chapter 36
two major components of ART resistance:
(1) transmission of drug-resistant HIV at the time of initial infection and (2) selective drug resistance in patients who are receiving nonsuppressive regimens
How is Kaposi sarcoma diagnosed?
- skin biopsy taken from center of skin lesion
How to confirm diagnosis of disseminated MAC disease
. is based on compatible clinical signs and symptoms coupled with the isolation of MAC from cultures of blood, lymph node, bone marrow, or other normally sterile tissue or body fluids
Turberculosis
A contagious bacterial infection (Mycobacterium) that mainly involves the lungs, but may spread to other organs. *An invasive, debilitating infection caused by the acid-fast organism.
Which of the following indicates that a client with HIV has developed AIDS?
A diagnosis of AIDS cannot be made until the person with HIV meets case criteria established by the Centers for Disease Control and Prevention. The immune system becomes compromised. The CD4 T-cell count drops below 200 cells and develops one of the opportunistic diseases, such as Pneumocystis carinii pneumonia, candidiasis, cytomegalovirus, or herpes simplex
Retrovirus
An RNA virus that reproduces by transcribing its RNA into DNA and then inserting the DNA into a cellular chromosome; an important class of cancer-causing viruses.
Evaluation of ART effectiveness:
An adequate CD4+ response for most patients on ART is an increase in CD4+ count in the range of 50 to 150 mm3 per year, generally with an accelerated response in the first 3 months
Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis?
Ataxia-telangiectasis is characterized by loss of muscle coordination and vascular lesions
what are Two surrogate markers are used routinely to assess immune function and level of HIV in the blood:
CD4+ T-cell count (CD4+ count) and plasma HIV RNA (viral load)
highly active antiretroviral therapy (HAART) Didanosine
Didanosine (Videx) should be taken 30 to 60 minutes before or 2 hours after meals.
Normal CD4 T cell count
Most people have about 700 to 1,000 CD4+ cells/mm3, but a level as low as 500 cells/mm3 can be considered within normal limits.
Treatments for Retinitis Cytomegalovirus
Oral valganciclovir (Valcyte), IV ganciclovir (Cytovene), IV ganciclovir followed by oral valganciclovir, IV foscarnet (Foscavir), IV cidofovir (Vistide), and a ganciclovir intraocular implant coupled with valganciclovir are all effective treatments for CMV retinitis. All of these drugs have significant toxicities (bone marrow suppression, neutropenia, hepatitis, renal toxicity, seizures, etc.) and are used with caution
opportunistic organism
Organism that is usually harmless, but can be pathogenic in a compromised host.
Respiratory difficulties and fever are associated with ? in HIV/AIDS patients:
Pneumocystis jirovecii, Mycobacterium avium-intracellulare, cytomegalovirus (CMV), and Legionella species.
what is the leading cause of blindness in patients with AIDS
Retinitis caused by Cytomegalovirus
Antidiarrheal therapy for persons with HIV:
Therapy with octreotide acetate (Sandostatin), a synthetic analog of somatostatin, has been shown to effectively manage chronic severe diarrhea.
Patients with antibody deficiencies receive which form of therapy ?
They receive regular Ig replacement therapy including both IV immunoglobulin (IVIG) and subcutaneous immunoglobulin (SCIG) to provide functional antibodies
viral set point
amount of virus present in the blood after the initial burst of virus in the blood and the immune response that follows
pneumocystis pneumonia
an opportunistic infection caused by the yeast-like fungus Pneumocystis carinii
serologic testing algorithm for recent HIV seroconversion (STARHS)
analyzes HIV-positive blood samples to determine whether an HIV infection is recent or has been ongoing
What are the Follow-up testing is performed if the initial test result is positive to ensure a correct diagnosis
antibody differentiation tests, which distinguishes HIV-1 from antibodies HIV-1 nucleic acid tests, which looks for the virus RNA directly
Three types of HIV tests
antibody tests, antigen/antibody tests, and nucleic acid (RNA) tests. Antibody tests detect antibodies, not HIV itself, while antigen and RNA tests directly detect HIV. The updated CDC recommendations (2014b) tests for HIV antigens and HIV nucleic acid because studies from populations at high risk for HIV demonstrated that antibody testing alone might miss a considerable percentage of HIV infections detectable by virologic tests, especially during stage 0.
