Transcript HIV Oct 22x

Outline
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Statistics (will not be tested on stats)
Viral Reproduction
CDC Classification
Modes of Transmission
Levels of Prevention
Antiretrovirals
Opportunistic Infections goes here
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HIV
1981 was the first reported case of acquired
immune deficiency syndrome diagnosed.
(diagnosed through symptoms
• Half a million Americans have died from the
condition.
• Since 1981 more than 68 million people
worldwide have been infected with the virus.
• Over 55 million people are living with HIV.
• HIV is the leading cause of death in South Africa.
HIV
• Global epidemic
– 55 million people living with HIV
• 39 million adults
• 4.5 million children under 15
• 14,000 new infections daily
– 27.8 million dead of AIDS
• 22.5 million adults
• 5.3 million children under 15
• 14 million orphaned: 25 million by 2010
– Estimated cost of $5 million/year
HIV
• During 2003
– 5 million new infections
– 3 million people died of AIDS
– 2.5 million were adults
– 500,000 were children under 15
HIV
• In the USA
– Approx 1 million infected with HIV
– ½ are NOT being treated, lack of access or lack
of knowledge (don’t know they are infected)
– Approx 40,0000 infected annually (1:12
minutes)
– Leading cause of death among AfricanAmerican women 25-34
HIV
• Since CDC began tracking cases
– More than 95,000 cases in Florida
• 1,476 pediatrics
– Annual incidence is more than 2x the national
– Florida has the third highest cumulative
number of AIDS cases in the nation (duval co is
2nd county in the state)
– Second highest number of pediatric AIDS cases
New Cases
• Leading cause of death for African American
men and women between the ages of 25 and
44.
• Accounted for 64% of AIDS deaths in state,
only represent 15% of the state’s population.
New Cases in Florida 5,500-6,000
– As of 7/1/97 any new person testing
positive for HIV is reportable
On the brighter side…
• Since the inception of HAART in 1996 the
death rate dropped by 70% (highly active…
retrovirus treatment??? )
• Incidence of pediatric AIDS has decreased
since 1994 (found that it is xmitted through
breast milk, also found that if they take
antrovirals their chance of passing it on to the
baby goes from 30% down to ?????
HIV
• 30% infection rate among inner-city young
adults who smoke crack, specially women who
exchange sex for drugs.
• More than 10,000 cases of HIV have been
attributed to transfusion infected blood or
blood components. Current risk is extremely
low.
AIDS rates
perper
100,000
women
AIDS Rates
100,000 Women
Reported in 1999
2.1
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1.8
2.0
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1.2
1.7
1.3
1.6
2.5
4.6
3.4
5.5 2.0
2.1
2.5
5.2
4.7
9.2
1.2
1.9
2.1
1.5
0.9
7.4
1.8
0.9
2.7
3.6
7.4
6.7
5.9
3.0
15.0
9.1
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30.0
6.3
11.0
PR 21.3
VI 30.1
NH
MA
RI
CT
NJ
DE
MD
DC
1.2
14.8
7.2
13.0
19.6
14.1
21.0
93.4
Rate per 100,000
<<55
13.4
23.2
1.6
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5 _ 9.9
10+
* <5 cases
US rate: 9.3
N=10,780
HIV- CDC Classification
• Stage I-Viral Syndrome-Present in 50% of all
cases within days to weeks (flu like) virus levels are very
high at the very beginning
• Stage II -Asymptomatic- may last up to 10
yrs. (maybe longer, used to call it dormant, it really isn’t dormant,
but the immune system is holding it down)
• Stage III-Persistent Generalized
Lymphadenopathy (PGL)-greater than 2 extra
inguinal nodes for more than 3 months
• (little diff than in the book)
HIV- CDC classification
• Stage IV (what has been called AIDS)
– A-Wasting-Fever > 1 month, weight loss
>10% of TBW, diarrhea (the diarrhea is not positive for some bacteria…
idiopathic)
– B-Neurologic manifestations-AIDS Dementia Complex
(ADC) (has been compared to Alzheimers,), Peripheral Neuropathy
(some meds for HIV can cause peripheral neuropathy, need to make sure the PN is
not related to those meds, can be so painful that pt is unable to walk)
– C-Opportunistic Infections (OIs)
– D-Kaposis Sarcoma (vasculature cancer, almost like blood blisters
on face & belly, some people get them in their GI system), Cervical
Cancer (women that were HIV positive have higher incidence of HPV
and cervical cancer)
• LOOK at chart in book to see the CDC guidelines… slides not
included in this powerpoint!
Transmission
**Can be transmitted only under specific
conditions**
HIV is not spread casually, it can not be
transmitted through hugging, kissing, shaking
hands, sharing utensils, or attending school
with an HIV infected person.
Transmission
• It is not transmitted through saliva, tears or
sweat.
