1 P RTAIL VIH / sida du Québec HIV What You Need to Know
2 Section Authors Dr. Jean-Guy Baril, physician, HIV Drug Resistance Nathalie Boies, social worker, Getting an HIV Diagnosis Dr. Marc-André Charron, physician, Clinical Follow-up of the HIV-positive Person Jean-Claude Chiasson, clinical nurse, HIV Screening Michèle Cossette, nutritionist, Living Well With HIV: Nutrution and Physical Activity Marie-Lou Dumont, social worker, Getting an HIV Diagnosis Nicolas Hamel, clinical nurse, HIV Transmission Marc Leclerc, Background and Statistics, Rights and Responsibilities Bruno Lemay, HIV / AIDS, HIV infection, CD4 Cells and HIV viral load, Progression of HIV infection, Virale Replication Benoît Lemire, pharmacist, Combination Antiretroviral Therapy and Guidelines, Adverse Effects Guylaine Morin, social worker, Women and HIV Nathalie Pelletier, sexologist and social worker, Sex and HIV Rachel Therrien, pharmacist, Antretrovirals, Treatment Adherence, Drug Interactions Jean-Marc Trépanier, nurse GMF (family medicine group), Post-exposure prophylaxis (PPE) Editorial Team Marc Leclerc Bruno Lemay Scientific Review Dr. Jean-Guy Baril Dr. Harold Dion Dr. Annie Talbot Graphic Design Kim Deslauriers Legal Review (Rights and Responsibilities section) Me Stéphanie Claivaz-Loranger Translation Alain Boutilier Design and Layout Marie-Christine André Kim Deslauriers Many thanks to Laurette Lévy for her collaboration, to Marc Leclerc for his contributions as a volunteer, and to all those who contributed locally or from afar to the creation of this publication. We are also grateful to Quebec s Ministère de la Santé et des Services sociaux for its support. Disclaimer The information in this guide is purely general in nature. It aims to convey a variety of information that may help people living with HIV/AIDS gain a better understanding of their situation and to better manage their health in collaboration with their health care professionals and other support workers. This information does not constitute medical opinion and must not take the place of a visit, call, consultation or opinion of a doctor or other health care provider. Portail VIH/sida du Québec does not recommend self-management of health problems nor does it recommend any treatment in particular. Portail VIH/sida du Québec cannot guarantee the reliabilty, accuracy, usefulness or completeness of the information contained in this guide. This publication also contains legal information that cannot be construed as legal advice or opinion. Financial support provided by: Bristol-Myers Squibb and Gilead The financial sponsors of HIV/AIDS: What You Need to Know did not contribute in any way to the content of this guide. Reproduction of this document This document is protected by copyright. Reproduction or printing of this document for non-commercial purposes is permitted. Any modification of its content must by authorized by Portail VIH/sida du Québec. HIV: What You Need to Know, 2 nd edition Portail VIH/sida du Québec. All Rights Reserved. ISBN Legal deposit - Bibliothèque et Archives nationales du Québec, 2012 Legal deposit - Library and Archives Canada, 2012 Portail VIH/sida du Québec 1287 Rachel St. East Montreal, Quebec H2J 2J
3 PORTAIL VIH/SIDA DU QUÉBEC HIV/AIDS: What You Need to Know CONTENTS Background and Statistics...02 A Look Back...04 Statistics...05 HIV/AIDS...06 HIV Infection...07 The Immune System...08 CD4 Cells and HIV Viral Load...10 Progression of HIV Infection...11 Virale Replication...12 HIV Transmission...14 HIV Screening Tests...17 Getting an HIV Diagnosis...18 Sex and HIV...20 Pots-exposure Prophylaxis (PEP)...21 Combination Antiretroviral Therapy and Guidelines...22 Antiretrovirals...24 Adverse Effects...26 Treatment Adherence...28 Drug Interactions...30 HIV Drug Resistance...31 Clinical Follow-up of the HIV-positive Person...34 Living Well With HIV...36 Women and HIV...39 Rights and Responsibilities...41 Lexicon...44 Sources...45 HIV / AIDS Ressources...47
4 PORTAIL VIH/SIDA DU QUÉBEC 02 BACKGROUND AND STATISTICS A GLOBAL PERSPECTIVE Amount of people living with HIV in the world in North America 1,4 million Western and Central Europe Eastern Europe and Central Asia 1,5 million East Asia Caribbean Middle East and North Africa South Asia 3,8 million Latin America 2,0 million Sub-Saharan Africa 22,4 million Oceania Source: UNAIDS (For English graphic, see English report on UNAIDS site Several scientific theories have attempted to explain the origin of AIDS. It has been established that it first appeared in Central Africa, with the first outbreak occurring specifically in the Democratic Republic of the Congo at the end of the 1950s. To gain a better understanding, it s important to distinguish between the origins of viruses and those of epidemics. HIV is a virus that is related to the simian immunodeficiency virus (SIV) that is found in certain African primates. Once humans became contaminated by the blood or flesh of infected monkeys, SIV mutated and gave rise to HIV. Several factors tend to explain how the disease spread to become a worldwide HIV (type 1 strain) pandemic: inadequate on non-existent sterilization of medical equipment, reuse of syringes used for vaccinations or the treatment of certain diseases, the mobilization and displacement of certain individuals or groups, prostitution, unprotected sex, poverty, etc. Although the spread of the virus began in Africa, AIDS was officially diagnosed in 1981 in the United States when doctors in New York and San Francisco began noticing similar symptoms and diseases among their male homosexual patients, such as asthenia, weight loss, certain rare forms of pneumonia and cancer (Kaposi s sarcoma). These observations were validated that same year by the Centers for Disease Control and Prevention (CDC) in Atlanta, which prompted the media to suggest the outbreak of a "gay cancer or plague." This terminology evolved in the following year, and the condition became known thereafter as AIDS (Acquired Immune Deficiency Syndrome).
