Starr, Whitney Marie MS, BSN, RN, FNP; Springer, Lucy Bradley PhD, MA, MSN, BSN, RN
The story of HIV infection involves two primary players: CD4+ T lymphocytes, commonly called CD4+ cells, and HIV. CD4+ cells turn the immune system on when foreign proteins, such as viruses or bacteria, invade the body. HIV is a retrovirus that causes immune dysfunction by killing CD4+ cells. When HIV infection is untreated it leads to severe immune dysfunction, opportunistic diseases, a diagnosis of AIDS, and death.
Figure. AIDS patient...Image Tools
There are two general types of HIV: HIV-1, which is most common throughout the world, and HIV-2, which is found primarily in West Africa. In HIV-2, disease appears to progress at a slower rate, but both types of the virus can lead to immune dysfunction and a diagnosis of AIDS, and both are transmitted in the same ways: through sexual intercourse, through exposure to infected blood (most often when drug users share equipment), and from mother to child during pregnancy, delivery, or breastfeeding.
When HIV infects the human body, it attaches to and enters CD4+ cells. Once inside the cell, HIV replicates, making hundreds of new virions and killing the host cell within about 48 hours. HIV is a member of the Lentivirus genus of retroviruses, which has a long latency and a slowly progressing disease course, even when untreated. In HIV, the immune system can compensate for the loss of CD4+ cells for eight to 12 years.1 But when compensation mechanisms can no longer keep up with the massive cell depletion, and the CD4+ cell count drops below the normal range of 800 to 1,200 cells/mm3, the immune response weakens. A CD4+ cell count below 200 cells/mm3 represents severe immune dysfunction and carries a diagnosis of AIDS. If left untreated, people at this stage of the disease generally die from opportunistic diseases—those that seldom harm people with intact immune systems but which can be life threatening to those whose immune systems are compromised.
At the end of 2009, more than 1.1 million people in the United States were estimated to be living with a diagnosis of HIV infection. In 2010, an additional 47,129 people discovered they were infected with HIV.2 According to the Centers for Disease Control and Prevention (CDC), about 50,000 new cases of HIV occur in this country every year.3 Without routine HIV testing, between 20% and 60% won't be diagnosed until several years after infection when they present with an opportunistic disease, at which point the HIV may be harder to treat.4
The incidence of HIV in the United States is highest among black men and men of all races and ethnicities who have sex with men,5 but it has increased among women, most of whom (86%) are infected during heterosexual sex.2 In addition to race, ethnicity, and sexual orientation, one of the greatest demographic risk factors for HIV infection in the United States is poverty. Within U.S. poverty areas, racial and ethnic disparities in HIV infection rates disappear (see Figure 1 6).6
In response to the epidemic, the Office of National AIDS Policy published the National HIV/AIDS Strategy for the United States in 2010.7 The goals of the policy are to decrease new infections, increase access to care, and reduce health disparities related to HIV infection. While progress has been made in all of these areas, there are plenty of opportunities for nurses to play a key role in controlling the epidemic, especially as the rollout of the Affordable Care Act (ACA) increases the need for nurses to be prepared to care for people living with HIV infection in a broad spectrum of care settings.
SCREENING FOR HIV INFECTION
Imagine working in a primary care setting at which Sam, a 35-year-old man, presents with rectal pain. (This hypothetical case is a composite based on our experience.) You perform a risk assessment and find that Sam has never had a blood transfusion, does not inject drugs, smokes a pack of cigarettes a day, and has had sexual intercourse with two women over the past 10 years: his ex-wife and the woman he has been living with for four years. Physical examination reveals blisters and inflammation around Sam's anus. You obtain a swab from the sores, and laboratory testing confirms a diagnosis of herpes simplex virus type 2. Sam is given a 10-day prescription of valacyclovir (Valtrex) and offered screening for other sexually transmitted infections (STIs), including HIV.
