Clinical Manual for Management of the HIV-Infected ... - myCME.com

ARV treatment in resource-limited settings
The discussion of ARV management is futile for the
majority of people in the world today who are living
with HIV/AIDS. According to the Joint United
Nations Programme on HIV/AIDS, as of June 2005,
only 11% of those needing ARV therapy in low- and
middle-income countries were receiving treatment.
ARV medications are becoming available in many parts
of the developing world, but the increase in availability
is slow and in no way is occurring at the pace and
with the efficiency warranted in this dire situation.
Medication choices are limited by the availability
and cost of drugs. Most resource-limited countries
that are able to provide ARVs use an NNRTI-based
combination for initial therapy. This regimen typically
includes nevirapine or efavirenz plus 2 NRTIs such as
zidovudine or stavudine plus lamivudine. Second-line
therapies or substitutions needed because of toxicities or
intolerance often are not readily available.
Widespread use of nevirapine to prevent mother-tochild
transmission of HIV has lowered the rate of HIV
transmission to infants, but the drug resistance that may
emerge after even single-dose administration to the
mother during labor has raised many concerns regarding
effective treatment options for the mother. Without
the availability of resistance testing, many women are
subsequently started on an ARV regimen that includes
an NNRTI. For women who have developed NNRTI
resistance during previous nevirapine exposure, these
regimens probably will be ineffective. In addition, NRTI
resistance is likely to develop, further limiting treatment
options.
Concern about adherence in resource-limited settings,
although often cited as a treatment-limiting factor, has
proven to be less of an issue than it is in the United
States and western Europe. Many treatment programs
require a lengthy educational process before ARVs
are initiated. In addition, the limited availability of
treatments paired with the widespread devastation of
entire communities and countries has enhanced the
motivation for strict adherence to therapies among
patients able to acquire ARV therapy.
CD4 count and viral load testing to identify patients
who should begin ART, and to monitor ARV
effectiveness and potential drug toxicities, are severely
limited by the lack of sufficient laboratories, equipment,
and funds to perform costly blood tests. In some
settings, patients are started on therapy based on clinical
presentation alone, and monitoring is based solely on
Section 3—Antiretroviral Therapy | 3–9
clinical criteria. Success of treatment may be assessed
by clinical response, such as resolution of opportunistic
infections, weight gain, and improvements in quality of
life. ARV toxicity may be assessed by clinical signs and
symptoms of adverse effects such as anemia or hepatitis.
Comorbid conditions such as tuberculosis and malaria,
and potential drug interactions associated with
their treatments, often complicate therapy choices.
Competing priorities of poverty, lack of clean water
or sanitation, and overburdened health care settings
and health care providers combine to complicate the
distribution of effective ARV treatment. Regardless
of the numerous challenges to treatment in resourcelimited
settings, human compassion and responsibility
dictate that we find a way to provide care for those who
require treatment.
Expert Consultation
The National HIV/AIDS Clinicians’ Consultation
Center (NCCC) is a valuable resource for any clinician
seeking expert advice about ART, HIV clinical
manifestations, laboratory evaluations, and other issues.
Its National HIV Telephone Consultation Service
(Warmline) is staffed by HIV-experienced physicians
and pharmacists. The Warmline operates Monday
through Friday, 8 am to 8 pm EST and is available free
of charge in the United States at 800-933-3413.
Patient Education
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Starting ARVs is rarely an emergency. Before
starting ARVs, health care providers must work with
patients to determine how important therapy would
be for them, what goals of therapy are likely to be
achieved, and which personal issues are pertinent for
selecting the best regimen to fit their lifestyles.
Providers should review the proposed drug regimen
with their patients. Be sure patients understand
the instructions about dosage, scheduling, food
requirements or restrictions, drug storage, adverse
effects, toxicities, and type of reactions that must
be reported immediately, as well as remedies for
common adverse effects.
Providers should explain to patients that ART
requires a commitment to taking the medications
precisely as prescribed. There is a limited number
of ARVs, and if they are taken incorrectly, the virus
can quickly become resistant to the medications.
This will mean even fewer choices and less effective
treatment in the future. It might also mean that they