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  • Four rapid tests approved by the FDA are currently commercially available: The Uni-Gold, Multispot, Reveal, and OraQuick Advance.
  • Kaposi’s sarcoma

Transcript

  • 1. HIV and AIDS
  • 2. Epidemiology
    • CDC issued case definition of AIDS in 1982
    • Number of people living with AIDS more than doubled between 1998 and 2003
    • AIDS kills more than 8000 people daily around the world
      • Unsafe sex predominate mode of transmission; also infected drug injection equipment
      • Racial & ethnic minorities have disproportionately high rates of HIV in US, especially African-American & Hispanics
  • 3. Transmission of HIV
    • Body fluids: Blood, semen, vaginal secretions, amniotic fluid, breast milk
    • Not transmitted via casual contact
    • Risk of transmission via transfusion virtually eliminated due to extensive testing, heat treatment & virus inactivation methods
  • 4. Transmission to health care workers
    • Standard precautions used on ALL patients
    • Post-exposure treatment reduces risk of HIV infection
      • Immediately cleanse exposed area; report it!
      • Begin tx immediately after exposure, no longer than 72 hours after
      • Baseline testing for HIV, hep. B & C for you & pt
      • Follow-up testing done at 1 month, 3 & 6 mo.
      • Antiretroviral therapy x 4 weeks
        • Can cost $500-$1000; may develop future resistance; S/E
  • 5. Pathophysiology
    • HIV is a retrovirus
      • Carry genetic material in RNA instead of DNA
      • Consists of viral core containing the RNA surrounded by an envelope of glycoproteins
      • HIV has complex life cycle of 8 steps
        • HIV attaches to an uninfected CD4 or CD8 cell surface
        • Enzyme “reverse transcriptase” copies the viral genetic material from RNA into DNA
        • Mutates quickly; now 12 sub-types identified
  • 6. Stages of HIV Disease
    • CDC classification system:
    • 3 groups (A, B, C) based on history, physical exam, lab values, S&S, and infections and malignancies
    • See Table 52-1 on page 1823
  • 7. Primary Infection (A)
    • Defined as the period from infection with HIV to the development of antibodies to HIV
      • Intense viral replication
      • Symptoms vary from none to flu-like or “mono”
        • Fever, enlarged lymph nodes, rash, muscle aches, H/A
      • “ Window” period exists where infection has occurred but no antibodies are detected (lasts 3 months up to 1 year)
  • 8. CDC Category A: HIV Asymptomatic
    • By about 6 months, viral replication reaches lower but steady state
    • CD4+ T-cell count greater than 500
    • Few, if any, symptoms
    • 8-10 years can pass before major HIV-related complication occurs
  • 9. CDC Category B: HIV Symptomatic
    • CD4+ T-cells drop to 200 to 499
    • Has developed a condition related to defect in cellular immunity
      • Candidiasis
      • Cervical dysplasia
      • Fever or diarrhea lasting more than 1 month
      • Hairy leukoplakia of the mouth
      • Herpes zoster
      • Idiopathic thrombocytopenic purpura
      • PID
      • Peripheral neuropathy
  • 10. CDC Category C: AIDS
    • CD4+ T-cell count drops below 200
    • Once classified as category C, patient remains in Category C (May qualify for entitlements)
      • Candidiasis of esophagus or trachea
      • Coccidioidomycosis
      • Cryptosporidiosis
      • Cytomegalovirus
      • HIV-related encephalopathy
      • Kaposi’s sarcoma
      • Lymphoma
      • Toxoplasmosis
      • Pneumocystis pneumonia
      • Wasting syndrome
  • 11. Lab Tests
    • EIA (enzyme immunoassay)
      • Antibodies are detected (end of window period)
    • Western blot
      • Also detects antibodies; confirms EIA
    • Viral load
      • Measures HIV RNA in the plasma