5 03 PORTAIL VIH/SIDA DU QUÉBEC The virus was discovered and isolated in 1983, although its mode of replication and mechanisms of action remained unknown. The ways that the virus was transmitted were clear, however. In Canada, the first AIDS death was reported around this same time, and the number of cases of infected people with opportunistic infections was exploding. In the medical field, observations about the disease continued to accumulate as death rates due to AIDS soared. The first HIV antibody screening test appeared in late 1984, early The 1st World AIDS Conference also took place in 1985, in Atlanta. AZT, the first anti-vih drug, appeared in At the same time, fear of the disease and the stigmatization of those with it were on the rise (particularly against homosexuals, who represented the majority of diagnosed cases in North America and Europe). Following the example of the United States, where HIV-positive people were denied entry to the country in 1987, several nations adopted a similar policy that remains in effect to this day in some places. The 1990s saw new HIV drugs come to market; in 1996, during the World AIDS Conference in Vancouver, a new class of drugs was unveiled: HIV protease inhibitors. Triple combination therapy - three HIV drugs used together - became the new treatment strategy. Patients health improved spectacularly and the death rate went down. Yet, despite this progress, taking medication remained a challenge for patients. Serious side effects were reported, in particular lipodystrophy (changes in body fat). The HIV viral load test became available that same year, making it possible to keep better track of the virus s progress in patients. As well, a study confirmed that the use of AZT in infected pregnant women greatly reduced the rate of HIV transmission from mother to child. Early in the 2000s, studies of HIV resistance to certain drugs were undertaken and treatment strategies were facilitated when a number of tests became available (for example, genotypic and phenotypic resistance tests). In 2000, the World AIDS Conference in Durban, South Africa, illustrated the lack of solidarity and the imbalance between the rich and underdeveloped countries of the world. The latter, where fewer than 1% of infected people were receiving HIV drugs, demanded access to affordable antiretrovirals. New classes of drugs arrived on the scene during that same decade, including fusion inhibitors, which are used as rescue therapy in multi-resistant patients. Throughout the world, more and more studies were launched in order to find a vaccine. In 2009, in Montreal, delegates at a scientific meeting about retroviruses learned the case of an HIV-positive German man with leukemia who became HIV-negative three years after receiving a bone marrow transplant from a donor with HIV-resistant genes. This example demonstrates the need for more research. AIDS has caused more than 25 million deaths throughout the world. Never before has there been such a mobilization of economic, scientific and medical resources in the fight against this disease. Despite ongoing vaccine research, the introduction of more effective medications and a longer life expectancy, it is still not possible to cure AIDS. People who live with HIV, be they men, women or children, continue to confront prejudice and must now reckon with new issues such as the criminalization of HIV in several countries.
6 PORTAIL VIH/SIDA DU QUÉBEC 04 A LOOK BACK 1981 to 2009 A few facts First case of AIDS reported in the United States COCQ-sida / Creation of the Coalition des organismes communautaires québécois de lutte contre le sida. Red ribbon / Universal symbol of compassion and solidarity with victims of HIV / AIDS Discovery and isolation of the HIV virus Double combination therapy: combining HIV drugs ( AZT, DDI, DDC ). Creation of the Canadian HIV /AIDS Legal Network /1985 First screening test for HIV is used. First World AIDS Conference held in Atlanta. American actor Rock Hudson dies of AIDSrelated complications. Creation of the Canadian AIDS Society. AZT is brought to market. First vaccine study begins. San Francisco / Names project. "The AIDS Quilt" is created to honour the memory of people lost to AIDS. More than 35 participating countries to date, including Canada. Creation of World AIDS Day on December 1 st CPAVIH / Creation of the Comité des personnes atteintes du VIH/sida du Québec. CATIE / Creation of the Canadian AIDS Treatment Information Exchange. Death of Queen lead singer Freddy Mercury from AIDS-related complications Ça Marche/ Farha Fondation / 1 st edition of Montreal AIDS Walk. 3TC - antiretroviral drug developed in Quebec. UNAIDS, launch of the Joint United Nations Program on HIV / AIDS. Beginning of triple combination therapy: arrival of protease inhibitors. Spectacular improvement in the health of patients. Death from AIDS-related complications of Dr. Lucille Teasdale, a Canadian surgeon working in Uganda. World AIDS Conference in Durban, South Africa: Emerging countries demand access to ARV medications. Creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria. Exhaustion of treatment strategies for multi-resistant patients; arrival of fusion inhibitors provides rescue therapy in such cases. Almost 20% of HIV-positive people in the world have access to combination therapy.