Sam consents to a full STI screening, including a rapid test for HIV. He appears nervous, so you ask, “How are you doing?” He responds, “I'm afraid. I used to go to bathhouses until I got gonorrhea. They tested me for HIV, and I didn't have it, but it scared me so much that I quit the bathhouse scene and got married. Then last month, I went again. It was a spur-of-the-moment thing. I had a fight with my girlfriend. I didn't use condoms… I think I may have screwed up.”
In 2006, the CDC issued recommendations that called for routine HIV screening of all patients between the ages of 13 and 64, with subsequent testing at least annually of patients whose behaviors put them at elevated risk for HIV.8 In April 2013, the U.S. Preventive Services Task Force (USPSTF) brought its guidelines into close agreement with those of the CDC, giving an “A” rating—indicating a “high certainty that the net benefit is substantial”—to the recommendation that practitioners provide routine HIV screening to all patients ages 15 to 65; previously, the A rating had been given to the routine testing of those ages 15 to 65 with behavioral risk factors for HIV.9 The new USPSTF A rating also ensures health insurance coverage for HIV testing under the ACA, which requires or provides incentives for plans to provide A- or B-rated preventive services at no cost to patients.
In addition, advances in HIV testing methods over the past 30 years have made testing more efficient and less stressful for patients. Rapid HIV testing, which has been available for several years, can be performed at the point of care, and in most cases the patient can get test results before leaving the clinic. In addition, unlike the older HIV tests that detected only antibodies to the virus, fourth-generation immunoassays test for both HIV antibody and HIV antigen (the presence of the virus itself). These tests help clinicians diagnose HIV in the very early stages of disease, potentially reducing the time from infection to treatment.
CASCADE OF CARE
Sam's rapid test shows he has antibodies to HIV, indicating likely infection with the virus. He is understandably upset. You say, “I know this is bad news, but I want you to know that HIV infection is no longer a death sentence. We have good medications, and they are well tolerated. The newer drugs are easier to take and have fewer adverse effects. I'd like to help you get an appointment with an NP in the HIV clinic so you can learn about your options.”
Connecting the patient to an HIV care specialist is the most important goal when counseling a patient with a positive HIV test result. The sooner a patient enters care, the better the outcome—especially if the patient stays in care, is adherent to combination antiretroviral therapy (cART), and achieves an undetectable viral load.10 The HIV “cascade of care,” which graphically represents the proportion of people living with HIV at each stage of care (see Figure 2 11), is also a way of depicting the tremendous opportunity that exists for U.S. nurses to help curb the growth of the HIV epidemic by encouraging testing, connecting newly diagnosed patients to specialty care, retaining patients in long-term care, and providing access to cART. An estimated 18% of infected people in the United States are unaware of their HIV status; therefore, they are neither taking advantage of the life-sustaining treatments available to them nor aware of the risk of HIV transmission they pose to others.11 Not only can early testing reduce morbidity and mortality in infected patients, but concurrent patient teaching about disease prevention, harm reduction, and long-term HIV care can help limit transmission—provided that infected patients are retained in appropriate care.
A number of barriers can hinder patient retention in care, including
* clinic hours that do not accommodate patient schedules (because of patient's work hours, child care needs, or other family responsibilities).
* a lack of transportation.
* a lack of health insurance.
* drug use.
* fear of stigma.
This is clearly demonstrated by the fact that only 66% of those living with HIV infection in the United States are “linked to care,” meaning that, following an HIV diagnosis, they have seen a care provider, had blood drawn for laboratory tests (including a CD4+ cell count and viral load test), been given information about HIV treatment, and been encouraged to return for additional HIV-related care within three months of their positive test. Of those so linked, only about half remain in care. When patients fall out of care, they are vulnerable to developing hard-to-treat, potentially fatal HIV-related complications. Retention in HIV care has thus become a focus of public health efforts, as it helps this population receive appropriate cART, avoid life-threatening opportunistic diseases, and obtain such support services as housing, food, and mental health care.
Engaging and retaining people with HIV infection in care is best achieved by an interdisciplinary team that focuses on basic life requirements, addresses economic limits, and treats comorbid conditions such as mental illness and hepatitis C infection. Retention in care also allows those living with HIV infection to be closely monitored for treatment efficacy and tolerability, leading to better health outcomes, preserved immune function, and reduced risk of new infections.
