Please help me??? I'm a registered nurse working for a prison in a country which has very little HIV management experience.In this prison, we have one male prisoner who is about to initiate HAART for the first time, and my team leader is of the impression that as nurses, we can provide his once daily dose at times that suit the staff, as long as he gets it once daily as prescribed.He's about to start therapy in about 2 days and I'm terrified that this attitude towards timing of doses may result in resistance...at no fault of the patient.Is there any advice you could provide me with that will help to change this attitude,or has it become acceptable practice to allow for varied timing of dose administration? (I recently moved here from a country with far more experience in HIV treatment, care and support).Thank you very much, and bless you. Registered Nurse, New Zealand

I can confirm that you and the patient do have reasons for concern if his once daily dose is not taken at the same time every day, leading to intervals that exceed 24 hours. The international standard of care for once daily dosing is to take the medications at the same time every day, and for good reason: adequate drug levels for all members of the once daily regimens are established based on the 24 hour interval. After 1-2 hours over that interval, sub-therapeutic drug levels may result with some regimens.

In most western countries, prison health authorities bear the responsibility for health care that conforms to national and international standards. (I am unaware of the law in New Zealand, but you could find out from them, or from the John Howard Association). You can certainly appeal to your senior physician and the prison authorities that the best way to proceed here, both for the patient and the institution, is to set the practice for once daily dosing at a single time, and stick with it. It would be best for the institution because, if they proceed otherwise, the patient is more likely to experience virologic failure, drug resistance, and clinical illness. This would be more expensive and more trouble for prison health facilities than good virologic control and good health. It would also be simpler as a matter of prison routine.

The same argument applies to the undesirability of another situation that, unfortunately, commonly occurs in prison settings, i.e. stock outs of certain drugs. You would also be well-advised to connect with the prison pharmacist in order to prevent this problem.