Post-exposure prophylaxis (PEP)
antiviral drugs used after possible HIV exposure but should be taken within 72 hours to prevent exposure. Must be taken for 28 days
wasting syndrome
defined as the involuntary loss of more than 10% of one's body weight while having experienced diarrhea or weakness and fever for more than 30 days
reverse transcriptase
enzyme that transforms single-stranded RNA into a double-stranded DNA
Clinical Manifestations of Immune reconstitution inflammatory syndrome:
fever, respiratory and/or abdominal symptoms, and worsening of the clinical manifestations of an opportunistic infection or the appearance of new manifestations.
Kaposi's sarcoma
malignant tumor of the blood vessels associated with AIDS. KS is caused by human herpesvirus-8 (HHV-8); affects eight times more men than women; and may spread through sexual contact. AIDS-related KS exhibits a variable and aggressive course, ranging from localized cutaneous lesions to disseminated disease involving multiple organ systems.
viral load test
measurement of the amount of AIDS virus (HIV) in the bloodstream
The HIV life cycle:
Attachment/Binding: In this first step, the GP120 and GP41 glycoproteins of HIV bind with the host's uninfected CD4+ receptor and chemokine coreceptors, usually CCR5, which results in fusion of HIV with the CD4+ T-cell membrane. Uncoating/Fusion: Only the contents of HIV's viral core (two single strands of viral RNA and three viral enzymes: reverse transcriptase, integrase, and protease) are emptied into the CD4+ T cell. DNA synthesis: HIV changes its genetic material from RNA to DNA through action of reverse transcriptase, resulting in double-stranded DNA that carries instruction for viral replication. Integration: New viral DNA enters the nucleus of the CD4+ T cell and through action of integrase is blended with the DNA of the CD4+ T cell, resulting in permanent, lifelong infection. Prior to this, the uninfected person has been only exposed to, not infected with, HIV. With this step, HIV infection is permanent. Transcription: When the CD4+ T cell is activated, the double-stranded DNA forms single-stranded messenger RNA (mRNA), which builds new viruses. Translation: The mRNA creates chains of new proteins and enzymes (polyproteins) that contain the components needed in the construction of new viruses. Cleavage: The HIV protease enzyme cuts the polyprotein chain into the individual proteins that make up the new virus. Budding: New proteins and viral RNA migrate to the membrane of the infected CD4+ T cell, exit from the cell, and start the process all over.
Blood test vs Oral fluid test for HIV
Blood tests can detect HIV infection sooner after exposure than oral fluid tests because the level of antibody in blood is higher than it is in oral fluid. Likewise, antigen/antibody and RNA tests detect infection in blood before antibody tests. Some newer antigen/antibody laboratory tests can sometimes find HIV as soon as 3 weeks after exposure to the virus. No antigen/antibody or RNA tests are available for oral fluid.
What are the characteristics of a B-cell deficiency, such as common variable immune deficiency (CVID)? Select all that apply.
CVID is the most common primary immunodeficiency seen in adults, not childhood.Two types of inherited B-cell deficiencies exist. The first results from lack of differentiation of B-cell precursors into mature B cells. As a result, plasma cells are absent, and the germinal centers from all lymphatic tissues disappear, leading to a complete absence of antibody production against invading bacteria, viruses, and other pathogens. Although it usually presents within the first two decades of life, most clients are diagnosed as adults, because CVID often goes unrecognized.
HIV encephalopathy (AIDS dementia)
Direct infection of the brain Impairment of mental functioning, changes in mood
Concept Mastery Alert
EIA is a diagnostic screening test that determines the presence of antibodies to HIV. The RT-PCR test, which measures viral load, is used along with the CD4+ count, which indicates the level of immune dysfunction, to assess the stage and severity of HIV infection. It is important to assess the extent of damage to the immune system before initiation of ART and/or prophylactic treatment for opportunistic infections.
A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started?
