
follow-up appointments and monitoring, lab tests
– Patient practices recommended behaviors (diet,
limiting use of alcohol)
The Importance of Treatment
Adherence
 Suboptimal adherence
– Treatment failure
– Limited future treatment options (secondline therapy much more expensive, often
unavailable)
– Increased risk of HIV transmission to others
– Increased mortality
Care and Support is Vital
for Treatment Adherence
ART Initiation
and Patient Readiness
 ART initiation involves a partnership
between PLHIV and the health system
–Critical to involve patient in decision
–Requires adequate preparation and
support
–Requires commitment from patient
Patient Preparation for ART
 Counseling
– To identify barriers and solutions
 Training
– Treatment literacy
 Patient Assessment
– Beliefs, attitudes, mental health
 Identification of social support
– Help with disclosure, socioeconomic situation
 Development of a treatment plan
Barriers to Treatment Adherence
Individual Factors
System Factors
Community Factors
Medication Factors
Despite Barriers, Treatment
Adherence Can Be Achieved
 Adherence is feasible in low-resource settings
– 77 percent of patients in Africa achieved adequate
treatment adherence (defined as taking 95
percent of prescribed pills) compared with just 55
percent in North American settings
 Good adherence has been shown within key
populations, including sex workers and People
Who Inject Drugs