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Treating HIV in 2016

From death sentence to lifelong chronic condition.

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The disease process known as human immunodeficiency virus (HIV) has evolved immensely since first being identified in the early 1980s.1 For many years, HIV infection was viewed as a diagnosis sure to lead to death. The turning point came in 1997, when highly active antiretroviral therapy (HAART) became the new standard for HIV care. Although many challenges remained, a more optimistic era unfolded.2

Today, in 2016, HIV is largely viewed as a chronic illness. This progress presents a paradigm shift for nurses. Whereas nurses were once at the forefront of palliative care for end-stage AIDS patients, HIV is now a medically managed disease process in which the patients themselves, in collaboration with healthcare providers, take responsibility for staying healthy. 

In 2016, nurses need to be aware of the types of regimens patients are treated with, the potential side effects of those regimens, and the influence of comorbidities.3 Additionally, it is important that nurses have an understanding of pre-exposure prophylaxis (PrEP), which has become a major preventive tool.

Treatment
HIV medications are grouped into six drug classes according to how they fight HIV: non-nucleoside reverse transcriptase inhibitors, nucleoside reverse transcriptase inhibitors, protease inhibitors, fusion inhibitors, CCR5 antagonists, and integrase strand transfer inhibitors. These classes encompass more than 25 HIV medications approved to treat HIV infection, either as a standalone medication or in combination.

The medication regimen prescribed depends on the patient's particular needs. Drug resistance testing is vital to ensure that the prescribed regimen is effective against the patient's HIV infection.4 Whenever feasible, nurses should advocate for treatment regimens that are as convenient as possible, in order to promote adherence.

In spite of improvements due to HAART, treatment adherence can still be challenging within segments of the HIV-infected population. People living with chronic HIV infection must take long-term, day-to-day responsibility for their own care. Missing doses of medication can increase viral load and decrease CD4 counts, putting patients at greater risk for HIV-related illnesses and putting their uninfected intimate partners at greater risk for newly acquired HIV infection. Treatment regimens that combine two or more medications into one pill are more convenient and may facilitate better regimen adherence.5 Once-weekly or monthly injectable medications are in the pipeline. Until then, nurses need to consider the issues that can make it difficult for a patient to maintain regimen adherence.6,7vials of HIV+ blood

Side Effects and Comorbidities
As with most medications, HIV medications can cause a variety of side effects. While some of the potential side effects of HIV medications may be minor and short term, others may occur over the long term and predispose HIV-infected patients to other HIV treatment-related comorbidities.

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Nurses should be aware that patients on a new HIV treatment regimen may report episodes of diarrhea, syncope, and nausea and vomiting. Patients may also report headaches, fatigue, rash or neural pain, and lab results may indicate abnormalities in red blood cells. While these side effects may be uncomfortable, many resolve. More troubling are the insidious side effects that occur over the long term.

Living longer with HIV infection has given way to a host of problems that result from long-term treatment. Long-term side effects include lipodystrophy, lipid abnormalities, insulin resistance, decreased bone density and lactic acidosis. Lipodystrophy is characterized by the redistribution of subcutaneous fat. Generally, fat loss occurs in the face, buttocks, arms and legs.8 It is most commonly redistributed to the back, neck, breasts and abdomen.

Lipid abnormalities and insulin resistance also occur. Decreases in bone density can be a significant issue, especially for older adults. Lactic acidosis, resulting from an accumulation of lactate throughout the body, can cause problems ranging from muscle aches to liver failure. When assessing an HIV-infected patient, nurses need to consider how lifestyle choices may adversely affect him or her. Evidence suggests that even moderate alcohol consumption may be more harmful for patients who are infected.9

Emerging evidence suggests that patients with long-term HIV infection may be at greater risk for cancer.10 For example, the incidence of anal cancer in the general population is 2 cases per 100,000 people, and the incidence in HIV-infected men who have sex with men is approximately 80 per 100,000 people.11

Pre-Exposure Prophylaxis
No discussion on the treatment of HIV in 2016 would be complete without a brief discussion about PrEP, which reduces a person's risk of becoming infected with HIV if he or she is exposed to the virus. Prevention is delivered by taking HAART medication.12

This approach to HIV prevention is not without controversy. Some have argued that in spite of the recommendation that it be used in combination with other safer sex practices, such as consistent condom use, it could increase risky sexual behaviors, resulting in an increase in HIV infections. Others argue that it simply provides yet another option for protecting against infection.13 Clinical trials have shown significant results in terms of regimen effectiveness in reducing HIV infection. PrEP has provided couples seeking to conceive (whether concordant or serodiscordant) with options they did not have prior to the availability of PrEP.14

Every Nurse is an HIV Nurse
One thing is for sure. While in the early years of the epidemic nurses dedicated themselves solely to the care of AIDS patients, today we are all HIV nurses.3 Nurses encounter HIV-infected patients in a variety of healthcare settings-and often, not because of the HIV infection itself. That is why it is so important for nurses to understand and recognize the impact of HIV in 2016.

Nurses today are charged with knowing treatment regimens and their side effects, understanding the link among HIV, treatment regimens and the comorbidities that can occur, and recognizing and identifying strategies for preventing HIV infection across the lifespan.

References
1. Sharp PM, Hahn BH. Origins of HIV and the AIDS pandemic. Cold Spring Harb Perspect Med. 2011;1(1):a006841.

2. Pepin J. The origins of AIDS: from patient zero to ground zero. J Epidemiol Community Health. 2013;67(6):473-475.

3. Bradley-Springer L, et al. Every nurse is an HIV nurse. Am J Nurs. 2010;110(3): 32-39.

4. Types of HIV/AIDS Antiretroviral Drugs. http://www.niaid.nih.gov/topics/HIVAIDS/Understanding/Treatment/pages/arvdrugclasses.aspx

5. Brechtl JR, et al. The use of highly active antiretroviral therapy (HAART) in patients with advanced HIV infection: impact on medical, palliative care, and quality of life outcomes J Pain Symptom Manage. 2001;21(1):41-51.

6. Overview of HIV Treatments. https://www.aids.gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/treatment-options/overview-of-hiv-treatments/

7. A Monthly Shot Could Soon Replace Daily HIV Meds. http://www.hivplusmag.com/treatment/2015/11/09/monthly-shot-could-soon-replace-daily-hiv-meds

8. Deeks SG, et al. The end of AIDS: HIV infection as a chronic disease. Lancet. 2013;382(9903):1525-1533.

9. HIV Update. http://www.aidsmap.com/HIV-update-17th-February-2016/page/3036620/

10. Silverberg MJ, et al. Risk of anal cancer in HIV-infected and HIV-uninfected individuals in North America. Clin Infect Dis. 2012;54(7):1026-1034.

11. Fenkl EA, et al. HPV and anal cancer knowledge among HIV-infected and non-infected men who have sex with men. LGBT Health. 2016;3(1):43-48.

12. Pre-exposure Prophylaxis. https://www.aids.gov/hiv-aids-basics/prevention/reduce-your-risk/pre-exposure-prophylaxis/

13. Cáceres CF, et al. The promises and challenges of pre-exposure prophylaxis as part of the emerging paradigm of combination HIV prevention. J Int AIDS Society. 2015;18(4 Suppl 3):19949.

14. Reproductive Options for HIV Concordant and Serodiscordant Couples. https://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/153/reproductive-options-for-hiv-concordant-and-serodiscordant-couples

Eric A. Fenkl is an assistant professor of nursing in the Nicole Wertheim College of Nursing and Health Sciences at Florida International University in Miami.


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