HIV/AIDS
non nucleoside analog reverse transcript inhibitors(nnrti's)
*Bind reverse transcriptase so that the virus can not convert HIV RNA into DNA, therefore these drugs inhibit viral replication 1)three NNRTIs available -nevirapine, (viramune) -delavirdine,(rescriptor) -efavirenz(sustiva) 2)side effects: -rash -headache -dizziness,insomnia, and nightmares -fatal hepatotxixity,hepaititis -stevns johnsons syndrome
A potent with good adherence is directed toward the following goals:
-A significant reduction of HIV RNA in the blood (viral load) -An increase in T cells (CD4 count) -An appropriate clinical response (wellness)
Chronic Infection
1)Asymptomatic- no symptoms 2)There is a dramtic decline in the rate of viral replication- if immune system is effective 3)symptoms which may occur:wheightloss and fatique
AIDS(acquired Immunodeficiency Syndrome)
1)Is diagnosed when client meets criteria set by CDC 2)without treatment typically occurs 10-11years after primary infection a)must be HIV+ b)Have CD4cell count that is below 200/mm3 or less than 14% of all lymphocytes, or HIV+, c)have an AIDs defining illness(TB,pneumonia)
Metabloic Complications of anti retroviral medications
1)May result in serious consequences to hepatic,cardiovascular and skeletal systems 2)Syndrome of peripheral lipodystrophy, hyperlipidemia, and insulin resistance 3)lactic acidosis and hyperlactatemia 4)osteoporosis and osteopenia 5)hepatotoxicity
Integrase inhibitors
1)Newest type of anti HIV drug 2)Inhibits enzyme integrase, needed to insert the viral DNA into the host cell's human DNA 3)viralproteins are not made and viral replication is inhibited 4)Drug name: Raltegravir 400mg orally twice daily 5)diarrhea most common side effect
Symptomatic HIV Infection
1)Symptoms increase and may include: periodic fever, frequent diarrhea,thrush,recurringvaginal yeast in women and pneumonia 2)symptoms are due to declining CD4 3)most HIV infections are diagnosed at this stage 4)clients usually seek medical treatment at this stage
Acute retroviral Syndrome
1)defined as time between intial exposre to virus and the appreance of antibodies "window period" 2)Dymptoms: fever,fatigue,rash,headache,lymphadenopathy,pharyngitis myalgia,diarrhea,and nausea and vomiting 3)this happens from 8 days to 10 weeks after the onset of acute retroviral syndrome
Antibody Tests
1)enzyme-linked immunosorbent assay (elisa)-(testing for antibody's HIV virus) 2)western blot- confirms a positive ELISA a)both are blood based tests and require trained personnel and special eqipment
Treatment fusion inhibitors
1)fusion inhibitors-new class of drugs,first approved in 2003 2)HIV must bind to Two receptors to enter cell 3)This drug binds to one, preventing HIV from entering the cell 4)Drug name: maraviroc 300mg oral twice a day 5)side effects: severe hypotention and liver function affected
Seroconversion
1)specific HIV antibodies are now detectable 2)Signs and symptoms resolve and viral load decreases 3)this happens from 8 days to 10 weeks after the onset of Acute retroviral syndrome
Recommendations for antiviral drugs used for HIV/AIDs
1. Antiviral drugs inhibit viral replication, but do not eliminate viruses from tissue 2. drug therapy recommended for clients who have: -CD4 coounts less than 500 -viral load of 20,000 copies of HIV RNA per ml of plasma 3.treatment is difficult because of the length of time the virus remains dormant 4.the side effects of the drugs used
Treament- Protease inhibitors (Pis)
1. Protease Inhibitors- block the HIV proteaseenzyme, preventing viral replication and release of viral particles 2)The Pis when in HIV infected cells, make the protease enzyme work on the drug rather thanthe large protein 3)active proteins are not produced and the viral particles cannot leave the infected cell 4)examples- ritonavir(norvir),indinavir(crixivan),saquinavir(invirase), nelfinavir(viracept),amprenavir(agenerase),lopinavr(kaletra),atazanavir (reyataz),fosamprenavir (lexiva) 5.side effects: -lipid abnormalities, hyperglycemia, fat reditribution,blood dyscrasias 6.Pia are more powerful then NRTIs and NNRTIs. C4 cell counts increase
nucleoside analog reverse transcriptase inhibitors(nrti's)
