Antiretroviral Therapy as an Intervention in the Treatment and Care of HIV in the US - Term Paper Example

RUNNING HEAD: ANTIRETROVIRAL THERAPY AS AN INTERVENTION IN THE TREATMENT AND CARE OF HIV IN THE US Antiretroviral Therapy as an Intervention in the Treatment and Care of HIV Name: Course: Institution: Date: Antiretroviral Therapy as an Intervention in the Treatment and Care of HIV Introduction Since 1996, antiretroviral therapy (ART) has become an increasingly preferred intervention for the treatment and care of HIV infected patients in the US. The use of Highly Active Antiretroviral Therapy (HAART) has increasingly become the preferred drug-based intervention for the management of HIV infections among children, adolescents and adults. HAART basically entails an aggressive combination of at least three effective antiretroviral drugs (ARVs) from at least two different drug classes (DHSS 2011, Aberg et al 2004: 2009, CDC 2009). The use of HAART has mainly been due to the strength of literary evidence which has indicated that ART has significantly lowered the morbidity and mortality due to HIV infection in the US (Richman et al 2004). In essence, ART interventions have been associated with increases in the longevity of HIV infected persons and have been increasingly adopted and integrated as critical components of any HIV/AIDS treatment and care strategy by both public and private health care providers (Egger et al 2002). This paper will describe ART as an intervention in the treatment and care of HIV in the US. The paper will first give a brief description of ART and some of the basic steps taken in ART (HAART) procedures practice by drawing on published guidelines and studies. The paper will highlight the importance of pre ART testing and how to select appropriate ARV regimens for patients. The paper will then examine how ART services are delivered in the United States based on different models of care. The paper will evaluate the benefits and limitations of individualised, vertical or centralised models and decentralized and community based models based on how they have been evaluated in the United States. Antiretroviral Therapy (ART) ART is a term basically used to refer to the administration of antiretroviral drugs to HIV- infected patients targeted at suppression of virological replication or the amount of active virus to levels below detection by most blood-testing techniques and to restore immune function through an increase in the CD4 cell count with minimal side effects (Egger et al 2002, May et al 2007). HAART, introduced in 1996, has become increasingly widespread and a popular form of ART due to its effectiveness in increasing longevity among HIV patients (DHSS 2011). HAART entails the administration of at least three ARV drugs from at least two classes. There are three classes of commonly prescribed ARV drugs; protease inhibitors (PIs), Non-nucleoside-analogue reverse transcriptase inhibitors (NNRTIs) and Nucleoside reverse transcriptase inhibitors (NRTIs) (DHSS 2011, Aberg et al 2004, CDC 2009). A typical HAART regime would include the administration of either a PI or NNRTI with two NRTIs. Pre- ART Laboratory Testing In its guidelines for the use of ART among HIV-infected adults and adolescents, the Office of AIDS Research Advisory Council (DHSS) recommends a variety of laboratory tests which should be conducted prior to the commencement of ART or for initial assessment and monitoring of patients. These tests assess the level of immune function, stage of HIV progression, presence of drug resistant HIV-strains and help determine the appropriate ARV regimen (Little et al 2002:2008). These tests include CD4 T-cell (CD4) count, Plasma HIV RNA (viral load) testing, drug resistance testing, HLA-B*5701 testing, viral tropism and other auxiliary tests such as pregnancy tests and urinalysis for patients suffering from kidney conditions (DHSS 2011, Murray et al 1999). Initiating and Monitoring ART in HIV-Infected Patients Once the requisite pre-testing is completed, ART is initiated through the prescription of the appropriate ARV regimens as recommended by medical personnel. The ARV regimen for each HIV patient should ideally be individualized factoring in their test results (Kaplan et al 2009, Carpenter et al 1998). There are a variety of factors to be considered in selecting ARV regimens for first time or ART-naive patients. These include any co-morbid conditions such as liver or cardiovascular diseases, tuberculosis or renal failure, potential side effects of the ARV drugs, pregnancy or pregnancy potential, CD4 count, results of genotypic resistance assays, HLA-B*5701 results, the patient’s potential to adhere to the ARV regimen and risk-behavioral analysis and convenience (Kitahata et al 2000). DHSS (2011) recommends several ARV regimens for first time ART patients in the US. A typical PI-based regimen would include a fixed dose combination of ritonavir and atazanavir taken with tenofovir or