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COURSE OBJECTIVE: The purpose of this course is to prepare healthcare professionals to care for people with HIV/AIDS based on a review of HIV clinical manifestations and treatment.
Upon completion of this course, you will be able to:
- Identify the clinical stages of HIV.
- Discuss AIDS-defining conditions.
- Describe elements of antiretroviral therapy (ART).
- Summarize which coinfections are common among patients with HIV.
TABLE OF CONTENTS
The trajectory between infection with HIV and the development of full-blown AIDS can be steep or gradual and may take as long as a decade or more. If the infection is untreated, the average time from HIV infection to a diagnosis of AIDS can be 10–15 years. However, early detection and appropriate medical treatment may extend the lives of those infected and reduce the rates of HIV transmission.
COURSE OF THE DISEASE AND DIAGNOSIS
As the HIV virus suppresses immune function, the infected person becomes more vulnerable to opportunistic infections caused by a wide variety of bacteria, viruses, fungi, and other pathogens encountered in daily life. The physical results of these opportunistic infections are called clinical manifestations. For example, the opportunistic infection cytomegalovirus (CMV) often causes the clinical manifestation of blindness in people with AIDS.
Some conditions, called co-factors—including age, genetic factors, drug use, smoking, nutrition, and coinfection with hepatitis C virus (HCV) and/or tuberculosis (TB)—can affect the course of the disease progression.
HIV Classification Systems
Currently there are two major ways to classify HIV:
- For surveillance case definition purposes
- For clinical diagnosis purposes
In 2008 the CDC revised its earlier surveillance case definitions of HIV and AIDS to require laboratory-confirmed evidence of HIV infection for all those aged 18 months and older. The revised definition also emphasizes the central role of the CD4 T lymphocyte counts and percentages in staging HIV disease. It is important to recognize that these case definitions are for surveillance purposes only and are not a guide for clinical diagnosis.
The CDC classification system identifies four stages of HIV infection, described in the following table.
|Source: CSTE, 2012.|
|Stage 3 (AIDS)||
The CDC, the U.S. Department of Health and Human Services, and other organizations such as the World Health Organization identify disease progression through three to five stages of clinical evidence for HIV/AIDS. The following is a synopsis of these various clinical stages.
|Stage 1: Acute Infection||
|Stage 2: Clinical Latency||
|Stage 3: Early-Stage AIDS||
|Stage 4: Middle-Stage AIDS||
|Stage 5: Late-Stage AIDS||
Opportunistic Infections and Cancers (AIDS-Defining Conditions)
People with normal immune systems have a natural resistance to microorganisms, but when the immune system is suppressed, viruses, fungi, protozoa, and bacteria take the opportunity to cause infection. The following are such “opportunistic infections” that can affect persons with HIV infection:
- Bacterial infections (multiple or recurrent)
- Candidiasis of bronchi, trachea, or lungs
- Candidiasis of esophagus
- Coccidioidomycosis, disseminated or extrapulmonary
- Cryptococcosis, extrapulmonary
- Cryptosporidiosis, chronic intestinal (>1 month’s duration)
- Cytomegalovirus disease (other than liver, spleen, or nodes)
- Cytomegalovirus retinitis (with loss of vision)
- Herpes simplex: chronic ulcers (>1 month’s duration) or bronchitis, pneumonitis, or esophagitis
- Histoplasmosis, disseminated or extrapulmonary
- Isosporiasis, chronic intestinal (>1 month’s duration)
- Lymphoid interstitial pneumonia or pulmonary lymphoid hyperplasia complex
- Mycobacterium avium complex (MAC) or M. kansasii, disseminated or extrapulmonary
- M. tuberculosis (TB) of any site, pulmonary, disseminated, or extrapulmonary
- Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
- Pneumocystis jirovecii pneumonia
- Pneumonia, recurrent
- Progressive multifocal leukoencephalopathy
- Salmonella septicemia, recurrent
- Toxoplasmosis of brain, onset at age >1 month
- Wasting syndrome attributed to HIV
People with HIV/AIDS are at high risk for developing certain cancers, such as Kaposi sarcoma, non-Hodgkin’s lymphoma, and cervical cancer. These three cancers are referred to as “AIDS-defining conditions,” and if a person has one of these cancers, it is very likely to signify HIV and the development of AIDS. The connection between HIV/AIDS and cancer is not completely understood but is believed to be the result of a weakened immune system. The following types of cancer are also common for people with HIV/AIDS:
- Hodgkin’s lymphoma
- Anal cancer
- Liver cancer
- Mouth or throat cancer
- Lung cancer
- Testicular cancer
- Colorectal cancer
- Multiple types of skin cancer including basal cell carcinoma, squamous cell carcinoma, and melanoma
(Robert H. Lurie Comprehensive Cancer Center, 2013)
Multisystem Effects of HIV/AIDS
HIV infection not only affects the immune system but also affects other body systems.
