Treatment and Clinical management

Antiretroviral medications are used to control the reproduction of the HIV virus and slow progression of HIV-related disease. Highly Active Antiretroviral Therapy (HAART) is the treatment protocol that is recommended for HIV infection. HAART combines 3 or more antiretroviral medications in a daily regimen. The exact medication regimen is highly individualized, depending upon many factors. Usually taking only 1 or 2 medications is not effective. Unless the individual is taking 3 or more medications, the decrease in viral load tends to be temporary. Treatment involves a number of considerations:

Antiretroviral medications Adjustments to treatment Non-occupational post-exposure prophylaxis (nPEP) Treatment during pregnancy Side effects of treatment
Antiretroviral medications
There are 4 classes of antiretroviral medication used in the treatment of HIV.
Class
Generic name
Brand name
Nonucleoside Reverse Transcriptase Inhibitors (NNRTIs) bind to and disable reverse transcriptase, a protein that HIV needs to replicate.
Delavirdine
Rescriptor, DLV
Efavirenz
Sustiva, EFV
Nevirapine
Viramune, NVP

Nuceleoside Reverse Transcriptase Inhibitors (NRTIs) are faulty versions of building blocks that HIV needs to replicate. When HIV uses an NRTI instead of a normal building block, reproduction of the virus is stalled.
Abacavir
Ziagen, ABC
Abacavir Lamivudine
Epzicom
Abacavir,Lamivudine,Zidovudine
Trizivir
Didanosine
Videx, ddI, Videx EC
Emtricitabine
Emtriva, FTC, Coviracil
Emtricitabine, Tenofovir DF
Truvada
Lamivudine
Epivir, 3TC
Lamivudine, Zidovudine
Combivir
Stavudine
Zerit, d4T
Tenofovir DF
Viread, TDF
Zalcitabine
Hivid, ddC
Zidovudine
Retrovir, AZT, ZDV
Protease Inhibitors (PIs) disable protease, a protein that HIV needs to replicate.
Amprenavir
Agenerase, APV
Atazanavir
Reyataz, ATV
Fosamprenavir
Lexiva, FPV
Indinavir
Crixivan, IDV
Lopinavir, Ritonavir
Kaletra,LPV/r
Nelfinavir
Viracept, NFV
Fusion Inhibitors function by blocking HIV entry into cells.
Enfuvirtide
Fuzeon, T-20
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One or two anti-retroviral medications are usually sufficient to decrease viral load.
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Adjustments to Treatment
People who are receiving antiretroviral medications should have a baseline viral load and CD4 count done and regular evaluations during treatments. If the viral load increases and CD4 count decreases, the treatment regimen may need to be adjusted. In that case, the physician will evaluate 3 factors to determine what adjustments need to be made:
· Adherence: Refers to how closely a person follows the medication regimen. If someone is unable to follow the regimen, treatment may need to be adjusted to give medication in fewer doses or fewer pills.
· Tolerability: Refers to side effects caused by the medications. If a particular drug is causing a very difficult side effect, a different medication may be prescribed. Medication interactions: Refers to drug reactions to other medicines a person may be taking. Since some drug reactions can have a negative effect on the efficacy of antiretroviral treatment, these reactions need to be identified, so treatment can be adjusted.

Criteria for AIDS

There are criteria to determine when an infection advances from HIV positive to AIDS.
· Infection with HIV must be present,
· CD4 count falls below 200 cells/mmm3 (cubic milliliter), or
· Development of an "AIDS-defining" condition
o Candidiasis
o Cervical cancer (invasive)
o Coccidioidomycosis, Cryptococcosis, Cryptosporidiosis
o Cytomegalovirus disease
o Encephalopathy (HIV-related)
o Herpes simplex (severe)
o Histoplasmosis
o Isosporiasis
o Kaposi's sarcoma
o Lymphoma
o Mycobacterium avium complex
o Pneumocystis carinii pneumonia
o Pneumonia (recurrent)
o Progressive multifocal leukoencephalopathy
o Salmonella septicemia (recurrent)
o Toxoplasmosis of the brain
o Tuberculosis
o Wasting syndrome


Routine HIV/AIDS testing
Testing is an essential component of HIV/AIDS diagnosis and treatment. Because people in the early stages of HIV/AIDS may be asymptomatic, they may be putting others at risk. While those with HIV/AIDS need multiple tests to accurately assess their physical condition, some tests are specific to HIV/AIDS:
HIV antibody CD4 t-cell Viral load
· HIV Antibody tests
The period between becoming infected and showing antibodies to HIV in the blood can range from 2 weeks to 6 months. During this period, a person can spread the disease even though the antibodies cannot be detected in the blood. The most common tests in recent years have been ELISA, Western Blot and IFA.
Enzyme-linked immunosorbent assay (ELISA).
· Usually the first test used to detect infection with HIV, but can cause false positive results
Western blot.
· More difficult than the ELISA to perform and interpret accurately, but less likely to give a false-positives; used to confirm ELISA results.
Indirect fluorescent antibody (IFA)
· Detects antibodies made to fight an HIV infection; used to confirm ELISA results.
New rapid HIV tests are now on the market, that are quick, easy to do, and allow for point-of-care testing. There are 4 rapid HIV tests that have been approved:
· OraQuick Advance HIV-1/2 - results in 20 minutes
· Uni-Gold Recombigen - results in 10 minutes
· Reveal G2 - results in 5 minutes
· Multispot HIV-1/HIV-2 - results in 15 minutes

