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MENU Risk Factors for Transmission Occupational Risk for Nurses HIV Pathophysiology Clinical Manifestations Etiology Treatment Nursing Care Case Study

The Basics: HIV/AIDS 101 HIV is a virus that attacks the immune system. HIV stands for Human Immunodeficiency Virus. It is a retrovirus which means it carries genetic information in the form of RNA rather than DNA. It is also a lentivirus - translated as slow virus because it has a long incubation period. AIDS is a state of weakened immune system due to HIV infection AIDS stands for Acquired Immuno-deficiency Syndrome. AIDS is the late stage of HIV infection, characterized by a severely weakened immune system that can no longer fight off opportunistic infections (OIs). If not treated, HIV infection will lead to AIDS. There is no cure for HIV (at this time), but there are very effective treatments. A cure for HIV wold have to remove or inactivate 100% of the HIV in the body. Currently, there are no drugs that can cure HIV. However, drugs called antiretrovirals (ARVs) can slow the rate of HIV infection. The gold standard for HIV drugs are called Highly Active Antiretroviral Therapy, more commonly known as HAART. A Piece of HIV History HIV was first identified in North America in the 1980's. The first antiretroviral drug, AZT, was approved just a few years later in 1987. Dr. David Ho, a Taiwanese-American AIDS researcher, found that using three or more different ARVs together has the highest efficacy1. These drug cocktails are now known as HAART. With treatment, HIV is a chronic illness. If treatment is available to individuals, HIV can be a chronic but progressive illness. This means that people receiving treatment can live with HIV for a long time, but the disease will eventually become more severe over time. Nurses play a vital role in caring for and educating people living with HIV at each stage of the illness. Back to Main page. Next Page: Risk Factors for Transmission

Risk Factors

Risk Factors for Transmission

People most affected by HIV

Canada has identified 8 vulnerable populations most affected by the effects of HIV². These include:

1. Gay men
2. People who inject drugs
3. Aboriginal people
4. Prison inmates
5. Youth at risk
6. Women
7. People from countries where HIV is endemic
8. People currently living with HIV/AIDS

Stigma is one of the biggest barriers to fighting HIV effectively.
Individuals from these populations may not only have a higher risk of contracting HIV, but may also experience more stigma and discrimination. Nurses need to be aware of these vulnerable populations in order to provide proper care and treatment and to avoid stigmatization and discrimination. As front-line workers, it is imperative that nurses contribute to an environment where people living with HIV/AIDS feel safe to seek help rather than feel fear of rejection.

HIV is a virus that can affect anyone.
Even though certain vulnerable populations are more susceptible to HIV, it is important to remember that HIV is a virus that can affect anyone, regardless of age, sexual orientation, ethnicity, or socio-economic background.

Question: You are a nurse working in a primary care setting. During a health history interview, a patient discloses that he uses intravenous drugs. How should you respond?

1. Recognize that IV drug users are at higher risk for contracting HIV.
   Continue the health history after you have donned gloves, goggles, and a gown to protect yourself.


2. Recognize that IV drug users are at higher risk for contracting HIV.
   Obtain an order from the physician to test for HIV.


3. Recognize that IV drug users are at higher risk for contracting HIV.
   Educate the patient on HIV transmission through sharing IV needles and ask the patient if he would like to be tested.

How is HIV transmitted?

HIV is primarily transmitted through unprotected sexual intercourse (almost 90%)³

Other modes of transmission include:

• mother to child transmission;
• blood products contaminated with HIV; and
• needles contaminated with HIV.

Fact: Canada tests 100% of blood products for HIV⁴. (Did you know less than 3.7% of people in Canada donate blood? Click here to donate!

These 2 conditions need to be present for HIV infection to occur:

1. Exposure to bodily fluids with high levels of HIV.
2. A way for HIV to enter the bloodstream.

Condition 1. Exposure to bodily fluids with high levels of HIV.

HIV is found in blood and bodily fluids.

The following fluids contain high levels of HIV:

• blood
• semen and vaginal fluids
• breast milk
• cerebrospinal fluid
• amniotic fluid

These bodily fluids do not contain enough HIV to infect, unless: 1) They are visibly contaminated by blood; and 2) There is significant and direct contact⁵.

• urine and feces
• sweat, tears, nasal secretions
• saliva, sputum
• emesis

Question: What PPEs would you want to wear in each of the following nursing care activities for an HIV positive patient who is on treatment?

