1. Introduction to ARV therapy
Principles of ARV Therapy
Introduction to ARV therapy
HAIVN
Havard Medical School AIDS Initiative in Vietnam
Basic training course for nurses - HAIVN
Introduction to ARV therapy - ENG
Revised 9/2012

2. Principles of ARV Therapy
Learning objectives
By the end of this session, participants should be able to:
Present the goals of ARV therapy
Outline ARV drugs used in Viet Nam
Instruct patients on medication adherence
Recognize common and/ or significant side effects of ARV drugs

3. Principles of ARV Therapy
What are the goals of ARV therapy? Why do we use ARV drugs knowing they don’t eliminate HIV?
ASK participants the questions on slide
ALLOW time for them to respond
USE their answers and discussions to go to next slide

4. Principles of ARV Therapy
Goals of ARV therapy
Ultimately: Improve patient’s quality of life
Reduce HIV replication in patient:
Reduce viral load
Lessen attack of the virus on the immune system
Create opportunities for the immune system to recover:
Help increase the number of CD4 cells
EXPLAIN that the improvement of quality of life helps them be able to carry out works involving family, hobby and friends.
Improve their ability to perform daily activities to help them be active, independent social members doing paid works

5. Relationship between CD4 count and viral load
HIV RNA (viral load) = Speed of train
Slow: <5,000
Fast: 50,000+
CD4 count = Distance to crash
EXPLAIN that progression of HIV is analogous to the speed of a train which is racing towards a cliff
Speed of train is analogous to viral load, and distance to crash is analogous to CD4 count.
The cliff represents the development of AIDS-defining conditions.
If the patient is initially treated with highly active ARV therapy (HAART), viral load reduces (speed of train slows down), CD4 count increases (the distance lengthens) and the train moves backwards and far from the cliff (improve patient’s health, life ….).

6. Results of decrease in viral load and increase in CD4 count
Principles of ARV Therapy
Results of decrease in viral load and increase in CD4 count
Prevent the progression from HIV to AIDS
Prevent opportunistic infections
Increase survival rate
Decrease HIV transmission

7. Principles of ARV Therapy
Effect of ARV
HIV uses CD4 cell as a “factory” to produce HIV
ARV goes into the “factory” and reduces its ability to “produce” HIV
When patient takes ARV, virus production can be minimized
CD4
EXPLAIN that CD4 represents the factory because:
Usually HIV uses CD4 as a factory. There are machines and equipment in the factory (CD4).
Virus goes into the factory, uses machines of CD4 cell and starts to replicate. Millions of new viruses are produced and get out of the factory (CD4).
ARV drugs inhibit the replication of virus in CD4 cell. Consequently new virus can’t be “produced” and therefore there are fewer viruses that infect and destroy other CD4 cells.

8. Why do we have to combine drugs in treatment?
Principles of ARV Therapy
Why do we have to combine drugs in treatment?
Each patient is infected with different strains of HIV
Each strain of HIV is sensitive to some but not all ARV drugs
To achieve the best and the longest effect, patient has to take at least 3 different ARV drugs
RECALL natural progression of HIV. When entering human body there are 4 stages to form new viruses and there are many ARV drugs, each group inhibits one stage of development, and studies show can be ineffective with development of resistance if using only 1 or 2 ARV drugs.
Must take at least 3 ARV drugs to inhibit effectively the development of HIV

9. Progression to AIDS according to ARV therapy
Principles of ARV Therapy
Progression to AIDS according to ARV therapy %
Month
Non therapy
Mono therapy 15
Dual therapy
Triple therapy
EXPLAIN that history of treatment in USA and Europe has shown some real-life experiences. In the diagram there are 4 lines pointing out :
Mono therapy is not better than non therapy and can limit future treatment options due to the development of drug-resistant HIV.
Dual therapy prevents the progression in a few months, but then it continues to progress. These patients can also develop resistant strains.
Triple therapy is the best, strongest and prevents the progression to AIDS in many years if patients take medications according to the regimen with absolute adherence.

