Adult HIV: Preparation for antiretroviral treatment


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Adult HIV was developed by doctors and nurses with wide experience in the care of adults with HIV, under the auspices of the Desmond Tutu HIV Foundation at the University of Cape Town. It covers: introduction to HIV infection, management of HIV-infected adults at primary-care clinics, preparing patients for antiretroviral (ARV) treatment, ARV drugs, starting and maintaining patients on ARV treatment, opportunistic infections

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Adult HIV: Preparation for antiretroviral treatment

  1. 1. 3 Preparation for antiretroviral treatmentBefore you begin this unit, please take the INDICATION FOR ANTI-corresponding test at the end of the book toassess your knowledge of the subject matter. You RETROVIRAL TREATMENTshould redo the test after you’ve worked throughthe unit, to evaluate what you have learned. 3-1 When should antiretroviral treatment be started? Objectives Antiretroviral treatment (ART) is best started when a patient’s immune function begins to fail. This is indicated by either or both of the When you have completed this unit you following: should be able to: • List the indications for antiretroviral 1. The clinical symptoms and signs treatment. 2. The CD4 count • Refer a patient for antiretroviral treatment. Antiretroviral treatment should be started when • Give the reasons for postponing antiretroviral treatment. a patient’s immune system begins to fail. • State the risks of starting antiretroviral treatment too early or too late. NOTE Until CD4 testing becomes much more widespread, clinical criteria are the • Prepare a patient for antiretroviral most important indication for antiretroviral treatment. treatment. Clinical staging is a more accurate • Describe the first and second screening predictor of death than is the CD4 count. visit. • Explain the role of lay counsellors. 3-2 Which clinical signs indicate that • Describe ‘treatment readiness’. antiretroviral treatment should be started? Current South African treatment guidelines recommends that antiretroviral treatment should be started when the patient reaches clinical stage 4 disease. Stage 4 indicates severe damage to the immune system. All patients with multi-drug-resistant (MDR) or extensively drug-resistant (XDR) TB
  2. 2. 44 ADULT HIVshould be started on antiretroviral treatment Both the clinical stage of HIV infection and theirrespective of their stage or CD4 count. CD4 count are used as independent indicators for NOTE The World Health Organisation recommends starting antiretroviral treatment. antiretroviral treatment be started when clinical stage 3 is reached for all HIV-positive individuals. NOTEA low CD4 count is the most common scenario for starting antiretroviral treatment. Antiretroviral treatment should be started when 3-5 Should patients be asked whether they stage 4 is reached. are ready for antiretroviral treatment? Yes. It is a major decision to start antiretroviral3-3 What CD4 count is an indication treatment as these patients will have to taketo start antiretroviral treatment? drugs every day for the rest of their life. TheAntiretroviral treatment should be started patients must be fully counselled and givenwhen the CD4 count falls below 200 cells/μl, time to consider all the implications. Theireven if the clinical stage is still 1, 2 or 3. The opinion is very important and they mustaim of antiretroviral treatment is to prevent agree before treatment is started. They mustthe CD4 count dropping further. A CD4 count understand the implications, the benefits andbelow 200 cells/μl indicates severe damage to the side effects. Patients must be preparedthe immune system. and ready to start antiretroviral treatment.However, the new South African guidelines Treatment will fail if the patient is not readyindicate that people who are pregnant or and willing to start.who have tuberculosis should be offeredantiretroviral treatment when their CD4 count Patients must be fully informed and willing toreaches 350 cells/μl, regardless of their clinical start antiretroviral treatment.stage. NOTE The World Health Organisation 3-6 What are the combined medical and recommends ART be started in all individuals personal criteria for preparing a patient when the CD4 count reaches 350 cells/μl. for starting antiretroviral treatment? Current South African guidelines suggest3-4 Are both the clinical stage and the a CD4 count below 200 cells/μl or stage 4CD4 count equally important indicators disease plus a readiness and commitment tofor antiretroviral treatment? lifelong treatment. Therefore both medical andYes. Both the clinical stage of HIV infection psychosocial factors are important in decidingand the CD4 count should be considered when when a patient should start antiretroviraldeciding on whether to start antiretroviral treatment.treatment or not. Either the clinical stageof HIV infection (e.g. stage 4) or the CD4 Both medical and personal factors must becount (e.g. below 200 cells/μl) may be used considered before starting antiretroviralas an indication to start treatment. Therefore,treatment is indicated in a patient who is treatment.stage 2 but with a CD4 count below 200 cells/μl. Similarly, treatment should be started in allstage 4 patients even if their CD4 count is stillabove 200 cells/μl.
