HIV/AIDS
Transmission of HIV
HIV can be transmitted as a result of contact with infected: -Blood -Semen -Vaginal secretions -Breast milk
Onset of transmission
HIV individuals can transmit HIV to others within a few days after becoming infected.
HIV
Human immunodeficiency virus (HIV)- Is a retrovirus that causes AIDS and interferes with the body's ability to fight infections.
Drug Alert (Efavirenz)
In pregnant patients, efavirenz can be used after the first 8 weeks of pregnancy. • Once-a-day doses should be taken at bed time (at least initially) to help patients cope with side effects, including dizziness and confusion. • Inform patients that many people who use the drug have reported vivid and sometimes bizarre dreams.
Most Common Mode of HIV Transmission
Is through unprotected sexual contact with an HIV- infected partner. *Semen, vaginal secretions and/or blood; higher risk for partner who receives the semen due to prolong exposure with infected fluids.
Which opportunistic disease associated with AIDS is characterized by hyper pigmented lesions of the skin , lungs and GI tract?
Kaposi sarcoma
How to Manage Fatigue
Managing fatigue in HIV patients: -teach patients to assess fatigue patterns and determining contributing factors -set activity priorities -conserve energy -schedule rest periods -exercise regularly -avoid substances such as caffeine, nicotine, alcohol, and other drugs that may disturb sleep
Drug Therapy (Fixed-Dose Combination Products)
More than one drug combined into a single tablet. Drugs may be from the same or different classes. Drugs: Atripla (tenofovir DF + emtricitabine + efavirenz) Combivir (lamivudine + zidovudine) Complera (tenofovir DF + emtricitabine + rilpivirine) Epzicom (abacavir + lamivudine) Trizivir (abacavir + lamivudine + zidovudine) Truvada (tenofovir DF + emtricitabine) Stribild (tenofovir DF + emtricitabine + elvitegravir + cobicistat§)
HIV is Most Prevalent In
Most prevalent among men who have sex with other men.
Decreasing Risk at Work
OSHA requires employer to use: -Precaution and safety devices to decrease risk of direct contact with blood and body fluids * If exposure happens, the Post-exposure prophylaxis (PEP) with combination ART can decrease the risk of infection.
Drug Therapy (Integrase Inhibitors)
Bind with integrase enzyme and prevent HIV from incorporating its genetic material into the host cell Drugs: saquinavir (Fortovase, Invirase) indinavir (Crixivan) ritonavir (Norvir)‡ nelfinavir (Viracept) atazanavir (Reyataz)
Preventing Transmission of HIV
Comprehensive HIV prevention strategy to reduce the risk of sexually acquired HIV infection in adult at high risk *PrEP includes: -Safe sex practices -Risk reduction counseling -Regular HIV testing *emtricitabine and tenofovir (Truvada) Used for high risk individual to help reduce the risk of HIV.
HIV is Not Spread Casually
The virus cannot be transmitted during: -Hugging -Dry kissing -Shaking hands -Sharing eating utensils -Using toilet seat -Casual encounters *HIV is not spread by tears, saliva, urine, emesis, sputum, feces ,sweat, respiratory droplets, or enteric routes. * Low risk for healthcare workers after needle stick injury.
Why do opportunistic infections develop in individual with AIDS?
These infections or tumors occurs in a person with an incompetent immune system.
Which characteristics describe Pneumocystic jiroveci infection, an opportunistic disease that can be associated with HIV?
Pneumonia with dry, non-productive cough
Patient Teaching (What to Report Withing 24hr)
Teach the patient to report the following signs and symptoms within 24hr: -New or different headache not relieved by over the counter medication -Headache accompanied by fever, nasal congestion, or cough -Burning, itching, or discharge from the eyes -New or productive cough -Difficulty eating because of mouth lesions -Vaginal discharge, pain, or itching
Patient teaching (What to Report Immediately)
Teach the patient with HIV and caregiver to report these signs and symptoms immediately: Any change in level of consciousness, lethargic, hard to arouse, unresponsive Any type of vision changes Persistent shortness of breath not relieved by a short rest period Nausea and vomiting accompanied by abdominal pain Vomiting blood Dehydration Blood in urine
Which characteristic corresponds with the acute stage of HIV infection?
