Antiretroviral drugs (ARVs) are a class of medications used to treat infections caused by retroviruses, most notably the Human Immunodeficiency Virus (HIV). HIV is the virus that causes Acquired Immunodeficiency Syndrome (AIDS). ARVs do not cure HIV infection, but they suppress the virus’s ability to replicate, allowing the immune system to recover and function more effectively. This significantly improves the health, quality of life, and lifespan of people living with HIV and also reduces the risk of transmitting the virus to others.

Understanding ARVs is crucial for nurses working in areas where HIV is prevalent, as they are involved in administering these complex drug regimens, monitoring for adherence and side effects, and providing ongoing education and support to patients.

How ARVs Work: Targeting the HIV Life Cycle

HIV is a retrovirus, meaning it uses an enzyme called reverse transcriptase to convert its RNA into DNA, which it then integrates into the host cell’s DNA. ARVs work by blocking different stages of the HIV life cycle, preventing the virus from replicating and spreading. Different classes of ARVs target specific steps:

1. Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs): These drugs are “fake” building blocks that the virus incorporates into its DNA chain, stopping the chain from growing. Examples: Tenofovir, Emtricitabine, Lamivudine, Abacavir, Zidovudine.

2. Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs): These drugs bind to reverse transcriptase and stop it from working. Examples: Efavirenz, Nevirapine, Etravirine, Rilpivirine.

3. Protease Inhibitors (PIs): These drugs block the enzyme protease, which HIV needs to cut large viral proteins into smaller pieces that are needed to assemble new virus particles. Examples: Lopinavir/Ritonavir, Atazanavir, Darunavir.

4. Integrase Strand Transfer Inhibitors (INSTIs): These drugs block the enzyme integrase, which HIV needs to insert its DNA into the host cell’s DNA. Examples: Raltegravir, Dolutegravir, Bictegravir.

5. Entry Inhibitors: These drugs prevent HIV from entering host cells.

   • CCR5 Antagonists: Block the CCR5 co-receptor on the surface of certain immune cells that HIV uses to enter. Example: Maraviroc.

   • Fusion Inhibitors: Prevent HIV from fusing with the host cell membrane. Example: Enfuvirtide (administered by injection).

6. Post-Attachment Inhibitors: Bind to a different part of the host cell to prevent entry. Example: Ibalizumab (administered intravenously).

Antiretroviral Therapy (ART)

HIV treatment involves using a combination of ARVs from different classes. This is called Antiretroviral Therapy (ART) or Highly Active Antiretroviral Therapy (HAART). Using multiple drugs is essential because:

• It is more effective at suppressing the virus.

• It significantly reduces the risk of the virus developing resistance to the medications.

Current guidelines recommend starting ART as soon as possible after diagnosis, regardless of the patient’s CD4 count (a measure of immune system health). ART is typically a lifelong treatment.

Important Considerations and Nursing Implications

Caring for patients on ARVs involves several key responsibilities for nurses:

• Adherence is Paramount: Taking ARVs exactly as prescribed, every day, at the correct time, is critical for treatment success and preventing drug resistance. Missing doses allows the virus to replicate and potentially develop mutations that make the drugs less effective.

  • Nursing Role: Educate patients thoroughly about the importance of adherence. Discuss potential barriers to adherence (cost, side effects, pill burden, stigma, lifestyle factors) and help patients develop strategies to overcome them (e.g., using pill boxes, setting alarms, linking medication taking to daily routines). Provide ongoing support and counseling.

• Side Effects: ARVs can cause a variety of side effects, which vary depending on the specific drugs used. Side effects can range from mild and temporary to severe.

  • Common Side Effects: Nausea, vomiting, diarrhea, headache, fatigue, rash, sleep disturbances, dizziness, abnormal dreams (especially with Efavirenz).

  • More Serious Side Effects: Liver problems (hepatotoxicity), kidney problems (nephrotoxicity – especially with Tenofovir disoproxil fumarate), bone density loss, skin reactions (including severe rashes like Stevens-Johnson syndrome), nerve damage (peripheral neuropathy – less common with newer drugs), metabolic complications (changes in cholesterol, triglycerides, blood sugar, fat redistribution – lipodystrophy).

  • Nursing Role: Educate patients about potential side effects and what to report to the healthcare provider. Monitor for signs and symptoms of side effects during clinic visits. Provide strategies for managing common side effects (e.g., taking certain drugs with food).

• Drug Interactions: ARVs can interact with many other medications, including over-the-counter drugs, herbal supplements, and recreational drugs. These interactions can affect the levels of ARVs or other medications in the body, potentially leading to reduced effectiveness or increased toxicity.

  • Nursing Role: Obtain a complete medication history, including all prescription, over-the-counter, and herbal products. Educate patients to always inform their healthcare providers and pharmacists about all medications they are taking.

• Monitoring: Regular monitoring is essential to assess the effectiveness of ART, monitor for side effects, and detect complications.

  • Viral Load: Measures the amount of HIV in the blood. The goal of ART is to achieve an undetectable viral load, which means the virus is suppressed to very low levels.

  • CD4 Count: Measures the number of CD4 T-cells, a type of immune cell targeted by HIV. An increasing CD4 count indicates that the immune system is recovering.

  • Blood Chemistry and Hematology: To monitor kidney function, liver function, blood counts, lipid levels, and blood glucose.

• Patient Education: Comprehensive and ongoing education is crucial for people living with HIV on ART. This includes:

  • Understanding HIV infection and how ARVs work.

  • The importance of adherence and strategies for managing missed doses.

  • Potential side effects and how to manage or report them.

  • Drug interactions.

  • The importance of regular medical check-ups and laboratory monitoring.

  • Preventing transmission of HIV to others (e.g., using condoms, the concept of “Undetectable = Untransmittable” or U=U).

  • Maintaining a healthy lifestyle (nutrition, exercise, avoiding smoking and excessive alcohol).

  • Disclosure and stigma.

• Psychosocial Support: Living with HIV and taking lifelong medication can be challenging. Nurses can provide emotional support, address concerns about stigma, and connect patients with support groups and counseling services.

• Prevention: Nurses also play a role in HIV prevention, including educating individuals about safe practices, promoting HIV testing, and providing information about pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) for HIV prevention.