HIV is no longer a terminal illness it has transitioned into a manageable chronic health condition as a result of advances in research and treatment (Public Health England, 2016). While HIV can have significant and multifaceted effects on the health and well-being of individuals, early diagnosis and effective treatment have revolutionised its management and prognosis.
Epidemiology
Between 2022 and 2023, the number of people tested in all sexual health services rose compared to testing levels seen in 2019. Compared to 2019, there was a decline in the number of heterosexual and bisexual women tested and a drop in heterosexual men tested in 2023. However, the number of gay, bisexual, and other men who have sex with men (GBMSM) tested increased (UKHSA 2023).
Among heterosexual people of Black African ethnicity, the number tested increased in 2023, with a stable positivity rate, suggesting ongoing transmission. For GBMSM, the number tested increased in 2023, with positivity falling in 2022 and 2023, indicating a possible decrease in transmission.
Overall, there are positive signs in terms of increased HIV testing, especially among higher-risk populations such as GBMSM. However, declines in testing among heterosexual men and women, as well as the stability in HIV transmission in some groups, indicate that targeted interventions and continuous outreach efforts are still necessary to reduce transmission and encourage testing across all populations.
Early diagnosis
Timely detection allows for the prompt initiation of ART, which is important for suppressing viral load. This suppression helps maintain a stronger immune system, reducing the risk of opportunistic infections and other complications and improves the overall quality of life for those living with HIV. Effective ART regimens have made it possible for individuals with HIV to achieve an undetectable viral load (O'Halloran, et al, 2019), meaning that the amount of HIV in the blood is so low that it cannot be detected by standard tests. Achieving and maintaining an undetectable viral load has profound implications, significantly reducing the risk of HIV-related illnesses and allows individuals to lead healthy, productive lives. Moreover, an undetectable viral load eliminates the risk of sexual transmission of the virus, encapsulated in the principle ‘undetectable equals untransmittable’ (U=U) (see box 1). This breakthrough has been a pivotal development in public health, empowering people with HIV and reducing the stigma associated with the virus.
Undetectable equals untransmittable (Source: adapted Kasadha, 2023; O'Halloran, et al, 2019; BHIVA, 2017).
Undetectable equals untransmittable (U=U) is a public health campaign that communicates a crucial fact about HIV treatment and prevention. The U=U concept means that individuals living with HIV who are on effective ART and have achieved and maintained an undetectable viral load in their blood for at least six months do not transmit the virus to their sexual partners.
Key Points
Managing HIV as a chronic condition requires ongoing care and support which may take place in the primary or secondary care setting (BHIVA 2018). Patients have to adhere to their ART regimen, attend regular appointments for monitoring and managing any side effects or comorbid conditions that may arise. Nurses play a crucial role in providing continuous and comprehensive care, ensuring that individuals receive the necessary support to manage their health effectively.
As well as the physical aspects, living with HIV can also have psychological and social impacts. The initial diagnosis can be overwhelming and ongoing stigma and discrimination can affect a person's mental health. Support services and community resources are key components of care, helping individuals navigate these challenges and maintain their mental and emotional well-being.
HIV remains a serious condition, with early diagnosis, effective treatment and comprehensive care, individuals with HIV can achieve viral suppression and live full, healthy lives. The focus is on continuing to improve access to testing and treatment, enhancing support services and challenging stigma to ensure everyone affected by HIV has the opportunity to thrive.
Treatment options
There are six primary classes of antiretroviral drugs, Pebody (2024) discusses these further (see table 1). Each class targets different stages of the HIV lifecycle to prevent the virus from replicating. The goal of ART is to reduce viral load, improve immune function and prevent HIV transmission.
| Class | Mechanism | Example |
|---|---|---|
| Nucleoside Reverse Transcriptase Inhibitors (NRTIs) |
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| Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) |
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| Rilpivirine (RPV) | ||
| Protease Inhibitors (PIs) |
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| Atazanavir (ATV) | ||
| Darunavir (DRV) | ||
| Integrase Strand Transfer Inhibitors (INSTIs) |
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| Bictegravir (BIC) | ||
| Fusion Inhibitors |
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| CCR5 Antagonists |
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Combination therapy
ART typically combines drugs from two or more classes to suppress HIV effectively and prevent resistance. Fixed-dose combinations consolidate two or three drugs into one pill, simplifying treatment, improving adherence and reducing the pill burden. Some regimens may use two drugs in one pill and a third in a separate pill for flexibility in adjusting treatment based on patient needs. Combination therapy targets multiple stages of HIV replication, lowers the risk of resistance and may reduce side effects by lowering individual drug doses (BHIVA, 2022). Simplifying the regimen with fixed-dose combinations improves patient adherence.
