HIV/AIDS
Risk for Fluid Volume Deficit r/t diarrhea
-Assess usual bowel habits -Assess frequency, amount & character of stool -Obtain stool cultures as ordered -Avoid high fat foods, milk products -Assess BMP, skin turgor, I&O, weights -Report rapid pulse, low BP, signs electrolyte disturbance, UO < 0.5mL/kg/hr -Admin anticholinergic meds as ordered -Maintain oral fluid intake of 3 L/day
Category A is?
-Asymptomatic, Acute Primary HIV or (PGL) Persistent Generalized Lymphadenopathy -Part of Primary Infection -Is a chronic, low-level infection -CD4+ T lymphocyte count over 500 cells/μL -*Consider risks/benefits of treatment*
How HIV Replicates
-Attaches to receptor on CD4 T-cell lymphocyte (or CD5), CD4 lymphocyte exposes viral GP120 glycoprotein receptor site -Virus can then attach to a chemokine receptor (CCR5, CCR4) on T cell -HIV RNA enters the cell -Viral enzyme reverse transcriptase converts the RNA to DNA -Viral DNA is incorporated into the "host" T-cell DNA -Requires the enzyme integrase -Now it is called a provirus -Host DNA is activated to produce new virons by antigens or cytokines (TNFα, interferon I or II) -Viral enzyme protease cleaves proteins off viral DNA -Virons enter the bloodstream and infect other CD4 T-cells
Window Period is?
(can last for 6 months) Intense viral replication & destruction CD4 T-cells
AIDS term
-AIDS stands for Acquired Immunodeficiency Syndrome -Acquired means you can contract it
Risk for Non-adherence (*strategies*)
-Accessible, trusting heath care team -Identify barriers -Provide resources -Involve patient -Assess adherence at every visit -Identify reason for non-adherence
Post-Test Counseling for HIV Testing
-Assess impact of results on patient & family (consider suicide risk) -Provide treatment options -Discuss partner counseling & disclosure of results -Begin a support & treatment plan
Primary Prevention: Assessment & Risk Reduction for Individuals
-High risk behaviors -High risk situations -Members of high risk groups
Safer Sex: MSM (men who sleep with men)
-Higher HIV concentration in semen than in vaginal fluid -Reason for latex condom use -How to use a condom -Use only water based creams & lubricants -Petroleum or oil based products lead to breakage -How & when to use dental dams (oral sex) -Avoid manual anal intercourse (fisting)
Nursing Assessment HIV+ Client
-Social supports, depression, substance use -Meaning of the infection +Stigma +Fear of death +Fear of transmission -Readiness to learn -Fatigue -Baseline nutritional status -Baseline labs -Progression of the disease
Birth Control Failure & ART
-Some antiviral medication interferes with effectiveness of hormone-based birth control +Birth Control Pill +Hormonal Implants
CDC Classification System
1) Category A 2) Category B 3) Category C
Mandatory HIV Testing in N.H.
1) Incarcerated individuals +Consent not required when necessary for placement or management +Convicted sex offenders 2) Occupational exposure +Employer pays cost +Not a lawful requirement for issuance of insurance
Primary Infection consists of?
1) Window Period 2) Aids-Related Complex 3) Viral Set point
What is the normal range for CD4 T cell count?
500-1200 mm cubed
Syndrome means?
A group of health problems that indicate a disease
Reducing opportunistic infections in someone with HIV is what?
A high priority?
Oral candidiasis is what in relation to AIDS?
A predictor for progression to AIDS within 2 years
Oral Candidiasis has 2 types
Erythematous candidiasis & Pseudomembranous candidiasis
What are the s/s of Immune Reconstitution Syndrome?
Fever, fatigue, lymphadenopathy
Developmental Considerations in HIV
-"Blameless Victims" (all are blameless) +Infants +Children -Teens -Adults -Families -Older client >50 yrs
Adults with HIV
-"Why me, I didn't do anything wrong"? (Sankar and Luborsky, 2003) -"...because I was married I did not think I could get it" -"You think you are safe until you find out that he is cheating on you with everybody" (Blake et. al., 2008) -"Once a month... Everybody brings something in for dinner, and my coworker always has to know what I've made because she will not eat it" (Sankar and Luborsky, 2003) -"HIV is considered a dirty disease, and society will judge you before they know how you got into these circumstances" -"Everybody is ashamed of it" (Blake et. al., 2008)
A Positive Test Means?