  3. 3. PREPARATION FOR ANTIRETROVIRAL TREATMENT 45REFERRAL FOR ANTI- PROBLEMSRETROVIRAL TREATMENT WITH STARTING ANTIRETROVIRAL3-7 Who should refer a patient TREATMENTfor antiretroviral treatment?The nurse at the HIV clinic or general 3-10 What happens if the criteria forprimary-care clinic, if an HIV clinic is not antiretroviral treatment are not met?available. As the decision to start antiretroviraltreatment is often complex, and as patient The patient is referred back to their local clinicpreparation is so important, this assessment with a letter providing the reasons why theshould be done at a special antiretroviral clinic patient has not been accepted for antiretroviralif possible. All HIV clinics should know the treatment. The local clinic should followcriteria for patient referral. Patients should not these patients and refer them again to thebe referred for antiretroviral treatment before antiretroviral clinic when the criteria (stage 4the criteria are met. or CD4 count below 200 cells/μl plus patient willingness) have been met. Any psychosocial3-8 How should patients be referred problems identified during screeningto the antiretroviral clinic? should be addressed. Provide counselling to encourage disclosure and obtain support.Patients should be sent to the antiretroviralclinic with a full referral letter. A standardised 3-11 Should psychosocial factorsreferral letter is helpful. Send the latest CD4 be used as exclusion criteria forcount if available. An appointment should antiretroviral treatment?be made. The patient must be told the venue,date and time of the appointment. Keeping No. However, psychosocial considerationsappointments is a good index of patient (emotional, family and community problems)reliability. are very important when a patient is being assessed for antiretroviral treatment. Antiretroviral treatment is likely to fail if there Patients who meet the criteria for treatment are major psychosocial problems. Therefore should be referred to the antiretroviral clinic. antiretroviral treatment may be postponed until the psychosocial problems have been addressed.3-9 Who makes the final decisionwhether a patient should be given Psychosocial problems are useful in predictingantiretroviral treatment? whether treatment is likely to be successful or not.The multidisciplinary team at the antiretroviralclinic. The team consists of the doctor, nurse 3-12 What are the common causes forand counsellor. If possible a social worker, postponing antiretroviral treatment?pharmacist, psychologist, dietician and patientadvocate should also be part of the team. Antiretroviral treatment is postponed (deferred) if: All the important management decisions are 1. The patient does not meet the medical made by a multidisciplinary team. criteria (staging or CD4 count). 2. The patient is not ‘treatment ready’, i.e. is not fully prepared for lifelong antiretroviral treatment.
