Perspectives v9n6 hiv treatment update by Alliance Health Project

HIV COUNSELOR

PERSPECTIVES Volume 9 Number 6 November 2000

HIV TREATMENT UPDATE A number of promising new drugs and treatment strategies have emerged over the past four years. However, they come with uncertainties about long-term efficacy and concerns about side effects. This issue of PERSPECTIVES provides an update on HIV antiviral drugs, new treatment strategies, and related psychosocial challenges.

Research Update An estimated 82 percent of all HIV-infected individuals in the United States use antiviral medications to treat HIV.1 Antiviral drugs aim to suppress levels of HIV by stopping the virus from replicating, that is, reproducing itself. To measure suppression of HIV levels, clinicians use viral load tests to quantify the concentration of HIV circulating in a person’s bloodstream. Suppressing HIV levels causes an increase in the number of CD4+ cells, thus improving immune functioning, slowing clinical progression of HIV disease, and, in turn, prolonging life.2 Designed to interrupt HIV replication, antiviral drugs approved by the Food and Drug Administration (FDA) fall into one of the following three drug classes: nucleoside reverse transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, and protease inhibitors. The two kinds of reverse transcriptase inhibitors interfere with an early stage of the HIV replication

cycle, and protease inhibitors disrupt a later stage.2 Other antiviral drugs as well as other types of HIV medications are in development. To suppress HIV levels more potently, clinicians prescribe two or more antiviral drugs, a strategy known as combination therapy. Most current antiviral treatment regimens consist of a combination of at least three medications. After triple combination therapy became commonly used in 1996, it quickly became the standard of care for people with HIV disease,3 and the number of AIDS-related deaths in the United States began to decline: there were 37,000 AIDS-related deaths in 1996; in 1999, the number of deaths dropped to 10,000.4 Combination therapy uses drugs that interfere with the HIV reproduction cycle at different stages and minimizes the possibility of drug resistance. Drug resistance is the process by which the virus mutates and becomes less sensitive to specific medications. Mutated virus then multiplies and forms new strains that predominate and may render drugs less effective or completely

ineffective. HIV can also become resistant to other drugs in the same class—a phenomenon known as cross-resistance—or to a number of different drugs, causing further treatment complications. Drug resistance can occur when people do not adhere to their dosing regimens, causing lower blood levels of the drug and less complete suppression of viral growth. Other reasons for drug resistance include drug interactions with non-HIV medications and the possibility that, for some people, certain drug combinations may not be as potent as others.3 Epidemiological studies have found cases of transmission of drug-resistant HIV. This means that

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Inside PERSPECTIVES Research Update Related Issue: Complementary and Alternative Treatment Implications for Counseling Case Study Test Yourself Using PERSPECTIVES

PERSPECTIVES: HIV TREATMENT UPDATE

transmission will lead not only to HIV infection, but also to pre-existing resistance to particular HIV antiviral medications. In one fouryear study of 80 newly infected people, most of whom were tested in New York or Los Angeles, 16 percent were infected with a drugresistant strain of HIV.5 In a larger, five-city study, however, only 2 percent of the 141 newly infected participants carried a drug-resistant strain. 6 In addition, anecdotal reports suggest that HIV-infected individuals may become re-infected with a drug-resistant strain of HIV.7 Treatment Success and Failure The long-term success of combination therapy depends on the continual suppression of HIV growth. Treatment regimens are often defined as successful if they reduce the levels of a person’s viral load below the level of detection.2 Some people misinterpret “undetectable viral load” to mean that HIV has been eradicated from the body and can no longer be transmitted, but it actually means that the levels of viral concentration are too low to be detected by a given test. Depending on the type of test, viral loads below the level of detection may range from less than 40 copies of viral RNA per milliliter of blood to 500 copies per milliliter.3 Increased viral load or symptoms of HIV disease progression often signify an unsuccessful treatment regimen.2 In clinical practice, about half of HIVinfected people achieve a viral load count below the level of detection.8 Lack of treatment success in clinical practice can result from inadequate drug potency, drug resistance, or interactions between different drugs that can lead to severe adverse side effects or lowered therapeutic efficacy.2 Unsuccessful treatment can also result from poor adherence to medication. Adherence to medication regimens is essential to treatment success because suppressing HIV and

