DE   EN   ES   FR   IT   PT Infectious diseases and parasitology Commitment to ARV-therapy for HIV/AIDS of patients.

Commitment to ARV-therapy for HIV/AIDS of patients.

Nobility and trust to live …

                                                                                         If the disease was sent me                  by my cruel fate,

 Medicine – is, so learns my lesson …

 W. Shakespeare


                                                                    To all my patients it is devoted.


Part 1. It is a little history.


                   For the first time I learned about HIV infection and AIDS only in 1989 when I studied on the 5th course of medical institute. Then this disease          of "the rotting West" seemed terrible, a little studied and that the most awful, incurably deadly. And it was presented to us, the Soviet medical students as a disease of marginal persons: prostitutes, addicts and homosexuals. At that time we were sure that to us it is not necessary not only to treat patients with AIDS, but also even to see them in the Soviet Union. Then I did not even represent that in the future all my work of the doctor will be devoted to prevention and treatment ВИЧСПИДа. But at history the laws and the course. The destiny disposed so that the USSR broke up, and I in 1997, having become the infectiologist in Zhlobinsky district, closely approached VICh-SPID problem at us in sovereign Belarus. The most part of my patients was made by HIV-positive residents of the area which in quantity of the registered cases of HIV was and is on the second place after the Svetlogorsk district in Gomelshchina. And now my professional activity can be divided into two temporary stages accurately: before implementation of anti-retrovirus therapy to HIV-positive patients and later.

                       Up to 2004 at identification at patients of HIV infection at the last stages of a disease I had to state only irreversibility of deterioration in their health in connection with continuously progressing immunodeficiency. To appoint at the same time huge doses of antibiotics, antifungal drugs, vitamin drugs which were already powerless to change a situation with health to the best and to understand that the lethal outcome is inevitable sooner or later. And to try to avoid any direct talk on death with the patients.

                         Emergence in us in the country in 2004 of the PROON Project with assistance of Global fund for prevention and treatment VICh-infitsirovnnykh of citizens of Republic of Belarus and implementation of highly active anti-retrovirus therapy (ARVT) for our patients became the real break in rendering medical care to them. Doctors – infectiologists received powerful weapon against HIV in the form of anti-retrovirus drugs. Then became possible considerably to change the disease course, to improve quality of life of patients and to really prolong them life. HIV infection from a number of deadly passed in a row chronic is long the proceeding diseases.


Part 2. What is ARVT?


                  It is an abbreviation of words anti-retrovirus therapy. – means anti-contra, the retrovirus is a virus of an immunodeficiency (HIV), therapy – it means treatment. Thus is a treatment against HIV. Anti-retrovirus therapy is not capable to kill a virus, but it  blocks its replication (reproduction and development) at various stages of life of a virus cell. Being in fact chemicals, anti-retrovirus drugs allow to suppress reproduction of HIV, to lower virus loading and to recover function of immune system. The combination from three or four ARV of drugs which influence a virus everyone from the point of application is most effective at the same time. The HIV cell appears in a peculiar blockade from chemical structures of medicine. If figuratively to present the HIV virus in the form of a scorpion, then ARV-therapy is peculiar chemical "cap" which isolates this scorpion from a human body. The scorpion lives, but is not capable to sting any more. And while the patient correctly accepts ARV drugs this "cap" will exist. Once "cap" disappears, "scorpions" - viruses will run up on all organism again and will strike immune cells to the last.

                    Against the background of ARVT except everything the number of complications decreases, quality of life (patients feel like absolutely healthy people) improves, life of HIV-positive patients is considerably prolonged. ARV-therapy became an integral part of complex medical care to HIV-positive patients, along with prevention, treatment of the accompanying diseases.

                     The basic principles of carrying out ARVT are:

             1. Treatment is provided to all patients needing it on medical indications and who expressed desire to be treated is not dependent on their social status.

