Nursing Care of the Client with HIV Infection

Prevention and teaching safe sex (Primary)

#1 goal we have for non-HIV pts?

QuantiFERON TB Gold In-Tube test (QFT-GIT) & the T-SPOT TB test (T-Spot)

2 TB blood tests (aka interferon-gamma release assays or IGRAs) for dx Mycobacteria Avium Complex (MAC)?

Mycobacteriumavium & Mycobacterium intracellulare

2 types of bacteria of Mycobacteria Avium Complex (MAC)?

Stage 1: Acute Infection Stage 2: Clinical Latency Stage 3: AIDS

3 Stages of HIV classifications?

-Saquinavir (Fortovase, Invirase) -Indinavir (Crixivan) -Nelfinavir (Viracept) -Amprenavir (Agenerase) -Atazanavir (Reyataz) -Darunavir (Prezista) -Fosamprenavir (Lexiva, Telzir) -Lopinavir/ritonavir (Kaletra) -Tipranavir (Aptivus)

9 Protease inhibitors (PIs)?

E) Georgia

According to the CDC, which US State has the highest rate of HIV infection? A) Texas B) California C) New Jersey D) Florida E) Georgia

Test for both p24 antigen & antibodies Best for detecting recent infection as early as w/in 14 days

Advantages of ELISA 4th generation immunoassay testing?

Antigen

Antibody vs Antigen testing for HIV: which one is Viral Detection?

Encephalitis

As a disseminated infection, Toxoplasmosis is a major cause of what?

The Panel recommends ART for all HIV individuals regardless of CD4+ count Includes daily medication w/ adherence of >90%

As of 2012, what does the Panel on Antiretroviral Guidelines for Adults and Adolescent recommend on initiation of medication? What does effective tx include?

Occurs when CD4+ < 50 cells

CD4+ count for Mycobacteria Avium Complex (MAC)?

less than 100 cells

CD4+ count with Toxoplasmosis?

-In all health-care settings -All persons who seek evaluation & tx for STIs -never w/out their knwledge; must be voluntary and free from coercion (has a right to opt out of testing!) -referred for immediate consultation w/infectious disease specialist

CDC recommendations for HIV screening: Where? All persons who seek what? Pts must not be tested without what? Those suspected of recently acquired HIV infection?

Avoid spicy food, acidic foods, hard textured foods like french bread -may need liquid supplements like Ensure to help

Candidiasis infection can cause pain in the throat with breakdown of mucosas impacting nutrition; What would we want to avoid? May need to resort to what?

Viral infection: Fever, night sweats, chills, headaches, sore throat, malaise, rash, cough, SOB, diarrhea, candidiasis, weight loss, lymphadenopathy

Clinical manifestations of HIV acute infection?

antimycobacterial agents & antibiotics such as fluoroquinolones -prophylactic therapy (zithromax) may be initiated if CD4+ cells <50

Combination therapy for Mycobacteria Avium Complex (MAC) includes?

Meningitis; so fever, seizures, altered consciousness, skin lesions! Kernigs & Babinskis test

Cryptococcosis primarily affects the central nervous system usually manifesting as what? What test can we perform to help dx?

occurs in small intestine affecting the entire GI tract Dehydration or electrolyte imbalances; 20-30 bowel movements a day MASSIVE Diarrhea (fluid loss of 10 liters/day)

Cryptosporidium occurs in what part of the body affecting what? Causing what as a result?

antibodies in serum

Cytomegalovirus is diagnosed by the presence of what?

T-cell (CD4) count < 200 cells has AIDS Without treatment, average survival time is 3 years

Defining criteria of Stage 3: AIDS?

Asymptomatic = positive TB skin test w/ 5 mm or > Symptomatic = negative TB skin test Both should undergo diagnostic evaluation

Diffence btwn Asymptomatic & Symptomatic Mycobacterium tuberculosis?

Amphotericin B (antifungal), fluconazole; long-term suppressive therapy required

Drugs of choice for tx of Histoplasmosis?