ACUTE HIV INFECTION
At Sam's first HIV clinic visit, the NP answers his questions. Because Sam believes he may have been infected recently, the NP performs a thorough physical examination that reveals diffuse lymphadenopathy. She sends additional tests to the laboratory, including an HIV viral load test and a CD4+ cell count. She sets up an appointment for Sam to meet with a social worker, who will help him apply to the AIDS Drug Assistance Program, which will give him access to HIV medications as soon as his diagnosis is confirmed. The NP schedules Sam for a follow-up visit in two weeks. When she asks Sam about his partner, he says, “She's still mad at me about a fight we had before I went to the bathhouse last month. She doesn't know I went to the bathhouse—she's just mad about the fight. Anyway, we haven't had any sex since then.” The NP talks to him about protecting his partner and about the need to tell her that he has HIV infection. He says, “OK, but I can't do it now. I won't have sex with her until I see you again.”
Acute HIV infection usually occurs four days to four weeks following exposure to the virus.12 Presenting symptoms often include fever, rash, lymphadenopathy, pharyngitis, malaise, lethargy, myalgia, headache, diarrhea, and oral ulcers, although some newly infected people are asymptomatic.12 Testing and identifying infected people during the acute period is important because the viral load is extremely high in blood and genital secretions at this time, and carriers of the virus are therefore more infectious than at any other time during the clinical course of the disease.13 In fact, up to half of all transmissions occur during acute infection. Unfortunately, the opportunity to test for and diagnose acute HIV infection is often missed because symptoms are common to other, less severe conditions, such as influenza, strep pharyngitis, or mononucleosis.
The best test for diagnosing acute HIV infection is the quantitative HIV RNA test for viral load, which can detect the virus within two to three weeks of exposure. Standard rapid HIV tests, including the fourth-generation tests, usually show positivity three to four weeks after exposure.13 Nurses can promote early testing through thorough risk assessment and identification of symptoms associated with acute HIV infection.
NEW DEVELOPMENTS IN ANTIRETROVIRAL THERAPY
Sam returns to the clinic for his follow-up visit, and the NP confirms his HIV diagnosis. She says his viral load is high (500,000 copies/mL) and that his CD4+ cell count is 640 cells/mm3. She tells Sam she would like to start him on cART and reviews the benefits and risks of therapy. She also tells him some good news. In addition to the quantitative HIV RNA test, she had ordered an HIV genotype test, which shows that Sam has pansensitive virus, meaning that his HIV is not resistant to any currently available antiretroviral medications. The NP reviews the latest guidelines for HIV treatment and explains the possible adverse effects of each regimen. Sam tells the NP that he has no known allergies and has never been diagnosed with any other chronic medical conditions, such as kidney disease. He says he finished the valacyclovir prescribed for his herpes infection two days ago, and he's not currently taking any medications. He explains that he's concerned about his ability to adhere to a complicated regimen because he has two jobs that keep him “pretty busy.” After considering Sam's medical history and lifestyle, the NP orders Atripla (a fixed-dose, combination medication that combines efavirenz, tenofovir, and emtricitabine in a single pill). She explains that Sam should take one pill at the same time every evening on an empty stomach.
Sam tells the NP that he's told his partner about his infection. The NP asks, “How did it go?” Sam replies, “Well, she was upset. I told her that was why we weren't having sex. Then I went with her to get tested and she isn't infected, thank goodness. Then we talked. For now, she has decided to stay.”
