Ch 56- Care of the Patient with HIV/AIDS

1. Therapeutic Management to Acute Intervention: Wasting and Lipodystrophy Syndromes Ch 56- Care of the Patient with HIV/AIDS

2. Basic Information from CDC • HIV stands for human immunodeficency virus. This is the virus that causes AIDS. HIV is different from most other viruses because it attacks the immune system. The immune system gives our bodies the ability to fight infections. HIV finds and destroys a type of white blood cell (T Cells or CD4 Cells) that the immune system must have to fight disease.

3. Organization of the HIV-1 Virion Structure of the Human Immunodeficiency Virus, courtesy of the NIAID.

4. Basic Information from CDC (cont) • AIDS stands for acquired immunodeficiency syndrome. AIDS is the final stage of HIV infection. It can take years for a person infected with HIV, even without treatment, to reach this stage. Having AIDS means that the virus has weakened the immune system to the point at which the body has a difficult time fighting infection. When someone has one or more specific infections, certain cancers, or a very low number of T cells, he or she is considered to have AIDS.

5. HIV Virus Electron microscope image of HIV, seen as small spheres on the surface of white blood cells

6. Origin of HIV • Scientists identified a type of chimpanzee in West Africa as the source of HIV infection in humans. The virus most likely jumped to humans when humans hunted these chimpanzees for meat and came into contact with their infected blood. Over several years, the virus slowly spread across Africa and later into other parts of the world.

7. Origins of HIV Species of Chimpanzee found In Western Africa

8. Brief History of HIV in the U.S. • HIV was first identified in the United States in 1981 after a number of homosexual men started getting sick with a rare type of cancer. It took several years for scientists to develop a test for the virus, to understand how HIV was transmitted between humans, and to determine what people could do to protect themselves.

9. Brief History (cont) • In 2008, CDC adjusted its estimate of new HIV infections because of new technology developed by the agency. Before this time, CDC estimated there were roughly 40,000 new HIV infections each year in the United States. New results shows there were dramatic declines in the number of new HIV infections from a peak of about 130,000 in the mid 1980s to a low of roughly 50,000 in the early 1990s. Results also shows that new infections increased in the late 1990s, followed by a leveling off since 2000 at about 55,000 per year. In 2006, an estimated 56,300 individuals were infected with HIV.

10. Brief History (cont) • AIDS cases began to fall dramatically in 1996, when new drugs became available. Today, more people than ever before are living with HIV/AIDS. CDC estimates that about 1 million people in the United States are living with HIV or AIDS. About one quarter of these people do not know that they are infected: not knowing puts them and others at risk.

11. How HIV Is and Is Not Transmitted • HIV is a fragile virus. It cannot live for very long outside the body. As a result, the virus is not transmitted through day-to-day activities such as shaking hands, hugging, or a casual kiss. You cannot become infected from a toilet seat, drinking fountain, doorknob, dishes, drinking glasses, food, or pets. You also cannot get HIV from mosquitoes.

12. How HIV is and is not transmitted (cont) HIV is primarily found in the blood, semen, or vaginal fluid of an infected person. HIV is transmitted in 3 main ways: • Having sex (anal, vaginal, or oral) with someone infected with HIV • Sharing needles and syringes with someone infected with HIV • Being exposed (fetus or infant) to HIV before or during birth or through breast feeding

13. How HIV is or is not transmitted (cont) • HIV also can be transmitted through blood infected with HIV. However, since 1985, all donated blood in the United States has been tested for HIV. Therefore, the risk for HIV infection through the transfusion of blood or blood products is extremely low. The U.S. blood supply is considered among the safest in the world.

