Chapter 35 HIV Presentation

1Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

HIV- AND AIDS-

RELATED

DRUGS


Immune System Structure

Immune system function

Antigen-Antibody-mediated immunity Acquiring antibody-mediated immunity

Cell-mediated immunity Protection provided by cell-mediated immunity


The Immune

System To

The Rescue


HIV Infection Pathophysiology

HIV is an RNA retrovirus.

HIV is unable to survive and replicate unless

it is inside a living human cell.

HIV destroys CD4+ T cells.

The destruction of CD4 cells by HIV results in

immune deficiency.

The CD4 cell count is an indicator for immune

function in those with HIV.

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HIV Life Cycle

The Life Cycle of the Human Immunodeficiency Virus.

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HIV Life Cycle



HIV Transmission

HIV is spread via intimate contact with blood,

semen, vaginal fluids, and breast milk.

Sexual contact

Direct blood contact

Mother to child


Routes of Transmission

Intimate sexual contact

Exposure to blood and body fluids

Mother to child


Laboratory Testing

CD4 T-cell count

Plasma HIV RNA quantitative assay (or viral

load [VL] test)

HIV resistance testing

Additional laboratory evaluation


Classification

Staging and classification systems

U. S. Centers for Disease Control and Prevention

(CDC)

• CD4 cell counts

• Presence of specific HIV-related conditions

• System is based on the lowest documented CD4 cell

count (nadir CD4) and on previously diagnosed HIV-

related conditions.

World Health Organization (WHO)

• Classifies HIV disease on the basis of clinical

manifestations that can be recognized by clinicians in

diverse settings and those with varying levels of HIV

expertise and training


Treatment Goals of ART

Anti-retroviral Therapy Reduce HIV-associated morbidity and

mortality

Prolong the duration and quality of life

Restore and preserve immunologic function

Maximally and durably suppress plasma HIV

viral load

Prevent HIV transmission


Indications for Antiretroviral

Therapy HIV-infected individuals

HIV-infected pregnant patients

Patients with a history of an AIDS-defining

illness

Patients with HIV-associated nephropathy, or

HIV and hepatitis B coinfection

Serodiscordant couples


Antiretroviral Agents

Reverse transcriptase inhibitors

Nucleoside/nucleotide reverse

transcriptase inhibitors (NRTIs)

Action

Take NRTIs with food (except Didanosine

should be taken 1 hour ac or 2 hours pc).

Side effects, adverse effects


HAART

Highly active antiretroviral therapy

(HAART) is the current treatment

recommendation. Regimens

• Two nucleosid/nucleotide reverse transcriptase

inhibitors (NRTIs)

• Either nonnucleotide reverse transcriptase inhibitor

or ritonavir-boosted (NNRTI) or unboosted protease

inhibitor (PI)

Typical results • Decreased viral load to undetectable levels

• Improved CD4+ T cell count


Antiretroviral Agents

Goals of antiretroviral therapy Decrease VL to undetectable levels

Preserve and increase number of CD4+ T cells

Prevent resistance

Have client in good clinical condition

Prevent secondary infections and cancers

Antiretroviral classification Reverse transcriptase inhibitors

• Nucleoside analogues

• Nonnucleoside analogues

Protease inhibitors

Entry inhibitors


Action Place of HIV Drugs



Antiretroviral Agents (Class 1)

Reverse transcriptase inhibitors Nucleoside/nucleotide reverse transcriptase

inhibitors (NRTIs)• Zidovudine (Retrovir), Didanosine (Videx)

• Stavudine (Zerit), Lamivudine (Epivir)

• Abacavir (Ziagen), Tenofovir (Viread)

• Emtricitabine (Emtriva)

Action

Take NRTIs with food (except didanosine

should be taken 1 hour ac or 2 hours pc)



Antiretroviral Agents (cont’d)

Reverse transcriptase inhibitors Nonnucleoside reverse transcriptase inhibitors

(NNRTIs)• Efavirenz (Sustiva)

• Delavirdine (Rescriptor)

• Nevirapine (Viramune)

Action

Adverse effects


Reverse

transcriptase

inhibitors



Protease inhibitors Currently FDA approved:

• Lopinavir/ritonavir (Kaletra), atazanavir (Reyataz),

fosamprenavir (Lexiva), etc.

Action



Protease

inhibitors



Entry inhibitors Enfuvirtide: only agent approved in this class

Action

Administration

Side effects, allergic reactions



CCR5 Antagonists Maraviroc (Selzentry)

Action

Side effects• Upper respiratory infection, cough, pyrexia

Adverse effects• Hepatotoxicity



Integrase inhibitors Raltegravir (Isentress)

Action

Side effects• Headache, pyrexia, nausea, diarrhea


Immune Reconstitution

Inflammatory Syndrome (IRIS) Related to specific opportunistic pathogens

Experienced by a low percentage of patients

early in ART

Two distinct entities

Paradoxical IRIS, which is an exacerbation of

treated (successful or partial) opportunistic

infection (OI)

Unmasking IRIS, a response to undiagnosed or

subclinical OI

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Adherence

Suggestions to promote client adherence Client understanding of each medication’s

purpose

Food and fluid restrictions

Recommended food choices

Storage of medications

Appropriate recording sheet

Contact person for questions


Nurse’s Role in Antiretroviral

Therapy

Drug regimen adherence

Nonadherence results

HIV viral replication

Increased viral loads

Immune system deterioration

Drug resistance

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Most Common HIV-Related

Opportunistic Infections/Diseases

Bacterial TB, MAC, pneumonia, septicemia

Protozoal PCP, toxoplasmosis,

cryptosporidosis, leishmaniasis

Fungal Candidiasis, crytococcosis

Viral Cytomegalovirus, herpes simplex,

herpes zoster

HIV Associated malignancies: Kaposi’s

sarcoma, lymphoma, squamous

cell carcinoma


Antiretroviral Drug Therapy In

Pregnancy

Timing of initiation of treatment and

the selection of regimens for

pregnant patients may differ from

those for non-pregnant adults or

adolescents.

