week 8 chronic: HIV
High Risk Groups Factors
can effect anyone, certain groups at higher risk Gender: male > female Behavior risks Race age impacted by: stigma, discrimination, income, education, and geographic region
Antiretroviral therapy (ART)
has dramatically reduced the incidence and prevalence of HIV related dementia, memory and other cognitive problems persist. (forgetfullness, exec fnxing/reasoning, speed of processing, attention, etc. )
Reducing Transmission Risk/Pt Education: High risk sexual practices
Higher risk Anal sex without a condom Vaginal sex without a condom
Signs & Symptoms of HIV (Stage 1)
"Flu-like" symptoms in some newly infected ppl - Many other people either do not experience acute symptoms, or have symptoms so mild that they may not notice them.
The Clinical Latency: Stage 2 (Asymptomatic Phase)
"Latency" means a period where a virus is living or developing in a person without producing symptoms.
Certain Diseases/illnesses put someone into AIDS classif, these are some; ID'd by CDC
-Bacterial diseases: TB, Pneumonia -Protozoal diseases: toxomplasmosis (parasite affects the brain), cryptosporidoiosis -Fungal diseases: PCP (pneumocystis pneumonia): Pneumocystis jiroveci pneumonia. used to be called Pneumocystis carini or PCP pneumonia. candidiasis (thrush/yeast mouth/esophagus/vagina) Coccidioidomycosis ("cocci") Cryptococcosis (fungal infection that can cause meningitis) - Histoplasmosis Pneumocystis jiroveci, or PCP (a type of pneumonia) -Viral diseases: cytomegalovirus (virus infects eye and colon), HSV, Herpes zoster (shingles) -HIV associated malignancies: Kaposi's sarcoma, lymphoma, squamous cell carcinoma
Recommendations for HIV Screening
-CDC recommended everyone 13-64 yo for 'opt-out' testing -21% of ppl with HIV don't know they have it - more likely to transmit if don't know they have it. -Goal to normalize testing and decrease stigma of testing, find hidden cases, get tx to individs, prevent new cases
Risky Behaviors
-Drug and alcohol use (esp before sexual encoutners) -Injectable drug use -Multiple sexual partners - unsafe sexual practices -Populations and greatest risk: Men who have sex with men
AIDS Diagnoses and Deaths
-In 2014, an estimated 20,896 people were dx'd with AIDS. -In 2013, were an estimated 12,963 deaths (due to any cause) of people with diagnosed HIV infection ever classified as AIDS, and 6,955 deaths were attributed directly to HIV.
Final stage of HIV infection
-Occurs when immune system badly damaged and vulnerable to opportunistic infections. -CD4 count <200 OR -If you develop 1 or more opportunistic infections, regarless of CD4 count.
HIV Classification 3 Stages
1. Acute infection 2. Clinical Latency (chronic HIV infection) 3. AIDS
HIV Prevalence
1/8 ppl w HIV do not know they are infected >1.2 Million in the US (1 in 8 don't know they have it) => WE DO NOT HAVE THE BIGGEST POPULATION OF HIV INFECTED INDIVD's (2015)
HIV Prevalence: globally
22 countries have a high burden = ALL IN SUB-SAHARA AFRICA except India Accounts for 12% of the global pop, but 70% of HIV infections worldwide (~23 million) 1/25 adults have HIV (worldwide) - most via heterosexual activity
HIV Transmission: Blood
= highest concentration of virus, followed by semen, followed by vaginal fluids, followed by breast milk.
What do the test results mean? -
A negative result means that: No antibodies were found in your blood at this time. - You may still be in the window period, A negative result does NOT mean: - You are not infected with HIV - You are immune to AIDS, - You have a resistance to infection, - You will never get AIDS.
What do the test results mean? +
A positive result means that: You are carrying the virus that causes AIDS (HIV+), and You can infect others (need to implement precautions to prevent doing so).