Workplace Home based Mobile School based Stand-alone voluntary testing

Examples of Community-based HIV testing and counseling?

Acute flu-like symptoms within 2 weeks

First symptoms and window period following HIV infection?

500-1500 Be concerned if below 200

HIV primarily effects the CD4 cells; what is the normal CD4 cell count range? What CD4 count would we really be concerned about?

Majority receive HIV testing in the community now which helped initiate treatment earlier rather than once in hospital for one reason or another..

HIV testing and counseling: Health facility vs Community influence?

A) Semen B) Blood D) Rectal fluids Also vaginal secretions and breast milk

HIV virus may be found in (select all): A) Semen B) Blood C) Urine D) Rectal fluids E) Tears Where else?

serum antibodies

HSV is diagnosed by the presence of what?

HIV infection

HSV remains dormant in the tissues and is reactivated in the presence of what?

Sexual = oral, anal, vaginal w/exposure of mucous membranes to infected semen or vaginal secretions (highest!) Parenteral = sharing needles or equipment contaminated or receiving contaminated blood products Perinatal (mother to child) = from placenta, from contact with maternal blood and bodily fluids during labor and delivery, or breast milk

How can HIV be transmitted? Which is the highest?

50% higher in less affluent countries

How do the women rates of HIV in the U.S. compare to other countries?

Viral load very high = more contagious So we want to keep the viral load very low or non-detectable level

How does the viral load effect HIV?

type 1 via oral & respiratory secretions type 2 via sexual contact

How is Herpes Simplex Virus (HSV) type 1 transmitted? type 2?

by skin biopsy;

How is Kaposi's Sarcoma diagnosed?

Airborne transmission -confined to lungs so biopsy in pts w/pneumonia: dyspnea or cough, diffuse bilateral infiltrates, blood gas analysis, and no evidence of bacterial pneumonia

How is PCP transmitted? How is it diagnosed?

for up to 2 years

How long can Cryptococcosis infection remain viable (or survive)?

May last from several months to many years

How long can the asymptomatic period of HIV last for ?

Only 3 out of 10 people

How many people living with HIV are undetectable?

every 3 months Get liver baseline Renal (BUN, creatinine) Test for all other STIs too!

How often should a HIV negative partner on PrEP get HIV testing? What other tests or labs are important to monitor?

not unless it spreads past the mouth and becomes thush of the esophagus or lungs

Is having thrush an AIDS determinant?

w/ human herpes virus-8

Kaposi's Sarcoma appears to be related to co-infection with what virus?

-Contaminated water -Contaminated food -Environmental -Respiratory -Sexual contact, blood borne -Pet and animal -Contact w/ children AVOID crowds and children (reduce chances of getting sick)

List all the exposure risks of opportunistic infections

Ganciclovir

Main drug of choice for Cytomegalovirus (CMV)?

25 - 34 yrs

More prevalent age of HIV diagnosis?

Mycobacteria Avium Complex (MAC) = Atypical (nontuberculous) mycobacteria

Most common bacterial infection in AIDS?

Kaposi's Sarcoma (KS)

Most common neoplasm or cancer in an individual w/ AIDS?

Continuous Antiretroviral therapy (ART) Infections might return when antibiotics are discontinued

Most effective way of preventing opportunistic infections from developing? When might they return?

-Raltegravir (Isentress) -Dolutegravir (Tivicay) -Elvitegravir (Vitekta)

Name 3 Intehrase Inhibitors?

-Efavirenz (Sustiva, Stocrin) -Nevirapine (Viramune) -Delavirdine (Rescriptor) -Etravirine (Intelence) -Rilpivirine (Edurant)

Name 5 (Non-NRTI's) NNRTI which Inhibits Reverse Transcriptase?

