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P RTAIL
VIH / sida du Québec
HIV
What You Need to Know
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
Legal Review (Rights and Responsibilities section)
Me Stéphanie Claivaz-Loranger
Graphic Design
Kim Deslauriers
Design and Layout
Marie-Christine André
Kim Deslauriers
Translation
Alain Boutilier
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, 2nd edition.
©2012 Portail VIH/sida du Québec. All Rights Reserved.
ISBN 978-2-9812430-6-5
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 2J9
514-523-4636
1-877-767-8245
E-mail: [email protected]
www.pvsq.org
P O RTA I L V I H / S I DA D U QU É B E C
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
02
PORTAIL VIH/SIDA DU QUÉBEC
BACKGROUND AND
STATISTICS
A GLOBAL PERSPECTIVE | Amount of people living with HIV in the world in 2008.
North America
1,4 million
Western and Central
Europe
850 000
Eastern Europe
and Central Asia
1,5 million
East Asia
850 000
Caribbean
240 000
Middle East
and North Africa
310 000
South Asia
3,8 million
Latin America
2,0 million
Sub-Saharan Africa
22,4 million
Oceania
59 000
Source: UNAIDS (For English graphic, see English report on UNAIDS site
http://www.unaids.org/en/dataanalysis/epidemiology/2008reportontheglobalaidsepidemic/
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).
03
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 1985. The 1st World AIDS
Conference also took place in 1985, in Atlanta. AZT, the
first anti-VIH drug, appeared in 1987.
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
P O RTA I L V I H / S I DA D U QU É B E C
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.
04
PORTAIL VIH/SIDA DU QUÉBEC
A LOOK BACK
1981 to 2009
First screening test for HIV is used. First
World AIDS Conference held in Atlanta.
Creation of the Canadian AIDS Society.
American actor Rock Hudson dies of AIDSrelated complications.
Death of Queen lead singer Freddy Mercury
from AIDS-related complications.
Treatment Information Exchange.
1991
1992
2000
Red ribbon / Universal symbol of
compassion and solidarity with victims of
HIV / AIDS.
Double combination therapy: combining
HIV drugs ( AZT, DDI, DDC ).
Creation of the Canadian HIV /AIDS Legal
Network.
Ça Marche/ Farha Fondation / 1st 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.
2002
1990
CATIE / Creation of the Canadian AIDS
1991
personnes atteintes du VIH/sida du Québec.
organismes communautaires québécois de
lutte contre le sida.
Creation of the Global Fund to Fight AIDS,
Tuberculosis and Malaria.
2004
CPAVIH / Creation of the Comité des
Exhaustion of treatment strategies for
multi-resistant patients; arrival of fusion
inhibitors provides rescue therapy in such
cases.
2009
1988
Creation of World AIDS Day on
December 1st
1989
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.
1996
AZT is brought to market.
First vaccine study begins.
1987
1993
1984 /1985
Discovery and isolation of the HIV virus.
1995
First case of AIDS reported in the United
States.
1986
1983
1981
A few facts...
COCQ-sida / Creation of the Coalition des
Almost 20% of HIV-positive people in the
world have access to combination therapy.
05
P O RTA I L V I H / S I DA D U QU É B E C
STATISTICS
GLOBAL EPIDEMIOLOGICAL PORTRAIT OF AIDS | ESTIMATES | DECEMBER 2008
People living with HIV
Adults (15 + )
Women
Children
Total
31.3 million
15.7 million
2.1 million
33.4 million
New cases of HIV Infection
Adults (15 + )
Children
Total
2.3 million
430 000
2.7 million
Death due to AIDS
Adults (15 + )
Children
Total
1.7 million
280 000
2.0 million
CANADIAN EPIDEMIOLOGICAL PORTRAIT OF AIDS | ESTIMATES | DECEMBER 2008
Estimated prevalence of HIV infection in Canada
Total
65 000
Estimated prevalence of HIV infection Quebec
MSM
MSM and IDU
9060
760
IDU
2710
Heterosexual contact / Endemic country
2350
Heterosexual contact / Non-endemic country
2900
Other
Total
Sources :
1 - ONUSIDA
2 - Public Health Agency of Canada
3 - Ministère de la Santé et des Services sociaux du Québec
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.
140
17 920
06
PORTAIL VIH/SIDA DU QUÉBEC
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
uman
mmunodeficiency
irus
A
cquired
I
mmune
D
S
eficiency
yndrome
07
P O RTA I L V I H / S I DA D U QU É B E C
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.
| 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.
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.
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.
08
PORTAIL VIH/SIDA DU QUÉBEC
THE IMMUNE
SYSTEM
BLOOD CONTAINS PLASMA AND THE FOLLOWING INGREDIENTS
WHITE BLOOD
CELLS
RED BLOOD
CELLS
PLATELETS
or Leucocytes
or Erythrocytes
or Thrombocytes
Immune response
Blood oxygenation
Blood clotting
AGRANULOCYTES
GRANULOCYTES
or Mononuclears
or Polynuclears
Including:
Phagocytosis1 and
1- Monocytes:
allergic reactions
become macrophages inside tissues.
Role: phagocytosis, cell presenting viral
antigen2.
2- Lymphocytes
T
B
LYMPHOCYTES
T4 (CD4)
Lymphocyte B
Conductor of the immune response. It sends
Stimulated by CD4 cells or a microbe’s
chemical signals to other cells in order to
antigen2. Produces special proteins called
activate the immune response.
antibodies that attach themselves to viruses
in order to destroy them before they have
T8 (CD8)
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
2
Phagocytosis: Defensive process (non-specific immunity) launched by cells that surround and destroy solid bodies, especially microbes.
Antigen: Foreign substance in the body that can trigger an immune response or react with its result (antibody).
Adapted from: Sida 101. 2e éd. Comité des personnes atteintes du VIH du Québec. 2000..
09
P O RTA I L V I H / S I DA D U QU É B E C
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.
In some cases, antibodies are able
to facilitate the destruction of various microbes. (viruses, bacteria,
etc.).
LYMPHOCYTE B
CELLULE CD8
ANTIBODIES
INFECTED CELL
VIRUS
Adapted from: Sida 101. 2e éd. Comité des personnes atteintes du VIH du Québec. 2000.
Stimulation of CD8 lymphocytes
by CD4s and production of
antibodies specific to a given
microbe.
10
PORTAIL VIH/SIDA DU QUÉBEC
CD4 CELLS
AND HIV VIRAL LOAD
CD4 CELLS
HIV VIRAL LOAD
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.
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.
11
P O RTA I L V I H / S I DA D U QU É B E C
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.
12
PORTAIL VIH/SIDA DU QUÉBEC
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
Nucleus
CD4 cell
RNA
Enzyme
Reverse
transcriptase
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.
STEP 2: TRANSCRIPTION
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.
13
P O RTA I L V I H / S I DA D U QU É B E C
STEP 3: INTEGRATION
Nucleus
Enzyme
Integrase
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.
STEP 4: ASSSEMBLY
Enzyme
Protease
New
viruses
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.
14
PORTAIL VIH/SIDA DU QUÉBEC
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).
15
P O RTA I L V I H / S I DA D U QU É B E C
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).
16
PORTAIL VIH/SIDA DU QUÉBEC
EVALUATING THE RISK
OF HIV TRANSMISSION
| 1 NO RISK |
| 3 LOW RISK |
Potential for transmission NONE
Evidence of transmission NONE
Potential for transmission YES
Evidence of transmission YES (under certain conditions)
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.
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 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.
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 |
| 4 HIGH RISK |
Potential for transmission YES
Evidence of transmission NONE
Potential for transmission YES
Evidence of transmission YES
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.
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.
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.
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
17
HIV
SCREENING TESTS
The first HIV screening tests were brought to
market in 1985. 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).
P O RTA I L V I H / S I DA D U QU É B E C
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.
