Hivaids Fa07
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Hivaids Fa07 Hivaids Fa07 Presentation Transcript

  • Barbara Weis MS, RN, CCRN Fall 2007 HIV/AIDS
  • History of HIV/AIDS
    • 1981
    • 1985
    • 1987
    • 1994
    • 1995-1999
    • 2000-present
    • Documented presence of new disease
    • Causative agent identified (HIV)
    • AIDS determined to be end stage
    • Antibody test developed
    • Routes of transmission determined
    • Drug therapy available
    • OK first state to mandate AIDS education
    • Other advances
    • Development of lab tests
    • Production of new drugs
    • Combination drug therapy
    • Test for antiretroviral drug resistance
    • Treatment to decrease risk of transmission from mother to baby
    • Protease inhibitors approved
    • Home testing available; Antigen testing & viral load testing available
    • New drug formulas approved; 1 st generic drug approved
    • Rapid HIV testing available
    • HIV genotyping approved to begin
  •  
  • Ribonucleic Acid Virus
  • HIV Replication
  • CD4+ T Cells
    • CD4 Receptors
      • lymphocytes
      • monocytes/macrophages Helper T cells
      • astrocytes
      • Oligodendrocytes
    • Adults normal
      • 800 to 1200 per microliter ( µl) of blood
      • Normal life span: 100 days
    • Healthy until 500 CD4+ T cells/ µl
    • Problems start at 200 to 499 CD4+ T cells/ µl
    • Severe problems start at < 200 CD4+ T cells/ µl
  • Transmission of HIV
    • Contact with infected body fluids
        • Blood
        • Semen
        • Vaginal secretions
        • Breast milk
    • One of three ways:
      • Sexual intercourse with infected partner
      • Exposure to HIV-infected blood or blood products
      • Perinatal transmission
        • During pregnancy
        • At time of delivery
        • Breastfeeding
  • Factors Affecting Transmission
    • Duration of contact
    • Frequency of contact
    • Volume of fluid
    • Virulence of virus
    • Concentration of virus
    • Host immune status
  • Sexual Transmission
    • Sexual contact with an HIV-infected partner
      • Contact with semen, vaginal secretions, and/or blood
        • Lymphocytes containing HIV
    • MSM account for most cases of sexual
    • transmission
    • MSW most common method of infection
    • for women
    • Unprotected anal intercourse most risky
    • Greatest risk for partner who receives
    • the semen
      • Receiver has prolonged contact with
      • semen
      • Can be transmitted to inserting partner
    • Most risky when blood involved
      • Menstruation
      • Trauma
      • Genital lesions from other STDs
  • Injection Equipment
    • Accidental or intended sharing
      • Illegal drugs
      • All used equipment is potentially contaminated
      • Only 1% of adult AIDS cases
    • Blood donation
      • Routine screening not until 1985
      • Still possible during first few
      • months after infection
    • Clotting Factors
      • Heat and chemical treated
  • Healthcare Workers
    • Occupational exposure
    • 57 heath care workers (24 nurses)137 more cases of accidental exposure
    • Risk of infection after needle-stick
        • 0.3% to 0.4%
        • Deep puncture wound
        • Hollow bore needle
        • Visible blood
        • Higher if patient has high viral load
        • Patient dies within 60 days
      • Risk of infection after splash exposure
        • Risk much lower
        • On skin with open lesion
    • Employer Requirements
    • Protect workers from exposure to blood and other potentially infectious materials
    • Postexposure prophylaxis (PEP)
      • Combination ART
        • Type of exposure
        • Volume of exposure
        • Status of source patient
    • Report exposures
    • OSHA requirements
    • Isolation needs
  • Diagnosis of HIV
    • Window period after infection
      • Will not test antibody positive
      • Median delay of 2 months before antibodies can be detected
    • Testing is highly accurate if proper sequence followed (Lewis Table 14-3)
    • Locations offering free testing
    • Not all tests available everywhere
      • Sample: Oral mucosa, urine and blood
      • Time: Standard or rapid (20 minutes)
      • Method: EIA, Western Blot
      • FDA approval and availability
  • Blood Testing
    • Standard blood test
    • First to be developed
      • Most widely used
      • May take 2 weeks
      • Initial assay used (EIA, ELISA)
      • Confirmed with Western Blot
    • OMT HIV Antibody Test
    • Alternative to standard blood test
    • Specially treated pad placed in mouth and gently rubbed between lower cheek and gum
    • Collect oral fluid called oral mucosal transudate (OMT)
    • Must be confirmed with Western Blot
    • Does not test saliva!
