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HIV Disease Complications

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Title: HIV Disease Complications


1
HIV Disease Complications
  • Patricia P. Gilliam, MEd, MSN, ARNP, BC
  • Nurse Practitioner, HIV Services
  • Tampa General Hospital Infectious Disease Center
  • Hillsborough County HD- Specialty Care Center
  • Faculty, Florida/Caribbean AETC
  • Tampa, Florida

2
Learning Objectives
  • 1. Identify potential complications of the
  • progression of HIV Disease when
  • CD4 is
  • 2. Identify and discuss potential complications
    related drug therapy

3
Stages of HIV Disease Progression
  • Acute Retroviral Syndrome
  • Asymptomatic HIV infection
  • Symptomatic HIV infection
  • AIDS defining illnesses
  • AIDS

4
Each Patient is Unique!
  • Each patient is a person, not simply a CD4 count
    and viral load.
  • The uniqueness of the HIV-infected patient
    creates many issues to address.
  • Medical issues surrounding a chronic disease with
    many unknowns
  • Psychosocial and economic issues which will
    impact health disease progression
  • Pharmacogenomics / Genetic Polymorphisms

5
Roles of the Nurse
  • Assessment
  • Diagnosis of Nursing Problems
  • Planning
  • Intervention
  • Collaboration with Providers
  • Direct Care
  • Patient Education
  • Evaluation

6
Clinical Categories
7
Updated DHHS Guidelines (Oct. 2004)When to Start
Treatment
8
HIV Disease Complications
  • HIV Disease Progression
  • Related to declining CD4 cell counts as they
    approach

9
Evidence of Mild Immune Deficiency (CD4 cell
count 200-500 cells/ml)
  • Oral candidiasis or thrush
  • Recurrent vaginal candidiasis
  • Recurrent herpes zoster
  • Especially 1 dermatome
  • Recurrent herpes simplex
  • Tuberculosis
  • Neurological abnormalities
  • Bells Palsy

10
Clinical Categories
11
Category B conditions
  • Listeriosis
  • Pelvic Inflammatory disease
  • Idiopathic thrombocytopenic purpura
  • Recurrent bacterial endocarditis, meningitis, or
    sepsis
  • Persistent or resistant vulvovaginal candidiasis

12
Category B conditions (cont.)
  • Constitutional symptoms, such as fever 38.5 C
    or diarrhea lasting 1 month
  • Nocardiosis
  • Peripheral neuropathy
  • Oropharyngeal candidiasis
  • Herpes Zoster involving at least 2 episodes of
    more than 1 dermatome

13
Clinical Categories
14
AIDS Defining IllnessesAKA AIDS-Indicator
Conditions
  • Bacterial pneumonia
  • Cervical CA, invasive
  • Candidiasis of bronchi, trachea, lungs or
    esophagus
  • Coccidioidomycosis (disseminated or
    extrapulmonary)
  • Cryptococcosis, extrapulmulmonary
  • Cryptosporidiosis, chronic intestinal (1 month)
  • CMV Disease (other than liver, spleen or nodes)
  • CMV retinitis (with loss of vision)

15
AIDS Defining Illnesses cont.
  • Kaposis sarcoma
  • Lymphoma, Burkitts
  • Lymphoma, immunoblastic
  • Lymphoma, primary in brain
  • HIV encephalopathy
  • Herpes simplex chronic ulcers 1 month or
    bronchitis, pneumonitis, or esophagitis
  • Histoplasmosis (dissem. or extrapulmonary
  • Isosporiasis, chronic intestinal (1 month)

16
AIDS Defining Illnesses cont.
  • Mycobacterium avium complex or M. kansasii
    (disseminated or extrapulmonary)
  • Mycobacterium, other species, disseminated or
    extrapulmonary
  • Pneumocystis pneumonia
  • Progressive multifocal leukoencephalopathy
  • Salmonella septicemia, recurrent
  • Toxoplasmosis of brain
  • Wasting syndrome (wt. loss 10 baseline body
    weight, associated with chronic diarrhea or
    fever)

17
Incidence of AIDS Indicator Conditions
  • Pneumocystis carinii Pneumonia 38
  • AIDS Wasting Syndrome 18
  • Candidiasis (esophageal, tracheal) 16
  • Kaposis sarcoma 7
  • HIV-associated dementia 5
  • Recurrent bacterial CAP
  • Mycobactium avium, disseminated
  • Cryptococcosis, extrapulmonary
  • (Bartlett, 2004)

