Continuing Education (CEU) course for healthcare professionals. View the course online at wildirismedicaleducation.com for accreditation/approval information, course availability and other details, and to take the test for CE credit. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional healthcare.
Contact Hours: 1
HIV/AIDS Treatment COPYRIGHT © 2015, WILD IRIS MEDICAL EDUCATION, INC. ALL RIGHTS RESERVED. BY Nancy Evans, BS; Judith Swan, MSN, BSN, ADN, RN
COURSE OBJECTIVE: The purpose of this course is to prepare healthcare professionals to care for people with HIV/AIDS based on a review of HIV clinical manifestations and treatment. LEARNING OBJECTIVES Upon completion of this course, you will be able to: •
Identify the clinical stages of HIV.
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Discuss AIDS-defining conditions.
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Describe elements of antiretroviral therapy (ART).
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Summarize which coinfections are common among patients with HIV.
The trajectory between infection with HIV and the development of full-blown AIDS can be steep or gradual and may take as long as a decade or more. If the infection is untreated, the average time from HIV infection to a diagnosis of AIDS can be 10–15 years. However, early detection and appropriate medical treatment may extend the lives of those infected and reduce the rates of HIV transmission.
COURSE OF THE DISEASE AND DIAGNOSIS As the HIV virus suppresses immune function, the infected person becomes more vulnerable to opportunistic infections caused by a wide variety of bacteria, viruses, fungi, and other pathogens encountered in daily life. The physical results of these opportunistic infections are called clinical manifestations. For example, the opportunistic infection cytomegalovirus (CMV) often causes the clinical manifestation of blindness in people with AIDS. Some conditions, called co-factors—including age, genetic factors, drug use, smoking, nutrition, and coinfection with hepatitis C virus (HCV) and/or tuberculosis (TB)—can affect the course of the disease progression.
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HIV Classification Systems Currently there are two major ways to classify HIV: • •
For surveillance case definition purposes For clinical diagnosis purposes
In 2008 the CDC revised its earlier surveillance case definitions of HIV and AIDS to require laboratory-confirmed evidence of HIV infection for all those aged 18 months and older. The revised definition also emphasizes the central role of the CD4 T lymphocyte counts and percentages in staging HIV disease. It is important to recognize that these case definitions are for surveillance purposes only and are not a guide for clinical diagnosis. The CDC classification system identifies four stages of HIV infection, described in the following table.
STAGES OF HIV INFECTION FOR SURVEILLANCE CASE DEFINITION Stage 1
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Laboratory confirmation of HIV infection and CD4 T lymphocyte count ≥500 cells/µL or CD4 T lymphocyte percentage of ≥29%
Stage 2
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Laboratory confirmation of HIV infection and CD4 T lymphocyte count 200–499 cells/µL or CD4 T lymphocyte percentage of 14%–28%
Stage 3 (AIDS)
• • •
Laboratory confirmation of HIV infection and CD4 T lymphocyte count 1 month’s duration) or bronchitis, pneumonitis, or esophagitis Histoplasmosis, disseminated or extrapulmonary Isosporiasis, chronic intestinal (>1 month’s duration) Lymphoid interstitial pneumonia or pulmonary lymphoid hyperplasia complex Mycobacterium avium complex (MAC) or M. kansasii, disseminated or extrapulmonary M. tuberculosis (TB) of any site, pulmonary, disseminated, or extrapulmonary Mycobacterium, other species or unidentified species, disseminated or extrapulmonary Pneumocystis jirovecii pneumonia Pneumonia, recurrent Progressive multifocal leukoencephalopathy Salmonella septicemia, recurrent Toxoplasmosis of brain, onset at age >1 month Wasting syndrome attributed to HIV
People with HIV/AIDS are at high risk for developing certain cancers, such as Kaposi sarcoma, non-Hodgkin’s lymphoma, and cervical cancer. These three cancers are referred to as “AIDSdefining conditions,” and if a person has one of these cancers, it is very likely to signify HIV and the development of AIDS. The connection between HIV/AIDS and cancer is not completely understood but is believed to be the result of a weakened immune system. The following types of cancer are also common for people with HIV/AIDS: •
Hodgkin’s lymphoma
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Angiosarcoma
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Anal cancer
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Liver cancer
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Mouth or throat cancer
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Lung cancer
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Testicular cancer
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Colorectal cancer
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Multiple types of skin cancer including basal cell carcinoma, squamous cell carcinoma, and melanoma (Robert H. Lurie Comprehensive Cancer Center, 2013) ! © 2015 WILD IRIS MEDICAL EDUCATION, INC.