10. ARV drugs currently available in Viet Nam
Principles of ARV Therapy
ARV drugs currently available in Viet Nam
Nucleoside/
Nucleotide RTI
AZT / Zidovudine
d4T / Stavudine
3TC / Lamivudine
ddI / didanosine
ABC / Abacavir
TDF / Tenofovir
Protease inhibitors
RTV / Ritonavir
IDV / Indinavir
LPVr / Lopinavir
+ ritonavir
Non-nucleoside RTI
NVP /Nevirapine
EFV / Efavirenz
EXPLAIN that all drugs listed above are ARV drugs currently used in Viet Nam.
There are fewer drugs available in Viet Nam than in some other countries, but these drugs are equally effective and rather similar to drugs of the first line regimen in rich countries.
Drugs are often written using 3 letter abbreviation before their full name. This is just a convenient way to write and refer to medication.

11. First line ARV regimens in Viet Nam
Principles of ARV Therapy
First line ARV regimens in Viet Nam +
Lamivudine (3TC)
Tenofovir (TDF)
Zidovudine (AZT)
Efavirenz (EFV)
Nevirapine (NVP)
Stavudine (D4T) is no longer recommended as a first line ARV drug
Modified and Supplemented from Guidelines for Diagnosis and Treatment of HIV/AIDS,11/2011
EXPLAIN that the first line ARV regimens in Vietnam comprise of 2 NRTIs plus one NNRTI.
EXPLAIN that from November 2011, the Ministry of Health no longer recommends the use of d4T.
Therefore there are 3 NRTIs and 2 NNRTIs recommended as 1st line ARV drugs

12. Principles of ARV Therapy
Side effects of ARV
ASK participants to “Outline common side effects of ARV”
ALLOW time for them to respond
USE their answers to go to next slides

13. Principles of ARV Therapy
Side effects of ARV (1)
Side effects can happen when taking ARVs
Usually in the first weeks of therapy
improve over time or with symptomatic management
Side effects can be mild or severe
Some side effects relate to dosage and/or drug interactions
EXPLAIN that patient needs to be counseled to inform doctor when side effects appear.
Patient will adhere better to the treatment if they are counseled about possible side effects.

14. Principles of ARV Therapy
Side effects of ARV (2)
Common side effects:
Peripheral neuropathy
Diarrhea
Rash
Nightmare
Uncommon but severe side effects :
Pancreatitis
Bone marrow suppression
Severe rash
hypersensitivity
Nurse should instruct patients to recognize side effects of ARV

15. Some examples of side effects of ARV
Principles of ARV Therapy
Some examples of side effects of ARV

16. Allergy to Nevirapine (1)
rash
EXPLAIN that allergy to Nevirapine causes rash on the trunk and extremities. These photos are of 2 patients at the center in Ho Chi Minh city.

17. Allergy to Nevirapine (2)
Stevens-Johnson syndrome
EXPLAIN that this is Stevens-Johnson syndrome – a severe allergic reaction to nevirapine. Patient has oral lesions with fever and general rash. This can progress very quickly and be fatal. Immediate discontinuation of the offending medicine is necessary.

18. Allergy to Nevirapine (3)
Stevens-Johnson syndrome
EXPLAIN that this photo is of a patient in An Giang province with Stevens-Johnson syndrome due to Nevirapine. Patient had exfoliation of skin all over the body.
Patient recovered quite well when stopping ARV for 1-2 months.

19. Allergy due to Efavirenz
Hội chứng Stevens-Johnson
EXPLAIN that Efavirenz can also cause Stevens-Johnson syndrome, but more rarely than nevirapine. Both nevirapine and efavirenz belong to the same class (NNRTI).
A patient who has Stevens-Johnson syndrome due to an NNRTI should never use another NNRTI.

