My introduction to ARV treatment started four years after my initial diagnosis with HIV in 2004. Soon after, I was diagnosed with cancer in 2008. My CD4 count dropped to 203 cells/mm3 in approximately four years. This was the then-recommended level to start treatment.

By Cindy Pivacic.


CD4 count

Unfortunately, it was too late for my body to respond at this low level resulting in my AIDS diagnosis. In earlier years, an HIV-positive person had to be at a specific level of CD4 count before treatment was accessible. 

Treatment regimen

Although I had numerous health conditions leading to many challenges, I have been on the same (first-line) treatment from day one. I have changed tablets, but the combined ingredients are still the same, meaning I am still on my first-line regimen.

ARV treatment guidelines

The first DoH guidelines, in 2004, recommended treatment initiation at CD4 count < 200 cells/mm3. In 2009, the CD4 threshold for treatment increased to 350 cells/mm3. Fortunately, the treatment process, inception and management are different now. The DoH recommends that ARV treatment starts with immediate effect. In South Africa, one of the main reasons for ARV treatment failure is non-adherence. Installing ATM-type dispensers around the country for chronic medication has provided some relief.  

Skipped doses

Taking your HIV medicine on time, every day is crucial. Skipping doses makes it easier for HIV to change form, and your medication can stop working. Once this happens, it is called drug resistance. HIV can become resistant to your ARV medication and similar medicines you have not yet taken. If you realise you have missed a dose, take the medication as soon as possible. Then, take the next ARV dose at your usual scheduled time. There may be some exceptions to this general rule. Taking medication such as efavirenz [Sustiva] during the day may cause unmanageable side effects. If you miss doses of your HIV medications, talk to your health provider about ways to help you remember to take the medications consistently. I have two alarm reminders on my phone, ten minutes apart. In the fourteen years of taking ARV medication, I have missed/delayed three doses.

ARV Failure

There may be other reasons, some of which may be unrelated to adherence and others that may predispose you to poor adherence. 

  • Acquired drug resistance: you ‘pick up’ a drug-resistant variant through intercourse, shared needles, or other modes of transmission.
  • Former treatment failure: you will likely have developed levels of resistance to ARVs of the same class.
  • High baseline viral load: some drug regimens are less effective when you have a high pre-treatment viral load.
  • Intolerable side effects: can lead some people skipping doses altogether or quitting the offending pill.
  • Drug interactions:  another drug may reduce the concentration of an antiretroviral in your blood, reducing its efficacy.
  • Poor drug absorption: this can happen to people with chronic HIV-associated diarrhoea or other malabsorption issues.
  • Not following food requirements: this can also affect drug absorption and metabolism.
  • Cost and affordability: including the lack of adequate health insurance. (ARVs are free in South Africa).
  • Substance abuse and mental health problems: can lead to unreliable dosing and risk-taking behaviours.
  • Other psychosocial issues: including poverty, unstable housing, discrimination, and the fear of disclosure. 

Unless these factors are resolved, an increased risk of treatment failure with future drug regimens will continue.

ARV treatment lines

  • First-line antiretroviral therapy for adults and adolescents consists of two nucleoside reverse-transcriptase inhibitors (NRTIs) and a nonnucleoside reverse transcriptase inhibitor or an integrase inhibitor.
  • Second-line antiretroviral therapy regimens are used when patients develop treatment failure for first-line drug regimens. It is costly and it is not widely available for patients in resource limited settings. There is a need to maximise the duration of stay on second-line regimen. (This is available free in South Africa).
  • Third-line therapy is defined to be any treatment regimen that included one of darunavir, raltegravir, or etravirine after documented PI-based ART failure and resistance.

The WHO recommends the use of the HIV drug dolutegravir (DTG) as the preferred first-line and second-line treatment for all populations, including pregnant women and those of childbearing potential.

Changing your ARV treatment regimen

Changing an ARV regimen is common in clinical practice for patients with either suppressed virologic replication or virologic failure. Those with virologic suppression usually have changes in ARV treatment in an attempt to alleviate acute toxicities, control chronic toxicities, or improve quality of life. This strategy generally appears reliable as long as the relevant issues, such as previous ARV treatment use, are considered.

A chronic condition can affect anyone. How you manage it is what makes the difference.

You can get cover of up to 1 million rand for your chronic health condition and up to 10 million if you are living with HIV. 

SMS CHRONIC to 33857 to find out more. 

I did!

Disclaimer: The information in this article is intended for educational purposes only. It is not intended to diagnose, treat or cure, and is not a substitute for professional consultation with a health professional.

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