14. Risk Factors for HIV Transmission You may be at increased risk for infection if you have: • Injected drugs or steroids, during which equipment (such as needles, syringes, cotton, water) and blood were shared with others • Had unprotected vaginal, anal, or oral sex (that is, sex without using condoms) with men who have sex with men, multiple partners, or anonymous partners • Exchanged sex for drugs or money

15. Risk Factors (cont) • Been given a diagnosis of, or been treated for, hepatitis, tuberculosis (TB), or a sexually transmitted disease (STD) such as syphilis • Received a blood transfusion or clotting factor during 1978-1985 • Had unprotected sex with someone who has any of the risk factors listed above

16. Preventing Transmission Your risk of getting HIV or passing it to someone else depends on several things. You might want to talk to someone who knows about HIV. You can also do the following: • Abstain from sex (do not have oral, anal, or vaginal sex) until you are in a relationship with only one person, are having sex with only each other, and each of you knows the other’s HIV status

17. Preventing Transmission (cont) • If both you and your partner have HIV, use condoms to prevent other sexually transmitted diseases (STDs) and possible infection with a different strain of HIV • If only one of you has HIV, use a latex condom and lubricant every time you have sex • If you have, or plan to have, more than one sex partner, consider the following:

18. Preventing Transmission (cont) • Get tested for HIV • If you are a man who has had sex with other men, get tested at least once a year • If you are a woman who is planning to get pregnant or who is pregnant, get tested as soon as possible, before you have your baby • Talk about HIV and other STDs with each partner before you have sex • Learn as much as you can about each partner’s past behavior (sex and drug use), and consider the risks to your health before you have sex

19. Preventing Transmission (cont) • Ask your partners if they have recently been tested for HIV; encourage those who have not been tested to do so • Use a latex condom and lubricant every time you have sex • If you think you may have been exposed to another STD such as gonorrhea, syphilis, or chlamydiatrachomatis infection, get treatment. These diseases can increase your risk of getting HIV

20. Preventing Transmission (cont) • Get vaccinated against hepatitis B virus • Even if you think you have low risk for HIV infection, get tested whenever you have a regular medical check-up • Do not inject illicit drugs (drugs not prescribed by your doctor). You can get HIV through needles, syringes, and other works if they are contaminated with the blood of someone who has HIV. Drugs also cloud your mind, which may result in riskier sex.

21. Preventing Transmission (cont) • If you do inject drugs, do the following: • Use only clean needles, syringes, and other works • Never share needles, syringes, or other works • Be careful not to expose yourself to another person’s blood • Get tested for HIV at least once a year • Consider getting counseling and treatment for your drug use • Get vaccinated against hepatitis A and B viruses

22. Preventing Transmission (cont) • Do not have sex when you are taking drugs or drinking alcohol because being high can make you more likely to take risks To protect yourself, remember these ABCs: A=Abstinence B=Be Faithful C=Condoms

23. Symptoms of HIV Infection • The only way to know whether you are infected is to be tested for HIV. You cannot rely on symptoms alone because many people who are infected with HIV do not have symptoms for many years. Someone can look and feel healthy but can still be infected. In fact, one quarter of the HIV-infected persons in the United States do not know that they are infected.

24. HIV Testing • Once HIV enters the body, the body starts to produce antibodies- substances the immune system creates after infection. Most HIV tests look for these antibodies rather than the virus itself. There are many different kinds of HIV tests, including rapid tests and home test kits. All HIV tests approved by the U.S. government are very good at finding HIV.

25. Finding a Testing Site • Many places offer HIV testing: health departments, doctors’ offices, hospitals, and sites specifically set up to provide HIV testing. • You can locate a testing site by visiting the CDC HIV testing database or by calling CDC-INFO (formerly the CDC National AIDS Hotline) at 1-800-CDC-INFO (1-800-232-4636) 24/7. You do not have to give any personal information about yourself to use these services to find a testing site

26. Pharmacological Management Therapeutic Management

27. Therapeutic Management • Focuses of Therapeutic Management • Monitoring HIV disease progression and immune function • Preventing the development of opportunistic diseases • Initiating and monitoring antiretroviral therapy • Detecting and treating opportunistic diseases • Managing symptoms • Preventing complications of treatment

28. Therapeutic Management (cont) • HIV-positive individuals need to be linked to various points of intervention, depending on their individual needs. Individuals often deny the infection, neglect their mental and physical health, and continue behaviors that put themselves and others at risk. • Interventions need to be sustained and reinforced • Providers need to stress safer behaviors and the need for medical and emotional support

29. Therapeutic Management (cont) • Types of assistance may include but are not limited to: • Family planning • Treatment for substance abuse • Treatment for STDs • Treatment for Tuberculosis (TB) • immunizations

