HIV & AIDS

1. HIV & AIDS Claire O’Gorman Claire Pettipas Michèle Weir-Cotnoir

2. Objectives • Describe the pathophysiology of HIV the consequential infections that occur • Understand the Epidemiology of the disease and the effects of HIV/AIDS on a society, including Canada • Understand the risk factors associated with contracting HIV and how to prevent infection • Describe how to protect yourself as a HCP from infectious blood borne diseases • Understand the nursing management of this terminal illness and the conditions associated with it.

3. What Is HIV? H – Human I – Immunodeficiency V – Virus

4. What is AIDS? A – Aquired I – Immune D- Deficiency S- Syndrome For diagnosis must be: HIV positive, and CD4 (T-cell) count below 200, or The presence of one or more opportunistic infections.

5. Class Activity STAND UP!

6. Global Epidemiology • 39.5 million people living with HIV/AIDS in 2006 • 4.3 million newly infected with HIV (more than half are younger than 25) • 2.9 million people died from AIDS • More than 25 million people have died from AIDS since 1981 • Africa has over 12 million AIDS orphans

7. Global Trends

9. Xtending Hope • What can you do on campus to address the global AIDS epidemic?

10. Canadian Epidemiology Public Health Agency of Canada. HIV and AIDS in Canada. Surveillance report to June 30, 2006. Surveillance and Risk Assessment Division, Centre for Infectious Disease Prevention and Control, Health Canada, November 2006 Health Canada. HIV/AIDS EPI Updates, August 2006, Surveillance and Risk Assessment Division, Centre for Infectious Disease Prevention and Control, Health Canada, 2006 58 000 people in Canada with HIV (as of Dec, 2005) 30% of people unaware of their infection Between 2 300 and 4 500 new HIV infections every year 329 people in Nova Scotia/PEI have AIDS (as of June, 2006)

11. Canadian Epidemiology • Affects ALL races, genders, ages • Most people who test HIV positive are between the ages of 20-40 • Minorities, such as aboriginals and black people, are over represented • Women remain around 1/3 of newly infected patients (increase since 1995) • Greater risk of infection with high risk activities

12. Risk Factors • Transmission: through bodily fluids from an infected person • Three Conditions: • 1. Virus Must be Present • 2. There must be a high enough concentration of the virus in the infected person • 3. There must be a way for the virus to enter the bloodstream • Through Blood, Seman, Vaginal Fluid, or Breast milk

13. Transmission Possible Sources of Transmission: • Blood products/ transfusions • Before 1985 • Mother to child • Pregnancy, birth, and breastfeeding • Contaminated needles • Injection drug use, tattoos, peircings, acupunture • Sexual contact • Unprotected sex • Unwashed sexual devices • Greater risk with other STI due to breaks in skin • Greater risk with increased number of partners

14. Risk Factors • NOT transmitted through • Casual contact (shaking hands) • Hugging • Kissing • Sweat • Tears • Donating Blood • Swimming Pools • Toilet seats • Telephones • Sharing bed linens, towels, eating utensils, or food • Insect bites

15. Societal Risk Factors • Many determinants of health! • These, in turn, become consequences of an epidemic • Societal factors that contribute to the epidemic: • People on the move • People in conflict • Poverty • Stigma and Denial • Cultural factors • Role of Women

16. Prevention • Prevention is the most realistic strategy • Vaccine or cure unlikely anytime soon • Prevention is done by decreasing both societal and individual risk factors • Barriers to prevention include: • Political instability • Lack of resources • Existence of other endemic health problems (ie: malaria and childhood diseases) • Inefficiency • Apathy and silence • Misconceptions and lack of knowledge

17. Decreasing Individual Risk Factors Nurses are responsible for educating their clients about how to protect themselves from HIV/AIDS! • Literacy appropriate teaching • Use multiple teaching methods • Provide visual/auditory/written material for different learning styles • Provide for kinetic learners, too, such as having the client demonstrate how put on a condom • Direct clients to community resources • Where they can be tested for HIV/AIDS and other STI’s • Support groups

