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

1. 3
Preparation for
antiretroviral
treatment
Before you begin this unit, please take the INDICATION FOR ANTI-
corresponding test at the end of the book to
assess your knowledge of the subject matter. You RETROVIRAL TREATMENT
should redo the test after you’ve worked through
the 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. 44 ADULT HIV
should be started on antiretroviral treatment
Both the clinical stage of HIV infection and the
irrespective 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 antiretroviral
3-3 What CD4 count is an indication
treatment as these patients will have to take
to start antiretroviral treatment?
drugs every day for the rest of their life. The
Antiretroviral treatment should be started patients must be fully counselled and given
when the CD4 count falls below 200 cells/μl, time to consider all the implications. Their
even if the clinical stage is still 1, 2 or 3. The opinion is very important and they must
aim of antiretroviral treatment is to prevent agree before treatment is started. They must
the CD4 count dropping further. A CD4 count understand the implications, the benefits and
below 200 cells/μl indicates severe damage to the side effects. Patients must be prepared
the immune system. and ready to start antiretroviral treatment.
However, the new South African guidelines Treatment will fail if the patient is not ready
indicate that people who are pregnant or and willing to start.
who have tuberculosis should be offered
antiretroviral treatment when their CD4 count Patients must be fully informed and willing to
reaches 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 suggest
3-4 Are both the clinical stage and the a CD4 count below 200 cells/μl or stage 4
CD4 count equally important indicators disease plus a readiness and commitment to
for antiretroviral treatment? lifelong treatment. Therefore both medical and
Yes. Both the clinical stage of HIV infection psychosocial factors are important in deciding
and the CD4 count should be considered when when a patient should start antiretroviral
deciding on whether to start antiretroviral treatment.
treatment or not. Either the clinical stage
of HIV infection (e.g. stage 4) or the CD4
Both medical and personal factors must be
count (e.g. below 200 cells/μl) may be used
considered before starting antiretroviral
as 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 all
stage 4 patients even if their CD4 count is still
above 200 cells/μl.

3. PREPARATION FOR ANTIRETROVIRAL TREATMENT 45
REFERRAL FOR ANTI- PROBLEMS
RETROVIRAL TREATMENT WITH STARTING
ANTIRETROVIRAL
3-7 Who should refer a patient TREATMENT
for antiretroviral treatment?
The nurse at the HIV clinic or general
3-10 What happens if the criteria for
primary-care clinic, if an HIV clinic is not
antiretroviral treatment are not met?
available. As the decision to start antiretroviral
treatment is often complex, and as patient The patient is referred back to their local clinic
preparation is so important, this assessment with a letter providing the reasons why the
should be done at a special antiretroviral clinic patient has not been accepted for antiretroviral
if possible. All HIV clinics should know the treatment. The local clinic should follow
criteria for patient referral. Patients should not these patients and refer them again to the
be referred for antiretroviral treatment before antiretroviral clinic when the criteria (stage 4
the criteria are met. or CD4 count below 200 cells/μl plus patient
willingness) have been met. Any psychosocial
3-8 How should patients be referred problems identified during screening
to the antiretroviral clinic? should be addressed. Provide counselling to
encourage disclosure and obtain support.
Patients should be sent to the antiretroviral
clinic with a full referral letter. A standardised
3-11 Should psychosocial factors
referral letter is helpful. Send the latest CD4
be used as exclusion criteria for
count 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 considerations
appointments 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 decision
whether a patient should be given
Psychosocial problems are useful in predicting
antiretroviral treatment?
whether treatment is likely to be successful or not.
The multidisciplinary team at the antiretroviral
clinic. The team consists of the doctor, nurse
3-12 What are the common causes for
and counsellor. If possible a social worker,
postponing antiretroviral treatment?
pharmacist, psychologist, dietician and patient
advocate 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. 46 ADULT HIV
3. 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 early
4. 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 for
Make every effort not to delay treatment if the antiretroviral treatment?
patient has a CD4 count below 100 cells/μl, Usually four weeks. During this time
is pregnant or has multi- or extremely drug- the patient is prepared for the start of
resistant pulmonary TB. antiretroviral treatment.
3-13 What problems may result if
It usually takes four weeks to prepare a patient
treatment is started too early?
for antiretroviral treatment.
Starting too early when a patient is not
treatment ready may lead to:
3-16 Is starting antiretroviral treatment
1. Unnecessary cost and inconvenience ever an emergency decision?
2. Poor compliance
Starting antiretroviral treatment is never an
3. Drug resistance
emergency. The patient must be fully prepared
4. Side effects
before treatment is started and this always
The health benefits of starting antiretroviral takes time. Never rush the decision or force
treatment early are not well defined and are patients to start antiretroviral treatment
currently still being studied. Poor adherence before they are ready. Patients must show
and drug resistance will decrease the chances a commitment to take their medication
of a good response to antiretroviral treatment correctly and follow instructions. However, in
when 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 delayed
3-14 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 usually
HIV infection if antiretroviral treatment is is not an emergency and must not be rushed.
started too late. Therefore, the correct timing
of starting treatment is very important 3-17 What psychosocial factors
and is a balance between the risks of poor should be considered before starting
compliance, drug resistance and side effects antiretroviral treatment?
if started too early, and the risk of serious
illness if started too late. If antiretroviral 1. Patients must show that they are both
treatment is started too late (e.g. with a CD4 motivated and reliable. Otherwise
count below 50 cells/μl) the immune system compliance will be poor and they will not
may have been so badly damaged that full attend clinic regularly.
recovery is no longer possible.

