HIV-infected patients' adherence to highly active antiretroviral therapy: a phenomenological study.

Adherence to the treatment regimen is essential to the success of highly active antiretroviral therapy for patients who are infected with HIV. The evidence suggests that poor adherence to antiretroviral drug therapy is a major problem that has the potential to diminish effective viral suppression, promote viral resistance, and place patients at risk for hospitalization, opportunistic infections, and an increased risk of HIV transmission. The primary aim of this study was to understand patients' experiences regarding their adherence to antiretroviral drug therapy. Thus, 19 participants were recruited for in-depth interviews regarding their adherence to drug regimens. All the interviews were transcribed verbatim and analyzed by using Benner's phenomenological analysis approach. Four main themes emerged from the data: (i) choosing to live and the decision to start taking medications; (ii) strategies for adhering to the regimen and managing the side-effects; (iii) relationships with healthcare providers; and (iv) advantages of the medications as a motivator to continue one's adherence to the regimen. Studying and understanding the experiences of patients can provide new insights and strategies in order to enhance patients' adherence to highly active antiretroviral therapy.

Overlooked potential: older-age parents in the era of ART.

The advent of widespread ART provision in low- and middle-income countries requires not just medical attention, but also social and psychological support to encourage and monitor strict adherence to drug regimens. Developing innovative approaches to providing this broad support is a major challenge, especially within the financial constraints of resource-limited countries hardest hit by the epidemic. In this study, we examine the role of older-age parents in monitoring ART treatment and caring for their HIV-infected children and grandchildren in Cambodia. Our results are based on 25 open-ended interviews with older-age parents of people with AIDS (PWHA). A high level of co-residence when PWHA become ill and a sense of parental responsibility and emotional attachment facilitate high parental involvement in their children's and grandchildren's illness, care and treatment. Our interviews indicate that parents play an important role in encouraging their children to get tested and to access treatment if they test positive. They consistently monitor antiretroviral therapy (ART) adherence and opportunistic infections and remind PWHA to attend medical appointments and support-group meetings. Parents also provide for the nutrition and hygiene of PWHA essential to the success of ART treatments. We find that despite low levels of education, older parents were able to express clear, correct and detailed knowledge of complicated ART treatment regimens, nutrition and hygiene. Overall, our findings show that older parents play a pivotal role in care and treatment if they are provided with proper resources and training and have the ability to understand the necessity and details of ensuring strict adherence to medications. Based on these results, we suggest that explicitly including older parents in policy and programs for care and treatment would allow Cambodia and other countries to take advantage of this unique and effective but overlooked asset in AIDS care and treatment.

Virologic response using directly observed therapy in adolescents with HIV: an adherence tool.

Virologic response to highly active antiretroviral therapy (HAART) treatment of HIV infection depends on viral sensitivity to antiretrovirals and excellent medication adherence. Adolescents with vertically acquired HIV may require complicated regimens because of significant treatment experience and often have poor medication adherence. A retrospective chart review identified five adolescents with vertically acquired HIV and plasma HIV viral load rebound or nonresponse on a stable HAART regimen followed by a period of directly observed therapy (DOT) in a clinic or hospital setting with serial viral load measurements. Four subjects had a virologic response (mean decline, 1.15 log10) after DOT. A response to HAART can be seen despite antiretrovirals resistance using DOT and treatment-experienced patients seemingly unresponsive to HAART may be nonadherent even with reassuring adherence measures. A period of clinic-monitored DOT may allow diagnosis of nonadherence, discussion of medication barriers, and avoidance of unnecessary medication changes.

Distal sensory polyneuropathy in the context of HIV/AIDS.

Peripheral neuropathy, or distal sensory polyneuropathy (DSPN), is the most common neurological problem in HIV disease. DSPN also represents a complex symptom that occurs because of peripheral nerve damage related to advanced HIV disease and in association with the use of antiretroviral therapy-particularly in individuals treated with dideoxynucleosides. Although DSPN is a frequent symptom, the specific pathophysiology is not well understood. The HIV-related neuropathies are commonly categorized as distal sensory polyneuropathies, although antiretroviral toxic neuropathies are described in the literature. Recently, mitochondrial toxicity has been identified as a possible etiology of DSPN. As individuals with HIV/AIDS survive longer, often living for decades with the disease, chronic symptoms like DSPN must be addressed. Pharmacologic approaches, complementary therapies, and self-care behaviors that may improve quality of life and limit symptoms of DSPN are important interventions for clinicians and those living with HIV/AIDS to consider in the management of peripheral neuropathy.

Dealing with the obstacles in adhering to highly active antiretroviral therapy.