-Zidovudine/AZT (Retrovir) -Tenofovir (Viread) -Didanosine/ddl (Videx EC) -Stavudine/d4T (Zerit XR) -Lamivudine/3TC (Epivir) -Abacavir/ABC (Ziagen) -Emtricitabine/FTC (Emtriva)

Name 7 nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) that inhibits reverse transcription? STD SLAY=ZTD SLAE

-Place in private room -Wash hands before & after caring -Ensure room is cleaned once a day -Do not use supplies from common areas w/ neutropenic clients -monitor vitals & IV sites q4h -Inspect mouth, skin, & mucous membranes (anal area) for fissures or abscesses q8h -change gauze dressings daily -limit visitors to healthy adults -NO fresh flowers or potted plants in room; no fruit w/skin -NO uncooked veggies, sushi -Implement reverse isolation PRN (Standard precautions!)

Nursing Interventions when caring for clients with HIV infection? (where? before and after? ensure? supplies? monitor? inspect? dressing care? limit what? allowed in room? precautions?)

Return for follow-up and repeat HIV testing (6 wks, 3 mo, & 6 mo)

PEP protocol for follow-up appointments?

-Adjustment disorder -Depression (can lead to lack of cohering to their meds) -Post Traumatic Stress Disorder (PTSD) -higher rates of suicide (usually during 1st yr) Need counseling!

Possible psychosocial issues diagnosed after HIV?

90% Still use condoms!

PrEP daily treatment reduces the risk of HIV transmission by what %? But should still use what?

-Wash dishes w/hot, soapy water or use a dishwasher -No digging in gardens or houseplants -Avoid traveling to areas of the world w/poor sanitation

Prevent Opportunistic Infection: Dishes? Gardening? Plants? traveling?

Avoid eating salads, raw fruits and vegetables, undercooked meat, fish & eggs, pepper, paprika, or unpasteurized dairy products -No drinking fluids standing longer than 1 hour

Prevent Opportunistic Infections: Avoid eating (specifically) and drinking what?

Do not share personal items like toothbrushes, wash cloths, linens and deodorant Oral hygiene; Clean toothbrush weekly by running in dishwasher or soaking in bleach

Prevent Opportunistic Infections: What not to share? Hygiene?

Abstinence, Condom use (correctly; consistent; male vs. female; dental dams for oral); HIV screening (as early as 14 if sexually active); Drug therapy (adherent); Smoking cessation; nutrition; decrease alcohol/drug use *Primary - educate on condoms Secondary - early diagnosis (Screening/testing) Tertiary - promote continuous ART & prevent infection

Primary & Secondary Prevention

Retinalitis (ocular emergency) report any visual changes immediately!!

S/E of Ganciclovir to report immediately?

Respiratory or pulmonary infection progressing to widespread infection: Dyspnea, fever, cough, and weight loss Think LUNGS!

S/S of Histoplasmosis?

Can be asymptomatic or present with tuberculosis-like pulmonary process: fever, physical weakness, weight loss, malaise, and sometimes swollen lymph glands (So similar s/s of TB but is not TB)

S/S of Mycobacteria Avium Complex (MAC)?

-Rash -CNS side effects (Sustiva) -False positive drug test for THC (Sustiva) -Hepatitis, SJS (Nevirapine) -Anemia

Side effects of (Non-NRTI's) NNRTIs?

-Diarrhea, nausea, vomiting -Headache -Fatigue -Insomnia -Abdominal pain -Rhabdo - muscle aching & breakdown RED ZONE

Side effects of Integrase Inhibitors?

-Increased cholesterol (>200), triglycerides (>150) = Increased risk of developing type 2 diabetes -Lipodystrophy (buffalo hump or breast enlargement in male, or abdominal fat accumulation for example) -Insulin resistance/diabetes -Diarrhea, nausea, vomiting, bloating -Kidney stones (Crixivan) -Liver toxicity -Circumoral tingling/numbness (Norvir)

Side effects of Protease Inhibitors (PIs)?