The development of cART in the mid 1990s drastically altered the prognosis for people with HIV infection, transforming the infection from a terminal illness into a chronic and manageable disease. The life span of someone diagnosed with HIV infection in the 1980s was less than two years; today, if Sam has no history of drug use and remains in care, taking his medications as prescribed, he can have a life span comparable to that of people without HIV infection.14 While challenges to treatment—such as adherence issues, access to expensive drug regimens, drug toxicities, pill burden, and comorbid conditions—still exist, most patients who are in care and taking medications consistently and correctly can radically limit viral replication.15
The objective of cART is to reduce viral load to an undetectable level. Five classes of antiretroviral medications are currently available (see Table 1). These drugs limit viral reproduction at different stages in the replication cycle and need to be used in combination. As a general rule, three antiretroviral drugs from at least two drug classes are required to achieve viral suppression and minimize the development of drug resistance.15 Several fixed-dose combination pills, containing two to four antiretroviral medications, have been produced in an effort to simplify regimens, increase adherence, and decrease pill burdens, and more are in development. Many people with HIV infection are able to achieve and sustain an undetectable viral load with just one pill a day.
The guidelines from the National Institutes of Health are an excellent reference for first-line and alternative HIV treatment regimens.15 They are updated every six months as new information becomes available through clinical trials. Several factors need to be considered before cART is initiated, including whether there is evidence of drug resistance, pill burden, comorbid conditions, medication allergies, interactions with other medications and supplements, patient readiness to start lifelong therapy, mental illness, economic issues (including access to prescribers and clinical care), high-risk behaviors, substance abuse, and partner HIV status.15 Providers should keep in mind that some regimens have a lower genetic barrier to resistance (it takes fewer mutations of the virus for it to become resistant to the drug's effects). Similarly, using only one class of antiretroviral drugs, such as nucleoside reverse transcriptase inhibitors, can lead more rapidly to resistance, as can the use of monotherapy.15
The most recent version of the guidelines indicates that everyone infected with HIV should be offered treatment, particularly in situations of severe immune suppression, acute HIV infection, pregnancy, HIV-associated dementia, hepatitis B coinfection, and HIV-associated nephropathy. Viral load suppression minimizes loss of immune function in the short term and over a lifetime, improving both quality and duration of life. Compared with HIV-infected patients who don't receive effective cART, those who do and have a suppressed viral load have fewer cardiovascular, renal, and metabolic complications, and a lower incidence of malignancy, opportunistic infection, and associated complications.15 For example, infection with cytomegalovirus in an immune-compromised patient can lead to blindness, which is rarely seen in people with functioning immune systems.
ADVERSE EFFECTS AND ADHERENCE
When Sam returns to the clinic, he says he's been experiencing fatigue, dizziness, and bad dreams. He is anxious to find out his laboratory values now that he has been taking cART for a few weeks. He is proud to say that he has not missed a daily dose of his cART tablet, but he is concerned about adverse effects. As the NP inquires about Sam's dosing routine, she notes that Sam has been taking his medication at different times each day and sometimes with food. The NP reminds him that his regimen works best when taken at bedtime and on an empty stomach. She says that taking it consistently and at the same time every day can help minimize adverse effects. Sam agrees to continue his current regimen with a more consistent dosing schedule and to follow up in four weeks.
All antiretroviral drugs have the potential to interact with other medications and supplements, so it's important to obtain accurate records of all medications and supplements patients take and to encourage them to report any and all adverse effects. With cART, mild to severe adverse effects—including nausea, fatigue, anorexia, peripheral neuropathy, diarrhea, hyperlipidemia, depression, insomnia, and taste disturbance—may be associated with any of the medications in the regimen. Advanced age, female sex, and an AIDS-defining event (one of several diagnoses, such as lymphoma, encephalopathy, histoplasmosis, wasting, pneumocystis pneumonia, or Kaposi's sarcoma, considered indicative of AIDS rather than simply HIV, even if the CD4+ cell count is above 200 cells/mm3) have been found to predispose patients to more severe adverse effects.16 Such effects may abate over time or be alleviated with secondary pharmacologic treatment, but in some cases they can be so severe as to cause patients to consider skipping doses or even stopping treatment. Gaps in adherence can lead to incomplete viral suppression and drug resistance, limiting treatment options and creating additional adherence challenges. For example, people with drug-resistant strains of HIV often require a higher pill burden and more frequent dosing to achieve viral suppression.