Improving patient adherence to highly active antiretroviral therapy (HAART) is essential to effective treatment and represents a major challenge confronting healthcare providers. Because of their holistic perspective, nurses are uniquely qualified to identify the psychosocial and practical obstacles to full adherence and help patients deal with these problems. Studies have shown that many factors related to the disease, the patient, the provider, and the treatment regimen all play important roles in adopting and maintaining adherent behavior. Therefore, any attempt toward improving adherence should include adherence assessment and an approach that targets the patient, the provider, and the regimen. The availability of antiretroviral agents that are administered once daily and/or are associated with lower toxicity can help to simplify treatment regimens and avoid certain side effects, thereby facilitating greater adherence to highly active antiretroviral therapy.

Unraveling the mystery of HIV medications.

Today, millions of people around the globe are infected with human immunodeficiency virus (HIV). This retrovirus attacks and renders ineffective the human immune system and leads to acquired immunodeficiency syndrome (AIDS), which leaves those with AIDS open to a variety of fatal infections. HIV knows no racial, gender, or age distinctions, and there is, as yet, no cure for HIV. However, after 25 years of research, there are three classes of medication that in various combinations may significantly slow the progress of HIV, thus improving and prolonging the life of infected individuals. Nurses in any practice arena will inevitably care for patients who are infected with HIV. With an understanding of HIV and the therapeutic benefits of antiretroviral medications, informed nurses have the opportunity and responsibility to educate infected persons in the appropriate use of antiretroviral drugs and the importance of preventing transmission of HIV to uninfected persons.

Motivating HIV positive women to adhere to antiretroviral therapy and risk reduction behavior: the KHARMA Project.

Women comprise the fastest growing group of persons with AIDS. They are often diagnosed later in the disease, when antiretroviral therapy (ART) is strongly indicated. Antiretroviral therapy has transformed the course of HIV/AIDS to a treatable, chronic illness. This article provides a profile of women with HIV/AIDS and describes ART. Selected research related to adherence and motivation is summarized. Psychosocial and economic concerns specific to women, ART, adherence, and motivation are presented. The article reviews challenges for risk reduction behaviors for HIV+ women, such as sexual activity and substance abuse. The authors discuss the Keeping Health and Active with Risk reduction and Medication Adherence (KHARMA) Project, a research project in progress that was designed to promote adherence to both ART and risk reduction behaviors in HIV+ women. The study includes two groups: a motivational group intervention based on motivational interviewing and a health promotion program control group tailored to the needs of HIV+ women. A description of the tailored intervention and project update is included.

Symptom management in HIV/AIDS: advancing the conceptualization.

For people living with HIV, symptoms related to the disease, comorbidities, and treatment side effects make symptom management essential. Poorly managed symptoms result in reduced medication adherence, disease progression, and lower quality of life. The Self-regulatory HIV/AIDS Symptom Management Model is a conceptual model that describes how persons living with HIV/AIDS manage their symptoms. The model links symptom experience, symptom management, social support, adherence, and health-related quality of life. It can assist nurses, through a multidimensional approach to illness management, to enhance symptom assessment, better understand factors influencing symptom experience, and to improve symptom management among people living with HIV/AIDS.

Cardiovascular considerations in patients treated with HIV protease inhibitors.

Highly active antiretroviral therapy (HAART) has dramatically reduced mortality from HIV infection, transforming it in many cases to a chronic condition. However, protease inhibitors (PIs), which are integral components of most HAART regimens, are commonly associated with a host of metabolic disturbances that may increase the risk of cardiovascular disease in patients with HIV infection, potentially counteracting some of the positive health effects of PIs. Dyslipidemia is of particular concern. The Adult AIDS Clinical Trials Group has established preliminary guidelines to evaluate and treat PI-associated dyslipidemia. A number of strategies exist for the management of PI-based dyslipidemia in HAART recipients; their advantages and disadvantages should be considered when treating patients with HIV infection.

Recognizing and preventing drug interactions in older adults with HIV.

Currently, adults older than 50 account for approximately 15% of the total number of acquired immune deficiency syndrome (AIDS) cases. As baby boomers age, the number of older adults infected with the human immunodeficiency virus (HIV) is expected to rise. This expected increase is due, in part, to an increase in the number of individuals newly diagnosed with HIV, and, in part, to improved efficacy of the highly active antiretroviral therapy (HAART) medications used to treat HIV/AIDS. Older individuals who are infected with HIV also are expected to seek treatment for common conditions associated with aging. Thus, a considerable risk for drug interactions between the medications used specifically for HIV treatment and those used for other conditions exists. This article is intended as a guide for gerontological nurses facing these complexities. It includes reviews of the goals of HAART therapy and of the mechanisms of drug interactions, as well as detailed discussions related to the effects of HAART and their potential interactions with medications used to treat conditions commonly found in aging populations.

HIV and older adults: clinical outcomes in the era of HAART.