inhibiting drug resistance requires a stable level of medication in the bloodstream. To achieve a desirable viral load, people need to maintain greater than 95 percent medication adherence, which means that no more than 5 percent of scheduled doses can be missed.9 Maintaining adherence can be difficult because combination treatment regimens can involve up to 40 pills and six specific dosing times per day. Some pills must be taken with food, while others require an empty stomach.10 A California study of 170 clients of university-based clinics found that 70 percent of participants maintained greater than 95 percent medication adherence.11 Combination therapy can lead to short- and long-term adverse side effects, including vomiting, nausea, diarrhea, liver disease, bone density loss, diabetes mellitus, and peripheral sensory neuropathy, a nerve disorder that causes pain in the extremities.12 Some people with HIV experience lipodystrophy, a disturbance in the way the body produces, uses, and distributes fat. Although many researchers believe lipodystrophy is a result of antiviral drugs, its cause remains unknown. Lipodystrophy can cause fat wasting of the face, arms, legs, or buttocks, and fat accumulation in the abdomen or back of the neck. The effects of lipodystrophy on physical appearance can affect selfesteem and act as a visible indication that a person is HIV-infected.13 To correct the effects of lipodystrophy, some people undergo surgery to remove fat, switch antiviral drugs, or stop combination therapy altogether. A small study of lipodystrophy found that short-term treatment with recombinant human growth hormones led to improved body shape. However, this treatment is expensive, has its own side effects, and appears to correct body shape only during the timespan of treatment.14

Some people misinterpret “undetectable viral load” to mean that HIV has been eradicated from the body. New and Experimental Treatments Recent research has identified new HIV medications that do not belong to any of the three FDAapproved classes of HIV treatments. Currently in clinical trials, antiviral drugs called “fusion inhibitors” interfere with HIV replication by preventing the virus from entering CD4+ cells. A small study found that injections of the fusion inhibitor T-20 given over a 14-day period resulted in significant viral load declines in all 16 participants. Based on these results, T-20 appears to be as potent as currently available antiviral drugs in lowering viral load levels. Fusion inhibitors reportedly have no significant side effects and work against common drug-resistant HIV strains.15 Researchers have also identified hundreds of potentially effective “integrase inhibitors,” including two highly potent compounds called luffin and saporin. Their effectiveness, however, has not been proven in clinical settings.16 Some clinicians now prescribe hydroxyurea, a ribonucleotide reductase inhibitor, because of its reported ability to help nucleoside analog reverse transcriptase inhibitors to impede HIV replication. In a study of 77 HIV-infected participants taking the same two reverse transcriptase inhibitors, 54 percent of those given hydroxyurea achieved viral loads below the level of detection, compared to only 28 percent of those given placebo. Advantages of hydroxyurea include its relatively simple regimen of two capsules per day, its low cost, and its low risk of leading to drug resistance.17 Dis-

PERSPECTIVES: HIV TREATMENT UPDATE

Related Issue: Complementary and Alternative Treatment Complementary and alternative medicine encompasses a broad range of healing philosophies, approaches, and therapies that mainstream Western medicine does not commonly use or study. Most of these therapies focus on self-healing, and some integrate physical, psychosocial, and spiritual aspects of disease and wellness.29 A large nationwide study identified more than 230 complementary and alternative therapies being used by HIV-infected individuals. 30 Alternative therapies popular among HIV-infected people include aerobic and non-aerobic exercise, prayer, massage, acupuncture, meditation, visual imagery, breathing exercises, vitamins, minerals, dietary therapy, and Chinese herbs.29,30 About one-third of HIV-infected people use complementary or alternative medicine, and although many of them gain a sense of control over their health, the therapies have shown limited success in clinical research.29 Alternative treatments are difficult to quantify, define, or study in a controlled environment,30 partly because many alternative treatment providers tailor therapies to individual clients.31 advantages include the risk of increased toxicity of other HIV drugs and lowered CD4+ cell counts.18 Another promising experimental drug is the non-nucleoside reverse transcriptase inhibitor calanolide A, a synthetic version of a compound found in nature. Research suggests that calanolide A reduces viral load and works against common drug-resistant strains of HIV.19 “Immune modulators,” drugs that stimulate the immune system

Because of the widespread efficacy of antiviral treatments, some people no longer perceive HIV to be a major threat, a belief that may affect their risk behavior.

