HIV Treatment and the

nurses rolePatrick ByrneAnele Waters

What should you know?Generic HIV nursing competencies

•For all nurses looking after HIV patients irrespective of where they are clinically based

Specialist HIV nursing competencies

•Experience HIV nurses working in a specialist HIV role such as a team leader or specialist nurse.

Reference National HIV Nurses’ Association (NHIVNA), HIV nurse competencies

What should you know?Generic HIV nursing competencies

• HIV transmission• identify the major presenting signs and symptoms • risks of illness associated with relevant CD4 counts• awareness of the impact of stigma• the impact of health beliefs, including adherence to

medication

NHIVNA competencies

What should you know?Generic HIV nursing competencies

• ART (how it works, drug classes, administration, times, dietary restrictions and key side-effects both short and long term)

• Routine bloods and investigations for stable patients • Common co-morbidities

NHIVNA competencies

What should you know?Generic HIV nursing competencies

• Confidentiality issues• Disclosure of HIV status and issues (emotional

difficulties, sexual partners, post-exposure prophylaxis and the potential criminalisation of HIV transmission)

• Recognises own limitations and seeks advice

NHIVNA competencies

What should you know?Specialist HIV nursing competencies

• All of previous but in more depth• Aetiology, manifestation, management and

treatment of main symptoms of HIV• Co-morbidities interpretation of investigations• Advises patients on ART, side effect, symptom

control, adherence support and treatments

NHIVNA competencies

What should you know?Specialist HIV nursing competencies

• Support patients in HIV education and impact on the patient

• Supports patients with a new diagnosis in treatment, psychological and social support

• End of life issues with patient and loved ones

NHIVNA competencies

Antiretroviral treatment

HIV therapy

• Highly Active AntiRetroviral Therapy (HAART)• Antiretrovirals (ARV’s) • Antiretroviral Therapy (ART)• Combination AntiRetorviral Therapy (cART)• Anti HIV drugs

What is HIV therapy?

• Antiretroviral medication usually with at least 3 drugs

• May be combination tablets• Many classes of drugs

Goals of HIV therapy

• The primary goal is to prevent HIV-related morbidity and mortality.

• Suppress HIV viral load to undetectable• Restore and/or preserve immunologic

function• Prevent HIV transmission• Tx is lifelong

Time line of ARV’s1985 1986 87 88 89 1990 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05 06 07 08 09 2010 11 12 13 14

Zidovudine (AZT)Didanosine (DDI)

Zalticabine (DDC)Stavudine (D4T)

Lamividine (3TC)Saquinavir (SQV)

Ritonavir (RTV)Indinavir (IDV)Neviripine (NVP)

Nelfinavir (NFV)Delavirdine (USA)

Efavirenz (EFV)Abacavir (ABC)

AmpranavirLovanavir/r (LPV/r)

Tenofovir (TDF)Enfuviritide (T-20)Atazanavir (ATV)Emtricitabine (FTC)Fosampranavir (FPR)

Tipranavir (TPV)Darunavir (DRV)

Maraviroc (MAR)Raltegravir (RAL)

Etravirine (TMC125)Rilpivirine (RIL)

Dolutegravir (DOL)

When to start ARTChronic infection• Start ART if the CD4 cell count is <350 cells/mL• AIDs diagnosis• HIV related co-morbidity• Non-AIDS-defining malignancies requiring

immunosuppressive radiotherapy or chemotherapy

When to start ARTCo-infection• HBV if the CD4 cell count is <500 cells/mL

• HCV if the CD4 cell count is <500 cells/mL

• HBV if the CD4 cell count is >500 cells/mL and treatment of hepatitis B is indicated

When to start ART

• Patients presenting with AIDS or a major infection

• Treatment of primary HIV infection

• Treatment to reduce transmission

Blood tests before starting• CD4• Viral load• Tropism test• Resistance assay• HLA B*5701• Liver function tests• FBC

ARV Classes• Reverse Transcriptase (RT) Inhibitors

– NRTI, NNRTI

• Protease Inhibitors (PIs)

• Fusion/Entry Inhibitors

• Integrase Inhibitors

Problems with ART

• We cannot eradicate the virus• There are reservoir sites for HIV • ART cannot penetrate into come areas

PREFERRED

ALTERNATIVE

NRTI backbone Tenofovir andEmtricitabine (Truvada)

Abacavir and lamivudine (Kivexa)

Third Agent

Atazanavir/ritonavirDarunavir/ritonavirEfavirenzRaltegravirElvitegravir/cobicistat

RilpivirineLopinavir/ritonavirFosamprenavir/ritonavirNevirapine

Abacavir is contraindicated if HLA B*5701 positiveNevirapine is contra-indicated CD4 >250/400 cells/μL in women/menAbacavir or Rilpivirine use only for viral load <100,000 copies/ml