  4. 4. 46 ADULT HIV3. The patient has a major psychosocial The timing of starting antiretroviral treatment is problem which needs to be addressed first. a balance between the risks of starting too early4. The patient is unreliable and does not attend the clinic regularly. and the dangers of starting too late.5. The patient has an HIV-associated infection (e.g. tuberculosis) which should 3-15 How long does it take to be treated first. assess and prepare a patient forMake every effort not to delay treatment if the antiretroviral treatment?patient has a CD4 count below 100 cells/μl, Usually four weeks. During this timeis pregnant or has multi- or extremely drug- the patient is prepared for the start ofresistant pulmonary TB. antiretroviral treatment.3-13 What problems may result if It usually takes four weeks to prepare a patienttreatment is started too early? for antiretroviral treatment.Starting too early when a patient is nottreatment ready may lead to: 3-16 Is starting antiretroviral treatment1. Unnecessary cost and inconvenience ever an emergency decision?2. Poor compliance Starting antiretroviral treatment is never an3. Drug resistance emergency. The patient must be fully prepared4. Side effects before treatment is started and this alwaysThe health benefits of starting antiretroviral takes time. Never rush the decision or forcetreatment early are not well defined and are patients to start antiretroviral treatmentcurrently still being studied. Poor adherence before they are ready. Patients must showand drug resistance will decrease the chances a commitment to take their medicationof a good response to antiretroviral treatment correctly and follow instructions. However, inwhen it is really needed. some cases the preparation may need to be as fast as possible, e.g. an ill woman in pregnancy. NOTE Severe side effects with nevirapine are more common if antiretroviral treatment is started Starting antiretroviral treatment becomes in patients who have a high CD4 count, above urgent when the patient is demented, in a 250 cells/μl in women and 400 cells/μl in men. coma or very weak and ill. In many of these cases the patient will die if treatment is delayed3-14 What may happen if antiretroviral until they are fully prepared.treatment is started too late?Patients may die of the complications of The decision to start antiretroviral treatment usuallyHIV infection if antiretroviral treatment is is not an emergency and must not be rushed.started too late. Therefore, the correct timingof starting treatment is very important 3-17 What psychosocial factorsand is a balance between the risks of poor should be considered before startingcompliance, drug resistance and side effects antiretroviral treatment?if started too early, and the risk of seriousillness if started too late. If antiretroviral 1. Patients must show that they are bothtreatment is started too late (e.g. with a CD4 motivated and reliable. Otherwisecount below 50 cells/μl) the immune system compliance will be poor and they will notmay have been so badly damaged that full attend clinic regularly.recovery is no longer possible.
  5. 5. PREPARATION FOR ANTIRETROVIRAL TREATMENT 472. They must accept their HIV status and Excellent drug adherence is extremely important have a good understanding of HIV for the successful management of AIDS. infection and antiretroviral treatment.3. There should be no alcohol or drug abuse.4. They should not have untreated active 3-20 What are the aims of preparing a depression. patient for antiretroviral treatment?5. They are strongly advised to disclose their 1. The patient must have a good status to at least one person. understanding of HIV infection.6. They must have access to an antiretroviral 2. The names, dosing and timing of the centre and HIV clinic. antiretroviral agents must be learned.7. They should have the support of their Patients should be taught to recognise their partner, a friend or family member. different drugs. 3. The risks and symptoms of side effectsPREPARING FOR ANTI- must be known. 4. The importance of excellent adherenceRETROVIRAL TREATMENT must be understood and accepted. 5. Disclosure to a partner, close family and friends is needed.3-18 Why is it important to 6. Social support is essential.prepare the patient before starting 7. The patient must learn a healthy lifestyle.antiretroviral treatment? 8. The patient must accept regular follow-upIf the treatment is begun before the patient ready to start treatment, there will almostcertainly be poor compliance. The success 3-21 What issues should be discussedor failure of antiretroviral treatment often with patients before startingdepends on whether the patients have been antiretroviral treatment?well prepared or not. One of the main reasons 1. The purpose of giving antiretroviralfor treatment failure and poor co-operation treatment is to give them a longer,from patients is inadequate preparation. healthier life. 2. Antiretroviral treatment cannot cure HIV Inadequate preparation is an important cause of infection. poor co-operation and treatment failure. 3. They will still be infectious and be able to pass on HIV even while on treatment. 4. Treatment is lifelong.3-19 Why is excellent 5. The drugs must be taken correctly everyadherence so important? day for the treatment to be effective.It is very important that HIV patients take 6. They will need regular blood tests andtheir correct medication on time every day. clinical check-ups.Poor adherence to taking medicine correctly 7. Side effects to the treatment may occur.(poor compliance) leads to HIV resistance to 8. They should find a treatment or more of the antiretroviral drugs being 9. They need to consider the effects of dailyused. This reduces the drug options later in the treatment on their lifestyle.course of the illness. Taking the first regimenof antiretroviral drugs correctly is the bestchance the patient has to be healthy and wellfor many years.