      • Better predictor of disease progression than CD4 count
    • CD4/CD8 ratio
  • 12. Uni-Gold Recombigen Multispot HIV-1/HIV-2 Reveal G2 OraQuick Advance
  • 13. Treatment of HIV
    • Protocols change frequently
    • CD4 count most important consideration in starting therapy (less than 350)
    • Treatment should be offered to all patients with primary infection
    • Tx regimens are complex, have major side-effects & require adherence to avoid resistance
    • Viral load/ CD4 counts checked every 3 months
      • Viral load should drop to less than 50 copies by 16-20 weeks; CD4 count should increase by 100-150 within 3 months
  • 14. Antiretrovial Agents
    • NRTIs (nucleoside reverse transcriptase inhibitors): Retrovir, AZT
    • NNRTIs (non-nucleoside reverse transcriptase inhibitors): Sustiva
    • Protease inhibitors: Agenerase, Kaletra
    • Fusion inhibitors: Fuzeon
    • See Table 52-3 on pages 1827-28
  • 15. HAART
    • Highly active antiretroviral therapy
    • More than one antiretroviral medication taken in order to achieve sustained viral suppression
  • 16. Medication S/E
    • Nausea, vomiting, diarrhea, rash, pancreatitis, peripheral neuropathy
    • Many cause lipodystrophy syndrome
      • Pseudo-Cushing’s appearance: fat loss in arms & legs, with build-up of fat in abdomen & neck
      • At risk for early-onset hypercholesterolemia, heart disease & diabetes
  • 17. Video Clip
    • http://www.instruction.greenriver.edu/Kmarr/Biology100/Biol%20100%20Lecture%20Notes.htm
    • Watch “HIV Case Study” Video
  • 18. Manifestations of HIV Infection
    • Sx are widespread and can involve any organ system
    • Fatigue very common
    • Opportunistic infections
    • Immune Reconstitution Syndromes
      • Fever & worsening of the opportunistic infection symptoms
      • Develops weeks after starting antiretroviral therapy
        • Tx with NSAIDs to alleviate inflammatory reaction
  • 19. Respiratory Infections
    • Most common infection in AIDS patients is Pneumocystis pneumonia (PCP)
      • Non-productive cough, fever & chills, SOB, dyspnea, crackles, decreased O2 sats.
      • Will lead to resp. failure without tx
    • Mycobacterium avium complex
    • TB which can disseminate to CNS, bone, stomach, peritoneum & scrotum
  • 20. GI Symptoms
    • Loss of appetite, N/V
    • Diarrhea occurs in 50-90% of AIDS pts.
      • Cryptosporidium, Salmonella, Giardia,
    • C. diff.
    • May develop profound weight loss, fluid & electrolyte imbalances, weakness, perianal excoriation
  • 21. Oral Candidiasis
    • Occurs in almost all AIDS pts
    • May precede life-threatening infections
    • Creamy white patches in the mouth
    • Can spread to esophagus
    • Difficulty swallowing
    • May also have oral lesions
  • 22. Mucocutaneous Candidiasis: Clinical Manifestations Erythematous candidiasis Credit: D. Greenspan, DSC, BDS, HIV InSite Pseudomembranous candidiasis Credit: Pediatric AIDS Pictorial Atlas, Baylor International Pediatric AIDS Initiative
  • 23. Skin Manifestations
    • Herpes zoster & simplex
    • Molluscum contagiosum (viral infection)
    • Generalized folliculitis
  • 24. Wasting Syndrome
    • Weight loss of more than 10%
    • Chronic diarrhea more than 1 month
    • Chronic weakness
    • Fever
    • Hypermetabolic state with protein-energy malnutrition
    • Elevated triglycerides
  • 25. Oncologic Manifestations
    • Kaposi’s sarcoma is most common HIV related malignancy
      • Skin lesions can occur anywhere on body
      • Brownish-pink to deep purple; flat or raised
      • Diagnosis confirmed by skin biopsy
    • B-cell lymphomas are second most common; resistant to tx
    • Invasive cervical CA in females
    • Also can get CA in stomach, skin, pancreas, rectum, bladder
  • 26.  
