hiv treatment and the nurses role patrick byrne anele waters
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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?