GI - Nausea/vomiting dizziness & headache subside overtime NEPHROTOXICITY Bone Density mineral loss (Osteoporosis) lactic acidosis muscle pain & possible changes in respirations

Side effects of Truvada?

-Injection site reactions -Bacterial pneumonia -Allergic reactions -Lipodystrophy (decreased absorption) if sites are not rotated

Side effects of fusion inhibitors like Enfuviritide (Fuzeon)?

-Anemia (AZT) -Headache -Nausea/vomiting -Rash -Peripheral neuropathy (decreased sensation) -Pancreatitis (ddl) -Kidney toxicity (Viread) -Hypersensitivity (ABC)

Side effects of nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)?

Neuropathy so may need folic acid

Side effects of pyrimethamine (daraprim)? Need what?

3-4 times higher chance

Someone with an STI has what chance of being infected w/HIV?

To have them fully engaged in HIV care and treatment and as early as possible Prevent HIV from advancing to AIDs

The #1 goal we have for an HIV patient?

Viral suppression w/medication = Undetectable viral load = virus is not replicating but can still be contagious

The goal of fully engaging in HIV care?

B) male to male sexual contact African American males having anal

The most prevalent mode of HIV transmission among males is: A) heterosexual contact B) male to male sexual contact C) IV drug use D) Blood transfusion Which males highest risk?

may not present a positive TB skin test

The patient with TB and a CD4 count below 200 may not present what test?

Trimethoprim-sulfamethoxazole (TMP-SMX); prophylactic treatment in certain circumstances; Bactrim drug of choice

Therapy of choice and specific drug of choice for PCP?

Isoniazid (INH) Rifampin Pyrazinamide (PZA) ethambutol (EMB) continue: INH & rifampin

Tx during first 2 months for active TB? Which ones would you continue during the next 4 months following?

Nystatin = liquid (swish in mouth and spit but if for the esophagus thrush, then swallow) or lozenges -Can also swish and spit normal saline rinse or magic mouthwash

Tx for Candidiasis?

Amphotericin B for initial infection; long-term suppressive therapy required to prevent recurrence -Also premedicate w/ acetaminophen to prevent chills and sometimes benedryl to prevent allergic reactions

Tx for Cryptococcosis?

No effective therapy; control pain, decrease peristalsis; improve immune status

Tx for Cryptosporidium?

Excise local lesions; treat systemic lesions w/ radiation or chemotherapy

Tx for Kaposi's Sarcoma?

Combination therapy for those w/AIDS Use pyrimethamine (daraprim) & sulfadiazine May need additional folic acid

Tx for Toxoplasmosis?

chest x-ray, CT scan, or biopsy

Used to dx Histoplasmosis?

Toxo, CMV, thrush, hyperglycemia & dyslipidemia, PCP, TB, heart disease, stroke, PID, yeast infections, HCV, HPV, etc

What are some examples of opportunistic infections?

blurred vision, n/v, neck stiffness, and confusion

What are some signs and symptoms of Cryptococcosis that we can assess for?

Only testing for the antibody.. It can take 3 wks to 3 months to develop the antibody so if negative, must return to test again;

What are the ELISAs testing for? What is the protocol if negative?

found in secretions, breast milk, blood

What can Cytomegalovirus (CMV) be found in?

high index of suspicion w/ pinkish purple lesions on the skin and mucous membranes involving blood vessels in immunocompromised individuals; Can affect internal organs

What characteristics are suspicious of Kaposi's Sarcoma? What can it affect?

nucleic acid amplification test (NAAT), chest x-ray, acid-fast sputum smear, & sputum culture

What diagnostic tests should follow a TB skin test if Mycobacterium tuberculosis suspected?

Lyme Disease

What disease may reflect a positive HIV test result?

Inhibits viral DNA from Integrating into CD4 + DNA

What do Integrase Inhibitors inhibit?

Inhibits protease from making functional smaller pieces

What do Protease Inhibitors (PIs) inhibit?

nurse = N-95 respirator pt = regular mask

What do nurses need to wear when in the room of a pt with Mycobacterium Tuberculosis? And pt wears when leaving the room?