    • FDA approved
    • Rapid Report
      • Orrasure©
      • OraQuick Advance HIV ½ ©
  • Urine HIV Antibody Test
    • Painless and Noninvasive
    • Not as sensitive or specific as blood testing
      • Urine EIA (ELISA)
      • Confirmed with Western Blot technique
    • FDA-licensed as alternative to blood test
    • Eliminates needle sticks and exposure-related dangers
      • Protects patient and healthcare worker
  • Rapid HIV Antibody Test
    • Results in 5 to 60 minutes
    • Collection
      • Fingertip lanced for small drop of blood
      • Oral fluid swabbed
      • Reactive test result
    • Must still be confirmed with Western Blot
    • FDA Approved
      • Reveal G2 HIV-Antibody Tests, manufactured by MedMira, Inc.
      • Multispot, manufactured by Bio-Rad Laboratories
      • Uni-Gold Recombigen, manufactured by Trinity Biotech
  • Home Testing Kits
    • Do-it-yourself
      • Finger-prick
      • Mailed to laboratory on card
      • Test results provided over phone
      • Available at drug stores
      • FDA approved
        • Home Access Kit
      • Rapid tests not accurate
  • Perinatal and Newborn Testing
    • HIV-infected Mother identified during pregnancy
      • Medications highly effective if initiated
      • Reduces risk to 1-2 percent
    • HIV-infected Mother identified at labor and delivery
      • Medications initiated at labor and delivery
      • Reduces risk to 9 to 13 percent
    • HIV-infected Mother not identified
      • Risk of transmission at 25 percent
      • All babies born to HIV –infected mothers will be positive
      • Antibodies remain present for up to 18 months
      • HIV DNA polymerase chair reaction (PCR),, HIV RNA PCR, or viral culture
  • Laboratory Studies
    • Decreased white blood cell count (WBC)
      • Low neutrophil count (neutropenia)
    • Low platelet counts (thrombocytopenia)
      • Anitiplatelet antibodies
      • Drug therapy
    • Anemia
      • Chronic disease process
      • Adverse effect of antiretroviral agents
    • Altered liver function tests
      • Disease Process
      • Drug therapy
    • Co infection
      • Hepatitis B virus (HBV)
      • Hepatitis C virus (HBC)
  • HIV Staging
    • Category 1
      • CD4 count >500
    • Category A
      • Asymptomatic or acute
      • HIV infection
      • Early Chronic Infection
    • Category 2
      • CD4 count 200 – 499
    • Category B
      • Symptomatic disease
      • Intermediate Chronic
      • Infection
    • Category 3
      • CD4 count <200
    • Category C
      • AIDS Conditions
      • Late Chronic Infection
      • Once at C, always at C
  • Timeline: Untreated HIV
  • Acute HIV Infection
    • Acute retroviral syndrome
      • Seroconversion
      • Occurs in 1 to 3 weeks
      • Lasts 1 to 2 weeks, to months
      • High viral load
      • CD4+ T Cells fall temporarily
      • Symptoms may be mistaken for flu
        • Fever, swollen lymph glands, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhea, diffuse rash
      • Neurologic complications
        • Aseptic meningitis, peripheral neuropathy, facial palsy, Guillian-Barre syndrome
  • Early Chronic HIV Infection
    • 10 years
    • CD4+ T lymphocyte cells remain above 500 cells/ µ/l
    • Viral load in blood will be low
    • Asymptomatic disease or