Temporary fall of CD4+T cells
HIV Testing
The CDC recommends universal voluntary testing for all people ages 13-64 regardless of the risk. *21% of people living in the US living with HIV are unaware that they are infected.
Normal CD4+T Cell count is
800-1200 cells/ µL
Delaying Disease progression
(1) getting nutritional support to maintain lean body mass and ensure appropriate levels of vitamins and micronutrients. (2) moderating or eliminating alcohol, tobacco, and drug use (3) keeping up to date with recommended vaccines (4) getting adequate rest and exercise (5) reducing stress (6) avoiding exposure to new infectious agents; (7) accessing mental health counseling (8) getting involved in support groups and community activities (9) developing a consistent relationship with health care providers, including attendance at regular appointments.
Drug Therapy for Opportunistic Disease
-ART Drugs -Vaccination (including hepatitis vaccination, influenza and pneumococcal)
Abnormal blood Test In HIV Infection
-Decrease WBC ( especially lymphocytes and neutrophils -Low platelets -Altered liver function
Pathophysiology of HIV
-HIV replicates backwards (Retrovirus) using RNA as a template to produce DNA -Like all other viruses, it cannot replicate outside of living host cells. -The HIV virus uses CXCR4 and CCR5 as their co-receptors to get access and bind to CD4 ''T" helper cells. -Once the HIV virus fuses inside the CD4 T helper cell, the RNA is released inside the T cell and the virus begins to replicate. -Immune dysfunction in HIV infection is caused by damage and destruction of the CD4 T helper cells. Because of this, the body looses the ability to fight infections, and is prone to life threatening opportunistic infections.
Drug Therapy (Reverse Transcriptase Inhibitors)
-Nucleoside Reverse Transcriptase Inhibitors (NRTI's) *Insert a piece of DNA into the developing HIV DNA chain, blocking further development of the chain and leaving the production of the new strand of HIV DNA incomplete Drugs:zidovudine (AZT, ZDV, Retrovir) didanosine (ddI, Videx, Videx-EC [time-released]) stavudine (d4T, Zerit) lamivudine (3TC, Epivir) abacavir (Ziagen) emtricitabine (FTC, Emtriva) -Nonnucleiside Reverse Transcriptase Inhibitors (NNRTI's) *Inhibit the action of reverse transcriptase Drugs: nevirapine (Viramune) delavirdine (Rescriptor) efavirenz (Sustiva) etravirine (Intelence) rilpivirine (Edurant) -Nucleotide Reverse Transcriptase Inhibitor (NtRTI) *Combines with reverse transcriptase enzyme to block the process needed to convert HIV RNA into HIV DNA Drug: tenofovir (Viread)
Mode of Transmission
-Sexual intercourse with an infected partner -Exposure to HIV infected blood or blood products -Perinatal transmission during pregnancy, at delivery or through breastfeeding.
The Progression of HIV Infection is Monitored by:
1- CD4+T cell count and viral load * As the disease progresses, the number of CD4+T cells usually decreases. *The higher the viral load, the more active the disease become.
Goal of Drug Therapy
1- Decrease the viral load 2-Maintain or increase CD4+T cell count 3-Prevent HIV- related symptoms and opportunistic diseases. 4-Delay the disease progression 5- Prevent the transmission. *HIV cannot be cure , but antiretroviral therapy (ART) can delay the disease progression by decreasing viral replication.
Variables Influencing Transmission
1- Duration and frequency of contact with the organism 2-Volume of virulence , and concentration of the organism. 3-Host immune status *The concentration of the virus is an important variable
Resistance Test
1- Genotype Assay *Detects drug-resistant to viral mutations that are present in reverse transcriptase and protease genes 2-Phenotype Assay *Measures the growth of HIV in various concentrations of the antiretroviral drugs(much like bacterial antibiotic tests).