When cART is prescribed, nurses should advise patients of potential adverse effects and possible coping strategies. Anticipating and treating adverse effects can improve long-term adherence.16 Nurses can also assess and address adherence issues related to insurance coverage, access to care, psychosocial issues, confusion about appropriate dosing, and other challenges that may complicate a commitment to lifelong treatment for HIV infection.
CHRONIC INFECTION AND AGING
Sam asks, “So what are my chances of living until I'm 65?” Sam's NP tells him that the average life span of a person with HIV infection who adheres to a prescribed cART regimen is very close to that of the general population. She encourages Sam to take his medication consistently and to return for follow-up clinic visits. She says that together they will focus on preventive health care to keep him well, including age-appropriate health screenings, immunizations, and adopting healthier behaviors, such as regular exercise and smoking cessation.
Although untreated HIV disease is associated with progressive immune dysfunction, the use of cART has changed disease progression and has dramatically reduced mortality for those with HIV infection. New drug regimens are easier to follow and to tolerate, and this has greatly improved adherence, resulting in sustained viral suppression and preserved immune function for many people infected with HIV.
Caring for people with HIV infection as they age has also changed in the past three decades. Care is no longer strictly palliative, although it can be complicated by such comorbid conditions as heart disease, diabetes, or arthritis, as well as by the associated polypharmacy.17 The aging process also causes gastrointestinal changes that modify the ability to absorb and metabolize drugs.16
Treatment for aging patients should focus on viral suppression, preventive care and screening for conditions such as hyperlipidemia and hyperglycemia, management of comorbid disorders such as hepatitis B and C, and lifestyle modifications such as cessation of smoking and substance use. Sustained undetectable viral loads are more common in older adults with HIV infection, possibly owing to better adherence, but HIV and cART can both contribute to liver, kidney, bone, and heart disease, as well as to other complications of aging.17
Older adults with HIV infection may also be particularly vulnerable to social isolation. Fear of disclosure and stigma may be factors. Assessing and helping patients cope with social isolation can improve health outcomes, because mood, behavior, and adherence are often linked to perceived self-reliance within a social network.17 Ask patients about relationships with family, friends, and work colleagues; provide them with options such as support groups or volunteer opportunities as needed to minimize social isolation.
PREVENTION OF HIV INFECTION
HIV is transmitted predominantly through sexual intercourse with an HIV-infected partner and through blood-to-blood contact. Over the course of the epidemic, clinicians and scientists have used behavioral approaches to mitigate these risks. Numerous studies have shown the benefits of harm reduction, social support, motivational interviewing, and access to condoms and sterile injection equipment.18, 19 In addition, ensuring the safety of the blood supply has significantly reduced the risk of HIV infection. Despite these efforts, the HIV epidemic in the United States has not diminished.2
Treatment as prevention. The best way to prevent HIV transmission is to keep viral loads as low as possible through use of cART.20-22 When the viral load is low, the sex and drug-using partners of people with HIV infection are exposed to fewer virions, which decreases their risk of infection.21, 23
One of the first successful treatment-based prevention interventions focused on mother-to-child HIV transmission. In one analysis, fewer than 1% of HIV-infected women treated with antiretroviral therapy for at least the last 14 days of pregnancy transmitted the virus to their newborns.24
A medical assistant sustains a needlestick injury while drawing Sam's blood. She reports the injury and is seen by Sam's NP. The NP reviews the risks with the medical assistant, draws baseline laboratory tests, and checks Sam's most recent viral load, which is undetectable. The medical assistant agrees to the NP's recommendation to take cART for 28 days to minimize her risk of infection.
The overall risk of HIV infection after occupational exposure is quite low (0.3% per percutaneous injury).25 Despite the low risk, nurses should use precautions to protect against exposure to infectious or potentially infectious blood or bodily fluids and should be aware that, in the event of exposure, postexposure prophylaxis (PEP) can reduce the risk of HIV infection by about 81%.25 The risk of HIV transmission is higher when the exposure26
* is to known HIV-infected bodily fluids.