Individualised care
Choosing an HIV treatment regimen involves a comprehensive evaluation of multiple factors to ensure the most effective and sustainable therapy for individual patients. Choosing an HIV treatment regimen is a complex process requiring careful consideration to ensure effective and sustainable therapy for each patient.
Viral and patient characteristics
The selection process begins with evaluating the patient's viral load and CD4+ count, which are critical in determining the urgency and type of treatment required. These metrics are monitored regularly (this may be in the primary or secondary care setting) to assess the effectiveness of the treatment and make necessary adjustments. Additionally, HIV genotype (the genetic makeup) and resistance testing are conducted to identify any mutations in the virus that may confer resistance to specific antiretroviral drugs. This information allows healthcare providers to tailor the treatment regimen to ensure maximum efficacy.
Patient-specific factors
The patient's overall health, including any comorbidities and coinfections, play a significant role in choosing the appropriate regimen. Conditions such as cardiovascular disease, liver disease, renal impairment and mental health disorders can influence drug choice due to potential drug-drug interactions and side effects. Moreover, the patient's lifestyle and potential for adhering to the treatment regimen are considered. Simplified regimens, such as single-pill combinations, are often preferred to improve adherence and support systems are put in place to assist the patient in maintaining consistent therapy.
Drug-specific factors
The efficacy and potency of the drugs are paramount in the selection process. Drugs that rapidly and sustainably suppress viral load and have a high barrier to resistance are preferred. The side effect profile of each drug is also considered to minimise adverse effects and improve tolerability, ensuring the patient's comfort and willingness to adhere to the regimen.
Treatment guidelines and recommendations
Established guidelines from organizations such as the British HIV Association (BHIVA) and the World Health Organization (WHO) should be followed. These guidelines recommend first-line regimens for most patients and alternative options are considered for those with specific needs or contraindications. Staying informed about the latest updates and evidence-based recommendations is crucial for providing the best care.
Patient preferences and socioeconomic factors
Involving patients in the decision-making process is essential to ensure they are comfortable with and committed to their treatment plan. This approach considers the patient's personal preferences and aims to improve their quality of life.
Changing/adjusting treatment
There are several reasons why it may be necessary to change HIV treatment. Each drug regimen has its own advantages and disadvantages and finding the most suitable treatment for the patient is crucial. Advances in HIV treatment mean there are now more options available than when the patient first started antiretroviral therapy (ART). These are reasons why treatment regimens may be changed, for example:
Treatment not working (virological failure)
Virological failure occurs when treatment fails to effectively suppress viral load. The most common cause of virological failure is missing doses, leading to drug resistance. Other factors include poor absorption, distribution, metabolism and excretion of the drugs.
Drug resistance
If the treatment is not taken as prescribed, the viral load may increase to detectable levels, causing the virus to become resistant to antiretroviral (ARV) drugs. Resistance to one drug can also lead to cross-resistance to other similar drugs.
Side effects
ARV therapy can cause side effects, which may appear soon after starting treatment or develop after months or years, if problematic, changing treatment might be necessary. Some potential long-term side effects include:
Drug interactions
Many people with HIV also need treatment for other health conditions. Taking multiple drugs can alter the effectiveness or increase the side effects of ARV drugs. Some drug combinations are contraindicated and changing HIV medication can help prevent interactions.
Special considerations
If a person is planning a pregnancy or has recently become pregnant, they may need to switch to a different treatment.
Finding the right HIV treatment involves considering the factors discussed to ensure that the therapy is effective, well-tolerated and fits the patient's lifestyle and health needs.
Emerging therapies and future treatment options
Emerging HIV therapies and future treatment options hold great promise for enhancing the quality of life for people living with HIV. Innovations in this field aim to simplify treatment regimens, reduce side effects and ultimately find a cure.
