Care of Patients with HIV/AIDS

1. Care of Patients with HIV/AIDS PVN 143 – the Immune System and Oncology Rebecca Maier, BSN August 2014

2. Transmission of HIV • HIV is an obligate virus • It cannot survive very long outside of the human body • Transmitted from human to human • Blood • Semen • Cervicovaginal secretions • Breast milk

3. Transmission of HIV • Other body fluids contain HIV; no evidence they are capable of transmission • Saliva • Urine • Tears • Feces

4. Transmission of HIV • Conditions that affect the likelihood of infection include: • Duration and frequency of exposure • Amount of virus inoculated • The virulence of the organism • The host’s defense capability

5. Transmission of HIV • Sexual transmission • Anal or vaginal intercourse • Parenteral exposure • Contaminated drug injecting equipment and paraphenalia • Transfusion of blood and blood products • Occupational exposure • Perinatal (vertical) transmission • Transmission from mother to child • May occur during pregnancy, delivery, or postpartum breastfeeding

6. Pathophysiology • Normal immune response • Foreign antigens interact with B cells • B cells initiate antibody development • B cells and T cells initiate cellular immune response • B cells reduce virus in blood • T cells reduce virus in lymph nodes

7. Pathophysiology • Immune dysfunction • T-cells or CD4+ lymphocytes are destroyed by HIV • HIV is then able to reproduce in the lymphatic system and eventually “spills over” into the blood • Helper T cells (CD4, or T4 cells) • T-helper cells contain CD4 receptors • Considered the “conductor” of the immune system because of their secretion of cytokines which control most aspects of the immune system

8. Pathophysiology • Immune dysfunction cont. • Helper T-cells cont. • These are the major target of HIV • Progressive Infection gradually destroys the available pool of T-helper cells overall CD4 cell count drops. • Lower CD4 cell counts correspond with more immunodeficiency  onset opportunistic infections

9. Pathophysiology • Decreases resistance to life-threatening infections • CD4+ 600-1200 = normal • CD4+200-499 = minor immune problems • CD4+ below 200 = severe immune problems

10. Pathophysiology • HIV is a member of the lentivirus (slow virus) family of retroviruses. • HIV carries its genetic material in RNA (rather than DNA) • HIV replicates by converting RNA into DNA • As an “obligate parasite”, it cannot replicate unless it is inside another living cell

11. Pathophysiology • Both cellular and humoral immune mechanisms limit HIV replication and slow down disease progression • Initial infection with HIV  viremia during which large amounts of the virus can be isolated in the blood • Amts as high as 10 mil. Particles of HIV per ml • Up to 10 bil. Particles of HIV are produced and cleared daily in an infected individual

12. Pathophysiology • The massive production of HIV is coupled with the production and destruction of nearly 2 bill. CD4 lymphocytes each day • The amount of virus in the blood is directly linked to the rate of virus production, which determines the rate of CD4 cell destruction

14. Spectrum of HIV • HIV disease is a broad diagnostic term that includes the pathology and clinical illnesses caused by HIV infection. • AIDS(Acquired Immunodeficiency Syndrome) is defined as an acquired condition that impairs the body’s ability to fight disease • The end stage of a continuum of HIV infection • CD4 count < 200

15. Spectrum of HIV • HIV infection may exist for many years without symptoms before it progresses to symptomatic HIV disease • Asymptomatic HIV infection • HIV seropositivity (seroconversion) • Positive HIV antibody test95% within 3 months; 99% within 6 monthsInfectious; no illness

16. Acute Retroviral Syndrome • Initial exposure • Virus replication occurs during the acute infection period • The viral load peaks in millions of copies of virus per milliliter right before the appearance of detectable antibodies can be measured in the blood. • Viral “set point” = stabilizing of the viral load; usually reached in 4-6 months after exposure

17. Acute retroviral syndrome • Seroconversion: the development of antibodies from HIV • Takes place approx. 5 days -3 months after exposure • Accompanied by a flu-like or mononucleosis-like syndrome with fever, night sweats, pharyngitis, headache, malaise, arthralgias, myalgias, diarrhea, nausea, and a diffuse rash pominent on the trunk

18. Early infection • Early HIV disease • Signs and symptoms may not appear until 10-14 years after exposure • Symptomatic infection • Persistent, unexplained fever • Night sweats • Diarrhea • Weight loss • Fatigue

