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.