1. Giving a bed bath	Gloves	Gown	Mask	Others:
2. Changing adult pads soiled with urine and feces	Gloves	Gown	Mask	Others:
3. Changing linens soiled with blood	Gloves	Gown	Mask	Others:
4. Giving an injection	Gloves	Gown	Mask	Others:
5. Withdrawing blood	Gloves	Gown	Mask	Others:
6. Changing a wound dressing	Gloves	Gown	Mask	Others:

See the answer.

Condition 2. A way for HIV to enter the blood stream.

Being exposed to bodily fluids with high levels of HIV (for example, blood splashes on clothing) will not result in infection unless HIV can enter the blood stream. HIV can enter the blood stream through breaks in the skin or through mucous membranes. Mucous membranes that are thin are more susceptible to HIV because it is easier for HIV to cross the membrane and because thin membranes are more likely to tear.

Mucous Membranes

The membrane lining of the anus and cervix are composed of simple columnar epithelium that are one cell layer thick thus make it easy for HIV to cross the membrane. In addition, the mucous membrane of the anus is more susceptible to tearing because it does not produce lubrication to reduce friction during sexual intercourse - making unprotected anal sexual intercourse the riskiest type of sexual behavior.⁶

The foreskin of the penis (the inner layer) is also a mucous membrane that is more susceptible to HIV infection. Although this area is composed of stratified epithelium with many cell layers, it has many immune cells, called dendritic cells, that HIV binds to in order to enter the body. In fact, circumcision has been found to reduce the chance of acquiring HIV by almost 50%.⁷

The mouth is also a mucous membrane where HIV can enter the body, although sexual intercourse still carries the highest risk for HIV infection. Factors that can increase the risk of contracting HIV through the oral mucosa include:

• poor oral health, such as gum disease or cuts/sores in the mouth;
• brushing or flossing, which can cause minor cuts, abrasions, and inflammation; and
• smoking, which can damage the mucous membrane in the mouth.

You cannot get HIV from:

Coughing or sneezing Insect bites Touching or hugging Kissing Public baths/swimming pools Handshakes Sharing utensils

Inflammation increases risk of HIV transmission.

In a person who is HIV positive: Inflammation can increase the viral load in certain bodily fluids because inflammation activates the immune system, which causes infected CD4+ cells to produce more copies of HIV, thus increasing the viral load.

In a person who is HIV negative: Inflammation and the resulting accumulation of CD4+ cells (helper T cells) in the area will make it easier for HIV to come into contact with non-infected CD4+ cells.

Question: You are caring for a young adult who has been diagnosed with gonorrhea - a bacterial infection that is transmitted sexually and causes inflammation of the penis and vagina. Through the health history, you learn that this patient has engaged in unprotected sex with multiple partners. What patient teaching would you provide in regards to the link between sexually transmitted diseases (STDs) and HIV?

1. The risk of infection for HIV is lower for someone with an STD because STDs cause your body to produce an immune response that can also fight off HIV.
2. The risk of infection for HIV is higher for someone with an STD because the partner who was the source of infection probably also has HIV.
3. The risk of infection for HIV is higher for someone with an STD because STDs can often cause inflammation - giving HIV easier access to the CD4 cells that respond to the site of inflammation.

Next Page: Occupational Risk for Nurses

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Sorry, wrong answer. Try again. :)

That's correct! Good job.

As a nurse, you recognize that IV drug users are at a higher risk for contracting HIV. Combined with a thorough health history including engagement in risky behaviors will inform you as to whether or not to refer the patient for HIV testing. Avoid stigmatization by assuming that everyone from a high risk population needs to be tested for HIV.

PPEs are usually not necessary during a health history interview. Over-protection may contribute to stigmatization of people living with HIV/AIDS by health care professionals. Consent is also necessary in order to refer a patient for HIV testing.

Go back to the question

Sorry, wrong answer.Try again. :)

That's correct! Good job.

STDs can cause inflammation, resulting in activation of CD4 cells - HIV's favorite target. An individual with inflammation from STDs who engages in unprotected sex has a higher risk of contracting HIV.
Wrong answers: The immune response to inflammation will not prevent HIV infection and it is incorrect to assume that someone with a sexually transmitted disease also has HIV.