ADR's
ADHERENCE Metabolic disorders with chronic ART - Lipodystrophy: fat redistribution - Increased risk for Cardiovascular Diseases Elevated LDL, decreased HDL Increased risk for insulin resistance: Hyperglycemia, diabetes - Lactic acidosis - Renal disease Rashes Peripheral neuropathy Lipodystrophy *Monitor for CVDs & DM
HIV Classification: Stage 3
AIDS As your CD4 cells fall below 200 cell/mm3 you are considered to have progressed to AIDS without treatment, people typically survive 3 years
Autoimmune Deficiency Syndrome (AIDS)
AIDS is the syndrome (group of characteristics/s&sx's) in advanced stages of HIV infection Stage 3: final stage of HIV -Immune fnx so poor clients become vulnerable to infections and infection-related cancers = opportunistic illness. -start to see infections and disease that are uncommon that most ppl can fight off
High Risk Groups: Race
African Americans - Make up ~12% of of US population, but ~44% of new HIV diagnoses Hispanic/Latino - Make up ~18% of of US population, but ~25% of new HIV diagnoses
When Should Testing Occur?
After the "Window Period" 3 months after exposure: Recent studies show that a test taken at least 12 weeks (3 months) after the last possible exposure to the virus provides highly accurate results
HIV Classification: stage 1
Acute infection During this time, large amounts of the virus are being produced in your body Many, but not all, people develop flu like symptoms often described as the "worst flu ever:
Common AIDS-related cancers are
Anal Cancer Cervical Cancer Kaposi sarcoma (KS), Lymphoma Other AIDS-related syndromes: HIV dementia (confusion) Wasting syndrome (severe weight loss)
The nurse working in an HIV testing and treatment clinic plans teaching about antiretroviral therapy for a A. patient who tested positive for HIV 3 years ago and has developed tuberculosis. B. male health care worker who is HIV negative but has unprotected sex with men. C. patient who was infected with HIV 10 years ago and has a CD4+ T-cell count of 650/μL. D. patient with persistent generalized lymphadenopathy who was exposed to HIV 2 years previously.
Answer: a Rationale: Antiretroviral therapy initiation is recommended for the following patients infected with HIV: history of AIDS-defining illness (such as tuberculosis), CD4+ T-cell count <200 cells/uL or between 200 and 350 cells/uL, pregnant women, persons with HIV-associated nephropathy, and persons co-infected with hepatitis B.
The nurse is caring for a patient who is receiving antiretroviral therapy (ART) for treatment of AIDS. Which assessment best indicates that the patient's condition is improving? A. Decreased viral load B. Increased drug resistance C. Decreased CD4+ T-cell count D. Increased aminotransferase levels
Answer: a Rationale: Goals of antiretroviral therapy (ART) in the treatment of a patient with HIV are to decrease the viral load and maintain or increase CD4+ T-cell counts. Combination drugs are prescribed to prevent or decrease drug resistance. Some of these drugs may impair liver function; increased aminotransferase levels indicate impaired liver function.
Reducing Transmission Risk/Pt Education: Lower risk
Lower risk Sex with a condom when used correctly Oral sex; no semen in mouth Sharing sex toys that have been cleaned or covered with a new condom between uses Deep kissing (French kissing or tongue kissing)**
The nurse informs the patient with a bacterial pneumonia that the most important factor in antibiotic treatment is A. antibiotics should have been used to prevent pneumonia. B. all of the supplied antibiotics should be taken even when symptoms have resolved. C. enough antibiotics for 2 days' treatment should be reserved in case symptoms recur. D. patients should request antibiotics for upper respiratory infections to prevent development of streptococcal-related diseases.
Answer: b Rationale: To prevent the emergence of antibiotic-resistant organisms, patients need to take the entire prescription even if symptoms have resolved. Antibiotics should not be used routinely to prevent bacterial pneumonia.
A diagnosis of AIDS can be made for a patient with HIV with A. a CD4+ T-cell count <500/µL. B. a WBC count <3000/µL (3 × 109/L). C. development of oral candidiasis (thrush). D. onset of Pneumocystis jiroveci pneumonia.