7 05 PORTAIL VIH/SIDA DU QUÉBEC STATISTICS GLOBAL EPIDEMIOLOGICAL PORTRAIT OF AIDS ESTIMATES DECEMBER 2008 People living with HIV Adults (15 + ) 31.3 million Women 15.7 million Children 2.1 million Total 33.4 million New cases of HIV Infection Adults (15 + ) 2.3 million Children Total 2.7 million Death due to AIDS Adults (15 + ) 1.7 million Children Total 2.0 million CANADIAN EPIDEMIOLOGICAL PORTRAIT OF AIDS ESTIMATES DECEMBER 2008 Estimated prevalence of HIV infection in Canada Total Estimated prevalence of HIV infection Quebec Sources : 1 - ONUSIDA 2 - Public Health Agency of Canada 3 - Ministère de la Santé et des Services sociaux du Québec MSM MSM and IDU IDU Heterosexual contact / Endemic country Heterosexual contact / Non-endemic country Other Total MSM : Man who has sex with other men. IDU : Injection drug user. Heterosexual contact / Endemic country: Non-IDU heterosexuals from countries where male-female sexual contact is the predominant mode of transmission of HIV. Heterosexual contact / Non-endemic country: Heterosexual contact with a person infected by HIV where this is the only known risk factor.
8 PORTAIL VIH/SIDA DU QUÉBEC 06 HIV and AIDS WHAT S THE DIFFERENCE? HIV is a virus that attacks the immune system. In particular, it infects CD4 lymphocytes, which are cells that control the immune response and defend us against infections caused by bacteria, viruses, fungi, parasites and even cancer cells. The HIV virus does not breathe or eat. All it does is replicate (make copies of itself). The word immunodeficiency refers to a weakening of the immune system that increases the risk of contracting other infections. People infected with HIV are said to be HIV-positive. If no treatment is undertaken to prevent the virus from replicating, the immune system becomes weak and can no longer defend itself against microorganisms such as bacteria and other viruses. The body may then be subject to opportunistic infections. These infections characterize the stage called AIDS or acquired immune deficiency syndrome. HIV infection and HIV / AIDS are both terms used to refer to the disease. H I V A I D S uman mmunodeficiency irus cquired mmune eficiency yndrome
9 07 PORTAIL VIH/SIDA DU QUÉBEC HIV INFECTION THE FOUR STAGES OF HIV INFECTION 1 PRIMARY INFECTION (ACUTE INFECTION) This is the period that follows the virus s entry into the body. During this stage, the virus multiplies rapidly and the risk of transmission is higher. This first stage may include flu-like symptoms such as fever, sore throat, muscle pain, fatigue, swelling of the lymph nodes and rash. These symptoms, which disappear after a few weeks, do not occur in all infected people. In some cases, primary infection goes unnoticed. It s during this period that the immune system produces antibodies to defend itself against the virus. SEROCONVERSION Seroconversion is the stage when the body begins to produce antibodies against HIV. It takes up to three months for the body to produce these new proteins that will attempt to fight the virus. 2 ASYMPTOMATIC STAGE During this period, the virus does not cause symptoms but remains active and continues to replicate and to infect other immune cells. Without treatment, this symptom-free stage can last for more than 10 years for some people, although it is shorter for others. It s important to remember that although the virus is causing no symptoms during this period, it is still present in the body and can be transmitted to other people. 3 SYMPTOMATIC STAGE During this stage, persistent symptoms begin to appear as a result of a weakened immune system. People may begin to experience symptoms of infection such as chronic fatigue, night sweats, diarrhea or significant weight loss. If the immune system continues to weaken, it will become more difficult for the body to defend itself against infections. 4 AIDS The AIDS stage is defined by the occurrence of opportunistic infections caused by bacteria, viruses or fungi, or by the onset of certain types of cancer. HIV-specific infections take advantage of a weakened immune system and some are potentially lifethreatening if no antiretroviral treatment is undertaken. These infections rarely occur in people with intact immune systems. The list of opportunistic infections includes the following: Pneumocystis Jiroveci pneumonia (formerly known as Pneumocystis Carinii pneumonia), toxoplasmosis, cytomegalovirus (CMV), Kaposi s sarcoma, etc.