5. PREPARATION FOR ANTIRETROVIRAL TREATMENT 47
2. 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 effects
PREPARING FOR ANTI- must be known.
4. The importance of excellent adherence
RETROVIRAL 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-up
If the treatment is begun before the patient care.
is ready to start treatment, there will almost
certainly be poor compliance. The success 3-21 What issues should be discussed
or failure of antiretroviral treatment often with patients before starting
depends on whether the patients have been antiretroviral treatment?
well prepared or not. One of the main reasons
1. The purpose of giving antiretroviral
for 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 every
adherence so important?
day for the treatment to be effective.
It is very important that HIV patients take 6. They will need regular blood tests and
their 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 supporter.
one or more of the antiretroviral drugs being 9. They need to consider the effects of daily
used. This reduces the drug options later in the treatment on their lifestyle.
course of the illness. Taking the first regimen
of antiretroviral drugs correctly is the best
chance the patient has to be healthy and well
for many years.

6. 48 ADULT HIV
SCREENING VISITS 9. Arrange a home visit, if possible.
3-24 What general medical screening
3-22 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 social
needed, 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 and
1. 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 physical
2. 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 at
the first screening visit? 1. Age.
2. Find out whether the patient understands
1. 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 reliable
2. Identify any psychosocial problems. contraception and if pregnancies are
3. 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. PREPARATION FOR ANTIRETROVIRAL TREATMENT 49
4. Assess the clinical stage of the patient.
Patients need to know about the drugs they will
be taking.
3-28 Who should prepare a patient
for antiretroviral treatment?
3-31 How is education provided?
This is best done by the multidisciplinary
staff of the health centre where antiretroviral 1. During individual counselling sessions
treatment is started. The doctor, nurse, 2. In group education classes
counsellor, social worker and pharmacist all 3. With pamphlets on HIV infection and
play an important role in preparing a patient antiretroviral treatment
for antiretroviral treatment. Sometimes 4. Posters and videos are helpful
patients 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 effects
special 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 and
3-29 What are the steps in preparing a finding someone who can support them. All
patient for antiretroviral treatment? patients preparing for antiretroviral treatment
1. Education should be encouraged to join a support
2. Counselling group. Patients need an opportunity to talk
about their fears and concerns. Counselling
3-30 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 make
1. Understand what HIV infection is choices.
2. Understand what antiretroviral treatment
is Disclosure and support are needed for successful
3. Know the names and appearance of the treatment.
antiretroviral drugs to be used
4. Know the dose and how to take these
drugs correctly 3-33 Why is co-trimoxazole
5. Know the symptoms and signs of the side prophylaxis started?
effects Co-trimoxazole provides protection against
6. Know about the common HIV-associated pneumocystis pneumonia, toxoplasmosis,
infections many bacterial infections and some causes of
7. Know that a good diet and a positive chronic diarrhoea.
lifestyle are important
The patient needs to understand antiretroviral 3-34 How is co-trimoxazole
treatment (‘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 effect
resistance is dangerous, and that failure of
is a maculopapular rash. Continue the
treatment and resistance are usually due to
co-trimoxazole if the rash is mild. Stop
poor adherence.
immediately if the rash is severe or blistering,