Go back to the question.

Next Page: Occupational Risk for Nurses
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Answer. There is no right or wrong answer. As a health care professional, you can use any type of PPEs you feel is necessary to protect yourself. However, you should be knowledgeable about the risks involved with the nursing care activities you undertake and keep in mind that when working with people who have experienced stigma and discrimination, over-protecting yourself may contribute to their negative experiences.

How do you balance protecting yourself with not contributing to stigmatization of people living with HIV/AIDS by over-protecting yourself and making patients feel like they cannot be touched? Comment on our wiki using Moodle

Go back to the question.

Occupational Risk

Occupational Risk for Nurses

The occupational risk of infection is low.

In Canada, there has been only one definite case of occupational transmission, and two probable cases.⁸

• 99.7% of exposure of HIV-infected blood to tissue under the skin would not result in infection. The average risk after an exposure of HIV-infected blood to tissue under the skin (eg. through a needle stick or cut) has been estimated to be approximately 0.3%.
• 99.9% of exposure of HIV-infected blood to mucous membranes would not result in infection. The average risk after an exposure of HIV-infected blood to mucous membranes (eg through a splash to the mouth, nose, or eyes) has been estimated to be approximately 0.1%.⁹,¹⁰

But you still need to protect yourself as a nurse.

The best way for nurses to protect themselves from occupational exposure to HIV infection is to:

1. Learn about HIV and understand the risks.
2. Practice universal precautions and use appropriate personal protection equipments (PPEs) when there is a risk of being exposed to bodily fluids such as blood.
3. Wash hands with soap and water during the 4 moments of hand hygiene.

   1. Before contact with patient or patient's environment.

   2. After contact with patient or patient's environment.

   3. Before a sterile procedure.

   4. After exposure to bodily fluids.

4. Practice safe disposal of sharps, including needles.
5. Practice safe disposal of bodily fluids.
6. Use appropriate disinfectants to clean up spills of blood and other bodily fluids.
7. Practice safe handling of contaminated linens.

Fact: HIV cannot survive for long outside of the body. Research has shown that even high concentrations of HIV (much higher than the amount found in blood and bodily fluids) are reduced by 90 to 99% within a few hours after exposure to air.¹¹

Next Page: HIV Pathophysiology
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HIV Pathophysiology

HIV's primary target is the CD4+ cell (also known as the helper T cell or Th) HIV primarily infects the CD4+ cells of the immune system, but it also attacks macrophages and central nervous system cells. Early on in the infection, the virus invades and multiplies in the lymphoid tissue which act as a reservoir for infection. This is the reason swollen lymph nodes are one of the clinical manifestations of HIV. The role of the CD4+ cell is to activate B cells and cytotoxic T cells during an immune response - without CD4+ cells, there would be no immune response. Interesting Fact: CD stands for Cluster of Differentiation and is a system developed in 1982 of naming surface molecules of white blood cells (leukocytes). A + or - symbol indicates whether a cluster of cells expresses or lacks a surface molecule. For example, a CD34+, CD31- cell is one that expresses CD34 but lack CD31.

HIV uses its 2 surface receptors to enter CD4 cells.

HIV has 2 protein surface receptors:

1. gp120
2. gp41

The gp120 receptor of HIV binds to the CD4 receptor of CD4 cells. Both HIV and CD4 cells also have co-receptors that aid in the binding - HIV's co-receptor is gp41 while CD4 cells can have either the CCR5 or the CXCR4 as a co-receptor.

Video animation clearly showing HIV binding to CD4 cells.

The most detailed 3D model of HIV to date.

HIV uses 3 enzymes to help it attack CD4 cells.

Recall that HIV is a retrovirus that carries RNA instead of DNA. Inside its cell membrane, it carries 2 strands of RNA and 3 viral enzymes.

HIV's 3 Viral Enzymes

1. Reverse transcriptase
Used to convert the single-stranded RNA into double-stranded DNA.
2. Integrase
Used to insert the viral double-stranded DNA into the genetic material (also double-stranded DNA) of the infected CD4 cell. Once HIV is integrated into the host DNA, it uses the cell's machinery to create viral proteins.
3. Protease
Used to cleave viral proteins into smaller strands so that it can be packaged into virions that includes the 2 single-stranded RNA and the 3 enzymes. These virions then bud from the host cell to infect other cells.