1.NRTI's are similar to the natural blocks of DNA but they are faulty 2.compete with the actual with the actual nucleotide for placement in DNA 3.supresses production of reverse transcriptase 4.inhibit viral DNA synthesis and replication 5. examples: zidovudine(retrovir, AZT), didanosine (ddl,Videx), zalcitabine,lamivudine,stavudine,tenofovir,emtricitabine,abacavir 6.Side effects a.they inhibit enzymes needed for mitochondrial function as a result side efffects occur after prlonged use. b.toxic effects are related to mitochondrial damage. complications are: -fatal latic acidosis -fat loss in the extremities -hepatotoxicity 7. best to use NRTIs in combination
How antiviral agents work to control HIV/AIDs
1.anti retrovirus drugs by interfering with the ability of the virus to use specific enzymes for replication -four major classes of antiretroviral drugs are: a.nucleoside analog reverse transcriptase inhibitors(nrti's) b.non nucleoside analog reverse transcript inhibitors c.protease inhibitors d.fusion inhibitors
HIV/AIDs How it is Transmitted
A)education is important to prevent HIV/AiDS b.Parenterally-IV use drugs-blood products 3)perinatal-mother to child *NOT transmitted by casual contact or by insects
Co-morbidities
a)HIV infected clients are at increased risk of developing: -AIDS defining malignancies amd non AIDS defining malignancies -mental health disorders, depression most common 40% -Hepatitis B or C, leadsto liver failure
Nursing Care
a)Nursing assassment should include: -through a detailed health history -assess clients mental status -assess for substance abuse -ask about medications they are on -assess how client adhered to past treatment -ask about past treatment with SRVs -discuss clients beliefs and attitude toward HIV -ask about clients support syste-check into clients socioeconmic conditions -asses for language barriers -assess for social barriers that might impact treatment adherence -clients with HIV/AIDs on ARV therapy need regular monitoring to assess: *response to therapy *watch for treatment,or disease related complications *check on continuing adherence to the treatment regimen
Quick tests for antibodies
a)Oraquick rapid HIV-1 antibody test- approved in 2002. Uses bllod from a finger stick,results ready in 20 minutes 99% accurate b)Uni-Gold recombigen- approved in 2003. Uses a finger stick, gives results in 10 min. and is 99% accurate
HIV/AIDs Prevention
a)abstinence and mutually monogamous sex with non-infected partner is the only absolutltely safe method of prevention b)risk differs by gender,sexual act, and the viral load c)HIV is more eaisly transmtted from infected male to female than vice versa
Post exposure Prophylaxis
a)goal:Prevent development of infection following possible exposureto HIV b)standard care involves: -4 weeks of therapy with 3 drug antiretroviral regimen -clients must understand the importance of compliance and completing treatment -close follow up is important -the CDC maintains a confidential registry of occupations PEP
HIV/AIDs Recomendations for testing
a)people with STDs b)injeaction drug users c)people who concider themselves at risk d)prostitutes and their customers e)people planning on getting married F)people who have symptoms of HIV related diseases g)people admitted to hospitals h)people in correctional instititions I)women of childbering age with risks
HIV/AIDS diagnostics
a)pretest and post testcounseling should be done b)helps to make informed decisions c)providesoppertunity to teach risk reduction d)interpret results of testing e)provide psychological support and health promotion if test is positive f)councled on how to inform sexual partners and thoswhom they shared needles g)lymphocyte count- decreased h)CD4/CD8 counts: CD4 decrease, CD8 normal
other tests might be used
a)viral culture- not used to often due to time involved b)viral load testing-measures the presenceod HIV viral genetic material (RNA)- used to monitor disease pregression and treatment effectiveness c)Qsuantitative RNA assays- dtermeines the amount of RNA in a clients sruum d)P24 antigen assay- p24 is a HIV viral core protein- not as sensitive
HIV/AIDs Treatment
a. Goals of antiviral therapy 1) suppress viral replication 2)reduce viral loads to undectable levels 3)improve quality of life 4)prelong health by enhancing the immune system 5)decrease the risk of drug resistance 6) reduce HIV releated morbidity and mortality
Incidence HIV