Nursing Management
1- Monitoring HIV disease progression and immune function. 2-Initiating and monitoring ART. 3- Preventing the development of opportunistic disease. 4-Detecting and treating opportunistic diseases. 5-Managing symptoms. 6-Preventing or decreasing complications of HIV.
HIV-Antibody Testing Steps for Reporting
1-A highly sensitive enzyme immunoassay (EIA) is done to detect serum antibodies that bind to HIV antigens on test plates. 2-Blood samples that are negative on this test are reported as negative and there is no further testing needed at this time unless patient reports risky behavior therefore retesting should be performed at 3 weeks, 6 weeks, and 3 months. 3-If test is positive, repeat testing. If test is repeatedly positive, a more specific confirming test, such as the Western Blot or some other confirmatory testing is performed. 4-Blood that is reactive in all of these phases is then reported to the patient as HIV antibody positive. 5-If the results are indeterminant, the following steps are taken If in-depth risk assessment reveals that the individual does not have a history of high-risk activities, reassure the patient that the HIV infection is extremely unlikely and suggest retesting in 3 months. If in-depth risk assessment reveals that the individual does have a history of high-risk activities, consider tests that detect HIV antigen.
Drug Therapy (Entry Inhibitors)
1-Entry Inhibitors- Prevents binding of HIV to cells, thus preventing entry of HIV into cells where replication would occur *enfuvirtide (Fuzeon) *maraviroc (Selzentry)
Clinical Manifestations of HIV
1-Progression is highly individualized 2- Treatment can significantly alter the pattern of progression. 3- An individual prognosis is unpredictable.
The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be seen first? A. The client who has flushed, warm skin with tented turgor. B. The client who states the staff ignores the call light C. The client whose vital signs are T 99.9 F, P 101, R 26, BP 110/68 D. The client who is unable to provide a sputum specimen
A -Right! Flushed warm skin with tented turgor indicates dehydration. The HCP should be notified immediately for fluid orders or other orders to correct the reason for the dehydration. B-The client issue can be addressed after we care for the pt with a physical problem C- The temperature is slightly elevated and the pulse is one beat higher than normal. This pt can also wait to be seen. D-Many clients who have had sputum specimens ordered are unable to produce sputum, but it doesn't warrant immediate intervention.
Atazanavir
Atazanavir (Protease inhibitor) Trade name: Reyataz Side effects: Rash, nausea, cough Adverse reactions: Hyperglycemia, diabetes mellitus, jaundice
Aids Diagnosis
According to the CDC, Aids is diagnosed when an individual with HIV develops at least one of the following: 1-CD4+T cell below 200 cells/µL 2-Opportunistic infections(e.g. fungal, viral, protozoal, bacterial). 3-Opportunistic cancers (e.g Kaposi,burkitts) 4-Wasting Syndrome- defined as loss of 10% or more of ideal body wt. 5-Aids dementia complex (ADC).
Drug adherence
Adherence is critical component of successful drug therapy for people with HIV infection. *Instruct patients on the important of taking medication as prescribed (right dose, right time) and not to miss any dose, because it can lead to drug resistance. *Patients can use reminders (e.g. alarm clocks, timers, calendars, pill boxes etc.)
Rapid HIV-antibody Test
Are done in the office, result takes 20 min or less *A positive should be followed by a confirming test. (Usually the Western blot).
Which statement made by a client indicates that they understand the results of a negative human immunodeficiency virus (HIV) antibody test? A. "I'm not infected with HIV " B. "I haven't produced antibodies to HIV" C. "I'm immune to HIV" D. "I have antibodies to HIV"
B. A negative HIV antibody test means that HIV antibodies weren't in the clients blood at the time the test was preformed. Antibodies may take a few weeks to 6 months or longer to develop. A negative test result doesn't indicate immunity. If antibodies to HIV are present, the test result would be positive. The primary phase of infection ranges from being asymptomatic to severe flu like symptoms, but during this time the test may be negative although the patient is infected with HIV.