             2. Treatment represents a combination from not less than 3 anti-retrovirus drugs which scheme of reception and a dosage is selected the doctor – the infectiologist to each patient individually according to the protocols of treatment approved by the Ministry of Health of RB.

            3. Treatment has to be continuous, that is lifelong. Dispensary observation, monitoring of the course of treatment is established by the attending physician. The main indicators of efficiency  of treatment are virus loading and quantity of SD-4 of cells (a so-called immunogramma).

            4. And most important: the patient has to be motivated on carrying out ARV - therapy and to have high commitment to treatment.



Part 3. What is commitment?


                        Literally from the explanatory dictionary the commitment is an affection, addiction, a good attitude for someone, to something.

      The commitment to ARV-therapy  is a reception of ARV of drugs according to the scheme appointed by the doctor: in certain time and in a certain dosage, at observance of the recommended diet. Thus is a good attitude to own treatment, full conscious understanding of its importance for itself, self-checking and self-discipline.

        Here it is possible to add trust to the attending physician, systematic voluntary implementation of medical recommendations about inspection during treatment.

        The commitment to treatment is  first of all good attitude to itself and to life.

        In my practice in 15 years of work with HIV-positive patients there were cases of full rejection of ARV of therapy, that is flat refusal of it more than once. At the same time the patient is willingly inspected, specifies the analyses, data иммунограмм and even treats some other diseases. It is sure that on the Internet or still somewhere it obtains additional information on modern methods of treatment ВИЧСПИДа, that is on the disease and its stage knows much. But as soon as it comes about purpose of ARVT, a full negative!

         I tried to analyze and to somehow systematize major factors of refusal of therapy. Here what turned out.

         On the first place the statement of the patient that he perfectly feels, it has no complaints to health, analyses in relative norm. Even eloquent immunogramma which prove on an advanced stage of HIV in anything such patient cannot convince.

          On the second place fear to do harm to ARV drugs of the liver. Generally people with the accompanying hepatitis worry about the liver. At the same time part of them do not appear to take alcohol and (or) drugs though to them it is explained that harm from them for a liver is much more enormous.

          On the third place fear of development of side effects during treatment. Especially hypochondriac patients sometimes so eloquently describe "pobochka" that you wonder though any pill ARV of drug was not taken for all the life. On a question: "From where data?"  Answer that from palsy-walsy have heard a lot.

           On the fourth place fear that therapy can kill with ARV the patient. At the same time patients sometimes give examples that, say, their acquaintances lived to themselves though had a serious illness, but is silent, and here is how began to accept ARVT in a month – the second died. Yes, unfortunately, it happened. But patients not perished from treatment, and that this treatment was begun very late and to help them already it appeared it is impossible.


Part 4. When to begin treatment?


         I will at once make one very important explanation: anti-retrovirus therapy most often there is no need to appoint urgently, that is according to vital indications. The start of ARVT-is planned approach to an initiation of treatment at a careful additional examination of the patient and from his personal consent. An exception HIV-positive pregnant women, ARV make drugs to which are appointed with a main goal - to reduce risk of vertical transfer of HIV from mother to the child during pregnancy and childbirth from 16 weeks of pregnancy. Even at the last stages of AIDS at serious condition of the patient of ARV therapy is appointed 2-4 weeks later from the beginning of clinical inspection of the patient. Especially important for this period to exclude active tubercular process as treatment of tuberculosis begins the first at the patient, and then anti-retrovirus therapy against HIV joins it.

       In general, ARV therapy has to begin in the presence at the patient of HIV 3 and 4 stages. The stage of a disease is specified by the doctor – the infectiologist by clinical and laboratory criteria. In the course of specification of a stage of a disease the role of immunological inspection of the patient, the so-called immune status of the patient is big. By comparison of all data of inspection the scheme ARV of therapy is appointed by the infectiologist, is explained to the patient and, in the presence of the written consent of the patient to carrying out ARVT, treatment starts. The start of therapy is made most often in out-patient conditions, is more rare in the conditions of a hospital if the condition of the patient demands hospitalization. The course of treatment monitorirutsya by carrying out all-clinical analyses: the general blood test and urine, biochemical analysis of blood, an immunogrammama and definition of virus loading in the beginning monthly, further at least once in six months. Efficiency of the scheme ARV of therapy, and also correctness of administration of drugs by the patient, is determined by an immunogramma.