30. Therapeutic Management (cont) • A transdisciplinary care approach is the most appropriate method of care for patients with HIV disease because of their complex medical and psychosocial needs • The HIV-infected person should be the primary member of this team working alongside with a physician who specializes in HIV and AIDS, a social worker, case manager, dietician, and nurse

31. Therapeutic Management (cont) • Other team members may include: • Dentist • PCP (medical doctor, doctor of osteopathy, nurse practitioner, or physician assistant) • Mental health worker • Substance abuse counselor • Nontraditional therapist (massage therapist or acupuncturist) • Individual’s family and significant other

32. Opportunistic Diseases Associated with HIV – Alternative and Complementary Therapies Pharmacological Management

33. Opportunistic Diseases Associated with HIV • A number of opportunistic diseases and debilitating problems associated with HIV can be delayed or prevented through the use of antiretrovirals and prophylactic interventions. • Prophylactic medications have contributed to the decreased morbidity and mortality associated with HIV infection during the past several years. • Prophylactic medications are recommended according to established parameters

34. Opportunistic Diseases Associated with HIV (cont) • The most difficult aspect of the medical management of HIV is dealing with the many opportunistic diseases that develop as the immune system degenerates • Although it is usually impossible to totally eradicate opportunistic diseases, there are treatments that can control their emergence or progression • Regimen must continue throughout the patient’s life or the disease will return • Advances in the diagnosis and treatment of opportunistic diseases have contributed significantly to increased life expectancy

35. Table 56-6 pg 2028 to 2029 Common Opportunistic Diseases Associated with HIV/AIDS

36. Respiratory System • Pneumocystisjiroveci pneumonia (PCP) • Clinical manifestations: • Fever, night sweats, nonproductive cough, progressive shortness of breath • Diagnostic Tests: • Chest radiograph, induced sputum for culture, bronchoalveolarlavage • Treatment: • Trimethoprim-sulfamethoxazole, dapsone+pyrimethamine+ leucovorin, clindamycin, atovaquone, pentamidine, steroids, trimetrexate, and folinic acid • Mycobacterium tuberculosis • Clinical manifestations: • Productive cough, fever, night sweats, fatigue, weight loss • Diagnostic Tests: • Chest radiograph, sputum for acid-fast bacteria (AFB) stain and culture, skin test • Treatment: • Isoniazid, ethambutol, rifampin, pyrazinamide, streptomycin, azithromycin, clarithromycin

37. Integumentary System • HSV-1 • Clinical manifestations: • Vesicular eruptions on mouth • Diagnostic tests: • Viral culture • Treatment: • Acyclovir, foscarnet, famciclovir, valacyclovir • Varicella Zoster Virus (VZV) • Clinical manifestation: • Shingles: erythematousmacules, rash, pain, pruritis • Diagnostic tests: • Viral culture • Treatment: • Acyclovir, foscarnet, valacyclovir

38. Eye • CMV Retinitis • Clinical manifestations: • Lesions on the retina, blurred vision, loss of vision • Diagnostic tests: • Ophthalmoscopic examination • Treatment: • Ganciclovir, foscarnet, cidofovir • VZV • Clinical manifestations: • Ocular lesions, acute retinal necrosis • Diagnostic tests: • Ophthalmoscopic examination, culture • Treatment: • Acyclovir, foscarnet, valacyclovir, famciclovir

39. Gastrointestinal System • Candida albicans • Clinical manifestations: • Whitish yellow patches in mouth, esophagus, gastrointestinal (GI) tract • Diagnostic tests: • Microscopic examination of scraping from lesion • Treatment • Nystatin, clotrimazole, ketoconazole, fluconazole, itraconazole, amphotericin B • Non-Hodgkin’s Lymphoma • Clinical manifestations: • Abdominal pain, fever, night sweats, weight loss • Diagnostic tests: • Lymph node biopsy • Treatment: • Chemotherapy, HAART (highly active antiretroviral therapy)

40. Neurological System • Jamestown Canyon (JC) virus • Clinical manifestations: • Progressive multifocal leukoencephalopathy, mental and motor declines • Diagnostic tests: • MRI, CT Scan, brain biopsy, autopsy • Treatment: • No proven therapy, but HAART may help, cutosinearabinoside • Central Nervous System Lymphomas • Clinical manifestations: • Cognitive dysfunction, motor impairment, aphasia, seizures, personality changes, headache • Diagnostic tests: • MRI, CT Scan • Treatment: • Radiation, chemotherapy

