1 Chapter 35 HIV- and AIDS-Related Drugs Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

2 HIV Infection Pathophysiology  HIV is an RNA retrovirus.  HIV is unable to survive and replicate unless it is inside a living human cell.  HIV destroys CD4+ T cells.  The destruction of CD4 cells by HIV results in immune deficiency.  The CD4 cell count is an indicator for immune function in those with HIV. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

3 HIV Life Cycle The Life Cycle of the Human Immunodeficiency Virus. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

4 HIV Transmission  HIV is spread via intimate contact with blood, semen, vaginal fluids, and breast milk.  Sexual contact  Direct blood contact  Mother to child Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

5 Laboratory Testing  CD4 T-cell count  Plasma HIV RNA quantitative assay (or viral load [VL] test)  HIV resistance testing  Additional laboratory evaluation Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

6 Classification  Staging and classification systems  U. S. Centers for Disease Control and Prevention (CDC) CD4 cell counts Presence of specific HIV-related conditions System is based on the lowest documented CD4 cell count (nadir CD4) and on previously diagnosed HIV- related conditions.  World Health Organization (WHO) Classifies HIV disease on the basis of clinical manifestations that can be recognized by clinicians in diverse settings and those with varying levels of HIV expertise and training Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

7 Treatment Goals of ART  Reduce HIV-associated morbidity and mortality  Prolong the duration and quality of life  Restore and preserve immunologic function  Maximally and durably suppress plasma HIV viral load  Prevent HIV transmission Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

8 Indications for Antiretroviral Therapy  HIV-infected individuals  HIV-infected pregnant patients  Patients with a history of an AIDS-defining illness  Patients with HIV-associated nephropathy, or HIV and hepatitis B coinfection  Serodiscordant couples Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

9 Antiretroviral Agents  Reverse transcriptase inhibitors  Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)  Action  Take NRTIs with food (except didanosine should be taken 1 hour ac or 2 hours pc).  Side effects, adverse effects Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

10 Antiretroviral Agents (Cont.)  Reverse transcriptase inhibitors  Non-nucleoside analogues (NNRTIs)  Action  Adverse effects Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

11 Antiretroviral Agents (Cont.)  Protease inhibitors  Currently FDA approved  Action  Side effects, adverse effects Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

12 Antiretroviral Agents (Cont.)  Entry (fusion) inhibitors  Enfuvirtide (Fuzeon): only agent approved in this class  Action  Administration  Side effects, allergic reactions Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

13 Antiretroviral Agents (Cont.)  CCR5 Antagonists  Maraviroc  Action  Side effects Upper respiratory infection, cough, pyrexia  Adverse effects Hepatotoxicity Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

14 Antiretroviral Agents (Cont.)  Integrase inhibitors  Raltegravir  Action  Side effects Headache, pyrexia, nausea, diarrhea Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

15 Immune Reconstitution Inflammatory Syndrome (IRIS)  Related to specific opportunistic pathogens  Experienced by a low percentage of patients early in ART  Two distinct entities  Paradoxical IRIS, which is an exacerbation of treated (successful or partial) opportunistic infection (OI)  Unmasking IRIS, a response to undiagnosed or subclinical OI Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

16 Nurse’s Role in Antiretroviral Therapy  Drug regimen adherence  Nonadherence results  HIV viral replication  Increased viral loads  Immune system deterioration  Drug resistance Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

17 Adherence  Suggestions to promote patient adherence  Patient understanding of each medication’s purpose  Food and fluid restrictions  Recommended food choices  Storage of medications  Appropriate recording sheet  Contact person for questions Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

18 Nursing Process: Antiretroviral Therapy  Assessment  Nursing diagnoses  Planning  Nursing interventions  Patient teaching  Cultural considerations  Evaluation Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

19 Most Common HIV-Related Opportunistic Infections/Diseases  Bacterial  TB, bacterial pneumonia, septicemia  Protozoal  PCP, toxoplasmosis, cryptosporidosis, leishmaniasis  Fungal  Candidiasis, crytococcosis  Viral  Cytomegalovirus, herpes simplex, herpes zoster  HIV  Associated malignancies: Kaposi’s sarcoma, lymphoma, squamous cell carcinoma Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

20 Antiretroviral Drug Therapy In Pregnancy  Timing of initiation of treatment and the selection of regimens for pregnant patients may differ from those for nonpregnant adults or adolescents.  Goal is to prevent mother-to-child transmission.  A patient infected with HIV can transmit the virus during pregnancy, labor, and delivery, and through breastfeeding. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

21 Occupational Exposure to HIV and Postexposure Prophylaxis  Postexposure prophylaxis regimens (PEP)  PEP regimen should be initiated within hours of the event and continued for 4 weeks.  Health care workers taking PEP have reported adverse reactions at rates of 17% to 47%, with the most common reactions being nausea, malaise, and fatigue. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

22 Practice Question #1 A patient asks the nurse what part of the body is most affected by the HIV virus. The nurse informs the patient that HIV primarily affects which system? A.Cardiovascular B.Immune C.Renal D.Hepatic Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

23 Practice Question #2 When providing teaching for the patient being discharged home on antiretroviral therapy for HIV, which statement will the nurse include? A.Do not eat raw fish. B.Limit food intake to proteins only. C.Avoid ingesting bananas. D.Applesauce may cause you to experience side effects of the medication. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

24 Practice Question #3 The nurse identifies which condition as a common bacterial opportunistic infection seen in patients with HIV? A.Cytomegalovirus B.Candidiasis C.Toxoplasmosis D.Tuberculosis Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

25 Practice Question #4 A health care provider has been exposed to HIV while caring for a patient. Following the postexposure prophylaxis regimen (PEP), the health care provider will most likely receive treatment for how long? A.1 week B.2 weeks C.3 weeks D.4 weeks Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.