PORTAIL VIH/SIDA DU QUÉBEC
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.
18
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.
19
P O RTA I L V I H / S I DA D U QU É B E C
Today, HIV is generally
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
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.
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.
We must never forget
that people with HIV are
complete beings with
strengths, weaknesses
and life goals.
PORTAIL VIH/SIDA DU QUÉBEC
20
SEX
and drugs and how quickly you are willing to trust
your partner.
AND HIV
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.
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
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.
21
P O RTA I L V I H / S I DA D U QU É B E C
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, 2008.
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
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.
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.
23
P O RTA I L V I H / S I DA D U QU É B E C
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
To prevent HIV transmission
Choosing a combination antiretroviral therapy that
is effective and well suited to your lifestyle
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
24
PORTAIL VIH/SIDA DU QUÉBEC
ANTIRETROVIRALS
Combined NRTIs
PI DOSAGE 1 or 2 times per day
NRTI
NNRTI
NOVEMBRE 2009 © RACHEL THERRIEN
www.guidetherapeutiquevih.com
25
P O RTA I L V I H / S I DA D U QU É B E C
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
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).
Classes combinations ( NRTI / NNRTI )
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
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.
Integrase : enzyme that fosters a stable relationship
between the virus’s genetic material (DNA) and the
host cell’s DNA.
26
PORTAIL VIH/SIDA DU QUÉBEC
ADVERSE
EFFECTS
Side effects (also called adverse effects or reactions)
are effects caused by a drug that go beyond what
is hoped for and that can be bothersome to the
person experiencing them. All antiretrovirals can cause
side effects. However, in studies involving the new
antiretroviral regimens, side effect rates seem to be
decreasing and are generally below 10%. Most side
effects are identified during clinical studies conducted
before a drug is put on the market. However, some
less frequent or long-term toxicities are only identified
once the drug has been used for several years. Side
effects are among the most common reasons cited for
modifying a given therapy.
Several factors may predispose patients to the adverse
effects associated with antiretrovirals. For example,
depending on the drug chosen, women or people
with a genetic predisposition may be at increased risk
of developing certain specific side effects or even an
allergy. The presence of additional health problems,
such as alcoholism or viral hepatitis, can also increase
the risk of side effects. Other factors, such as the
concomitant use of drugs that may cause similar side
effects or drug interactions with antiretrovirals, can
lead to an increase in side effect symptoms.
When choosing antiretrovirals, the ultimate goal is to
select a combination that is not only effective, but
also safe. To do so, one must take into account the
patient’s underlying conditions, the other drugs being
used and any previous intolerances.
The side effects associated with antiretrovirals can be
divided into two categories: short-term effects and
long-term effects.
Short-term effects:
The most commonly reported side effects appear
within days of starting therapy. During this period,
many patients report experiencing fatigue, insomnia,
a decreased ability to concentrate, loss of appetite,
nausea or diarrhea. Because antiretrovirals are
taken in combination, it’s often difficult to pinpoint
a single culprit behind these side effects. Beginning
antiretroviral therapy is a stressful moment in a
person’s life, and this may explain why people are
more sensitive to side effects at the start of therapy.
Indeed, some believe that side effects can be confused
with the physical effects of stress.
Most short-term side effects are transitory: they
occur more frequently at the beginning of therapy
but gradually fade as the body becomes used to the
medications, usually after two to six weeks.That’s why
it’s important not to stop taking the drugs as soon as
side effects appear, unless they are intolerable. If that
is the case, consult your care team before deciding to
stop your medication.
To reduce the risk of short-term side effects, it’s best
to maintain as healthy a lifestyle as possible during the
early days of therapy.
Healthy lifestyle hints:
1. Allow yourself as many hours of sleep as you
need to be well rested
2. Eat at least three balanced meals per day, but
don’t force yourself to eat if you’re not hungry
3. Keep well hydrated by drinking between 1.5
and 2 litres of liquid a day
4. Avoid sources of stress
5. Exercise moderately, taking care not to overdo
it
6. Avoid alcohol and drugs
7. Avoid overeating
27
P O RTA I L V I H / S I DA D U QU É B E C
It’s often possible to relieve the early side effects of
treatment without having to resort to medication.
When necessary, certain over-the-counter drugs can
be used to relieve moderate side effects. In all cases,
it’s important to consult a health-care professional
before taking a non-prescription drug or natural
health product in conjunction with antiretrovirals to
ensure that everything is compatible.
Long-term effects:
Many patients worry about the long-term effects that
antiretrovirals will have on their body. Will they be
toxic for my liver or kidneys? Will they prevent me
from working or having children? Might they cause
changes that would be visible to the people around
me?
When choosing to take medication, it’s always
important to consider not only the risks, but also the
potential benefits. Nowadays, in the vast majority of
cases, the benefits of therapy, such as prolonged life
expectancy and a decreased risk of developing AIDS,
outweigh the low risk of long-term side effects. By
far, most people who choose to take antiretrovirals
return to a "normal life" and can continue to do the
same activities they did before.
The liver and kidneys are the main organs responsible
for eliminating wastes from the body. It’s true that
taking medication on a regular basis causes these
organs to work harder. However, in the vast majority
of cases, their effectiveness changes little or not at all.
In any case, your care team will check your response
to your antiretrovirals using various tests, including
blood tests. If these tests reveal toxicity, your team
will have a better chance of preventing permanent
damage and will be able to change one or more
drugs in your combination.
Lipodystrophy is a subject that concerns many
patients who are about to begin therapy. Lipodystrophy
is a body fat distribution problem that is caused by
some antiretrovirals. In concrete terms, a person with
lipodystrophy (in this example, lipoatrophy) may have
sunken cheeks and buttocks, as well as skinny arms
and legs. In other cases, the abdomen may become
distended, a bump may appear on the upper back
(buffalo hump), and the breasts may appear larger.
When these side effects were observed early in the
2000s, they caused quite a lot of upset, both in the
HIV community and among health-care professionals.
Research was begun immediately to discover which
medications were responsible for lipodystrophy and
how to prevent or reverse the problem. Fortunately,
thanks to the antiretrovirals used nowadays, new
cases of lipodystrophy are very rare.
PORTAIL VIH/SIDA DU QUÉBEC
TREATMENT
ADHERENCE
Adherence (also called compliance) to antiretroviral
therapy remains a key determinant of its success.
Adherence means taking the correct dose of a drug at
the right time and in accordance with the instructions
(for example, with or without food) of your doctor or
pharmacist. It also requires persistence and taking the
drug for the entire duration of the treatment, without
stopping, either for a period of time or completely,
without consulting your doctor.
The rate of adherence necessary to achieve
viral suppression varies according to the class of
antiretrovirals and the different components of
a given regimen. Some classes, and even certain
specific antiretrovirals, are considered more robust
when doses are taken late or skipped because they
stay in the blood longer and are less subject to viral
resistance. Despite this, it’s important to remember
that when adherence is close to perfect, ideally better
than 95%, the risk of treatment failure decreases.
Incomplete adherence is associated with a detectable
viral load, development of resistance to antiretrovirals,
disease progression and an increase in sickness and
death.
28
FACTORS RELATED TO
NON-ADHERENCE
• Factors associated with the health-care system:
- Accessibility: environment, access to care, place
of residence.
-Doctor-patient relationship: a poor relationship
between the doctor, care team and patient will
have a negative effect on adherence.
• Factors related to the individual: drug and
alcohol abuse, mental health problems
(particularly depression), psychosocial distress.
• Factors related to the medication: cost, side
effects, treatment complexity, dosing schedule,
pill burden.
• Factors related to the disease: if the disease
progresses, some people may lose interest
in taking their treatment; on the other hand,
complications of the disease (opportunistic
infections, for example) will encourage some
patients to take their treatment more faithfully.