Answer: d Rationale: The Centers for Disease Control (CDC) has established criteria for a patient to be diagnosed with AIDS. AIDS is diagnosed when an HIV-positive individual develops at least one of several criteria: examples are CD4+ T-cell count less than 200 cells/uL and fungal infection such as Pneumocystis jiroveci pneumonia (PCP). Candidiasis infection must be of the bronchi, trachea, lungs, or esophagus (not only the mouth).
Medication ManagementSelf-Management
Antiretroviral therapy (ART) - Zidovudine (AZT ) - Dolutegravir (DTG) - Abacavir (ABC) - Lamivudine (3TC) - Ritonavir (RTV) - Efavirenz (EFV) - Many, many more Many medication and herb interactions ART meds are taken for life!
HIV Testing
Available at many HCP offices/clinics that will give results in less than 30 mins. Positive results: need a confirmation blood test Western Blot Both forms, by blood draw or orally, have the same accuracy with their results.
HIV and Pregnancy: Meds
Meds during pregnancy - Most HIV meds are safe (Retrovir, AZT) - Significantly reduces the risk of transmitting HIV to baby Prophylactic antiviral treatment reduces risk of active infection Babies receive ART 6-12 hrs after birth - Protects baby from any HIV that passed from mom during childbirth.
High Risk Groups: Behavior Risks
Men who have sex with men (gay, bisexual) - Account for ~70% of new HIV infections Injection drug users - ~9% of new infections Heterosexual individuals - ~23% new infections
Opportunistic Infections (OIs)
Bacterial diseases: TB, Pneumonia Protozoal diseases: Toxomplasmosis, cryptosporidoiosis Fungal diseases: PCP or PJP (most common OI in HIV/AIDS), candidiasis : PCP (pneumocystis pneumonia): Pneumocystis jiroveci pneumonia. used to be called Pneumocystis carini or PCP pneumonia. candidiasis (thrush/yeast mouth/esophagus/vagina) Viral diseases: Cytomegalovirus (CMV), HSV, Herpes zoster HIV associated malignancies: Kaposi's sarcoma, lymphoma, squamous cell carcinoma
HIV Transmission: From an infected person to another through
Blood (including menstrual blood) Semen Vaginal secretions Breast milk Work related: puncture wounds
HIV Testing Types
Blood test Saliva test Both forms have same accuracy
Symptomatic Phase: Stage 2
CD4 count 200-500 Viral Load increases HIV advances to more active stages Symptoms increase: Constant fever, night sweats, chronic diarrhea, persistent/recurrent h/a, severe fatigue, localized infections (skin and yeast infections)
Stage 3 (AIDS) if:
CD4 count <200 &/OR Dx'd w/ an opportunistic infection (infections that occur more often or are more severe in people with weakened immune systems)
Asymptomatic Infection
CD4 count remains above 500, viral load is low Also called "Asymptomatic infection" phase May have some sx = fatigue, h/a, low-grade fever, night sweats, persistent generalized lymphadenopathy, etc Sx are vage and non-specific=> Often ppl are UNAWARE they have been infected If continue high risk behaviors -> high risk for transmission!!
HIV and Nutrition
COMMON: WEIGHT loss and DIARRHEA r/t meds and disease Other common problems HIV & ART ➔ Loss of appetite, Make food taste bad, Decreased absorption of food Increased eating difficulty r/t: sore mouth N/V Other symptoms: Food prep difficulty: Fatigue from HIV and/or meds Wt loss and diarrhea are related to both the virus itself and the Med therapy Side effects
HIV Transmission: Through Animals
Can you contract HIV from an animal: -Animals do not harbor/carry HIV. -A similar virus: Simian Immunodeficiency Virus (SIV) can infect primates: it's believed that this virus mutated before jumping species to humans where it became HIV.
Category B Symptomatic Conditions
Category B symptomatic conditions are defined as symptomatic conditions occurring in an HIV-infected adolescent or adult that meet at least one of the following criteria: - They are attributed to HIV infection or indicate a defect in cell-mediated immunity. - They are considered to have a clinical course or management that is complicated by HIV infection.