      • Fatigue, headache, low-grade fever, night sweats, persistent generalized lymphadenopathy (PGL)
    • May not be aware of infection
  • Intermediate Chronic Infection
    • CD4+ T cell count to 200 - 499 µl
    • Viral load rises
    • Early phase symptoms become worse
      • persistent fever, frequent drenching night sweats, chronic diarrhea, recurrent headaches, and fatigue severe enough to interrupt normal routines
    • New symptoms
      • localized infections, lymphadenopathy, nervous system manifestations, and opportunistic infections begin
  • Opportunistic Infections
    • Oropharyngeal candidiasis (thrush)
    • Varicella zoster virus (shingles)
    • Vaginal candidal infections
    • Oral or genital herpes
    • Oral hairy leukoplakia
      • Epstein-Barr virus
    • See Lewis Table 14-1 for lists of other infections
  • Late Chronic Infection (AIDS)
    • CD4+ count below 200
      • CD4 (helper) to CD8 (suppressor) ratio reverses
      • Absolute number of lymphocytes increase
      • Percentage of lymphocytes increases
    • Development of opportunistic infection (OI)
    • Development of opportunistic cancer
    • Wasting Syndrome
      • loss of 10% or more of body weight
    • Dementia
  • Collaborative Management
    • Monitoring disease progression
    • Monitoring immune function
    • Initiating and monitoring ART (antiretroviral drug therapy)
    • Preventing development of opportunistic diseases
    • Detecting and treating opportunistic diseases
    • Managing symptoms
    • Preventing or decreasing complications of treatment
  • Tests for Resistance
    • Tests for resistance to antiretroviral drugs
      • Genotype assay
        • Detects drug-resistant viral mutations that are present in the reverse transcriptase and protease genes
      • Phenotype assay
        • Measures the growth of the virus in various concentrations of antiretroviral drugs
  • Starting ART
    • Old guidelines: “Hit early, hit hard”
    • New guidelines: Wait for viral load to go up
    • Consider:
      • Client readiness
      • Client ability to adhere to regimen
        • 95% adherence rate required to prevent disease progression, opportunistic disease, viral drug resistance.
        • Electronic reminders, beepers, timers on pillboxes
  • Drug Therapy for HIV Infection
    • Goals:
      • Decreases HIV RNA levels to less than 50 copies/ µl
      • Maintain or raise CD4+ T cell counts to greater than 200 cells/µl
        • Also known as Immune reconstitution
      • Delay development of HIV-related symptoms
        • Opportunistic diseases
    • Lewis Table 14-4 Principles of Therapy
      • National Institutes of Health website
  • Disease and Drug Side Effects
    • Anxiety, fear, depression
    • Diarrhea
    • Peripheral neuropathy
    • Pain, n & v
    • Fatigue
    • Skin breakdown
  • Nursing Assessment
    • Focus on behaviors:
      • Have you ever had a blood transfusion or used clotting factors? If so, was it before 1985?
      • Have you ever shared needles, syringes, or other injecting equipment with another person?
      • Have you ever had a sexual experience in which your penis, vagina, rectum, or mouth came into contact with another person's penis, vagina, rectum, or mouth?
      • Have you ever had an STD?
    • Positive response requires in-depth exploration!
