# Situation: A 31-year-old man was diagnosed with human immunodeficiency virus (HIV) infection and chronic hepatitis B at the same visit. He is enrolled at a treatment hub and starts one tablet of tenofovir–lamivudine–dolutegravir once daily. He works rotating day and night shifts at a call center and lives with his female partner, whose hepatitis B status is unknown. Which advice will BEST help him take his antiretroviral tablet consistently despite his changing shifts?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629853  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 31-year-old man was diagnosed with human immunodeficiency virus (HIV) infection and chronic hepatitis B at the same visit. He is enrolled at a treatment hub and starts one tablet of tenofovir–lamivudine–dolutegravir once daily. He works rotating day and night shifts at a call center and lives with his female partner, whose hepatitis B status is unknown.

Which advice will BEST help him take his antiretroviral tablet consistently despite his changing shifts?

## 보기

1. Take it at a fixed clock time every day, set with a phone alarm **✔ 정답**
2. Take it after his first meal of each workday, whatever the hour
3. Take it only on days when his sleep and meals are regular
4. Take it when he wakes up, whether that is morning or evening

**정답: 1**

## 해설

Antiretroviral therapy works only when every dose is taken at about the same time each day; missed or irregular doses let the virus rebound and develop resistance. A fixed clock time with a phone alarm does not depend on his shifting meals or sleep. Pill boxes and a treatment partner can support this further.

## 심화 해설

Core principle: why timing matters more than meals or sleep

Antiretroviral therapy (ART) suppresses HIV replication only while drug concentrations in the blood remain above the level needed to stop the virus from copying itself. Dolutegravir, tenofovir, and lamivudine all have long intracellular half-lives, but none of them is forgiving enough to allow doses to drift unpredictably across a rotating shift schedule. When a dose is taken late, skipped, or moved by many hours, the drug level can dip. During that dip, HIV resumes replicating, and each replication cycle is an opportunity for a resistance mutation to emerge. Once resistance develops, the same regimen may no longer control the virus, and future treatment options narrow. A fixed clock time keeps the interval between doses as close to 24 hours as possible, which is the single most reliable way to maintain steady drug levels.

Why a fixed clock time is the best answer

A fixed clock time, supported by a phone alarm, is independent of the patient’s changing meal times, sleep times, and wake times. Rotating shifts mean that “after the first meal” or “when he wakes up” can occur at very different hours from week to week. If the patient anchors the dose to a meal or to waking, the interval between doses can stretch to 30 hours or shrink to 18 hours depending on the shift rotation. That variability is exactly what promotes subtherapeutic trough levels and resistance. Anchoring the dose to the clock rather than to a daily routine removes the influence of shift work. A phone alarm provides an external cue that does not depend on memory, fatigue, or meal timing.

Why the other options are less reliable

Taking the tablet after the first meal of each workday sounds practical because food can reduce gastrointestinal upset, but it ties the dose to a variable event. On a day shift, the first meal may be at 7:00 AM; on a night shift, it may be at 7:00 PM. That creates a 12-hour swing in dosing time, which is far too wide for consistent viral suppression. Taking the tablet only on days when sleep and meals are regular is dangerous because rotating shift workers rarely have fully regular days. Skipping doses on irregular days would cause frequent treatment interruptions, which is the fastest route to virologic failure and drug resistance. Taking the tablet when he wakes up, whether morning or evening, is better than skipping doses, but it still allows the dosing time to shift by many hours as his sleep schedule rotates. Watch out! Options that tie dosing to sleep or meals feel patient-friendly, but they create the very irregularity that ART cannot tolerate.

Practical supports that reinforce a fixed clock time

A phone alarm is the core strategy, but it works best when combined with other adherence aids. A weekly pill organizer lets the patient see at a glance whether today’s dose has been taken. Keeping the pill organizer in a place he sees at the same time every day, such as next to his toothbrush or phone charger, adds a visual cue. A treatment partner, such as his female partner, can also help by reminding him or checking the pill organizer. These supports do not replace the fixed clock time; they strengthen it. Because his partner’s hepatitis B status is unknown, she should also be tested and vaccinated if susceptible, but that is a separate issue from the patient’s own ART adherence.

How this connects to the nursing process

In the assessment phase, the nurse identifies rotating shift work as a barrier to adherence. In the planning phase, the nurse and patient agree on one fixed clock time that fits his life, such as 9:00 PM, which is likely to be awake time on both day and night shifts. In the implementation phase, the nurse teaches the patient to set a daily phone alarm and to use a pill organizer. In the evaluation phase, the nurse asks at follow-up visits whether doses were taken at the agreed time, reviews viral load and CD4 results, and adjusts the plan if the patient reports difficulty. Key point! Adherence counseling for ART is not about telling the patient to “try harder”; it is about building a system that makes the correct timing automatic and independent of a chaotic schedule.

Why every dose matters for this specific regimen

The single-tablet regimen of tenofovir, lamivudine, and dolutegravir is potent and generally well tolerated, but its success depends on near-perfect adherence. Dolutegravir has a relatively high barrier to resistance, meaning that the virus must accumulate multiple mutations to escape it. However, this advantage is lost if doses are frequently late or missed, because subtherapeutic drug levels allow partially resistant viral populations to expand. Tenofovir and lamivudine are also active against hepatitis B, which is relevant because this patient has chronic hepatitis B. Stopping or interrupting this regimen can cause a hepatitis B flare in addition to HIV rebound, so consistent daily dosing protects both infections. This dual indication makes adherence even more critical than in a patient with HIV alone.

## 임상 시나리오

ART Adherence in Shift WorkersAnchor the dose to the clock, not to meals or sleep
For patients on dolutegravir–tenofovir–lamivudine, the goal is to keep the interval between doses as close to 24 hours as possible. A fixed clock time with a phone alarm is the most reliable strategy because it does not depend on changing meals, wake times, or sleep patterns.

Rotating shifts make meal-based or wake-based dosing unpredictable. If the dose is tied to the first meal or waking, the interval may stretch to 30 hours or shrink to 18 hours. That variability can lower trough drug levels and allow HIV replication to resume, increasing the risk of resistance.

CautionNever advise skipping doses on irregular days. Missed or delayed ART doses let the virus rebound and develop resistance, narrowing future treatment options. Pill boxes and a treatment partner can reinforce clock-based adherence.

## 핵심 개념

- **Antiretroviral therapy (ART)** — Treatment that suppresses HIV replication by keeping drug levels above the threshold needed to stop viral copying.
- **Dolutegravir** — An integrase strand transfer inhibitor with a long half-life used in first-line HIV regimens.
- **Tenofovir** — A nucleotide reverse transcriptase inhibitor active against both HIV and hepatitis B virus.
- **Lamivudine** — A nucleoside reverse transcriptase inhibitor active against HIV and hepatitis B virus.
- **Resistance mutation** — A genetic change in HIV that allows the virus to replicate despite the presence of antiretroviral drugs.

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