18. Community Resources Halifax Sexual Health Centre (HSHC)201-6009 Quinpool RoadHalifax, Nova Scotia, B3K 5J7Phone: 902 455 9656Monday–Friday 8:30am–4:30pmBy Appointment OnlyLesbian Gay Bisexual Youth Project2281 Brunswick StreetHalifax, Nova Scotia, B3K 2Y9Phone: 902 429 5429Every Fourth Thursday 5:00pm-8:00pmBy Appointment OnlyTeen Scene16 Dentith Road (South Centre Mall)Spryfield, Nova Scotia, B3R 2H9Phone: 902 455 9656Every Fourth Thursday 3:30pm–5:30pm AIDS Coalition of Nova Scotia (ACNS)326-1657 Barrington StreetHalifax, Nova Scotia, B3J 2A1Phone: 902 425 4882Alternate Thursday Evenings 5:00pm–8:00pmCall for Schedule - By Appointment OnlyMainline Needle Exchange5511 Cornwallis StreetHalifax, Nova Scotia, B3K 3B4Phone: 902 423 9991Every Second Monday 9:30am–11:30amCall for Schedule - Drop InHealing Our Nations Aboriginal AIDS Task Force607-45 Alderney DriveDartmouth, Nova Scotia, B2Y 2N6Phone: 902 492 4255

19. Prevention: Practice SAFER sex • Nurses must be comfortable discussing their clients’ sexual activites • Assess: number of partners, protection being used, and whether it is being used properly • Ask everyone! Don’t assume! • Educate: know STI status of sexual partners, HIV/AIDS and other STI testing, use of latex condoms, dental dams, latex gloves, water-based lubricants

20. Prevention: Clean Needles • Risk reduction school of thought • Nurse can : • Direct client to addiction services • Direct client to needle exchange program if quitting is not an option at this time • Alcohol kills HIV • Educate! Sharing needles with friends is just as risky as sharing with strangers

21. Prevention: Screening • Many STI’s are tested with gyne exams, but HIV requires a blood test • HIV antibody test

22. Prevention: Education • Many myths and misconceptions ie: • HIV doesn’t exist within this community • HIV only affects sex-trade workers, homosexuals and injection drug users • If you get HIV you will show symptoms • Having sex with a virgin will cure you of HIV • Nurses play a large role in providing the facts!

23. Prevention: Policy • Society contributes to HIV transmission! • Empowering women • Promoting Justice • Addressing Poverty • Providing Education • Addressing Stigma

24. What exactly is HIV? • Human Immunodeficiency Virus- a retrovirus belonging to the family of lentiviruses. • Uses their RNA and host DNA to make viral DNA • Uses CD4+ cell to replicate itself and destroying CD4+ • Two types: HIV-1 + HIV-2 • Leads to Acquired Immunodeficiency Syndrome

25. HIV • 2 types: HIV-1 and HIV-2 • Subtypes of HIV-1: A, B, C, D, E, F, G, H, O. (No subtypes of HIV-2) • HIV-1 subtype C makes up for more than 50% of all new HIV infections worldwide. • HIV-2 progresses slower • HIV-2 makes up the majority of cases of HIV infection in Africa

27. Pathophysiology of HIV/AIDS

28. HIV LIFE CYCLE

29. Diagnosis of HIV infection • EIA (enzyme immunoassay) [formerly ELISA (enzyme-linked immunosorbent assay)] identifies antibodies that are specifically directed against HIV. • Western blot assay: used to confirm seropositivity when the EIA is positive • Seropositivity: when blood or saliva contains HIV antibodies

30. Other Tests • Viral load tests: used to quantify HIV DNA or RNA levels in the plasma. These tests include: reverse transcriptase polymerase chain and nucleic acid sequence-based amplification. • This can help determine response to treatment. • Viral load is a significant predictor of disease progression.

31. Home Testing Kits • Home testing kits are available, but are of concern to HCP. • Why? • The lack of counselling, as well as the possibility of inaccurate results.

32. S&S of HIV infection • Often, there are no S&S in the early stages of HIV infection • Why? • The CD4 lymphocytes are still numerous enough to fight off infections

33. S&S of HIV infection • There may be slight flu-like symptoms 2-6 weeks after initial infection. • Other S&S (generally advanced infection): Lymphadenopathy (often the first sign) profuse night sweats, rapid weight loss, recurrent fever, chronic diarrhea, unexplained fatigue, persistent headaches (http://www.mayoclinic.com/health/hiv-aids/DS00005/DSECTION=2)

34. Stages of HIV disease • Based on “clinical history, physical examination, laboratory evidence of immune dysfunction, signs and symptoms, and infections and malignancies” (Smeltzer & Bare, 2004, 1559) • 3 categories: A, B, C