Research suggests that zinc and dehydroepiandrosterone (DHEA) have beneficial effects for people with HIV, 32,33 while studies of certain Chinese herbs and acupuncture found no such correlation.31,34 In addition, it is uncertain if the use of some alternative medicines in combination with HIV antiviral treatments is safe. For instance, one study found that the use of St. John’s wort, an herbal anti-depressant, decreased levels of the protease inhibitor indinavir by 57 percent,35 potentially leading to drug resistance and treatment failure. Furthermore, adverse effects of alternative medicine may be mistaken for antiviral side effects.36 There is a general lack of information regarding the pharmacology, drug interactions, and safety of these treatments. Moreover, there is a lack of industry-wide quality control for herbal products. For instance, depending on the manufacturer, the same kind of product can contain varying quantities of an active ingredient.36 Finally, success in combining complementary or alternative therapies has also not been well-documented.29

itself, also show signs of being effective. Two of the most promising immune modulators are interleukin-2 (IL-2) and WF10. Recent research suggests that adding IL-2 to triple combination treatment regimens improves immune function by increasing CD4+ cell counts, especially in people recently infected with HIV.20 Results of a small study suggest that WF10 is clinically safe, enhances immunologic function, and does not cause seriously harmful side effects.21 To simplify adherence, oncedaily dosing drugs from the three FDA-approved drug classes have recently become available, and researchers continue to study others. However, this makes taking each daily dose more important and requires precise timing.22 New Treatment Strategies Researchers and clinicians have varied opinions about when to start antiviral therapy. The approach that

became the most prevalent after the introduction of triple combination treatment is often called “hit early, hit hard.” This strategy dictates initiating an antiviral regimen that offers the most potent suppression of HIV replication as soon as possible after HIV diagnosis. The theory behind treating early and aggressively is to minimize the loss of immune function by quickly and sharply reducing viral replication.23 An increasingly common strategy, however, is to delay treatment to reduce the risks of drug resistance and side effects, which increase over the duration of treatment. This strategy recognizes that treatment cannot make asymptomatic people feel better, and that side effects may make them feel worse and eventually reduce adherence.23 Most experts agree that symptomatic HIV infection requires antiviral therapy.2 People who fail to respond to initial antiviral treatment may attempt

PERSPECTIVES: HIV TREATMENT UPDATE

Commercially Available HIV Antiviral Drugs Generic Name

Abbreviation

Brand Name

Nucleoside Reverse Transcriptase Inhibitors zidovudine ZDV or AZT didanosine ddI zalcitabine ddC stavudine d4T lamivudine 3TC zidovudine + lamivudine ZDV + 3TC abacavir sulfate 1592 adefovir dipivoxil PMEA

Retrovir Videx Hivid Zerit Epivir Combivir Ziagen Preveon

Protease Inhibitors saquinavir hard gel saquinavir ritonavir indinavir nelfinavir amprenavir lopinavir + ritonavir

Invirase Fortovase Norvir Crixivan Viracept Agenerase Kaletra

Non-Nucleoside Reverse Transcriptase Inhibitors nevirapine Viramune delavirdine Rescriptor efavirenz Sustiva Sources: Meyer S. Drug Guide 2000. Positively Aware. 2000; 11(1): 30-56. James JS. Kaletra (ABT-378/r) approved. AIDS Treatment News. 2000; (351): 2-3.