* occurs through percutaneous injury, especially deep percutaneous injury.
* is to a large amount of fluid.
* happens during procedures involving an artery or vein.
A detectable HIV viral load in the source patient increases the risk of transmission. Hepatitis B and C are also spread through infected blood and bodily fluids. Exposed employees should seek immediate evaluation and treatment to minimize the risk of infection with any blood-borne infection.27
PEP guidelines following occupational exposure to HIV were first published in 1996 and updated in 1998, 2001, and 2005. A fourth update was published in September 2013.26 Current recommendations support the use of cART as first-line therapy.26 Initiation of PEP is individualized, with consideration given to the following:
* severity and type of exposure
* timing of initial evaluation
* the source patient's HIV status, viral load, and HIV drug resistance profile
* the employee's pregnancy status and history of other conditions that may influence the type of cART offered
All employees exposed to potentially infectious blood or body fluids should have serial HIV testing at baseline and at six weeks, 12 weeks, and six months after exposure. (For more on testing and treatment of PEP, see Table 2.)
NONOCCUPATIONAL POSTEXPOSURE PROPHYLAXIS
Sam brings his partner to his next visit. He says, “The condom broke last night. She's afraid she's been infected. What can you do?” The NP tells the couple about nonoccupational PEP (nPEP). She orders baseline testing for Sam's partner and a 28-day course of cART. The NP also reinstructs the couple on the appropriate use of male and female condoms.
As with PEP, nPEP requires a 28-day course of cART.28 It can be used for accidental exposure, such as the condom breakage described by Sam, as well as after unprotected sexual intercourse, rape, or the sharing of injection equipment during drug use. The initiation of nPEP provides an excellent opportunity to discuss protective methods such as appropriate condom use and alternatives to sharing drug-using equipment.
After 28 days of therapy, Sam's partner is retested for HIV and her test is negative. The NP says that Sam and his partner might be interested in preexposure prophylaxis (PrEP), which would provide protection for Sam's partner but would require her to take cART every day. The NP stresses how important it is for Sam to take cART consistently, to keep his viral load at an undetectable level, and to use condoms to protect his partner.
PrEP involves the prescription of Truvada, a combination of two antiretroviral drugs—tenofovir and emtricitabine—that can be used in uninfected individuals who are at elevated risk for HIV infection. These would include uninfected people who use injection drugs, participate in high-risk sexual behaviors, or are part of a discordant couple, where one partner is infected with HIV and the other is not. It's been shown that taking Truvada daily can be a safe and effective way for uninfected people at high risk to reduce their risk of acquiring HIV infection.29 Use of PrEP is limited at this time; access to the expensive medication is a barrier for many patients, as is the need to adhere to daily medications. If PrEP is used, the uninfected partner should be counseled to29
* continue following safe sexual practices.
* continue refraining from sharing injection equipment.
* return for follow-up drug toxicity monitoring.
* have an HIV test every few months.
THE FRONT LINES OF HIV CARE
Over the past three decades, HIV infection has evolved from a diagnosis of certain death to one of a chronic and manageable disease. Advances in HIV testing technologies, medication options, and comprehensive care have significantly reduced HIV-related morbidity and mortality. These advances, however, can only help those with HIV infection who
* are aware they have HIV.
* have access to care.
* stay in care.
* adhere to their medication regimen.
* achieve and maintain an undetectable viral load.
The hypothetical case presented here reflects the experience of patients who have the awareness, access, and commitment required. But Sam would be considered one of the luckier patients; his case is not typical. In addition to HIV, many people living with HIV have to deal with rejection, stigma, a lack of insurance, comorbid conditions, poverty, and other significant barriers to care. Nurses are on the front lines of patient care, where they can provide the assessments, education, referrals, and support for these patients. As such, they are an essential part of the team that helps people with HIV infection live longer and healthier lives.
To watch a video about Lucy Bradley-Springer's early experience with an HIV-infected patient and how it changed her nursing perspective, go to http://links.lww.com/AJN/A56.
© 2014 Lippincott Williams & Wilkins. All rights reserved.