Care of Patients with HIV/AIDS

1. Care of Patients with HIV/AIDS

2. Transmission of HIV • HIV is an obligate virus • It cannot survive very long outside of the human body • Transmitted from human to human • Blood • Semen • Cervicovaginal secretions • Breast milk

3. Transmission of HIV • Other body fluids contain HIV; no evidence they are capable of transmission • Saliva • Urine • Tears • Feces

4. Transmission of HIV • Conditions that affect the likelihood of infection include: • Duration and frequency of exposure • Amount of virus inoculated • The virulence of the organism • The host’s defense capability

5. Transmission of HIV • Sexual transmission • Anal or vaginal intercourse • Parenteral exposure • Contaminated drug injecting equipment and paraphenalia • Transfusion of blood and blood products • Occupational exposure • Perinatal (vertical) transmission • Transmission from mother to child • May occur during pregnancy, delivery, or postpartum breastfeeding

6. Pathophysiology • Normal immune response • Foreign antigens interact with B cells • B cells initiate antibody development • B cells and T cells initiate cellular immune response • B cells reduce virus in blood • T cells reduce virus in lymph nodes

7. Pathophysiology • Immune dysfunction • T-cells or CD4+ lymphocytes are destroyed by HIV • HIV is then able to reproduce in the lymphatic system and eventually “spills over” into the blood • Helper T cells (CD4, or T4 cells) • T-helper cells contain CD4 receptors • Considered the “conductor” of the immune system because of their secretion of cytokines which control most aspects of the immune system

8. Pathophysiology • Immune dysfunction cont. • Helper T-cells cont. • These are the major target of HIV • Progressive Infection gradually destroys the available pool of T-helper cells overall CD4 cell count drops. • Lower CD4 cell counts correspond with more immunodeficiency  onset opportunistic infections

9. Pathophysiology • Decreases resistance to life-threatening infections • CD4+ 600-1200 = normal • CD4+200-499 = minor immune problems • CD4+ below 200 = severe immune problems

10. Pathophysiology • HIV is a member of the lentivirus (slow virus) family of retroviruses. • HIV carries its genetic material in RNA (rather than DNA) • HIV replicates by converting RNA into DNA • As an “obligate parasite”, it cannot replicate unless it is inside another living cell

11. Pathophysiology • Both cellular and humoral immune mechanisms limit HIV replication and slow down disease progression • Initial infection with HIV  viremia during which large amounts of the virus can be isolated in the blood • Amts as high as 10 mil. Particles of HIV per ml • Up to 10 bil. Particles of HIV are produced and cleared daily in an infected individual

12. Pathophysiology • The massive production of HIV is coupled with the production and destruction of nearly 2 bill. CD4 lymphocytes each day • The amount of virus in the blood is directly linked to the rate of virus production, which determines the rate of CD4 cell destruction

14. Spectrum of HIV • HIV disease is a broad diagnostic term that includes the pathology and clinical illnesses caused by HIV infection. • AIDS(Acquired Immunodeficiency Syndrome) is defined as an acquired condition that impairs the body’s ability to fight disease • The end stage of a continuum of HIV infection • CD4 count < 200

15. Spectrum of HIV • HIV infection may exist for many years without symptoms before it progresses to symptomatic HIV disease • Asymptomatic HIV infection • HIV seropositivity (seroconversion) • Positive HIV antibody test95% within 3 months; 99% within 6 monthsInfectious; no illness

16. Acute Retroviral Syndrome • Initial exposure • Virus replication occurs during the acute infection period • The viral load peaks in millions of copies of virus per milliliter right before the appearance of detectable antibodies can be measured in the blood. • Viral “set point” = stabilizing of the viral load; usually reached in 4-6 months after exposure

17. Acute retroviral syndrome • Seroconversion: the development of antibodies from HIV • Takes place approx. 5 days -3 months after exposure • Accompanied by a flu-like or mononucleosis-like syndrome with fever, night sweats, pharyngitis, headache, malaise, arthralgias, myalgias, diarrhea, nausea, and a diffuse rash pominent on the trunk