Respiratory tract defenses are affected by HIV. Alveolar macrophages in persons with HIV may serve as reservoirs for the virus. These protected viruses may infect other cells and may contribute to the accelerated HIV disease in the presence of opportunistic infections (Hopewell, 2011).
The gastrointestinal system is affected by AIDS enteropathy, a condition characterized by changes in the villus of the small bowel. This leads to malabsorption resulting in malnutrition and wasting (Barlett, 2011).
Integumentary system problems increase in frequency and severity. There may be pruritus without evident skin lesions. Herpes zoster may be a reliable sign of the presence and progression of HIV in a person who is otherwise asymptomatic. Necrotizing gingivitis and recurrent oral ulcers are common (Penneys, 2011).
The sensory system effects include visual impairment or blindness related to infectious or noninfectious ocular disorders, such as microvascular disease, retinitis, acute retinal necrosis syndrome, and optic nerve damage (Jacobson, 2011).
The effects on the hematologic system include morphologic abnormalities in the bone marrow resulting in cytopenias, most commonly anemia (Scadden, 2011).
Of great significance is the effect of HIV on the neurological system, resulting in HIV encephalopathy and AIDS dementia complex (ADC). The virus does not affect brain nerve cells but indirectly inflames or kills them. This occurs as CD4+ cell counts drop to less than 200. ADC varies from individual to individual, and symptoms may develop rapidly or slowly, affecting thinking abilities, behavior, coordination and movement, and mood. With the use of antiretroviral drugs, however, a less severe dysfunction known as minor cognitive motor disorder (MCMD) has become more common than ADC (Singh, 2013).
HIV-RELATED CONDITIONS AMONG SPECIAL POPULATIONS
HIV/AIDS imposes an additional burden on African Americans. The risk of end-stage renal disease (ERD) in HIV-infected black patients was 4–5 times greater than the risk of ERD in HIV-infected white patients. Studies reveal a gene variant that increases the risk of kidney disease in African Americans (NIH, 2011).
Children infected with HIV/AIDS may have different reactions to the virus, its progression, and their virologic and immunologic response. Without drug treatment, children may be developmentally delayed, experience failure to thrive, and be vulnerable to Pneumocystis jirovecii pneumonia and recurrent bacterial infections. Antiretroviral treatments available for adults with HIV/AIDS may not be available in pediatric formulations and may cause different side effects in children. (Pediatric HIV/AIDS is a specialty that is beyond the scope of this course.)
MANAGEMENT AND CARE
Optimal care of people with HIV/AIDS includes antiviral therapies, health maintenance, and referral to support services in addition to an emphasis on prevention of transmission to uninfected partners.
The Institute for Healthcare Improvement (2013) notes that it is extremely important that patients with HIV/AIDS play a major role in managing their condition. Each patient has unique desired outcomes and needs that require appropriate interventions. Each patient should be given basic information about HIV/AIDS and its treatment; assistance with self-management skill building; and ongoing support from the healthcare team, family, friends, and community.
The Institute recommends that self-management include:
- Collaborative goal setting
- Monitoring of symptoms
- Lifestyle modifications to improve overall health and well-being
- Adherence to the medication regimen
- Good communication with the healthcare team, family members, and others
- Involvement in ongoing problem-solving to overcome potential barriers
The healthcare team is advised to assist the patient’s self-management efforts by supporting and emphasizing the patient’s role in self-management, making recommendations, using effective interventions, and assisting with care-planning and problem-solving to aid in reducing barriers to self-management activities.
HIV/AIDS has proved to be a moving target, spreading beyond gay white men in cities to women, children, and seniors in small towns and rural areas. As people with HIV live longer, needs for healthcare services are changing. Depending on their personal support system and other resources, some people may require the assistance of a case manager to link them with various care services.