-for fluid and electrolytes -possible wasting syndrome due to loss of electrolytes

What do we want to assess for with Cryptosporidium?

mental status changes! including neuro deficits, headache, seizures, difficulty w/speech, gait, vision, & confusion

What do we want to assess for with Toxoplasmosis?

Ask about allergies!

What do you want to ask about with all sulfa drugs?

-effectiveness of HIV treatment and prompt engagement in medical care -what to expect as they enter medical care for HIV infection -REPORTABLE disease

What do you want to inform a newly diagnosed patient of HIV?

Post-exposure Prophylaxis (not 100% effective)

What does PEP tx stand for?

Pre-exposure Prophylaxis for HIV negative individuals; Use of oral ARV before HIV exposure; Goal= preventing HIV infection

What does PrEP for HIV stand for? Goal? And used for?

-medical hx -physical exam -urinalysis and STI screening -Hep B & C -gender specific (Pap test, culture, GYN exam) -CBC, blood chemistry profile, & lipid profile -Toxoplasma antibody test -CD4- T cells and VL analysis -TB skin test & chest radiograph -Partner-based risk

What does the initial evaluation of a newly diagnosed patient include?

Soft Cheeses

What food to avoid with Mycobacteria Avium Complex (MAC)?

Enfuviritide (Fuzeon)

What fusion inhibitor prevents the entry of HIV into CD4 cell?

9 months of INH

What is Latent TB treated with?

-glistening white patches on tongue or oral mucosal surfaces; creamy white vaginal discharge -found in mouth (commonly), throat, esophagus, stomach, bowel, vagina, skin

What is characteristic of Candidiasis and where can it be found?

Acyclovir daily suppressive therapy for chronic lesions

What is the antiviral drug of choice effective for acute episodes of HSV? What can this drug also be used as?

Truvada (emtricitabine & tenofovir) daily dose (everyday!) Still use condoms!!

What is the drug therapy of PrEP?

Follow it with a Confirmatory test such as the Western Blot (WB) test

What is the next step if the ELISA test returns positive?

Standard Precaution Reverse Isolation (Pt protected from us) mostly at advanced disease, when risk for infection is high (Neutropenic)

What kind of precautions are needed to care for pts with HIV infection?

PREP

What needs to be used for Partner-based risk?

having anal male to female higher .. the individual receiving anal is higher at risk

What puts women more at risk? male to female or female to male higher?

Photosensitivity and Dysrythmias

What s/e of Cyprofloxin to be cautious of?

Mycobacterium Tuberculosis

What should HIV-positive individuals be tested for annually?

-clean immediately w/soap & water; report it! Inform charge nurse & head to emergency department to determine if PEP will be administered. If so, administer w/in 2 hrs

What should a healthcare worker do after a needle stick or fluid contact?

Go immediately to a clinic or emergency room and ask for PEP

What should a person do if they think they have been exposed to HIV?

Avoid undercooked foods, raw fish, sushi, or contaminated water; Do NOT leave bottled water out for more than 1 hr -not recommended to have cats, turtles, birds

What should we avoid when CD4+ count is low?

Anemia so get an H&H baseline; Renal toxicity so test BUN & Creatinine Monitor I/Os Allergic reactions (prevent with benedryl) Can cause phlebitis so monitor dressing site closely

What side effects of Amphotericin B would need to monitor for?

Avoid gardening or working in the soil

What to avoid with risk of Histoplasmosis?

May be asymptomatic With effective treatment - go decades

What to expect during Stage 2: Clinical Latency stage?

Use of rapid HIV tests.. Confirmatory testing required before..

What type of HIV test should be considered for HIV screening? What is required before diagnosis?

Produces painful vesicular lesions (vesicle filled w/an infectious fluid) eventually forming a crust brain, liver, lungs

What type of lesions does Herpes Simplex Virus (HSV) produce? Disseminated infections affect which parts of the body?

