CURRENT TREND IN THE USE OF HAART (HIGHLY

ACTIVE ANTI-RETROVIRAL TERAPY).

INTRODUCTION:

The current national seroprevalence rate (2003) is 5.0% varying

from
1.2% in Osun State to 12% in Cross Rivers State.
40 million people are estimated to be Living with the HIV virus,
28
million from Sub-Saharan African, Nigeria being the 4th worst
affected
nation in the world after, South Africa, India and Ethiopia.
 DEFINITION

WHAT IS HAART
WHAT IS MEGA/GIGA HAART.

WHAT IS HAART
The combination of three or more drugs from at least two
different
groups is called highly active anti-retroviral therapy (HAART).

WHAT IS MEGA/GIGA HAART.

when 6 or more anti-retroviral drugs are used. (useful in case of
treatment failure, as a salvage therapy).
 TRENDS
The British HIV Association BHIVA (The Obstetrician and Gynaecologist
2002; 4: 197-200) guide line recommend ARV drug regimen as
follows.
1. Combination anti-retroviral therapy should be commenced in
pregnancy.
(a) women not already taking treatment, but requiring HAART,
should defer commencement until second trimester after the
period of organogenesis and when symptoms of morning sickness
are likely to have settled.
(b) SHORT-HAART Regimen (Short Term anti-retroviral therapy
(SART): Here HAART is started around 28 weeks gestation.
This regimen decrease viral load to undetectable level if
adherence is optimal.
TRENDS Contd.
(c) Twice daily zidovudine regimen started between 28 and 32
weeks. This does not suppress viral load to undetectable level.
- TREND OF ARV IN NIGERIA
HIV/AIDS emergency action plan (HEAP) 2002 July
recommended.
4. Use of HARRT only for adults and non pregnant population.
5. Use of Nevirapine monotherapy for obstetric population and
their neonates, with the hope of women transferring to HARRT
after delivery.
This came into disfavour due to wide range of resistance and
lack of facilities for monitoring of resistance and also inability to
evaluate efficacy of monotherapy.
TRENDS CONTINUE
THE NATIONAL anti-retroviral drug (ARV) access programme of the
federal ministry of Health 2005 – Guidelines for the use of anti-retroviral
(ARV) drugs in Nigeria.
- Recommended that combination of drugs from different points in the
HIV life cycle.
- The more number of sites on the life cycle of the virus the drugs acts,
the less the likelihood of development of drug resistance.
RECOMMENDED REGIMEN
- There are many drug combinations that could be used, however, due to
availability, accessibility and affordability, the are recommended.
ADULTS/ADOLESCENTS
FIRST LINE REGIMEN
D4t/3Tc/NvP
ZDV/3Tc/NVP
Alternative first line drugs special category of adults.
 Pregnant women or women who are likely to become pregnant
ZDV/3Tc/NVP
CHILDREN
FIRST LINE REGIMEN
d4T or ZDV/3TC/NVP.
FIRST LINE REGIMEN: RECOMMENDATION FOR HIV/TB
PATIENTS

ADULTS/ADOLESCENTS AND PREGNANT WOMEN.

(ZDV or Dt4) + 3Tc + NVP – If during non Rifampicin containing
continuation phase.
(ZDV or Dt4) + 3Tc + EfV – If during rifampicin containing
intensive or continuation phase.
CHILDREN
d4T or ZDV/3Tc/EfV (EFV not recommended for children below
3years.
CLASSIFICATION OF ARV
Nucloside Reverse Nucleotide Reverse Non- Fusion Protease
Transcriptase Transcripase inhibitor Nucloside inhibitors inhibitor CPIs
Inhibitors (NRTIs) (N+RT1) Reverse
Tenofovir C Disoproxil Transcriptase
fumarate (TDF 250mg Inhibitors
(NRTIs)
Zidorudine (ZDV) NEVIRAPINE Enfuvirti Saquinavir
250-300mg B.D (NVP) 200mg de (T-20) (Sqv)
B.D. 1200MG TID

EFAVIRENZ Ritonavir
(EFV) 600mg (RTV) (as
B.D pharmacoen
hence)
100mg
DELAVIRDIN
E (DLV)
Indinavir
(IDV) 800mg
T.I.D
 Amprenavir
APV 1200mg
B.D

Lopinavir-
ritonavir
133.3mg.
100mg (LPV)r

Atazanavir
(AZO
Tipranavir

Didanosine (ddl) 25mg,

30mg, 100mg, 150mg,
200mg: 400mg O.B

Zalcitabine lddo 0.75mg

BD

Stavudine (d4T) 40mg

B.D 1 weight

Lamivudine (3TC)
150mg B.D.
 CLASS SPECIFIC ADVERSE REACTION
CLASS Adverse Reactions
Reverse (1) All NRTI are capable of inhibiting mitochondria DNA
Transcriptase Polymerase.
inhibitors (2 On marrow – it causes depression of haemopoiesis leading
(NRTI) to anaemia, leucopoenia and thrombocytopaenia

(3) On the muscle: it causes myopathy

(4) On fat cells: it causes lipolysis resulting in fat atrophy.
(5) Though rare, prolonged usage may also affect myocardial
cells resulting in cardiomyopathy.
(6) It may affect peripheral neurones-peripheral neuropathy.

