Transcript Concept 14: HIV/AIDS

Concept 14: HIV/AIDS
Fall 2011
Barbara E. Connell, RN, MSN
Overview
• 1981
• 5 cases of PCP and 26 cases of Kaposi’s
Sarcoma diagnosed in young, healthy gay men
• LA and NY
• Labeled Acquired Immunodeficiency
syndrome
• 1984 the HIV (retrovirus) isolated
• Was spread primarily by sexual contact
Overview cont.
• Became apparent that AIDS was the final, fatal
stage of HIV infection
• Is now a world wide concern
• Estimated 36.2 million infected
• Highest incidence in sub-Sarahan Africa (70%)
• No vaccine or cure
• Progression of disease has been slowed due to
HAART: highly affective antiretroviral therapy
Pathophysiology and Etiology
• AIDS is caused by the HIV
• Best example of primary immunodeficiency
disorder
• Present in blood, semen, vaginal and cervical
secretions, and cerebrospinal fluid
• Also found in breast milk and saliva
• Sexual contact primary mode of transmission
• Transmitted through blood, needle sharing
Pathophysiology and Etiology cont.
• Approx 13-40% of infants born to infected
mothers are infected perinatally
• The virus infects cells that have the CD4
antigen
• Once inside the cell, the virus sheds its protein
coat and uses reverse transcriptase to convert
the viral RNA to DNA
• The viral DNA is then integrated into host cell
DNA, and duplicates during cell division
Pathophysiology and Etiology cont.
• Virus may remain latent
• May become activated to produce new RNA
and form virions (produce outside a host)
• It then buds from the cell surface, disrupts the
cell membrane, destroys host cell
• With inactive virus: antibodies are produced
• This is called seroconversion
• Antibodies detected about 6 wks/6months
Pathophysiology and Etiology cont.
• Helper T and CD4 cells are primary ones
infected
• Also infects macrophages and certain cells in
the CNS
• Helper T cells: recognize foreign antigens and
infected cells
• Also activate antibody producing B cells
• Direct cell-mediated immune activity
Pathophysiology and Etiology cont.
• Also direct cell-mediated immune activity
• Influence the phagocytic activity of monocytes
and macrophages
• Loss of helper T cells leads to
immunodeficiencies
• Children: perinatal transmission (vertical
transmission), transmission during birth
(blood or genital tract secretions), breast milk
Pathophysiology and Etiology cont.
• Risk reduced when mothers identified receive
zidovudine (Retrovir, AZT) during pregnancy,
deliveries by c-section, therapy after birth
• Mandatory blood screening instituted in 1985
• Prior to 1985 children infected during
treatment of hemophilia
• Today: infected through unprotected sex
Etiology
• 1981-2006: 982,498 cases U.S.
• 2006: 35,314 new cases in the 33 states with
long-term reporting data
• Men: majority of cases, women only 26%
• Females: high-risk heterosexual contact (80%),
drug use (19%), other (1%)
• African-American and Latino (82%)
• 2001-2004: 15, 338 children and teens
Etiology cont.
• The most rapid increases have been seen in
young gay and bisexual men, women, innercity drug users
• Rate of perinatal transmission has declined
dramatically
• Death from AIDS has decreased due to
improved treatment modalities
• Increase in older persons contracting the
disease
Risk Factors
• Behavioral
• Men
– Gays, bisexuals, prison population
– Unprotected anal intercourse
– Injection drug use
• Women
– Heterosexual intercourse with infected drug user
– Trading sex for drugs
Risk Factors cont.
• Hemophilia and blood transfusions
– Screening for high-risk behavior has reduced the
number of donors found to be positive
– Risk of contracting disease from blood donors
limited to those who may be in the window period
(have no detectable antibodies yet)
• Health care as an occupation
– Needlesticks or nonintact skin with exposure to an
infected individuals body fluids
Risk Factors cont.
• Poverty
• Increases one’s risk for HIV/AIDS
• Have less access to preventive health care and
health care education
• Risk for increased illiteracy
• Less likely to have access to internet
• African American women greater risk
Risk Factors cont.
• Pregnancy and breast feeding
• Perinatal transmission risk factors: cigarette
smoking, illicit drug use, genital tract
infections, unprotected sexual intercourse:
multiple partners
• Infants usually positive after birth, does not
mean they are infected
• Avoid breast feeding if possible
Risk Factors cont.