20. Allergy to Cotrimoxazole (1)
Allergy to cotrimoxazole may cause erythematous rash, flat or slightly elevated lesions on the trunk and extremities 20

21. Allergy to Cotrimoxazole (2)
Rash
EXPLAIN that these photos are of 2 patients who are showing their rash due to allergy to Cotrimoxazole. 21

22. Principles of ARV Therapy
Adherence
ASK participants “Meaning of Treatment Adherence” and “Content of Treatment Adherence”
ALLOW time for them to respond
USE their discussion to go to the next slide

23. Principles of ARV Therapy
Adherence
Adherence means taking the correct medications, in proper doses and on time
To achieve the best effect with ARV therapy, adherence rate is required to be above 95%.
Example: If medications are prescribed 2 times a day, don’t forget more than 2 doses a month.
EXPLAIN that patient has to take medicine for the rest of their life, and adherence is very difficult but necessary to be above 95%
INSTRUCT patient to take medicine at the right time
Example: take medicine 2 times a day, 12 hours apart, for instance, 8am and 8pm or 7am and 7pm…
INSTRUCT patient in case they forget to take medicine at the right time:
If they remember 1-2 hours after the time, take it right away and take the next dose on time.
If they remember 3-4 hours after the time, take it right away and take the next dose 2 hours after the appointed time, then at the appointed time…

24. Non adherence to ARV therapy is common
Principles of ARV Therapy
Non adherence to ARV therapy is common
Assessments of rates of non adherence to treatment range from 20% to 80%, with the average rate of 50%.
Adherence rate in IDUs (40% - 80%) and non-IDUs (30% - 70%) are similar.
ASK participants how many of them have difficulty to complete their last antibiotic regimen when they were prescribed?
EMPHASIZE that non-adherence to HIV treatment is common even with patients who don’t have to face major obstacles/ difficulties in life such as working, taking care of family…
Though non adherence is not only a problem for IDUs but also for the group of people belonging to lower socioeconomic status (often accompanied by addiction), IDUs usually exaggerate this problem.

25. Common levels of adherence
Three types of patient’s adherence
Adherence
Treatment time (month)
100% 0% 12 24
Very good adherence
Reduced adherence
Non adherence
Howard AIDS 2002; Ickovics Antiviral Ther 2002; Moss CID 2004
EXPLAIN that this diagram describes the adherence, and as it was stated in the previous slide and from result of the research there are 3 types of patient’s adherence
The uppermost line shows very good adherence (not able to be 100% during 24 months)
Middle line: reduced adherence, the diagram shows clearly changes in patient’s adherence
Bottom line: represents non adherent patients who stopped taking medicines after enrolling in the study

26. Common reasons for non adherence to ARV
Principles of ARV Therapy
Common reasons for non adherence to ARV
Reason %
Simply forgot or were busy
66%
Not at home
57%
Had a change in daily routine
51%
Slept through dose time
40%
Sick
28%
Sad, sorrowful
18%
Individual problems
14%
Side effects
12%
EXPLAIN that there are 8 top reasons reported about non adherence in research on non IDUs.
EXPLAIN that for IDUs adherence is extremely difficult because:
They have a lot of disturbance in their life.
They have difficulties with mental illness, sadness, homelessness, as well as the psychological impacts of illicit drug use.

27. Factors influencing non adherence to HIV treatment
Principles of ARV Therapy
Factors influencing non adherence to HIV treatment
Medications interfere with daily life
Drinking alcohol or using drugs
Sad mood, stress
Pessimistic about HIV
Treatment is less effective than desired
ASK participants if “there is other factor different from the list above affecting the adherence especially for IDUs”
ALLOW time for them to respond
USE their answers and discussions to explain more about affecting factors
EXPLAIN that difficulty with adherence is a common problem, but it is more difficult to IDUs, therefore there need to be a lot of ways to support IDUs to maintain treatment adherence.