  6. 6. 48 ADULT HIVSCREENING VISITS 9. Arrange a home visit, if possible. 3-24 What general medical screening3-22 What visits to the antiretroviral clinic examination is necessary?are needed before treatment is started? 1. Take a medical history.Usually two treatment readiness visits are 2. Obtain details of the patient’s socialneeded, followed by the final visit when circumstances.treatment is started. 3. Find out whether the patient has disclosed his/her HIV status to their partner and1. The first screening visit (often referred close family and friends. to as the week -4 visit). This visit is 4. Ask what family and community support usually the patient’s first contact with the is available. antiretroviral clinic. 5. Perform a full general physical2. The second screening visit (often referred examination. to as the week -2 visit). The first and second visits are used to prepare and assess whether the patient is ready for treatment. 3-25 What medical history is needed?3. The start of treatment visit (often referred 1. Any symptoms or signs of HIV and to as the week 0 visit). At this visit a final associated infections. decision is made and, if the patient is ready, 2. Recent weight loss. treatment is started. 3. Recent hospital admissions. 4. Recent history of TB. Usually two visits are needed to fully assess a 5. Any sexually transmitted diseases. 6. Current medication or allergies. patient for antiretroviral treatment. 3-26 What social history is important?3-23 What should be done atthe first screening visit? 1. Age. 2. Find out whether the patient understands1. A doctor should confirm that the clinical what AIDS is and what the implications of or immunological selection criteria for the diagnosis are. antiretroviral treatment have been met. 3. Family structure and home environment. This requires a general medical screening 4. Sexual relationships and condom use. examination. 5. Whether women are on reliable2. Identify any psychosocial problems. contraception and if pregnancies are3. Make sure that tuberculosis has been planned. excluded. This may require a chest X-ray 6. Employment and family income. and sputum tests. 7. Available support.4. Diagnose and treat any HIV-associated 8. Disclosure. infection. 9. Alcohol or drug abuse.5. The patient’s information record must be 10. Severe emotional problems, e.g. completed. depression.6. The patient must meet or be referred to the multidisciplinary team for group education 3-27 What physical and individual counselling. examination is required?7. Supply a 28-day supply of co-trimoxazole tablets. 1. Full general physical condition.8. Give the patient an appointment for the 2. Any signs of weight loss. next visit (usually the second visit in two 3. Clinical signs of HIV and associated weeks’ time). infections.
  7. 7. PREPARATION FOR ANTIRETROVIRAL TREATMENT 494. Assess the clinical stage of the patient. Patients need to know about the drugs they will be taking.3-28 Who should prepare a patientfor antiretroviral treatment? 3-31 How is education provided?This is best done by the multidisciplinarystaff of the health centre where antiretroviral 1. During individual counselling sessionstreatment is started. The doctor, nurse, 2. In group education classescounsellor, social worker and pharmacist all 3. With pamphlets on HIV infection andplay an important role in preparing a patient antiretroviral treatmentfor antiretroviral treatment. Sometimes 4. Posters and videos are helpfulpatients are referred to a special treatment 5. A treatment chart illustrating the drugs,readiness centre. Patient preparation classes or timing of doses and possible side effectsspecial day courses are very helpful. 3-32 What counselling is needed? Patients need to attend a treatment readiness The patient may need help in accepting course. their HIV status and the importance of antiretroviral treatment. They may also have difficulty disclosing their HIV status and3-29 What are the steps in preparing a finding someone who can support them. Allpatient for antiretroviral treatment? patients preparing for antiretroviral treatment1. Education should be encouraged to join a support2. Counselling group. Patients need an opportunity to talk about their fears and concerns. Counselling3-30 What education is needed? empowers patients to make the best decisions for themselves and take control of their lives.The patient needs to: It