10 PORTAIL VIH/SIDA DU QUÉBEC 08 THE IMMUNE SYSTEM BLOOD CONTAINS PLASMA AND THE FOLLOWING INGREDIENTS WHITE BLOOD CELLS or Leucocytes Immune response RED BLOOD CELLS or Erythrocytes Blood oxygenation PLATELETS or Thrombocytes Blood clotting AGRANULOCYTES or Mononuclears Including: 1- Monocytes: become macrophages inside tissues. Role: phagocytosis, cell presenting viral antigen Lymphocytes T GRANULOCYTES or Polynuclears Phagocytosis 1 and allergic reactions LYMPHOCYTES B T4 (CD4) Lymphocyte B Conductor of the immune response. It sends chemical signals to other cells in order to activate the immune response. T8 (CD8) Stimulated by CD4 cells or a microbe s antigen 2. Produces special proteins called antibodies that attach themselves to viruses in order to destroy them before they have time to infect cells. Destroyer of other cells infected by viruses. Once an infection is under control, it sends a signal to other cells to slow down so the immune system can return to its normal state. 1 Phagocytosis: Defensive process (non-specific immunity) launched by cells that surround and destroy solid bodies, especially microbes. 2 Antigen: Foreign substance in the body that can trigger an immune response or react with its result (antibody). Adapted from: Sida e éd. Comité des personnes atteintes du VIH du Québec
11 09 PORTAIL VIH/SIDA DU QUÉBEC THE IMMUNE SYSTEM SPECIFIC IMMUNITY TARGETING EACH MICROBE ONCE IT HAS BEEN IDENTIFIED BY THE DEFENCE SYSTEM VIRUS CD4 CELL CHEMICAL SIGNALS Stimulation of CD8 lymphocytes by CD4s and production of substances designed to destroy infected cells. LYMPHOCYTE B CELLULE CD8 Stimulation of CD8 lymphocytes by CD4s and production of antibodies specific to a given microbe. In some cases, antibodies are able to facilitate the destruction of various microbes. (viruses, bacteria, etc.). ANTIBODIES INFECTED CELL VIRUS Adapted from: Sida e éd. Comité des personnes atteintes du VIH du Québec
12 PORTAIL VIH/SIDA DU QUÉBEC 10 CD4 CELLS AND HIV VIRAL LOAD CD4 CELLS CD4 cells (lymphocytes) orchestrate the fight against infections. They detect viruses and other microbes present in the body and organize the immune response. When they encounter a virus such as HIV, CD4 cells send signals to other white blood cells, prompting them to combat the infection. Unfortunately, white blood cells are unable to destroy all HIV viruses. HIV VIRAL LOAD Viral load is an indication of the amount of HIV in the blood. It is expressed as the number of copies of viral RNA in a single milliliter of blood. HIV quickly makes copies of itself and exerts a great deal of stress on the immune system. In general, as the viral load increases, the CD4 count decreases. HIV treatments are designed to lower viral load to the point where it becomes undetectable. In the meantime, HIV destroys CD4 cells by using them to replicate. In general, the CD4 count declines over time, while the risk of infections increases. The CD4 count is an important immune system marker. A high CD4 count (>500) is generally an indicator of a vigorous immune system. Treatment recommendations are based in part on the CD4 count. The viral load is said to be undetectable when the number of copies of virus is lower than 40 copies/ml, or lower still depending on the test used. The international standard for an adequate virologic response is a viral load below 50 copies/ml. Despite this low number, the virus is still present in the blood and can be transmitted. An undetectable viral load is the result of effective treatment.
13 11 PORTAIL VIH/SIDA DU QUÉBEC PROGRESSION OF HIV INFECTION WITHOUT TREATMENT 1 CD4 Count 2 Asymptomatic Stage 3 Viral Load 1 During the first few days following HIV infection, the virus multiplies rapidly, causing a high viral load and decreased CD4 count. It s during this period (called primary infection) that non-specific symptoms can occur, such as fever, swollen lymph nodes, myalgia (muscle pain), etc. If and when they occur, these symptoms resolve spontaneously within a few weeks. An HIV antibody screening test may give a negative result at this point in time. 2 After this period, the virus continues to multiply, but at a slower rate than during the primary infection. Many infected people will have no clinical manifestations of HIV during this asymptomatic stage that lasts on average from seven to ten years. 3 If no antiretroviral treatment is undertaken, the CD4 count will fall, the viral load will climb and AIDS-related symptoms or opportunistic infections may occur.
14 PORTAIL VIH/SIDA DU QUÉBEC 12 VIRAL REPLICATION OR HIV LIFE CYCLE The HIV virus has only one goal: to replicate. To do so, it must insert its genetic material into a specific type of immune system cell called a CD4 lymphocyte; the virus then uses the infected cell to produce new viruses. The replication process includes four distinct and successive steps. The various classes of antiretrovirals target different steps of the viral replication cycle in order to stop the virus in its tracks. HIV STEP 1: ENTRY Co-receptors and receptor CD4 cell Nucleus HIV spots a CD4 cell and attaches itself to the cell s main receptor using a protein called gp120 that is found on the virus s outer surface. Next, the virus must attach itself to a CCR5 or CxCR4 co-receptor in order to fuse with the CD4 cell and penetrate its interior. CCR5 co-receptor inhibitors and fusion inhibitors are two classes of antiretrovirals used to prevent the virus from entering CD4 cells. RNA STEP 2: TRANSCRIPTION Enzyme Reverse transcriptase Viral DNA Once inside the cell, the virus must transform its genetic material (RNA) into DNA in order to make it compatible with the cell s genetic material. To convert its RNA into DNA, the virus uses an enzyme called reverse transcriptase. Nucleoside and non-nucleoside reverse transcriptase inhibitors are used to stop this action from occurring.
