AIDS/HIV One Hour, Current Evidence Based Practice (FL INITIAL Autonomous Practice- Pharmacology)

The infectious disease known as Human Immunodeficiency Virus (HIV) has brought devastation and debilitation to individuals and nations since its world debut in the 1980s. HIV remains a fatal communicable infection whose final terminal stage is Acquired Immunodeficiency Syndrome (AIDS). Individuals, countries, and cultures, particularly in central and southern Africa, have suffered tremendously due to the devastation accompanying HIV, which has rightly been referred to as a scourge of our time (Tumwebaze et al., 2023).

In the past few years, new treatments have been developed which may extend by decades the lifespan of those infected, effectively shifting HIV from an acute terminal illness to a chronic debilitating condition requiring a distinct perspective on care and monitoring. As healthcare professionals, we must keep current on the latest information regarding HIV as it is continuously being discovered. We will review the current evidence-based information concerning the spread (i.e., modes of transmission), available treatments, and the care of the HIV-infected individual, both before and after they progress into the final stage of AIDS. Our informed care is crucial as we strive to help those infected to live healthier, more satisfying lives.

The prospect of having HIV may provoke fear and dread in the sexually active. This anxiety is reasonable given the history surrounding HIV and AIDS in the United States and globally. HIV infection is a profoundly serious medical condition, though not the sentence of an agonizing wasting death that it was during the 1980s and 1990s. There are now medications that can slow the progression of the disease by decades, in many cases, giving an extension of life to those diagnosed with this progressive lethal virus rather than the near specter of a wasting, suffering death.

The question remains as to why so many in the United States avoid HIV testing and prevention when it is so important to avoid or at least become aware of an infection early. It is allowing early treatment with the potential to slow or avoid the fate they see that is being portrayed by the news media visiting impoverished AIDS-stricken countries in Africa's west, central, and southern regions where a diagnosis of HIV has been the equivalent of a death sentence (Senate Foreign Relations Committee [SFRC], 2023). Perhaps it is the fear of receiving a diagnosis with a fatal infectious disease, or the fear of living with the responsibility of keeping a demanding disease such as HIV/AIDS under control. Keeping HIV under control is a time and resource-consuming task. However, the option of letting the disease run its course unchecked would be an extremely poor choice, as well.

Whatever factors bring hesitation to those needing HIV prevention counseling, screening, or treatment, we know that one commonly held fear is the stigma attached to having HIV or AIDS. Having HIV brings a "scarlet letter" fear of repercussions due to possessing an unwanted health status. When questioned, many of those newly diagnosed with HIV seem unaware that federal laws exist to protect them from discrimination and ensure that benefits such as any social or medical services they would otherwise qualify for will not be withheld. As healthcare professionals, it is important to share with those in high-risk groups that key legislative pieces exist that offer protection from discrimination. Interestingly, some of the mandates and pieces of legislation protecting those with current needs predate the HIV/AIDS epidemic, e.g., Section 504 of the Rehabilitation Act of 1973 and pieces of the 1990 Americans with Disabilities Act (ADA) (HIV.gov, 2023c; Centers for Disease Control and Prevention [CDC], 2022b). These well-established laws mean services that apply to an otherwise qualified individual will also be available to HIV-infected individuals.

Title II of the ADA prohibits discrimination by state and local government organizations, even those not dependent on federal funding. For those nervous or fearful concerning how those close to them might be treated should they acquire HIV, Title II of the ADA also protects an HIV positive individual's friends and family against discrimination or denial of services that might come from being related to someone with HIV (HIV.gov, 2023c).

Information privacy regarding an individual's HIV status, or any other issue of a sensitive nature, is addressed in the 1996 Health Insurance Portability and Accountability Act (HIPAA), whose Privacy Rule is enforced by the Office for Civil Rights (OCR). HIPAA protects the privacy of health information while allowing each individual access to their records to see what is written about them and even ask to make corrections to what is documented (Badahman, 2023).

Awareness of their individual rights and the value that each life inherently possesses are crucial foundational steps leading to the inclusion of those suffering from HIV into society and better health. By emphasizing the importance of everyone’s lives, we, as healthcare professionals, can increase participation of the HIV infected individual in their own care and educate them as well.

Important things to educate all individuals about include:

• Keep informed of any changes in HIV knowledge and care
• Use measures to stop the transmission of HIV
• Avoid high-risk behaviors
• Get routine screening for HIV infection, if necessary
• Actively participate in treatment should the individual become infected

Therefore, as we progress to viewing the magnitude of the current HIV pandemic with its slowly widening reach into our culture and homes, remember that we are really dealing with the frightened and wounded. Each is faced with the sudden overwhelming burden of managing the chronic terminal condition of HIV/AIDS.

According to the U.S. government website, HIV.gov, around 1.2 million Americans are currently infected with the HIV virus (HIV.gov, 2022b). Around 13% of them are unaware of their infection and infectious state. The following table includes a breakdown of the most recent HIV/AIDS statistics.