8. 50 ADULT HIV
the mucous membranes are involved, or the role models for patients starting antiretroviral
patient 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 lay
3-35 Can the degree of drug
counsellors, most antiretroviral clinics would
adherence be assessed before
not be able to function. They are essential
starting antiretroviral treatment?
members of the treatment team as they
Yes, as patients who are not compliant with know the community well, usually speak the
prophylactic co-trimoxazole will probably not patients’ home language and help to maintain
be compliant with antiretroviral treatment. close contact between patients and the clinic.
Patients should bring their unused tablets to
Lay counsellors promote a healthy lifestyle and
each clinic visit. These should be counted to
often follow up the patient once antiretroviral
assess compliance. If all the tablets needed
treatment is started. Tracing patients that fail
have not been taken, the patient should be
to collect their medicines regularly or miss a
counselled to find out why compliance is poor.
clinic appointment is an important function.
The advantages and importance of excellent
adherence 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 if
A home visit is very helpful to assess the
it is possible to have one. Often the success of
home circumstances and family support, and
antiretroviral treatment depends on the help
whether the patient has provided the correct
and support of a lay counsellor. The counsellor
contact and social details. A reliable home
should develop a special, caring relationship
address is essential and a telephone contact
with the patient. They can perform the home
number is useful. A home visit also helps to
visit, meet the patient at each clinic visit and
determine whether the patient has disclosed
act as the contact between the patient and the
his/her HIV status. The storage facilities can be
clinic team.
inspected (e.g. whether there is a refrigerator
or not).
It is a great advantage if each patient can have a
3-37 Who does the home visit? personal counsellor.
This is usually done by a lay counsellor or a
home 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 two
of lay counsellors? weeks after the first visit. During this time
Some lay counsellors are on antiretroviral the patient has had time to consider the
treatment themselves. They have a personal implications of antiretroviral treatment.
understanding of what it means to have HIV The following should be done at the second
infection and successfully adhere to treatment. assessment visit:
As a result, these lay counsellors are good 1. The clinical assessment should be repeated.

9. PREPARATION FOR ANTIRETROVIRAL TREATMENT 51
2. 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 signs
multidisciplinary team discussion.
of common side effects.
3-41 What is the multidisciplinary If patients are not treatment ready yet the
team discussion? start of antiretroviral treatment should be
postponed until they are ready and all the
Following the second visit the patient must requirements have been met.
be assessed for readiness for antiretroviral
treatment by a multidisciplinary team. This
3-44 What safety baseline
is done by the whole treatment team and not
blood tests are needed?
just one person. All the available information
must be ready for the discussion (clinical 1. The baseline CD4 count has usually been
assessment, results of the two educational done before the patient is referred for
and 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 count
is fully prepared for treatment. was not measured, this should be done at
the second screening visit. These baseline
Patients who are ready for treatment should be
results are important when later assessing
given an appointment for their antiretroviral
the success or failure of antiretroviral
treatment commencement visit which will
treatment.
be two weeks later. Every patient needs a
2. Special blood tests depending on the likely
treatment plan.
side effects of the specific drugs being used:
• Full blood count if AZT (zidovudine)
3-42 What is a treatment plan? is used
The treatment plan is the formal guide to the • Serum ALT (alanine aminotransferase)
patient’s future management. Each patient if nevirapine is used
must be fully aware of their own treatment • Fasting serum glucose, cholesterol and
plan. 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 / serum
3. They accept that lifetime treatment is creatinine concentration (× 0.85 in women).
required.
4. They understand the possible side effects of
antiretroviral treatment.

