All About Antiretroviral Treatment (ART) PDF Print E-mail

This section provides information on the following:

Human immunodeficiency virus (HIV) is the name of the germ that causes HIV infection, which eventually develops into AIDS (Acquired Immuno-Deficiency Syndrome). HIV is passed from person to person in certain body fluids such as sexual fluid, blood and mother’s milk. It is not present in saliva, sweat or urine and so you cannot get HIV infection from: kissing; sharing food and/or eating utensils; hugging or touching; toilet seats. The most common way HIV is passed onto another person in South Africa is via sex between a man and a woman (heterosexual sex). The second most common method of transmission is from an infected mother to her baby. This commonly happens at delivery or during breastfeeding (see Prevention of Mother-to-Child Transmission section for more details). Other methods of transmission include man-to-man sex and exposure to infected blood through contaminated medical instruments or accidents.
 
HIV disease is a very common illness in South Africa: approximately one in every five people in South Africa is now infected. In some parts of the country nearly one out of every two people is HIV-positive. Anyone can become infected with HIV and it is not a disease to be ashamed of, and should not therefore be kept secret. If a person is HIV-positive they should disclose their status to someone they trust, or join an HIV support group. Sharing their burden and talking to others who are in the same situation has helped many people to manage their disease more effectively, enabling them to live POSITIVELY. With proper care and treatment, HIV disease is no longer a death sentence, but a chronic disease that needs careful management and commitment.
 
How ART works
Antiretroviral medicines work by interfering with the way the virus multiplies. The number of the viruses in the body is therefore brought under control, allowing a person’s immune system to become strong again. ART prolongs and improves a person’s quality of life. It is not a cure and does not remove the virus from the body; it only keeps it under control. If a person stops taking ART or does not take the treatment as instructed then the virus will start to multiply and the person will become sick again. ART must therefore be taken for life once it is started.
 
Tests to measure the stage of HIV disease
The following two blood tests need to be done:
  • A CD4 cell count (cells/mm3). The CD4 cell count is a measure of how strong a person’s immune system is because these particular cells are some of the most important cells for fighting viral and bacterial infections. An uninfected person has an average CD4 cell count of around 1 000 (the actual count can vary from 600-1 500). Once a person becomes infected with HIV disease, because HIV targets and kills CD4 cells, the average number of CD4 cells starts to drop. People, especially if they are not well nourished or develop other illnesses as well, can lose around 100 or more cells per year. Symptoms of AIDS usually develop when the CD4 cell count drops below 200. 
  • The viral load. This test measures the number of viruses in the body. 
  • These two tests are used to determine how advanced a person’s HIV disease is. They are also used regularly to check that ART is working properly. With successful ART the viral load become undetectable and the CD4 count increases progressively.  
The stages of HIV infection
HIV disease progresses at different speeds in different people. A higher number of viruses in the blood, or viral load, causes more rapid damage to the immune system, including the very important CD4 cells. As the CD4 count drops other infections can start entering the body. A person infected with HIV goes through the four stages described below. Some people pass through the stages rapidly (under six years), while others take well over 10 years. This is why it is important for people to live healthily by eating well and not smoking or drinking alcohol to help their immune systems remain strong for as long as possible. It is also important for them to practise safe sex so they don’t expose themselves to more viruses.
 
Stage 1: A person with Stage 1 HIV disease usually still looks and feels well. Swollen glands in the neck and groin are quite common in this stage, and if they become large and/or painful a doctor should be consulted. Roughly half of people who become infected experience an illness similar to glandular fever 4-6 weeks after being exposed to the virus. The rest do not have any symptoms, but after this period it becomes possible to test for the presence of the virus with an HIV test.

Stage 2: As the CD4 count starts to drop a person may start to develop minor illnesses, such as skin rashes and diarrhoea.

Stage 3: As the disease progresses a person will start to suffer from thrush, and a variety of other diseases. Weight loss and diarrhoea can also become a problem.

Stage 4: During this stage, because of a very weakened immune function (CD4 count below 200), a person can develop many different serious illnesses such as pneumonia and certain types of cancer. Weight loss and problems such as diarrhoea and oral thrush become more pronounced. This is the stage of AIDS and once a person has reached this stage he or she can only survive for 1-2 years without treatment.
 
When ART must start
People who are infected with HIV should begin ART when the disease has progressed to the point where either of the following happens:
  •  The CD4 cell count falls below 200 cells/mm3 or
  • The patient develops profound weight loss and/or one of the life-threatening opportunistic infections that are associated with Stage 4 of HIV disease, such as pneumonia (note that tuberculosis is not a criterion for initiating ART unless the CD4 cell count is below 200).

Who can access ART?

People cannot attend an ART centre directly to access treatment. They first need to be monitored and assessed by their local health facility. Once they qualify for treatment they will be sent to the nearest ART centre with a referral letter containing the details of their CD4 counts and medical history. They will then be given an appointment to see whether they are suitable candidates for treatment. (Note that people accessing general HIV medical care in a facility which also provides ART, such as a large hospital, must also go through the same process requiring a referral letter and appointment. This is to ensure that all patients get equal access to ART.)