a.2001-850,000-950,000 americans live with HIV b.worlwide-40,000,000 c.about 40,00new HIV infections in us d.half are younger than 25 e.worldwide-5.3million new cases 2001 f.number of women infected are increasing g.aids is 5th leading cause of death among .people under 25 yrs old h.AIDs related deaths in US fell from 1995-2001 i.as result more oppertunities to transmit the disease to others j.new data suggests that the sharp decline in AIDS deaths and new diagnosis may have caome to an end k.400,000-500,000 in us may be undiagnosed,untreated or both l.in US,1/4 of HIV + persons are also infected with hep c m.40 million childern worldwide will have lost 1 or both parents to HIV/AIDS by 2010 n.in 2001in US 175 children age 13 and younger were living with AIDS o.the # of new pediatric AIDS cases in US fell from 954-101 in 2001
Recommendations for clinical practice
a.Measure HIV RNA levels before starting new therapy and repeat test 2-8 wks after initiation b.Initiate treatment for client within 6mnths of sero-conversion c.Use combination antiviral therapy if available, except during pregnancy d.Typically initiate 3 drug regimen e.Start ritonavir and nivirapine at lower dosages and increase gradually. Start other drugs at theraputic doses f.Assess for adverse drug effects at least twice during the first month of treatment and every 3 months thereafter g.Evaluate drug effectiveness HIV RNA levels should decrease h.refrain from interrupting drug therapy i.give medications during infection and malignancy if possible j,CD4 counts should be measured at DX and q 3-6 months afterward
HIV/AIDs: The Virus
a.Retrovirus:genetic material contains RNA(copy of DNA) b.virus attaches itself to T-cell(also known as CD4 or helper/inducert-cell or T4-cell) c.After attatched, it injects genetic material (RNA) d.uses cell as a factory to replicate e.has enzyme- reverse transcriptase(RT), which increases efficiency of viral replication f.RT converts HIV's RNA into HIV DNA g.HIV makes enzyme-integrase, which allows the HIV DNA to be inserted onto the host DNA i.New virus particles are made-long protein strands(protease needed to create these protiens) j.New HIV vision are released from the T cell killing it k.the virus mutates over time, because each generation is slightly different l.each generation destroys CD4 cells m.over a period of years, the CD4 cells loose thier protective ability n.when CD4cell count drops to 200 of blood,opportunistic infections and rare cancers can occur-aids
Progerssion Of HIV
a.acute retroviral syndrome (primary HIV infection) b.seroconversion c.chronic infection d.symptomatic HIV infection e.Aids
Demographics HIV
a.more cases in large urban areas than rural b.HIV infects more people in the 17-55 age category c.Who reports AIDS in 162 countries and in each state in the US d.Barriers to accurate counts:econmics,lack of insrance,stigma e.cost care for HIV client for 1 yr $20,000 f.HIV historically affects people and those not working g.HIV affects people in color disproprtionatley than the white population in US h.Strategies(education)for adressing the barriers for not testing or treating HIV -1)increase # of people who know their HIV status -2)decrease stigma and discrimination associated with the disease -3)increase access to care and coverage for people with HIV/IDs through expansion of public and private coverage i.priority research:vaccicne development, prevention, microbides and theraputic research
History of the disease
a.thought to exist in U.S. since 1978 b.1981-CDC classified as gay related immune deficiency syndrome c.1982-related disease with blood, found disease existed in other than gay people d.1983-virus causing aids isolated-called human immunodeficiency virus e.1987-AZT 1st drug approved by FDA for treatment of aids f.1992-Fda approved 2nd drug to be used in combination with AZT g.1993-european drug trials found AZT not effective in persons HIV+ without symptoms h.1996-FDA approve protease inhibitors for HIV+ individuals 1998-1st human trial of AIDs vaccine in US 2001-concern about side effects of drugs used and failure of medications to control the disease k.2003-CDC and us Dept of health and human services launched "advancing HIV Prevention: New strategies for a changing epidemic, to reduce barriers to earlydiagnosis of HIV *making HIV testing routine as other screenings are *using new models for diagnosing HIV *prevent new infection *decreasing perinatal HIV transmission