emtricitabine. Another strongly recommended INSTI based regime would be raltegravir taken with tenofovir or emtricitabine. For pregnant women, a regimen including a daily double dosage of ritonavir boosted lopinavir taken with zidovudine or lamivudine (DHSS 2011). Each regimen based on a certain class of ARVs has its potential advantages and disadvantages. Therefore, the regimen prescribed should aim to minimize on the negative side effects of each class of ARVs. For instance, most PIs are frequently associated with metabolic complications and skin rash. Some ARV combinations are also not recommended due to their negative side effects on patients such as the use of dual NRTI regimens or the use of Efivarenz in pregnant women (Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission 2010, CDC 2009). Initiation and Monitoring of ART Once a patient has been put on an ARV regimen, it is important to continuously monitor their progress in order to determine the efficacy of HAART. The patient should be subjected to continuous CD4 count, viral load testing and drug resistance assays to be able to detect immunological or virological failure (DHSS 2011, Aberg et al 2009). Cases of immunological or virological failure are indicators of the need to change the ARV regimen due to a number of factors such as the patient’s acquisition of drug resistant strains of HIV due to sexually risky behaviour (Egger et al 2004, Richman et al 2004). There may also develop a need for regimen simplification, where the ARV regimen is modified to either reduce the pill burden, to resolve developing drug-resistance, lower the food requirement or to substitute current ARVs with newer and more efficient FDA approved ARVs (DHSS 2011). It is also important during HAART to encourage ART adherence. Some of the factors which negatively impact ART adherence include illiteracy, high risk behaviour, poverty and the persistence of negative side effects (Aberg et al 2009, DHSS 2011). Such factors should be managed by medical personnel through efforts such as education to enable patients under HAART to understand the importance of adhering to their ARV regimens. Delivery of ART services in models of HIV care and treatment the United States There are different models of care applied in delivery of ART services for HIV-infected patients in the United States. The main distinguishing characteristics between these models are whether they are outpatient or inpatient, doctor or community based (centralized or decentralized) and publicly funded or privately funded (Levi and Kate 2000, Levi et al 2000). However, the predominant model applied in the United States since 1996 has been the administration of HAART in a specialised and individualised hospital based and doctor-managed setting (Carpenter et al 1998). The HIV-infected patient undergoes pre-ART laboratory testing, is placed on an ARV regimen as professionally recommended based on the patient’s specific needs, characteristics, results of pre-testing such as drug-resistance, CD4 count and viral load testing. The patient usually makes scheduled visits and appointments to the health service provider for continuous consultation, monitoring and counselling where the effectiveness of the ARV regimen is determined and or modified according to their response (London, Leblanc and Anenshel 1998). Such vertical care takes place in both private and public health settings. The major advantage of models with specialised or individualized delivery of ART (HAART) lies in the effect this model has on life expectancy and the quality care delivered to patients. This model has proved very effective as early initiation of HAART has a number of positive outcomes for patients infected with HIV-1 such as increasing the survival rate for patients within wide ranging CD4 counts by preventing opportunistic infections (Kitahata et al 2000, May et al 2007). Under such models of care, doctors are able to effectively monitor the patient’s progress and modify the ARV regimens according to the patient’s response in light of issues such as drug resistance. Individualized care models have also proven to be very effective in preventing intrapartum or mother to child HIV transmission (Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission 2010). ART in these models is often delivered from the hospital as the focal care point. However, HAART as an intervention in the treatment and care of HIV patients is very costly (Chen et al 2006, Gebo et al 1999). Therefore, the major disadvantage of individualised models of care in delivery of ART is that they often imply high costs for the patients and severely limits access to and availability of ART. In addition to the high cost of ARVs, there are other expenses such as the frequent consultation visits, the incremental costs of laboratory testing and monitoring and the requisite changes in diet and nutrition to accommodate the ARV regimen (Bozette et al 2001). Schackman et al (2006) estimated