-*"Seroconversion" (doesn't mean they're immune to HIV)* -There are HIV antibodies in the blood -AIDS is not necessarily present -The client is not immune to HIV -Take precautions not to spread of infection -Practice "safer-sex" -Do not donate sperm or blood -Avoid sharing needles, razors, sex toys, toothbrushes or blood contaminated articles
Category C is?
-*AIDS* -Absolute CD4 T lymphocyte count below 200 cells/μL -Disability benefits, housing & food stamps now eligible -Cannot revert to Category A or B -Anti-retrovirals strongly recommended -Opportunistic infections & cancers can manifest -HIV related encephalopathy can occur -Wasting syndrome can occur/occurring
Standard Precautions are?
-*Barrier protection against contact with blood & body fluids* (CSF, synovial, pleural, peritoneal, pericardial, amniotic, semen & vaginal secretions) -*Replace soiled face shields, gowns, gloves* -*Wash hands after glove use* -*Clean re-usable patient care equipment between uses* -*Avoid needle stick injuries* (needless systems, prompt disposal of needles, one-handed scoop to cover needle sheath)
Goals of Highly Active Antiretroviral Therapy (HAART)
-*Functional cure*: immune system controls the virus (transmission is still possible). -"Toddler Cured of HIV" (components of viruses present in body). -Reduce HIV RNA load to below 50 copies/mL +HIV in lymph nodes is not measurable +Blood test before therapy & at 6 months +If no improvement is seen, regimen is re-evaluated -Maintain or ↑CD4 T cell count (repeat q 3-6 mos) -Increase lifespan (CD4 count should increase by 100-150cells/mm³ per year/best response seen in first 3 months) -Higher quality of life (reduced opportunistic infection/ability to manage SEs) -Reduced mother-baby transmission in pregnant clients
Over age 50: 25% of those Living with HIV
-15% are new cases, 10% reflect more ART effectiveness -Delayed diagnosis (often present with CD4 count <200 cells/ mm³) -Less routine screening (providers don't consider high risk) -Those presenting with dementia before age 60 should be tested
Children with HIV
-6-12 year olds whose parents did not disclose the child's dx of HIV for period of 2-8 years exhibited severe emotional distress, disturbed self-image, & social isolation (*they know something is wrong*) -Chronic illness can negatively impact achievement of developmental milestones -Providers should counsel parents on how to disclose HIV status to children
Expected HIV Outcomes: The client will
-Attend follow-up lab tests & office visits -Demonstrate knowledge of disease process, transmission & treatment -Maintain fluid balance & nutritional intake -Demonstrate understanding of drug therapy by accurately describing SEs & precautions (or risks/ benefits of tx) -Identify social support system -Make an adherence plan for follow-up
During category B HIV what conditions can manifest?
-Bacillary angiomatosis -Candidiasis -Cervical Dysplasia -Oral Hairy Leukoplakia -Herpes zoster -Idiopathic Thrombocytopenic Purpura -Peripheral Neuropathy -Conditions due to HIV, or course is complicated by HIV
CDC & oral candidiasis
-CDC recommends prophylactic treatment against pneumocystis carinii(jirovici) pneumonia for HIV positive patients with oral candidiasis (can kill the HIV patient/doesn't mean pt with Thrush whose on antibiotics will convert to AIDS)
HAART is?