“salvage therapy” using a new set of drugs to which the virus might be sensitive.2 To help determine an appropriate salvage therapy regimen, clinicians may use genotype and phenotype tests to assess which drugs are ineffective for an individual by detecting the presence of drug-resistant mutations of HIV in a blood sample.5 Structured treatment interruption (STI), sometimes called structured intermittent therapy (SIT), is a controlled break from antiviral treatment under a physician’s supervision. The theory behind this recent and controversial strategy is that interrupting treatment can offer a break from rigorous schedules and adverse side effects and, at the same time, possibly strengthen the immune response to HIV during brief rises in viral levels and while

the immune system is in the process of recovery. A study of 12 long-term HIV-infected participants found no harmful events during the STI, which ranged from about 14 days to 30 days, depending on viral load. After beginning antiviral treatment again, four study participants experienced boosted immune systems.24 Other research, however, has not supported the efficacy of STI. Although STI can provide hope and a break from difficult drug regimens and side effects, there is also the risk of a rapid increase of viral load and drug resistance.25 Psychosocial Impacts of Treatments Because of the widespread efficacy of antiviral treatments, some people no longer perceive HIV to be a major threat, a belief that may affect their risk behavior. While

some studies have found no such effect, most large-scale studies on this topic have found that beliefs about the efficacy of new treatments and about resulting “undetectable” viral loads affect risk behavior. For example, a seven-state study conducted between 1998 and 1999 found that 31 percent of the uninfected or untested participants were “less concerned” about becoming infected and 17 percent were “less safe” about sex or drug use because of new HIV treatments.26 As people with HIV live longer and in better health because of antiviral treatments, they are more likely to be sexual. With a growing pool of increasingly healthy HIV-infected people, it is important to address the prevention of HIV transmission from infected people to the uninfected people with whom they may have risky contact.27 Dramatic improvements in health lead many HIV-infected people to reconstruct their life plans. Some people face “hope-fear dilemmas,” in which they experience a combination of optimism and uneasiness that arises from uncertainties about antiviral medications. People who initiate an antiviral treatment regimen must balance their hopes for improved health and investments in future plans with fears about potential side effects and the possibility that the treatment will fail.28 Some people for whom treatment has not been effective blame themselves for treatment failure while feeling defeated, forgotten, and isolated. Although combination treatment is expensive—ranging from $10,000 to $15,000 annually—publically funded programs such as California’s AIDS Drug Assistance Program (ADAP) help eligible citizens pay for treatments. People who benefit from antiviral treatments may face decisions about returning to work that must be balanced with the risk of losing government sponsored health and disability benefits.28

PERSPECTIVES: HIV TREATMENT UPDATE

Implications for Counseling One of the greatest challenges for HIV test counselors is a result of one of the greatest gains achieved by AIDS researchers. In response to the widespread efficacy of antiviral treatment, some people consider HIV risk to be less significant than it once was, and it is increasingly common for counselors to report clients having a more casual attitude about the possibility of HIV infection. Many young people have not experienced the ravages of HIV disease, while many older at-risk men and women—either out of joy or exhaustion—no longer consider AIDS to be a devastating disease. For many people, the risk of HIV infection is no longer a sufficient reason to change their behaviors, and the prospect of taking a drug and continuing life plans uninterrupted often appears to be a more appealing option than facing the ongoing challenges of reducing risk. However, while HIV infection is now manageable for some people with proper treatment, the regimens are complex and often have adverse side effects. It also remains unclear how long antiviral treatments will be effective, and there is a growing number of HIV-infected people for whom treatments have failed or are beginning to lose their efficacy. Making behavior changes is often overwhelming and may be

A Counselor’s Perspective “Ten years ago, I thought there would be a cure by now, but there isn’t. Now I have clients who think that a cure is around the corner. But there is no reason to expect it to happen soon.”

