What is antiretroviral therapy?
Antiretroviral therapy (ART) is the use of a combination of drugs to slow down the progression of HIV infection and prevent its further transference i.e. chance of passing on HIV infection to other people.
ART achieves this by decreasing the amount of virus in the infected person’s blood and body fluids. It must be noted that HIV has no cure yet, however, ‘ART medicine enables HIV positive persons to have quality of life like that of HIV negative persons – do job and everything else,’ says Dr Prabhu Narayan Prasad, Medical Officer at the ART centre in New Delhi’s Dr Ram Manohar Lohia Hospital.
Every person who’s detected with HIV infection must be put on ART, as per the National AIDS Control Organisation (NACO), a government arm that leads India’s HIV/AIDS control programme. In essence, ART is not only a medication but a whole process to keep up the health of an HIV positive person.
(Want to know about HIV prevention by pills - PrEp and PEP, go here.)
Where is ART provided
ART is provided at private as well as government medical institutions. In India, just as the government provides free HIV testing, it also provides ART free of cost at over 500 ART centres across India. A list of ART centres can be found here.
If one gets tested and turns out to be positive at a government facility, called Integrated Counselling and Testing Centres (ICTC), one is directly referred to an ART centre by the ICTC.
ICTCs are usually located in areas with medical institutions that serve specific population groups – people at higher risk of getting HIV, pregnant women, TB patients, etc.
At Rajan Babu Institute of Pulmonary Medicine and Tuberculosis, in Delhi’s Kingsway Camp area, the ICTC in-charge says, ‘We counsel all TB patients to go for HIV testing, and also offer HIV testing to those who voluntarily come in for the test.’
From ICTC to ART Centre
A post-test counselling happens at ICTC for persons who test positive for HIV so that they don’t take any extreme measures and to help understand the way forward on treatment. They are provided a referral to one of the ART centres it has a tie up with or that is convenient for patients to visit.
‘Counsellor from ICTC can also accompany person to ART centre, if needed – say in a situation where patient does not have money to commute to ART centre or needs emotional support in that time,’ says Dr Mala Vinayak, HOD Microbiology and in-charge at ICTC in Delhi’s Pt. Madan Mohan Malviya Hospital in south Delhi.
She adds that this task of accompanying patient to ART centre is also done by NGOs that work in collaboration with ICTCs.
What happens once at ART centre?
At ART centre, the person who has tested positive for HIV are also screened for various other infections that are likely in HIV positive people.
A few of these infections are TB, oral candidiasis, hepatitis B and C, syphilis. Tests are done to check their possibility, and also for total blood count, for the functioning of kidney and liver. This set of tests takes about 5-7 days, and these tests too are done free of cost at a government facility.
After the results of these tests are available, the medical officers at the ART centre decide on the course of treatment with the HIV positive person over next two visits. Counselling on mental and social issues of patient is a parallel process of this medical process at the same ART centre, performed by specialised counsellors.
‘If TB infection is present, medication for TB is started immediately and ART medicine for HIV is started two weeks later,’ says Dr Prabhu Narayan Prasad, medical officer at ART Centre of Dr Ram Manohar Lohia Hospital, Delhi.
If person is co-infected with any other infection, other than TB, then the treatment for that infection is started simultaneously with ART. Person is given dosage for until the next visit.
'For the first six months, patients are asked to visit ART once every month. But after six months, it’s about once every three months,’ says Dr Naresh Goel, Deputy Director General of NACO. A freshly infected person who starts with ART medicine is put on the first line of treatment.
A person can expect to consume 1-3 tablets per day for HIV infection that are made from a combination of drugs, and medication continues for life.
Kousalya Periasamy, founding member of Positive Women Network, a collective of HIV positive women, based in Chennai, advises HIV positive persons to do research and find information on the drugs they’re being given for ART. Medical officers and counsellors at ART centres and NACO’s (National AIDS Control Organisation) 24 hours national helpline – 1097 – are the most easily approachable sources of information as of now.
Dr Prasad holds up two booklets – one in green colour and the other in white. The white booklet contains personal information on the patient, like personal details and information on how they contracted HIV infection, and lists out details of each consultation at the ART centre. This booklet is kept at the ART centre.
The patient keeps the green booklet, wherein the medical officer records the details of drugs given in each visit. The medical officer checks the adherence – whether patient took medicine regularly – by matching details in the green booklet and the remaining stock of medicine with patient. ‘If they do not adhere, then we give counselling,’ says Dr Prasad.
The series of tests are repeated after six months, and that also include viral load and CD4 tests. The latter two are repeated every six months.
It is not common to change medicine. ‘If adherence is maintained, the same treatment might continue for up to 10 years,’ says Dr Goel.
“People doing night jobs aren’t able to take certain ART drugs because they must be taken at night and make patient dizzy, while these people need to be awake,” Periasamy says. “Counsellors and doctors need to provide alternatives so that such patients don’t skip medicines.”
If HIV positive person skips medicine, the HIV virus may multiply quickly, affecting their health and bringing up need to switch to second, or subsequently, third line of treatment. This multiplication of HIV virus may lead also lead to occurrence of opportunistic infections – that usually don’t arise in immune-competent persons but in those with weakened immunity systems -- like TB, oral candidiasis, etc.
Effects of ART therapy
In addition to its positive outcomes for persons living with HIV/AIDS (PLHAs), ART medicine also has several side effects. The most common side effects are giddiness, gastro issues, rashes on the body, nausea, dizziness.
It may also affect liver function and a consultative process is needed to address the unwanted effects of ART medicine.
‘But most of these get settled in a month of two,’ says Dr Prasad.
Periasamy shares few long-term side effects of few ART drugs specific to women -- cysts in uterus, reduction in bone density, and change in pattern of fat deposit that affects mobility. 'There needs to be a lot of medical research on side effects on women and controlling those'.
'With medication, we are told to take protein rich diet or calcium rich diet -- we should have money to get that natural and rich diet,' Periasamy says. A person undergoing ART might not have the money to afford such a diet. For this, Periasamy urges the State to support PLHAs by extending monthly food allowance for PLHAs, on the lines of nutrition allowance for TB patients.
It is important to remember that HIV is not a disease but an infection that requires regular medicine intake, just like we do for maintaining diabetes or thyroid levels imbalance.
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