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Kee: Pharmacology, 7th Edition

Chapter 35: HIV- and AIDS-Related Drugs

Key Points: Audio and Print

Highly active antiretroviral therapy, which consists of at least three agents, has

dramatically improved the course of the human immunodeficiency virus, or HIV

epidemic. Improvement has been seen in the number of clients attaining undetectableviral loads and in overall survival. No longer does a person diagnosed with HIV

receive an early death sentence; instead, he or she is identified as having a chronic

disease. One important negative outcome of current therapy is increased drug resistance to

current therapies. The makeup of HIV DNA strands allows the virus to mutate from a

drug-sensitive form to a drug-resistant form, so clients must be treated with a

combination of medications rather than monotherapy to avert the problem of drug

resistance. The nurses role with clients taking complex regimens of antiretroviral medications

includes ongoing assessment, analysis, and education. Thorough assessment of theclients physiologic and psychosocial health needs is required initially. Follow-up

assessment after therapy begins should include drug side effects, adherence to the

prescribed regimen, and issues affecting medication adherence. Clients may confusemedication side effects with a new onset of symptoms. Careful follow-up assessment

can detect the need for additional medical care or medication management. Issues of adherence are common with antiretroviral therapy. Individual assessment of

adherence issues with an analysis of the clients lifestyle is essential. Multiplestrategies for adherence are available and should be discussed with clients.

The nurse should further educate the client regarding current recommendations forinitiation of drug therapy. Those recommendations are to initiate therapy for patientswith symptomatic established HIV disease; asymptomatic patients before the CD4

count decreases to fewer than 350; and patients with a CD4 count greater than 350

based on comorbidities, risk of disease progression, and willingness and ability toadhere to long-term treatment.

If therapy is to be initiated, appropriate agents must be selected based on

comorbidities, pregnancy status, adherence potential, food restrictions, side effects,and potential drug-drug interactions.

The current components of antiretroviral therapy are reverse transcriptase inhibitors,

protease inhibitors, entry inhibitors,CCR5 antagonists, and integrase inhibitors. The

nurse should educate the client regarding specific side effects of the drugs prescribed.Many of these agents cause gastrointestinal upset, including nausea, vomiting, and

diarrhea. Fortunately, most of the gastrointestinal disorders are transient, but they may

inhibit compliance with the drug regimen. The nurse must stress to the client theimportance of taking these drugs as prescribed. Written information regarding the

drugs may be necessary for the client. Further client education includes discussing the

importance of the following: meticulous handwashing technique, because the client isat increased risk for opportunistic infections; increased fluid intake; and follow-up

with the health care provider for serum monitoring of drug effectiveness. The nurse

Copyright 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

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Key Points: Audio and Print

should also be aware that the diagnosis of HIV is life altering and ensure that the

client has adequate support. Optimal drug therapy should be used for women of reproductive age and for those

who are pregnant. When initiating antiretroviral therapy for women of reproductive

age, the criteria for starting therapy and the goals of treatment are identical to those

for other adults and adolescents. Because of considerations related to the preventionof transmission of HIV to the child during pregnancy, the timing of initiation of

treatment and the selection of regimens may differ from nonpregnant adults or

adolescents. Some antiretroviral agents are contraindicated in pregnancy. Antiretroviral therapy is recommended in all pregnant women who test positive for

HIV infection, regardless of virologic, immunologic, or clinical parameters for the

purpose of preventing mother-to-child transmission of HIV. Combination drug

therapy is considered the standard of care for both treatment of maternal HIVinfection and prophylaxis to reduce the risk for perinatal HIV transmission.

For the HIV-infected pregnant woman who is not on antiretroviral agents and is

indicated for therapy, highly active antiretroviral therapy should be initiated, avoiding

the use of efavirenz and other potentially teratogenic agents. Zidovudine as acomponent of the regimen is recommended when possible. HIV transmission to health care workers continues to be related to exposure to

infectious materials and their sources. An increased risk of HIV transmission to health

care workers exists when the worker is exposed to a device with visible blood, a

needle placed in an artery or vein, a deep injury, large volume losses, or exposure toinfectious materials containing a high viral load. The majority of HIV exposures

warrant a two-drug regimen. The addition of a third or fourth medication should be

considered for exposures posing an increased risk for transmission or involving a

source in which antiretroviral drug resistance is likely. Management of a potentialHIV exposure must be initiated within hours of the event and continued for 4 weeks.

Copyright 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

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