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Review of Antiretroviral Therapy in Adults

HAIVNHarvard Medical School AIDS

Initiative in Vietnam

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Learning Objectives

By the end of this session, participants should be able to:

Explain the criteria for starting ART Identify the first line ARV regimens Describe the common side effects

caused by NRTIs and NNRTIs Describe the protocol for performing

routine follow-up with ARV patients

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Drug Classes of Antiretrovirals (ARV)

1. Nucleoside Reverse Transcriptase Inhibitors

(NRTI)

2. Non-nucleoside Reverse Transcriptase

Inhibitors (NNRTI)

3. Protease Inhibitors (PI)

4. Fusion/Entry Inhibitors

5. Integrase Inhibitors

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ARV Drugs Currently Available in the World and Vietnam

Nucleoside/Nucleotide RTI

AZT / Zidovudine

d4T / Stavudine

3TC / Lamivudine

ddI / didanosine

ABC / Abacavir

TDF / Tenofovir

FTC /Emtricitabine

Non-nucleoside RTI

NVP /Nevirapine

DLV / Delavirdine

EFV / Efavirenz

ETR / Etravirine

Protease inhibitors

SQV / Saquinavir

RTV / Ritonavir

IDV / Indinavir

NFV / Nelfinavir

APV / Amprenavir

LPVr / Lopinavir + ritonavir

ATV / Atazanavir

Fos-Amprenavir

DRV / Darunavir

TPV / Tipranavir

Integrase inhibitors

RAL / Raltegravir

Fusion/Entry inhibitors

MVC / Mariviroc

ENF / Enfuvirtide

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Goals of ARV Therapy

Inhibit HIV replication• As low as possible (undetectable)• For as long as possible

Allow recovery of the immune system Prevent opportunistic infection Improve survival, health and quality

of life

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When to Start ART?

ARV therapy is never an emergency Patients with high CD4 are not at risk

for OIs and can delay ARV treatment Decide when to start ARV based on:

Risks Benefits

• Allergy• Side Effects• Adherence• Costs

• Improve immune function • Improve quality of life• Decrease risk for OIs

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When to Start ARV in Vietnam

Patients with: CD4 ≤ 350 cells/mm³ irrespective of

clinical stage Clinical stage 3 or 4 irrespective of CD4

cell count

Modification and Supplement to the Guidelines for Diagnosis and Treatment of HIV/AIDS, MOH November 2011

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First Line ARV Regimens in Vietnam (1)

2 NRTI + 1 NNRTI

Stavudine (D4T) is no longer recommended as a first line ARV

Lamivudine (3TC)Tenofovir (TDF)Zidovudine (AZT)

Efavirenz (EFV)Nevirapine (NVP)

Modification and Supplement to the Guidelines for Diagnosis and Treatment of HIV/AIDS, MOH November 2011

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First Line ARV Regimens in Vietnam (2)

3TCEFVor

NVP+

Modification and Supplement to the Guidelines for Diagnosis and Treatment of HIV/AIDS, MOH November 2011

+TDFor

AZT

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First Line ARV Regimens in Vietnam (3)

Priority Regimens Alternative Regimens

TDF/3TC/EFVTDF/3TC/NVP

AZT/3TC/EFVAZT/3TC/NVP

Modification and Supplement to the Guidelines for Diagnosis and Treatment of HIV/AIDS, MOH November 2011

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Side Effects of 1st Line ARVs

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Class Drug Common Side Effects

NRTI

d4T• Peripheral neuropathy• Lipoatrophy• Lactic acidosis

AZT• Headache, nausea• Anemia

TDF • Renal Dysfunction

NNRTIEFV

• Rash• CNS symptoms• Teratogenicity

NVP• Rash• Hepatotoxicity

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Monitoring Patients on ART

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Monitoring: How Often?

Month 1 Month 2 Month 3+

Once per week every 2 weeksOnce per month

orevery 2 months

If the clinical situation is stable:

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What to Monitor? (1)

Adherence Monitoring

Assess missed doses

Provide counseling about adherence, prevention, and healthy living

Clinical Monitoring Weight,

temperature WHO Clinical Stage ARV side effects or

toxicity Signs of IRIS

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What to Monitor? (2)

Laboratory Monitoring:

Test Frequency

CBC Every 6 monthsAlso after 1st month if on AZT

ALT Every 6 monthsAlso after 1st month if on NVP

CD4 Every 6 months

Lipids and Glucose

Every year

Creatinine Every 6 months if on TDF

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Key Points

Patients with clinical stage 3 or 4 or CD4 ≤ 350 should start ART

Two priority first ARV regimens in Vietnam:• TDF + 3TC + EFV• TDF + 3TC + NVP

All ART patients need routine clinical and laboratory monitoring

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Thank You!

Questions?