Treatment training for advocates

Overview Contents Learning resources Questions

Treatment training for advocates: a manual

Full section index

1 Immune system and CD4 count: 1.1 Introduction; 1.2 Aims for this section; 1.3 Definition of AIDS (SIDA); 1.4 Basic organs in the body; 1.5 How the immune system works; Protection from infection; Antigens and antibodies; Cellular and humoral immunity; Humoral immunity is based on antibodies; Cellular immunity is based on CD4 and CD8 responses; 1.6 How HIV specifically interacts with immune system; HIV and the immune system before ARV treatment; HIV and the immune system after ARV treatment; 1.7 CD4 count as surrogate marker; What is a CD4 count?; What is a surrogate marker?; Pattern of CD4 count after HIV infection; 1.8 How quickly does HIV progress in different people; Approximate time for CD4 count to drop to 200 cells/mm³; 1.9 Interpreting CD4 results: CD4 count and CD4 percentage; Looking at a CD4 count trend; CD4 percentage (CD4%); 1.10 Differences between adults and children; Table: CD4% and CD4 counts for babies and children; 1.11 Different stages of infection; WHO classification; US CDC clinical categories; Table: CDC categories of HIV infection; 1.12 CD4 count and opportunistic infections; Opportunistic infections that may occur at different CD4 counts; CD4 count below 300; CD4 count below 200; CD4 count below 100; CD4 count below 50; 1.13 Use of CD4 count for starting therapy; The main use of CD4 counts is to know when to start HIV treatment; What CD4 count indicates time start ARV treatment?
2 Virology, HIV and viral load: 2.1 Introduction; 2.2 Aims for this section; 2.3 Definition of HIV; 2.4 Other causes of illness; Bacteria; Fungi; Parasites and protozoa; 2.5 HIV: key facts; 2.6 Viral dynamics – natural history of HIV infection, effect of ARVS; Natural history of HIV infection; Infection; Seroconversion; Primary (HIV) infection – PHI; Chronic infection; Late stage infection; Effect of ARVs on viral dynamics of HIV infection; 2.7 Reinfection with HIV; 2.8 What is a viral load test?; Types of viral load test; Using viral load and CD4 count to monitor HIV; 2.9 History of viral load technology; 2.10 Impact of coinfections on viral load; 2.11 Compartments and sanctuary sites; 2.12 Viral load on treatment and off treatment; Viral load when not on treatment; Viral load when on treatment; How often to use viral load tests – what happens if you do not have access to them; 2.13 Viral lifecycle, drug resistance and adherence; Viral life cycle: copies, mistakes and mutations; Resistance, treatment and viral load; Resistance and adherence are closely related; Drug levels and resistance; 2.14 How CD4 and viral load are related; CD4 count and viral load without ARV treatment; Effect of ARVs on CD4 count and viral load
3 Introduction to anti-retrovirals (ARVs): 3.1 Introduction; 3.2 Aims for this section; 3.3 What is combination therapy?; 3.4 Do the drugs really work?; 3.5 How HIV drugs work – types of drugs; Different drugs work at different stages of the HIV life cycle; 3.6 Treatment guidelines; Guidelines on the Internet; 3.7 When to start treatment; Being ready to start treatment; 3.8 Why 3 or more drugs are used; 3.9 Reducing viral load to less than 50 copies/mL; 3.10 Treatment choice; 3.11 Side effects; 3.12 Can I change treatment?; 3.13 Can I take a break in my treatment?; 3.14 Recreational drugs, alcohol and complementary therapy; 3.15 Adherence – and why it is so important; What is adherence?; How much is enough?; Table: Adherence rates and % of people undetectable; 3.16 Tips to help adherence; 3.17 What if I forget to take my pills?; 3.18 Resistance to ARVs; What is resistance?; How does resistance occur?; What is cross-resistance?; What is a resistance test?; What if I can't get a resistance test?; How do I avoid resistance?; Missing doses = increased risk of resistance; 3.19 Treatment failure; Virological failure; Clinical failure; Managing treatment failure
