Antiretroviral therapy: adherence, resistance and adverse effects

Link adherence directly to resistance

ART does not cure HIV, but consistent use can reduce the viral load to undetectable levels. CDC explains that when doses are missed, HIV can multiply, damage the immune system and mutate. Resistant virus may no longer respond to the current regimen, limits future options and can be passed to others. Adherence is therefore a treatment outcome in itself.

Ask about barriers without judgement: cost, stigma, housing, side effects, mental health and pill burden. Single-tablet combinations, phone reminders and linking doses to routines can help. Teach patients not to stop or skip medicines because they feel well or because of side effects, and to contact the team early instead.

Treatment is recommended for everyone with HIV, regardless of how long they have had it, and starting soon after diagnosis protects the immune system and reduces transmission. Delays allow ongoing immune damage. The nurse's role includes helping the patient link to care, understand the plan and know who to contact between appointments.

Use viral load and CD4 results to frame teaching

Viral load shows how well ART is controlling HIV, while CD4 count reflects immune health. Both are checked regularly, often every few months once stable. A rising viral load after suppression may signal missed doses, interactions or resistance and needs prompt review rather than reassurance.

Undetectable equals untransmittable: people who keep an undetectable viral load do not transmit HIV through sex. This message can motivate adherence. It also reduces transmission risk in pregnancy and delivery. Avoid overstating it for needle sharing, where the effect is less clear, and continue harm-reduction teaching.

Recognise the adverse effects that need action

Abacavir, a nucleoside reverse transcriptase inhibitor, can cause a serious hypersensitivity reaction. Genetic testing is done to identify people at higher risk before starting. Patients are taught to report symptoms from two or more groups: fever, rash, gastrointestinal upset, flu-like aches or respiratory symptoms. After a reaction, abacavir is never restarted.

Efavirenz, a non-nucleoside reverse transcriptase inhibitor, commonly causes dizziness, confusion and vivid dreams; taking it at bedtime may ease these. Report depression or suicidal thoughts. Dolutegravir, an integrase inhibitor, can cause insomnia and headache; rash with fever, blistering, mouth sores or jaundice needs urgent review because it may signal hypersensitivity or liver injury.

Check interactions before anything new is started

Antacids and supplements containing calcium, iron, magnesium or aluminium can reduce dolutegravir absorption, so timing is separated as the label and pharmacist advise. St John's wort can lower levels of several antiretrovirals and should be avoided. Ask about all prescription, over-the-counter and herbal products at every visit.

Efavirenz can reduce the effectiveness of hormonal contraception, so a barrier method is advised alongside it. Interactions differ between regimens and products. Before any new prescription, the nurse should confirm the full ART regimen is on the medication list so the pharmacist can screen it.

Liver and kidney disease should also be documented before starting, because these conditions affect regimen choice and monitoring. Patients should report jaundice, dark urine or abdominal pain promptly, and keep laboratory appointments so the team can catch problems early.

Work a hypothetical abacavir question

Imagine a hypothetical patient who started an abacavir-containing regimen ten days ago and now reports fever, nausea and a new rash. Options include advising acetaminophen and fluids for a viral illness, continuing doses but adding an antihistamine, or holding abacavir and contacting the prescriber urgently. Holding and escalating is strongest because symptoms from two groups suggest hypersensitivity.

Treating it as a minor illness risks a worsening reaction. Adding an antihistamine masks the problem while exposure continues. The patient must also be taught never to restart abacavir after a suspected reaction, because re-exposure can be life-threatening. In practice the prescriber chooses a replacement regimen to avoid gaps in viral suppression.

Sources and further reading

CDC: HIV treatment. Treatment for all people with HIV, adherence, viral suppression, undetectable equals untransmittable, resistance and viral load and CD4 monitoring.

MedlinePlus: Abacavir. NRTI class, hypersensitivity symptom groups, genetic testing and never restarting after a reaction.

MedlinePlus: Dolutegravir. Integrase inhibitor class, mineral supplement and antacid timing, St John's wort, hypersensitivity and liver warning signs.

MedlinePlus: Efavirenz. NNRTI class, CNS effects and bedtime dosing, psychiatric symptoms, St John's wort and reduced hormonal contraceptive effect.