15 13 PORTAIL VIH/SIDA DU QUÉBEC Enzyme Integrase Nucleus STEP 3: INTEGRATION HIV inserts its modified genetic material (viral DNA) into the cell s nucleus with the help of another enzyme called integrase. Integrase inhibitors stop the virus from entering the cell s nucleus. Enzyme Protease New viruses STEP 4: ASSSEMBLY The cell now takes on a new function and begins producing long chains of viral protein. An enzyme called protease acts as a pair of scissors to cut these protein chains into several pieces and assemble them to make new copies of HIV. These new copies are then expelled from the cell through a process called budding and then go on to infect other CD4 cells. Protease inhibitors block the action of the protease enzyme, thereby preventing the production of new viruses.
16 PORTAIL VIH/SIDA DU QUÉBEC 14 HIV TRANSMISSION the body. Page 16 provides a detailed table outlining the risks of HIV transmission associated with various sexual activities. TRANSMISSION THROUGH BLOOD HIV is transmitted through sex, by contact with the blood of an infected person or from an HIV-positive mother to her child during pregnancy or delivery. HIV IS TRANSMITTED BY: - Blood - Sperm - Pre-ejaculatory fluid (precum) - Breast milk - Vaginal secretions HIV can be transmitted when contact occurs between these infected fluids and an open sore or mucus membrane. It s important to note that the concentration of virus in these fluids, that is to say the viral load, has an impact on the risk of HIV transmission. SEXUAL TRANSMISSION Certain sexual practices carry a greater risk of transmission than others. Anal or vaginal penetration without a condom is considered a high-risk activity, both for the person who is penetrated and the one who penetrates. The risk of contracting HIV when performing fellatio (giving a blow job) is considered low, but it is best not to allow sperm into the mouth because tiny lesions on bleeding gums or an irritated throat could provide an entryway for the virus into HIV can also be transmitted when the blood of an infected person comes into contact with the blood of someone else. Such blood-to-blood contact can occur when: - people share equipment for injecting medications, drugs or steroids - people share needles for tattooing or amateur body-piercings (non-professional piercings involving unsterile equipment). With regard to blood transfusions, it s important to note that Héma-Québec has been using preventive measures for years in order to ensure that blood donations are not infected with HIV. MOTHER TO CHILD TRANSMISSION All pregnant women should be tested for HIV as part of their prenatal care. The treatments given to prevent mother-to-child transmission greatly reduce the risk of HIV transmission during pregnancy and delivery by decreasing the concentration of virus in the blood and other bodily fluids. Breast-feeding is also strongly discouraged. HIV-positive women who wish to become pregnant should speak to their health-care team to receive counseling about the different options available (also see Women and HIV on page 39).
17 15 PORTAIL VIH/SIDA DU QUÉBEC TRANSMISSION AND VIRAL LOAD The risk of HIV transmission increases as the concentration of virus in an HIV-positive person s bodily fluids rises. That s why taking antiretrovirals to reduce viral load can decrease the risk of HIV transmission. However, in certain situations, even if the viral load in the blood is undetectable, it may be higher in the genital fluids. The presence of an STI (sexually transmitted infection such as gonorrhea, chlamydia or syphilis) can increase the concentration of HIV in the genital fluids of an HIVpositive person, making them more likely to transmit the virus. As well, when an HIV-negative person has an STI, he or she is at greater risk of contracting HIV because the lesions or irritations caused by the infection can make the mucus membranes of his or her genitals more permeable. Using a condom for sex remains the most effective way of reducing the risk of HIV transmission, even when the blood viral load is undetectable (less than 40 copies/ml) by laboratory tests. List of the most common sexually transmitted and blood-borne infections (STBBI): Chlamydia Condyloma (HPV) Gonorrhea Hepatitis A, B, C, D, E Genital herpes Vaginal infection Scabies Crabs Lymphogranuloma venereum (LGV) Syphilis The information above and on the following page relates to HIV transmission only and does not take into account other STIs and blood-borne diseases (such as the viruses that cause hepatitis).