4 Side effects of ARVs: 4.1 Introduction; 4.2 Aims for this section; 4.3 Side effects overview; Why do side effects occur?; Do all drugs have side effects?; Summary of Product Characteristics; How are side effects for drugs reported?; Starting treatment for the first time; Can I change drugs easily?; Can I predict the side effects I may get?; Are side effects different in men and women?; What about side effects and adherence?; Getting your doctor to do something; What happens if side effects persist?; 4.4 Common side effects: feeling sick, diarrhoea and tiredness; 4.5 Liver toxicity and rash: nevirapine, efavirenz; Liver toxicity; Rash; Differences in men and women; 4.6 Peripheral neuropathy: d4T, ddI, rarely 3TC; 4.7 Lipodystrophy: d4T, AZT, nevirapine, efavirenz, protease inhibitors; Fat gain; Fat loss; Changes to blood fats; Changes to blood sugars; Differences in men and women; 4.8 Mood changes, paranoia, strange dreams, nervousness: efavirenz; 4.9 Anaemia: AZT and lactic acidosis: d4T, ddI, AZT; Anaemia; Lactic acidosis; 4.10 Other side effects; Finding information on drugs and side effects; 4.11 How to report side effects; Recording side effects; How often? – frequency; How long? – duration; How bad? – severity; Quality of life; 4.12 How side effects are graded; Table: side effects graded; Discussion; 4.13 Side effects diary
5 Opportunistic infections and coinfections: 5.1 Introduction; 5.2 Aims for this section; 5.3 OI and coinfection overview; What to find out about an OI; Type of infection; Main symptoms; Diagnosis; Treatment; Prophylaxis; Research; 5.4 Gut infections: giardia, cryptosporidia, microsporidia; Type of infection; Main symptoms; Diagnosis; Treatment; Prophylaxis; 5.5 Candida and other skin problems; Type of infection; Main symptoms; Diagnosis; Treatment; Prophylaxis; Research; Other skin problems; 5.6 PCP; Type of infection; Main symptoms; Diagnosis; Treatment; Prophylaxis; 5.7 TB; Type of infection; Main symptoms; Diagnosis; Treatment; Adherence is critical; Is HIV treatment the same for people with TB coinfection?; Interactions between ARVs and TB treatment; Summary of TB drug interactions; How to use ARVs with active TB infection; TB drug side effects; Prophylaxis; Research; 5.8 MAI and MAC; Type of infection; Main symptoms; Diagnosis; Treatment; Prophylaxis; 5.9 Hepatitis B and C; Type of infection; Main symptoms; Hepatitis B (HBV); Hepatitis C (HCV); 5.10 CMV; Type of infection; Main symptoms; Diagnosis; Treatment; Prophylaxis; Research; 5.11 Toxoplasmosis; Type of infection; Main symptoms; Diagnosis; Treatment; Prophylaxis; Research; 5.12 Cryptococcal meningitis; Type of infection; Main symptoms; Diagnosis; Treatment; Prophylaxis; 5.13 Cancer: lymphoma,and sarcoma; AIDS-defining cancer; Other types of cancer; What is cancer?; Main symptoms, diagnosis and treatment; 5.14 Wasting and weight loss; Type of infection; Main symptoms; Diagnosis; Treatment; Prophylaxis; 5.15 Malaria; Type of infection; Main symptoms; Malaria and HIV; Malaria, pregnancy and anaemia; Diagnosis; Treatment; Prophylaxis; Research
6 HIV and pregnancy: 6.1 Introduction; 6.2 Aims for this section; 6.3 HIV and pregnancy overview; Can HIV-positive women become mothers safely?; How is HIV transmitted from mother to a baby?; Viral load is the strongest risk factor; Other risk factors; Do HIV drugs protect the baby?; Treat as non-pregnant adult; 6.4 Mother's health and pregnancy; HIV; CD4 count; Opportunistic infections; 6.5 ARVs in pregnancy: when to treat; If a woman is pregnant and does not need HIV treatment for her own health; If a woman is HIV-positive and needs treatment for her own HIV; If a woman discovers she is HIV-positive