-Combination therapy using at least 3 drugs: costly -Some pills contain drugs from two manufacturers -Huge drug-drug interactions! (see p. 203/table 17)
Community Assessment: Risk for HIV/AIDS
-Community interest/readiness -Barriers & resources -Community survey -Number of schools, colleges, brothels, bars -CDC data -Incidence by age, sex, race, ethnicity -Teen pregnancy -Census data -Concentration of high risk groups -Behavioral youth surveillance surveys -High risk behaviors -High risk situations
Collaborative Program Evaluation (*Process*)
-Community participation in program development -More preventative programs -Attendance at programs -Satisfaction measures of the program
Collaborative Community Planning
-Decide where, who & when and how to target -Towns +AIDS awareness programs (info on HIV must be provided at time marriage license is issued) +Drug treatment programs -Schools (health class, assembly, condom distribution programs) -Health care organizations (community programs & worker education) -Community groups
Detecting HIV
-Detectable within 3 weeks to 6 months 1) HIV combination immunoassay to look for HIV 1, HIV 2 antibodies & HIV 1 p24 antigen (results will be reactive or nonreactive) 2) If reactive, more specific immunoassay identifies which genotype is causing the infection Multispot HIV-1/HIV-2 Rapid Test. 3) If nonreactive then: HIV nucleic acid testing (HIV RNA assay)
Immune Reconstitution Syndrome is?
-Develops weeks after ART therapy begun (*is a SE of ART therapy*) -Is an inflammatory response to medication -May take weeks or months to subside -May be treated with NSAIDS or steroids -Also associated with infection of TB, CMV, PCP -Those starting antiretroviral therapy should seek medical advise for fever or worsening of symptoms
RISKS OF EARLY TREATMENT (CD4 count 350mm³-500mm³)
-EXPENSIVE! -Side effects & toxicity -Drug resistance -Reduced efficacy future Rx -Less time to learn about HIV & treatment -Less time to make a plan to adhere to rx -Better drugs may be developed -Potential transmission of resistant HIV strain
Secondary Prevention of HIV
-Early detection -Screening -Helping individuals choose treatment options -Helping communities choose effective ways to limit spread of HIV
Employment Challenges with HIV
-Effects of illness -"It drags me down where I can't get out of bed sometimes because I get so fatigued" -Medication side effects -"If you want a job, it is difficult when you have doctor appointments...
AIDS-Related Complex is?
-Flu-like symptoms (fever, lymphadenopathy, weight loss, diarrhea, herpes, candidiasis) -Happens for 3-6 weeks (?) -Antibodies may be detected
Oral hairy leukoplakia
-From Epstein-Barr virus -Usually asysmptomatic -May cause alteration in taste -Treatment not required
CDC (2006) Recommends Screening all Teens, Adults & Pregnant Women
-General consent for medical care should be sufficient to encompass consent for HIV testing. -Appropriate post-test counseling -All patients in all health-care settings unless the patient declines (opt-out screening). -Annual screening: Persons at high risk for HIV infection -For pregnant women (HIV screening for all pregnant women/repeat screening in the 3rd trimester in geographic areas with high rates of HIV infection among pregnant women) -In NH: teens over age 14 may seek STD testing
HIV & AIDS 10 Year Trends
-Global reduction in new AIDS cases, mortality from AIDS & an increase in people living with HIV/AIDS (UN AIDS, 2010) -Incidence of new HIV infection in US was stable. -AIDS decreased d/t antiretroviral therapy (ART) +Prolongs time from HIV infection to progression to AIDS -Racial disparities continue -Reduced maternal/child transmission
HIV is?
-HIV (human immunodeficiency virus) is the virus that causes AIDS -HIV destroys a certain kind of blood cell (CD4+ T cells) which is crucial to the normal function of the human immune system -Early detection of infection allows for more options for treatment & preventative health care
Category B is?
-HIV Symptomatic -CD4 T lymphocyte count 200-499 cells/μL -Specified conditions associated with HIV exist -*Cannot revert to category A even if treated successfully*
AIDS is?
-HIV becomes AIDS when the immune system becomes damaged ,*<200 CD4+cells or an opportunistic infection* -A diagnosis of AIDS is made by a physician using specific clinical or laboratory standards -HIV 1 & HIV 2 Genotype (same transmission, different treatment)
Perinatal Transmission of HIV (2005)
-HIV can be passed during pregnancy, delivery & breastfeeding -Is the most common transmission route in children -Infants of HIV + moms will test + for HIV antibodies, but (hopefully) negative for the virus -Infection rate has decline d/t increased testing during pregnancy -Increased use of zidovudine (ZVD, AZT) in expectant mothers & newborns
Pre-Test Counseling for HIV Testing consists of?