more manageable in increments. By emphasizing this, counselors can help clients begin to take their next steps. If clients perceive risk reduction to be unnecessary because of the availability of new treatments, it is essential for counselors to clarify misconceptions about treatments. HIV is Still a Threat In light of the benefits of new treatments, it is important for counselors to help clients recognize that becoming infected with HIV can still lead to illness, and that treatments may be ineffective, may cause severe side effects, and may necessitate major life-changing activities. There is still no cure for HIV and no way to eliminate the virus from the body once a person has become infected. The best alternative to a cure remains avoiding infection. Counselors must be able to present information about HIV infection and the related disease process as objectively as possible. When clients deny the possibility of becoming infected despite their risk behaviors, it is important to address this contradiction. It may be appropriate to help clients visualize what an HIV-infected life may be like, especially with clients who seem to have unrealistically positive ideas of what life would be like under treatment. When discussing HIV antiviral treatment, elements of misinformation and denial come into play. Counselors must be able to provide clear and accessible factual information as needed, then guide the conversation back to the same kinds of issues counselors and clients traditionally discuss. Some clients contradict the best information available and insist either that they are exceptions to the rule or that things are “not that bad any more.” Respond to such statements by asking clients to clarify how they see themselves as exceptional and what

A Counselor’s Perspective “I sometimes get frustrated by clients who say they’ll just start taking antivirals if they get infected. Talking to my supervisor really helps me to cope with this.” they mean by “not that bad.” Contradictions between clients’ desires and actions may become apparent as clients explain their reasons for testing, discuss their risk behaviors, and describe their understanding of risk information. Counselors may find it difficult to address contradictions, partly because they may consider doing so to be too confrontational. However, it is important for counselors to distinguish between being inappropriately confrontational—in content, tone, and presentation— and reflecting a client’s contradictory statements or beliefs in a neutral and balanced way. Remaining client-centered and establishing trust and rapport helps counselors build relationships that can more effectively address and anticipate some of the dilemmas and challenges clients may have to face. When educating clients about HIV treatments, counselors must keep in mind their limited role. Even if a counselor has a great deal of knowledge about various new medications and treatment regimens, it is not within the scope of the HIV test counseling session to discuss these topics in detail. What matters most is that counselors understand the basic facts about treatment possibilities, for example, that various drugs attack the virus at different stages of replication. It is best for HIV-positive

PERSPECTIVES: HIV TREATMENT UPDATE

clients to discuss information about specific treatments with HIV-knowledgeable health care providers. With clients who test negative, concentrate as much as possible on the fallacy that HIV is easy to treat, but also refer them to other resources for further information about treatment.

Counselor Frustration As is true for other topics that arise with clients, it is important for counselors to understand their own feelings and beliefs about HIV treatments. In particular, counselors need to explore their attitudes about the choices HIV-positive people make about treatment

and the choices of people who put themselves at risk for HIV because of hopes raised by new treatments. Because HIV is a preventable disease, it is understandable that counselors may sometimes feel frustrated. Human behavior, however, is more complex than simple educational messages sometimes suggest.

References

for nursing practice. Journal of the Association of Nurses in AIDS Care. 2000; 11(2): 36-42.

26. Lehman JS, Hecht FM, Wortley P, et al. Are at-risk populations less concerned about HIV infection in the HAART era? Presentation at the 7th Conference on Retroviruses and Opportunisitic Infections. San Francisco. January 30, 2000.

1. Scott-Levin’s HIV Therapy Audit: 4th Quarter 1999 Highlights. March 7, 2000: http://www.scottlevin.com/news. 2. Gallant JE. Strategies for long-term success in the treatment of HIV infection. The Journal of the American Medical Association. 2000; 283(10): 1329-1334. 3. Shernoff M, Smith RA. HIV Treatment: Mental Health Aspects of Antiviral Therapy. San Francisco: UCSF AIDS Health Project, 2000. 4. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. 1999; 11(2). 5. Boden D, Hurley A, Zhang L, et al. HIV-1 drug resistance in newly infected individuals. The Journal of the American Medical Association. 1999; 282(12): 1135-1141. 6. Little SJ, Daar ES, D’Aquila RT, et al. Reduced antiretroviral drug susceptibility among patients with primary HIV infection. The Journal of the American Medical Association. 1999; 282(12): 1142-1148. 7. Howard D. What we don’t know about reinfection. Bay Area Reporter. March 11, 1999. 8. Grabar S, Pradier C, Le Corfec E, et al. Factors associated with clinical and virological failure in patients receiving a triple therapy including a protease inhibitor. AIDS. 2000; 14(2): 141-149. 9. Paterson DL, Swindells S, Mohr J, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Annals of Internal Medicine. 2000; 133(1): 21-30. 10. Holtzer CD, Roland M. The use of combination antiretroviral therapy in HIV-infected patients. The Annals of Pharmacotherapy. 1999; 33(2): 198-209. 11. Haubrich RH, Little SJ, Currier JS, et al. The value of patient-reported adherence to antiretroviral therapy in predicting virologic and immunologic response. AIDS. 1999; 13(9): 1099-1107. 12. Gay Men’s Health Crisis. Treatment Issues’ second survey of physicians’ treatment practice. GMHC Treatment Issues. 1998; 12(1): 3-17. 13. Lyon DE, Truban E. HIV-related lipodystrophy: A clinical syndrome with implications

