HIV Disease Complications

Slide 1:HIV Disease Complications

Patricia P. Gilliam, MEd, MSN, ARNP, BC Nurse Practitioner, HIV Services Tampa General Hospital Infectious Disease Center Hillsborough County HD- Specialty Care Center Faculty, Florida/Caribbean AETC Tampa, Florida

Slide 2:Learning Objectives:

1. Identify potential complications of the progression of HIV Disease when CD4 is < 500, < 350 <200, <100, and <50 2. Identify and discuss potential complications related drug therapy

Slide 3:Stages of HIV Disease Progression

Acute Retroviral Syndrome Asymptomatic HIV infection Symptomatic HIV infection AIDS defining illnesses AIDS

Slide 4:Each Patient is Unique!

Each patient is a person, not simply a CD4 count and viral load. The uniqueness of the HIV-infected patient creates many issues to address. Medical issues surrounding a chronic disease with many unknowns Psychosocial and economic issues which will impact health & disease progression Pharmacogenomics / Genetic Polymorphisms

Slide 5:Roles of the Nurse

Assessment Diagnosis of Nursing Problems Planning Intervention Collaboration with Providers Direct Care Patient Education Evaluation

Slide 6:Clinical Categories

Slide 7:Updated DHHS Guidelines (Oct. 2004)When to Start Treatment

Slide 8:HIV Disease Complications

HIV Disease Progression Related to declining CD4 cell counts as they approach: < 500 cells/mm3 < 200 cells/mm3 < 100 cells/mm3 < 50 cells/mm3

Slide 9:Evidence of Mild Immune Deficiency (CD4 cell count 200-500 cells/ml)

Oral candidiasis or thrush Recurrent vaginal candidiasis Recurrent herpes zoster Especially > 1 dermatome Recurrent herpes simplex Tuberculosis Neurological abnormalities Bell�s Palsy

Slide 10:Clinical Categories

Slide 11:Category B conditions

Listeriosis Pelvic Inflammatory disease Idiopathic thrombocytopenic purpura Recurrent bacterial endocarditis, meningitis, or sepsis Persistent or resistant vulvovaginal candidiasis

Slide 12:Category B conditions (cont.)

Constitutional symptoms, such as fever > 38.5 C or diarrhea lasting > 1 month Nocardiosis Peripheral neuropathy Oropharyngeal candidiasis Herpes Zoster involving at least 2 episodes of more than 1 dermatome

Slide 13:Clinical Categories

Slide 14:AIDS Defining IllnessesAKA: AIDS-Indicator Conditions

Bacterial pneumonia Cervical CA, invasive Candidiasis of bronchi, trachea, lungs or esophagus Coccidioidomycosis (disseminated or extrapulmonary) Cryptococcosis, extrapulmulmonary Cryptosporidiosis, chronic intestinal (>1 month) CMV Disease (other than liver, spleen or nodes) CMV retinitis (with loss of vision)

Slide 15:AIDS Defining Illnesses cont.

HIV encephalopathy Herpes simplex: chronic ulcers >1 month or bronchitis, pneumonitis, or esophagitis Histoplasmosis (dissem. or extrapulmonary Isosporiasis, chronic intestinal (>1 month) Kaposi�s sarcoma Lymphoma, Burkitt�s Lymphoma, immunoblastic Lymphoma, primary in brain

Slide 16:AIDS Defining Illnesses cont.

Mycobacterium avium complex or M. kansasii (disseminated or extrapulmonary) Mycobacterium, other species, disseminated or extrapulmonary Pneumocystis pneumonia Progressive multifocal leukoencephalopathy Salmonella septicemia, recurrent Toxoplasmosis of brain Wasting syndrome (wt. loss >10 % baseline body weight, associated with chronic diarrhea or fever)

Slide 17:Incidence of AIDS Indicator Conditions

Pneumocystis carinii Pneumonia 38% AIDS Wasting Syndrome 18% Candidiasis (esophageal, tracheal) 16% Kaposi�s sarcoma 7% HIV-associated dementia 5% Recurrent bacterial CAP Mycobactium avium, disseminated Cryptococcosis, extrapulmonary (Bartlett, 2004)

Slide 18:Prevention of Disease Progression

Prevention of Immune System Deterioration HAART Prevention of OI�s Prophylactic medications Patient Education

Slide 19:Preventing Exposure to OI�s

Sexual exposure IVDU exposure Environmental and occupational exposure Child-care provider and parental exposure Pet related exposures Food and Water-related exposure Travel related exposure

Slide 20:2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus. Recommendations to Help Patients Avoid Exposure to or Infection with Opportunistic Pathogens. Appendix: pp. 61-65 http://www.aidsinfo.nih.gov/guidelines/op_infections/OI_112801.html

Slide 21:Clinical Management of the HIV-Infected Adult: A Manual for Midlevel Clinicians (March, 2003)

This manual is available in both print and compact disk formats from the Southeast AIDS Training and Education Center (SEATEC) and from the Midwest AIDS Training and Education Center (MATEC), through the communication channels below. In addition, the manual is downloadable from the Internet site of the AIDS Education and Training Center National Resource Center at: http://www.aids-etc.org/pdf/tools/se_midlevel_2003.pdf

Slide 22:Prophylaxix to Prevent OI�s

PCP pneumonia Toxoplasmosis Mycobacterium Avium Complex

Slide 23:PCP pneumonia

Given to prevent a primary episode or a recurrence of infection Recommended to all HIV+ patients with a CD4 <200/mm3 or with hx of thrush Prophylactic Treatment Recommendations TMP-SMX Dapsone Aerosolized pentamidine