helps them understand, accept and make1. Understand what HIV infection is choices.2. Understand what antiretroviral treatment is Disclosure and support are needed for successful3. Know the names and appearance of the treatment. antiretroviral drugs to be used4. Know the dose and how to take these drugs correctly 3-33 Why is co-trimoxazole5. Know the symptoms and signs of the side prophylaxis started? effects Co-trimoxazole provides protection against6. Know about the common HIV-associated pneumocystis pneumonia, toxoplasmosis, infections many bacterial infections and some causes of7. Know that a good diet and a positive chronic diarrhoea. lifestyle are importantThe patient needs to understand antiretroviral 3-34 How is co-trimoxazoletreatment (‘patients must know their meds’). prophylaxis given?It is particularly important that the patient Two single-strength tablets daily (i.e.accepts that excellent adherence is essential, 80/400 mg). The commonest side effectresistance is dangerous, and that failure of is a maculopapular rash. Continue thetreatment and resistance are usually due to co-trimoxazole if the rash is mild. Stoppoor adherence. immediately if the rash is severe or blistering,
  8. 8. 50 ADULT HIVthe mucous membranes are involved, or the role models for patients starting antiretroviralpatient becomes ill with fever. treatment. NOTE Dapsone can be used if patients have Lay counsellors undergo careful training severe side effects to co-trimoxazole. which provides them with the knowledge and skills to function in their new role as counsellors and educators. Without lay3-35 Can the degree of drug counsellors, most antiretroviral clinics wouldadherence be assessed before not be able to function. They are essentialstarting antiretroviral treatment? members of the treatment team as theyYes, as patients who are not compliant with know the community well, usually speak theprophylactic co-trimoxazole will probably not patients’ home language and help to maintainbe compliant with antiretroviral treatment. close contact between patients and the clinic.Patients should bring their unused tablets to Lay counsellors promote a healthy lifestyle andeach clinic visit. These should be counted to often follow up the patient once antiretroviralassess compliance. If all the tablets needed treatment is started. Tracing patients that failhave not been taken, the patient should be to collect their medicines regularly or miss acounselled to find out why compliance is poor. clinic appointment is an important function.The advantages and importance of excellentadherence must again be stressed. Lay counsellors are valuable members of the Adherence to co-trimoxazole is a good indicator treatment team. of adherence to antiretroviral treatment. 3-39 Should patients have their own counsellor?3-36 Is a home visit always needed? A personal counsellor is a great advantage ifA home visit is very helpful to assess the it is possible to have one. Often the success ofhome circumstances and family support, and antiretroviral treatment depends on the helpwhether the patient has provided the correct and support of a lay counsellor. The counsellorcontact and social details. A reliable home should develop a special, caring relationshipaddress is essential and a telephone contact with the patient. They can perform the homenumber is useful. A home visit also helps to visit, meet the patient at each clinic visit anddetermine whether the patient has disclosed act as the contact between the patient and thehis/her HIV status. The storage facilities can be clinic team.inspected (e.g. whether there is a refrigeratoror not). It is a great advantage if each patient can have a3-37 Who does the home visit? personal counsellor.This is usually done by a lay counsellor or ahome carer from the community. 3-40 What should be done at the second screening visit?3-38 What are the benefits The second visit is usually arranged for twoof lay counsellors? weeks after the first visit. During this timeSome lay counsellors are on antiretroviral the patient has had time to consider thetreatment themselves. They have a personal implications of antiretroviral treatment.understanding of what it means to have HIV The following should be done at the secondinfection and successfully adhere to treatment. assessment visit:As a result, these lay counsellors are good 1. The clinical assessment should be repeated.