The introduction of ARV injections represents a significant advancement in the management of HIV, offering an alternative to daily oral medications (Cairns, 2024; European Medicines Agency (2020). These long-acting injectable therapies have the potential to improve adherence, reduce the stigma associated with daily pill intake and enhance overall quality of life for people living with HIV.
Long-acting ARV therapies are designed to be administered less frequently, such as monthly or even less often. This approach can significantly improve adherence and reduce the burden of daily pill intake, this represents a significant advancement in the delivery of ART and PrEP (Sherman et al, 2024).
Work is being undertaken on therapeutic vaccines which aim to boost the immune system's ability to respond to HIV. These vaccines used alongside traditional ARVs aim to improve viral suppression and potentially reduce the need for continuous therapy.
It is important to note that while these treatments show great promise, they are still under development and remain in the early stages of clinical evaluation. Similarly, therapeutic vaccines aim to enhance the body's immune response to HIV, potentially offering a functional cure. Despite their potential, these vaccines are currently in experimental phases, and further research is required before they can be fully integrated into standard treatment protocols (National Institutes of Health 2022)
Health promotion
Primary care nurses play a crucial role in promoting overall health and well-being in the population as a whole as well as for HIV-positive patients. This approach involves not only managing the medical aspects of HIV but also addressing lifestyle factors, mental health and social determinants of health. It is recalled that some patients with HIV will prefer to have their care managed in the secondary care sector. Terence Higgins Trust (2023) discusses care provision and health promotion in further detail.
Care provision and the role of the nurse
Primary care nurses are central to the comprehensive care and management of people with HIV, adopting a holistic, patient-centred approach that integrates medical, emotional and social support. Their role encompasses a range of responsibilities, including coordinating with multidisciplinary teams, managing individual cases, advocating for patients and providing continuous monitoring and follow-up supported by UK guidelines and practices.
Holistic, patient-centred approach to HIV care
A holistic, patient-centred approach involves addressing the complete spectrum of a patient's needs—physical, emotional and social. This is essential for improving health outcomes and quality of life for individuals living with HIV, care provision extends beyond just managing HIV. Nurses are tasked with evaluating and addressing various aspects of a patient's life, including physical health, psychological well-being and social circumstances. This involves coordinating care for coexisting conditions, providing mental health support and connecting patients with social services to address broader needs.
Coordinating with multidisciplinary teams
Effective HIV care frequently requires collaboration with a variety of healthcare professionals, such as nurse specialists, doctors, pharmacists, social workers and mental health specialists. Primary care nurses play a pivotal role in this coordination, ensuring that all aspects of a patient's care are integrated and well-managed. According to the BHIVA (2018), a multidisciplinary approach is essential for optimal HIV management.
Continuous support involves advising patients about managing their HIV, addressing any issues that arise and offering encouragement to adhere to their treatment regimen. Integrated care systems bring together NHS organisations, local authorities and others to take collective responsibility for planning services, improving health and reducing inequalities across geographical areas (Charles, 2022; British HIV Association and British Association of Sexual Health and HIV, 2023).
Continuous monitoring, follow-up and support
Regular monitoring and follow-up are crucial for managing HIV effectively and preventing complications. Nurses provide ongoing support to ensure that patients are managing their ART and maintain good health. The importance of routine follow-ups to monitor the effectiveness of ART, detect any side effects and assess overall health should not be underestimated.
Nurse-patient relationships
Building strong relationships with patients is essential for effective HIV care. A trusting and supportive relationship encourages patients to be open about their health, adhere to treatment and engage actively in their care. Effective communication and a supportive nurse-patient relationship enhance treatment adherence and improve health outcomes. Nurses provide emotional support and reassurance, helping patients manage the psychological impacts of living with HIV and countering any stigma they may encounter. This strong rapport fosters a therapeutic environment where patients feel valued and supported.
Conclusion
Primary care nurses are integral to the effective prevention, treatment and care of people living with HIV. Their roles encompass early diagnosis, patient education and holistic, patient-centred care. By coordinating with multidisciplinary teams, managing cases, advocating for patients and providing continuous support, they ensure comprehensive care that addresses both the medical and psychosocial needs of individuals living with HIV.