At the appointment new laboratory tests will be done and people will be assessed to see whether they still fulfil the medical criteria for treatment. They will also be assessed to see whether they also fulfil the following psychosocial criteria:
  • Reliability (for example if the person has attended three or more scheduled visits to an HIV clinic).
  • Compliance. People must be prepared to take their tablets every day exactly as instructed. If they think they are not ready to take them every day they should not start treatment as this will lead to viral resistance, which makes the virus much more difficult to control.
  • No active alcohol or other substance abuse.
  • No untreated active depression.
  • Safe Sex. People must be prepared to use male or female condoms every time they have sex. Women will also need to take the contraceptive pill or injection to prevent unplanned pregnancies.
  • Disclosure. It is strongly recommended that patients have already disclosed their HIV status to at least one friend or family member, or have joined an HIV support group.
  • Insight. People need to demonstrate insight into the consequences of HIV infection and understand how ART works and the commitment required for treatment to be successful.
  • Ability to regularly attend the ART centre (transport may need to be arranged for patients in rural areas or for those living far from the treatment site).
  • Contactability. People must be easily contactable for follow-up and treatment support.  
NOTE In order to qualify for ART in South Africa it is not necessary to have an ID document or be a South African citizen. Access to health care is guaranteed by the constitution for everyone, not just those with citizenship or residence papers. All a person needs is a fixed address to enable follow-up.
 
What happens next?
If ART is indicated, treatment will only start once the patient does the following:
  • Attends a series of courses about ART. This initiation programme includes information on nutrition, how to live positively, the basics of HIV and AIDS, opportunistic infections, and how to take antiretroviral medicines properly. The programme runs over several weeks.
  • Tells at least one family member or friend about the treatment programme so that this person can help make sure the medication is taken as instructed. Most programmes advise the patient to bring this person with them to attend the preparation courses.  
As soon as treatment starts the patient will be required to visit the clinic or hospital regularly. This may be on a weekly basis in the beginning, but will then stretch to every three or six months. Blood samples will be taken at every visit so that tests can be done to ensure the ART is keeping HIV disease under control. Many non-profit organisations offer treatment support for people starting ART. Specially trained people offer support and help to make sure people take their medicines properly.

Once people start taking ART they will usually start to feel better quickly. If other infections are present, such as TB, which are also being treated, then it may take longer for the person to start feeling better. ART needs to be continued for the rest of a person’s life.
 
ART and pregnancy
In order to avoid pregnancy while on ART it is recommended that women use the contraceptive injection as well as condoms every time they have sex. The contraceptive pill may not provide reliable protection when taken with antiretroviral drugs. If a woman receiving ART wants to conceive she must tell her doctor so that she can be given antiretroviral drugs that will not harm the developing baby.

Common questions about ART
 
If my viral load becomes undetectable does that mean I am cured?
No. It just means the treatment is working very well at keeping the virus totally under control. (ART is considered successful if the viral load drops below 400 copies/ml)
 
Is there any alternative to ART?
No. Good nutritional support and positive living will only help to delay the progress of the disease. Once the disease reaches a certain stage ART is the only treatment that will be able to help.
 
Can I still pass the virus on to someone else when I am on ART?
Yes. You must continue to practise safe sex at all times as you can still pass on the virus. It is also possible for you to get infected by another different strain of the HIV virus, which might be resistant to the antiretroviral medicines you are taking.
 
What is antiretroviral (ARV) resistance?
This means that the ARV drugs are no longer effective at keeping the virus under control. This may happen if you have been re-infected with a resistant strain of virus. It can also develop if you do not take your medicines every day as instructed. Even missing only one dose every two weeks can lead to viral resistance. Resistance can also develop if you previously started ART and then stopped for a period. Once you start ART it is important to continue taking it for the rest of your life.
 
Is ART dangerous? What are the side effects?
ART is not dangerous, it is a life-saving treatment. However ARV drugs, like all medicines, can have side effects. Common side effects include: nausea, vomiting, headaches, tiredness, stomach pains, diarrhoea, numbness in the legs, and skin rashes. These symptoms are usually mild and disappear after a while. If they persist or become serious, you must tell your doctor. Sometimes the drugs need to be changed.
 
Will I lose my disability grant is I start ART?
Yes. Once you start ART and your CD4 cell count increases to an acceptable level, you will lose your grant. Various organisations are trying to have this changed because a lot of people are not starting ART because they cannot afford to lose their grants. Many patients in rural areas also need the disability grant to provide the money for travel to the HIV service point to get their treatment.
 
Benefits of providing ART
The first and foremost benefit is that ART is life saving. This not only benefits the individual concerned but also society as a whole for the following reasons:
  • The lives of many breadwinners are prolonged, enabling them to continue providing and caring for their families.
  • Families can stay together, which reduces the emotional and psychological stress of the disease. The elderly are not left to cope with the burden of caring for their sick children and grandchildren.
  • The cost of providing disability, childcare and foster grants, care for orphans and vulnerable children, care for people living with AIDS, and hospitalisation costs is dramatically reduced.
  • The workforce remains productive, reducing the costs of absenteeism, illness and death, and the training of new staff.