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Multisystem Effects of HIV/AIDS HIV infection not only affects the immune system but also affects other body systems. Respiratory tract defenses are affected by HIV. Alveolar macrophages in persons with HIV may serve as reservoirs for the virus. These protected viruses may infect other cells and may contribute to the accelerated HIV disease in the presence of opportunistic infections (Hopewell, 2011). The gastrointestinal system is affected by AIDS enteropathy, a condition characterized by changes in the villus of the small bowel. This leads to malabsorption resulting in malnutrition and wasting (Barlett, 2011). Integumentary system problems increase in frequency and severity. There may be pruritus without evident skin lesions. Herpes zoster may be a reliable sign of the presence and progression of HIV in a person who is otherwise asymptomatic. Necrotizing gingivitis and recurrent oral ulcers are common (Penneys, 2011). The sensory system effects include visual impairment or blindness related to infectious or noninfectious ocular disorders, such as microvascular disease, retinitis, acute retinal necrosis syndrome, and optic nerve damage (Jacobson, 2011). The effects on the hematologic system include morphologic abnormalities in the bone marrow resulting in cytopenias, most commonly anemia (Scadden, 2011). Of great significance is the effect of HIV on the neurological system, resulting in HIV encephalopathy and AIDS dementia complex (ADC). The virus does not affect brain nerve cells but indirectly inflames or kills them. This occurs as CD4+ cell counts drop to less than 200. ADC varies from individual to individual, and symptoms may develop rapidly or slowly, affecting thinking abilities, behavior, coordination and movement, and mood. With the use of antiretroviral drugs, however, a less severe dysfunction known as minor cognitive motor disorder (MCMD) has become more common than ADC (Singh, 2013). HIV-‐RELATED CONDITIONS AMONG SPECIAL POPULATIONS HIV/AIDS imposes an additional burden on African Americans. The risk of end-stage renal disease (ERD) in HIV-infected black patients was 4–5 times greater than the risk of ERD in HIV-infected white patients. Studies reveal a gene variant that increases the risk of kidney disease in African Americans (NIH, 2011). Children infected with HIV/AIDS may have different reactions to the virus, its progression, and their virologic and immunologic response. Without drug treatment, children may be developmentally delayed, experience failure to thrive, and be vulnerable to Pneumocystis jirovecii pneumonia and recurrent bacterial infections. Antiretroviral treatments available for adults with HIV/AIDS may not be available in pediatric formulations and may cause different ! © 2015 WILD IRIS MEDICAL EDUCATION, INC.
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side effects in children. (Pediatric HIV/AIDS is a specialty that is beyond the scope of this course.)
MANAGEMENT AND CARE Optimal care of people with HIV/AIDS includes antiviral therapies, health maintenance, and referral to support services in addition to an emphasis on prevention of transmission to uninfected partners.
HIV/AIDS Self-Management The Institute for Healthcare Improvement (2013) notes that it is extremely important that patients with HIV/AIDS play a major role in managing their condition. Each patient has unique desired outcomes and needs that require appropriate interventions. Each patient should be given basic information about HIV/AIDS and its treatment; assistance with self-management skill building; and ongoing support from the healthcare team, family, friends, and community. The Institute recommends that self-management include: •
Collaborative goal setting
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Monitoring of symptoms
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Lifestyle modifications to improve overall health and well-being
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Adherence to the medication regimen
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Good communication with the healthcare team, family members, and others
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Involvement in ongoing problem-solving to overcome potential barriers
The healthcare team is advised to assist the patient’s self-management efforts by supporting and emphasizing the patient’s role in self-management, making recommendations, using effective interventions, and assisting with care-planning and problem-solving to aid in reducing barriers to self-management activities.