HIV Classification: stage 2
Clinical latency - chronic HIV infection During this stage of the disease, HIV reproduces at very low levels, although it is till alive During this period, you may not have symptoms. With proper treatment, people may live with clinical latency for several decades. Without treatment, this period lasts an average of 10 years, but some people may progress through this stage later
Highly Active Antiretroviral Therapy (HAART)
Combination therapy is best Highly active anti-retroviral therapy (HAART): combo of 3 med classes For HIV patients: HAART is for life Complicated regimens Expensive Many side effects For 'at risk' patients: Pre-exposure prophylaxis (PrEP) Reduces risk of HIV transmission for high risk individuals Does not reduce risk of other STIs orblood borne pathogens like Hep C Post-exposure prophylaxis (PEP) Start ASAP after exposure Need to start within 72 hrs of exposure Take for 28 days
Adherence
Crucial! Poor adherence is major cause of therapeutic failure Importance Sustained HIV suppression Reduced risk of drug resistance Improved overall health, QOL, survival Decreased transmission (d/t dcrs'd viral load)
Signs & Symptoms of HIV (Stage 1): Early symptoms
Early symptoms (lasting no more than a few days): Fevers Swollen glands Sore throat Rash Fatigue Muscle aches and pains Headache
Living With HIV
End of 2012, (most recent year data are available), -estimated 1,218,400 (1.2 million) adults and adolescents living with HIV. -156,300 (13%) had not been diagnosed. -Young ppl were the most likely to be unaware of their infection. -Among 13-24 yo's, estimated 44% (25,300) of living with HIV didn't know.
Stage 3: Progression to AIDS
Evident Clinical Manifestations Autoimmune deficiency syndrome
Category B Symptomatic Conditions: examples
Examples include, but are not limited to, the following: - Bacillary angiomatosis - Oropharyngeal candidiasis (thrush) - Vulvovaginal candidiasis, persistent or resistant - Pelvic inflammatory disease (PID) - Cervical dysplasia (moderate or severe)/cervical carcinoma in situ - Hairy leukoplakia, oral - Herpes zoster (shingles), involving two or more episodes or at least one dermatome - Idiopathic thrombocytopenic purpura - Constitutional symptoms, such as fever (>38.5°C) or diarrhea lasting >1 month - Peripheral neuropathy
Nutrition Management: extra protein
Extra Protein: cottage cheese, fish, protein supplements, meats, eggs spread nut butter on toast, crackers, fruit, or vegetables.Add cottage cheese to fruit and tomatoes. Add canned tuna to casseroles and salads. Add shredded cheese to sauces, soups, omelets, baked potatoes, and steamed vegetables. Eat yogurt on your cereal or fruit. Eat hard-boiled (hard-cooked) eggs. Use them in egg-salad sandwiches or slice and dice them for tossed salads. Add diced or chopped meats to soups, salads, and sauces Add dried milk powder or egg white powder to foods (such as scrambled eggs, casseroles, and milkshakes).
Nutrition ManagementFood Safety w/ altered immunityInfection Control/Self-Management
Food and water safety are important Weakened immune system working hard to fight off infections Clean counters and utensils often. Do not eat food past its expiration date Rinse well all fresh fruits and vegetables with clean water before eating and/or cook. Cook all meat, fish, and poultry "well-done" Avoid = DO NOT EAT:
How is HIV transmitted?
From an infected person to another Blood = highest concentration of virus You can't contract HIV from another animal! HIV-1 shares the highest degree of similarity (85%) with the chimpanzee strain of SIV. It is believed that HIV-1 mutated from this strain of SIV before jumping species to infect humans and HIV-1 can infect chimpanzees.
Nutrition Management Self-Management
HIGH calorie & HIGH protein - Nutritional supplements: calories, protein, etc. Increased fluids/water - Helps avoid dehydration (fluid loss), dry mouth, and constipation - Helps decrease fatigue - Reduces side effects of medications - Helps excrete metabolized meds Avoid alcohol
What is AIDS?