29
P O RTA I L V I H / S I DA D U QU É B E C
ADHERENCE
ADVICE
Here are some practical tips for making adherence
easier:
• Integrate the medication into your lifestyle, and
not the opposite.
• Use a pillbox. If refrigeration is necessary, use a
sticker to indicate the location of the medication.
• Prepare the medication in advance.
• Make a reminder list or leave yourself Post-it
notes.
• Use an alarm.
• Make a note of doses to be taken or skipped
doses in a day planner.
• Plan your vacations or weekend outings.
• Call your pharmacist before running out of
drugs. Some pharmacies do refills.
• Establish a good environment to obtain adequate
support.
• Ask for help to manage side effects or other
problems.
• Foster good communication with your doctor
and care team.
• Be honest with yourself and your care team to
achieve the best results possible.
Several types of interventions are necessary for
evaluating and facilitating adherence. Strategies that
address education (to improve knowledge about
antiretroviral therapy), behaviour and the patient’s
feelings (to broaden his or her support network)
are recommended. A combination of these three
types of strategies gives better results. At the present
time, there is no evidence that one strategy is more
effective than another.
Usually, a positive approach is best. It’s important to
encourage and highlight success and to work towards
improving negative behaviours. Anyone can have
adherence problems from time to time, whether it’s
a money issue, concerns about confidentiality, side
effects or simple forgetfulness, etc. Adherence is an
evolving phenomenon and not a static one. One day,
you may take your drugs just as recommended and
the next, not so much. It’s important to be honest
with your doctor and treatment team in order to
manage your daily medication as well as possible.
PORTAIL VIH/SIDA DU QUÉBEC
DRUG
INTERACTIONS
The term drug interaction is used whenever two
medications that are taken at the same time produce
an additive, synergistic or antagonistic effect. Such
effects can alter a drug’s activity or cause toxicity. For
example, if someone takes two drugs that are known
to cause anemia (drop in red blood cells), the risk of
developing this side effect will be greater than if only
one of the drugs in question is taken.
A drug interaction is also said to occur when
one drug alters the absorption, metabolism or
elimination of another drug. Were that to happen, the
concentration of the other drug might increase in the
blood (when the concentration goes up, so does the
risk of side effects or toxicity), or it might decrease (if
the concentration goes down, the drug will become
less effective).
Drug interactions can occur with several antiretrovirals.
This is particularly so with the non-nucleoside reverse
transcriptase inhibitors (NNRTI), protease inhibitors
(PI) and the CCR5 co-receptor inhibitor maraviroc.
As well, because of certain related illnesses, such as
kidney or liver failure, some people are particularly at
risk and should be monitored carefully.
It’s important to detect all interactions in order to
avoid drug concentrations that are below or above
therapeutic levels; this helps to lower the risk of lost
efficacy or serious side effects.
30
Sometimes, it’s necessary to adjust the dose of a
drug, to ensure specific follow-up for a given period
or even to choose another drug.
A blood test can be done to determine the precise
concentration of a drug in the blood (therapeutic
drug monitoring). The means used to manage
the interaction will depend on several factors, and
different solutions will be found for different people.
Prescription drugs are not the only substances
that can cause interactions. Indeed, many over-thecounter products can also cause problems. For
example, anti-inflammatory drugs such as ibuprofen
or drugs for digestive problems such as ranitidine
can cause interactions. Also, natural health products
and recreational drugs can sometimes cause serious
effects that are due to underlying interactions.
It’s very important to mention all the drugs and
health products you take to your doctor and
pharmacist, whether they are prescribed or not. The
list must be complete and include prescription drugs,
over-the-counter drugs, natural health products, illicit
substances, vitamins, etc.
It’s also important to ensure that your treating
physician is aware of any prescriptions you have
received from other specialists. Ask your pharmacist
to check for interactions each time a new drug is
added to your regimen or removed from it.
31
P O RTA I L V I H / S I DA D U QU É B E C
HIV DRUG
RESISTANCE
reproduce more quickly. Eventually, they will replace
viruses that have remained sensitive to the drugs,
that is to say viruses whose replication is still being
inhibited by therapy. The most adapted viruses are
said to have become drug resistant.
How do you prevent the development
of drug-resistant virus?
Resistance is the main reason why HIV drugs cease
to be effective. In more than 90% of patients who
take their drugs regularly, current treatments help
achieve an undetectable level of virus. However, over
time, the virus can adapt to the drugs used. When this
happens, the drug has developed resistance.
What is resistance?
Resistance occurs when the virus manages to
reproduce despite the presence in the blood of drug
levels that would normally be enough to stop viral
replication. It occurs when the virus has adapted to
the drugs used. Viral load then becomes detectable
again, despite the continued use of antiretrovirals.
How does the virus adapt to
medication?
When the medication is effective, the virus remains
in a dormant state inside cells and reproduces
very little or not at all. Viral load then becomes
undetectable. However, when the amount of drugs in
the blood is insufficient, the virus begins once again to
reproduce. While doing so, the virus makes mistakes
that are referred to as genetic mutations (structural
modifications within the virus). Some of these
mutations allow the virus to adapt to the drugs used.
When exposed to an insufficient amount of drugs,
viruses with genetic mutations will adapt better and
Since resistance usually results from viral replication
that occurs in the presence of HIV drugs, it’s essential
to prevent any possibility of this happening. When
there is no replication, no genetic mutations are
possible and the virus cannot develop resistance (see
the blue area in Figure 1 on the next page).
When no drugs are present in the blood, resistance
cannot occur because the virus is not forced to adapt
to them (see the gray zone in Figure 1 on the next
page). The virus can however reproduce very quickly
when no drugs are used, causing rapid weakening of
the immune system and disease progression.
The virus adapts and resistance develops when viral
replication occurs in the presence of a low level of
HIV drugs (see green area in Figure 1 on the next
page).
In what situations can HIV reproduce
despite the use of medication?
HIV can reproduce in the presence of antiretroviral
drugs:
• If the therapy is not effective enough. For example,
if a person were to take one or two drugs only,
instead of at least three.
• When drug levels are not high enough because of
irregular adherence.
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PORTAIL VIH/SIDA DU QUÉBEC
• If therapy is stopped. Because some antiretrovirals
are eliminated more quickly than others, the virus
could be alone in the blood with only one drug if
therapy were stopped.
Resistance can occur even when good adherence to
therapy is maintained. Although rare, this situation
may occur because of genetic factors that alter
absorption and drug levels in the blood.
• If food requirements are not met (such as taking
a drug on an empty stomach or with food), drug
absorption could be compromised, causing an
inadequate concentration of drugs in the blood.
Why must HIV drugs be taken every day?
• If there are interactions between HIV drugs and
other drugs or certain over-the-counter products.
These products may lower the concentrations of
HIV drugs in the blood and allow resistance to
develop.
The best way to avoid drug resistance is to take your
drugs when and how they are prescribed, without
skipping a single dose, and by following any instructions
there may be regarding food intake. Some drugs need
to be taken every eight hours, others every 12 hours
and still others only once a day. In general, when
recommendations about taking the medication are
followed, resistance is prevented. FIGURE 1
The white line represents the amount of
drug in the blood after a dose is taken. In this
example, the drug is to be taken every 12
hours, at 8 a.m. and 8 p.m.
In this example, the second dose scheduled for 8 p.m.
was forgotten, but was eventually taken at 12:30 a.m.
In the meantime, the level of drug in the blood fell too
low to stop viral replication, allowing the virus to adapt
to the drug.
A large amount
of drug in the
blood
Amount of drug required to
stop viral replication and prevent
resistance.
A small amount
of drug in the
blood
Area where resistance
may develop.
No drug in the
blood
Area where there is more drug in
the blood and no development of
resistance.
8h
20h
8h
8h
20h
00h30
8h
Critical
area
Adapted from : Jean-Guy Baril. HIV Drug Resistance. HIV Treatment Update – A Doctor Explains. Article 7, May 2005.