19. Early symptomatic disease • CD4+ cell count drops below 500 cells/mcl • Persistent, unexplained fevers • Drenching night sweats • Chronic diarrhea • Headaches • Fatigue • Lymphadenopathy • Recurrent or localized infections • Neurological manifestations

20. Diagnostic Studies • HIV antibody testing • ELISA • Detects the presence of HIV antibodies • If positive, ELISA is done a second time • Western blot • Done if second ELISA is positive • More sensitive than ELISA

21. Diagnostic Studies • Seropositive • All three tests are positive (ELISA x 2 and Western blot) • Does NOT mean the person has AIDS • Seronegative • Not an assurance that an individual is free from HIV infection • Seroconversion may not have occurred yet

22. Diagnostic Studies • CD4+ lymphocyte count • Normally 600-1200 mcl • Decreases as the disease progresses • Best marker for the immunodeficiency associated with HIV infection • Viral load monitoring • Level of virus in the blood • Provides significant information toward predicting the course of the disease

23. Therapeutic Management • Therapeutic management focus • 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

24. Therapeutic Management • Pharmacological management • Antiretroviral therapy • Nucleoside Reverse Transcriptase Inhibitors: inhibit activity of reverse transcriptase • Abacavir (Ziagen • Didanosine (Videx): • Lamivudine (Epivir) • Stavudine (d4T, Zerit) • Zidovudine (Retrovir, AZT) • Zalcitabine (ddC, Hivid) • Tenofivir(Viread)

25. Therapeutic Management • Pharmacological management • Antiretroviral therapy • Non-nucleoside reverse transcriptase inhibitors • Nivirapine (Viramune) • Delavirdine (Rescriptor) • Elfavirenz (Sustiva)

26. Therapeutic Management Alternative and complementary therapies • Massage • Acupuncture • Acupressure • Biofeedback • Nutritional supplements • Herbal remedies

27. Pulmonary Opportunistic Infections • Most common opportunistic diseases associated with HIV • Pneumocystiscarinii (now called jiroveci) pneumonia (PCP) -most common bacterial infection

28. Pulmonary Opportunistic Infections • PneumocystisCarinii (jirovici) • Symptoms • Fever; night sweats; productive cough; SOB • Treatment • Bactrim or Septra; pentamidine; steroids • Wear gown, mask, and gloves during patient care

29. Pulmonary Opportunisitc Infections • Histoplasmosis – fungal infection • endemic in central, southern US • Spores inhaled, original infection in lung • Can be disseminated to other organs • Symptoms: fever, night sweats, weight loss, dyspnea • Education: Avoid areas where fungus is common: disturbed soils, chicken coops, caves; do not clean bird cages

30. Histoplasmosis

31. Pulmonary Opportunisitc Infections • Tuberculosis –bacterial-infection • More likely if CD4 counts drop below 200 cells/mm3 • Treated with INH (isoniazid), rifampin, pyrazimide

32. Gastrointestinal Opportunisitc Infections • Mycobacterium avium Complex –bacterial • M. aviumcausative agent, found everywhere • May affect any organ of body • Symptoms: fever, fatigue, weight loss, night sweats, diarrhea, abd. pain • Depending on organism

33. Gastrointestinal Opportunistic Infections • Cytomegalovirus (CMV) – viral • Found in semen, cervical secretions, saliva, urine, blood, organs • Transmitted through blood, body fluids through unprotected sex • Complications of CMV for patients with AIDS include retinitis, radiculopathy, encephalitis, colitis, esophagitis, pneumonia • Treatment: Gancyclovir, Foscarnet

34. Gastrointestinal Opportunistic Infections • Cryptosporidosis –parasitic - infection • Fairly common in environment • Special threat when CD4 count falls below 200 cell/mm3 • Symptoms: watery diarrhea that may be severe, persistent dehydration, electrolyte imbalance • Treatment: maintain F/E balance, treat infection, good hygiene, avoid ingestion of contaminated water

35. Oral Opportunistic Infections • Oral/esophageal candidiasis - fungal • Caused by Candida albicans, found in most soils, foods • Approx 80% HIV pts. will develop • Symptoms: whitish yellow patches in mouth, esophagus, GI tract, vagina, anus • Treatment: Nystatin, chlortrimezole, ketoconazole, fluconazole, itraconazole, amphotericin B