  9. 9. PREPARATION FOR ANTIRETROVIRAL TREATMENT 512. A second group education and information 5. They recognise the importance of excellent session is provided. daily adherence.3. The patient is again counselled about the 6. They have disclosed to a family member or importance of excellent adherence. friend who can support them.4. The co-trimoxazole tablets are counted 7. They are able to attend the clinic regularly. (pill count) to assess adherence. 8. They have a personal treatment plan.5. Blood for baseline tests is taken. 9. They must know the names and recognise which drugs are to be taken.The second visit is followed by a 10. They must know the symptoms and signsmultidisciplinary team discussion. of common side effects.3-41 What is the multidisciplinary If patients are not treatment ready yet theteam discussion? start of antiretroviral treatment should be postponed until they are ready and all theFollowing the second visit the patient must requirements have been assessed for readiness for antiretroviraltreatment by a multidisciplinary team. This 3-44 What safety baselineis done by the whole treatment team and not blood tests are needed?just one person. All the available informationmust be ready for the discussion (clinical 1. The baseline CD4 count has usually beenassessment, results of the two educational done before the patient is referred forand counselling sessions, and co-trimoxazole treatment consideration and, therefore,count). This is the final check that the patient need not be repeated. If the CD4 countis fully prepared for treatment. was not measured, this should be done at the second screening visit. These baselinePatients who are ready for treatment should be results are important when later assessinggiven an appointment for their antiretroviral the success or failure of antiretroviraltreatment commencement visit which will two weeks later. Every patient needs a 2. Special blood tests depending on the likelytreatment plan. side effects of the specific drugs being used: • Full blood count if AZT (zidovudine)3-42 What is a treatment plan? is usedThe treatment plan is the formal guide to the • Serum ALT (alanine aminotransferase)patient’s future management. Each patient if nevirapine is usedmust be fully aware of their own treatment • Fasting serum glucose, cholesterol andplan. Usually the treatment plan is given to triglyceride if ‘PIs’ such as lopinavir/each patient as a printed form. ritonavir are used • Creatinine clearance if tenofovir (TDF) is being used It is essential that each patient has a clearly understood treatment plan. A baseline CD4 count is needed before antiretroviral treatment is started.3-43 When are patients ‘treatment ready’?1. They show a willingness for treatment. NOTE To calculate creatinine clearance:2. They demonstrate insight into their illness. (140 – age in years) × weight in kg / serum3. They accept that lifetime treatment is creatinine concentration (× 0.85 in women). required.4. They understand the possible side effects of antiretroviral treatment.
  10. 10. 52 ADULT HIV3-45 What should be done when 4. Should psychosocial factorspatients are ready for treatment? exclude her from treatment?They should be asked to continue their co- No, but she should be counselled and betrimoxazole prophylaxis and be given an helped to become ‘treatment ready’. Withoutappointment for their next visit in two weeks disclosure, support and a firm commitment towhen antiretroviral treatment will begin. daily medication, she will almost certainly not succeed with antiretroviral treatment.Once it is agreed that antiretroviral treatmentshould be started, the drug regime and dosesmust be decided on and the drugs should be 5. Would tuberculosis result inordered from the pharmacy. It is helpful to postponement of treatment?have a system which maintains a close check Tuberculosis treatment should be startedon medication collected. before beginning antiretroviral treatment.CASE STUDY 1 CASE STUDY 2A patient who has had symptomatic HIV A patient who meets both the medical andinfection for the past year is referred to psychosocial criteria for treatment attends hisan antiretroviral clinic for treatment. Her first screening visit. He is very keen and wantsCD4 count is 150 cells/μl and she has been treatment to start immediately.clinically graded as stage 4. She is unhappyabout starting treatment as she does not want 1. Should he be offered treatmentto disclose her HIV status to her partner and immediately as he wants tofamily. She has a chronic cough. start straight away?1. Does her immunological status meet No. It is always important to make sure thatthe criteria for antiretroviral treatment? the patient is well prepared before starting treatment. Starting antiretroviral treatment isYes, as her CD4 count is below 200 cells/μl. never an emergency.This indicates that her immune function isfailing and she is at high risk of dying of HIV 2. What should be done atinfection unless she receives antiretroviral the first screening visit?treatment. A careful history should be taken and a full2. Is stage 4 disease a criteria for treatment? physical examination done to confirm that all the criteria for treatment have been met.Yes. Stage 4 HIV infection (i.e. AIDS), with Counselling and education sessions must beor without a low CD4 count, is a criteria arranged and co-trimoxazole started.for treatment. She therefore meets boththe immunological and clinical criteria for 3. Who should provide thetreatment. counselling and education?3. Do you think she should start All the members of the multidisciplinaryon antiretroviral treatment? team play a role. Individual counselling is important. Pamphlets, videos and posters areNo, as she has psychosocial problems. She is helpful. A group education course may benot happy about starting treatment and has available.not disclosed her status to either her partneror family.