33
What if the drugs stop working?
It’s possible to check for drug resistance with the help
of a blood test. When viral load becomes detectable
and there’s reason to believe that resistance is the
main cause, this test helps identify the drugs to which
HIV has become resistant. When the virus adapts
to a particular drug, it can compromise the efficacy
of other drugs in the same class. Drug resistance is
generally irreversible.
Once resistance has developed, treatment options
include changing drugs or classes of drugs. In such
cases, resistance tests help doctors choose an
appropriate alternative treatment. Since the number
of drugs available is limited, the best way to fight
resistance is to prevent it.
Resistant virus can be transmitted in some cases. As
a result, a person who has never taken HIV drugs
could contract a strain of HIV that is already resistant
to drugs. That’s why resistance testing is performed
before the start of therapy, even for patients who
have never before taken HIV drugs.
P O RTA I L V I H / S I DA D U QU É B E C
34
PORTAIL VIH/SIDA DU QUÉBEC
CLINICAL FOLLOW-UP
OF THE HIV-POSITIVE PERSON
HIV infection is a chronic disease that requires longterm medical follow-up to achieve optimal health.The
number of visits to the doctor will vary according to
each person’s needs. Once every three to six months
may be enough when all is well, with more frequent
follow-up at other times, such as the period following
diagnosis, after initiation of antiretroviral treatment or
at any other time it is deemed necessary.
Visits will include a physical exam, various screening
tests, blood tests, vaccines and a review of previous
test results.
PHYSICAL EXAM
A complete physical exam is needed at least once a
year. This includes a gynecological exam for women
and a rectal exam for men (to screen for anal diseases
in men who have sex with other men [MSM] or
prostate conditions in men over 50). A more general
examination will be done during routine visits, when
doctors should check your blood pressure, weight
and waist circumference.
SCREENING TESTS
Screening tests are used to detect diseases or
infections before they become symptomatic. Initial
screening for other sexually transmitted and bloodborne (STBBI) infections is done and then repeated
in accordance with a person’s risk factors (number
of partners, unprotected sex, sharing of injection
equipment or drug use, etc.). Screening includes
checking for gonorrhea and chlamydia at various
sites (throat, urethra, anus or cervix), blood tests for
syphilis and hepatitis A, B and C and a visual exam
to detect condylomas and genital herpes. A skin
test for tuberculosis (TCT or PPD) is indicated for
people with specific risk factors, such as immigrants
from countries or communities where this disease is
common.
Women should undergo an annual cervical cytology
to screen for cervical cancer. In MSM, an annual anal
cytology may be considered to screen for anal cancer.
Availability of these tests may vary from place to
place.
A bone density test is another screening test that
may be suggested. It is indicated for women after
menopause and for both sexes when bone fracture
risk factors are present. Because HIV and antiretroviral
treatments seem to contribute to the loss of bone
mass, this test may be done in the absence of these
indications or as part of a research protocol.
35
P O RTA I L V I H / S I DA D U QU É B E C
BLOOD TESTS
Blood samples are routinely sent to a laboratory for
analysis. The results allow doctors to monitor the
health of their HIV-positive patients and to detect
anomalies. Certain changes in the blood may be a
sign of treatment toxicity or the onset of a disease
such as diabetes.
Biochemical tests allow doctors to evaluate the
condition of the various systems of the body. They
include measures of electrolytes (sodium, potassium),
kidney function (creatine, urine analysis), liver function
(AST and ALT enzymes, alkaline phosphatase, bilirubin,
albumin) and pancreatic function (amylase), as well
as tests measuring minerals such as phosphorus
and calcium. For some important tests, patients
are required to have an empty stomach to ensure
valid results, such as those measuring blood lipids
(cholesterol and triglycerides) and blood sugar levels
(glycemia).
HIV-SPECIFIC TESTS
The HIV viral load (amount of HIV in the blood)
and lymphocyte count (CD4 count) are the
main markers used to monitor disease progression
and the response to treatment. Both the absolute and
relative values of these tests are used.
Genotypic resistance testing of the virus is
performed before initiating treatment in order to
detect viral mutations that might indicate resistance to
treatment. This test is repeated in cases of treatment
failure, as well as before changing therapy.
Phenotypic resistance testing is another
test that is used less frequently to determine the
resistance and sensitivity of certain antiretrovirals to
the HIV virus.
It’s also possible to check the amount of antiretroviral
medication in the blood using a technique called
therapeutic drug monitoring.
The HLA B5701 allele screening test is a
genetic test used to predict an adverse reaction to
the antiretroviral drug abacavir.
The CCR5/CxCR4 tropism test helps determine if
a patient could benefit from the use of maraviroc, a
drug belonging to the class of CCR5 inhibitors.
VACCINES
Medical follow-up includes exams and tests
designed to prevent patients from developing or
contracting other diseases. Vaccines are designed
to stimulate the immune system in such a way that
it can develop resistance to infections. In certain
cases, doctors will administer vaccines for tetanus,
pneumococcal pneumonia, hepatitis A and B and
HPV (human papillomavirus). A yearly flu vaccination
is recommended for all people living with HIV.
Live vaccines, such as the one for yellow fever, are
contraindicated and will only be administered in
specific situations.
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PORTAIL VIH/SIDA DU QUÉBEC
LIVING WELL WITH HIV
VEGETABLES AND FRUITS
Vitamin C, beta carotene, folic acid,
iron, antioxidants, phytochemicals, fibre
GRAIN PRODUCTS
To live well with HIV, you need to take care of yourself
on a day-to-day basis by adopting a healthy lifestyle.
Choosing a high-energy and nutritious diet will help
optimize your immune system.
Eating a variety of foods helps ensure you’re getting
enough essential nutrients. Although some foods
contain more nutrients than others, no type of food
is complete all alone. The weakness of one food is
compensated by the strength of another. For example,
meat is rich in protein but contains little vitamin C,
unlike the orange. A diet based on a variety of foods
that contribute to our well-being leaves less room for
foods of poor quality.
By choosing the amount and types of food
recommended in the Canada Food Guide, you’ll be
able to meet your vitamin, mineral and other nutrient
needs.
Maintain a healthy body weight. It’s true that
insufficient caloric intake can contribute to immune
suppression, but an excessive intake of calories can
also be harmful.
A nutritious diet and physical activity help maintain a
healthy weight and reduce the risk of chronic diseases
such as cancer, diabetes, cardiovascular disease and
osteoporosis.
B vitamins, iron, fibre if whole grains
are used
MILK AND ALTERNATIVES
Calcium, vitamin B2, protein
MEAT AND ALTERNATIVES
Protein, iron, zinc, B vitamins, vitamin A
Active people typically report an improvement in
their energy level and mood. Regular physical activity
and a fitter body will help you perform your daily
tasks with greater ease and less fatigue. But don’t
forget to hydrate. Drink a litre to a litre and a half of
water every day.
Being active and healthy requires energy!
By spreading your meals out sufficiently throughout
the day, you’ll be able to recharge your body and
prevent fatigue without overloading your digestive
system. Eat three meals a day and snacks when
necessary.
37
Get your energy from breads, cereals and other
whole grain products, as well as from fruits and
vegetables. The carbohydrates (starchy foods and
sugars) found in plant products are the main source
of energy needed by the body.
P O RTA I L V I H / S I DA D U QU É B E C
of carbohydrates, which helps to control blood sugar
levels in people with diabetes. Fiber is found in whole
grain breads, cereals and pasta, legumes, fruits and
vegetables, nuts and seeds (sunflower, for example).
THE IMPORTANCE OF PROTEIN
Increase your strength and endurance
and keep it.
Maintaining strong muscles and bones is necessary for
conserving or increasing your strength and resistance.
Strong muscles and bones require regular intake of
protein, calcium and vitamin D.