For a client undergoing a hematopoietic stem cell transplant, immunosuppression is started to ensure engraftment of depleted bone marrow.
Which type of phagocytic disorder (formerly known as Job syndrome) occurs when white blood cells cannot initiate an inflammatory response to infectious organisms
Hyperimmunoglobulinemia E
Common manifestations of Pneumocystis jirovecii:
Hypoxemia is the most characteristic laboratory abnormality, along with elevated lactate dehydrogenase levels. subacute onset of progressive dyspnea, fever, nonproductive cough, and chest discomfort that worsens within days to weeks. In mild cases, pulmonary examination usually is normal at rest. With exertion, tachypnea, tachycardia, and diffuse dry (cellophane) rales may be auscultated. Oral thrush is a common co-infection
Immune reconstitution inflammatory syndrome medications:
IRIS is treated with anti-inflammatory medications such as cortisone
what is CCR5 MOLECULE?
It is a chemokine cell receptor molecule used for entry into the T cells for HIV-1. About 1% of Caucasians lack functional CCR5 and are highly protected against HIV infection even if exposed (although protection is not absolute); about 18% are not markedly protected against infection but, if infected, demonstrate significantly slower rates of disease progression. CCR5 levels on T cells influence HIV acquisition, disease progression rates, viral load, and immune recovery during ART
Treatment of Latent TB in a person with HIV:
Latent TB in a person with HIV infection is treated with isoniazid (INH), supplemented with pyridoxine (Aminoxin) to prevent peripheral neuropathy, for 9 months since it has proven efficacy, good tolerability, and infrequent severe toxicity.
Common candidiasis in patients with HIV
Oropharyngeal and esophageal candidiasis (fungal infections) are common in patients with HIV infection. Oropharyngeal candidiasis is characterized by painless, creamy white, plaque-like lesions that can occur on the buccal surface, hard or soft palate, oropharyngeal mucosa, or tongue surface. Lesions can be easily scraped off with a tongue depressor or other instrument
Cryptococcus neoformans
A fungal infection, Cryptococcus neoformans is another common opportunistic infection among patients with AIDS, and it causes neurologic disease. Cryptococcal meningitis is characterized by symptoms such as fever, headache, malaise, stiff neck, nausea, vomiting, mental status changes, and seizures. Diagnosis is confirmed by CSF analysis.
Stages of HIV infection
About 40% to 80% of patients develop clinical symptoms of a nonspecific viral illness (e.g., fever, fatigue, or rash) lasting 1 to 2 weeks. After 2 to 3 weeks, antibodies to the glycoproteins of the HIV envelope can be detected in the sera of people infected with HIV, but most of these antibodies lack the ability to totally control the virus. By the time neutralizing antibodies can be detected (stage 1), HIV-1 is firmly established in the host.Stage 2 occurs when CD4+ T-lymphocyte cells are between 200 and 499, stage 3 when the count drops below 200 cells/mm3 of blood and at this point, the person is considered to have AIDS for surveillance purposes. HIV disease progression is classified from less to more severe; once a case is classified into a surveillance severity stage, it cannot be reclassified into a less severe stage even if the CD4+ T-lymphocytes increase, which often occurs when a person receives ART. A stage 3 diagnosis has implications for services (e.g., disability benefits, housing, and food stamps), because these programs are often linked to living with severe immune dysfunction.
A client with suspected human immunodeficiency virus (HIV) has had two positive enzyme-linked immunosorbent assay (ELISA) tests. What diagnostic test would be run next?
The ELISA test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. The test is repeated if results are positive. If results of a second ELISA test are positive, the Western blot is performed. A positive result on Western blot confirms the diagnosis
Fat redistribution syndrome:
The fat redistribution syndrome (lipodystrophy) consists of lipoatrophy (localized subcutaneous fat loss in the face, arms, legs, and buttocks) and lipohypertrophy (central visceral fat [lipomata] accumulation in the abdomen, although possibly in the breasts, dorsocervical region [buffalo hump], and within the muscle and liver). Facial wasting, characterized as a sinking of the cheeks, eyes, and temples caused by the loss of fat tissue under the skin, may be treated by injectable fillers such as poly-l-lactic acid (Sculptra)
The nurse is preparing to infuse gamma-globulin intravenously (IV). When administering this drug, the nurse knows the speed of the infusion should not exceed what rate?