14. Wanke C, Gerrior J, Kantaros J, et al. Recombinant human growth hormone improves the fat redistribution syndrome (lipodystrophy) in patients with HIV. AIDS. 1999; 13(15): 2099-103. 15. Kilby JM, Hopkins S, Venetta TM, et al. Potent suppression of HIV-1 replication in humans by T-20, a peptide inhibitor of gp41mediated virus entry. Nature Medicine. 1998; 4(11): 1302-1307. 16. Au TK, Collins RA, Lam TL, et al. The plant ribosome inactivating proteins luffin and saporin inhibitors of HIV-1 integrase. Federation of European Biochemical Societies. 2000; 471(2-3): 169-172. 17. Rutschmann OT, Opravil M, Iten A, et al. A placebo-controlled trial of didanosine plus stavudine, with and without hydroxyurea, for HIV infection. AIDS. 1998; 12(8): F71-F77. 18. Goodrich J, Khardori N. Hydroxyurea toxicity in human immunodeficiency viruspositive patients. Clinical Infectious Diseases. 1999; 29(3): 692-693. 19. Calanolide looks promising. AIDS Patient Care and STDs. 2000; 14(4): 225-226. 20. Hecht F, Kahn J, Chesney M, et al. A randomized trial of IL-2 added to HAART for primary HIV infection. Presentation at the 13th International AIDS Conference. Durban, South Africa. July 2000. 21. Raffanti SP, Schaffner W, Federspiel CF, et al. Randomized, double-blind, placebocontrolled trial of the immune modulator WF10 in patients with advanced AIDS. Infection. 1998; 26(4): 202-207. 22. Pietrandoni G. New drugs coming down the pike. Positively Aware. 2000; 11(3): 30-31. 23. Levy J. Caution: Should we be treating HIV infection early? The Lancet. 1998; 352(9132): 982-983.

27. Temoshok LR, Frerichs RR. Secondary HIV prevention. FOCUS: A Guide to AIDS Research and Counseling. 1998; 13(7): 1-4. 28. Farber EW, McDaniel JS. Assessment and psychotherapy practice implications of new combination antiviral therapies for HIV disease. Professional Psychology: Research and Practice. 1999; 30(2): 173-179. 29. Evans BM. Complementary therapies and HIV infection. American Journal of Nursing. 1999; 99(2): 42-45. 30. Greene KB, Berger J, Reeves C, et al. Most frequently used alternative and complementary therapies and activities by participants in the AMCOA study. Journal of the Association of Nurses in AIDS Care. 1999; 10(3): 60-73. 31. Weber R, Christen L, Loy M, et al. Randomized, placebo-controlled trial of Chinese herb therapy for HIV-1-infected individuals. Journal of Acquired Immune Deficiency Syndromes. 1999; 22(1): 56-64. 32. Mocchegiani E, Muzzioli M. Therapeutic application of zinc in human immunodeficiency virus against opportunistic infections. Journal of Nutrition. 2000; 130 (5S Suppl): 1424S-1431S. 33. Rabkin JG, Ferrando SJ, Wagner GJ, et al. DHEA treatment for HIV+ patients: Effects on mood, androgenic and anabolic parameters. Psychoneuroendocrinology. 2000; 25(1): 53-68. 34. Shlay JC, Chaloner K, Max MB, et al. Acupuncture and amitriptyline for pain due to HIV-related peripheral neuropathy. The Journal of the American Medical Association. 1998; 280(18): 1590-1595.