-HIV risk -Prevention -Implication of positive & negative test -Assess supports/readiness to cope with results -Discuss implications of disclosure to others & if mandatory reporting to exposed individuals is required -Explain that positive results will be reported (anonymously) to CDC
Disclosure of Parental HIV Status to Children 5-17 years old
-Interviews with 274 HIV-infected parents -44% of their children were aware +11% worried they could catch HIV -Heterosexual parents, higher income, with higher CD4 counts, with more social isolation, & with younger children were less likely +Worried about the emotional consequences (67%) +Worried the child would tell other people (36%) +Did not know how to tell their child (28%).
HIV in the "Older 50" Crowd
-Less knowledge of safer sexual practices (education targets younger people) -Less need to use birth control (condoms) -Phosphodiesterase inhibitors (viagra) -Higher potential for drug interactions -CAD, diabetes & dyslipidemia appear earlier in HIV -Better adherence to therapy
NIH Statement on AIDS 12/13
-Less than 1/3 of HIV-infected individuals in the U.S. have suppressed viral loads -Undiagnosed HIV infection -Failure to link or retain diagnosed patients in care -Failure to take medications as prescribed.
Health Promotion in HIV
-Maintain social relationships +Work, friends, family +Referral to support groups -Make a plan to reduce transmission -Reduce cardiovascular risk (HIV is an independent risk factor for CAD) -Exercise regularly within limits of fatigue -Maintain a healthy diet -Avoid cigarettes, recreational drugs, etoh (70% of HIV + clients smoke cigarettes) -Seek treatment for depression (Suicide risk highest immediately after diagnosis)
Risk for Infection Interventions & Teaching
-Monitor for chills, fever, cough, urinary frequency, integrity of oral mucosa -Teach ways to avoid infection (use for anyone immunosuppressed): +Avoid eating out (especially buffets) +Use bottled water or boil water +Report signs of infection immediately +Household pets can be a source of infection +Avoid crowds during cold season +Annual flu shot +Inactivated vaccines only
Risk for Alteration in Nutrition, less than body requirements r/t decreased oral intake
-Monitor labs -Obtain diet history & preferences -Determine barriers to adequate intake -Initiate dietary consult (foods easy to swallow & HCHP diet) -Encourage rest before meals -Encourage oral hygiene after meals -Encourage social interaction during meals -Limit fluids one hour before meals -Encourage small, frequent meals -Consider viscous lidocaine before meals -Consider appetite stimulants (Megace, marinol)
Bacillary Angiomatosis
-Nodules on skin, larynx, diaphragm, GI tract -Gram negative bacillus -Use Erythromycin -Associated with exposure to cats
Evaluating the Outcome of Primary Prevention Activities with Individuals
-Practices safer sex, or abstains from sex -Women state risks & benefits of birth control options -Does not share needles -Attends prenatal visits, adheres to antiretroviral medication, plans for C/S, plans to bottle feed -Practices standard precautions
Promoting Optimism in HIV/AIDS: Cognitive Coping Skills
-Provide "Presence" & show empathy -Regulate emotional response to symptoms -Describe feelings +Recognize unhelpful thoughts +Raise awareness of how unhelpful thoughts effect emotional state -Promote positive self-talk & "reframing" -Help generate more positive thoughts -Support & reinforce cognitive coping skills
Recreational Drug Use
-Reduced inhibition (drugs or alcohol, less likely to use "protection") -Sharing needles, referral to: +Drug treatment programs +Methadone weaning programs +Needle exchange programs +Syringe vending machines (Europe) -Needle sharing is very high risk (10% of new HIV infections)
Benefits of Early Treatment
-Reduces disease progression -Lower risk for opportunistic related problems (Neuropathy, TB, opportunistic malignancies, CNS involvement/HIV effects brain function) -Lower risk of non-opportunistic related complications (CAD, renal & liver problems) -Reduced transmission
AIDS Reporting in N.H.