Test Yourself

Question: What 3 enzymes does HIV carry? Match the enzymes with its function.

Enzyme 1:

Enzyme 2:

Enzyme 3:

1. converts viral single stranded RNA into double-stranded DNA
2. combines HIV's genetic material into the host's genetic material
3. cleaves HIV proteins into smaller proteins for packaging into virions

See the answer.

HIV's 3 enzymes:

1. Reverse Transcriptase: A) converts viral single stranded RNA into double-stranded DNA
2. Integrase: B) combines HIV's genetic material into the host's genetic material
3. Protease: C) cleaves HIV proteins into smaller proteins for packaging into virions

Back to question.


Page reference¹²
Next Page: Clinical Manifestations
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Clinical Manifestations HIV infections generally progress through 4 stages. Acute HIV infection Asymptomatic stage Symptomatic stage Progression from HIV to AIDS

	HIV Stage 1: Acute HIV Infection Pathophysiology: Once HIV enters the body, it infects CD4+ cells and uses the cell to starts replicating itself. The viral load (the amount of HIV in the blood) spikes to a high level. CD4+ cells may decrease because it is being killed by HIV Antibodies to HIV have not yet developed. Tests for HIV antibodies at this stage will be negative even if the patient is infected Patients must wait for antibodies to develop (a process known as seroconversion) before HIV antibody tests will be accurate. This is known as the window period. Most people develop HIV antibodies within 6-12 weeks of infection. Research has shown that 95% of people who are infected with HIV develop antibodies within 34 days of the date of infection.13 Very rarely, it can take up to 6 months. The clinical manifestations of this stage resemble flu-like symptoms. Due to the non-specific nature of the signs and symptoms during this stage of HIV, diagnosis is often missed. Nurses play a role in helping to identify individuals at risk of contracting HIV and initiating HIV testing. Initial HIV infection resembles the flu: Fever/fatigue; Sore throat; Swollen lymph nodes; Headaches; Rash; Cough/congestion; Question: A patient is presenting with signs of the flu. During the history, the patient discloses engaging in recent unprotected sex with multiple partners. As his nurse, you recognize the increased risk of HIV from the engagement in risky behaviors and flu-like symptoms. An HIV antibody test is recommended and accepted by the patient. However, the results come back negative for HIV antibodies. What is your top priority for patient teaching? (Click one of the options below.) Educate the patient on the risks involved with engaging in unprotected sex. Educate the patient on the risk of HIV transmission even with a negative HIV antibody test and recommend retesting 3 months later. Inform the patient, s/he is HIV negative and provide education on the risks of HIV transmission and unprotected sex. [Back to top]
	HIV Stage 2: Asymptomatic stage Pathophysiology: The CD4+ cell count will remain stable as the body begins the long war against HIV. With treatment, this stage lasts an average of 10 years.15 The viral load decreases from its initial spike and remains stable. However, the patient remains infectious since HIV has integrated with the host's genetic material. Risk of transmission increases with increased viral load. HIV antibodies have developed, but have been shown not to be effective against HIV.16 Clinical symptoms This stage is generally free from major symptoms. Although research has shown that HIV is very active in the lymph nodes, rather than being dormant17. Thus, there may be swollen lymph nodes. Treatment usually begins when the CD4+ cell count is less than 200 cells/mm3 (1 mm3 = the size of a pinhead). The purpose of treatment is to help prevent further damage to the immune system by inhibiting HIV replication. Patients on treatment usually remain asymptomatic. [Back to top]
	HIV Stage 3: Symptomatic stage Pathophysiology: Over time, damage occurs to the immune system and causes the body to have difficulty fighting opportunistic infections that it would have been able to fight previously. CD4+ cell count decreases. The drop in CD4+ cell count is associated with a rise in viral load. HIV infection becomes symptomatic due to infections that can occur in almost all body systems. Clinically: Treatment at this stage will focus on targeting HIV as well as the specific infections and illnesses. It is important to monitor drug interactions at this stage to minimize drug interactions. Co-trimoxazole has been used as a prophylaxis to prevent several HIV-related opportunistic infections (including TB, bacterial pneumonia, malaria, septicemia). Research has shown it to be effective in reducing deaths among individuals with HIV who are beginning treatment.14 [Back to top]
	HIV Stage 4: Progression of HIV to AIDS Pathophysiology: As the immune system becomes more and more damaged, the individual may develop increasingly severe opportunistic infections and cancers, leading eventually to an AIDS diagnosis. In adults and children older than 5, the preogression to AIDS is diagnosed when the CD4 count is less than 200 cells/mm3 and the individual becomes highly susceptible to life-threatening infections (bacterial, viral, fungal) as well as cancers (especially Kaposi sarcoma and non-Hodgkin lymphoma). Some common life threatening conditions associated with AIDS: PCP A lung infection that causes pneumonia. Toxoplasmosis An infection that affects the brain, causing headaches and vomiting. CMV A viral infection of the eye that can cause blindness. MAC An infection of the GI system. Other common opportunistic infections Tuberculosis An infection of the lungs that progresses rapidly in individuals with HIV Kaposi sarcoma A cancer that causes blue lesions on the skin. Back to top Next Page: Etiology Back to main page Good job! #2 is correct. HIV antibody tests may be negative because the body has not yet undergone seroconversion (antibody development), although the virus is present in the body if infection has already occured. The risk of transmission is the highest at this time because of the spike in the viral load (amount of virus in the blood). Back to question. Sorry, wrong answer. Try again. :) Next Page: Etiology Back to Main Page