the lifetime costs of HIV treatment and care for adults at the time may escalate up to $619, 000 dollars. The most significant component driving up the cost of HIV treatment and care was identified as ART. The high costs have adverse effects on people infected with HIV from disadvantaged social and ethnic groups, rural dwellers, low income earners and persons with disability or suffering from other diseases and conditions. Levi and Kates (2000) have documented the inequitable access to ART services by rural residents, low income earners and other disadvantaged groups. Public financing for ART services also highlights the disadvantages of such models of care. In the US, the principal source of financing for people living with HIV is Medicaid (Levi and Kates 2000). Medicaid provides supplementary funding for purchase of ARVs for people in low income brackets who cannot afford HAART or patients disabled due to full blown AIDS. To qualify for Medicaid funding, a patient must have developed full blown AIDS and become severely disabled (Levi at al 2000). The major disadvantage of Medicaid and similar programs such as Medicare is the inherent inequity in HIV treatment and care. Unlike patients with private health insurance, Medicaid and Medicare do not enable poor patients to accessing early HAART services which would significantly improve their prognosis (Shapiro et al 2009, Levi and Kates 2000). Other federal programs such as the Ryan White Comprehensive AIDS Resources Emergency Act (the CARE Act) attempt to address the shortcomings of public funding through safety nets such as Medicare and Medicaid as “payers of last resort” when there are no other funding options for poor people. Unlike Medicare and Medicaid which essentially only provide funding in what can be described as a “death and dying” model for patients with full blown AIDS, the CARE Act aims to provide chronic disease care and management for those who are yet to be eligible for funding under the social safety net programs (Levi and Kates 2000, Page et al 2003). The alternative models of care in delivery of ART services are in the community or home based multidisciplinary primary health care setting (Parry et al 2004). ARV regimens are provided and the patient’s progress monitored from a community based clinic or health centre by community nurses within broader HIV primary health care models such as the San Francisco model (Pary et al 2004, Soto et al 2004). These models often entail a multidisciplinary and decentralised approach to delivery of ART where the patient receives consultation, support, counselling, testing and monitoring at localised primary health care centres (Sherer et al 2002). The major advantage of such delivery models is that they make ART less costly, more affordable and enhance access to HAART for marginalised groups such as Hispanics, people with disabilities and low income earners (Bozzette et al 2001 ). Conclusion Since 1996, ART (in the form of HAART) has been increasingly adopted as an intervention for the treatment and care of HIV in the United States. ART entails the use of ARV regimens which aim to restore the patient’s immune function (CD4 count) and lower their viral load count.HAART has a number of positive outcomes for patients infected with HIV-1 such as increasing the survival rate for patients by preventing opportunistic infections (Kitahata et al 2000). HAART has aided patients in combating co-morbid infections such as Tuberculosis, Hepatitis and Cardiovascular disease by restoring their immune function which has enhanced their recovery (DHSS 2011 and May et al 2007) and is an effective means of preventing and reducing perinatal or mother to child transmission of HIV (Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission 2010). ART services in the United States are delivered through different models of care. Individualized, doctor managed and hospital based care is the predominant model of care employed in the US. The major benefit of such models is that they are supported by federal funding through programmes such as Medicare, Medicaid and the Ryan White CARE Act which help cushion the effect of the high costs of HAART. However, they have severe limitations as they only provide support subject to eligibility criteria such as disability due to AIDS which implies that access to early HAART is inequitable for a range of marginalized groups. ART is also provided as part of community based and multidisciplinary models of care such as the San Francisco model. Under such models, patients receive ART as part of a wider care program from localized health centers or home based care under community nurses. These models make HAART less costly and enhance access to ART for marginalized groups. References Aberg, J. A., Gallant, J.E., Anderson, J. et al (2004). Primary care guidelines for the management of persons infected with human immunodeficiency virus. 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