• 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.

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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.
  

Non-occupational Post-exposure prophylaxis (nPEP)

In January 2005, the CDC issued guidelines for non-occupational post-exposure prophylaxis (nPEP). The recommendations cover those exposed to HIV from rapes, accidents or isolated episodes of drug use or unsafe sex. The previous recommendation (1996) had recommended prophylactic treatment only for health care workers accidentally exposed on the job.

The nPEP regimen is intended for people seeking care within 72 hours of exposure to blood, genital secretions (semen and vaginal fluids), or other potentially infectious body fluids of a person of unknown HIV status, if a positive HIV status would pose a substantial risk of transmission. In many cases, the HIV status may be known, but, for example, a condom may break, exposing someone to infected semen. The recommended drug regimen is a 28-day course of highly active antiretroviral therapy (HAART).

No recommendation is made if the exposure was more than 72 hours prior to seeking treatment. People who receive nPEP should receive counseling and be scheduled for followup testing at 4-6 weeks, 3 months, and 6 months after exposure, to determine if HIV infection has occurred. Additional testing for sexually transmitted diseases, hepatitis B and C, and pregnancy should also be offered. Patients need instruction about the signs and symptoms of HIV infection.

Health care workers who incur accidental needle pricks will also be treated with this regimen of drugs. A case control study of health care workers who had needlestick injuries showed that prompt initiation of treatment with zidovudine was associated with an 81% decrease in the risk of acquiring HIV. A number of international studies have shown that nPEP results in almost 100% protection from HIV.

This protocol is not recommended for people who continually or repeatedly engage in high-risk behavior, because they would essentially have to be on the drug regimen fulltime. Because people seeking treatment may not know their own HIV status, it is recommended that all who are candidates for nPEP be tested for HIV, preferably with an FDA-approved rapid test kit that provides results within an hour prior to initiating therapy.

Treatment during pregnancy

The U.S. Public Health Service has recommended that HIV-infected pregnant women should receive treatment with antiretroviral drugs as though they were not pregnant. If a woman is diagnosed in her first trimester, she should be evaluated and treated. Depending on lab test results, she may be able to postpone treatment until the second trimester when drug-related risks to the fetus are lower. If an HIV-infected woman is already on medications prior to pregnancy, she should continue the drugs. While the risk that the drugs pose to the fetus are not completely clear, they appear to be low. However, efavirenz is known to cause birth defects and should be avoided. Drug treatment during pregnancy greatly reduces the risk that HIV will be transmitted to the fetus or newborn. With new treatments that are available, the risk of a treated mother passing on the infection to her baby has been reduced to 2%.

Both the fetus and the newborn of a mother who is HIV positive are vulnerable to infection. Infection can occur in utero, during labor and delivery, or from breast feeding. To avoid transmitting the infection from mother-to-child, a woman who knows she is HIV positive should be carefully monitored and ideally should receive 500 to 600 mg Zidovudine (ZDV), divided into 2 to 5 doses daily, starting at 14 to 34 weeks of pregnancy, Together the physician and mother will determine whether vaginal delivery or C-section should be performed. Vaginal delivery of HIV infected mothers may be advised if viral load is <1000 copies. The mother-to-child transmission may be higher in vaginal delivery, but the caesarean delivery carries an increased risk of infection for the mother, as well as other surgery-related complications.

In order to minimize the danger of transmission of HIV to the infant, the mother should receive IV ZDV during labor. For a Caesarean delivery, the ZDV should be started 3 hours before delivery and continue until delivery. For a vaginal delivery, IV ZDV should be given throughout labor and delivery. With either type of delivery, the infant should receive anti-HIV drug treatment, usually 6 weeks of ZDV, for prevention of mother-to-child transmission. Mothers with HIV should not breast feed their infants because HIV can be transmitted through breast milk.

Side effects of HIV treatment

Numerous anti-viral drugs, some in combined form, have been approved by the FDA for treatment of HIV, to reduce the viral load and prevent destruction of the immune system. These drugs must be given in combination. However, they are all associated with side effects. The primary method of treating the side effects is to make a change in the antiviral medications. Major side effects may include the following:

• Hepatotoxicity: Women, especially those who are pregnant; those with existing liver diseases, such as Hepatitis B or C; and those who use alcohol may be at higher risk for developing hepatotoxicity.
• Hyperglycemia: An increase in blood glucose levels by itself, or as part of diabetes mellitus, is a side effect of all protease inhibitors (PIs).
• Hyperlipidemia: An increase in the lipids in the blood, such as cholesterol and triglycerides, is a side effect of some protease inhibitors (PIs).
• Lactic Acidosis: Too much lactate in the blood and a low blood Ph (acidic) are side effects of mitochondrial toxicity, caused by of all nucleoside reverse transcriptase inhibitors (NRTIs).
• Lipodystrophy: Fat redistribution, a disturbance in the way the body produces, uses and stores fat, is a side effect of the concurrent use of nucleoside reverse transcriptase inhibitors (NRTIs) and protease inhibitors (PIs).
• Osteonecrosis, osteoporosis, osteopenia: Damage to the bones is a side effect of HIV and some of the damage is related to protease inhibitors (PIs).
• Skin rash: NNRTIs cause most skin rashes, with Viramune causing the most severe rashes. NRTIs can also cause skin rashes.
  

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