The client with acquired immune deficiency syndrome (AIDS) asks the nurse why he must take so many medications. What is the best response by the nurse? A. "Because the earlier we start multiple medications the better for you" B. "To decrease the possibility of the virus developing resistance to the medications" C. "To provide you with the most effective treatment for your illness" D. " Research has shown single medications to be ineffective"
B. Decreasing the possibility of resistance is key; single drugs can be effective, but viral resistance is a problem. Multiple medications will provide the best treatment, but this is not as good of an answer as preventing drug resistance. It is debatable if multiple drugs should be used early in the course of the disease.
What is the primary reason that the normal immune response fails to contain the HIV virus?
CD4+T cells become infected with the HIV and are destroyed.
The nurse does health teaching with a client who has AIDS and who has been started on antiviral medications. The nurse recognizes teaching has been effective when the client makes which statement? A. " I will not be able to continue working at my high stress job anymore" B. "I will need to limit my travel to avoid people with other infections" C. "I will still need to take precautions to avoid spreading the virus to others" D. "I will need to be on a high calorie diet to enhance the effect of the medication"
C. Precautions are still necessary to avoid spreading the virus to others. A well balanced diet is the best diet for a client with AIDS. There is no need to limit travel at this point. A high stress job is not ideal, but at this point the client doesn't need to stop working.
The nurse accidentally sticks herself with a needle after starting an intravenous (IV) line on a client with acquired immune deficiency syndrome (AIDS). The nurse tells the supervisor about the accident. What is the best initial response by the supervisor to decrease anxiety in the nurse? A. "If you are started on medications soon, it will decrease the severity of the disease" B. "Workers compensation will cover the cost of your illness and medications" C. "Fortunately, the chances of you contracting human immunodeficiency virus (HIV) after the stick are very small" D. "Did you use the hospital protocols for starting intravenous (IV) lines on a client with acquired immune deficiency syndrome (AIDS
C. There have been only about 56 cases of client to healthcare worker transmission; the risk is very small. A, is wrong because telling the nurse to start on medication will not reduce her anxiety. If the nurse did contract HIV, workers compensation would cover the cost, but the risk of HIV transmission is small and this response will not reduce anxiety. Asking the nurse if she used protocols is not therapeutic at this point, and will most likely increase anxiety.
Improving Adherence to ART
Determine whether the patient understands the importance of adherence and is ready to start therapy. • Provide teaching on medication dosing. • Review potential side effects of drugs. • Assure the patient that side effects can be treated. If not, medication regimens can be changed. • Use teaching and memory aids, including pictures, pillboxes, and calendars. • Engage family and friends in the teaching process. Solicit their support to help the patient take treatment. • Simplify regimens, dosing, and food requirements as much as possible. • Use a team of nurses, physicians, pharmacists, case managers, and mental health and peer counselors to support the patient. • Help the patient integrate the medication regimen into his or her typical life activities and work schedules.
Diagnosis Studies
Diagnosis is made by: -Testing for HIV antibodies and/or antigen in the blood. *HIV antibodies test detect HIV specific antibody, but typically takes several wks after the infection before the antibody can be detected on a screening test(window Period). -Standard antibody test -Rapid -Home kit
Efavirenz
Efavirenz (NNRTI) Trade name: Sustiva Side effects: Rash, CNS effects (dizziness, insomnia, abnormal dreams/thinking, impaired concentration, amnesia, agitation, hallucinations, euphoria, anxiety), nausea, diarrhea Adverse reactions: Aggressive reaction, allergic reaction, convulsion, liver failure, neuropathy, suicide, abnormal vision
End of Life Care
End-of-life care: Focuses on keeping the patient comfortable Facilitating emotional and spiritual acceptance Helping the patients significant other with grief and loss Maintaining a safe environment
Patient Teaching
Focus of teaching for the patient is to improve adherence to the antiretroviral therapy, and preventing drug resistance. - ASSESSMENT! Determining what the patient knows already, and assessing if the patient understands why it is so important to adhere to the regimen - Reviewing the major SE of the drugs and assuring the patient that if they do experience the SE notify the MD and the side effects can be treated, or the medication change, VERY IMPORTANT! - involve the patients support system in the teaching process, so they can aid the patient in remembering when to take their medication. Support is key with HIV/AIDS. - Making the drug regimen as simply as possible and help the patient integrate the regimen into their daily schedule. Take ALL the medications prescribed and ALWAYS report to the HCP if you cannot tolerate a medication Don't take any new drugs without checking with the HCP for possible interactions
Drug Therapy (Protease Inhibitors (PIs))
Prevent the protease enzyme from cutting HIV proteins into the proper lengths needed to allow viable virions to assemble and bud out from the cell membrane Drugs: saquinavir (Fortovase, Invirase) indinavir (Crixivan) ritonavir (Norvir)‡ nelfinavir (Viracept) atazanavir (Reyataz) fosamprenavir (Lexiva)tipranavir (Aptivus) darunavir (Prezista) lopinavir + ritonavir (Kaletra)
What Is a Major Problem Encountered With Art Therapy
Resistance, this can develop rapidly when antiretrovirus drugs are used as monotherapy. For that reason a combination of three or more drugs are utilized. *Multiple side effect and drug to drug interaction especially with herbal (St. John's wort)and OTC's , patient is to use caution.