-Required by the lab & the provider -NHDHHS HIV program specialist contacts the 'index' client +Informs about follow-up & treatment +Solicits names of contacts +Much like an STD investigation. +The contacts will be 'strongly encouraged' to seek testing & offered such testing +No information about the index client is revealed +Insurance companies are not notified of test results in N.H.
Deficient knowledge r/t retroviral medication (as an RN...teach)
-Review common side effects -Administered with food? -Consider anti-emetic before dose if nausea occurs -Consider bulk-forming products if diarrhea occurs (metamucil) -Seek medical attention for worsening symptoms -Immune reconstitution syndrome -Disease progression -Anticipatory guidance re: expected effects -Lipodystrophy; body image changes -Liposuction, diet, exercise -Medication schedule -Drug interactions/OTC meds -Resistance/rebound with non-adherence
Planning for Individual Health Education perform during?
-Routine health visits -Maternal health visits -Orientation to a new job -Workers -Hospitalization -Recreational drug users -Visits to prison infirmary -Incarcerated individuals
Tests with Quick Turnaround
-Saliva +Results in 20 minutes +HIV immunoassay in 3 hours +"OraQuick" is now OTC +Must be confirmed with laboratory testing (false +) *Used when delay could seriously effect treatment*
Collaborative Program Evaluation (*Outcome*)
-Self-report of use of clean needles, or no needles -Self-report of safe sex practices -Access to condoms & "clean" needles -Observed adherence to standard precautions -Lower rate of HIV infection
Members of high risk groups for HIV are?
-Sexually active adolescents & adults & elderly -"Do you sleep with men, women or both?" -Recreational drug users -Infants of infected mothers -Incarcerated individuals -Certain occupations -Those requiring frequent blood transfusion
HIV Infection in Infants
-Study of untreated HIV positive infants 18-30 months old -Mean cognitive development was 7.63 months delayed -Mean motor development was 9.65 months delayed -Language delay in 82.5% -Disease progression or HIV encephalopathy
Continued Use of Health Care
-Supportive -Informed -Non-judgmental -Know your own biases & feelings ("Treat us like we're normal-as if we have any other disease, like heart disease or cancer") -Empower clients with knowledge -Reduce uncertainty by providing anticipatory guidance
Teens with HIV
-Teens with peri-natal acquired HIV -HIV infection delays onset of puberty -Interviews with 40 HIV + youths aged 16-18 28% of HIV+ youth at Time 1 & 41% at Time 2 reported being sexually active. -73% used condoms, 30% felt they knew how to use it correctly, & 41% felt they could discuss HIV prevention with their partner. -HIV positive teens need education!
Negative Test Means?
-There are no HIV antibodies in the blood -It takes 3 weeks to 6 months to build antibodies -Either the person is not infected, or they have not yet developed antibodies -Continue to take precautions -High risk individuals should be retested
Perceptions of Health Care Providers for HIV/AIDS
-Treated with discourtesy & lack of respect ("Don't treat me like the last one on the food chain") +Non-HIV related problems not addressed -Lack of knowledge of providers ("I've fired 4 doctors since the beginning. My 1st doctor told me... I had to go on AZT right away, & I asked him what are my chances, & he says, 'The AZT usually works for 2 yrs & then most people die.' It took me a while through counseling to get through that, & then when I did find this self-empowerment, I fired him...")
Family Adaptation to HIV/AIDS
-Uncertainty about the illness (knowledge about disease management) -Social support? (rejection by family, church, care-givers) -Optimistic expectancies (buffer against stress) -Coping & problem-solving abilities (positive role models, support groups, "motivational speakers")
Nursing Responsibilities in Post-Test Counseling
-Unless nurses are specially trained, physicians disclose results -Be present -Offer opportunity to vent -Help clarify next steps -Decision re: disclosure -Decision re: early treatment -Assess emotional response -Refer to services
Collaborative Program Implementation
-Use community strengths -Prepare for community resistance -Include "naysayers" in program -Build community capacity
Safer Sex: WSM (women who sleep with women)
-Viral load is higher in sperm than vaginal secretions -Latex condoms -How to insert & remove a female condom -How to use a male condom -Condoms reduce rate of seroconversion by 1% annually compared to a 7.2 % conversion rate without condoms
Primary Prevention: What to do in case of occupational exposure
-Wash wounds & skin with soap & water -Flush mucous membranes with water -Incident report -Employee health -Source tested for HBsAg, anti-HCV and HIV -Pregnancy testing -Initiate post-exposure prophylaxis within hours -Follow-up testing
Viral Set Point is?