36. Oral Candidiasis

37. Oral Hairy Leukoplakia

38. Gynecological Opportunisitc Infections • Vaginal candidiasis - fungal • Persistent infection - can be early indicator of HIV • Cervical intraepithelial neoplasia - cancer

39. August 19 - Tuesday (Rm. 302) 2hr – 12:30– 2:30 • 12:30–You guys keep asking about the oncology assignment • As a Heads Up for Oncology – You will be getting this assignment – . • 1) The practice of health care providers at all levels brings you into contact with people of a variety of faiths. This calls for acceptance of a diversity of faith expressions. • 2) Research three diverse faiths. Choose faiths that are less well-known than mainstream faiths or are less known to you, such as Sikh, Bahai, Buddhism, Shintoism, Native American, etc. Compare the philosophy of providing care from the perspective of each of these three faiths with that of the Christian perspective and your own personal perspective. • This will be a 5 slide presentation so that we can all learn something new about another culture. • I want you to prepare for this assignment but our schedule was changed again so we may not get to this assignment. • 12:30 – 13:10 Question by question go over the Mid term and show where it was found in the study guide and the rationales • 13:10 – 13:30 Break

40. CNS Opportunistic Infections • AIDS dementia complex • Triad of cognitive, motor and behavioral dysfunction, progressive • Zidovidine may help

41. CNS Opportunistic Infection • Toxoplasmosis parasitic • Caused by Toxoplasma gondii; cats, mammals, birds are host agents • Humans infected by ingesting contaminated undercooked meat, vegetables; contact with cat feces • Can affect any tissue in body, but mostly brain, lungs, eyes • In HIV, encephalitis most common form

42. CNS Opportunistic Infections

43. CNS Opportunisitc Infection • Cryptococcosis fungal • Causative agent Coccidiodesimmitis; endemic in SW US and N Mexico • Most common systemic fungal infection in AIDS patients • Symptoms appear ~ 30 d after exposure fever, HA, malaise, N/V, altered LOC, stiff neck

44. August 25 – Monday 3 hr • 08:00 – 10:40 – Room 211 • - ATI testing – 2 hours                                                 11-1       PVN143 (ATI)                     Room 104 • 08:00 - 08:15 Group 4 presentation • 08:15 – 0830 . discuss presentation • 08:35 – 0850 - Group 3 presentation • 08:50 – 09:05. discuss presentation • 09:10 – 09:30 Break • 09:35 – 09:50 . – Group 2 presentation • 09:50 – 10:05 discuss presentation • 10:10 – 10:25 - Group 1 presentation • 10:25 – 10:40 discuss presentation • 10:40 – 11:00 Break • 11-1       PVN143 (ATI)                     Room 104 • If there is any extra time after ATI we will go over the end of the cancer slides • 12:10 – 12:20 – explain Oncology project – grade wise it is = to a quiz – 5 slide presentation on • 12:20 – 13:00 - Power Point - Chapter 17 - Care of the Patient with Cancer (slide 72 pathophysiology of Cancer (Therapies) - 80 summery) • August 26 – Tuesday 1 hr • -                                   08:00 – 09:00 – Review for Final              Room 211 if power point not complete do it first • 10-12     PVN143 (ATI)                     Room 104 (if needed until 12:00)

45. Opportunistic Malignancies

46. Opportunistic Malignancies • Kaposi’s sarcoma • Diagnosed by appearance, biopsy • No cure, treatment is palliative • Treatment: observation, surgical removal, cryotherapy, radiotherapy, chemotherapy

47. Kaposi’s Sarcoma

48. Opportunistic Malignancies • Lymphomas • Immunodeficient patients have 14x greater risk of getting lymphomas • Non-Hodgkin’s lymphoma (NHL) second most common malignancy in pts with AIDS • Symptoms: vague, include fever, night sweats, weight loss. • A fever longer than 2 weeks suggests lymphoma

49. Opportunistic Malignancies

50. Nursing Interventions • Patients need to be treated in a nonjudgmental and caring manner regardless of their sexual practices or history of drug use • Must see the patient as a unique individual with a need to be cared for with compassion, consideration, and dignity