  11. 11. PREPARATION FOR ANTIRETROVIRAL TREATMENT 534. What must the patient learn 3. What are the advantagesabout antiretroviral treatment? of a lay counsellor?He must know what drugs are to be taken, They sometimes are HIV positive and wellthe dose and timing of treatment, and the managed on antiretroviral treatment. As aside effects. He must ‘know his drugs’. The result they have personal experience of theimportance of excellent adherence must be problems of HIV management. They comestressed at every meeting. He must be aware of from the local community and have a goodthe risks and advantages of treatment. understanding of the social circumstances. Usually the lay counsellor can speak the5. Why should he start co-trimoxazole? patient’s home language. The lay counsellor is a good role model for the patient startingIt prevents many of the infections associated antiretroviral treatment.with HIV. It is also a measure of the patient’swillingness to take regular medication. A ‘pill 4. Would alcohol abuse be acount’ assesses whether all doses have been contraindication for startingtaken. Taking all his co-trimoxazole tablets antiretroviral treatment?as prescribed suggests he will also adhere toantiretroviral treatment. Yes. So would untreated active depression or drug abuse. These problems would need to be6. What is the most important lesson to successfully managed before treatment couldlearn about taking antiretroviral drugs? start. Discovering this problem stresses the importance of a home visit.For successful treatment drug adherence mustbe excellent. 5. What other support can a lay counsellor provide?CASE STUDY 3 They help with counselling and education. Lay counsellors keep close contact betweenAfter the first screening appointment a patients and the clinic. They help promote ahome visit is arranged. This is done by a lay healthy lifestyle with a positive outlook.counsellor. The lay counsellor discovers thatthe patient is drinking heavily over weekends. CASE STUDY 41. What is the aim of the home visit? A patient attends the second screening visit.To help asses the home circumstances, While she is waiting to be seen by the doctor,especially disclosure and support. It is also blood samples are taken. She is assessed forimportant to confirm the home address and treatment readiness and told to return incontact phone number. two weeks to start treatment. She is given a treatment plan.2. Should the home visit not be doneby a professional counsellor? 1. What blood tests are doneUsually there are not enough professional at the second visit?counsellors to do all the home visits. Therefore A CD4 count is done if this has not alreadylay counsellors and home carers are often been checked. Additional blood tests areused. They are well trained and employed by done depending on the drugs to be used.the clinic. A full blood count for AZT, serum ALT for nevirapine and fasting glucose, cholesterol and triglyceride for lopinavir/ritonavir.
  12. 12. 54 ADULT HIV2. When are patients ‘treatment ready’? 3. What is a treatment plan?When they are willing to accept that treatment It is a clear plan of what drugs should be taken,is for life and excellent adherence is the key to their doses and time of medication. Eachsuccessful treatment. They must understand patient must be given a written treatment to take their medication correctly andknow what side effects to expect. They should 4. Who decides when a patientalso be able to attend clinic regularly, have is ready to start treatment?disclosed their HIV status and have goodhome support. The multidisciplinary team. The decision should not be taken by the doctor alone.