41. Table 56-7 pg 2030 to 2031 Opportunistic Illness Prophylaxis Guidelines

42. Strongly Recommended as Standard of Care • Problem: • Mycobacterium tuberculosis • Indication: • Skin test (PPD) is greater than or equal to 5 mm or prior positive skin test • Preventive Regimens: • First Choice: isoniazid + pyridoxine for 9 months • Alternative Choices: refampin, 600 mg qid (four times a day) for 6 months • Comments: r/o active or extrapulmonary disease which requires multidrug therapy; remember that a negative PPD in the presence of HIV does not exclude a diagnosis of tuberculosis

43. Generally Recommended • Problem: • Hepatitis A Virus (HAV) • Indication: • All susceptible patients at risk for HAV infection: illicit drug users, men who have sex with men (MSM), hemophiliacs, chronic liver disease • Preventive regimens • First choice: Hepatitis A vaccine (2doses) • Alternative choices: none • Comments: combination vaccine available for hepatitis A and hepatitis B (Twinrix)

44. Antiretroviral Therapy • Combination antiretroviral therapy is an important component in the management of HIV infection • There are many antiretroviral medications approved by the U.S. FDA for treatment of HIV disease • In 1987, zidovudine was the only medication available to treat patients with HIV disease • Today, there are 18 approved anti-HIV medications available, with significantly more in development

45. Antiretroviral Therapy : Cocktails • At least two, but generally three or more compounds given together • Most effective medication regimen that scientists have discovered • Makes it much more difficult for the virus to develop resistance to the drugs • May also slow the progression from asymptomatic or mildly symptomatic HIV infection to a more advanced disease • Combination therapies offer renewed optimism for successful disease management and improvements in the quality and duration of life

46. Antiretroviral Therapy (cont) • Recent developments include therapies that can dramatically reduce the quantity of circulating virus in the blood; in many cases, blood circulating levels become undetectable • Protease inhibitors directly reduce the ability of HIV to replicate, or make copies of itself inside cells • As increasing numbers of therapeutic agents and clinical trial results become available, decisions about antiretroviral therapy have become increasingly complex

47. Antiretroviral Therapy (cont) • It is important for the nurse to administer anti-HIV medications around the clock • Example: medication ordered three times per day (TID) should be given as close to every 8 hours as possible, not 3 times while the patient is awake • When medications are not given regularly, the drug levels in the blood fall low enough to allow HIV to develop resistance • This is a critical teaching point for nurses to communicate to patients

48. Antiretroviral Therapy: Considerations • Combination therapy is now the standard of care. A single drug (monotherapy) is no longer recommended due to the likelihood of the development of viral and therapeutic resistance. Cocktails are more effective than single-drug therapy. This is referred to as “highly active antiretroviral therapy” or HAART. • Previous antiretroviral experience may affect the efficacy of a proposed therapy, because previous drug therapy may have allowed the HIV to become resistant to those medications taken by the patient in the past (e.g. AZT, 3TC) • Certain combinations of antiretrovirals may reverse the resistance built up against a single drug. Recycling drugs previously taken can sometimes lead to improved viral suppression. Incorrect dosing (timing) or usage (missed doses) can cause drug resistance

49. Antiretroviral Therapy: Considerations (cont) • Drug incompatibilities, similar side effect profiles, and toxicities must be considered when choosing a regimen • The individual’s commitment and ability to adhere with complex drug regimens must be considered. Inadequate adherence can lead to drug resistance and, ultimately, to drug failure. This point must be stressed to the patient. Adherence is paramount to survival and success of treatment

50. Antiretroviral Therapy (cont) • There is considerable difference of opinion as to when to initiate antiretroviral therapy • A provider with expertise in HIV should supervise the care of the HIV-infected person • With regard to specific recommendations, treatment should be offered to all patients with acute HIV syndrome (seroconversion illness), those within 6 months of HIV seroconversion, and all patients with symptoms credited to HIV infection • In general, treatment should be offered to individuals with fewer than 350 CD4+ T Cells per millimeter cubed or plasma HIV viral loads exceeding 30,000 copies per mL (bDNA method) or 55,000 copies per mL (PCR method)