Goal is to prevent mother-to-child

transmission.

A patient infected with HIV can

transmit the virus during pregnancy,

labor, and delivery, and through

breastfeeding.


Antiretroviral Therapy

in Pregnancy

Pregnant women

FIRST, YOU MUST ESTABLISH IF THE WOMAN IS HIV+

• If YES, SCREENING IS CRUCIAL

IF THE HIV + WOMAN IS NOT ALREADY ON HAART THERAPY IT IS STARTED AFTER WEEK 14

• WHY ? DUE TO THE TERATOGENIC POTENTIAL OF SOME OF THE DRUGS IN THE FIRST TRIMESTER OF PREGNANCY

THEN CONTINUED FOR THE DURATION OF THE PREGNANCY.

THEN SHE RECEIVES THE DRUG ZDV IV DURING LABOR/DELIVERY


Occupational Exposure to HIV

and Postexposure Prophylaxis

Postexposure prophylaxis

regimens (PEP)

PEP regimen should be initiated

within hours of the event and

continued for 4 weeks.

Health care workers taking PEP

have reported adverse reactions

at rates of 17% to 47%, with the

most common reactions being

nausea, malaise, and fatigue.


Postexposure Prophylaxis

(PEP) for Health Care Workers

Institution specific

Must be made available to all employees. See

Table ??? Treatment is for 4 wks minimum.

Available to all employees

lab techs, nurses and surgery staff are at high risk.

Will be counseled and have a baseline test from worker & client if status is unknown. Retested at 3, 6, & 12 mo. marks


Postexposure Prophylaxis

(PEP) for Health Care Workers

Comprehensive reference:

MMWR 47 (RR-7): May 15, 1998

Will be counseled and have a baseline test from worker & client if status is unknown. Retested at 3, 6, & 12 mo. marks. DON’T EVER RECAP AN NEEDLE! WATCH WHAT YOU ARE DOING! LOOK AT THE NEEDLE BOX WHEN YOU PUT SOMETHING IN! CHANGE NEEDLE BOXES WHEN THEY ARE 2/3RDS FULL!!!!


Practice Question #1

A patient asks the nurse what part of the body

is most affected by the HIV virus. The nurse

informs the patient that HIV primarily affects

which system?

A. Cardiovascular

B. Immune

C. Renal

D. Hepatic

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When providing teaching for the patient being

discharged home on antiretroviral therapy for

HIV, which statement will the nurse include?

A. Do not eat raw fish.

B. Limit food intake to proteins only.

C. Avoid ingesting bananas.

D. Applesauce may cause you to experience side

effects of the medication.

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The nurse identifies which condition as a

common bacterial opportunistic infection seen

in patients with HIV?

A. Cytomegalovirus

B. Candidiasis

C. Toxoplasmosis

D. Tuberculosis

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A health care provider has been exposed to

HIV while caring for a patient. Following the

postexposure prophylaxis regimen (PEP), the

health care provider will most likely receive

treatment for how long?

A. 1 week

B. 2 weeks

C. 3 weeks

D. 4 weeks

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Nurse’s role

Drug regimen adherence

Nonadherence results HIV viral replication

Increased viral loads

Immune system deterioration

Drug resistance


Explain prophylactic treatment for

opportunistic infections

Common CD4 cell count below 350

cells/ml:

Herpes simplex virus: tx includes acyclovir,

famciclovir, or valacyclovir

Herpes zoster virus: tx includes acyclovir,

famciclovir, or valacyclovir

Tuberculosis infections: tx isoniazid,

pyridoxine, rifampin, pyrazinamide, and

ethambutol


The Haunted House of

VIR





cells/ml:

Kaposi sarcoma: tx depends on location

• Local lesions: tx vinblastine

• Radiotherapy for areas i.e around eyes and face

• Chemotherapy for severe widespread disease





cells/ml:

Candidal infections: tx fluconazole or

itraconazole

Bartonella infections: tx erythromycin,

clarithromycin, azithromycin and doxycycline

Pneumocystis carinii pneumonia: tx Bactrim,

Septra, clindamycin, oral primaquine





cells/ml:

Toxoplasmosis encephalitis: tx pyrimethamine,

sulfadiazine, clindamycin, leucovoran

Common CD4 cell count below 50 cells/ml:

Mycobacterium avium complex: tx

clarithromycin, azithromycin, ethambutol,

rifabutin

Cytomegalovirus infection: tx ganciclovir,

valganciclovir, foscarnet, cidofovir



in Newborns

Newborns

FOLLOWING DELIVERY, THE INFANT IS GIVEN ZDV FOR 6 WEEKS STARTING 6-12 HOURS AFTER BIRTH.

IN THE U.S. THE MOTHER WILL FORMULA FEED THE INFANT.

KEEP IN MIND THAT FORMULA FEEDING REQUIRES A CLEAN WATER SUPPLY, SO SOMETIMES THAT IS NOT AN OPTION IN PARTS OF THE WORLD.



The nurse realizes that the component of client

goals for HAART therapy includes all of the following

except:

A. The viral load is undetectable.

B. The CD4+ count is as low as possible.

C. Secondary infection does not occur.

D. Medication regimen is adhered to.


Practice Question #1 (cont’d)

Answer: B

Chapter 35 HIV Presentation

Education

Transcript of Chapter 35 HIV Presentation