NNRT Drug: (1) Life threatening skin rash (stevens-Johnson syndrome)

Nevirapine NVP which occurs in less than 5% of patients and usually within
8 weeks of treatment.
(2) DRESS Syndrome.
(drug rash, oesinophilia and systemic symptoms) manifesting
as fever, athralgia.
Efavirenz (EFV (1) Mobiliform rash
(2) CNS side effects may occur in about 50% of patients (usually
self- limiting) include:
* Hallucinations
* Insomnia
* Abnormal dreams
* Somnolence
* Amnesia
* Abnormal thinking
* Confusion
* Euphoria

Contraindicated in psychiatric patients and pregnant or women who might become pregnant.
Protease inhibitors (PI) * Physical Components
* Peripheral loss of subcutaneous fat (Lipotrophy)
though to be due to RTI component of HAART regimen.
* Fat accumulation within the abdominal cavity.
(Protease-paunch of crix-belly).
* Buffalo hump or dorso-cervical pad (fat
accumulation in the breast) in females.
* Fat accumulation in subcutaneous tissue
(peripheral lipomatosis.

BIOCHEMICAL COMPONENTS INCLUDE

* Hypertriglyceridaemia
* Hypercholesterolaemia
* Hyperinsulinaemia
* Hyperglycaemia (insulin-resistant diabetes
* Low plasma testoterone level.
 USE OF HAART FOR POST EXPOSURE-PROPHYLAXIS (PEP)

The exposure should be classified as low risk or high risk for HIV
infection.
LOW RISK
Solid needle, superficial exposure on intact skin.
Small volume (drops of blood) on mucous membrane or non-intact skin
exposures.
HIGH RISK
Large bore needle, deep injury, visible blood on device, needle in patient
artery/vein.
Large volume (major blood splash on mucous membrane or non-intact skin
exposures.
Source patient is symptomatic, acute seroconversion, high viral load.
Rape or sexual contact.
PEP Cont’d
NOTE: - Take anti-retroviral drugs recommended for post-exposure prophylaxis
immediately – these should be started within 1 hour if possible and at the latest
within 72 hours of the exposure . (Persons presenting after 72 hours of the
exposure should also be considered for PEP.
- Those of low risk should take 2 drug combination and those with high risk
should take a 3 drug combination.
- Where the risk cannot be ascertained a 2 drug combination should be
used.

RECOMMENDED COMBINATION FOR PEP

- 2DRUG LOW RISK
- ZDV (300mg twice daily) + 3Tc
150mg twice daily
- d4T (40mg twice daily + 3Tc
150mg twice daily
- d4T (40mg twice daily + ddL
400mg once daily.
 3 DRUG HIGH RISK
 Any of the 2 drug combinations
+ EFV or a protease inhibitor (EFV)
should be avoided if pregnancy or suspected.
Preferred combination is EFV 600mg once daily) or NFV (1250mg twice daily
or LPV/RTV (400mg/100mg twice daily.
- The chosen regimen is continued for 28days or until results of HIV Test for
patient and exposed worker is known to be negative.
Monitoring
PERIOD RECOMMENDED INVESTIGATION
Baseline - Full blood count
- Liver function test
- Renal function test
- HIV screening.

Two weeks Full blood count

Liver function test
Renal function test

Six weeks HIV Screening

Three months HIV Screening
Six months HIV Screening.
HAART AND PMTCT
Drug combination from at least two different groups.
- 2NRTI + 1NNRTI
OR
- 2NRTI + 1 Protease inhibitor
- 3NRTI + 1 NNRTI
Regimen used ZDV/3TC/NVP from 14 weeks
ARV INTRAPARTUM/POST PARTUM PERIOD
Four Treatment Options.
- Single dose Nevirapine for mother at onset of Labour followed by single dose of
Nevirapine for the newborn within 48-72hrs.
- Oral ZDV/3TC For mother during labour followed by one week oral ZDV/3TC to the
newborn.
- Intrapartum IV ZDV followed by six weeks ZDV for the newborn.
- The two-dose Nevirapine regimen as above – combined with intrapartum.
IV ZDV and six weeks ZDV for the newborn.
 BENEFITS OF HAART
 Suppression of viraemia and virus shedding in
semen and vaginal secretion.
 Increased CD4 Plus T-cell count.
 Reduced immune activation.
 Restoration of Lymph node, architecture.
 Clinical improvement.
 Prolonged survival.

.
LIMITATION OF HAART
 Patient unwilling to tolerate HAART for life.
 STI and cycles of HAART are increasingly popular.
 Patients wish to defer therapy.
 Younger patients are ever more reluctant to accept
HAART.
 Cost of drugs very expensive
 Adherence usually poor.
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