Patient education: Tips for taking HIV medications by mouth (Beyond the Basics)

HIV TREATMENT OVERVIEW — Medications used to treat HIV are referred to as antiretroviral therapy (ART). Patients usually take a combination of two to three HIV medications by mouth. Several of these medicines are often combined into one tablet.

ART regimens typically include one or two nucleoside or nucleotide reverse transcriptase inhibitors (NRTIs) in combination with an integrase strand transfer inhibitor (INSTI), a non-nucleoside reverse transcriptase inhibitor (NNRTI), or a protease inhibitor (PI). Each class of medication has a specific task, which works best when it is combined with another class of medication. The medication should be refilled regularly and is considered a "chronic medication," which means it should be continued indefinitely, providing you are tolerating it and it is working well to suppress the HIV viral load.

Most ART regimens require you to take one or more pills per day. Skipping a dose or taking it late can have several possible effects:

●The viral load (the amount of HIV in the body) can increase. This can make it easier to transmit HIV to others and can lower your T cell count, which is also called a CD4 count and is a measurement of your immune system. The lower the T cell count, the higher your risk of HIV-related complications or even death.

●The virus can become resistant to treatment. The likelihood of developing medication resistance depends upon the individual patient, the specific HIV medication(s) being taken, and how many pills were missed. Becoming resistant means that the current treatment no longer works and a new medication(s) is required. In some cases, if one medicine stops working because of resistance, several other related medicines may also not work. This includes medications that you may never have taken before. This is called "medication cross-resistance."

This topic review discusses tips for taking medications correctly and on time so you can avoid treatment failure and drug resistance. Other topic reviews about HIV treatment are available separately. (See "Patient education: Initial treatment of HIV (Beyond the Basics)".)

IMPORTANT GENERAL ADVICE — The following tips can help to reduce your risk of developing HIV medication resistance, failed treatment, HIV-related complications, and medication interactions.

Remembering to take medications

●Fill a pill organizer once per week to make it easier to take your medications. A pill organizer also makes it easier to know if you have taken the dose(s) for the day. Keep this box where you will see it.

●Get in the habit of taking your medications with an activity you do daily (eg, brushing your teeth).

●Use a cell phone, watch, computer application, or alarm to help remind you to take medications.

●Keep a back-up supply in a handbag, backpack, or at work, in case you forget your pills.

●Your health care provider may ask you to bring your pill bottles to your visit; this is a good way to be sure that you are taking the correct medication and dose and that your doctor is aware of ALL the medicines you take. Get a written copy of your treatment plan at the end of each visit.

●If your sleep, work or school schedule, or your responsibilities at home interfere with taking your medication on time, discuss this with your provider. Plan ahead for weekends, vacations, and other changes in your routine.

●Using alcohol or street drugs can make it hard to remember to take medications on time. Be honest about these issues with your provider before agreeing to a treatment plan.

●It is important to take all of the medications in your regimen each and every day. Taking only a portion of the HIV medications can lead to resistance. When resistance occurs, that medication is no longer effective against your HIV infection.

●Call your health care provider's office immediately if you have difficulty getting any of your prescriptions filled or you have run out of medications. To avoid treatment interruptions, pay attention to renewal notices you get in the mail and requirements for medication insurance coverage.

●If you think your insurance coverage may be changing or may be terminated, let your provider or social worker know as soon as possible. They may be able to help you obtain coverage for medications during this process. Check with your provider or social worker if you are thinking about changing your medication insurance plan electively. Some plans may be better than others with respect to your specific HIV medication needs.

●Always contact your health care provider if you feel you want to stop your pills or change the type of pills you are taking.

Dealing with side effects

●The newer antiretroviral medications are generally well tolerated and have many fewer side effects than the older medications. However, side effects may still occur, and although some can improve over time, others may not. You should contact your health care provider about side effects immediately so they can help you decide the best way to proceed.

●There may be times that you are not able to take medication because of illness (eg, nausea and vomiting). Contact your health care provider immediately to discuss these issues.

Pharmacy issues

●Check with your pharmacist or health care provider immediately if the medications from your pharmacy look different from how they looked previously, or if the dosage is different from what you recall.

●When you need refills, call your pharmacy several days in advance to be sure they are in stock. Consider using a pharmacy that specializes in HIV medicines; many pharmacies will call once per month to see if you need refills.

●It is generally better to use one pharmacy for all of your medication needs. If you have to use more than one pharmacy, make sure each pharmacy is aware of all of the medications you are taking.

Hospitalization and HIV medications — If you have to go to the hospital, it is helpful to bring a list of your medications, or even the medications themselves, to be certain that there is no interruption in your schedule. You should give the medications to your physician, nurse or hospital pharmacist. Home medications should not be taken (unless this is advised by the physician) once you are in the hospital.

Other medications — Some HIV medications can interact with other medicines. For example, garlic supplements, milk thistle and St. John's wort substantially reduce the concentrations of some protease inhibitors. There are some other commonly used medications that can interfere with your HIV medications as well, including some multivitamins and those used to treat cholesterol, asthma, obesity, and heartburn. Ask your pharmacist or other health care provider to determine if there are any interactions between medications and any other prescription, over-the-counter, or herbal medications that you take.

Some HIV medications should be taken at the same time as other HIV medications. For example, atazanavir (Reyataz) and darunavir (Prezista) must be taken at the same time as ritonavir (Norvir).

With food or without? — Some HIV medications should be taken with food, while others must be taken on an empty stomach. An empty stomach is defined as one hour before eating or two hours after. For example, darunavir, atazanavir, and rilpivirine should be taken with food to be effective, but efavirenz should be taken on an empty stomach or the medicine might be too strong. The United States brand names for these medications are listed in the table (table 1).

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: HIV/AIDS (The Basics)
Patient education: Starting treatment for HIV (The Basics)
Patient education: Tests to monitor HIV (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Initial treatment of HIV (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

When to initiate antiretroviral therapy in persons with HIV
Overview of antiretroviral agents used to treat HIV
Selecting antiretroviral regimens for treatment-naïve persons with HIV-1: General approach
Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings
Switching antiretroviral therapy for adults with HIV-1 and a suppressed viral load
Selecting an antiretroviral regimen for treatment-experienced patients with HIV who are failing therapy

The following organizations also provide reliable health information.

●CDC (Centers for Disease Control and Prevention) National AIDS Hotline

●HIV/AIDS Treatment Information Service

Toll-free: (800) 448-0440

(www.clinicalinfo.hiv.gov/)

●AIDS Clinical Trials Information Service (ACTIS)

     Toll-free: (800) 874-2572

     (www.actis.org)

Patient Support — There are a number of online resources where patients can find information and support:

●The Body: The Complete HIV/AIDS Resource

●HIVinfo: Understanding HIV/AIDS

●www.HIV.gov

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