Case managers are often the primary contact people for services, including medical care, insurance programs, volunteer groups, home care, hospice, and other types of care that may be needed during the course of a person’s or family’s living with HIV/AIDS. Local community-based organizations may also provide additional support to adults, children, and families who are dealing with HIV/AIDS.
Evolving Treatment Guidelines
Treatment guidelines are revised frequently based on ongoing research findings. The most up-to-date information can be found online at aidsinfo.nih.gov/guidelines.
ANTIRETROVIRAL THERAPY (ART)
Antiretroviral therapy has become the gold standard for treatment of HIV/AIDS, with antiretroviral drugs administered in “cocktails” of three or more. (ART is also sometimes referred to as highly active antiretroviral therapy, or HAART.) People with HIV may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia.
ART has dramatically reduced HIV-associated morbidity and mortality and has transformed HIV disease into a chronic, manageable condition. In addition, effective treatment of HIV-infected individuals with ART is highly effective at preventing transmission to sexual partners. However, less than one third of HIV-infected individuals in the United States have suppressed viral loads, which is mostly a result of undiagnosed HIV infection and failure to link or retain diagnosed patients in care. Despite remarkable improvements in HIV treatment and prevention, economic and social barriers that result in continued morbidity, mortality, and new HIV infections persist (USDHHS, 2015).
Antiretroviral treatment of people with HIV continues to prove complex, controversial, dynamic, and expensive. These drugs do not constitute a “cure” for HIV/AIDS. If therapy is discontinued, viral load will increase. Even during treatment, the virus is replicating and the person remains infectious to others.
Seven major classes of drugs are used to treat HIV/AIDS:
- Nucleoside reverse transcriptase inhibitors (NRTIs)
- Nonnucleoside reverse transcriptase inhibitors (NNRTIs)
- Protease inhibitors (PIs)
- Fusion inhibitors
- HIV integrase strand transfer inhibitors (INSTIs)
- Entry inhibitors, CCR5 co-receptor antagonists
- Multi-class combination products
Source: U.S. FDA, 2013.
In 1996, tests to measure an individual’s viral load became available, providing objective criteria for treatment decisions. Following are treatment recommendations by the Panel on Antiretroviral Guidelines for Adults and Adolescents (USDHHS, 2015):
- ART is recommended for all HIV-infected individuals to decrease the risk of disease progression.
- ART also is recommended for HIV-infected individuals for the prevention of HIV transmission.
- Patients initiating ART should be willing and able to commit to treatment and understand the benefits and risks of therapy and the importance of adherence. Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy based on clinical and/or psychosocial factors.
ART Treatment Goals
Once ART therapy has begun, the Panel recommends these goals of therapy:
- Maximal and durable suppression of plasma HIV viral load
- Reduction of HIV-related morbidity and prolonging survival
- Improvement in quality of life
- Restoration and/or preservation of immunologic function
- Prevention of HIV transmission
ART for Pregnant Women
Recommendations for combination antiretroviral therapy (cART) during pregnancy include:
- All pregnant HIV-infected women should receive cART to prevent perinatal transmission.
- Combined antepartum, intrapartum, and infant antiretroviral (ARV) prophylaxis is recommended because ARV drugs reduce perinatal transmission.
- The known benefits and potential risks of ARV use during pregnancy should be discussed.
- ARV drug-resistance studies should be performed as indicated in the guidelines.
- Coordination of services among prenatal, primary, HIV specialty care providers, and others is essential to ensure ARV treatment adherence.
The efficacy of ART can be measured by plasma HIV RNA testing. Optimal viral suppression is defined as a viral load consistently below the level of detection (<20 to 75 copies/mL). Treatment failure at this point may be due to nonadherence, inadequate potency of drugs, suboptimal levels of antiretroviral agents, viral resistance, or other factors not completely understood.
Patients whose treatment fails despite careful adherence to the regimen should have their regimen changed. A thorough drug treatment history plus drug resistance testing should guide the design of the new regimen.
Patients who are cared for by clinicians with expertise in HIV/AIDS have better outcomes—in mortality, rate of hospitalizations, compliance with guidelines, cost of care, and adherence to medication regimens—than those cared for by less-experienced providers. Expertise is defined in terms of the number of patients actually managed. The DHHS panel recommends HIV primary care by a clinician with at least 20 HIV-infected patients and preferably at least 50 HIV-infected patients.