• Healthcare workers may be infected with HIV
through needlesticks or direct contact with
HIV-infected blood
• 1:300 without prompt antiretroviral
treatment (24 hrs -7 days)
Transmission
• Modes
– Sexual
– Contact with blood/blood products
– Perinatal transmission
HIV- Levels of prevention
Primary Prevention
• 1) Safe Sex Counseling– No sex is safe sex
– Proper use of barrier contraception
• 2) High Risk Reduction– Identification of High Risk groups
– Substance abuse counseling
– Clean needles and paraphernalia
HIV- Levels of prevention
• 3) Perinatal Transmission– Gestation
– Delivery
– Breast feeding
– (w/ antiretrovirals & no breastfeeding, the transmission can be
reduced to 10%)
HIV- Levels of prevention
Secondary Prevention
• 1) Identification through early screening
currently available
Tests
• A) Elisa & Western Blott (WB)Antibodies present within
6 weeks, newborns within 18 months.(have to wait 1.5 yrs to
find out if baby is pos for HIV, initially ALL babies will test positive)
• B) Rapid oral HIV test 3/20/04 Antibody tests 99.3%
effective, 99.8% specificity
• C) Home testing kits (very effective & specific, problem is that
the person is tested & then told over the phone that the person is
pos… no follow up)
• 2) Drug Cocktails
HIV- Levels of prevention
Tertiary Prevention
– 1) Medical management for patients
classified as stage IV to prevent
complications
• Prophylaxis (prevention) against PCP,
MAC, CMV retinitis, candidiasis
Testing Guidelines
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1985-Blood in blood banks (still not 100%)
1987-All patients with STDs
1993-Inpatients where HIV.1%
1995-All pregnant women
2001-Public and private health care settings
2006-Voluntary screening in all health care
settings
Laboratory Tests
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ELISA
Western Blot
OraQuick Rapid HIV-1/2 Antibody Test
T-cells (about 1000 for most of us, not HIV positive)
Viral load/viral burden/viral RNA (check
number of RNA strands… if below 200 the
virus is undetectable, Magic Johnson)
Cases
1)Viral load
CD4
non-detectable
650
2)Viral load
CD4
30,000
3)Viral load
CD4
100,000
(look healthy)
(maybe lymphnode problems)
200
(probably sick)
90
Treatments
• Primary factor limiting effectiveness of drugs
is the development of resistance
– Resistance-the ability of HIV to replicate in
the presence of antiretroviral agent. (don’t take
drug as prescribed… )
– HIV replicates frequently with up to 10 bill.
copies/day.
Reverse Transcriptase Inhibitors
(NRTIs)
– Combivir
zido (AZT available in 1985) & lami
(AZT & 3TC)
– Emtriva
emtricitabine (FTC)
– Epivir
lamivudine (3TC)
– Hivid
zalcitabine (ddC)
– Retrovir
zidovudine (AZT)
– Trizivir abacavir+zido+lami
– Videx
didanosine (ddI)
– Viread
tenofovir disoproxil (TDF)
– Zerit
stavudine (d4T)
– Ziagen
abacavir (ABC)
NON-NUCLEOSIDE REVERSE TRANSCRIPTASE
INHIBITORS (NNRTI)
– Rescriptor delavirdine
– Sustiva
efavirenz
– Viramune nevirapine
• Neuropathies… all meds have their side effects
(DLV)
(EFV)
(NVP)
PROTEASE INHIBITORS
– Agenerase
– Crixivan
– Fortovase
– Invirase
– Kaletra
– Lexiva
– Norvir
– Reyataz
– Viracept
amprenavir (APV)
indinavir
(IDV)
saquinavir (SQV-sgc)
saquinavir (SQV-hgc)
lopinavir, ritonavir (LPV)
fosamprenavir (FPV)
ritonavir (RTV)
atazanavir (ATZ)
nelfinavir (NFV)
Entry Inhibitors/
Fusion Inhibitors
• Fuzeon Injectable requires 2 shots/day
– Reserved for individuals who are resistant to
PIs, NRTIs and NNRTIs.
– Drug binds to gp41 protein on the HIV surface
so it can not bind with T cells
– (work on penetration phase, injectable, 2 shots daily, used on pts
w/ resistance to coctails)
HIV-Medications
ANTIMETABOLITE ANTINEOPLASTIC
– Hydroxyurea
Current Guidelines for HAART
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Symptomatic
Asymptomatic w/CD4 <200
Asymptomatic w/CD4 200-350
Asymptomatic w/CD4>350
Treat
Treat
Offer
Defer
Development of Resistance
• Genotype resistance- mutation of virus
• Phenotype resistance-decreased sensitivity to
drug
• Cross-resistance-resistance to multiple drugs
• Monotherapy-only on one drug
• Subtherapeutic levels-not taking full dosage or
not at prescribed intervals
HAART-Associated Adverse Events
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Lactic Acidosis/Hepatic steatosis (fatty liver)
Hepatotoxicity
Hyperglycemia (meds hurt pancreas)
Fat Maldistribution (face loses fat, but develop belly or
back fat)
• Hyperlipidemia (from protease inhibitors)
• Osteopenia/Osteoporosis/Osteonecrosis
Maintenance of HIV-Infected individuals
• CD4< 500
Antiretroviral Therapy
• CD4< 200
P. jiroveci pneumonia prophylaxis
• CD4< 100
M. avium prophylaxis
• CD4< 50
CMV prophylaxis
• Give antibiotics (bactrim) for pneumonia…
treatment will be the same as for a non HIV pt.