• Older adults
• Fail to use condoms, because they are past
child bearing age
• Believe they cannot contract the disease
• May have delayed diagnosis and increased
severity of the disease
• Need routine screening for anyone who has
risk factors
Risk Factors cont.
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Myths and misconceptions
Not transmitted by casual contact
Nor by mosquitoes
Only by contact with blood and body fluids
Newer drugs are improving the longevity of
infected people
• Early detection improves outcomes
• May be difficult to dispel peoples beliefs
• Many believe if not homosexual or IV drug users
they don’t need to worry
Clinical Manifestations
• Often contribute initial manifestations to a
common viral illness
• Following the acute illness, clients enter a
long-lasting asymptomatic period
• Virus is present and can be transmitted to
others
• Asymptomatic period varies: mean duration is
8-10 years
• May develop generalized lymphadenopathy
Clinical Manifestations cont.
• Diarrhea
• Oral lesions, hairy leukoplakia, candidiasis,
and gingival inflammation and ulceration
• Advanced HIV typically occurs 10-11 years
after initial infection
• Varies according to viral load, rate of disease
progression, development of resistance to
antiretroviral therapy
Clinical Manifestations cont.
• AIDS
– Neurologic manifestations
– Opportunistic infections
– Cancers
• Categorized by clinical symptoms and by T4
cell counts
• Antiretroviral therapies stop or suppress the
activity of a retrovirus
Clinical Manifestations cont.
• They prevent further weakening of the
immune system
• Minimize opportunistic infections
• AIDS: survival 2-3 years after diagnosed
• PCP infection
– In undiagnosed individuals
– Have a late diagnosis of HIV infection
– Fail to take prophylactic antibiotics when CD4
count is less than 200/mm3
AIDS Dementia Complex
• Neurologic manifestations: affect 40-60% of
those with AIDS
• Include dementia, delirium, seizures
• From virus and opportunistic infections
• Impacts cognitive, motor and behavioral
functioning
• Fluctuating memory loss, confusion, difficulty
concentrating, lethargy, diminished motor
speed
AIDS Dementia Complex cont.
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Become apathetic
Leads to severe dementia
Ataxia, tremor, spasticity, incontinence, paraplegia
Toxoplasmosis and non-Hodgekin’s lymphoma
– May cause H/A, altered mental status, neurologic deficits
• Develop neuropathies: numbness, tingling, pain in LE’s
• May develop inflammatory demyelinating
polyneuropathy
• This is similar to Guillain-Barre
Opportunistic Infections of AIDS
• Normal CD4 counts: greater than 1,000/mm3
• Immunodeficiency develops below 500/mm3
• CD4 less than 200/mm3: opportunistic infections
and cancer are likely
• PCP: most common, about 80% develop it at
some time during their disease
– Is recurrent and causes death in about 20%
– Present with fever, cough, dyspnea, tachypnea,
tachycardia, mild chest pain, cyanosis, respiratory
distress
Opportunistic Infections cont.
• TB: 4% with AIDS develop
• Can be caused by reactivation of a previous
infection
• May be new, primary disease
• Has a more rapid progression, diffuse infiltrates,
and disseminated disease
– Affects bone marrow, joints, liver, spleen, CSF, skin,
kidneys, GI tract, lymph nodes, brain
• Present with cough, purulent sputum, fever,
fatigue, weight loss, lymphadenopathy
Opportunistic Infections cont.
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Candiasis
Common, opportunistic fungal infection
Oral thrush or esophagitis
Often first indication of progression to AIDS
Difficulty swallowing, substernal pain or
burning (increases with swallowing)
• Women: vaginal candidiasis frequent and
often recurrent
Opportunistic Infections cont.