late in pregnancy; If a woman is already using HIV treatment when she becomes pregnant; 6.6 ARVs in pregnancy: choice and safety; Which ARVs to use in pregnancy; ARVs not recommended for use in pregnancy; 6.7 ARVs in pregnancy: side effects; 6.8 ARVs in pregnancy: resistance and adherence; Resistance; Adherence; 6.9 Screening and tests; Tests to be avoided by HIV-positive pregnant women; 6.10 Other infections; PCP, MAI, TB; CMV, candida, invasive fungal infections; Herpes; 6.11 ARVs and the baby's health; Exposure to ARVs; Prematurity; Abnormality; Development; Mitochondrial toxicity; 6.12 Choices for delivery and use of C-section; 6.13 When the baby is born; The baby's diagnosis; The baby's treatment; 6.14 Breastfeeding; HIV transmission from breast milk; Bottle feeding is strongly recommended for all HIV-positive mothers; When bottle feeding is difficult
7 Drug users and HIV: 7.1 Introduction; 7.2 Aims for this section; 7.3 Drug users and HIV overview; What WHO says about HIV treatment for drug users; Injecting drug use is main route of transmission in many countries; Interactions between ARVs and street drugs; Drug users sometimes excluded from ARV treatment programmes; Excluding drug users from ARV treatment is unjustified; 7.4 Comprehensive and accessible care; 7.5 ARVs and recreational drug interactions: overview; Interactions summary; Theoretical information is not as useful as studies on humans; 7.6 ARVs and recreational drug interactions: ritonavir; Ritonavir and street drugs; Ritonavir and the liver; History; 7.7 ARVs and recreational drug interactions: street drugs; Safer drug use; 7.8 ARVs and recreational drug interactions: methadone
8 Clinical trials and research: 8.1 Introduction; 8.2 Aims for this section; 8.3 Why trials are important; 8.4 Developing a new treatment: Phase I, II, III and IV studies; Phase I studies; Phase II studies; Phase III studies; Phase IV studies; 8.5 Hypothesis and endpoints; Trial question - the hypothesis; Primary endpoint; Secondary endpoints; 8.6 Main types of trial design; Observational vs experimental (or interventional); Cross-sectional vs longitudinal; Retrospective vs prospective; 8.7 Randomised, double-blind, placebo-controlled trials; Randomisation; Blind and double-blind studies; Placebo; Control group; 8.8 Other types of studies; Randomised controlled trial (RCT; Cohort study; Case-control study; Cross-sectional study; Case study and case-note review; Literature review and systematic literature review; Meta analysis; 8.9 Grading given to different types of evidence; Table: Grading of recommendations and levels of evidence; 8.10 Glossary of other terms; 8.11 How studies are reported; 8.12 Patient involvement in clinical studies and research; 8.13 Confidentiality for advocates involved in research; 8.14 Summary of different advocacy roles

Learning resources.

Glossary.
AIDS-defining infections for CDC clinical categories.
European ARV drugs and doses.
Interactions between ARVs and street drugs.
Log value conversion table.
Opportunistic infections by disease type.
Related websites by topic.
Risk of opportunistic infections by CD4 count and effect of ARV treatment.
Side effects record sheet.
TB and ARV drug interactions.
WHO classification system for HIV infection.
WHO recommended ARVs.

1 Immune system and CD4 count | Answers
2 Virology, HIV and viral load | Answers
3 Introduction to anti-retrovirals (ARVs) | Answers
4 Side effects of ARVs | Answers
5 Opportunistic infections and coinfections | Answers
6 HIV and pregnancy | Answers
7 Drug users and HIV | Answers
8 How to read science | Answers

Authors and acknowledgements

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This manual was developed by HIV i-Base.

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Last updated on Monday 22nd September 2008.