Symptoms of infection

A person who is HIV positive does not automatically have AIDS. AIDS, by definition, is a syndrome with multiple specific symptoms. However, there are certain symptoms that commonly occur along with an HIV infection. Sometimes HIV infected people who do not have AIDS, but are exhibiting certain symptoms, are said to have "acute retroviral syndrome."
All health care workers, and people who are HIV positive, should be aware of the following symptoms and their significance.

Signs/ symptoms
Percentage of occurrence
Fever 96%
Lymphadenopathy 74%
Pharyngitis 70%
Rash (Erythematous maculopapular with lesions on face, trunk, and sometimes extremities, including palms and soles; mucocutaneous ulceration of mouth, esophagus, or genitals) 70%
Myalgia or arthralgia 54%
Diarrhea 32%
Headache 32%
Nausea and vomiting 27%
Hepatosplenomegaly 14%
Weight loss 13%
Thrush 12%
Neurologic symptoms
o Meningoencephalitis or aseptic meningitiso Peripheral neuropathy or radiculopathyo Facial palsyo Guillain-Barré syndromeo Brachial neuritiso Cognitive impairment or psychoses 12%

Modes of Transmission

It's important to understand some basic information about how HIV gets into the cells of the body and replicates, and then is transmitted to other people.
There are a number of steps in the infection process:
Biological mechanism for infection Transmission Symptoms of infection Criteria for AIDS

Biological mechanism for infection
Infection takes place when the human immunodeficiency virus (HIV) enters the body and goes through a number of steps:

1. Binding and fusion: The virus binds with receptors (CD4 and one additional) on the surface of T-lymphocytes and then fuses with the host cell, releasing its RNA into the host cell.

2. Reverse transcription: An HIV enzyme (reverse transcriptase) uses the single-stranded HIV RNA to assemble a double-stranded HIV DNA molecule.

3. Integration: The HIV DNA enters the host cell's DNA, where an HIV enzyme (integrase) “hides” the HIV DNA within the host cell's own DNA. This now-integrated DNA is called a provirus and may remain inactive for several years, producing few or no new copies of HIV.

4. Transcription: When the host cells receives a signal to activate, the provirus uses an enzyme in the host called "RNA polymerase" to create copies of the HIV genomic material, as well as shorter strands of RNA called "messenger RNA (mRNA)." The mRNA is used as a blueprint to make long chains of HIV proteins.

5. Assembly: An HIV enzyme, called protease, cuts the long chains of HIV proteins into smaller individual proteins. These small proteins come together with copies of HIV's RNA genetic material, to create a new viral particle.

6. Budding: The new virus pushes out, or buds, from the host cell. During budding, the new viruses take part of the cell's outer envelope, which acts as a covering, and is studded with protein/sugar combinations, called HIV glycoproteins. These HIV glycoproteins are necessary for the virus to bind CD4 and co-receptors on other host cells. The new copies of HIV can then move on and infect other cells.
This process destroys the CD4T cells, making the CD4 count go down, and thus weakens the immune system of the body, while it increases the HIV viral load of the body.

HIV/AIDS Update for Nurses

Wanda Lockwood

Introduction

In the early 1980's, a strange new disease seemed to come out of nowhere. It was initially called GRID (Gay-Related Immunodeficiency Disease) because it was thought to only affect gay men. Then, people with hemophilia started to die. The disease was eventually called Autoimmune Deficiency Syndrome or AIDS.

By 1982, the Centers for Disease Control (CDC) had linked the AIDS virus to the blood supply, and warned blood banks about the danger of blood being infected with the AIDS virus. In 1983, Luc Montagnier, at the Pasteur Institute in France, identified a virus he thought was implicated in AIDS. At that time, he couldn't prove it caused AIDS. Then, in 1984 Robert Gallo in the United States announced that he had identified the virus responsible for AIDS "human immunodeficiency virus (HIV)." Through an unusual agreement, Montagnier and Gallo share credit for identifying HIV. By 1985, dozens of Americans had been infected with HIV, which they received during blood transfusions. To protect the blood supply, the ELISA (enzyme-linked immunosorbent assay) test was universally adopted by blood banks and plasma centers in the US.

According to the CDC, at the end of 2003, an estimated 1,039,000 to 1,185,000 persons in the United States were living with HIV/AIDS, with 24-27% undiagnosed and unaware of their HIV infection. Approximately 40,000 new infections with HIV occur annually in the United States, including 300 infants who are infected by their mothers. Among all people in the United States, the annual number of new HIV infections has declined from a peak in the mid-1980s (of more than 150,000) and stabilized since the late 1990s. However, people of minority and ethnic groups are disproportionately represented and HIV/AIDS remains an ongoing challenge.