Etiology

Etiology (Origin of HIV)

There is evidence that HIV originated from Africa After HIV was first identified by the Centre for Disease Control in the United States, evidence emerged that indicated the HIV virus originated from monkeys in sub-Saharan Africa. HIV arises from the simian immunodeficiency virus (SIV), which shares significant genetic similarities to HIV and has only been found on the African continent1. There are 2 different strains of HIV: HIV-1 and HIV-2. The different strains of HIV differ in their genetic makeup. HIV-1 is more common and more lethal - it accounts for about 95% of infections world-wide19. HIV-2 is rare is mainly found in West Africa - it also has a slower progession than HIV-119. The most common form of HIV world-wide is HIV1-M. The most common form of HIV in North America is HIV1-B.

Different strains of HIV can mix to create new hybrids.

Co-infection with two or more different strains of HIV in an individual can occur which increases the likelihood of creating hybrids called circulating recombinant forms (CRFs).

Question 2: If two individuals are both HIV positive, do they need to use protection?

1. No, since they are both HIV positive, they cannot be infected again.
2. Yes, if they have different strains of HIV, co-infection may result in CRFs and can change the efficacy of HAART.
3. Yes, contact with infected bodily fluids will increase the viral load of a person already infected with HIV.
4. Both B and C.

HIV is a retrovirus, containing RNA, as opposed to carrying genetic information in the form of DNA. It primarily infects the CD4+ Th cells, but also attacks macrophages and central nervous system cells. Early on in the infection, the virus invades and multiplies in the lymphoid tissue which acts as a reservoir for infection. HIV uses various viral enzymes to help it attack the Th cells. Reverse transcriptase is used to convert RNA to new double-stranded DNA. Integrase is used to insert this DNA into the genetic material of the infected Th cell. Protease is used to facilitate the production of new virions. The course of HIV/AIDS is summarized in the following figure:

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Treatment

Treatment Education

Nurses play a role in providing education about treatment.

HIV/AIDS treatment begins with the provision of knowledge and information that can be used by patients as resource tools for make informed decisions regarding their treatment. Educating patients is the primary step in establishing a successful treatment plan.

Treatment advocacy programmes have been established a tool to help newly diagnosed aids patients deal with the realities of HIV. Advocacy programmes not only provide clients with medical resources, they also provide them with unique perspectives on HIV that stem from outside of the medical field. Treatment advocacy programmes also serve as support systems for patients who may not always feel comfortable discussing their concerns with health care providers. In doing so, treatment advocacy programmes provide patients with the ability to have a positive health experience²⁰.

List of information and services provide through treatment advocacy programmes²⁰

• Pathogenesis of HIV
• Treatment options
• Information regarding Co- infection
• Medication sides effects
• Reproductive Cycle
• Consequences of non adherence
• Lab results
• Nutrition
• Client center health and treatment counselling
• Referrals to treatment facilities and Services Advocacy to healthcare providers and community
• Educational Forums

In providing patients with this knowledge and information, treatment advocacy programmes provide patients with the opportunity to collaborate with health care providers in developing Individual Service Plans (IPS) that carter to the patients' specific needs²⁰.