18 PORTAIL VIH/SIDA DU QUÉBEC 16 EVALUATING THE RISK OF HIV TRANSMISSION 1 NO RISK Potential for transmission NONE Evidence of transmission NONE None of the practices in this category have been shown to cause HIV infection. There is no potential for transmission because the basic conditions necessary for it to occur are not present. Kissing (with no exchange of blood); masturbation (with no penetration); passive insertion of an unshared sex accessory; contact between fecal matter or urine and healthy skin; injection using new and unshared instruments; sniffing or smoking drugs using a new and unshared instrument (straw or tube); sadomasochistic activities (provided universal precautions are applied); tattooing, electrolysis and acupuncture when universal precautions are applied; manicures and pedicures. 3 LOW RISK Potential for transmission YES Evidence of transmission YES (under certain conditions) All the activities in this category carry a potential for HIV transmission because they involve an exchange of bodily fluids such as sperm (including precum), vaginal secretions, blood or breast milk. Indeed, cases of infection have been attributed to these activities (generally in case studies or anecdotal reports that include identifiable conditions for transmission). Kissing (with exchange of blood); giving fellatio (without a condom); cunnilingus without a barrier; penetration (vaginal or anal) with a condom; needle injection, shared disinfected syringe or drug preparation material; tattooing, electrolysis and acupuncture with non-professional instruments; taking blood into the mouth; occupational exposure. 2 NEGLIGIBLE RISK Potential for transmission YES Evidence of transmission NONE All the activities in this category carry a potential for HIV transmission because they involve an exchange of bodily fluids such as sperm (including precum), vaginal secretions, blood or breast milk. However, the quantity of fluid and means of exchange seem to greatly decrease the efficacy of transmission. No confirmed case of infection has been linked to these activities. Receiving fellatio or cunnilingus (having someone go down on you); giving cunnilingus using a barrier; receiving or giving fellatio with a condom; rimming; fingering; fisting; passive insertion of a shared accessory with a condom; insertion of a disinfected accessory; sadomasochistic activities; contact between fecal matter or urine and a mucus membrane or cut, open sore, lesion, ulcer, burn or oozing rash; vulva to vulva frottage; docking; taking breastmilk into one s mouth; sniffing or smoking drugs with a shared instrument (pipe or tube); tattooing, electrolysis and acupuncture with a shared instrument that has not been disinfected; fighting; sharing a toothbrush or razor. 4 HIGH RISK Potential for transmission YES Evidence of transmission YES All the activities in this category carry a high risk of HIV transmission because they involve an exchange of bodily fluids such as sperm (including precum), vaginal secretions, blood or breast milk. Indeed, a significant number of studies have demonstrated time and time again the link between these activities and HIV infection. Even when the precise mechanism of transmission is not completely understood, studies allow us to conclude that the risk of transmission associated with these activities is high. Penetration (vaginal or anal) without a condom; passive insertion of a shared sex accessory, without a condom; injection with a shared or uncleaned instrument. The information in this table was taken from the Canadian AIDS Society s Guidelines for Assessing Risk, fifth edition, 2005
19 17 PORTAIL VIH/SIDA DU QUÉBEC HIV SCREENING TESTS The first HIV screening tests were brought to market in During the years that followed, people had to wait six months after a risky activity to be tested. Nowadays, screening is done routinely across Quebec and results can be obtained in just a few weeks. ANTIBODY SCREENING TEST The HIV screening test that is widely used today looks for the presence of antibodies in a person s blood. It takes up to three months for the human body to produce HIV antibodies. That s why people need to wait three months after a possible exposure to HIV to be tested. This period is referred to as the "window" period. The test is called ELISA and a negative result can generally be obtained two weeks after the blood test, depending on the location. When the result is positive, the same blood sample is tested using the more precise Western Blot test, in order to confirm the result. A second test must always be done using a new blood sample to validate an initial diagnosis of HIV. The same is true when the first result is deemed to be indeterminate. The HIV antibody screening test can be done in specialized STI clinics, CSSS centres (formerly known as CLSC) and hospitals, according to demand. The cost of the test is covered by the Régie de l assurance maladie du Québec (RAMQ). ANONYMOUS SREENING TEST (no name is required) If you wish to test anonymously, you will be given a code. To obtain your result, you will have to provide that code, which only you will know. No mention of the test will be included in your medical record. This service is offered by some SIDEPs (Services intégrés de dépistage et de prévention des ITSS), which are in fact Centres de santé et de services sociaux (CSSS). This test is also available through certain HIV prevention organizations (see the Resources section in this guide). RAPID HIV ANTIBODY SREENING The rapid HIV screening test allows patients to get their result 30 minutes after providing a blood sample. The sample is obtained in the usual way or by a simple finger prick. This test is 99.8% reliable, but is not covered by the RAMQ. Although not yet available, the HIV saliva screening test does seem to be promising. VIRUS SCREENING TEST (P24) There exists a highly sensitive test that makes it possible to screen for HIV early on. Due to the presence of the P-24 antigen, a viral component and marker associated with recent infection by HIV, it is possible to screen for the virus a few weeks after a potential exposure. This costly test can detect the presence of the virus in a blood sample, but a followup test is recommended three months later.
20 PORTAIL VIH/SIDA DU QUÉBEC 18 GETTING AN HIV DIAGNOSIS Learning that you have HIV is upsetting. People deal with this news in a wide variety of ways. It s a life crisis that inevitably affects both the person concerned and those close to him or her. But nowadays being HIVpositive does not necessarily mean that the disease is far along or that death is near. Thanks to better drugs and more effective care, the quality of life of people living with HIV has greatly improved. Indeed, most HIV-positive people are living longer and can expect to lead a normal life. If you have HIV, your treating physician and other health-care professionals are allies that you should not hesitate to consult, as well as other care providers such as psychologists, social and community workers and nutritionists. THE JOURNEY A positive diagnosis causes upset and changes at several levels. The emotions experienced during this time resemble those associated with grief. Understanding the stages of this process can help you cope with the disease and make life choices by establishing your priorities, both in terms of your relationships and professional life. Coping with HIV (stages of grief) SHOCK is a psychological state characterized by physical and/or emotional pain. It s important to take the time to absorb the news before making important decisions. Once the shock has subsided, it s important to inform your sexual partner or partners and encourage them to be tested. If this proves to be too difficult, your doctor may be able to help you. Public Health authorities also offer an anonymous partner notification service. DENIAL is characterized by doubt, a refusal to accept reality or the hope of going back in time. BARGAINING involves negotiation. The aggrieved person attempts by any means possible to remedy the situation. For example, he or she may try miracle cures or insist that the tests results are false and want to repeat them, or cling to conflicting information: "One doctor told me this, another that, who should I believe?". ANGER (sadness) sometimes conceals great sadness related to the new situation. It s important to explore the reasons for your anger as well as its targets. Speaking to a trusted person (friend, family member, professional) may help you release tension and express your pain. AWARENESS implies realizing the inevitable nature of your situation. It is sometimes accompanied by shame and guilt. These feelings are completely normal. This stage is marked by the realization of the disease s impact on all aspects of your life. ANXIETY stemming from awareness is sometimes accompanied by sadness and in some cases depression. The latter can have a considerable impact on your quality of life, your loved ones and your adherence to treatment. Do not hesitate to consult a doctor if you experience one or more symptoms of depression.