Part 5. What is an immunogramma?


Immunogramma is a complex blood test in which components of immune system are investigated. For a research a venous blood of the patient undertakes. The main components for a research T lymphocytes, so-called cell SD-4. They are surprised the human immunodeficiency virus (HIV) during a disease, and the clinical picture of a disease and a condition of the patient depends on their quantity. The quantity  of SD-4 of cells is shown by laboratory to the attending physician both in absolute figures, and in a percentage ratio in terms of microlitre (мкл) of the patient's blood. If the scheme ARV of therapy is effective, then the SD-4 level of cells steadily increases, it is shown in improvement of the state of health of the patient. But as the main criterion of efficiency of treatment serves the virus loading (VL) - it is the number of RNA copies of a virus (HIV) in microlitre of blood of the patient, that is quantity of a virus in a human body. If figuratively to present VIChSPID disease in the locomotive form, then virus loading is a speed with which this locomotive (disease) moves to  the tragic finish. Effective ARV therapy suppresses virus loading in the first week from start. Desirable indicators of VN during treatment make less than 200-500 RNA копиймкл blood, it is the so-called not defined virus loading. Such indicators are especially important when carrying out ARV of prevention of HIV at pregnant women as they reduce risk of transfer of HIV from mother to the child practically to zero. At strictly maintained high concentration of ARV-drugs in blood virus loading has to remain not defined if not always, then long enough. Necessary high concentration of ARV of drugs is reached by their correct dosing and the mode of reception. For this purpose it is necessary that the patient accepted the appointed ARV-drug dose strictly on hours continuously and constantly, that is was highly committed to treatment.

        And it is still important to know that unauthorized disturbance or the termination of the scheme of anti-retrovirus therapy is fraught that the HIV virus gains resistance (resistance) to ARV to drugs, sometimes to several at once, and it leads to progressing of a disease, complicates selection of a new combination of ARV of drugs. As a result these combinations from simple become difficult, from reception of 2-3 tablets in days increase to reception of 6-9 tablets in days that creates still great difficulties in achievement of success in treatment.

        Here therefore the commitment of the patient to therapy ARV is so important.

        By the way will be to tell that in the nature there are some more diseases at which lifelong reception of medicines is necessary. One of such diseases is the diabetes mellitus of 1 type at which the patient has to receive insulin on hours all the life.




Part 6. Difficulties of reception of ARV-drugs.


   To understand that chronic patients when they have to take for life this or that medicine feel, it is necessary to rise at least for a while on their place. And not in physical sense of this concept, and more likely in psychological. Then will be though it is a little clear that own treatment is a work first of all over itself, this courage, patience and huge will power. It is refusal of some habits, first of all, harmful!), from  traditions, sometimes even refusal of a former circle of contacts. It is difficult. Lifelong treatment is even more psychologically difficult for HIV-positive patients because it is necessary to recognize the disease in the beginning, will get used to it and to continue to live. My very many patients do not let the relatives into a secret of the disease and how then to explain to them why they take medicine?

      Therefore I consider the main complexity of reception of ARVT a psychological factor when there comes the psychological fatigue from continuous treatment. But awareness of advantage of treatment and huge patience allows to discard a disease far back and to continue fight against a disease. I have patients who have high commitment to treatment, accept ARVT since 2004, and it more than 8 years. Eight years of continuous hourly reception of tablets! Moreover, there are HIV-positive children to whom 12 - 14 years, they accept ARV therapy since the birth! To the most senior young man who got HIV infection from the mother and continues ARVT, 20 years! It is also an example of high commitment to treatment of mothers of these children, but also children still more.