Many new medications for HIV/AIDS are in clinical trials. Patients experiencing drug resistance may be appropriate candidates for drugs still in trials. Physicians without extensive experience in treating HIV/AIDS are strongly urged to consult with specialists in this area when considering clinical trials for their patients.
Discontinuing or interrupting ART may become necessary due to factors such as serious drug toxicity, intervening illness, surgery, or unavailability of medications. Although unplanned short-term interruption of therapy may be unavoidable, planned interruption is no longer recommended. Interrupting therapy increases the risk of AIDS-related complications, declining CD4 counts, and other non-AIDS-related complications such as heart attack and liver failure.
While extending and improving lives of people with HIV, long-term use of some of these drugs increases the risk of liver problems, high cholesterol, stroke, heart disease, osteoporosis, diabetes, pancreatitis, neuropathy, and skin rashes. Some of the skin rashes can be life-threatening, such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), which are two different forms of the same kind of skin rash. TEN may involve as much as 30% of the total body skin area. Both these severe rashes must be treated by a physician.
Antiretroviral drugs may also interact with other drugs used to treat opportunistic infections. For example, taking oral erythromycin along with protease inhibitors increases the risk of sudden death from cardiac arrest. As patients live longer with HIV/AIDS, many develop drug-resistant strains of the virus, which further complicates treatment.
HIV Drug Resistance
HIV drug resistance is caused by mutations in the virus’s genetic structure. Such mutations are common in HIV because the virus replicates at a very rapid rate and does not contain the proteins needed to correct mistakes made during copying. Most mutations are harmless and actually reduce the virus’s ability to infect CD4 cells. However, some mutations can give HIV an advantage for survival when HIV medications are being taken. For persons with HIV, drug resistance can cause drugs to be less effective or even completely ineffective, resulting in reduced treatment options.
WHEN MUTATIONS CAN OCCUR
HIV drug-resistance mutations, known as “wild-type” viruses, can occur before or during treatment and can happen with transmission of drug-resistant HIV from one person to another. In countries where HIV treatment is in wide use, between 5% and 10% of new HIV cases involve drug-resistant strains of virus.
Mutations can also occur while using pre-exposure prophylaxis. HIV-negative people taking FDA-approved Truvada (emtricitabine/tenofovir disoproxil fumerate) are at risk if they become infected and are not diagnosed right away. If they continue to take the drug, their newly acquired virus may develop resistance to one or both of the medications in Truvada.
Drug resistance mutations can occur during treatment because genetic changes still occur over time and there may be a large mixture of virus in the body. Some of the variants may contain mutations that can partially or fully resist an antiretroviral drug. This is why one-drug treatment should never be used to treat HIV. With the development of combination HIV drug treatment, the amount of wild-type virus is dramatically reduced.
Of concern is that the mutations can cause cross-resistance. This means that the HIV that becomes resistant to one drug can cause resistance to other drugs in the same class.
Another reason for the occurrence of HIV drug resistance is poor treatment adherence. Successful treatment not only requires the patient to have significant financial resources but also the ability to understand and comply with a complex regimen. Unfortunately, many of the patients with the greatest need for treatment lack the necessary financial resources to make treatment a reality. However, patient demographics, such as race/ethnicity, sex, age, and socioeconomic status, do not predict who will adhere to a treatment regimen.
Drug resistance can also be the result of poor absorption, which can be affected by diet or diarrhea and vomiting. The latter can cause drugs to be expelled too quickly, thus affecting absorption. Varying pharmacokinetics can cause interactions between drugs, affecting how a drug is absorbed, distributed, broken down, and removed from the body.
Recent studies have identified novel compounds that may lead to new, cost-effective HIV treatments and a means for combating resistance to today’s antiretrovirals (Dapp et al., 2013).
Experts recommend that pretreatment drug-resistance testing be done with patients when HIV infection is first diagnosed, when changing antiretroviral regimens after drugs cease to be effective (treatment failure), and during pregnancy. Resistance testing helps clinicians better predict viral response to newly initiated therapy.
HIV drug-resistance testing should be performed:
- To assist in selecting active drugs when changing antiretroviral regimens in cases of virologic failure
- When managing suboptimal viral load reduction
In cases of virologic failure, drug resistance testing should be performed while the patient is taking his or her drugs or within four weeks of discontinuing therapy.