28. Goals of adherence to ARV drugs
Principles of ARV Therapy
Goals of adherence to ARV drugs
Maximizes inhibition of viral load
Reduces drug resistance
Increases time of exposure to effective medication
Above all, helps:
Delay progression to AIDS
Prolong survival
Improve quality of life
Goals or benefits???

29. Components of adherence
Principles of ARV Therapy
Components of adherence
Take medicine on time
Maintain regular check up
Maintain “healthy lifestyle with HIV”
Eat healthy food
Exercise regularly
Do not smoke tobacco or drink alcohol
EXPLAIN that we need to pay attention to components of adherence to support patient appropriately in different communities.

30. Nurse should pay attention to
Principles of ARV Therapy
Nurse should pay attention to

31. Learn about the patient (1)
Principles of ARV Therapy
Learn about the patient (1)
Find out attitudes, knowledge and beliefs of the patient by asking questions :
About medication generally:
For example: Did you take medication before? Tell me about that.
About HIV/AIDS:
For example: Can HIV be cured?
GIVE a few questions to help participants learn more about the attitudes, knowledge and beliefs of the patient:
Have you ever had to take medicine? Why did you have to take medicine?
Tell us the name of drug if you remember? Did you have prescription or not?
Did you follow the prescription or just take medicine a few days ...? Why did you not follow the prescription?
You knew that you were HIV infected and wanted to have medications? You know that HIV can be cured?
Why do you need to have ARV therapy?

32. Learn about the patient(2)
Principles of ARV Therapy
Learn about the patient(2)
About ARV drugs:
Do you know someone who is on ARV therapy?
How is his/ her health after taking ARVs?
What would happen if you take ARV drugs?
Patient’s desires:
benefit and cost of treatment
changes in appearance (or not)
side effects
EXPLAIN that medical staff who works with patients in preparation for ARV therapy needs to understand their patients to support them the best possible

33. Learn about the life circumstances of the patient (1)
Principles of ARV Therapy
Learn about the life circumstances of the patient (1)
Has patient ha disclosed his / her HIV status to anyone?
Who is the main support person for the patient?
Does s/he know that the patient has HIV?
What does s/he know about ARV drugs?
EXPLAIN that healthcare workers need to understand the patients’ life circumstances to find the most appropriate and effective way to support them

34. Learn about the life circumstances of the patient (2)
Principles of ARV Therapy
Learn about the life circumstances of the patient (2)
Life circumstance
Have a house?
Is anyone in the family aware of the patient's diagnosis?
Are there any children at home?
Daily living
work?
child care?
EXPLAIN that healthcare workers need to understand the patients’ life circumstances to workers need to understand the patients’ life circumstances to
For example: Can the patient stay with family or friends or does s/he wander from house to house? Does the patient have a job with steady income?

35. The role of nurses in ARV therapy groups (1)
Principles of ARV Therapy
The role of nurses in ARV therapy groups (1)
Instruct patients on ARV therapy purposes
Understand how ARV impacts patients’ lives
Collaborate with physicians and pharmacists in ARV therapy group to give patients the best care
EXPLAIN that nurses working in ARV therapy group should have:
knowledge about HIV, AIDS
counseling skills, instruct and support patients
ability to coordinate with colleagues to achieve the best results in patient care

36. The role of nurses in ARV therapy groups (2)
Principles of ARV Therapy
The role of nurses in ARV therapy groups (2)
Ensure that patients:
understand how to take medicine before leaving the clinic
have plans to remember to take medicine
Instruct patients on:
possible side effects
what to do if side effects occur
Give patients and their families a message of: HOPE
EXPLAIN that nurses working in ARV therapy groups need to support patients to achieve all the objectives on the slide.

37. Principles of ARV Therapy
Key points
The goal of ARV treatment is to reduce viral load and increase CD4 count and ultimately to increase quality of life
A 3-drug combination is most effective
The role of nurses is to help patients adhere to treatment to obtain the best results from ARVs

38. Principles of ARV Therapy Question?
Thank you
Question?