24. Ruiz L, Martinez-Picado J, Romeu J, et al. Structured treatment interruption in chronically HIV-1 infected patients after long-term viral suppression. AIDS. 2000; 14(4): 397-403.

35. Piscitelli SC, Burstein AH, Chaitt D, et al. Indinavir concentrations and St John’s wort. The Lancet. 2000; 355: 547-548.

25. Grinberg L. HAART breaks: Structured treatment interruptions. FOCUS: A Guide to AIDS Research and Counseling. 2000; 15(10): 5-6.

36. Piscitelli SC. Use of complementary medicines by patients with HIV: Full sail into uncharted waters. Medscape HIV/AIDS. 2000; 6(3).

PERSPECTIVES: HIV TREATMENT UPDATE

Case Study Jared is a 19-year-old bisexual man who lives in a small city. Jared says that within his circle of friends, sexual relationships are “open,” and he has several male and female partners with whom he regularly has sex. Jared says that he and his friends do not use condoms because the women are on birth control pills and the men are all “clean and young.” He also says, “AIDS is no big deal anymore. It’s an old gay guy’s disease.” Support Jared for seeking counseling and testing, and ask him why he chose to do so at this time. Assess his knowledge of HIV, and explore what leads him to say that AIDS is no longer a big deal and that only older gay men get HIV. Explain to Jared that HIV infects people of all genders, ages, and sexual orientations, and that one of the fastest growing segments of the HIV-infected population is young people. Make sure he understands the facts about HIV transmission and its relationship to risk behavior. Jared may need basic information to clear up any misconceptions he may have about “new treatments.” Explain that currently available drug treatments have had some success, but they do not work for everyone, their effects may be debilitating and cause serious side effects, and they may only delay illness rather than prevent it from ever occurring. If Jared has questions about HIV treatments, present both the positive and the negative aspects. Be sure he understands that there is no cure and that there is unlikely to be one in the near future. If this information moves Jared to a new understanding and willingness to examine his own HIV risk, follow his lead. For example, if Jared states that this information is new to him and that it “changes things” for him, ask him how it changes things and, by listening and being attentive, try to determine if he is now serious about considering change. If Jared tries to explain that the facts are not relevant to his situation, it may be useful to draw on Jared’s emotions. Trying to elicit an emotional In the face of HIV treatment “miracles” and the profound desire to engage in behaviors that are either pleasurable, addictive, or both, some clients resist acknowledging the risk HIV poses to them and their sex or needle-using partners. Frustration may be difficult to avoid for counselors who are aware of the consequences of HIV infection, especially when clients appear unable or unwilling to change their risk behaviors. It is

response does not mean using pressure or scare tactics; a more effective approach is to address emotional factors instead of the risk information he does not accept as valid. For example, tell Jared about past clients who were similar to him—in age, lifestyle, or other aspects—and who tested positive for HIV antibodies. Counselors who have not personally worked with such clients can quote other sources for similar scenarios. The goal of this approach is to make HIV real for Jared with specific examples. If he responds to this intervention, explore its meaning to him. Gently but clearly address any contradictions that may arise between Jared’s responses to the facts about HIV treatments and his concerns about HIV infection as expressed in his decision to test for antibodies. For example, state, “It seems that you’re concerned about HIV risk, and you understand the limitations of treatments, but you seem reluctant to consider your own risk and what you might need to do to avoid infection. What do you think about this?” Remember that following the client’s lead means accurately assessing Jared’s stage within the continuum of behavior change, deciding on interventions that are appropriate for that stage of change, making those interventions, and reassessing Jared’s stage of behavior change based on his response. Keep in mind that even if he does not appear to have progressed to the next stage during the counseling session, his progression along the continuum may occur in the future based on this counseling session.

important to remember, however, that each appropriate intervention can contribute to a client’s progress in the continuum of behavior change. Emotions may cause some counselors to lose sight of the fact that it is ultimately the client’s responsibility to make change. An HIV test counselor’s effort is part of a much larger decision-making process in a client’s life. It can be helpful for counselors to explore their feelings, beliefs, and values

about these matters with peers and clinical supervisors. Counselors may find it especially disturbing that HIV treatments are sometimes not effective or that there is still no cure, and it is important for them to explore and express these feelings. This can be especially significant for seasoned counselors who have witnessed many promising and often disappointing treatments become available over the years.