10. 52 ADULT HIV
3-45 What should be done when 4. Should psychosocial factors
patients are ready for treatment? exclude her from treatment?
They should be asked to continue their co- No, but she should be counselled and be
trimoxazole prophylaxis and be given an helped to become ‘treatment ready’. Without
appointment for their next visit in two weeks disclosure, support and a firm commitment to
when antiretroviral treatment will begin. daily medication, she will almost certainly not
succeed with antiretroviral treatment.
Once it is agreed that antiretroviral treatment
should be started, the drug regime and doses
must be decided on and the drugs should be 5. Would tuberculosis result in
ordered from the pharmacy. It is helpful to postponement of treatment?
have a system which maintains a close check Tuberculosis treatment should be started
on medication collected. before beginning antiretroviral treatment.
CASE STUDY 1 CASE STUDY 2
A patient who has had symptomatic HIV A patient who meets both the medical and
infection for the past year is referred to psychosocial criteria for treatment attends his
an antiretroviral clinic for treatment. Her first screening visit. He is very keen and wants
CD4 count is 150 cells/μl and she has been treatment to start immediately.
clinically graded as stage 4. She is unhappy
about starting treatment as she does not want 1. Should he be offered treatment
to disclose her HIV status to her partner and immediately as he wants to
family. She has a chronic cough. start straight away?
1. Does her immunological status meet No. It is always important to make sure that
the criteria for antiretroviral treatment? the patient is well prepared before starting
treatment. Starting antiretroviral treatment is
Yes, as her CD4 count is below 200 cells/μl. never an emergency.
This indicates that her immune function is
failing and she is at high risk of dying of HIV 2. What should be done at
infection unless she receives antiretroviral the first screening visit?
treatment.
A careful history should be taken and a full
2. 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 be
or without a low CD4 count, is a criteria arranged and co-trimoxazole started.
for treatment. She therefore meets both
the immunological and clinical criteria for 3. Who should provide the
treatment. counselling and education?
3. Do you think she should start All the members of the multidisciplinary
on antiretroviral treatment? team play a role. Individual counselling is
important. Pamphlets, videos and posters are
No, as she has psychosocial problems. She is helpful. A group education course may be
not happy about starting treatment and has available.
not disclosed her status to either her partner
or family.

11. PREPARATION FOR ANTIRETROVIRAL TREATMENT 53
4. What must the patient learn 3. What are the advantages
about antiretroviral treatment? of a lay counsellor?
He must know what drugs are to be taken, They sometimes are HIV positive and well
the dose and timing of treatment, and the managed on antiretroviral treatment. As a
side effects. He must ‘know his drugs’. The result they have personal experience of the
importance of excellent adherence must be problems of HIV management. They come
stressed at every meeting. He must be aware of from the local community and have a good
the risks and advantages of treatment. understanding of the social circumstances.
Usually the lay counsellor can speak the
5. Why should he start co-trimoxazole? patient’s home language. The lay counsellor
is a good role model for the patient starting
It prevents many of the infections associated antiretroviral treatment.
with HIV. It is also a measure of the patient’s
willingness to take regular medication. A ‘pill
4. Would alcohol abuse be a
count’ assesses whether all doses have been
contraindication for starting
taken. Taking all his co-trimoxazole tablets
antiretroviral treatment?
as prescribed suggests he will also adhere to
antiretroviral treatment. Yes. So would untreated active depression or
drug abuse. These problems would need to be
6. What is the most important lesson to successfully managed before treatment could
learn about taking antiretroviral drugs? start. Discovering this problem stresses the
importance of a home visit.
For successful treatment drug adherence must
be excellent.
5. What other support can a
lay counsellor provide?
CASE STUDY 3 They help with counselling and education.
Lay counsellors keep close contact between
After the first screening appointment a patients and the clinic. They help promote a
home visit is arranged. This is done by a lay healthy lifestyle with a positive outlook.
counsellor. The lay counsellor discovers that
the patient is drinking heavily over weekends.
CASE STUDY 4
1. 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 for
important to confirm the home address and treatment readiness and told to return in
contact phone number. two weeks to start treatment. She is given a
treatment plan.
2. Should the home visit not be done
by a professional counsellor? 1. What blood tests are done
Usually 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 already
lay counsellors and home carers are often been checked. Additional blood tests are
used. 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. 54 ADULT HIV
2. 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. Each
successful treatment. They must understand patient must be given a written treatment plan.
how to take their medication correctly and
know what side effects to expect. They should 4. Who decides when a patient
also be able to attend clinic regularly, have is ready to start treatment?
disclosed their HIV status and have good
home support. The multidisciplinary team. The decision
should not be taken by the doctor alone.