The nurse should administer the IV infusion at a slow rate, not to exceed 3 mL/min, usually at 100-200 mL/h.
primary infection
The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection, or stage 1. Initially, there is a period during which those who are HIV positive test negative on the HIV antibody blood test, although they are infected and highly infectious, because their viral loads are very high. and is part of stage 0
what are the 6 classes of antiretroviral therapy:
These six classes include the nucleoside/nucleotide reverse transcriptase inhibitors (step 3), non-nucleoside reverse transcriptase inhibitors (step 3), protease inhibitors (step 6), a fusion inhibitor (step 1), a CCR5 antagonist (step 1), and integrase strand transfer inhibitors (step 4). In addition, two drugs (cobicistat and ritonavir) are used to improve the pharmacokinetic profiles of some of the other ART drugs.
Treatment for Cryptococcal meningitis:
Treating cryptococcosis consists of three phases: induction, consolidation, and maintenance therapy. The preferred induction treatment for cryptococcal meningitis and other forms of extrapulmonary cryptococcosis is the IV lipid formulation of amphotericin B in combination with fluconazole (Diflucan).
Two types of HIV:
Two genetically different but closely related forms of HIV (HIV-1 and HIV-2) have been identified. The course of illness is slower when infection is caused by HIV-2, which seems to be more common in Western Africa compared to HIV-1, which is more common in other regions of the globe. Blood tests may be used to screen for both forms of HIV
Common symptoms of Mycobacterium avium-intracellulare:
a common opportunistic infection that typically occurs in patients with CD4+ T-lymphocyte (CD4+) cell counts less than 50 cells/. Early symptoms may be minimal and can precede detectable mycobacteremia by several weeks and include fever, night sweats, weight loss, fatigue, diarrhea, and abdominal pain
apathy
a lack of feeling, emotion, or interest
polymerase chain reaction
a sensitive laboratory technique that can detect and quantify HIV in a person's blood or lymph nodes
Immune Reconstitution Inflammatory Syndrome (IRIS)
a syndrome that results from rapid restoration of pathogen-specific immune responses to opportunistic infections; most often occurs after starting antiretroviral therapy
Enzyme Immunoassay (EIA)
a test that screens for the presence of HIV antibodies in the blood
severe combined immunodeficiency disease (SCID)
an inherited disease in which stem cells of WBCs lack an enzyme that allows them to fight infection. Treatment options for SCID include stem cell and bone marrow transplantation. Hematopoietic stem cell transplantation is the definitive therapy for SCID; the best outcome is achieved if the disease is recognized and treated early in life. The ideal donor is a human leukocyte antigen-identical sibling.
Persons in stage 3 HIV infection with pneumocystis pneumonia should receive:
chemoprophylaxis to prevent PCP with trimethoprim-sulfamethoxazole (TMP-SMX) if they have CD4+ counts less than 200 cells/ or a HX of oropharyngeal candidiasis. Once the CD4+ count improves, prophylaxis can be discontinued. Adjunctive corticosteroids (Prednisone) are indicated as early as possible, preferentially within 72 hours after starting specific PCP therapy. Treatment duration is usually 21 days
Diagnosis of HIV encephalopathy :
diagnosis of HIV encephalopathy can be difficult. Extensive neurologic evaluation includes a computed tomography scan, which may indicate diffuse cerebral atrophy and ventricular enlargement. Other tests that may detect abnormalities include magnetic resonance imaging, analysis of CSF through lumbar puncture, and brain biopsy
Adverse effects associated with all HIV treatment regimens include :
hepatotoxicity, nephrotoxicity, and osteopenia, along with increased risk of cardiovascular disease and myocardial infarction Many of the antiretroviral agents may cause fat redistribution syndrome and metabolic alterations such as dyslipidemia and insulin resistance, which put the patient at risk for early-onset heart disease and diabetes.