21 19 PORTAIL VIH/SIDA DU QUÉBEC Possible symptoms of depression: Sadness Existential void Persistent anxiety Despair Pessimism Dark and / or suicidal thoughts Feelings of guilt, powerlessness Loss of interest, pleasure, appetite or weight Loss of energy, severe fatigue Reduction in activities Insomnia Unstable mood Decreased concentration and memory Panic FEAR OF SUFFERING AND DYING can become obsessive and paralyzing. As well, questions about the direction you want your life to take can come to light once again. Psychological support is a valuable tool for dealing with these issues. Support services are also offered by various community HIV/AIDS organizations. ACCEPTANCE / REORGANIZATION marks a turning point with respect to your values, relationships with others and life habits (physical activity, diet, rest, recreation, etc.). TRANSFORMATION involves the search for wellbeing, balance and the integration of various aspects of HIV into your daily life. At this stage, many people take the opportunity to take stock of their life and to give it new meaning. Today, HIV is generally considered to be a chronic disease with highs and lows. The important thing is to become aware of the tools and strategies available to make informed choices. We must never forget that people with HIV are complete beings with strengths, weaknesses and life goals.
22 PORTAIL VIH/SIDA DU QUÉBEC 20 SEX AND HIV An HIV diagnosis causes people to review their thoughts about sex and their sexual habits and to redefine the notion of intimacy in their relationships. Being confronted with your responsibility regarding safer sex becomes unavoidable and can be distressing. Thinking about it can help you feel more at ease. Rethinking Sexuality It is completely normal to question the nature of your sexuality and sex life. Some people opt for a stable relationship, while others prefer relationships without emotional commitment. These are all legitimate options, provided you respect your values and personal sexual well-being. An HIV diagnosis provokes different emotional reactions in people. Some feel the need to increase their sexual activity, while others experience a "sexual depression," the length of which varies. Sexual depression can be defined as a difficulty disclosing one s HIV status, the fear of not being desired or an aversion to sex that is fueled by a feeling of being dangerous and the fear of infecting one s sexual partner. This period can be an opportunity to rethink the way you express your sexuality. It s a chance to address the issues of risky sexual behaviour, sexual compulsions, the relationship between sex, alcohol and drugs and how quickly you are willing to trust your partner. Changes in sexual habits can be a source of anxiety and have an impact on self-esteem. Body image and self-confidence must be taken into account in order to improve your ability to feel good about yourself and to experience a satisfying sexuality. Where does the condom fit in? Using a condom can be perceived as restrictive and as a reminder of HIV infection. Yet it remains a way of reducing your anxiety about infecting your partner or contracting STIs. Some people experience a loss of spontaneity when using a condom for sex. Selfaffirmation and effective communication can help involve your partner in your efforts to increase spontaneity and sensuality. There are many ways to regain control of your sex life: talk to your doctor or other professional (sexologist, psychologist, etc.), join a sexual health discussion group at a community AIDS organization, discuss with your partner... These approaches can be effective at reducing anxiety and restoring pleasure to your sex life. It s a matter of giving new meaning to the different dimensions of your sexuality and living it in a fulfilling way.