35. Clinical Category A • This category is asymptomatic. • The virus reaches a “set point” level after about 6 months. • The “set point” generally determines rate of disease progression. • In general, 8-10 years can pass before HIV-related complications occur. • Why asymptomatic? CD4 levels are high enough to fight off other pathogens (>500 CD4+ T-lymphocytes/mm^3)

36. Clinical Category B • CD4 cell level starts dropping (200-499 CD4+ T-lymphocytes/mm^3). • This category consists of conditions that are not covered under category C. The conditions must: • Be due to HIV infection • Require management that is complicated by HIV infection

37. Clinical Category B • Some of the conditions under this category include: • Candidiasis (oropharyngeal or vulvovaginal) • Cervical carcinoma in situ • Fever (38.5 C), or diarrhea > 1 month duration • Herpes zoster (shingles) • Pelvic inflammatory disease • Peripheral neuropathy

38. Clinical Category C • When CD4 T-cell levels drop below 200 CD4+ T-lymphocytes/mm^3, the client is said to have AIDS. Below 100, the immune system is significantly impaired. • Once a client is classified as having category C infection, s/he remains in this category.

39. Clinical Category C • Some conditions in this category include: • Candidiasis (bronchi, trachea, lungs, or esophagus) • Cervical cancer, invasive • HIV-related encephalopathy • Kaposi’s sarcoma • Pneumocystis carinii pneumonia • Toxoplasmosis of brain • Wasting syndrome due to HIV

40. Treatment of HIV • Antiretroviral treatments • Compliance may be decreased by the side effects of the drugs, or by clients deficiency of knowledge about the treatment. • In developing and transitional countries, 7.1 million people are in immediate need of life-saving AIDS drugs; of these, only 2.015 million (28%) are receiving the drugs.

41. Nucleoside Reverse Transcriptase Inhibitors (NRTI’s) • These were the first antiretrovirals approved by the European and American regulatory agencies. • Becomes part of the viral DNA, stopping the building process. • These are the cornerstone for HIV therapy.

42. Side Effects of NRTI’s • Some possible adverse effects of this class of drugs: Peripheral neuropathy, pancreatitis, lactic acidosis, bone marrow suppression, neutropenia, anemia, arthralgia, myopathy, kidney dysfunction, hepatomegaly, liver failure, hypersensitivity, abdominal pain, oral ulcers, irritability, anxiety. (Smeltzer & Bare, 2004, 1563)

43. Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI’s) • Blocks the HIV reverse transcriptase in a different method from the NRTI’s. • Attaches to the reverse transcriptase and prevents conversion of HIV RNA into HIV DNA. • Used in combination with NRTI’s and PI’s.

44. Side Effects of NNRTI’s • Possible adverse reactions of this class of drug include: Abnormal liver function tests, hepatitis, stomatitis, numbness, muscle pain, drowsiness, changes in dreams, trouble concentrating.

45. Protease Inhibitors (PI’s) • Prevents protease enzyme from cleaving HIV proteins into the smaller, functional units. When PI’s are taken, the HIV copies that are made cannot infect CD4+ cells and lymphocytes. • When taken alone, the virus quickly develops resistance to its effects, so PI’s are always taken with other drugs. • Missed doses leads to virus resistance and drug failure.

46. Side Effects of PI’s • The following may be some of the adverse effects associated with PI’s: Hemolytic anemia, parasthesia, kidney stones, asymptomatic hyperbilirubinemia, dyspepsia, altered taste, mood alterations, drowsiness.

47. HAART • Highly active antiretroviral treatment • A regimen that consists of 2 NRTI’s + a PI (or NNRTI) OR • 2 PI’s + one other antiretroviral agent

48. Decision Making • Treatment decisions for every patient is individualized and based on 3 factors: • Viral load • CD4 T-cell count • Clinical condition of patient

49. Opportunistic Infections (OI’s) • Infections that occur because of the client’s compromised immune system- do not occur in people with normal immune systems.

50. Pneumocystis carinii Pneumonia (PCP) • Most common OI which leads to a diagnosis of AIDS. • Without prophylaxis, 80% of all HIV-infected clients will develop PCP. • S&S: nonproductive cough, fever, chills, SOB, dyspnea, chest pain. • Untreated, it causes respiratory failure.