Slide 24:Toxoplasmosis

Test for presence of Toxo IgG Ab If IgG negative, counsel to avoid sources of infection Raw or undercooked meats Garden soil Avoid stray cats Keep pet cats indoors and feed commercially prepared cat food Prophylactic treatment is recommended to all HIV+ Toxoplasmosis IgG positive patients with a CD4 <100/mm3 Prophylactic Treatment Recommendations TMP-SMX Pyrimethamine + Dapsone + Leukovorin Dapsone alone is ineffective

Slide 25:DMAC:disseminated mycobacterium avium complex

Prophylactic treatment is recommended to all HIV+ patients with a CD4 < 50/mm3 Prophylactic Treatment Recommendations Azithromycin 1200 mg/week

Slide 26:HIV Disease Complications

Complications R/T drug therapy Assess for development of signs & symptoms Manage the problems to allow continuation of therapy if possible

Slide 27:HAART-Associated Side Effects

Rash GI symptoms N&V Diarrhea Headache Malaise

Slide 28:HAART AssociatedAdverse Events:

Stevens-Johnsons Syndrome Lactic acidosis/hepatic steatosis Hepatotoxicity Hyperglycemia Fat maldistribution Hyperlipidemia Osteopenia, osteoporosis Osteonecrosis

Slide 29:Stevens-Johnsons Syndrome

Disseminated Rash Fever Cutaneous sloughing

Slide 30:Lactic acidosis / Hepatic Steatosis

Possibly due to mitochondrial toxicity Associated w/ NRTIs Clinical presentation variable: have high index of suspicion Lactate >2-5 mmol/dL plus symptoms Treatment: d/c NRTI, supportive care

Slide 31:Lactic acidosis / Hepatic Steatosis

Rare, but high mortality* The combination of stavudine + didanosine was associated with several maternal deaths due to lactic acidosis. This antiretroviral combination should be used during pregnancy only when other NRTI drug combinations have failed or have caused unacceptable toxicities. D4T + ddI in pregnancy: The combination of ddI and d4T was associated with several maternal deaths secondary to severe lactic acidosis with or without hepatic steatosis and pancreatitis after prolonged use of regimens containing these two agents in combination [151]. This antiretroviral combination should be used during pregnancy only when other NRTI drug combinations have failed or have caused unacceptable toxicities. D4T + ddI in pregnancy: The combination of ddI and d4T was associated with several maternal deaths secondary to severe lactic acidosis with or without hepatic steatosis and pancreatitis after prolonged use of regimens containing these two agents in combination [151]. This antiretroviral combination should be used during pregnancy only when other NRTI drug combinations have failed or have caused unacceptable toxicities.

Slide 33:Hepatotoxicity

Severity variable: usually asymptomatic, may resolve without treatment interruption May occur with any NNRTI or PI: Nevirapine: risk of severe hepatitis in first 12 wks of use (monitor LFT), increased risk in women, chronic Hepatitis B & Hepatitis C PI: especially RTV, RTV/SQV; increased risk in Hepatitis B or Hepatitis C, ETOH, & with other hepatotoxins

Slide 34:Potential Etiology for BodyComposition Abnormalities

Etiology? Age Protease inhibitors Genetic predisposition Immune reconstitution Mitochondrial toxicity 2y to NRTIs HIV

Slide 35:Fat maldistribution

Lipodystrophy: No uniform definition Mechanism not understood peripheral fat wasting more associated w/ NRTIs central fat accumulation perhaps more associated with PIs May be associated with dyslipidemia, insulin resistance, lactic acidosis Treatment: insufficient data

Slide 36:Morphologic Complications:Fat Loss (Lipoatrophy)

Slide 37:Morphologic Complications:Fat Accumulation (Lipohypertrophy)

Slide 38:Buffalo hump: Ultrasound-guided liposuction

Good cosmetic result with buffalo hump, but relapse may occur (1/18 in one series, 5/10 in another) Gervason C, 10th CROI, Boston 2003, #723; Piliero P, et al. ibid, #724; photographs courtesy of Dr P. Piliero BEFORE AFTER RELAPSE

Slide 39:Other Interventions?

Aerobic exercise Weight training Anabolic steroids Human growth hormone (Serostim)

Slide 40:Hyperglycemia

Hyperglycemia and diabetes associated with all PIs, especially with chronic use Mechanism not well understood Insulin resistance, relative insulin deficiency Regular screening via fasting glucose

Slide 41:Hyperlipidemia

Elevations in total cholesterol, LDL, and triglycerides Associated w/ all PIs (varies w/ agent) Mechanism unknown Consequences uncertain: concern for cardiovascular events, pancreatitis Monitor regularly Treatment: consider substitution for PI; lipid-lowering agents (caution w/ PI + certain statins)

Slide 42:Bone abnormalities

Osteopenia and Osteoporosis Mechanism: ill-defined; decreased osteoblast or increased osteoclast activity Associated with PIs Dx: DEXA in symptomatic pts (no role for screening) Prophylaxis: No data. Consider calcium/Vit D, weight-bearing exercise, bisphosphonates for secondary prevention??

Slide 43:Bone abnormalities

Osteonecrosis (AVN) Mechanism unknown Associated w/ PIs; increased in: corticosteroid treatment, alcohol abuse, hemoglobinopathies, hyperlipidemia, hypercoagulable states Dx: CT or MRI

Slide 44:Roles of the Nurse

Assessment Diagnosis of Nursing Problems Planning Intervention Collaboration with Providers Direct Care Patient Education Evaluation

Slide 45:Nursing Actions

Patient Education prevent early recognition Assessment of s/s when they present Is it drug related? Is it a side effect or adverse event ? OI related

Slide 46:Know the Latest Clinical Data

Knowledge of HIV/AIDS changes at a blinding pace Lag time always exists between release of new information and publication of Guidelines Sources of new information Internet websites Conferences Teleconferences/webcasts Local organizations