Fungal infection found in bird and bat droppings

What type of opertunistic infection is Histoplasmosis and where can it be found?

Fungal infection acquired by inhalation; found in pigeon droppings (soil too?) and Eucalyptus tree

What type of opportunistic infection is Cryptococcosis and how is it transmitted and where can it be found?

Protozoal infection; animal-to-human, person-to-person; waterborne transmission

What type of opportunistic infection is Cryptosporidium? How is it transmitted?

Fungal infection found in air, water, on food - common, severe among persons w/AIDs CD4+ count less than 200 cells

What type of opportunistic infection is Pneumocystis jiroveci pneumonia (PCP) and where is it found? CD4+ count?

Protozoal infection; transmission primarily through ingestion of uncooked or undercooked meats & vegetables or drinking contaminated water Also transmitted in cat feces

What type of opportunistic infection is Toxoplasmosis? How is it transmitted?

when immune system is weakended (CD4+ less than 200 cells); at risk just by engagement in daily life

When are opportunistic infections experienced?

asymptomatic in immunocompetent host, latent or chronic; Reactivated in presence of HIV infection

When is Cytomegalovirus (CMV) asymptomatic and when is it reactivated?

-must begin within 72 hours of exposure -month long course (28 days) 2-3 antiretroviral medications HCP determines tx s/e: Nausea

When must one begin PEP? For how long? How many medications does the PEP consists of? Side effects?

found in water, soil, unpasteurized dairy products, aerosol droplets

Where can atypical (nontuberculous) mycobacteria be found?

Cytomegalovirus (CMV) Cryptosporidium Influenza

Which Opportunistic infections are associated with a risk of contact with children?

Toxoplasmosis Cryptosporidium Cryptococcosis Mycobacteria Avium Complex (MAC) Histoplasmosis

Which Opportunistic infections are associated with a risk of pets and animals?

Mycobacterium - TB, influenza

Which Opportunistic infections is associated with Respiratory risks?

Toxoplasmosis Cryptosporidium Histoplasma Cryptococcosis

Which Opportunistic infections is associated with a risk of contaminated food?

Cytomegalovirus (CMV) HBV HCV

Which Opportunistic infections is associated with a risk of sexual contact or blood borne?

Nucleic acid test (NAT) very pricey so not used for everyone..

Which diagnosing HIV antigen test shows the active virus w/a reaction w/in 10 days of infection and is highly accurate? What is the downside of this test?

Antigen testing

Which has a much shorter testing window: Antigen testing or Antibody testing?

Cryptosporidium

Which opportunistic infection is associated with a risk of contaminated water?

Liver (review TB med sheet)

Which organ are we concerned for when on TB meds?

IV drug users

Who is at risk of Cytomegalovirus?

Everyone..at least once btwn ages 13-64 Multiple sex partners, sex workers, male to male contact, anyone w/an STI, had any blood transfusions back prior to 1985

Who should get tested for HIV?

-Health workers exposed to HIV fluids on the job -Anyone who may have been exposed

Who would need to use PEP?

having more sex today thanks to Viagra and other happy go lucky libido drugs

Why are the elderly (65 and older) just as much at risk today?

Bc risk of TB jumps 2-4 times w/HIV

Why do we want to do a TB PPD and chest x-ray test with a newly diagnosed HIV patient?

to get a baseline to see if they get worse so WBC and CD4 count..

Why do we want to get a CBC for a newly diagnosed patient?

in lungs, CNS, liver, eyes

With Cytomegalovirus (CMV) infection in HIV individuals, inflammatory reactions of what occur?

Enlarged lymph nodes night sweats fatigue weight loss low-grade fever

what does the symptomatic period of HIV consist of?

Candidiasis

what fungal infection might be an early sign of HIV infection?

2-4 weeks post exposure symptoms possible HIGHLY contagious (HIGH viral load)

window frame and what to expect during Stage 1: Acute Infection?