HIV Classification: Stage 3 infection CD4 cells < 200 cell/mm3 of blood. Normal CD4 counts: 500 and 1,200 cells/mm3. AND/OR Being diagnosed with one or more opportunistic illnesses regardless of the CD4 count.
HIV testing and Pregnancy
HIV testing 14-21 days after birth 1-2 months Again at 4-6 months
Perinatal transmission:
HIV transmission from mother to child during pregnancy, labor and delivery or breastfeeding 25% of infants born to untreated moms are born w HIV Moms that are tested and treated => 2% born w HIV For HIV mothers....the BIGGEST risk of transmission is breast feeding!
The Clinical Latency: Stage 2
HIV virus reproduces at very low levels, although it is still active. If taking antiretroviral therapy (ART), person may live with clinical latency for several decades. For people who are not on ART, this clinical latency stage lasts an average of 10 years.
Nursing Management
Identify those at risk for poor adherence Identify Barriers! Implement strategies to enhance adherence Proper way to take meds Report intolerable ADRs Inform HCP of other meds Integrate into daily life Support of family/friends
When Should Testing Occur? (notes)
If test negative on an antibody test taken 3 months or longer after your last possible risk of possible exposure to HIV, you can feel safe in assuming that you do not have the virus. If for some reason you feel anxiety about relying on the 3-month result, you could opt to have another test taken again at 6 months.
Annually test high risk pts such as:
Injectable drug users & their partners - Old/used/dirty/shared needles Partners of HIV infected persons High risk sexual practices - Multiple Sex Partners - Heterosexual w >1 partner or whose partner has had >1 sexual partner since previous HIV test
Opportunistic Infections: AIDS what is looks like
KS very telling sign of AIDS: WHAT IT LOOKS LIKE: purple, red, or brown blotches or tumors on the skin
Opportunistic Infections: what it looks like
KS very telling sign of AIDS: WHAT IT LOOKS LIKE: purple, red, or brown blotches or tumors on the skin
Diagnosing HIV:
Most tests look for "antibodies" to HIV. Newer HIV tests can look for signs of the virus itself in the blood.
Reducing Transmission Risk/Pt Education: No risk
No risk Hugging Massage Masturbation Fantasizing Dry kissing Phone or cyber sex Sex toys not shared
HIV Is NOT Transmitted Via...
Non-infections Bodily fluids: Saliva, Tears, Sweat, Feces Urine Air or water, closed mouth kissing, insects or pets, sharing toilets, food or drinks Swimming Pools and Hot Tubs Chemicals used in swimming pools and hot tubs instantly kill any HIV, if the hot water (and time) hadn't killed it already.
HIV and Pregnancy
Perinatal transmission - Most common route of HIV infection in children. Most infants born to HIV+ mothers are not infected with the virus Babies born to HIV+ mothers have positive HIV antibody titers - It does NOT reflect HIV infection - Reflects passive transfer of maternal antibodies
Human immunodeficiency Virus (HIV)
Progressive failure of the immune system Over time, HIV can destroy so many of these CD4 T-cells that the body can't fight off infections and disease A virus that attacks our immune system and turns it against ourselves. The HIV virus specifically targets CD4+ T cells which are important components of the human immune system. The virus attaches itself to the outside of the T-cells before infecting them. This leads to apoptosis and the immune system becomes progressively weaker until the patient picks up an infection or cancer and is considered to be suffering from AIDS. It is important to note that people do not die of AIDS; they die from the other conditions, illnesses and infections that their bodies can no longer fight off due to their weakened immune systems.
HIV Prevalence: Oregon (2013)
Ranked 31st out of 50 states Approx: 6,000 living in Oregon with HIV
Medication Management:Antiretroviral Therapy (ART)
Recommended for: Strong recommendation: CD4 < 500 cells/mm3 Moderate recommendation: CD4 count > 500 Strong recommendation regardless of CD4 count, IF: - Pregnant, - History of AIDS-defining illness, - HIV-associated nephropathy, - Co-infection with hepatitis B virus.