-When balance is achieved between immune response & HIV virus -CD 8 lymphocytes attack extracellular HIV particles -*HIV moves to lymphatic system*
Youth Perspective of HIV
-Youths (<25)comprise 50% of new HIV dx -Feelings of isolation, loneliness & hopelessness -Barriers to full participation in society -Specific support needs -Difficulty accessing appropriate support services -Need specialized health & support services that are developmentally appropriate
Health Education for HIV + Women
1) *Prenatal, perinatal, postnatal* -ART meds during pregnancy reduces the rate of perinatal transmission to 0.1% -C-section is recommended -Breast feeding is discouraged in the US (CDC,2010) 2) *Health promotion post-partum* -Some protease inhibitors reduce effect of oral contraceptives -Gynecologic infection & malignancy are more common in HIV+ women
Treatment Failure
1) *Stopping therapy causes rebound HIV replication* -Drug holidays not recommended -Adherence is critical (causes rapid rate of replication) 2) *Rapid rate of mutation* -Combination therapy required -"Hit it hard & fast" from a variety of angles -Resistance develops quickly -Prolonged therapy increases resistance -Decision to begin therapy in adults when asymptomatic is difficult -Early therapy always recommended in infants -Infant reported to be "cured" was started on HAART within 30 hours of delivery.
AIDS Prevention
1) *Vaccine?* -Parents are resistant to the HPV vaccine... denial of sexual activity, etc... 2) *PrEP* (Approved April 2012) -Oral once daily tenofovir disoproxil fumarate plus emtricitabine (TDF/FTC) -Indication: sexually active men & women not consistently using safer sex practices 3) *PEP*: antiretroviral taken for 28 days to decrease the likelihood of contracting HIV
Tracking HIV/AIDS Progression
1) CD4 T-cell counts 2) Viral Load Tests (HIV RNA) -Better predictor for progression to AIDS -Also used to detect HIV in high risk seronegative cases before HIV-1 antibodies are detectable -"Undetectable" levels do not equate "cure" -Can still transmit the disease
What type of precautions would you use for Herpes Zoster?
Airborne (full contact precautions)
Terms
Anergy Cytomegalovirus HIV encephalopathy Kaposi's sarcoma CDC categories Opportunistic infection Window period Pneumocystis jiroveci pneumonia Primary infection Retrovirus Viral load test Enzyme-linked immunosorbent assay Wasting syndrome
Collaborative programs focus on what?
Community strengths
What should be taught to the parents of children with positive HIV?
Counsel the parents on how to disclose HIV status to their children
Nurses don't do what regarding tests?
Disclose results
What is something you can't do with needle care?
Don't recap needles!!!
Lewis terms Category A HIV as?
Early chronic infection
What do HIV positive teens need?
Education
Needle sharing in prisons is from?
Homemade needles, tattoos, & drugs
CD4 T cell is crucial to what?
Immune function
Lewis terms Category B HIV as?
Intermediate chronic infection (CD4 T: <500)
Lewis terms Category C as?
Late chronic infection (CD4 T: <200)
HIV RNA Assay is what?
More definitive testing for someone highly suspicious of having HIV
Needle exchange sites are illegal in what state?
NH
Suspected Occupational HIV Transmission 1981-2010 N=143
Nurses: 36 Health Aides: 14 Lab Worker: 17 Physicians: 13 Housekeeper: 14 Surgeon/surgical tech: 8 Paramedics: 12 Dental worker: 6
Selzentry/Maraviroc is used for what?
Someone with resistant HIV
Immunodeficiency means?
The disease is characterized by a weakening of the immune system
Why is formula prohibited for infants with HIV positive mothers in foreign countries?
Water in foreign countries is contaminated with deadlier viruses. It's better to have the infant be HIV positive than to consume toxic water.