Concept 14: HIV/AIDS

1. Concept 14: HIV/AIDS Fall 2011 Barbara E. Connell, RN, MSN

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

12. 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

13. Etiology cont. • The most rapid increases have been seen in young gay and bisexual men, women, inner-city 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Risk Factors cont. • 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

20. 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

22. 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

23. 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

24. 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

27. 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

28. AIDS Dementia Complex cont. • 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 demyelinatingpolyneuropathy • This is similar to Guillain-Barre

29. 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

30. 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

31. Opportunistic Infections cont. • 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

32. 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)

33. Other Infections • Herpes virus • CMV • Affects the retina, GI tract, lungs • Herpes simplex, or zoster • Toxoplasmagondii and cryptococcusneoformans affect CNS • Toxoplasmosis: encephalitis, changes in mental status • Cryotococcus: lungs • Cryptosporidium: protozoon: GI tract diarrhea • Women: PID

34. 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

35. 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

36. Pediatric Manifestations cont. • Within 2 years from infection develop conjunctivitis, ear infections, tonsillitis • With disease progression: infections with Streptococcus, Haemophilusinfluenzae, Salmonella, PCP • Develop lymphoma, lymphocytic interstitial pneumonitis, encephalopathy • Developmental delays, decreased motor functioning

37. Collaboration • 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

38. Nursing • 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 +

39. 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

40. Diagnostic Tests cont. • 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

41. 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

42. 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

43. 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

44. Pediatric Testing cont. • 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

47. 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

48. Pharmacologic Therapies cont. • 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

49. 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

50. Pharmacologic Therapies cont. • 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