Most adults are sexually active and good sexual health is important to individuals and communities. Poor sexual health can lead to unintended pregnancies and sexually transmitted infections (STIs). The National Institute for Health and Care Excellence (NICE) defines sexual health as a state of physical, emotional, mental and social wellbeing in relation to sexuality (NICE, 2019). Most people become sexually active between the ages of 16 and 24 years.
While there is currently no cure for HIV, with appropriate management, effective social care and support systems, along with prescribed medication, regular exercise and prevention of infections, those who are living with HIV are able to live a reasonably full and healthy life.
Epidemiology
Epidemiology is the study of how often diseases occur in different groups of people and why they occur (Cogan et al, 2003). Epidemiological data can be used to plan and evaluate strategies that can then help to prevent illness and assist in the care, support and management of those living with a disease such as HIV.
The Joint United Nations Programme on HIV/AIDS (UNAIDS) set the 90–90–90 targets for HIV–AIDS treatment and prevention in 2014, aiming to diagnose 90% of all HIV-positive people, provide antiretroviral therapy (ART) for 90% of those diagnosed, and achieve viral suppression for 90%, by 2020 (UNAIDS, 2014). The latest estimates for undiagnosed HIV infections indicate that the UNAIDS targets have been met in the UK overall (Public Health England (PHE), 2019).
In 2017, 92% of the estimated 101 600 people living with HIV in the UK were diagnosed, 98% of those diagnosed were receiving treatment, and 97% of people receiving treatment were virally suppressed. Overall, 87% of people living with HIV in the UK were estimated to have an undetectable viral load and as such are unable to pass on the infection (PHE, 2019).
PHE has reported on HIV data for the UK in 2019. In the UK, the estimated annual number of new infections acquired by men who have sex with men has more than halved from a peak of around 2700 in 2012 to 1200 in 2017 (PHE, 2019).
Among gay and bisexual men, there has been a continuation in the decline of new HIV diagnoses (31% decline, from 3390 in 2015 to 2330 in 2017). Previously, diagnoses among this group had been increasing year on year from 2820 in 2008 to 3390 in 2015.
New HIV diagnoses in both black-African and black-Caribbean heterosexuals have been falling steadily over the past 10 years (black-African: 78%, from 2424 in 2008 to 542 in 2017; black-Caribbean: 77%, from 231 to 52). Declines have been seen for the first time among non-black African and non-black Caribbean heterosexual men, particularly among white heterosexual men (31%, from 429 in 2016 to 296 in 2017) (PHE, 2019).
There is a shortage of data regarding transgender and non-binary people receiving HIV care in the UK, but PHE is beginning to address this. In England in 2017, 123 trans people were recorded as accessing HIV care (Kirwan et al, 2019). Those who offer care and support to transgender people should address the specific biological, psychological and social needs of this population.
The population of people living with diagnosed HIV infection (93 385) is growing older, and diversifying. In 2017, more than a third (39%) of people receiving HIV care were aged 50 years or above; 14% of gay and bisexual men receiving care were from black, Asian and other minority ethnic groups and 26% of heterosexuals receiving care were white.
HIV and social determinants of health
Social determinants of health play an important role in driving the HIV epidemic, both in the UK and globally. The social determinants of health refer to the interrelating social, cultural, environmental, and economic factors responsible for the majority of most health inequalities. Our understanding of the connections between these determinants and their relative importance to each other has evolved over time in public health and secondary care (Baylis, 2017).
Considering and examining these social determinates of health can help to explain the disproportionate burden of HIV in certain populations. Understanding the multilevel and overlapping nature of the determinants of health is key to designing and implementing more effective prevention programmes.
HIV treatment and care
There have been incredible advances in the treatment and prevention of HIV over the years. People living with HIV are living longer, and the age of people living with HIV has risen. The availability of HIV antiretroviral therapy (ART) has seen a disease that once significantly shortened life expectancy evolve into a long-term, chronic condition.