Two types of resistance assays are used: genotypic and phenotypic assays. Genotypic assays detect drug resistance mutations in the viral genes, while phenotypic assays measure a virus’s ability to grow in different concentrations of antiretroviral drugs. Genotypic assays take 1–2 weeks and phenotypic assays, 2–4 weeks. A genotypic assay is generally recommended for patients who have never had antiretroviral therapy. Genotypic resistance testing also is recommended for all pregnant women prior to initiation of therapy and for those entering pregnancy with detectable HIV RNA levels while on therapy.
OTHER MEDICATIONS AND THERAPIES
In addition to ART, people with HIV/AIDS may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia. Some of these medications may have serious interactions with ART, so prescribing physicians need to be familiar with all ART medications, as well as with their potential toxicities, when administered with other drugs.
Some people with HIV infection supplement their prescription drugs with vitamins, acupuncture, massage, yoga, meditation, herbs, naturopathic remedies, and other complementary therapies. People who turn away from prescription HIV medications and choose only herbs, vitamins, and other supplements are said to be using alternative therapies. Many of these remedies have not been studied to see if they offer any real benefit.
Therapies such as yoga, meditation, and massage can help reduce stress and enhance quality of life. However, herbs and other “natural” remedies may also interact with prescription medication. For example, St. John’s wort has major interactions with HIV medications. Therefore, people on HIV medications need to tell their physician, pharmacist, and social worker about all other supplements and nonprescription drugs they take.
Infections that are commonly found in HIV-positive patients include a number of other sexually transmitted diseases, TB, and hepatitis. Coexisting infections may increase the risk of transmission of HIV and make its treatment more complex.
Mycobacterium tuberculosis (M. tuberculosis, or TB) is the most common and most deadly coexisting infection for HIV-positive individuals. TB can also hasten the progression of HIV infection. Likewise, the spread of HIV/AIDS has helped fuel the TB epidemic.
One third of the people living with HIV/AIDS globally are also infected with tuberculosis. In high-burden countries, people with HIV/AIDS are 20 times more likely to contract TB. Globally, there were 8.6 million new TB cases in 2012 and 1.3 million TB deaths. Of these, 0.3 million deaths were HIV associated (TB Alliance, 2014).
In an HIV-infected person, TB disease can develop in either of two ways. A person who already has latent TB infection can become infected with HIV, and then TB disease can develop as the immune system is weakened. Or, a person who has HIV infection can become infected with M. tuberculosis and TB disease can then rapidly develop because their immune system is not functioning.
Antiretroviral therapy is the most effective treatment for controlling the progression of HIV; however, drug-drug interactions between the current first-line TB regimen and certain commonly used HIV drugs complicate treatment. To avoid these interactions in infected patients, new treatment regimens are desperately needed.
TB is transmitted by airborne droplets from people with active pulmonary or laryngeal TB during coughing, sneezing, or talking. When these infected droplets are inhaled, the bacteria enter the bloodstream and lymphatic system and circulate throughout the body.
Most of the bacteria settle in the lungs, where they multiply and may cause pneumonia-like symptoms. This process is called primary infection and in most cases resolves by itself within 4–12 weeks, after which a latent state of TB develops. Nine out of 10 people with latent TB never experience subsequent disease and are not infectious to others. The only evidence of TB infection is a positive tuberculin skin test.
In 10% of infected individuals, the TB infection undergoes reactivation at some point, causing active TB disease. Progression to active disease and obvious symptoms (cough, weight loss, and fever) usually occurs within the first two years after infection but may occur at any time.
TB TESTING AND TREATMENT
All people infected with HIV should be tested for TB and, if infected, begin complete therapy as soon as possible to prevent active TB disease. HIV-infected persons with either latent TB infection or active TB disease can be effectively treated. The first step is to ensure that HIV-infected persons are tested for TB. The second step is to help those infected with TB to get proper treatment and prevent rapid progression from latent TB infection to active TB disease.
Treatment of HIV/TB coinfected patients involves a complex 6- or 9-month multidrug regimen. All these drugs have significant side effects, which can lead to nonadherence and development of multidrug-resistant TB (MDR-TB) or extensively drug-resistant TB (XDR TB), which is much more difficult to treat successfully. Extensively drug-resistant TB is of special concern for persons with HIV infection. Coinfected individuals are at increased risk of developing active TB disease once they are infected and also have a higher risk of death once they develop TB.