Opportunistic Diseases (OI)
• Fungal Infections
– Candidiasis-(thrush) frequently first sign of disease (soil, food,
on the skin, mouth, vagina, large intestine) Most infections are
endogenous.
– Clinical presentation is dependent on site of infection
• Esophagitis-dysphagia
• Thrush-oral legions
• Intertrigo (folds in body… under breasts or fat folds)-cutaneous
lesions
• Vaginitis-vulvovaginal lesions and discharge
• Disseminated disease (throughout the body)-constitutional symptoms
– Treated with clotrimazole, miconazole, ketoconazole,
fluconazole or itraconazole. Disseminated- Amphoteracin B
– “zole” is antifungal
– Amphoteracin… “amphoterrible” bad side effects, sometimes
w/ steriods, gives chills & fever just from IV infusion, will get rid
of the infection but it has rough side effects.
Opportunistic Diseases (cont)
• Protozoal
– Pneumocystis jiroveci (formerly PCP)(Airborne,
found in lungs)
– 7% are asymptomatic, coughing, non-productive
cough, fever, DOE (dry cough)
– Treated with TMP-SMX (Bactrim)not for pt w/ sulfa allergy,
pentamidine, atovaquone, dapsone (also given for
malaria), clindamycin-primaquin
– Maintenance therapy on TMP-SMX, pentamidine
aerosol, atovaquone, dapsone
– Toxoplasmosis (injestion of contaminated foods)
• Usually CNS symptoms (brain), presents like meningitis
Opportunistic Diseases (Cont)
• Bacterial
– Fever, night sweats, fatigue, anorexia, weight loss,
abdominal pain, diarrhea
– Mycobacterium Avium Complex (MAC) (soil, water,
animals, eggs, unpasteurized dairy)
– May require 2-6 drug to treat including
Azithromycin (Z pack, drug of choice), clarithromycin,
ethambutol, ciprofloxacin, rifabutin, and amikacin.
– Mycobacteria Tuberculosis (airborne)
Opportunistic Diseases (Cont)
• Viral
– Cytomegalovirus (CMV). Almost everyone becomes
infected with CMV which is transmitted through direct
contact with infected secretions including saliva,
cervical fluid, urine, semen, breast milk, feces, and
blood. Infection can be asymptomatic or not.
Medications used include gancyclovir, foscarnet and
cidofovir. Treatment may also include intraocular
gancyclovir implants or intravitrial injections of
ganciclovir, foscarnet or cidofovir. Maintenance
lifetime suppressive therapy is required. (a lot of children
have this, often seen in the eyes “CMV retinitis”, can become blind
from this)
– Herpes Simplex (often same meds as for CMV)
Opportunistic Diseases (Cont)
– Progressive Multifocal Leukoencephalopathy
(PML)
Caused by the JC virus, ubiquitous in nature and
infects most middle-aged people. Active disease
results in limb weakness, ataxia, cognitive
impairment, vision loss, speech impairment, and
headache. In latter stages it progresses to
dementia, blindness, paralysis and death.
There is no effective therapy.
Opportunistic Diseases (Cont)
• Cancers
– Kaposis Sarcoma (KS)
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Classic KS- Older Black, Mediterranean or certain Jewish men
African KS- Seen in Africa
Transplant KS- people who receive transplanted organs
HIV-related KS- disseminated throughout the body, resulting
in shorter survival
– Initial patch is flat and pink, looks like a bruise,
symmetrical on both sides of the body. Later dark
violet
• Localized or systemic- Chemotherapy such as: bleomycin,
alpha-interferon, daunorubicin
Opportunistic Diseases (Cont)
– Cervical Cancer-occurs at a high rate, progresses
more rapidly, less responsive to therapy, related to
low CD4 counts.
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Early- asymptomatic
Diagnosed by Pap Smear
Post-coital bleeding, blood-tinged vaginal discharge
Late-stage Back, pelvic, leg apin, weight loss, vaginal
bleeding, anemia. Lymphadenopathy, edema of legs.
• Treatment-conization, laser therapy, cryosurgery,
electrocautery, or hysterectomy
Opportunistic Diseases (Cont)
• Central Nervous System
– Dementia-HIV encephalopathy-affects mostly the
very young and older clients
• Cognitive dysfunction, motor problems, behavioral
changes (Five stages of progression)
– Peripheral Neuropathies
• Greatly debilitating, interfereing with ability to
ambulate
Opportunistic Diseases (Cont)
• HIV Wasting Syndrome-profound involuntary
weight loss (>10%) with either chronic
diarrhea or chronic weakness and fever.
– Primary causes: decreased food intake,
malabsorption, altered metabolism
– Treatment usually results in only partial recovery
– Megace and Dronabinol, Human growth hormone.
Critical Thinking
• Your HIV-infected client tells you “I don’t have
HIV anymore. The doctor just told me my viral
load was undetectable.”
• How would you respond?
Critical Thinking
• Explain how you can decrease your risk of
occupational exposure to HIV.