Currently, there is no cure for HIV. But there are a number of drugs available that can slow or halt disease progression. Whilst ART increases life expectancy significantly and decreases the risk of complications associated with premature ageing, it should be noted that morbidity and mortality remain slightly higher than in those people who are uninfected.
The aim of treatment
Treatment aims to prevent the morbidity and mortality that is associated with chronic HIV infection, while at the same time minimising drug toxicity. Treatment should be started before the immune system is permanently damaged, and the need for early drug treatment has to be balanced against the risk of toxicity. There is a need for commitment to treatment over many years; the drug regimen chosen should take into account convenience and patient tolerance.
Treatment also reduces the risk of HIV transmission to sexual partners, but the risk is not eliminated completely. This risk and strategies to reduce HIV transmission should be discussed with patients and their sexual partners.
Antiretroviral therapy
ART became available in the mid 1990s and, since its introduction, treatment options and guidelines continue to evolve. HIV treatment stops the virus from reproducing. It does not cure HIV, but it can reduce the amount of virus in the blood to an undetectable level. When this is achieved, the person cannot transmit HIV. HIV drug treatment is sometimes also known as combination therapy, as people usually take three different drugs at the same time (often combined into one tablet). This is also known as highly active antiretroviral therapy (HAART).
It is recommended that all those diagnosed with HIV commence treatment straight away (NHS England, 2018). In the UK, national guidelines set out standards for HIV treatment and recommend that those with HIV who are ready to commit to treatment should start it regardless of their CD4 count (Lundgren et al, 2015). Starting treatment as soon as possible reduces viral load to undetectable levels and protects health. Early diagnosis and treatment can ensure that people living with HIV live as long as the general population.
There are various classes (types) of ART, with each class of drug working in a different way. It is usual for drugs from two (or sometimes three) classes to be combined to ensure efficacy of treatment. Those commencing HIV treatment begin with two drugs from the nucleoside/nucleotide reverse transcriptase inhibitors class combined with either one integrase inhibitor, one non-nucleoside reverse transcriptase inhibitor or one protease inhibitor. This is known as triple therapy. Table 1 provides an overview of the classes of drugs used in HIV.
Table 1. Classes of ARTs
| Class | Discussion |
|---|---|
| Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs/NtRTIs) | NRTIs and nucleotide reverse transcriptase inhibitors (NtRTIs), often all referred to as NRTIs, act by targeting the action of reverse transcriptase (an HIV enzyme) |
| Non-nucleoside reverse transcriptase inhibitors (NNRTIs) | NNRTIs also target reverse transcriptase but in a different way to NRTIsNNRTIs interfere with the reverse transcriptase enzyme by binding directly to it, blocking the reverse transcription process |
| Integrase inhibitors | HIV uses a protein called integrase to send its genetic material into the cells that it targets (for viral replication). Integrase inhibitors block this action, targeting integrase, preventing the virus from inserting itself into the DNA of human cells |
| Entry inhibitors | As the name suggests, these drugs prevent the virus from entering the targeted cells. There are two types:
|
| Protease inhibitors (PIs) | PIs block the activity of the protease enzyme. HIV requires protease to replicate. While HIV can still replicate in the presence of protease inhibitors, the resulting virions are immature and therefore unable to infect new cells |
| Booster drugs | Booster drugs are used to ‘boost’ the effects of protease inhibitors. Adding a small dose of a booster drug to an antiretroviral makes the liver break down the primary drug more slowly, meaning it stays in the body for a longer time or at higher levels. Without the use of a boosting agent, the prescribed dose of the primary drug would be ineffective |
Each class of drug will target a different step in the viral life cycle as the virus infects a CD4 T lymphocyte or other target cell. In clinical practice, the use of these agents is largely dictated by their ease or complexity of use, side-effect profile, efficacy based on clinical evidence, and practice guidelines.
Prevention of HIV
The field of HIV prevention (HIV prophylaxis) has advanced over the years, just as HIV treatment has also progressed. While traditional preventative measures, such as the use of physical barriers to prevent transmission sexually along with routine HIV testing, remain significant considerations, the introduction and development of biomedical preventative measures have provided a new option. Biomedical preventative options, for example pre-exposure prophylaxis (PrEP), offer both patients and those who provide care with more opportunities to control the spread of HIV infection.