Regular physical activity helps to maintain strength,
flexibility, balance and coordination. Weight-bearing
activities that include running, jumping or moving
heavy loads, such as weight-training, are essential
for bone health and reduce the rate of bone lose
associated with osteoporosis.
Put colour in your plate. Vegetables and fruits
contain several protective nutrients (antioxidants,
vitamins, minerals, fiber, phytochemicals) that help
prevent cancer, heart disease and stroke. Low in
calories and high in fiber, they also contribute to
healthy weight control and the prevention of obesity.
By eating at least one vegetable or fruit with each
meal or as a snack, you can obtain the number of
portions of each that you need each day. Eat at least
one dark green and one orange vegetable every day.
Choose whole or sliced fruits and vegetables instead
of juices, as these contain no fiber.
WHAT DOES FIBER DO?
Fiber helps regulate bowel movements, slows the
movement of food through the digestive tract, lowers
heart disease risk by reducing blood cholesterol
levels and slows down the digestion and absorption
Protein contributes to the building and repair
of muscles and vital organs, as well as the daily
regeneration of hair, nails and skin. Digestive enzymes
and immune system antibodies are also produced
during the remodeling of absorbed proteins. Low-fat
proteins are preferable, such as lean meats, skinless
poultry, legumes, tofu, skim milk products and fish
(especially those high in omega-3 fatty acids).
CALCIUM
Calcium gives bones their strength and rigidity. It also
contributes to good heart, nerve and muscle function,
as well as other vital functions. Bones contain the
main reserves of calcium in the body. If the body lacks
calcium to function properly, it takes it from bone,
leading to a decrease in bone density (osteopenia).
When the bones become very weak and the risk of
fracture increases, it is called osteoporosis.
Low bone density is common in people with HIV.
Dairy products (milk, yogurt, cheese) and fortified
soy beverages are the best sources of calcium.
VITAMIN D
Vitamin D facilitates the absorption of calcium. It is
usually produced by the skin when it is exposed to
sunlight. A supplement ranging from 600 to 1000 IU
per day may be necessary to ensure sufficient vitamin
D intake. In some situations, vitamin D levels can be
assessed by a doctor.
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PORTAIL VIH/SIDA DU QUÉBEC
FRIENDLY FAT
PREVENTING FOOD POISONING
To stay healthy, it’s essential to eat a small amount
of unsaturated fat (2 or 3 tablespoons or 30 to 40
ml) every day. This includes oils used for cooking,
salad dressings, margarine and mayonnaise. It’s best to
choose olive, canola and peanut oils. It’s important to
limit your intake of butter, hard margarine, shortening,
baked goods and pastries (crackers, croissants, donuts,
store-bought muffins, etc..) that contain hydrogenated
fats, trans fats and saturated fats.
It’s important not to neglect the prevention of food
poisoning. Food must be handled and cooked safely
in order to prevent problems. Food poisoning is more
dangerous when the immune system is weak.
Fat can also help improve the absorption of
medications or increase their side effects (check with
your pharmacist about the drugs prescribed for you).

DIETARY SUPPLEMENTS
To date, studies have not shown that taking dietary
supplements is beneficial against HIV infection in
people who maintain a healthy diet.
However, dietary supplements may be necessary
if food intake is insufficient or if a person’s health
requires it (absorption problems, low bone density,
liver problem, etc.). Depending on the situation, a
dietitian can join forces with a patient’s doctor to
assess his or her vitamin and mineral needs.
Also, eating certain foods can be more risky because
of the way they are produced (non-pasteurized foods
for example), as well as due to storage conditions
and duration. This is particularly the case of nonpasteurized cheeses (made from raw milk), raw or
undercooked eggs and raw alfalfa.
39
P O RTA I L V I H / S I DA D U QU É B E C
WOMEN
CONTRACEPTION:
AND HIV
Male and female condoms are the best way to
prevent the sexual transmission of HIV and other
STIs. Women who do not wish to become pregnant
have several additional options:
GYNECOLOGICAL MONITORING
Women living with HIV should undergo a gynecological
exam every year.This includes an external and internal
inspection of her genitals in order to detect certain
anomalies or conditions. A clinical exam includes a
physical examination, an abdominal, a breast exam, a
perineal exam, a pelvic exam and a Pap smear.
Gynecological monitoring facilitates the prevention
and treatment of the following:
• Vaginal infections (caused by fungi or Candida
albicans, bacterial vaginosis, sexually transmissible
vaginal trichomoniasis, contact or allergic dermatitis,
etc.)
• Other sexually transmitted and blood-borne
infections (gonorrhea, genital herpes, syphilis,
chlamydia, condylomas (HPH), etc.)
• Pelvic inflammation (salpingitis, etc.)
• Cervical dysplasia (abnormal cells of the cervix);
screening test: PAP
• Women with HIV have a higher risk of developing
cervical cancer and signs or symptoms caused by
HPV (human papilloma virus), herpes, etc.
• Oral, injectable and transdermal (skin
patch) contraceptives: With this category,
it’s very important to remember that some
antiretrovirals can accelerate the metabolism of
contraceptive hormones in the liver and reduce
the level of estrogen in the blood by nearly a third.
Consultation with a doctor is therefore essential
to ensure an appropriate dose of estrogen, as well
as the compatibility of your contraceptives and
HIV meds.
• IUD (hormonal intra-uterine device): Most HIVpositive women can use an IUD. The device can
be inserted during the asymptomatic stage of
HIV infection and is safe for use by women taking
antiretroviral treatment. The IUD can still be used
if the woman develops an illness.
• Other methods: Other options include
the cervical diaphragm, contraceptive ring,
microbicides, emergency contraception (day-after
pill), etc.
GETTING
PREGNANT
THINKING ABOUT IT...
OR
Women who wish to become mothers should
discuss the HIV screening test with their partner. This
blood test allows both partners to know their HIV
status and to evaluate their plans more thoroughly.
When only the man is HIV-positive, the woman
could contract HIV when trying to get pregnant. If
an untreated, HIV-positive woman becomes pregnant,
her baby has a one in four risk of contracting HIV
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PORTAIL VIH/SIDA DU QUÉBEC
during pregnancy, delivery or breastfeeding. Before
becoming pregnant, consult a doctor to determine
your best HIV drug strategy to reduce the risk of
mother-to-child transmission.
• Taking antiretroviral drugs during pregnancy.
• Continuation of antiretrovirals during labour and
delivery.
in HIV-positive women. Various studies have found
that other factors affecting the general population
may also be associated with early menopause, such
as smoking, being African-American, a low level of
education and the use of medications. In light of these
points, it is very difficult to distinguish to what degree
early menopause is caused by HIV infection, lifestyle
factors or demographic factors.
• The baby receives medication during the first six
weeks of his or her life.
This three-step treatment helps reduce the risk of
mother-to-child transmission to less than 1% (Dec.
2009: 422 pregnant women treated; transmission
rate: 0.24%).
Early screening during pregnancy not only helps to
spare the baby from HIV infection, it also helps to
ensure that the mother receives treatment, thereby
preventing any deterioration of her health and quality
of life.
If a woman who is already undergoing treatment
wishes to become pregnant, she should consult her
doctor to ensure the compatibility of her medication
with her pregnancy plans. As well, several reproductive
methods help reduce the risk of infection between
sero-discordant partners, such as insemination
techniques, sperm washing, etc.
MENOPAUSE:
Some studies have shown that HIV can cause the early
onset of menopause. As well, suppressed immunity, a
lack of physical activity and antiretroviral therapy are
all factors that can contribute to early menopause
LIPODYSTROPHY:
The body shape changes associated
with lipodystrophy syndrome (see pg.
27) can be different in women from
what they are in men. Because of
morphological differences between
men and women, fat deposits do
not necessarily accumulate in the
same places on their bodies. Also,
differences in the composition of fat
tissue cause women to experience
more changes in body fat. Finally, due
to differences in bone tissue, women
and girls who take antiretrovirals
are more prone to osteopenia and
osteoporosis.