As the human immunodeficiency virus (HIV) epidemic enters its third decade, nurses are caring for increasing numbers of older adults with HIV who are on complicated medication regimens or highly active antiretroviral therapy (HAART). Although HAART has revolutionized HIV and acquired immunodeficiency syndrome (AIDS) care, little is known about how older adults respond to the new therapies. A review of the medical records of 19 older (> or = 50 years) and 18 younger (< 40 years) adults initiated on their first HAART regimen revealed both older and younger adults had similar positive clinical outcomes. Nurses need to individualize their care to patients of all ages rather than develop specific clinical guidelines for older adults with HIV.

Taking HAART in the fight against HIV/AIDS.

Drug therapy for HIV/AIDS has come a long way since the 1980s when the focus was treating opportunistic infections that often accompany HIV. Today, caregivers target HIV itself with highly active (or highly aggressive) antiretroviral therapy (HAART) that interrupts viral replication.

Pharmacological considerations in human immunodeficiency virus-infected adults in the intensive care unit.

According to estimates, 1.2 million Americans are infected with human immuno deficiency virus (HIV). Because of antiretroviral therapy, persons who have HIV infection or have progressed to AIDS are living longer. As a result, the likelihood that they will need critical care nursing is increasing. Unlike in years past, when these patients were often admitted because of the consequences of immunosuppression, today they are also being cared for in critical care units for other conditions associated with aging, other chronic health conditions, and trauma. When persons who have HIV disease or AIDS are admitted to the intensive care unit, nurses must be prepared to provide care, especially management of complexities associated with antiretroviral therapy. Therefore, this article examines critical care nurses' role in initiating and administering antiretroviral therapy in the intensive care unit and reducing the risk of drug interactions associated with the therapy.

An integrated approach for antiretroviral adherence and secondary HIV transmission risk-reduction support by nurses in Kenya.

Ongoing antiretroviral therapy (ART) adherence and secondary HIV transmission-risk reduction (positive prevention) support are needed in resource-limited settings. We evaluated a nurse-delivered counseling intervention in Kenya. We trained 90 nurses on a brief counseling algorithm that comprised ART and sexual-risk assessment, risk-reduction messages, and health-promotion planning. Self-reported measures were assessed before, immediately after, and 2 months post-training. Consistent ART adherence assessment was reported by 29% of nurses at baseline and 66% at 2 months post-training (p < .001). Assessment of patient sexual behaviors was 25% at baseline and 60% at 2 months post-training (p < .001). Nurse practice behaviors recommended in the counseling algorithm improved significantly at 2 months post-training compared with baseline, odds ratios 4.30-10.50. We found that training nurses in clinical counseling for ART adherence and positive prevention is feasible. Future studies should test impact of nurse counseling on patient outcomes in resource-limited settings.

Primary, secondary, and tertiary prevention of cardiovascular disease in patients with HIV disease: a guide for nurse practitioners.

HIV infection elevates a patient's risk for developing cardiovascular disease (CVD), due in part to direct effects of increased infection-producing inflammation and to drugs used to treat the infection, which can have untoward effects on serum lipid profiles. HIV-infected older adults often present with multiple comorbidities, including CVD, making disease management more challenging. Treatment paradigms are evolving, and nurse practitioners (NPs) are expected to play an ever-larger role in the management of HIV infection. Due to their accessibility and close patient contact, NPs are especially well suited to work with and educate patients to manage multiple risk factors. Appropriate use of primary, secondary, and tertiary CVD prevention strategies, including education to modify lifestyle risks, individualized antiretroviral treatment regimens to achieve serum lipid targets, and use of additional lipid-modifying strategies to minimize a patient's overall CVD risk profile will be important throughout the treatment lifecycle.

Nurse-initiation and maintenance of patients on antiretroviral therapy: are nurses in primary care clinics initiating ART after attending NIMART training?

OBJECTIVES: To determine the percentage of nurses initiating new HIV-positive patients on therapy within 2 months of attending the Nurse Initiation and Maintenance of Antiretroviral Therapy(NIMART) course, and to identify possible barriers to nurse initiation. METHODS: A brief telephonic interview using a structured questionnaire of a randomly selected sample (126/1736) of primary care nurses who had attended the NIMART course facilitated by the Foundation for Professional Development (FPD) between October 2010 and 31 March 2011 at primary care clinics in 7 provinces. Outcome measures were the number of nurses initiating ART within 2 months of attending the FPD-facilitated NIMART course. RESULTS: Of the nurses surveyed, 62% (79/126) had started initiating new adult patients on ART, but only 7% (9/126) were initiating ART in children. The main barrier to initiation was allocation to other tasks in the clinic as a result of staff shortages. CONCLUSIONS: Despite numerous challenges, many primary care nurses working in the 7 provinces surveyed have taken on the responsibility of sharing the task of initiating HIV-positive patients on ART. The barriers preventing more nurses initiating ART include the shortage of primary care nurses and the lack of sufficient consulting rooms. Expanding clinical mentoring and further training in clinical skills and pharmacology would assist in reaching the target of initiating a further 1.2 million HIV-positive patients on ART by 2012.