Serious potential adverse effects of amphotericin B :
include anaphylaxis, kidney and hepatic impairment, electrolyte imbalances, anemia, fever, and severe chills. After at least 2 weeks of successful induction therapy—defined as substantial clinical improvement and a negative CSF culture after repeat lumbar puncture—amphotericin B and flucytosine can be discontinued. Follow-up or consolidation therapy is then initiated with oral fluconazole daily which should continue for at least 8 weeks
AIDS related lymphoma
include both Hodgkin lymphoma and non-Hodgkin lymphoma. Non-Hodgkin lymphoma is more common. AIDS-related lymphoma is usually aggressive; there are three main types: diffuse large B-cell; B-cell immunoblastic; and small noncleaved cell lymphoma. Symptoms include weight loss, night sweats, and fever.
Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS)
is a serious complication that arises during successful ART in patients with HIV-TB co-infection who are receiving TB treatment. In the majority of patients, TB-IRIS occurs within the first few weeks of ART but can occur much later.
Whats the initial four-drug combination of TB isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol (Etibi)
isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol (Etibi)
Signs and symptoms of HIV encephalopathy (AIDS dementia)
may be subtle and difficult to distinguish from fatigue, depression, or the adverse effects of treatment for infections and malignancies. Early manifestations include memory deficits, headache, difficulty concentrating, progressive confusion, psychomotor slowing, apathy, and ataxia. Later stages include global cognitive impairments, delay in verbal responses, a vacant stare, spastic paraparesis, hyperreflexia, psychosis, hallucinations, tremor, incontinence, seizures, mutism, and death.
Mycobacterium avium complex (MAC)
opportunistic infection caused by mycobacterial organisms that commonly causes a respiratory illness but can also infect other body systems
Progressive multifocal leukoencephalopathy
opportunistic infection that infects brain tissue and causes damage to the brain and spinal cord, it affects the oligodendroglia. Clinical manifestations often begin with mental confusion and rapidly progress to include blindness, aphasia, muscle weakness, paresis (partial or complete paralysis), and death. ART has greatly reduced the threat of mortality associated with this disorder.
optimal viral load
optimal viral suppression is defined generally as a viral load persistently below the level of detection (HIV RNA less than 20 to 75 copies/mL, depending on the assay used
Pre-exposure prophylaxis (PrEP)
pill containing antiviral drugs that is taken before exposure to HIV to prevent infection, recommended to high risk individuals. (tenofovir disoproxil fumarate 300 mg and emtricitabine 200 mg [Truvada]) daily in order to avoid the risk of sexual HIV acquisition in adults and adolescents age 12 and older . HIV status should be checked every 3 months to be sure that the person has not become infected.
Adverse effects of trimethoprim-sulfamethoxazole (TMP-SMX)
rash (30% to 55%) (including Stevens-Johnson syndrome), fever (30% to 40%), leukopenia (30% to 40%), hepatitis (20%), thrombocytopenia (15%), azotemia( urea in the blood) (1% to 5%), and hyperkalemia.
Immune reconstitution inflammatory syndrome
results from rapid restoration of organism-specific immune responses to infections that cause either the deterioration of a treated infection or new presentation of a subclinical infection. This syndrome typically occurs during the initial months after beginning ART and is associated with a wide spectrum of organisms, most commonly mycobacteria, herpes viruses, and deep fungal infections.
Treatment for Mycobacterium avium Complex
should consist of two or more antimycobacterial drugs to prevent or delay the emergence of resistance. Clarithromycin (Biaxin) is the preferred first agent; however, azithromycin (Zithromax) can be substituted for clarithromycin when drug interactions or intolerance to clarithromycin preclude its use. Ethambutol is the recommended second drug
peripheral neuropathy
the most common neurologic symptom of HIV infection. It may be a side effect of some ART drugs, and may occur in a variety of patterns, with distal sensory polyneuropathy or distal symmetric polyneuropathy the most frequently occurring type. It can lead to significant pain of feet and hands and functional impairment.
How to achieve viral suppression?
viral suppression requires the use of ART with at least two, and preferably three, active drugs from two or more drug classes and should occur within the first 12 to 24 weeks of therapy especially if the patient is new to ART