The Centers for Disease Control and Prevention (CDC) reports indicate that the estimated incidence of new HIV infections has stabilized at about 36,000 per year while HIV.gov indicates that the United States has been showing a slow yet steady decrease in newly diagnosed cases each year (CDC, 2023; HIV.gov, 2022). At the height of the HIV pandemic, around 1985, around 130,000 new annual cases were reported, as opposed to the 36,136 in the year 2022 (Myhre & Sifris, 2022a).

Gay, bisexual, and other men who have sex with men (MSM) of all races and ethnicities account for 71% of all new cases of HIV (HIV.gov, 2022b). Young to middle-aged Black American MSM remain the population most profoundly affected by HIV, accounting for around 30% of all new infections (HIV.gov, 2022b). Latinx MSM comes in second at around 20% of new infections, and white MSM amounts to about 15% of new infections (Myhre & Sifris, 2022a).

Another behavior warranting following by public health is the use of illegal injectable medications (CDC, 2023; HIV.gov, 2022a). In the United States, injection drug use in all sex and age groups accounted for around 7% of all HIV cases in 2020.

How HIV viral particles enter the bloodstream for an individual to become infected relates directly to the prevention of HIV. This virus, once having invaded the body, is tough and resilient, impossible for the infected individuals' body defenses to destroy. However, outside the body, HIV is fragile and does not survive for long. Misleading rumors about the ease of viral spread have led the CDC to provide a list of ways HIV cannot be spread (CDC, 2021):

• HIV cannot be spread in the air or water
• HIV cannot be spread by insects, including bed bugs, ticks, or mosquitoes
• HIV cannot be spread in saliva, sweat, or tears and no documented case exists of HIV being transmitted by spitting
• HIV cannot be spread by casual contact, as in sharing dishes or shaking hands
• HIV cannot be spread by closed mouth or social kissing
• HIV cannot be spread from toilet seats

Marissa, 28, comes to you after a public health worker identified her as a newly diagnosed HIV patient contact. Marissa is especially concerned because she recently became pregnant and plans to carry her baby to term.

Confirmation tests indicate Marissa is indeed pregnant and, unfortunately, has also contracted the HIV virus.

The National Institute of Health (NIH) and the CDC recommend HIV testing for all pregnant women. Some regions automatically include HIV testing as part of routine prenatal care. In contrast, others separate it as an additional opt-in test. The CDC recommends and requests that HIV tests be routine for all pregnant women.

Marissa was provided with information about the means of protecting her unborn child, herself, and potential contacts from the dangers of HIV infection. Nonjudgmental information was provided that the unborn baby would be at heightened risk for mother-to-child transmission of HIV during pregnancy, labor, and delivery, and afterward by breastfeeding. Marissa was assured that less than two babies in 100 with HIV-positive mothers get the infection before or during birth with proper medication and treatment.

Antiretroviral HAART medications are strongly recommended:

• Throughout the pregnancy – combinations of at least three different ART medications are used based on effect profiles.
• During labor and delivery – additional intravenous ART may be given to the mother during labor and through the delivery process.
• After birth – liquid ART is often given to the newborn as a six-week preventative. Babies whose mothers were not on a pre-birth ART regimen may also receive additional anti-HIV medications.
• After delivery – the new mother's ART regimen will be amended to include medications, whose adverse effects prevented their use during the pregnancy.
• Breastfeeding might be discouraged after delivery to decrease the possibility of transmitting the virus to the newborn.

Marissa was informed that she would also be at risk for the progression of the HIV infection if medications were not started now to slow the infective processes. Potential sexual partners will also be at risk of infection unless deliberate steps to prevent the spread of HIV are implemented in a thoughtful, methodical manner.

A cesarean delivery (C-section) may be preferred to regular vaginal delivery as a means of minimizing exposure of the newborn to infected blood and delivery fluids. The preferred time for the C-section is around 38 weeks gestation or about two weeks before the expected due date.

Marissa was reassured that ongoing monitoring of her newborn would occur at two weeks, two months, and six months to make sure the baby remains HIV-free.

Should the newborn have a positive HIV virologic test result, a combination of HIV medications will be an option.

The Human Immunodeficiency Virus belongs to a viral family known as retroviruses. Some viruses are known as retro, or backward, due to an ability to transcribe or copy their genetic code from RNA into the DNA of a host cell instead of the more common DNA to RNA method of transcription. Like other viruses, HIV can neither self-reproduce, nor grow independently. HIV requires a living host, in this case, a human, to make copies of itself, a process known as replication, which, in the end, destroys the host cells enslaved to be production factories.

Favorite prey of HIV viral particles is our CD4 T-cells, macrophages, and dendritic cells. Once the favored cell has been located, the virus locks onto it and quickly regurgitates its core to the inside of the doomed host allowing viral RNA to begin the process of transcribing into the host cell's DNA using an enzyme called reverse transcriptase. The resulting rewritten DNA integrates into the human genome of the body's cells. HIV may remain a quiet passenger in the genome of its human host cell for some time, or it may immediately exert itself, forcing the enslaved human genome to make more copies of viral particles, becoming a mass producer of new viruses ready to continue the spread and conquest throughout more of the infected human body.