41
RIGHTS
AND RESPONSIBILITIES
"People living with HIV/AIDS
are full-fledged citizens and
benefit from the rights and
responsibilities that entails."1
P O RTA I L V I H / S I DA D U QU É B E C
HEALTH CARE SETTING
You may willingly choose to disclose your status in
order to optimize your health care. The principles
of universal precautions, including sterilization of
instruments and equipment and the use of gloves,
apply to all health care providers. Therefore, they
cannot require you to disclose your status by claiming
that they wish to avoid the risk of transmission.
OTHER TYPES OF BODY CARE AND
SERVICES
You are not required to disclose your status in order
to receive aesthetic care, acupuncture or massage
therapy or to get a tattoo or haircut.
These rights are recognized by various laws in both
Quebec and Canada. Although the law is intended
to protect these rights, cases of discrimination,
harassment and breach of confidentiality are still
reported. Being well informed about your rights can
help reduce worry and uncertainty about different
issues. First, obtaining legal information fosters a
better understanding of the law and its application,
while helping you evaluate the legal options available
to you. If necessary, consultation with a lawyer will
provide legal advice and help determine your course
of action in a given context. The law is subject to
change at any time.
WORKPLACE
DISCLOSURE: PRIVACY,
CONFIDENTIALITY
INSURANCE
Your health conditions, medical records and HIV
status are all confidential information. No person who
is in possession of your confidential information may
share it with a third party without your prior written
and informed consent. This is applicable in your daily
life, at both the professional and personal level.
At no time during the hiring process may an employer
ask questions regarding the health or private life of
a candidate, unless the employer can demonstrate
that these questions are necessary to evaluate the
candidate’s skills and aptitudes necessary to perform
the job in question. An HIV screening test may not be
required before or after the job is obtained.
The principle of confidentiality applies to the
workplace. No person is required to disclose his or
her HIV status to a client, colleague or employer. If the
employer discovers that the employee is HIV-positive,
in no case may he or she disclose that information to
anyone else or compel the employee to do so.
There are two types of drug coverage: private
insurance and public insurance (RAMQ). If you have
access to a private plan, either through your employer,
professional association, spouse or parents, you are
obligated to use it. Only those people who do not
have access to a private plan have the right – and
obligation - to subscribe to the public drug plan of
the RAMQ. Any questions regarding eligibility can be
discussed with the RAMQ.
Me D.Thomson, C.Bédard, Le sida, la loi et moi. 1995, p.9 (free translation)
1
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PORTAIL VIH/SIDA DU QUÉBEC
If you wish to obtain life or personal disability insurance,
or if you have access to a collective insurance plan at
work, your insurer has to right to ask your HIV status.
Insurance applicants have a legal obligation to declare
any circumstances that might influence the insurer’s
risk assessment and decision to accept the applicant,
as well as the premium established. In the case of
some collective insurance plans, basic insurance is
provided without health questions, and disclosure
of one’s HIV status is not required. In other cases,
omitting the truth could result in cancellation of
one’s eligibility, benefits or other consequence. For all
types of insurance, it’s important to check all contract
clauses and to be well informed before subscribing or
modifying any clauses or coverage.
TRAVELING ABROAD
Traveling abroad requires a minimum of preparation.
For people with HIV, it’s important to do a thorough
check of which vaccines are required and of the health
conditions of the country or countries to be visited,
etc. Do not forget to check the list of countries that
restrict the entry of HIV-positive people onto their
territory. Restrictions may apply in the case of short
or long stays. The list of such countries is available
on certain Web sites (see the Resources section).
Finally, do not forget to check the insurance coverage
(health or other insurance) offered for travel outside
of Quebec.
CRIMINALIZATION OF HIV EXPOSURE
In recent years, cases involving HIV exposure have
been heard by Canadian courts of various jurisdictions
(mainly cases involving sexual activity). Currently,
based on Canadian criminal law and judgments
rendered by the Supreme Court of Canada in 1998
and 2003, it is established that:
Any person with HIV is obligated to disclose his or
her HIV status before having sexual relations involving
a "significant risk" of HIV transmission. A person who
does not fulfill this obligation may be found guilty of a
criminal infraction or infractions and receive a prison
sentence. This law applies even when the sexual
partner does not become infected.
When is disclosure a legal obligation? The courts have
established that vaginal or anal intercourse without a
condom carries a significant risk of HIV transmission.
You must therefore disclose your HIV status to your
partner before having sexual relations of this kind. In
a recent decision, however, an HIV-positive person
was acquitted because he had an undetectable viral
load. That said, it still remains far from certain that
criminal law does not require disclosure in cases of
undetectable viral load, especially since this issue has
only recently come before the courts.
The situation regarding other types of sexual activity
is also murky (intercourse with a condom, oral sex,
etc.). There may be an obligation to disclose in such
cases, but the law is not yet clear in this regard.
The criminalization of HIV is an important issue that
is not unique to Canada. Some other countries have
also placed the non-disclosure of one’s HIV status
under the rule of criminal law.
WHERE CAN I GET HELP?
It’s best to proceed by stages. Conflict resolution is
sometimes a complex and arduous task, be it a case
of breach of confidentiality, discrimination, illegal
dismissal, medical error, insurance claim or other
issue. It’s essential to gather the information needed
to make decisions and plan a course of action. Once
that’s done, it may be possible in some cases to
contact the different organizations and institutions
directly involved. As a final step, there are various
civil and administrative courts in Quebec that can be
called upon to deal with the matter at hand.
43
P O RTA I L V I H / S I DA D U QU É B E C
"Every person has a
right to the safeguard of
his dignity, honour and
reputation. Every person
has a right to respect for
his private life and to nondisclosure of confidential
information."
"No one may invade the
privacy of a person without
the consent of the person,
unless authorized by law."
Civil Code of Quebec (C.c.Q.), art.35
Quebec Charter of Human Rights and Freedoms, R.S.Q.,
chapter 1, articles 4, 5 and 9
INFORMATION
HIV community organizations, COCQ-Sida HIV rights
and legal information service, social worker, health
establishments, unions, legal aid or lawyer, notary, etc.
1
INSTITUTIONS
Commission des droits de la personne, Commission
des normes du travail, professional association unions,
Commission d’accès à l’information (privacy), etc.
2
TRIBUNALS
Civil tribunals, administrative tribunals.
3
This section contains legal information
that must not be taken as legal advice or
opinion.
PORTAIL VIH/SIDA DU QUÉBEC
44
LEXICON
Antibody: Protein produced by the immune system in response to antigens (foreign substances) that enter
the body; antibodies’ function is to destroy or neutralize antigens.
Pathogen: An entity that causes disease.
RNA: Ribonucleic acid: molecule that ensures the synthesis of cell proteins in accordance with the program
inscribed in its genetic code.
DNA: Deoxyribonucleic acid: molecule that makes up chromosomes and their various segments that form
genes, the carriers of hereditary characteristics.
Immunity: Property of an organism that enables it to resist infections. Immunity can be natural (congenital) or
acquired (after an infectious disease or through some kind of therapy, ie. a vaccine).
Lymph: Liquid that flows in the lymphatic vessels. Lymph comes from the blood and contains leucocytes and
the same substances as blood serum, but in smaller proportions.
Prophylaxis: Treatment designed to prevent a disease or the onset of symptoms of a pre-existent infection.
STBBI: Sexually transmitted and/or blood-borne infection.
Plasma: Blood plasma: liquid component of the blood in which red blood cells, white blood cells and platelets
float about.
Virus: Specific pathogen that can only replicate inside a living cell that is has hijacked.
Retrovirus: RNA virus that can convert its RNA into DNA with the help of the reverse transcriptase enzyme.