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Antiretroviral (ARV) Drugs²¹

The first antiretroviral drugs (ARVs) were developed in 1987, just a few years after HIV was recognized in the United States. Interesting fact: The first ARV to be discovered was called AZT (zidovudine), which is a nucleoside reverse transcriptase inhibitor (NRTI).

Since then there has been an increasing development of antiretroviral drugs against the HIV virus. Today there are over 2 dozen FDA approved drugs available to treat HIV. These drugs are categorized into 6 classes each designated to target a specific aspect of the virus life cycle. Drug classes include:

1. Nucleoside reverse transcriptase inhibitors

Nucleoside reverse transcriptase inhibitors (NRTI) function by inhibiting the enzymatic function of reverse transcriptase by binding to the polymerase active site of the reverse transcriptase enzyme of the HIV virus. In doing so, NRTI prevent the transcription of the virus's single stranded RNA into a double stranded DNA genome. The inability to produce new DNA strands interrupts thse production of new virons.

2. Non nucleoside reverse transcriptase

Non nucleoside reverse transcriptase inhibitors (NNRTI) operate by decreasing nucleoside incorporation rate by inducing structural modification of reverse transcriptase. NNRTI achieve this by binding to the hydrophobic pocket adjacent to the polymerase active site of reverse transcriptase as allosteric non competitive inhibitors.

3. Protease inhibitsors

Protease inhibitors (PI) function by inhibiting an enzyme known as Protease. Protease is responsible for cleaving large proteins into smaller structural proteins and reverse transcriptase, element required for the construction of a mature virus.

4. Integrase Inhibitors

Integrase inhibitors function by inhibiting the integration of the HIV virus into the host cell.

5. Entry inhibitors

Entry inhibitors operate by either inhibiting or antagonizing one of three main steps in the required for the entry of the HIV virus into the host cell.
These steps involve²⁶:

1. Attachment of the viral gp120 to the CD4 T cell receptor.
2. Binding of the viral gp120 to CCR5 or CXCR4 co receptor.
3. Fusion of the viral and cellular membranes.

Entry inhibitors are further subclassified into 3 categories based on the step of the viral entry process that they inhibit.

• Fusion inhibitors - Function by targeting viral proteins instead of the host cell
• Co receptor inhibitors function by binding to and blocking CCR5 surface receptors or inhibiting the attachment and entry of the HIV virus into the host cell.
• CD4 receptor inhibitor prevent the interaction of viral gp120 and CD4 T cells
6. Maturation Inhibitors

Maturation inhibitors are a potential new drug class which seeks to stop HIV particles from maturing after they have emerged from human cells. These drugs disrupt the final step in the processing of the HIV-1 Gag protein, leading to the formation of noninfectious, immature virus particles, incapable of infecting other cells. However, there are no currently available drugs from this class

Summary of ARVs

"Nukes" Nucleoside Reverse Transcriptase Inhibitors	"Non-nukes" Non-nucleoside Reverse Transcriptase Inhibitors	Protease Inhibitors
abacavir (ABC / Ziagen) zidovudine (AZT / Retrovir) stavudine (d4T / Zerit) didanosine (ddl / Videx) emtricitabine (FTC / Truvada) tenofovir (Viread) lamivudine (3TC)	delavirdine (Rescriptor) efavirenz (Sustiva) etravirine (Intelence) nevirapine (Viramune)	atazanavir (Reyataz) darunavir (Prezista) fosamprenavir (Telzir) indinavir (Crixivan) lopinavir-ritonavir (Kaletra) nelfinavir (Viracept) ritonavir (Norvir) saquinavir (Invirase) tipranavir (Aptivus)
Integrase Inhibitors raltegravir (Isentress)	Fusion inhibitor enfuvirtide (T-20 / Fuzeon)	Co-receptor Inhibitor maraviroc (Celsentri)

Question: Match the drug(s) with its target (Click the drug names for a hint):

1. zidovudine (AZT / Retrovir) & nevirapine (Viramune) See the answer.
2. raltegravir (Isentress) See the answer.
3. nelfinavir (Viracept) See the answer.
4. enfuvirtide (T-20 / Fuzeon) & maraviroc (Celsentri) See the answer.