  • 27. Neurologic Manifestations
    • 80% of AIDS patients will have neurologic involvement resulting from direct effects of HIV, opportunistic infections or neoplasms
    • Cryptococcus meningitis
    • Leukoencephalopathy
    • Peripheral neuropathy R/T demyelination
    • Depression
  • 28. HIV Encephalopathy
    • Formerly called “AIDS dementia complex”
    • Progressive decline in cognitive, behavioral and motor functions
    • Memory deficits, headache, difficulty concentrating, confusion, apathy, ataxia
    • Later stages include global cognitive impairment, delayed verbal response, vacant stare, spastic paraparesis, hyperreflexia, psychosis, tremor, hallucinations, incontinence, seizures
    • CT shows diffuse cerebral atrophy & ventricular enlargement
  • 29. Additional Medical Management
    • Treatment of infections
      • T-cell count less than 200 should receive prophylaxis against PCP with Bactrim or Septra (TMP-SMZ)
      • PCP treated with Septra; pentamidine used if Septra ineffective
        • Aerosolized pentamidine no longer used
      • Prophylaxis against Mycobacterium avium with Biaxin or azithromycin, for T-cell counts less than 50
  • 30. Additional Medical Management
    • Tx of cryptococcal meningitis with amphotericin B, with or without Diflucan
      • Diflucan also used for suppressive therapy
    • Retinitis due to Cytomegalovirus (leading cause of blindness in AIDS patients): tx prophylactically with ganciclovir for T-cell counts less than 50
      • Tx for retinitis must be taken for life
      • Common adverse reaction is neutropenia
        • May be given intravitreally
  • 31. Additional Medical Management
    • Herpes infections treated with acyclovir or famciclovir
    • Oral or esophageal Candidiasis treated with Mycelex, nystatin, Nizoral or Diflucan
    • Chronic diarrhea treated with Sandostatin
    • Kaposi’s sarcoma treated with alpha-interferon, surgical excision, liquid nitrogen, radiation
    • Lymphoma treated may be treated with chemo & radiation but usually has limited effect
  • 32. Additional Medical Management
    • Depression treated with Tofranil, Prozac
      • ECT used for severe cases not responsive to meds
    • Appetite stimulants such as Megace
    • Dronabinol (synthetic THC) used to control N/V
    • Nutritional supplements usually lactose-free: Advera specifically for AIDS
      • Parenteral nutrition is final option due to risk of infections
  • 33. Nursing Assessment
    • Potential risk factors: IV drug use, risky sexual behavior
    • Nutritional status: anorexia, N/V, oral pain, diarrhea, weight pattern, serum protein & albumin levels
    • Skin & mucous membranes: Look for breakdown, ulcerations, peri-anal excoriation
    • Fluid & electrolyte status: Turgor, V/S, urine output, electrolyte values
  • 34. Nursing Assessment
    • Respiratory Status: cough, sputum, SOB, chest pain, pulse-ox, breath sounds, CXR
    • Neuro Status: LOC, orientation, memory, H/A, neuropathy, seizures, visual changes, depression
    • Knowledge level: transmission, psychological reaction, ability to manage treatments
  • 35. Nursing Diagnoses for HIV/AIDS
    • Risk for infection
    • Diarrhea
    • Ineffective airway clearance
    • Imbalanced nutrition
    • Deficient knowledge
    • Social isolation
    • *See Care Plan pages 1838-44
  • 36. Nursing Interventions
    • Monitor for S&S of infection
    • Balance activities with rest
    • Prevent skin breakdown; administer treatments as ordered
    • Promote usual bowel patterns
      • Avoid bowel irritants; small frequent meals
      • Anti-diarrheals on routine basis
    • Improve airway clearance
      • Cough/ deep breathe, postural drainage
  • 37. Nursing Interventions
    • Nutritional support
      • Anti-emetics, soft foods, topical Lidocaine
      • Supplements & high-cal foods
    • Pain management
      • NSAIDs, opioids, tricyclics for neuropathy
    • Social isolation: Many feel guilt, shame, suffer loss normal roles, anger
      • Offer accepting attitude
      • Reassure that HIV not transmitted casually
  • 38. Nursing Interventions
    • Monitoring for medication side-effects
    • Teaching self-care: preventing transmission of HIV & other infections (safe sexual practices, handling soiled items, handwashing, personal and environmental hygiene)
      • Avoid exposure to sick people
      • Avoid alcohol, tobacco
      • Avoid cleaning bird cages & cat litter boxes
      • Medication administration
      • Nutrition
      • Importance of keeping follow-up appointments
      • Community resource referrals
  • 39. Ethical Considerations
    • Must protect patient’s right to privacy
    • This sometimes conflicts with sexual or drug partners’ right to know about their exposure
    • State laws vary as to whether contacts are notified & who is responsible for notification
    • Indiana law requires that persons infected with HIV who know their status, warn past & present sexual or needle-sharing partners of their HIV status & need to seek testing
      • Court can order restrictive limitations on person who presents a danger to public health