Counselling in HIV and AIDS 4: ART and adherence 艾滋病咨询培训 4 ： 抗病毒药物和依从性

1. Counselling in HIV and AIDS 4:ART and adherence艾滋病咨询培训4：抗病毒药物和依从性 Dr Petrak Jenny Dr Yao Bing VSO

2. Aims目的 • To review the goals of ART回顾ART的目的 • To define adherence定义依从性 • To define barriers to adherence定义导致依从性的障碍 • To increase management of side effects 提高控制副作用的管理 • To practice ART counselling ART咨询实践

3. What is ART？什么是ART? • What ARVs are provided in China？中国提供哪些ARVS药物? • What are first-line regimens？什么是一线组合? • When do patients start on these？什么时候开始治疗?

5. Goals of ARTART的目的 • Prolong and improve the quality of life for PLWHA延长和提高PLWHA的生活质量 • Reduce the viral load in PLWHA 减少病毒载量 • Increase the CD4 count in PLWHA提高CD4细胞数目 • Boost the immune system; stop HIV to AIDS提高免疫系统，阻止HIV感染发展为AIDS • Reduce the amount of opportunistic infections (by increasing the CD4 count)减少机会感染 • Lower the risk of infecting others with HIV (by decreasing the viral load)降低HIV引起的其他感染 • Reduce mother-to-child transmission of HIV减少HIV的母婴传播

6. ARVs: effect on CD4 and viral load ARVs：对于CD4和病毒载量的影响 Start treatment Viral load <50 copies/mL 2 million 1000 CD4+ cells/mm3 viral load (RNA) copies/mL 500 200 < 50 copies/mL 0 0 + 1-40+ years !! 1-12 yrs +1-6 mo Time Chronic Infection

7. HIV and AIDS diagnoses and deaths, UK艾滋病诊断和死亡，英国 Numbers will rise, for recent years, as further reports are received. Clinician reports of new HIV/AIDS diagnosis

8. Combination Therapy(i-base,2006)组合疗法 • HIV is continually reproducing - and it uses CD4 cells as factories to produce more virus.HIV持续产生，用CD4细胞作为工厂来产生更多的病毒 • The drugs work at different parts of the HIV lifecycle药物在不同的HIV生命周期发挥作用 • Available drugs work in one of four ways:目前药物通过如下四种方式发挥作用： i) reverse transcriptase inhibitors 逆转录抑 制物(RTIs, nukes) ii) NNRTIs - non-nukes 非核苷类逆转录酶抑制剂 iii) protease inhibitors 蛋白酶抑制物(PIs) iv) entry inhibitors 进入受体(T-20)

9. HIV uses CD4 cells as factories to make hundreds of copies of itself. Different drugs work at different stages of the HIV life cycle HIV将CD4作为工厂来复制自身。在HIV生命周期的不同阶段，应采用不同的药物进行治疗。(www.I-base.info)

10. Adherence counselling依从性咨询 • What is adherence?什么是依从性 • How adherent are people in taking medications?患者口服药物的依从性是怎样的 • How much adherence is required for ARVs to be effective?需要怎样的依从性才能使抗病毒药物有效？

11. List factors affecting adherence under each heading 在每个标题下面列出影响依从性的因素

12. MEDICATION BELIEFS(true or false?) 药物的观点（对或错） • ARVs are a cure抗病毒药物可以根治 • They finish you off, lose your sight, hearing, taste, eventually die它们最终可以让你失去视觉、听力、味觉，最后死亡 • Drugs are poisonous 药物是毒药 • ARVs have irreversible side effects 抗病毒药物有不可逆转的副作用 • All HIV+ should take the drugs 所有HIV感染的病人都应该吃药 • You can’t bear children　你不能生小孩 • You can’t infect others when on ART当口服抗病毒药物的时候，你不能传染别人 • You can’t contract sexually transmitted infections when on ART当抗病毒治疗时，你不能得性传播疾病 • They are a ‘cure for all’ drug, e.g. TB他们是可以治疗所有疾病的药物，例如结核 • Taking ARVs means one has lost faith in God口服抗病毒药物是对上帝的不忠诚 • Taking ARVs during pregnancy damages your baby　怀孕的时候服药会伤害孩子 • Lack of belief in ‘western’ medicine　对西药缺乏信任 • Can’t cope, won’t remember taking the drug　做不到，会不记得吃药 • Won’t be able to have a social life, e.g. beer drinking不能正常进行社会生活，例如喝啤酒 • ARVs cause loss of libido　抗病毒药物可以导致性欲下降 • Taking pills is a reminder that one is positive口服药物提示一个人是阳性

