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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. 32 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. 36 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. 38 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 40 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 42 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 P O RTA I L V I H / S I DA D U QU É B E C SOURCES Public Health Agency of Canada. Surveillance and Risk Assessment Divison, Centre for Communicable 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 46 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/ Mapping of restrictions on the entry, stay and residence of people living with HIV. Geneva.2009. http://extranet.who.int/iris/bitstream/123456789/1004/1/9789291737949_eng.pdf World Health Organization (WHO) http://www.who.int/hiv/data/en/index.html Portail VIH/sida du Québec. Conférences Info-traitement. 2009. VIH/sida : 25 années de traitement avec Dr 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. Radio-Canada. Archives. Thématique : santé. Sida : les premières années. 2008. Copyright Société Radio-Canada. http://archives.radio-canada.ca/dossier.asp?IDDossier=400 Canadian HIV/AIDS Legal Network. Criminalization of HIV exposure: Canada. 2010. http://www.aidslaw.ca/EN/lawyers-kit/documents/Canadianlaw.pdf Criminal law and HIV. Criminalization of HIV Exposure: current Canadian law. Prosecutions under the Criminal Code. Criminalization of HIV exposure: issues for front-line workers. Factsheets 1, 2 and 5. 2008. Toronto. Copyright Canadian HIV/AIDS Legal Network. http://www.aidslaw.ca/publications/interfaces/downloadFile.php?ref=1318 Summary: R. v. Cuerrier. 9 p. http://www.aidslaw.ca/EN/lawyers-kit/documents/2.Cuerrier1998summary.pdf Canadian AIDS Society. HIV Transmission: Guidelines for Assessing Risk. 5th edition. 2005. Ottawa. Delamarre, Jacques et al. Dictionnaire des termes de médecine.25e éd. 1999. Paris : Ed. Maloine. Le Robert pour tous. Dictionnaire de la langue française.1994.Paris. Dictionnaires Le Robert. Institut de recherche pour le développement. Origine du VIH 1 : Une étude épidémiologique en Afrique centrale offre un nouvel éclairage. Fiches d’actualité scientifique no134. Avril 2001. Marseille. http://www.ird.fr/la-mediatheque/fiches-d-actualite-scientifique/134-origine-du-vih-1-une-etude-epidemiologique-en-afriquecentrale-offre-un-nouvel-eclairage 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 Katrak SM. The origin of HIV and AIDS: An enigma of evolution. Annals of Indian Academy of Neurology [serial online] 2006 [cited 2012 Mar 12]; 9:5-10. http://www.annalsofian.org/text.asp?2006/9/1/5/22815 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 Financial support provided by