  • Nursing Diagnosis
    • Nursing Outcomes
  • Patient Education
      • Adhere to drug regimens
      • Promote a healthy lifestyle
      • Prevent opportunistic disease
      • Protect others from HIV
      • Maintain or develop healthy, supportive relationships
      • Maintain activities and productivity
      • Come to terms with issues related to disease, death, and spirituality
  • Illicit Drug Use
    • Sharing injecting equipment
    • Unsafe sexual experiences while under influence of drugs
    • The basic rules are as follows:
      • Do not use drugs
      • If you use drugs, do not share equipment;
        • Use alternatives (smoking, snorting, ingesting)
        • Needles, syringes, cookers (spoons or bottle caps used to mix drugs), cotton, rinse water
        • Community Needle and Syringe Exchange Programs
      • Do not have sexual intercourse when under the influence of any drug (including alcohol) that impairs decision-making ability
  • Initial Response to Diagnosis
    • Empowerment
      • Education
      • Honest discussions
        • Health status
        • Treatment Options
      • Referrals
        • Local agencies
        • Web resources
        • Literature
        • Groups
  • Health Promotion
    • Promote healthy immune system
      • Nutritional Support
        • Maintain lean body mass
        • Ensure appropriate levels of vitamins and micronutrients
      • Moderation or elimination of alcohol, nicotine, and drug use
      • Adequate rest and exercise
      • Stress reduction
      • Avoidance of exposure to new infectious agents
      • Mental Health counseling
      • Involvement in support groups and community activities
  • Pneumocystis Carinii Pneumonia
    • CD4 counts < 200
    • Prevent with antibiotics
    • S/S:
      • SOB, fever, night sweats, fatigue, weight loss, non-productive cough
    • May require intensive therapy
  • Cryptococcus Neoformans
    • 6 to 10% of all HIV-infected clients
    • Meningitis
      • Prolonged waxing and waning period of fever Headache and malaise Nausea & vomiting
      • Altered Mental Status Stiff neck
      • Visual disturbances, papilledema
      • Light sensitivity
      • Seizures
      • Aphasia
      • Ataxia
    • Relapse rate: 50-75%
      • Maintenance therapy
  • Cytomegalovirus Retinitis
    • Retinitis
      • Decreased vision
      • floaters
      • One-sided visual field loss
      • blindness
    &quot;Blue Yonder,&quot; Elliott Linwood
  • Kaposi's sarcoma
    • Skin
      • Lesions flat or raised
      • Variety in color and shape
    • Lungs and GI Tract
      • Bleeding
      • Respiratory distress
    • Palliative care
    • Lesions resolved with ART
  • Mycobacterium Avium complex
    • Gastrointestinal tract problems
    • Can also infect blood, spleen, lymph nodes, bone marrow, liver.
    • Chronic diarrhea, abdominal pain, fever, malaise, weight loss, anemia, neutropenia, malabsorption syndrome, obstructive jaundice
    • Teach about drug therapy
    • Teach how to deal with diarrhea, n & v
  • Metabolic Disorders
    • Changes in body shape
      • Fat redistribution to abdomen, upper back, breasts
      • Wasting in arms, legs and face
      • Hyperlipidemia
        • Elevated triglycerides
        • Decreases in high-density lipoproteins
      • Insulin resistance and Hyperglycemia
      • Bone disease
        • osteoporosis, osteopenia, avascular necrosis
      • Lactic Acidosis
      • Cardiovascular disease
  • AIDS-Dementia Complex
    • Cognitive, behavioral motor abnormalities
      • Decreased ability to concentrate, apathy, depression, inattention, forgetfulness, social withdrawal, personality change, insomnia, confusion, hallucinations, slowed response rates, clumsiness, ataxias
    • HIV-Associated Cognitive Motor Complex
      • Lymphoma, toxoplasmosis, CMV, herpes virus, Cryptococcus, Progressive multifocal leukoencephalopathy, dehydration, drug side effects
      • Reversible if treatable cause identified
    • Interventions: Safety, maintaining meaningful environment, frequent reorientation, stress reduction, family support
  • Terminal phase
    • Disease progresses toward disability and death
      • Calculated decision to forego further treatment
    • Comfort care, facilitate emotional and spiritual acceptance of finite nature of life
    • Help SO’s deal with grief and loss
    • Hospice
  • Suicide Rates
    • 66 times greater
    • than that of others
    • Art from:
    • thebody.com
      • Untitled (self-portrait), c. 1993-96, Nelson Edwin Rodriguez