Antiretroviral therapy (ART) aims to suppress the HIV virus and improve health outcomes. It works by targeting different stages of the HIV lifecycle using combinations of antiretroviral drugs from several classes. Regular monitoring of viral load and CD4 levels helps assess treatment effectiveness and risk for disease progression. While ART has significant benefits if taken correctly, non-adherence risks developing drug resistance and limiting future treatment options. Ensuring strong patient education and support for following complex drug regimens is essential for ART programs to successfully reduce HIV-related morbidity, mortality and transmission at population levels.

1. INTRODUCTION TO ART

2. Goals Of Antiretroviral Therapy
• Reduce HIV-related morbidity and mortality
• Improve quality of life of infected persons
• Reduce viral load to undetectable level for as long
as possible
• Revitalize the immune system by increasing the
CD4 level
• Provide an antiretroviral regimen which:
– High likelihood of success
– Preserve future therapeutic option
– Has relatively few side effects
– Is tailored to individual need

3. The HIV viral load
• A count of the number of HIV RNA molecules in 1
ml of plasma (copies/ml)
• A direct measure of the level of HIV infection
• A predictor of disease symptoms and of the rate of
CD4+ T cell decline
• What’s a good viral load for a patient on
treatment? An undetectable viral load (<50
copies/ml)!
– If viral load is this low, patients are unlikely to have
disease progression, resistance, or to pass HIV through
MTCT and sexual transmission.

4. THE CD4 CELLS
• A count of the T-helper cells in the blood
• It is a subset of the lymphocytes
• It gives a reflection of the
strength/weakness of the immune system in
the body
• Predictor of the rate of development of
opportunistic infections (OIs) in the body

5. ARV MEDICATION GROUPS
Anti-retro virals act at the different stages of the HIV
life cycle to interfere with its reproduction. The main
stages of the cycle where these drugs acts are:
• Nucleoside (Nucleotide) reverse transcriptase
inhibitors (NRTIs)
• Non-Nucleoside reverse transcriptase inhibitors
(NNRTIs)
• Protease Inhibitors (PIs)
• Fusion Inhibitors

6. REVERSE TRANSCRIPTASE
INHIBITORS (NRTIs &
NNRTIs)
PROTEASE
INHIBITORS
ATTACHMENT
INHIBITORS
INTEGRASE INHIBITORS
FUSION
INHIBITORS
HIV DRUG TARGETS: CURRENT AND FUTURE
ENTRY INHIBITORS

7. Different drugs work together to
reduce viral load
Example:
Viral load before treatment might be
100,000 copies/ml
Treatment Viral load reduced to:
One drug alone 10,000
Two drugs together 1,000
Three drugs together Greater chance of undetectable

8. HIGHLY ACTIVE ANTIRETROVIRAL
THERAPY (HAART)
• The use of ≥3 drugs from at least 2 classes
to achieve effective viral suppression
• Any antiretroviral that will:
– Prevent disease progression
– Optimize opportunity for recovery
– Prevent selection for drug resistance
In practice, must maintain viral load to < 50
copies/ml of blood

9. ARV Agents Included
in South Sudan’s ARV Guidelines
Nucleoside
reverse
transcriptase
inhibitors
(NsRTIs)
Nucleotide
reverse
transcriptase
inhibitor (NtRTI)
Non-nucleoside
reverse
transcriptase
inhibitors
(NNRTIs)
Protease inhibitors
(PIs)
• Zidovudine
(ZDV, AZT)
• Lamivudine
(3TC)
• Emtricitabine
(FTC)
• Abacavir
(ABC)
• Tenofovir
disoproxil
fumarate
(TDF)
• Nevirapine
(NVP)
• Efavirenz
(EFZ)
• Ritonavir (RTV)
(pharmacoenhanc
er)
• Lopinavir/ritonavir
(LPV/r)

10. Benefits of ARV
 encouragement to test
 awareness of HIV
 motivation of health care workers
 expenses for palliative and OI care
 number of orphans
Keeps households and businesses intact
Potential to enhance prevention
a. Behavioral: access to prevention education during care
encounters
b. Biological: decreased transmission due to lowered viral
load

11. Risks Of ARV
• Risk: If the virus is not suppressed fully, drug
resistance can develop which will make the
current ARV regimen less effective and limit future
ARV treatment options
• Risk: Possible short and long term side effects for
patients
• Risk: Possible interactions with other medications
or natural remedies

12. Strategies to reduce ARV risks
Strategies to Reduce Risks:
– A comprehensive ARV program
– Excellent patient education and preparation
before starting ARVs
– Perfect or near perfect patient adherence to
ARVs
– Provider knowledge of ARVs and proper use
– Excellent patient follow-up and monitoring

13. Prerequisites for a Successful ARV
Program
 Adequate infrastructure
 Lab facilities for patient diag. & monitoring
 Access to OI/symptomatic treatment
 Continuous supply of ARVs
 Informed communities
 Counseled patients
 Trained ART team members
 ARV treatment guidelines in place
 Political will & view for sustainable program

14. -Limited resources
-Procurement of affordable ARVs
-Ensuring ARV supply
-Security of ARV storage
-Limited physical infrastructure
-Providing necessary laboratory monitoring
-Need for trained doctors and nurses
-Staff turnover
Challenges for ART Programs in
Resource-Constrained Countries

15. The 3 most important things to know
about HIV treatment
1. Resistance will evolve if virus grows in the
presence of drug
2. Treatment must be potent enough to stop virus
from growing and must present a high genetic
barrier to resistance
3. All drugs must be taken every day or all drugs
must be stopped (but can later be restarted).
Accomplishing successful treatment requires that the
patient and HIV care team work together.

16. IMPORTANCE OF ADHERENCE
• ARVs, when taken correctly, can tremendously
enhance a patient’s life and dramatically halt
progression of disease
• However, in order to derive the most benefit from
the medications, adherence must be EXCELLENT
– Should work with the patient to develop adherence
strategy
– If ARVS are taken improperly, problems may occur on
a personal and public health level
• Implications on resistance, cross resistance, spreading
resistant virus and cost

17. Summary
• Antiretroviral therapy should reduce morbidity
and mortality from HIV/AIDS
• While there are risks of drug resistance and
anticipated side effects from medications,
antiretroviral therapy’s benefits outweigh the
risks
• Monitoring patients on therapy is critical
• Adherence to therapy is the key to success
• ART programs should address programmatic
challenges to ensure success in scaling up ART

18. THANK YOU