23 21 PORTAIL VIH/SIDA DU QUÉBEC POST-EXPOSURE PROPHYLAXIS (PEP) When a person is exposed to blood or other bodily fluids that are infected with HIV, taking antiretroviral drugs without delay for a period of 28 days may prevent seroconversion. This practice is called postexposure prophylaxis or PEP. Studies show that this preventive treatment can be effective after exposure to bodily fluids. PEP has been used for several years in professional settings and by pregnant women known to be HIV-positive in order to prevent mother-to-child transmission. However, the effectiveness of this form of prophylaxis in nonprofessional settings has not been demonstrated, although studies are underway. PEP is indicated after a significant exposure to bodily fluids (sperm, blood, vaginal secretions, saliva tainted with blood, etc.) capable of transmitting HIV that come from an HIV-infected person. When the HIV status of the source is not known, the decision to undertake a preventive treatment or not is based on the risks of transmission, the type of exposure and the population in question (men who have sex with other men, injection drug users, at-risk heterosexual contact [source comes from an endemic country, sex workers or their clients]). Source: MSSS, PEP should begin within two hours of the potential exposure and no longer than 72 hours thereafter. The treatment must include medical follow-up for six to 12 months, including several HIV screening tests. There are no programs that offer PEP for free. However, the antiretroviral treatment is reimbursed by the RAMQ if the patient has a valid health card and is registered with the public drug plan. Most private and collective insurance policies offer similar coverage, but a deductible may be required in most cases. There are several types of exposure: sexual contact, sharing injection equipment, contact with blood or bodily fluids visibly tainted with blood and/or contact between sperm or vaginal secretions and unhealthy skin or mucus membrane, and needle-stick injuries. PEP is not a morning-after pill. Instead, it should be promoted as a way of preventing new infections. People should be informed and encouraged to consult a doctor quickly after a sexual exposure with a risk of HIV transmission. Recommendations state that
24 PORTAIL VIH/SIDA DU QUÉBEC 22 COMBINATION ANTIRETROVIRAL THERAPY AND GUIDELINES When caring for patients with HIV, health-care professionals follow guidelines that are established by groups of experts. These experts rely on numerous scientific studies to determine the best approach to treatment. Guidelines are updated regularly in order to ensure that treatment is based on the most recent data available about the disease. By studying the conclusions drawn by the expert authors of the guidelines, your treatment team can advise you about the best time to begin antiretroviral treatment and which drugs to choose. Quebec s guidelines are available on line (via the Web site of the Ministère de la Santé et des Services sociaux). To suppress HIV in the blood successfully, initial drug therapy must ideally include three drugs that act in at least two different ways to combat HIV. This approach is referred to as combination (or highly active) antiretroviral therapy. Current guidelines recommend choosing two drugs from the nucleoside reverse transcriptase inhibitors class and one drug from either the non-nucleoside reverse transcriptase inhibitors class, protease inhibitors class or integrase inhibitors class. Most protease inhibitors need to be boosted with ritonavir. Currently available antiretroviral therapies are not able to cure HIV infection. The virus is believed to still be present in reservoirs inside the body, where it lingers for a long time, even when the viral load has been suppressed in the blood in a sustained way. Consequently, once therapy is started, it is usually best not to interrupt it, even for a short period. Stopping therapy usually causes a rapid increase in viral load and a drop in the CD4 count, such that both values return to where they were before the treatment. It has been shown that treatment interruptions increase the risk of developing an HIV-related condition. Deciding when to begin therapy is hugely important because the treatment will have to continue as long as it remains effective. As well, the drugs will have to be taken exactly as directed, otherwise viral resistance could easily develop. Your doctor will help you determine the best time to begin therapy by weighing the potential benefits against the long-term risks. The most recent guidelines recommend that treatment begin when the CD4 count is between 350 and 500 cells per microlitre of blood. In some cases, however, therapy should begin sooner. For example, a doctor may recommend an earlier start if the patient has an opportunistic infection or cancer, is pregnant, has a CD4 count in rapid decline or a very high viral load.
25 23 PORTAIL VIH/SIDA DU QUÉBEC OBJECTIVES OF THERAPY To suppress plasma viral load in a sustained way; in other words, to reduce, for as long as possible, the amount of virus in the blood to a point where it is undetectable using currently available tests To rebuild the immune system and thereby reduce the risk of opportunistic infections and AIDS FACTORS THAT HELP ACHIEVE THE GOALS OF THERAPY: To prolong survival To improve quality of life Choosing a combination antiretroviral therapy that is effective and well suited to your lifestyle To prevent HIV transmission Taking your meds on a very regular basis Having a low viral load at the start of therapy Having a high CD4 count at the start of therapy Achieving a rapid decrease in viral load during the first few weeks of treatment Most people who begin therapy are able to reduce considerably the amount of virus in their blood
26 24 PORTAIL VIH/SIDA DU QUÉBEC ANTIRETROVIRALS Combined NRTIs PI DOSAGE 1 or 2 times per day NRTI NNRTI NOVEMBRE 2009 RACHEL THERRIEN
27 25 PORTAIL VIH/SIDA DU QUÉBEC Fusion inhibitor DEFINITIONS CCR5 inhibitor Inhibitor: a chemical that targets and blocks a specific stage of viral replication. Fusion inhibitor: substance that prevents HIV from entering the cell by inhibiting the HIV envelope transmembrane protein (gp41), which usually fuses with the CD4 receptor on T cells, HIV s main target. CCR5 inhibitor: substance that prevents HIV from attaching itself to CCR5, one of two co-receptors found on T cells. Integrase inhibitor Classes combinations ( NRTI / NNRTI ) Reverse transcriptase: enzyme used for the transcription of a chain of DNA on a chain of RNA (inverse operation to that which occurs in a normal cell). Protease : enzyme (viral protease) that facilitates the division and assembly of viral proteins, a process that is indispensable to the replication of infectious viruses. (Emtricitabine/ Rilpivirine/Tenefovir) 200/25/300 mg Integrase : enzyme that fosters a stable relationship between the virus s genetic material (DNA) and the host cell s DNA. NRTI: nucleoside reverse transcriptase inhibitor (nuke). NNRTI: non-nucleoside reverse transcriptase inhibitor (non-nuke). PI: Protease inhibitor. Norvir is available in two formulations: tablet or capsule. There are other antiretrovirals that are prescribed less and less or not recommended.
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