Vaccine: Substance derived from a pathogen that confers immunity to a disease when a small quantity is
injected into a person.
Hepatitis: Inflammation of the liver.
Antiretroviral: Substance that possesses the ability to fight retroviruses. This type of drug is prescribed for HIV
infection.
Treatment failure: Occurs when a treatment no longer works and loses its efficacy.
Prevalence: Number of cases of a disease or other event such as an accident within a given population,
without distinction between new cases and old cases.
Incidence: Term that has replaced "frequency of new cases" (World Health Organization, 1966).
Serodiscordant: Term describing a couple in which one partner is HIV-positive and the other HIV-negative.
Naive patient: Term describing a person who has never taken antiretroviral treatment.
Receptor : "Macromolecule equipped with chemical sites to which endogenous molecules and specific
medications can attach themselves" (Erhenpreis, 1969).
45
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Diseases and Infection Control.
A Brief History of HIV/AIDS in Canada.2007. http://www.phac-aspc.gc.ca/aids-sida/info/1-eng.php
HIV/AIDS Epi Update - Nov. 2007.
http://www.phac-aspc.gc.ca/aids-sida/publication/epi/pdf/epi2007_e.pdf
Summary: Estimates of HIV Prevalence and Incidence in Canada, 2008.
http://www.phac-aspc.gc.ca/aids-sida/publication/survreport/estimat08-eng.php
HIV and AIDS in Canada: Surveillance Report to December 31, 2008.
http://www.phac-aspc.gc.ca/aids-ida/publication/survreport/2008/dec/index-eng.php
CATIE (Canadian AIDS Treatment Information Exchance).
Factsheet: "The Epidemiology of HIV in Canada." 2009. Toronto.
http://www.catie.ca/eng/PreventingHIV/fact-sheets/epi-overview.shtml
Managing Your Health: a guide for people living with HIV. 4th edition. 2009. Toronto.
http://www.catie.ca/eng/MYH/toc.shtml
Centers for Disease Control and Prevention (CDC). Department of Health and Human Services, HIV/
AIDS. 2010. Atlanta, Georgie, USA. http://www.cdc.gov/hiv/
Coalition des organismes communautaires québécois de lutte contre le sida.
Les mêmes droits que vous. 2010. Montréal : Comité Droits et VIH de la COCQ-Sida.
http://cocqsida.com/nos-dossiers/droits-et-vih.html
Commission des droits de la personne et des droits de la jeunesse. 2010.
http://www2.cdpdj.qc.ca/en/pages/Default.aspx
Desroches, Danielle et Marzarli, Judith. S’informer pour mieux se traiter.2005-2006. Montréal.
Gouvernment of Quebec. Charter of Human Rights and Freedoms. (R.S.Q., chapter C-12).
Official Quebec edition (Copyright).
http://www2.publicationsduquebec.gouv.qc.ca/dynamicSearch/telecharge.php?type=2&file=/C_12/C12_A.htm
Haut Courant. « Ces pays qui refusent les séropositifs sur leur sol ». Ecole Professionnelle de la Faculté de
Droit et Science Politique. Montpellier, France.2010.
http://www.hautcourant.com/Ces-pays-qui-refusent-les,912
The Global Database on HIV Travel & Residence Restrictions http://hivtravel.org/
The Names Project-Canada: Canadian AIDS Memorial Quilt.1998. http://www.quilt.ca/e_home.html
Me David Thomson, Bédard Christian et al. 1995. Le sida, la loi et moi - Recueil d’informations juridiques à
l’intention des personnes vivant avec le VIH et leurs proches. CPAVIH, COCQ-Sida et Projet Accès.
MSSS of Quebec. 2009. Portrait des infections transmissibles sexuellement et par le sang (ITSS) au Québec - Année
2008 (et projections 2009). Coll. « analyses et surveillance », no 35. 2009.
http://msssa4.msss.gouv.qc.ca/fr/document/publication.nsf/4b1768b3f849519c852568fd0061480d/83698a50f7
74f1328525767400700174?OpenDocument
PORTAIL VIH/SIDA DU QUÉBEC
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Dre Anne Bruneau et al. Guide pour la prophylaxie après une exposition au VIH, au VHB et au VHC dans un
contexte non professionnel, 2010.
UNAIDS. 2009. Report on the Global AIDS Epidemic-2008. 2009. Joint United Nations Program on HIV/AIDS.
Geneva. http://www.unaids.org/en/dataanalysis/epidemiology/2008reportontheglobalaidsepidemic/
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Réjean Thomas. Montréal. http://www.pvsq.org/rejeanthomasvideo.html
Prévost, Marie et Perron, Chantal. Sida 101. 2000. 2e éd. Comité des personnes atteintes du VIH du Québec
(CPAVIH). Montréal.
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http://archives.radio-canada.ca/dossier.asp?IDDossier=400
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Criminalization of HIV exposure: issues for front-line workers. Factsheets 1, 2 and 5. 2008. Toronto. Copyright
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Delamarre, Jacques et al. Dictionnaire des termes de médecine.25e éd. 1999. Paris : Ed. Maloine.
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offre un nouvel éclairage. Fiches d’actualité scientifique no134. Avril 2001. Marseille.
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Simon F. Le point sur l’origine du VIH et sa diffusion dans l’espèce humaine. Transcriptases no 92. Mai 2001. Rouen.
http://www.pistes.fr/transcriptases/92_1309.htm
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Jacques Pépin. The Origins of AIDS. Oct.2011. Cambridge University Press.
Avert. History of HIV & AIDS in Africa. http://www.avert.org/history-aids-africa.htm
47
P O RTA I L V I H / S I DA D U QU É B E C
HIV / AIDS RESSOURCES
HIV TREATMENT
INFORMATION
Clinique 30 St-Joseph
Phone: 514-845-4240
Portail VIH/sida du Québec
514-523-4636 or toll free 1-877-767-8245
E-mail: [email protected]
http://www.pvsq.com
Rézo
Phone: 514-521-7778
http://www.rezosante.org
Aids Community Care Montreal
514-527-0928
E-mail: [email protected]
HIV LEGAL INFORMATION
Coalition des organismes communautaires
québécois de lutte contre le sida
(COCQ-sida)
Phone: 514-844-2477 extension:34
Toll free: 1 866-535-0481 extension: 34
E-mail : [email protected]
HIV SCREENING
MONTREAL
Clinique du Quartier Latin
Phone: 514- 285-5500
http://www.cliniquequartierlatin.ca
Clinique A, rue McGill
Phone: 514- 787-0055
http://www.cliniquea.ca
Clinique L’Actuel Phone: 514- 524-1001
http://www.cliniquelactuel.com
Clinique médicale de l’alternative
Phone: 514-281-9848
http://www.cliniquedelalternative.com
Clinique médicale de l’ouest
Phone: 514-765-3600
Clinique médicale GLR
Phone: 514- 935-1197
Clinique médicale La Cité
Phone: 514- 281-1722
Clinique médicale 1851
Phone: 514-524-7564
SPOT (Free anonymous screening for MSM
only)
Phone: 514-529-7768
http://www.spottestmontreal.com