13. Side effects副作用 Mild 不严重的 • Sleeplessness　失眠 • Upset stomach (nausea)恶心 • Diarrhea 腹泻 • Drowsiness/ Fatigue 困、疲劳 • Headache 头痛 • Mild Rash 皮疹 • Confusion　旋晕 • Nightmares　恶梦 • Dizziness　旋晕 Major主要的 • Severe headaches 严重头痛(neuropathy) • Fat changes 脂肪改变 • Severe abdominal pain 严重上腹痛(pancreatitis) • Liver damage and jaundice肝功能损伤 • Severe rash 严重皮疹 • Fever发热 • Severe muscle pain or cramping严重肌肉痛或 • Mental disturbance失常 • Severe fatigue or shortness of breath (lactic acidosis)严重疲倦或气短 Day-to-day TOP 3: Pain, Fatigue, Disrupted Sleep (Savoye, IAS, 2005)

14. Counselling and side effects咨询和副作用 • Provide support to a person who is experiencing poor sleep, ‘pins and needles’ in their legs, and fatigue. They tell you they are fed up taking ARVs.对经历严重困倦、下肢针刺感和疲劳的患者提供支持。他们告诉你已经厌烦吃药 • What other social and emotional factors could be contributing to these difficulties？哪些其他社会和情感因素可以导致这些困难?

15. How do you measure if a person is taking their ARVs correctly你怎样能够衡量一个人是否正确服药了? • Self-report自我报告 • Medication diaries服药日记 • Pill boxes药盒 • Electronic devices (e.g. alarms)电子设备（例如闹钟） • Biological markers(e.g. CD4, Viral load)生化指标（例如：CD4、病毒载量） • DOT

17. Steps to increase ART adherence提高依从性的步骤 • Increase knowledge about ART and how it works提高ART和它如何发挥作用的知识 • Check motivation to take medication 检测服药的动力 • Establish health beliefs and address 建立健康信仰 • Simplify the drug regimen简单药物组合 • Check for satisfaction with information检测信息的满意度 • Clarify and check understanding of dose, frequency, timing and what to do if doses missed明确和检测药物计量、频率和准时，如果有漏服，该怎么办 • Ensure rationale for treatment understood保证治疗理解的合理性 • Provide information; e.g. pictures of pills, diaries and charts提供信息：药物的图片，笔记和表格 • Involve support from others从其他人得到支持 • Provide problem-solving support提供问题解决支持

18. What is adherence counselling？什么是依从性咨询? • What needs to be assessed如何评估? • How much is needed prior to starting treatment？After starting?开始治疗前需要哪些? 治疗后呢？

19. Adherence Role Play 1依从性角色扮演1 • You are asked to see a 45 year old man before he starts ARVs. He tested for HIV 3 months ago after being in hospital with pneumonia. He has not disclosed his status to his wife and family. He works at a car repair workshop full-time but is finding it difficult. He likes to drink beer most nights.你被告之要与即将开始口服药物的45岁男子见面。他3个月前因肺炎确诊为HIV。他没告诉妻子和家人。他在汽车修理厂工作，觉得很难。他现在夜里很喜欢喝很多啤酒 • What does the doctor need to consider？医生应该怎样考虑?

20. Adherence Role Play 2依从性角色扮演2 • Dr. speaks with a 26 year old woman about starting ARVs . She was open about HIV with her husband but he left her when she disclosed and his family blame her. She is not working and has a young child. Her sister helps with food but she says there is never enough. She has lost weight and is worried that she looks “like AIDS”. She is not very communicative and seems unhappy. She questions why take ARVs?医生与一个26岁的妇女谈论开始口服药物，患者确诊后，向丈夫公开了病情，丈夫离开了她。她没有工作，有小孩。她姐姐给她些吃的，但这还远远不够。她明显消瘦，担心她发展到艾滋病。她不愿意交谈，不高兴。她问为何吃药 • What does the doctor need to consider?医生应该考虑什么？