Case Management HIV/AIDS has proved to be a moving target, spreading beyond gay white men in cities to women, children, and seniors in small towns and rural areas. As people with HIV live longer, needs for healthcare services are changing. Depending on their personal support system and other resources, some people may require the assistance of a case manager to link them with various care services. Case managers are often the primary contact people for services, including medical care, insurance programs, volunteer groups, home care, hospice, and other types of care that may be needed during the course of a person’s or family’s living with HIV/AIDS. Local community! © 2015 WILD IRIS MEDICAL EDUCATION, INC.
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based organizations may also provide additional support to adults, children, and families who are dealing with HIV/AIDS. Evolving Treatment Guidelines Treatment guidelines are revised frequently based on ongoing research findings. The most up-to-date information can be found online at aidsinfo.nih.gov/guidelines.
ANTIRETROVIRAL THERAPY (ART) Antiretroviral therapy has become the gold standard for treatment of HIV/AIDS, with antiretroviral drugs administered in “cocktails” of three or more. (ART is also sometimes referred to as highly active antiretroviral therapy, or HAART.) People with HIV may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia. ART has dramatically reduced HIV-associated morbidity and mortality and has transformed HIV disease into a chronic, manageable condition. In addition, effective treatment of HIV-infected individuals with ART is highly effective at preventing transmission to sexual partners. However, less than one third of HIV-infected individuals in the United States have suppressed viral loads, which is mostly a result of undiagnosed HIV infection and failure to link or retain diagnosed patients in care. Despite remarkable improvements in HIV treatment and prevention, economic and social barriers that result in continued morbidity, mortality, and new HIV infections persist (USDHHS, 2015). Antiretroviral treatment of people with HIV continues to prove complex, controversial, dynamic, and expensive. These drugs do not constitute a “cure” for HIV/AIDS. If therapy is discontinued, viral load will increase. Even during treatment, the virus is replicating and the person remains infectious to others. HIV/AIDS DRUGS Seven major classes of drugs are used to treat HIV/AIDS: • • • • • • •
Nucleoside reverse transcriptase inhibitors (NRTIs) Nonnucleoside reverse transcriptase inhibitors (NNRTIs) Protease inhibitors (PIs) Fusion inhibitors HIV integrase strand transfer inhibitors (INSTIs) Entry inhibitors, CCR5 co-receptor antagonists Multi-class combination products
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Source: U.S. FDA, 2013.
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Initiating ART In 1996, tests to measure an individual’s viral load became available, providing objective criteria for treatment decisions. Following are treatment recommendations by the Panel on Antiretroviral Guidelines for Adults and Adolescents (USDHHS, 2015): •
ART is recommended for all HIV-infected individuals to decrease the risk of disease progression.
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ART also is recommended for HIV-infected individuals for the prevention of HIV transmission.
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Patients initiating ART should be willing and able to commit to treatment and understand the benefits and risks of therapy and the importance of adherence. Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy based on clinical and/or psychosocial factors.
ART Treatment Goals Once ART therapy has begun, the Panel recommends these goals of therapy: •
Maximal and durable suppression of plasma HIV viral load
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Reduction of HIV-related morbidity and prolonging survival
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Improvement in quality of life
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Restoration and/or preservation of immunologic function
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Prevention of HIV transmission
ART for Pregnant Women Recommendations for combination antiretroviral therapy (cART) during pregnancy include: •
All pregnant HIV-infected women should receive cART to prevent perinatal transmission.
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Combined antepartum, intrapartum, and infant antiretroviral (ARV) prophylaxis is recommended because ARV drugs reduce perinatal transmission.
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The known benefits and potential risks of ARV use during pregnancy should be discussed.
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ARV drug-resistance studies should be performed as indicated in the guidelines.
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Coordination of services among prenatal, primary, HIV specialty care providers, and others is essential to ensure ARV treatment adherence. (USDHHS, 2014)
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Treatment Efficacy The efficacy of ART can be measured by plasma HIV RNA testing. Optimal viral suppression is defined as a viral load consistently below the level of detection (500 cell/mm3. In coinfected patients with lower CD4 counts (