CSSS Jeanne-Mance :
CLSC des Faubourgs - Sanguinet
CLSC des Faubourgs - Visitation
CLSC du Plateau Mont-Royal
Phone: 514-527-2361
REGIONS
Services intégrés de dépistage et de
prévention des ITSS (SIDEP)
Info santé: 811 (for information about SIDEP services)
http://www.msss.gouv.qc.ca/sujets/prob_sante/
itss/index.php?listes_centres_depistages
MIELS-Québec (rapid testing, free and
anonymous)
Phone: 418- 649-1720
http://www.miels.org
PREVENTION/SUPPORT
MONTREAL
Aids Community Care Montreal (A.C.C.M)
Phone: 514- 527-0928
E-mail: [email protected]
http://www.accmontreal.org
Anonyme (mobile intervention unit)
Phone: 514- 842-1488 Mobil unit: 514- 236-6700
E-mail: [email protected]
http://www.anonyme.ca
C.A.C.T.U.S. Montréal
Phone: 514- 847-0067
E-mail: [email protected]
http://www.cactusmontreal.org
Centre d’action Sida Montréal (C.A.S.M)
Phone: 514- 495-0990
E-mail: [email protected]
http://www.netrover.com/~casm
Centre d’amitié autochtone de Montréal
(C.A.A.M)
Phone: 514- 499-1854
E-mail: [email protected]
http://www.nfcm.org
Comité Jase (Jeunes adultes
séropositifs/ensemble)
Phone: 514-529-9462
E-mail: [email protected]
Centre associatif polyvalent d’aide
hépatite C (et VIH)
Phone: 514- 521 0444
Phone outside of Montreal :
1 -866- 522-0444
E-mail: [email protected]
http://www.capahc.com
Dopamine
514- 251-8872
E-mail: [email protected]
http://www.dopamine.ca
Fondation aide directe – Sida Montréal
Phone: 514- 522-1993
E-mail: [email protected]
http://www.fadsm.org
GAP-VIES
Phone: 514- 722-5655
E-mail: [email protected]
http://www.gapvies.ca
G.E.P.S.I
Phone: 514- 523-0979
E-mail: [email protected]
Maison Plein Cœur (Montréal)
Phone: 514- 597-0554
E-mail: [email protected]
http://www.maisonpleincoeur.org
48
PORTAIL VIH/SIDA DU QUÉBEC
Comité P.A.S.F. (Femmes)
Phone: 514-767-9270 E-mail : [email protected]
REZO
Phone: 514- 521-7778
E-mail: [email protected]
http://www.rezosante.org
Spectre de rue
Phone: 514- 524-5197
(day centre and fixed local) E-mail: [email protected]
http://www.spectrederue.org
Stella
Phone: 514- 285-1599
E-mail: [email protected]
http://www.chezstella.org
BAS ST-LAURENT
M.A.I.N.S. - BAS ST-LAURENT
Phone: 418-722-7432
E-mail: [email protected]
http://www.mainsbsl.qc.ca
SAGUENAY/LAC-ST-JEAN
M.I.E.N.S. (Saguenay/Lac St-Jean)
Phone: 418-693-8983 or 1-800-463-3764
E-mail : [email protected]
http://www.lemiens.com/organisme.php
QUEBEC
M.I.E.L.S. – Québec
Phone: 418-649-1720 Support line : 418-649-1720
E-mail : [email protected]
http://www.miels.org
CENTRE-DU-QUÉBEC
LAURENTIDES
B.L.I.T.S.
Phone: 819-758-2662 or
1- 866-758-2662
E-mail: [email protected] http://www.blits.ca/
Centre Sida Amitié
Phone: 450-431-7432
E-mail: [email protected]
ESTRIE
A.R.C.H.E de l’Estrie
Phone: 819-348-2670
E-mail: [email protected]
http://www.archedelestrie.org
Sidaction Mauricie
Phone: 819- 374-5740
E-mail : [email protected]
http://www.sidaction-troisrivieres.ca
Les Oies blanches - Actions Hépatites - VIH
Phone: 450- 773-5050
Toll free: 1-866-523-5050
E-mail: [email protected]
www.sidamonteregie.com
I.R.I.S. - ESTRIE Phone: 819- 823-6704
E-mail: [email protected]
www.iris-estrie.com
Émiss-ère
Phone: 450- 651-9229
Toll free: 1-888-CAP-SIDA
E-mail: [email protected]
http://www.emiss-ere.ca
OUTAOUAIS
SHELTER
B.R.A.S. - OUTAOUAIS
Phone: 819-776-2727
E-mail: [email protected]
http://www.lebras.qc.ca
MONTREAL
ABITIBI-TÉMISCAMINGUE
Corporation Félix Hubert d’Hérelle
Phone: 514- 844-4874
E-mail: [email protected]
http://www.maisondherelle.org
Centre des R.O.S.É.S.
Phone: 819-764-9111
E-mail: [email protected]
http://www.centredesroses.org
Le conseil national des femmes juives du
Canada (Chesed house - Montreal)
Phone: 514- 733-2589
E-mail: [email protected]
CÔTE-NORD
Les Hébergements de l’Envol
Phone: 514- 374-1614
E-mail: [email protected]
http://pages.infinit.net/lenvol2/
Actions Sida Côte-Nord
Phone: 418-962-6211
E-mail: [email protected]
http://www.ascn.qc.ca
LAVAL
MAURICIE
MONTÉRÉGIE
Sida-vie Laval
Phone: 450- 669-3099
E-mail: [email protected]
http://www.sidavielaval.org/
Maison du Parc
Phone: 514- 523-6467
E-mail: [email protected]
http://maisonduparc.org
Maison Plein Cœur
Phone: 514- 597-0554
E-mail: [email protected]
http://www.maisonpleincoeur.org/
Sidalys Montréal :
Centre Amaryllis
Phone: 514- 526-3635
Centre Sida Secours
Phone: 514- 842 4439 (extension 101)
E-mail: [email protected]
Les Appartements Jean-Pierre Valiquette
Phone: 514- 842 4439
SAGUENAY/LAC ST-JEAN
M.I.E.N.S.
Phone: 418-693-8983 or 1-800-463-3764
E-mail: [email protected]
http://www.lemiens.com/organisme.php
QUÉBEC
M.I.E.L.S. – Québec
Phone: 418-649-1720 E-mail: [email protected]
http://www.miels.org
MAURICIE
Maison Re-Né Phone: 819-379-2495
E-mail: [email protected]
LAVAL
Maison Dominique
Phone: 450- 681-1441
E-mail: [email protected]
PROVINCIAL ORGANIZATIONS
CANADIAN ORGANIZATIONS
Camp Positif
Phone: 514- 937-5351 poste 240
E-mail: [email protected]
Canadian Treatment Action Council (CTAC)
Phone: 416-410-6538
E-mail [email protected]
http://www.ctac.ca
Coalition des organismes québécois
de lutte contre le sida (COCQ-Sida)
Phone: 514- 844-2477
E-mail: [email protected] http://www.cocqsida.com
Canadian Aboriginal AIDS Network (CAAN)
Phone: 604-266-7616
E-mail: [email protected]
http://www.caan.ca
Coalition Sida des sourds du Québec
Phone: 1-800- 709-7932, ask for
514-521-1780 *
AIDS info-line: 1-800- 709- 7932
E-mail: [email protected]
http://www.cssq.org
Canada’s source for HIV and hepatitis C
information (CATIE)
Phone: 416-203-7122
Toll-free: 1-800-263-1638
E-mail: [email protected]
http://www.catie.ca
First Nations of Quebec and Labrador Health
and Social Services Comission (FNQLHSSC)
Phone: 418-842-1540
E-mail: [email protected]
http://www.cssspnql.com
Canadian HIV Trials Network
Phone: 604-806-8327
Toll-free: 1-800-661-4664
E-mail: [email protected]
http://www.hivnet.ubc.ca/f/accueil/
Quebec Native Women
Phone: 450-632-0088
E-mail: [email protected]
http://www.faq-qnw.org
Canadian HIV / AIDS Legal Network
Phone: 416-595-1666
E-mail: [email protected]
http://www.aidslaw.ca
Farha Foundation
Phone: 514- 270-4900
E-mail: [email protected]
http://www.farha.qc.ca
Canadian AIDS Society
Phone: 613-230-3580
E-mail: [email protected]
http://www.cdnaids.ca
Fréquence VIH
E-mail: [email protected]
http://www.frequencevih.ca
Portail VIH/sida du Québec
Phone: 514-523-4636
Toll-free: 1-877-767-8245
E-mail: [email protected]
http://www.pvsq.org
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