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Zero detectable blood viral levels and living a positive life

HIV/AIDS | June 23, 2015 | Author: The Super Pharmacist

AIDS, HIV, HIV/AIDS

Zero detectable blood viral levels and living a positive life

Many patients who are diagnosed with HIV have different understandings, expectations and adherence levels when it comes to their treatment programmes. With the management of HIV now better understood than ever before through a combination of pharmaceutical treatment options and psychosocial support, there are a number of different monitoring strategies that can be used to help ensure patients manage their condition appropriately and live positive, fulfilling lives.

What factors determine how well patients respond to treatment?

A patient’s understanding of their own treatment programme is central to the chances of it being successful, as is the level to which they want to be involved. Patients who want to understand more about the role of Antiretroviral Therapy (ART) in their treatment have been evidenced to have better outcomes – patients who consider ART central to their improved health over a prolonged period of time, regularly seek out information regarding new treatment options, and ask healthcare professionals questions regarding any concerns they may have in regards to living with HIV, will generally display better long term outcomes (1). Patient engagement and self-management regarding their own treatment regimen is particularly important, as many antiretroviral treatment options, when taken with other medicines (including a number of over the country drugs and herbal remedies) can affect the toxicity and efficacy of the drug itself (2).

How are patients with established ART treatment programmes managed?

Patients with long-term ART treatment plans are often reviewed annually by their physician and pharmacist, although this timescale can be considerably shorter if the patient has a number of complex needs or does not adhere to their treatment programme and becomes unwell. Typically, at each new prescription of ART drugs, a wide range of topics relevant to treatment will be covered such as mood, contraception and any plans for conception, adherence, patient understanding of dosing instructions, medicine interactions/adverse effects, and a full history of all drugs taken in the past 12 months, both medical and recreational (3). Patients who are classified as ‘ART-naive’ and do not have a well developed sense of their own health and wellbeing, or express a less clear intention to successfully manage their own treatment, will often be asked a range of other questions relating to their overall health. For patients with particularly complicated or complex lives, further support may be offered around employment, benefits and accommodation, and a range of other medical interventions that are important for patients with HIV such as certain vaccinations (such as PCV and the seasonal flu jab), smoking cessation, and levels of physical activity.

Is patient non-compliance and non-adherence a serious issue?

Patients who regularly do not adhere to their treatment programme place themselves at significant risk of further illness that could threaten their life. If patients no longer take ART, and their CD4 cell count drops down below 200, they are prone to ‘opportunistic infections’ that take advantage of an immune system weakened by HIV. Patients who follow their treatment programme have a very small chance of contracting these types of illness, whilst those who do not have a much greater risk of contracting bacterial infections (such as tuberculosis or pneumonia), fungal infections (such as oral thrush), viral infections (such as shingles), and parasitical infections (such as toxoplasmosis). HIV patients who do not take their treatment are also at greater risk of some forms of cancer (such as lymphoma). Many healthcare organisations rely on self-reporting regarding patient adherence, and it is widely considered to be the most inexpensive and simple method of understanding how well patients are doing in regards to their treatment plan. Physicians will take time to understand reasons behind non-adherence, which are often complex and can be social, physical, and psychological in nature. If patients have stopped taking certain medication due to concerns over their side effects, or their acceptability and tolerability, then new combination treatments can be explored. A 2006 qualitative study investigating some of the reasons behind patients falling behind with their plans, concluded that many patients found it physically difficult to take all their HIV medication exactly as prescribed, often causing them distress (4).

What are ‘drug holidays’? Why they are a bad idea:

Drug holidays are extended periods of time in which some patients choose not to take any form of antiretroviral drug treatment. They are also sometimes referred to as structured treatment interruptions. There are no treatment guidelines that advise drug holidays to be taken, with the exception of post exposure prophylaxis (PEP) which can be taken up to 72 hours after coming into contact with the virus for the first time to try and prevent the patient becoming infected. A number of randomised controlled trials (RCTs) have evidenced the detrimental effect of breaks in treatment, with higher incidence of opportunistic infection, lymphoma, heart attacks and deaths reported in patients who voluntarily choose to stop their ARTs (5,6).

Does successful ART treatment reduce the viral load of individuals down to a point where they can no longer transmit HIV to another person?

Zero detectable blood viral levels are possible with the use of ARTS, although at no point does a patient with HIV have 0% risk of transmitting the virus to someone else. However, a number of studies have shown that transmission risk is significantly lower when patients have zero detectable viral loads – a large cohort study, currently being undertaken by the EU-funded PARTNER study and due to produce its final results in 2017, has so far demonstrated that no one taking part in the study with a viral load of < 200 copies/ml has transmitted HIV by either anal or vaginal sex. A statistical analysis of all current study participants has shown transmission rate risk as between only 1-4% (7): if these initial findings are replicated, it may have a significant impact on the way in which future prevention and treatment strategies are designed and delivered.

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References

1. Palmer S, Maldarelli F, Wiegand A et al (2008) Low-level viremia persists for at least 7 years in patients on suppressive antiretroviral therapy Proc Natl Acad Sci 10:3879-3884

2. Staltari O, Leporini C, Caroleo B et al (2014) Drug-drug interactions: antiretroviral drugs and recreational drugs Recent Pat CNS Drug Discov 9(3):153-63

3. Poppa A, Davidson O, Deutsch J et al (2004) BHIVA guidelines on provision of adherence support to individuals receiving antiretroviral therapy HIV Med 5(Suppl 2):46-60

4. Simoni JM, Kurth AE, Pearson CR et al (2006) Self-report measures of antiretroviral therapy adherence: a review with recommendations for HIV research and clinical management AIDS Behav 10:227-45

5. CD4+ Count–Guided Interruption of Antiretroviral Treatment New England Journal of Medicine 355(22): 2283–2296

6. Risk of cancers during interrupted antiretroviral therapy in the SMART study AIDS 21(14)1957–1963. 2007

7. ‘No one with an undetectable viral load, gay or heterosexual, transmits HIV in first two years of PARTNER study’ NAM: aidsmap Available online at http://www.aidsmap.com/No-one-with-an-undetectable-viral-load-gay-or-heterosexual-transmits-HIV-in-first-two-years-of-PARTNER-study/page/2832748/ (last accessed 14th June 2015)

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