Image 1:

(HIV Overwhelming Immune Cells, source CDC)

Currently, there is no cure for HIV infection. Yet, with diligent, consistent lifelong treatment it is possible to slow, or prevent, the progression of the disease from one stage to the next. It is not a cure. However proper medication may help those infected live longer, and healthier, lives.

HIV infection has three distinct stages defined by the CDC:

1. HIV Primary or Acute infection
2. HIV Chronic or Asymptomatic infection
3. HIV as AIDS (acquired immunodeficiency syndrome)

Currently, there is no cure for HIV infection. An individual's lifespan can be extended and their quality of life enhanced. Yet, every individual diagnosed with HIV infection will die from it if another life-ending event does not take them first. Consequently, prevention is the key, the goal, and the focus of early intervention. Once an HIV diagnosis does occur, early and aggressive therapy can add decades of lifespan and enhance the quality of life.

The current best practice for HIV treatment is early and continuing antiretroviral therapy (ART) for all HIV-infected individuals. It is important to understand that antiretroviral medications do not kill the HIV virus nor cure the disease. ARTs are intended to slow or prevent the growth and spread of the virus.

Several antiretroviral agents are in use since the HIV virus has shown itself proficient in forming single-agent resistance. Highly active antiretroviral therapy (HAART) combines three or more antiretroviral agents that are given to prevent treatment resistance from forming within the infected individual.

Each drug class of antiretroviral medications works by a different mechanism to combat HIV. There are currently six main classes of antiretroviral medication (Eggleton & Nagalli, 2022):

1. Nucleoside Reverse Transcriptase Inhibitors (NRTIs) or "nukes" block reverse transcriptase. This is an enzyme that HIV needs to create altered DNA from viral RNA to make copies of itself.
   • Examples are abacavir, didanosine, lamivudine, stavudine, tenofovir, and zidovudine.
2. Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) or "non-nukes" bind to and later alter reverse transcriptase to block the altered DNA creation from viral RNA, though in a different fashion from the NRTIs.
   • Examples are delavirdine, efavirenz, nevirapine, and rilpivirine.
3. Protease Inhibitors (PIs) interfere with the process of the newly formed HIV virus using the enzyme protease to gather components it needs to mature into full function.
   • Examples are atazanavir, darunavir, and indinavir.
4. Entry Inhibitors, sometimes called Fusion Inhibitors (FIs), block proteins on the CD4 cells that HIV needs to enter cells. This category includes the CCR5 antagonists, which block viral entry into CD4.
   • An example is enfuvirtide.
5. Chemokine Receptor Antagonists (CCR5 Antagonists), selectively and reversibly block entry into the CD4 T-cells by preventing interaction between CD4 cells and the gp120 subunit of the viral envelope glycoprotein.
   • An example is maraviroc.
6. Integrase Strand Transfer Inhibitors (INSTI) act to prevent the DNA from the virus from being inserted into the chromosome of the host cell by interfering with the HIV integrase enzyme, the tool the virus uses to unzip and then patch in its own genetics.
   • Examples are dolutegravir, elvitegravir, and raltegravir.

CDC guidelines recommend initiating prompt treatment following diagnosis with combination antiretroviral medications (cART's). Everyone should have personalized medications based on drug resistance testing, epidemiologic determination of susceptibilities of the local prevalent viral strains, comorbid conditions, possible drug-to-drug interactions, and anticipated adverse effect profiles. The CDC provides recommendations for a general starting combination therapy focused on the HIV-1 strain most common in North America.

In an antiretroviral-naive patient, general guideline suggestions include a starting regimen considering the following factors (Welhe, 2023):

• All new HIV-positive patients should be offered ART.
• While there are more than twenty-five medications from six major antiretroviral medication classes used for HIV treatment, the most used are NRTIs, NNRTIs, and PIs.
• The general starting regimen should include two nucleoside/nucleotide reverse transcriptase agents (NRTIs), plus a drug from the NNRTI class, boosted with a PI inhibitor.

HIV infection is a chronic medical condition that those infected will have until they succumb to it in its final stage of AIDS, or death ensues from another cause. There is no cure for HIV infection, which means prevention is key to controlling its spread. Distributing knowledge of HIV and information concerning an infected individual's rights and the value that their lives hold form essential parts for positively affecting individuals/groups whose behaviors place them at a heightened risk for exposure and infection. It is important to share information concerning the transmission of HIV along with the risks of unprotected sex, sharing of needles, and exposure to unsterilized blood-contaminated devices as methods by which the HIV retrovirus can be transmitted to still another victim.

It is estimated that one in five HIV-infected individuals is unaware of their infection and therefore unable to begin life-extending treatment. HIV testing is available both from healthcare professionals and home tests. Once a positive test is confirmed, early aggressive treatment with antiretroviral medications is highly encouraged. 

The state of HIV medications allows those infected to live decades longer than they otherwise would without medication, and with a greater quality of life. However, the medication regimen can be taxing. Support for adherence to the medication regimen and behavioral changes that minimize the chance of spread of the virus by those infected are important objectives for healthcare professionals as they work toward helping the HIV infected live healthier, more satisfying lives.

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