Combination HIV prevention
A key reason for the recent decline in new HIV diagnoses is that a combination of HIV prevention efforts have been implemented (PHE, 2019). The key elements of combination HIV prevention include:
- Condoms
- PrEP
- HIV testing
- Treatment as Prevention (TasP) and U=U (undetectable= untransmissible).
Condom use
Condoms are still central to the combination prevention approach of HIV and STIs. When they are used correctly and consistently during vaginal and anal sex they are effective in the prevention of transmission. The use of condoms has been a key aspect of prevention initiatives and when used with other elements of combination prevention, will have contributed significantly to the containment of the UK HIV epidemic.
Pre-exposure prophylaxis
PrEP reduces the risk of acquiring HIV, and the effectiveness of ART as a prevention tool is undisputed. Currently, it involves the use of antiretroviral medicines. Typically, this is a single-tablet regimen containing a tenofovir preparation combined with emtricitabine, taken by those who are HIV-negative with the aim of reducing their risk of acquiring HIV infection. When PrEP is used consistently (consistent adherence) this is a highly effective approach to reducing the risk of HIV acquisition in gay and bisexual men and others who are at risk of HIV. Truvada is taken once daily, orally, with or without food, and may be of benefit for those people who:
- Have multiple sex partners
- Have been diagnosed recently with an STI
- Use condoms inconsistently
- Inject drugs or share drug-use paraphernalia
- Use recreational drugs for chemsex (for example, crystal meth, mephedrone and GHB)
- Have a HIV-positive partner who is finding it difficult to be adherent to their HIV medications.
Before starting PrEP, the person's HIV-negative status must be confirmed. If the person is already HIV-positive and does not realise this, they could develop drug resistance.
If there are any flu-like symptoms and the person has had a recent HIV risk, then commencing PrEP should be deferred, as these symptoms could be related to a recent HIV infection. As PrEP can affect renal function, (creatinine clearance), this must be assessed, and a urine test will also be needed for evidence of proteinuria. Testing for hepatitis B (HBV) is required as PrEP medications are active against both HIV and HBV. PrEP can still be used if the person has HBV, those with HBV need to take PrEP every day along with medical advice, particularly if they wish to stop PrEP. Table 2 provides information regarding the various tests required for PrEP.
Table 2. Various tests associated with PrEP
| Laboratory test | Rationale |
|---|---|
| HIV antigen-antibody test (4th generation) | To determine HIV status (4 weeks ago). Risk of drug resistance if the person is already HIV-positive and was unaware |
| Renal function (creatinine) | PrEP may impact on renal function, those with a creatinine clearance of less than 60 mL/min should not be prescribed Truvada |
| Hepatitis screen (hepatitis A, B, C) | Medications used with PREP are active against both HIV and HBV |
| Urinalysis | Can indicate abnormal renal function |
| Pregnancy test | Pregnancy is not a contraindication for Truvada, there are insufficient data on its use as HIV prophylaxis during pregnancyIf the person is planning a pregnancy or not using contraception, using PrEP can make sure that the person does not become HIV-positiveRecommendations on using PrEP during pregnancy are being revised |
| STI screen | The person may request an STI screen. PrEP does not protect against other STIs |
Monitoring of the patient's health and wellbeing is required once PrEP has commenced. Every 3-4 months, it is important for those taking PrEP to have their HIV status monitored, have a full screen for other STIs, provide urine for a dipstick test for protein. There may be a need for renal function blood tests, particularly if the person is over 40 years old or at risk of renal problems.
Annually, there is a need to assess renal function. Serology for hepatitis C is undertaken if the person is having sex with gay men.