Hepatitis is inflammation of the liver that may be caused by drugs and toxic agents or by one of several viruses, including hepatitis A, B, C, D, and others. People who are HIV positive are at risk for hepatitis A, B, and C infection. Hepatitis A is transmitted by fecal/oral route, usually by contamination of water or food due to poor sanitation. Hepatitis B (HBV) and C (HCV) are transmitted by the blood and body fluids of an infected person.
HIV-infected people should be tested for both A and B viruses, and if they test negative, should receive vaccines against both. However, there is no vaccine for HCV.
|Source: WA DOH, 2007.|
|Target in the Body|
|Risk of Infection (after needlestick exposure to infected blood)|
Hepatitis B can cause chronic liver disease or liver cancer, which makes vaccination essential to prevention. HBV vaccine is relatively inexpensive for infants and children and commonly administered to most infants before their first birthday. It is critical that infants whose mothers are HBV positive receive the vaccine; otherwise, they have a 90% chance of developing the disease. Adult doses of HBV vaccine cost about $139 per person, which may explain why most adults are not vaccinated against HBV.
In 2011 there were a total of 2,890 cases of acute hepatitis B reported to the CDC. The overall incidence rate for 2011 was 0.9 cases per 100,000. In 2011 a total of 39,636 cases of chronic hepatitis B was reported to the CDC. The greatest number (80%) of all reports received were from California.
Coinfection with hepatitis B and HIV is common. In the United States 70%–90% of HIV-infected persons have evidence of past or active HBV infection. HBV is often acquired via sexual contact or injection drug use. Chronic HBV infection occurs in 5%–10% of HIV-infected persons exposed to HBV. This is 10 times higher than for the general population. HIV increases the risk of cirrhosis and end-stage liver disease in HBV infection.
It is important to inform HIV/HBV-coinfected patients that HBV can be more infectious than HIV and can be transmitted to others in a household via dried blood, open cuts, and shared toothbrushes or razors.
Because of the elevated rates of HBV among people infected with HIV and the shared transmission routes between the two viruses, all HIV-infected individuals should be screened for HBV coinfection with HBsAG testing.
Those who receive hepatitis B vaccine should be tested for antibodies to hepatitis B surface antigen (antiHBs) 1–2 months after completion of the primary series of hepatitis B vaccine. Those who fail to respond should be revaccinated with up to three additional doses.
Risk factors for HBV include:
- Being born in areas with a high prevalence of HBV (China, Southeast Asia, Africa, the Pacific Islands, the Middle East, South America, and Alaska)
- Sharing injection paraphernalia
- Having sexual intercourse with an infected person or with multiple partners
- Men having sex with men
- Occupational exposures that involve contact with blood or body fluids, such as in a healthcare setting or prison
- Sharing personal care items such as razors or toothbrushes with an infected person
- Being on kidney dialysis
- Getting a tattoo or body piercing with equipment contaminated with the blood of someone infected with HBV
There are no medications available for recently acquired (acute) HBV infection. There are antiviral drugs available for the treatment of chronic HBV infection, but they are not always effective.
Hepatitis C is the most common chronic bloodborne infection in the United States and a leading cause of chronic liver disease. HCV was discovered in the late 1980s, although it was probably being spread for decades prior to that. People infected with HCV may have no symptoms for decades. When symptoms do appear, they are similar to those of HBV.
The CDC (2015) estimates 21,870 new infections occurred in 2012. An estimated 3.2 million Americans are infected with HCV, many of them from blood transfusions; half of them do not know they are HCV positive. (Since 1992, all blood donations in the United States have been tested for HCV.) Each year more than 8,000 people die from HCV-associated liver disease.
An estimated one third of HIV-positive people in the United States are also infected with HCV. Incidence is even higher among HIV-positive injection drug users (50%–90%). Coinfection with HIV and HCV is associated with higher titers of HCV, more rapid progression to HCV-related liver disease, and increased risk for cirrhosis of the liver.
Liver disease from chronic HCV is now one of the leading causes of death among people living with HIV. Individuals coinfected with HIV and HCV should restrict alcohol consumption and, if possible, avoid alcohol altogether because of potential liver damage.