1. gp120 and gp41 (HIV's surface proteins)
2. HIV's enzyme, reverse transcriptase
3. HIV's enzyme, protease
4. HIV's enzyme, integrase

Things to keep in mind in regards to treatment

• NRTI/NNRTIs are available in most countries.
• Entry inhibitors and Integrase are usually only available in resource-rich countries.
• Protease needs to be taken multiple times a day with food and are more expensive.
• Protease inhibitors are generally less suitable for starting treatment in resource-limited settings due to the cost, number of pills which need to be taken, and the particular side effects caused by protease drugs.

• Different strains of HIV will respond to different combination of drugs.
• Co-infection of 2 different HIV strains may result in hybrids that don't respond to drugs that used to work.
• Nurses can help manage the various side effects.
• Access to treatment has the potential to change HIV infection from an acute and fatal illness to a chronic disease.
• Adherence to treatment is important to prevent HIV from becoming resistent to drugs.

Resistance and Cross-resistance
Remember that HIV can also develop cross-resistance - that is, if one strain of HIV in an individual becomes resistant, similar strains will also have resistance to the same drugs.

"I became resistant to almost everything [in 2003]… We were waiting for a new drug called T-20. At one point my doctor pulled me off everything because the T-20 has to be taken in combination with other drugs, and if I’d stayed on all the drugs I would have become resistant to them all and the T-20 would have been useless." -Joe

Managing Side Effects

There are several options for dealing with side effects:

• Wait for things to improve, especially if in the first weeks of treatment.
• Address other possible contributing factors, such as diet, exercise, or smoking.
• Change how the drug is taken (eg. time of day, dosage, with or without food).
• Try treating the side effects with other drugs.
• Last resort: Change one or more antiretroviral drugs.
  Because there are a limited number of different drugs available, changing drugs (which may lead to resistance) must be done sparingly.

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Complementary and Alternative Medicine

Note: Difference between alternative and complementary medicine:

• Alternative medicine: seeks to replace traditional ARVs as a replacement.
  ARVs are the most effective treatment for HIV so alternative medicine is not recommended where ARVs are widely available.
• Complementary medicine: used in addition to traditional ARVs as a complement.

In relation to HIV, alternative therapies are most commonly used in areas where it is difficult to access Western medicine. In the absence of antiretroviral treatment, people may seek other ways to delay the onset of AIDS, or to treat opportunistic infections. In sub-Saharan Africa, for example, traditional healers outnumber medically qualified doctors eighty-to-one²².

Because these treatments are so effective, there is less demand for alternative HIV medicine, except perhaps for addressing relatively minor infections, or when antiretroviral treatment cannot any longer be taken, for example because of drug resistance. Many instead look to complementary medicine as a way to prevent or relieve aids treatment side effects, some of which are not easily treatable with conventional medicine.

Interesting fact: In Gambia, the president himself has treated patients with a herbal mixture he claims is an AIDS cure. Analysis of data has not proven his "cure" to be effective, yet he continues to "treat" patients to this day.

Homeopathy should not be used to treat HIV

There are also therapies that are not considered credible by the scientific community at large. The most notorious of these is homeopathy, which the World Health Organization recommends should not be used to treat HIV²³.

St. John's wort negatively interacts with ARVs

St. John's wort is a popular herbal medicine for treating depression. It interacts with the liver and negatively interacts with anti-HIV drugs (protease inhibitors and NNRTIs). Patients taking ARVs should not take St. John's wort.

Herbal medicine: naturally occurring ARVs have been identified

Calanolide A, an isolated compound from a type of tree, has been found to act like ARVs, more specifically to be a naturally occurring non-nucleoside reverse transcriptase inhibitor (NNRTI). It has been found to be effective against some strains of HIV that had become resistant to other ARVs24,25. It is thought to work by binding to 2 sites on the reverse transcriptase enzyme of HIV.

Nursing Approach

• Evaluate potential for harm as well as drug interactions.
• Alternative medicine is not recommended since ARVs are most effective against HIV.
• Do not use a judgmental attitude towards patients who use complementary or alternative medicine.

KEY MESSAGE: Support patients in taking control of their own healthcare decision-making. Nursing role is to provide information so that patients can make informed decisions.

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gp120 and gp41 (HIV's surface proteins) Back to question.

HIV's enzyme, reverse transcriptase Back to question.

HIV's enzyme, protease Back to question.

HIV's enzyme, integrase Back to question.