What ART to start

Adherence

• Must take 95% of the doses • Adherence is the second strongest

predictor of progression to AIDS/death, after CD4

• Reduces HIV transmission• Prevents transmission of drug resistant

strains of HIV

Adherence vs Compliance

Adherence: the act or quality of sticking to something, steady devotion; act of adhering

– Acceptance of an active role in one’s own health care

Compliance: The act of conforming, or yielding

– Lack of sharing in the decision made between provider and client

Consequences of poor adherence

• Incomplete viral suppression• Continued destruction of immune system• Disease progression• Emergence of resistant strains• Limited future options

Adherence associated Factors

• Lack of understanding• Younger age• Psychosocial issues • Nondisclosure of HIV serostatus • Substance abuse• Stigma

Adherence associated Factors• Personal commitment• Lifestyle and work

• Difficulty with taking medication • Complex regimens and adverse drug effects• Cost issues• Support from partner, family, friends

Nursing Role in ongoing adherence• Acknowledge you understand it’s difficult• Confirm understanding of their regimen• Assess adherence• Find out reasons for missed doses• Ask about side effects• Offer suggestions to overcome obstacles

Multidisciplinary approachSame message

from all

Adherence message for the patient

Doctors

Pharmacist Counsellor

Nurses

ART resistance

• Resistance occurs with poor adherence• Mutations cause virus to multiply while on

ART• Resistant drugs lead to viral load failure• Resistance testing

ART resistance

Side effectsCommon short acting

• GI gastrointestinal : nausea, vomiting, diarrhoea, abd pain

• CNS Central nervous system: headache, dizziness, fatigue, insomnia, vivid dreams, depression, anxiety

• Skin: Jaundice, rash

Side effects

Efavirenz: CNS effects,sleep disturbance, abnormal dreams, rashAtazanavir: Jaundice, increased bilirubinAbacavir: Hypersensitivity reactionNevirapine: Stevens Johnson syndrome, liver toxicityKaletra: Diarrhoea

Managing side effectsDiarrhoea• Anti-diarrhoea medications (loperamide)• Avoid spicy foods• White rice, white pasta, pulses, bananas• Continue to eat and drink• If severe contact Dr; >5xday, >5days, weight

loss, blood/fever/mucous

Managing side effectsNausea/Vomiting• Anti nausea drugs• Small frequent meals, bland foods• Dry or salty foods, crackers, dry toast• Herbal tea or root ginger• Sips fluids• Refer to Dr: dehydrated/unable to drink,

fever, abd pain

Managing side effectsHeadache• Paracetomal• Avoid caffeine• Rest, quiet, dark• Refer to Dr: frequent and severe, blurred

vision, altered consciousness

Managing side effects

CNS effects• Inform Dr especially if depression etc• Take medication at night• Avoid alcohol or drugs• Seek counselling• If does not lessen or not tolerated may

switch

Managing side effectsRash• Use mild soaps, Tepid baths• Keep hydrated• Inform Dr• Check for additional effects• Are they on ABC EFV or NVP• May treat through with antihistamines

Managing side effectsFatigue• Get enough sleep• Good balanced diet• Avoid alcohol tobacco or drugs• Regular exercise• Inform Dr

Long term side effects• Kidney problems• Metabolic changes• Heart disease• Liver problems• Lipodystrophy• Peripheral neuropathy• Bone

Summary

• ART prolongs life• Adherence is important• Side effects can be managed• Nurses can be an important support for

those taking ART

Case Studies

Lydia

• 30 year old, sex worker• Recent partner died of AIDs related illness• Has 5 year old child• They live with Lydia’s mother• Lydia provides only source of income

Lydia

• Usually uses condoms with clients• 2 years as sex worker• No sexual health checks in last 5 years• Tests positive for HIV• Feels devastated

Lydia

• Has several concerns • Sex work?• Daughter?• Mother?• Will she live?

Lydia

• Has blood tests and sees consultant• CD4 370 • Viral load 120,000• What next?

Lydia

• What reasons should she start ART?• What combination should she start and

why?• What should be considered when starting

ART?

Lydia

She starts ART because• She is very close to the recommended

starting CD4• She has a high viral load so taking ART will

reduce her risk of transmitting HIV• Starts Truvada and Efavirenz (cannot take

Kivexa due to VL >100,000)

Maria• 45 years old with 4 children• Works as a ward nurse in local hospital• Husband is international truck driver• Not been feeling well for the last year,

always tired• Has had some minor skin and mouth

infections• Recent antibiotics for chest infection

Maria• Last 6 weeks short of breath going upstairs• Exhausted• Cough was dry at first now productive• Night sweats that doctor thought were early

menopause• Collapsed at work admitted as an emergency

Maria

• Investigated for respiratory symptoms• HIV test done was done and positive• Presumptive PCP (pneumocystis pneumonia)• Started on Antiretroviral therapy

Maria

• Terrified the medical team will tell husband• Afraid husband will see the pills and know• Eldest daughter looking after family as

husband is away• Daughter only knows Maria has pneumonia

Maria

• What issues are there in her starting ART?

• What issues are there for her regarding her husband and daughter?