The National Institutes of Health (2014) recommends that all HIV-infected persons be screened for HCV infection. Other people who will benefit from HCV testing include:
- Current or former injection drug users
- Those who received blood transfusions or an organ transplant prior to 1992
- People with hemophilia who received clotting factor concentrates produced before 1987
- Those who received chronic hemodialysis
- Infants born to infected mothers
- Healthcare workers who have been occupationally exposed to blood or who have had accidental needlesticks
- Sex partners of people with HCV
- People with type 2 diabetes
Coinfected patients also need to consult their health professional before taking any new medications—including over-the-counter, alternative/complementary, or herbal medicines—because of their possible effects on the liver. Those receiving ART may also be at risk for drug-induced liver injury (DILI) and should be carefully monitored.
Combined treatment of HIV and HCV can be complicated due to large pill burden, drug interactions, and overlapping toxicities. ART should be initiated for most coinfected patients, however, some clinicians may elect to defer ART until HCV treatment is completed in patients with CD4 counts >500 cell/mm3. In coinfected patients with lower CD4 counts (<200 cell/mm3), it may be preferable to initiate antiretroviral therapy and delay HCV therapy until CD4 counts increase.
Although there is no cure for HIV infection, there are treatment options that can help people living with HIV experience long and productive lives. Antiretroviral therapy for the treatment of HIV infection has improved steadily since the advent of potent combination therapy in 1996. New drugs have been approved that offer new mechanisms of action, improvements in potency and activity even against multidrug-resistant viruses, dosing convenience, and tolerability.
Because the science evolves rapidly, therapeutic options and preferences are continually changing. Treatment guidelines are updated frequently and are available on the AIDSinfo website (see below).
AIDSinfo (U.S. DHHS)
Perinatal HIV/AIDS (Rapid perinatal HIV consultation)
UCSF Clinician Consultation Center: 888-448-8765
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
Barlett JG. (2011). Gastrointestinal manifestations of AIDS. Retrieved from http://www.health.am
Centers for Disease Control and Prevention (CDC). (2012b). Vital signs: HIV infection, testing and risk behaviors among youths–United States. MMWR, 61(47), 971–6. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2015). Hepatitis C FAQs for health professionals. Retrieved from http://www.cdc.gov
Council of State and Territorial Epidemiologists (CSTE). (2012). HIV surveillance training manual. Retrieved from http://c.ymcdn.com
Dapp MJ, Bonnac L, Patterson SE, Mansky LM. (2013). Discovery of novel ribonucleoside analogs with activity against human immunodeficiency virus type 1. Journal of Virology, published ahead of print 23 October. doi:10.1128/JVI.02444-13.
Hopewell PC. (2011). Effects of HIV on respiratory tract defenses. Retrieved from http://www.health.am
Institute for Healthcare Improvement. (2013). HIV/AIDS: self-management and adherence. Retrieved from http://www.ihi.org
Jacobson MA. (2011). Ophthalmologic manifestations of AIDS. Retrieved from http://www.health.am
National Institutes of Health (NIH). (2014). Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Retrieved from http://aidsinfo.nih.gov
National Institutes of Health (NIH). (2011). Gene variant increases the risk of kidney disease in African Americans. Retrieved from http://www.nih.gov
Pennys NS. (2011). Cutaneous signs of AIDS. Retrieved from http://www.health.am
Robert H. Lurie Comprehensive Cancer Center. (2013). Types of cancer: AIDS/HIV-related malignancies. Retrieved from http://cancer.northwestern.edu
Scadden DT. (2011). Hematology/oncology in AIDS. Retrieved from http://www.health.am
Singh NN. (2013). HIV encephalopathy and AIDS dementia complex. Retrieved from http://emedicine.medscape.com
TB Alliance. (2014). Global tuberculosis report 2013. Retrieved from http://www.tballiance.org
U.S. Department of Health and Human Services (USDHHS). Panel on Antiretroviral Guidelines for Adults and Adolescents. (2015) Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Retrieved from http://www.aidsinfo.nih.gov
U.S. Department of Health and Human Services (USDHHS). Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. (2014). Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. Retrieved from http://aidsinfo.nih.gov
U.S. Food and Drug Administration. (2013). Antiretroviral drugs used in the treatment of HIV infection. Retrieved from http://www.fda.gov
Washington State Department of Health (WA DOH). (2007). Know curriculum. Retrieved from http://www.doh.wa.gov