• Mycobacterium Avium Complex (MAC)
– 25% of AIDS clients
– Late in course of the disease
– CD4 counts less than 50/mm3
– More common in women than men
– Found in food, water and soil
– Present with fever, chills, weakness, night sweats,
abd pain, diarrhea, weight loss
– Usually disseminated disease (any or all organs)
Other Infections
• Herpes virus
• CMV
– Affects the retina, GI tract, lungs
• Herpes simplex, or zoster
• Toxoplasma gondii and cryptococcus neoformans
affect CNS
– Toxoplasmosis: encephalitis, changes in mental status
– Cryotococcus: lungs
• Cryptosporidium: protozoon: GI tract diarrhea
• Women: PID
Secondary Cancers
• Kaposi’s Sarcoma (old man’s cancer)
– Late HIV disease
– Survival time: 18 months maximum
– See primarily face (nose) and pinnae of ears
– Visceral disease: GI tract, lungs, lymphatic’s
• Lymphoma’s (aggressive tumors)
– Lymphocyte’s, lymph nodes, spleen, bone marrow
– Non-Hodgkin’s, primary lymphoma of brain
• Cervical Cancer: Pap smear every 6 months
Pediatric Manifestations
• Neonate is asymptomatic at birth
• Onset of AIDS shorter in children
• Gram negative sepsis and prematurity primary
causes of mortality in HIV + babies
• Risk factors: prematurity, SGA, FTT
• Signs and symptoms may occur within days
• Early infancy: enlarged spleen/liver, swollen
glands, recurrent URI/LRI, UTI’s, oral candidiasis,
loss of achieved milestones
Pediatric Manifestations cont.
• Within 2 years from infection develop
conjunctivitis, ear infections, tonsillitis
• With disease progression: infections with
Streptococcus, Haemophilus influenzae,
Salmonella, PCP
• Develop lymphoma, lymphocytic interstitial
pneumonitis, encephalopathy
• Developmental delays, decreased motor
functioning
Collaboration
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The most vital strategy is prevention
Goals of care for client with HIV disease
Early identification of the infection
Promoting health maintenance to prolong the
asymptomatic period as long as possible
• Prevent opportunistic infections
• Treat the complications of the disease
• Provide emotional and psychosocial support
Nursing
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Education on using one pharmacy for meds
Educate the community on prevention
Provide support to clients
Educate public on standard precautions in
handling blood and body fluids
• Limit exposure to infectious diseases when
HIV +
Diagnostic Tests
• To detect infection with HIV and monitor client’s
disease and immune status
• Rapid diagnostic tests: immediate results
• Requires further testing to confirm a diagnosis
• ELISA: most widely used
• Tests for HIV antibodies, not the virus itself
• Can have negative result in the early course of
the disease
• 99.5% sensitivity 13 weeks after infection
Diagnostic Tests cont.
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Positive result: retest using different method
Western Blot antibody testing
More reliable than ELISA
More time-consuming
More expensive
Combined with ELISA: greater than 99.9%
reliability
• Clients blood is mixed with HIV proteins: if
antibodies are present an antigen-antibody
reaction will occur
Diagnostic Tests cont.
• HIV viral load tests: levels correlate with
disease progression and response to antiviral
medications
– 5,000-10,000 indicate the need for treatment
• CBC: to detect anemia, leukopenia,
thrombocytopenia
• CD4 cell count: to monitor disease and guide
therapy
• Do every 3-6 months once diagnosed
Other Diagnostic tests
• Blood culture for HIV: rarely done
• Immune-complex-dissociated p24 assay
• Indicates active reproduction of HIV and tends
to be positive before seroconversion
• TB skin test
• MRI for brain lymphomas
• Culture and sensitivity: infections
• PAP smears
Pediatric Testing
• ELISA and Western Blot: cannot distinguish
between maternal and infant antibodies
• May take up to 18 months to form their own
antibodies
• Preferred test: DNA polymerase chain reaction
– Within 48 hours from birth
– Do not use umbilical core blood
• Acid associated p24 antigen used in infants
older than one month
Pediatric Testing cont.
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Second test at 1-2 months
Third test at 2-4 months
Infection + if two out of three are positive
Confirm absence at 12-18 months with a negative
HIV antibody assay
• PCR: if negative at birth, retest at 1-2 month, 3-6
months, 15 and 18 months
• With two negative tests: ELISA at 12,15, 18 mos
• CBC and CD4 counts at 3-6 months
Pharmacologic Therapies
• HAART: three antiretroviral agents
• Zidovudine (Retrovir, AZT)
• An NRTI: nucleoside reverse transcriptase
inhibitor
• An NNRTI: nonnucleoside reverse transcriptase
inhibitor
• PI’s: protease inhibitors
• Term infants: AZT 2mg/kg po every 6 hours for 6
weeks
• If infant HIV + use multidrug antiretrovirals
Pharmacologic Therapies cont.