Key Aspects to Achieving & Maintaining an Undetectable Viral Load
Regular visits with HIV specialist Blood work evaluations Viral Load CD4 count Renal function (BUN/Cr) Adherence to ART!
Who Should Get Tested?
Routine testing for all ages 13-64 yrs 21% of people with HIV unaware Being treated for TB Seeking tx for STIs Annually test high risk pts
Virus that affects the CD4 T-cells
Specific cells of the immune system Virus invades CD4 T-cells, uses them to make more copies of itself, and then destroys CD4 cells
Immunity
The body's protective response to infection and disease; the natural or induced resistance to infection and conditions associated with impaired response Impaired immunity ➔ decreased ability to fight infections and/or increased susceptibility to diseases; (Or altered response to pathogens) The nurse must be knowledgeable regarding active and passive immunity, as well as the effects of alterations in immune function for clients receiving care. Exemplars of impaired/altered immunity: HIV/AIDS, rheumatoid arthritis, lupus, hypersensitivity
"Window Period"
The time it takes for a person who has been infected with HIV to seroconvert (test positive) for HIV antibodies This is Stage 1: The virus establishing itself in the body and beginning to produce antibodies Usually 3-12 weeks Most infectious time
What Is Viral Load?
The viral load test measures the amount of HIV virus in your blood. *undetectable does not mean no virus/eliminated
Non-infections Bodily fluids
These fluids and substances cannot transmit HIV. -Sweat contains no HIV. -The other fluids don't contain enough HIV to infect another person. Regardless of how they get into the bloodstream. No cases of HIV transmission have ever been documented as a result of these substances.
Monitoring known HIV infection:
Viral Load Test: how much virus is in the blood CD4 test: strength of immune system CD4 counts are used to indicate when to start certain types of drug therapy: CD4 < 200 or < 14% = AIDS
HIV Prevalence: Nationally (oct 2015)
~50,000 ppl contract/yr -National prevalence = 0.39% adults <60 yrs (according to new data from the CDC). -MSM, blacks, illicit drug users and people with 10 or more sexual partners were more likely to have HIV. - >1/2 of HIV+ ppl surveyed -- 51.9% -- were receiving antiretroviral therapy. -# of lifetime number of sexual partners (LSPs) was associated with higher HIV prevalence. Zero to four LSPs (0.14%) Five to nine LSPs (0.21%) 10 or more LSPs (0.68%)
Symptomatic Phase: Stage 2 (notes)
Vaginal and penile herpes lesions Dermal yeast infections Oral yeast infections (thrush/candidiasis) Subcategory of stage 2
What is HIV?
Virus that affects the CD4 T-cells Leads destruction of too many CD4 T-cells: body cant fight off infcetions/diseases There's no cure! Meds can dramatically slow the progression.
Stage 1: Signs and Sx
acute HIV infection Systemic: fever, weight loss Mouth: sores, thrush sores in esophagus pharyngitis myaglia liver and speel enlargement central: malaise, headache, neuropathy lymphadenopath rash nausea and vomiting
High Risk Groups: Age
Youth have highest rate of HIV occurrence (21% of new diagnoses between ages 13-24 years of age) 1 in 2 didn't know they had the virus
High risk - test annually
injectable drug users and their partners, persons who exchange sex for money or drugs, sex partners of HIV-infected persons, and MSM or heterosexual persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test. MANY 'RISKY' BEHAVIORS put at risk for OTHER STI's...NEED TO CHECK/SCREEN Coinfection w/ Hepatitis is common
Opportunistic Infections (OIs) definition
opportunistic infections: "opportunistic" bc are caused by organisms which can't induce disease in people with normal immune systems, but take the "opportunity" to flourish in people with HIV). Infections occur more frequently and severe in individs with weakened immune systems EX: HIV pts...the lower their CD4 count, the more OIs they will have (1 or 2 = AIDS)
HIV Transmission
sexual contact injection drug use pregnancy, childbirth and breast feeding occupational exposure blood transfusion/ organ Transplant