Clinical Manifestations (Acute)
Seroconversion (When HIV specific antibodies develop) signs and symptoms : -Acute infection (2-4 wks after contact) Fever, swollen lymph nodes, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhea, and or a diffuse rash. Some people may develop neurologic complications such as: -Aseptic meningitis -facial palsy -Guillain Barrre syndrome *Acute can last 1-3 wks or can persist for several months.
Complication of HIV and/or Art
Some HIV infected patients, especially those on long term used of ART, develop a set of metabolic disorders that include: -Changes in body shape (fat deposit in the abdomen, upper back and breast along with fat loss from arms, leg and face. -Hyperlipidemia -Elevated triglyceride -Osteoporosis -Insulin resistance -Lactic acidosis -Renal disease -Cardiovascular disease
Standard Antibody Test
Standard antibody test can be completed on blood or oral fluids specimens. They are sent to the laboratory, results take 1-7 days.
HIV Treatment (ART)
Standard antiretroviral therapy (ART) consists of the combination of antiretroviral (ARV) drugs to maximally suppress the HIV virus and stop the progression of HIV disease. ART also prevents onward transmission of HIV.
Clinical Manifestation (Chronic-Symptomatic)
Symtomatic (T cells 200-500) Viral load increases, HIV advances to a more active stage. Earlier symptoms worsen: -Persistent fever -Frequent drenching night sweat -Chronic diarrhea -Recurrent headaches -Fatigue severe enough to interrupt normal routines *Localized infections (most common is oral thrush) varicella virus, persistent vaginal candida infections, outbreak of oral or genital herpes, and bacterial infections. *Kaposi sarcoma & oral hairy leukoplakia may be present.
Clinical Manifestation (Chronic-Asymptomatic)
Viral load is low- symptoms may be present : 1- Asymptomatic (T cells >500) Fatigue , headache, low grade fever, night sweats, persistent generalized lymphadenopathy
Viral Load Testing
Viral loads are reported as a real number (e.g. 1260 copies/ µL or as undetectable. *Undetectable does not means that the virus has been eliminated from the body, it means that the viral load is lower than the test is able to report.
Prevention And Early Detection of HIV
•Increase safe sexual practices, including condom use. • Decrease equipment sharing among IV drug users. • Increase clinician skills to assess for risk factors for HIV infection, recommend HIV testing, and provide counseling for behavior change. • Make voluntary HIV testing a routine part of health care. • Increase access to new HIV testing technologies, especially rapid testing. • Increase access to HIV testing facilities in traditional health care settings, as well as in alternative sites such as drug and alcohol treatment facilities and community-based organizations. • Increase risk assessment and individualized behavior change messages to people with HIV to prevent new infections. • Decrease perinatal HIV infection by offering voluntary HIV testing as a part of routine prenatal care. • Provide counseling and appropriate HIV therapy to those who are infected.