      Anti-retrovirus drugs are chemicals. Often with unpleasant taste and a smell, and to the same extent it belongs both to tablets, and to syrups. Therefore second complexity of reception of ARVT-this flavoring perception of medicine. What – that a part of ARV of drugs it is necessary to accept on an empty stomach, other part with food. These recommendations are made by the doctor for the fact that efficiency of absorption of medicine in digestive tract was maximum. It is clear, that the patient will feel all taste and a smell of drug at once. I recommend to adhere strictly to the rule to wash down medicine with enough water, not less than 100 ml in order that it was quicker dissolved and soaked up in blood. If after taking the medicine there was vomiting, then do not accept a new portion of ARV of drug, and wait for the following reception of the next dose. During this time you can eat or drink something tasty, but digestible to reduce unpleasant aftertaste.

        Any medicine has side effects. Write about them in summaries to drug, the attending physician has to warn about them. One more complexity of reception of ARV-drugs is a fear of development of side effects. As treatment of HIV/AIDS is very long process, side effects can arise at all stages of therapy. All this is discussed with the patient. For the fact that in time to notice side effects the doctor appoints regular inspections of the patient with a research of blood tests and urine. Most often the patient himself points to such by-effects as nausea, a diarrhea, dizziness, a headache, an increase in weight, a sleep disorder,  rash is less often noted. All these phenomena gradually disappear independently, and in case of their long current the doctor appoints  in parallel other medicines facilitating symptoms. Happens that the doctor cancels ARV-drug at all and  replaces it with another. This or that decision is discussed with the patient and is accepted for the benefit of the patient.

      Side effects against the background of ARVT which can threaten the patient's life develop extremely seldom and at drug withdrawal have reversible result.

      I want to warn that alcohol intake and (or) drugs, and also smoking during ARVT can provoke approach of side effects and makes heavier their manifestations.

       To me the case from my practice when one my HIV-positive patient already gave the written consent to carrying out ARV of therapy by it was remembered and even received the corresponding drugs on hands, but did not begin to accept them. On the next visit to me (a month later!) she admitted it and declared that "it developed side effects in the form of nausea and vomiting at only one type of your tablets". This "side effect" at it successfully was necessary to eliminate by means of consultations of the psychologist.

       All patients usually are interested in side effects of ARV-drugs, many ask about compatibility with other drugs which are appointed by other doctors parallel to treatment. And it is correct. But there are cases when the patient more is afraid of side effects from therapy, than the effects connected with progressing of AIDS. And this big mistake! Side effects can be warned, eliminated, and here a progression of a fatal disease without the corresponding treatment – no. It should be understood accurately.

       On starting phase ARVT the doctor usually tries to appoint the effective scheme at which the minimum quantity of tablets in days is used, most often five – six, and sometimes, in case of a combination of two ARV-drugs in one tablet, only three in days. In case of inefficiency of ARV-therapy, the scheme of treatment have to change, and it can lead to increase in quantity of tablets up to 8-10 pieces a day. And inefficient the scheme of ARV-therapy can become also because of the       patient if he is not committed to treatment and a healthy lifestyle.



Part 7. Epilog.


        Each person is a personality with the merits and demerits, with the fears and force. But everything that combines people - it is reason and huge thirst of life. Life is the invaluable gift given us by God and the nature, it is necessary to appreciate it and has to.

        The Chinese wisdom according to philosophy of wushu says: "We cannot affect the beginning of the life, but here what will be its end - completely our choice."   

       I want to wish to all not to make a right choice, to continue to live and rejoice to each lived day, to give care and love,  to love and be darlings to live, say, life so that always to remain the Person.




Infectiologist of the highest category        Dodaleva Elena Nikolayevn                Minsk. Republic of Belarus.

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