PERSPECTIVES: HIV TREATMENT UPDATE

Test Yourself Review Questions 1. True or False: Combination therapy is an effective HIV treatment because it eradicates the virus from the body.

2. True or False: Drug resistance refers to the phenomenon by which a drug loses its effectiveness because of a mutation, that is, a change in the structure of HIV. 3. Combination therapy has resulted in which of the following effects? a) a decrease in AIDS-related deaths; b) short- and long-term adverse effects; c) decreased incidence of opportunistic illnesses; d) all of the above. 4. True or False: An HIV-positive person who has achieved “undetectable viral load” no longer has the virus in his or her body. 5. Which of the following classes of antiviral drugs have received approval from the Food and Drug Administration (FDA)? a) nucleoside reverse transcriptase inhibitors; b) non-nucleoside reverse transcriptase inhibitors; c) protease inhibitors; d) all of the above.

6. “Salvage therapy” refers to which of the following? a) using a new set of antiviral drugs to treat HIV-infected individuals for whom initial treatment was not effective; b) prescribing a random combination of drugs; c) resorting to a treatment regimen because of its low cost; d) none of the above. 7. True or False: There have been reports of transmission of drugresistant HIV among newly infected individuals. 8. Structured treatment interruption can have which of the following effects? a) boosting of the immune system; b) rapid increase of viral load; c) development of drug resistance; d) all of the above. Discussion Questions 1. How can counselors correct misconceptions clients may have about HIV treatments while remaining neutral, objective, and client centered?

2. How can test counselors stay abreast of the latest developments and trends related to HIV treatments and care?

Using PERSPECTIVES

HIV Counselor PERSPECTIVES

PERSPECTIVES is an educational resource for HIV test counselors and other health professionals.

Editor: Alex Chase

Each issue explores a single topic. A Research Update reviews recent research related to the topic. Implications for Counseling applies the research to the counseling session. Also included are a Case Study and two sets of questions for review and discussion.

3. How can counselors maintain a current file of appropriate referrals related to HIV treatments while keeping in mind the different needs of clients depending on their test results? 4. How can counselors respond to clients who state that they no longer feel threatened by HIV because of new treatments? 5. How can counselors cope with their own frustrations about antiviral treatments and the related psychosocial impacts on clients? Answers 1. False. Combination therapy combats HIV by suppression of viral replication and, consequently, slows disease progression. It cannot eradicate HIV from the body. 2. True. 3. d. 4. False. “Undetectable viral load” means that HIV is still present in the blood but that its concentration is too low to be detected by a given viral load test. 5. d. 6. a. 7. True. 8. d.

Volume 9 Number 6 November 2000

Researcher and Writer: Pegoh Pajouhi Primary Clinical Consultant: Jd Benson, LMFT Clinical Consultants: Barbara Adler, LMFT; Stephen E. Follansbee, MD; Miriam Garfinkel, LMFT; Heather Lusk; Francis Salmeri, LMFT Production: Saul Rosenfield

Executive Director: James W. Dilley, MD

Circulation/Administrative Support: Carrel Crawford; Cassia Stepak

Manager of Publications: Robert Marks

Proofreading: Carrel Crawford; Cassia Stepak

Designer: Saul Rosenfield

PERSPECTIVES is funded in part through a grant from the California Department of Health Services, Office of AIDS. PERSPECTIVES is published six times a year and is distributed to HIV counseling and testing sites in California.

For subscription information, contact: UCSF AIDS Health Project, Box 0884, San Francisco, CA 94143-0884. (415) 476-6430.

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The AIDS Health Project produces periodicals and books that blend research and practice to help front-line mental health and health care providers deliver the highest quality HIV-related counseling and mental health care. For more information about this program, visit http://ucsf-ahp.org/ HTML2/services_providers_publications.html.