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To suppress the infection itself
Decrease symptoms and prolong life
To provide prophylaxis of opportunistic infections
Stimulate hematopoietic response
To treat opportunistic infections and malignancies
Effectiveness is monitored by viral load and CD4
counts
Pharmacologic Therapies cont.
• Positive results: reduced viral load and CD4
counts above 350/mm3
• Treatment recommended when CD4 falls below
200/mm3
• Do not initiate therapy in asymptomatic clients
with higher CD4 levels
• HARRT: 3-4 antiretrovirals
• Reduces incidence of drug resistance and
increase the likelyhood of decreasing viral loads
and symptoms
Pharmacologic Therapies cont.
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Triple combination drug: Trizivir
$1,030 per month
Does not include preventative/currative AB’s
Less than perfect adherence to therapy
Multiple meds throughout day
Physical changes from therapy: increased fat
deposition in breast, midsection, neck, atrophy in
face, buttocks, extremities
• Labs: increase LDL’s and triglycerides, insulin
resistance
NRTI’s
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Inhibit the action of viral reverse transcriptase
VRT converts viral RNA into cellular DNA
Drug substitutes a particular nucleoside base
Zidovudine (AZT, Retrovir)
Given to clients with CD4 counts less than 500
Slows the progression to severe disease
May be used prophylactically following a
documented exposure
NRTI’s cont.
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Didanosine: used with AZT
Stravudine: increases CD4 counts
Clients intolerant to AZT
Lamivudine: for low CD4 counts with AZT
Combivir: to decrease zidovudine resistant HIV
strains
Protease Inhibitors (PI’s)
• Protease needed for viral assembly and
maturation
• PI’s: result in production of immature,
noninfectious particles
• Increase the chance of eliminating the virus
– Interfere with different stages of the virus life cycle
• Used in conjunction with antiretrovirals
• Elevate cholesterol: pravastatin or atorvastatin
• Can NOT use simvastatin or Lovastatin
NNRTI’s and other drugs
• May be used with NRTI’s and PI’s
– High incidence of cross-resistance to NRTI’s
• Entry inhibitors
– Prevent HIV from entering target cells
– Binds to protein that surrounds the cell
– Improves CD4 counts, lowers viral load
• Interferon: KS
• Meds to treat opportunistic infections
Clinical Therapies
• Implanted venous access device
– Blood work, IV meds, transfusions, nutrition
– Use strict infection control principles
• Pregnancy:
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Evaluate and treat for STD’s
Monitor fetus
HepB andPneumoccal vaccine, annual flu shot
CBC with diff, platelet count
AZT reduces transmission to fetus to 1%
Prophylactic treatment for PCP by 4-6 weeks of age to
12 months or two negative HIV tests
Nursing Process
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To provide physical and psychosocial support
Health history
Physical assessment
Children: height and weight frequently
Assess family support system
Coping mechanisms
Assess understanding on transmission of
disease
Nursing Process cont.
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Diagnosis
Plan
First step dealing with prevention
Measures to prevent transmission
Evaluating test results
HIV/AIDS education for students
Counseling
Implementation
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Preventing Infection with HIV
Education and behavioral modification
Educating sexually active adolescents/adults
Safe sex is HIV status of partner unknown
Totally safe sex practices
– No sex
– Long-term mutually, monogamous sexual relations
between two non-infected people
– Mutual masturbation without direct contact
Implementation cont.
• Needle exchange programs
• Autologous transfusions for surgery
• HIV + abstain from donating blood, sperm,
getting tattoos
• Inform care givers of HIV status
• Practicing standard precautions
Postexposure Prophylaxis
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AZT therapy
Must be initiate immediately: within 72 hours
Preferably within 2-3 hours of exposure
Effectiveness has yet to be established
CDC recommend HAART
4 week course
Counseling and testing must be provided
Implementation cont.
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Prevent infections in those with HIV/AIDS
Promote adherence to Medication Regimen
Address ineffective coping
Maintain skin integrity
Manage imbalanced nutrition: less than body
requirements
• Address ineffective sexuality patterns
• Address knowledge deficits
• Evaluation
Have a great weekend!!