18. Early infection • Early HIV disease • Signs and symptoms may not appear until 10-14 years after exposure • Symptomatic infection • Persistent, unexplained fever • Night sweats • Diarrhea • Weight loss • Fatigue

19. Early symptomatic disease • CD4+ cell count drops below 500 cells/mcl • Persistent, unexplained fevers • Drenching night sweats • Chronic diarrhea • Headaches • Fatigue • Lymphadenopathy • Recurrent or localized infections • Neurological manifestations

20. Diagnostic Studies • HIV antibody testing • ELISA • Detects the presence of HIV antibodies • If positive, ELISA is done a second time • Western blot • Done if second ELISA is positive • More sensitive than ELISA

21. Diagnostic Studies • Seropositive • All three tests are positive (ELISA x 2 and Western blot) • Does NOT mean the person has AIDS • Seronegative • Not an assurance that an individual is free from HIV infection • Seroconversion may not have occurred yet

22. Diagnostic Studies • CD4+ lymphocyte count • Normally 600-1200 mcl • Decreases as the disease progresses • Best marker for the immunodeficiency associated with HIV infection • Viral load monitoring • Level of virus in the blood • Provides significant information toward predicting the course of the disease

23. Therapeutic Management • Therapeutic management focus • Monitoring HIV disease progression and immune function • Preventing the development of opportunistic diseases • Initiating and monitoring antiretroviral therapy • Detecting and treating opportunistic diseases • Managing symptoms • Preventing complications of treatment

24. Therapeutic Management • Pharmacological management • Antiretroviral therapy • Nucleoside Reverse Transcriptase Inhibitors: inhibit activity of reverse transcriptase • Abacavir (Ziagen • Didanosine (Videx): • Lamivudine (Epivir) • Stavudine (d4T, Zerit) • Zidovudine (Retrovir, AZT) • Zalcitabine (ddC, Hivid) • Tenofivir(Viread)

25. Therapeutic Management • Pharmacological management • Antiretroviral therapy • Non-nucleoside reverse transcriptase inhibitors • Nivirapine (Viramune) • Delavirdine (Rescriptor) • Elfavirenz (Sustiva)

26. Therapeutic Management Alternative and complementary therapies • Massage • Acupuncture • Acupressure • Biofeedback • Nutritional supplements • Herbal remedies

27. Pulmonary Opportunistic Infections • Most common opportunistic diseases associated with HIV • Pneumocystiscarinii (now called jiroveci) pneumonia (PCP) -most common bacterial infection

28. Pulmonary Opportunistic Infections • PneumocystisCarinii (jirovici) • Symptoms • Fever; night sweats; productive cough; SOB • Treatment • Bactrim or Septra; pentamidine; steroids • Wear gown, mask, and gloves during patient care

29. Pulmonary Opportunisitc Infections • Histoplasmosis – fungal infection • endemic in central, southern US • Spores inhaled, original infection in lung • Can be disseminated to other organs • Symptoms: fever, night sweats, weight loss, dyspnea • Education: Avoid areas where fungus is common: disturbed soils, chicken coops, caves; do not clean bird cages

30. Histoplasmosis

31. Pulmonary Opportunisitc Infections • Tuberculosis –bacterial-infection • More likely if CD4 counts drop below 200 cells/mm3 • Treated with INH (isoniazid), rifampin, pyrazimide

32. Gastrointestinal Opportunisitc Infections • Mycobacterium avium Complex -bacterial • M. aviumcausative agent, found everywhere • May affect any organ of body • Symptoms: fever, fatigue, weight loss, night sweats, diarrhea, abd. pain • Depending on organism

33. Gastrointestinal Opportunistic Infections • Cytomegalovirus (CMV) - viral • Found in semen, cervical secretions, saliva, urine, blood, organs • Transmitted through blood, body fluids through unprotected sex • Complications of CMV for patients with AIDS include retinitis, radiculopathy, encephalitis, colitis, esophagitis, pneumonia • Treatment: Gancyclovir, Foscarnet