HIV testing
Expanded HIV testing and speedy initiation of ART after a diagnosis is made is also a key component of combination HIV prevention in the UK. The aim of any HIV testing policy is to offer and encourage the uptake of testing in a number of clinical and community settings. This includes offering tests to all attendees with an STI-related need at sexual health services, people attending general practice, or emergency departments, those admitted to hospital in areas of high and extremely high HIV prevalence, and people with HIV indicator conditions. Encouraging regular test seeking by those at continuing risk of HIV acquisition is also recommended (NICE, 2016; Public Health England, 2015).
Treatment as Prevention (TasP) and U=U
Treatment as prevention (TasP) refers to HIV prevention methods and programmes that use ART to decrease the risk of HIV transmission. NHS England published a clinical commissioning policy for TasP (NHS England, 2015). TasP is designed to benefit the HIV-negative partner by reducing the risk of acquisition of HIV. It is a term describing HIV prevention methods that use ART treatment to significantly decrease the chance of HIV transmission between individuals and reduce the number of new cases of HIV at population level. Treatment is started to reduce the risk of transmission as opposed to managing HIV in the body.
In those who have been diagnosed with HIV, the viral load (the amount and activity of HIV virus in the person's bodily fluids) is the single biggest risk factor for onward transmission of HIV. By decreasing viral load this not only reduces morbidity and mortality but will also significantly decrease the risk of transmitting HIV.
Twenty years of evidence demonstrates that HIV treatment is highly effective in reducing the transmission of HIV. People living with HIV taking ART who have an undetectable level of HIV in their blood have no risk of transmitting HIV sexually (UNAIDS, 2018; Prevention Access Campaign, 2019). The U=U campaign (undetectable=untransmissible) highlights the benefits of ART, emphasising that having an undetectable viral load when taking ART also stops HIV transmission. Even though a person taking ART is still HIV-positive, HIV transmission is no longer a risk.
The nurses' role
Since the beginning of the HIV epidemic in the 1980s, nurses have been at the forefront in helping people manage what was then a terminal infection. Nurses very often lead on public health initiatives and this is the case in HIV.
As HIV treatment and prevention approaches continue to advance, it is essential that all nurses, irrespective of where they practice, are knowledgeable about the contemporary approaches to the prevention, diagnosis and treatment of HIV, so as to offer people individualised and holistic care, regardless of the person's HIV status.
Nurses who are working in the community or primary care setting are ideally placed to identify those people who are at risk of HIV infection. Numerous opportunities exist for nurses practicing in the community or in primary care to discuss and advise on combination HIV prevention. This includes advocating the use of condoms, explaining the availability of PrEP, encouraging HIV testing in care areas and promoting the use of ART, decreasing the risk of HIV transmission (TasP) and promoting the U=U campaign.
Conclusion
Since the HIV and AIDS epidemic first emerged over 40 years ago, the field of HIV treatment and prevention has changed exponentially. New therapies have transformed HIV into a chronic disease, rather than a terminal one, and the use of PrEP is offering effective options for reducing the risk of HIV infection. Innovations in the medical field have enabled more people who are living with HIV to reach older adulthood. This, in turn, will mean that nurses in all care settings are and will be seeing more people who are living with HIV, with the complications of or exposure to ART and also experiencing concurrent chronic conditions that are often seen as the person ages.
There has been a decline in HIV incidence and diagnoses in the UK. Currently there is no cure for infection caused by HIV, however, a number of drugs slow or halt disease progression. Individually oriented interventions reduce risky behaviour, taking on board broader structural factors that shape or hinder individual behaviour will complement and enhance individual interventions.
Key Points
- Appropriate management and treatment alllows patients who have contracted HIV to live out full lives
- 97% of those surveyed who receive treatment were virally supressed
- PrEP is key to reducing the risk of acquiring HIV in some patients
- A nurses' role is vital in this process; this includes advocating contraception use, prescribing PrEP and encouraging HIV testing.
CPD reflective questions
- What should a practitioner consider when prescribing PrEP?
- What tests should be carried out before prescribing PrEP?
- How is decreasing the viral load important when lowering the risk of transmitting HIV?
- How is the viral load lowered?
- What are the different classes of ART?