34. Gastrointestinal Opportunistic Infections • Cryptosporidosis –parasitic - infection • Fairly common in environment • Special threat when CD4 count falls below 200 cell/mm3 • Symptoms: watery diarrhea that may be severe, persistent dehydration, electrolyte imbalance • Treatment: maintain F/E balance, treat infection, good hygiene, avoid ingestion of contaminated water

35. Oral Opportunistic Infections • Oral/esophageal candidiasis - fungal • Caused by Candida albicans, found in most soils, foods • Approx 80% HIV pts. will develop • Symptoms: whitish yellow patches in mouth, esophagus, GI tract, vagina, anus • Treatment: Nystatin, chlortrimezole, ketoconazole, fluconazole, itraconazole, amphotericin B

36. Oral Candidiasis

37. Oral Opportunistic Infections • Oral Hairy Leukoplakia (OHL) viral • Associated with Epstein-Barr virus, more common among smokers • Thick white patches on buccal mucosa, soft palate, floor of mouth, tongue • Plaques cannot be scraped off (unlike candida) • Often painful-ice cream, popsicles to numb area

38. Oral Hairy Leukoplakia

39. Gynecological Opportunisitc Infections • Vaginal candidiasis - fungal • Persistent infection - can be early indicator of HIV • Cervical intraepithelial neoplasia - cancer

40. CNS Opportunistic Infections • AIDS dementia complex • Triad of cognitive, motor and behavioral dysfunction, progressive • Zidovidine may help

41. CNS Opportunistic Infection • Toxoplasmosis parasitic • Caused by Toxoplasma gondii; cats, mammals, birds are host agents • Humans infected by ingesting contaminated undercooked meat, vegetables; contact with cat feces • Can affect any tissue in body, but mostly brain, lungs, eyes • In HIV, encephalitis most common form

42. CNS Opportunistic Infections • Toxoplasmosis • Symptoms include dull constant HA, weakness, seizures, altered LOC, hemiparesis, tremor, visual field defects, photophobia • Bactrim used to tx. • Education: wash hands, avoid undercooked, raw meat, avoid cat litter boxes

43. CNS Opportunisitc Infection • Cryptococcosis fungal • Causative agent Coccidiodes immitis; endemic in SW US and N Mexico • Most common systemic fungal infection in AIDS patients • Symptoms appear ~ 30 d after exposure fever, HA, malaise, N/V, altered LOC, stiff neck

44. Opportunistic Malignancies • Kaposi’s sarcoma (KS) • Thought to be caused by sexual transmission of human herpes virus 8 • Affects skin first-macular, painless, nonpruritic lesion • Varies in color-pink, red, purple, brown • Symptoms develop when spreads to GI tract (bleeding), lungs (hypoxia)

45. Opportunistic Malignancies • Kaposi’s sarcoma • Diagnosed by appearance, biopsy • No cure, treatment is palliative • Treatment: observation, surgical removal, cryotherapy, radiotherapy, chemotherapy

46. Kaposi’s Sarcoma

47. Opportunistic Malignancies • Lymphomas • Immunodeficient patients have 14x greater risk of getting lymphomas • Non-Hodgkin’s lymphoma (NHL) second most common malignancy in pts with AIDS • Symptoms: vague, include fever, night sweats, weight loss. • A fever longer than 2 weeks suggests lymphoma

48. Opportunistic Malignancies • Non-Hodgkin’s lymphoma • Diagnosis based on biopsy of lymphoid tissue • Survival rates: • CD4 higher than 100 cells/mm 3 -24 months • CD4 less than 100 cells/mm 3-4.5 months • CNS affected-2 months

49. Nursing Interventions • Patients need to be treated in a nonjudgmental and caring manner regardless of their sexual practices or history of drug use • Must see the patient as a unique individual with a need to be cared for with compassion, consideration, and dignity

50. Nursing Interventions • Knowledge of HIV transmission and competence in standard precautions and body substance isolation • See Box 16-3 p. 794 of AHN text re: subjective and objective data of the Nursing Assessment for the pt. with HIV infection • See Box 16-4 p. 796 for a summary of Nursing Interventions for the pt. with HIV infection or HIV Disease