18
Prevention of Disease Progression
  • Prevention of Immune System Deterioration
  • HAART
  • Prevention of OIs
  • Prophylactic medications
  • Patient Education

19
Preventing Exposure to OIs
  • Sexual exposure
  • IVDU exposure
  • Environmental and occupational exposure
  • Child-care provider and parental exposure
  • Pet related exposures Food and Water-related
    exposure
  • Travel related exposure

20
  • 2001 USPHS/IDSA Guidelines for the
  • Prevention of Opportunistic Infections in
    Persons Infected with Human Immunodeficiency
    Virus. Recommendations to Help Patients Avoid
    Exposure to or Infection with Opportunistic
    Pathogens. Appendix pp. 61-65
  • http//www.aidsinfo.nih.gov/guidelines/op_infectio
    ns/OI_112801.html

21
Clinical Management of the HIV-Infected Adult A
Manual for Midlevel Clinicians (March, 2003)
  • This manual is available in both print and
    compact disk formats from the Southeast AIDS
    Training and Education Center (SEATEC) and from
    the Midwest AIDS Training and Education Center
    (MATEC), through the communication channels
    below. In addition, the manual is downloadable
    from the Internet site of the AIDS Education and
    Training Center National Resource Center at
  • http//www.aids-etc.org/pdf/tools/se_midlevel_2003
    .pdf

22
Prophylaxix to Prevent OIs
  • PCP pneumonia
  • Toxoplasmosis
  • Mycobacterium Avium Complex

23
PCP pneumonia
  • Given to prevent a primary episode or a
    recurrence of infection
  • Recommended to all HIV patients with a CD4
  • Prophylactic Treatment Recommendations
  • TMP-SMX
  • Dapsone
  • Aerosolized pentamidine

24
Toxoplasmosis
  • Test for presence of Toxo IgG Ab
  • If IgG negative, counsel to avoid sources of
    infection
  • Raw or undercooked meats
  • Garden soil
  • Avoid stray cats
  • Keep pet cats indoors and feed commercially
    prepared cat food
  • Prophylactic treatment is recommended to all HIV
    Toxoplasmosis IgG positive patients with a CD4
  • Prophylactic Treatment Recommendations
  • TMP-SMX
  • Pyrimethamine Dapsone Leukovorin
  • Dapsone alone is ineffective

25
DMACdisseminated mycobacterium avium complex
  • Prophylactic treatment is recommended to all HIV
    patients with a CD4
  • Prophylactic Treatment Recommendations
  • Azithromycin 1200 mg/week

26
HIV Disease Complications
  • Complications R/T drug therapy
  • Assess for development of signs symptoms
  • Manage the problems to allow continuation of
    therapy if possible

27
HAART-Associated Side Effects
  • Rash
  • GI symptoms
  • NV
  • Diarrhea
  • Headache
  • Malaise

28
HAART AssociatedAdverse Events
  • Stevens-Johnsons Syndrome
  • Lactic acidosis/hepatic steatosis
  • Hepatotoxicity
  • Hyperglycemia
  • Fat maldistribution
  • Hyperlipidemia
  • Osteopenia, osteoporosis
  • Osteonecrosis

29
Stevens-Johnsons Syndrome
  • Disseminated Rash
  • Fever
  • Cutaneous sloughing

30
Lactic acidosis / Hepatic Steatosis
  • Possibly due to mitochondrial toxicity
  • Associated w/ NRTIs
  • Clinical presentation variable have high index
    of suspicion
  • Lactate 2-5 mmol/dL plus symptoms
  • Treatment d/c NRTI, supportive care

31
Lactic acidosis / Hepatic Steatosis
  • Rare, but high mortality
  • The combination of stavudine didanosine was
    associated with several maternal deaths due to
    lactic acidosis. This antiretroviral combination
    should be used during pregnancy only when other
    NRTI drug combinations have failed or have caused
    unacceptable toxicities.

32
Frequency of Lactic AcidosisWith Different NRTIs
  • 60 cases reported to FDA through June 30, 1998
  • Number of cases on different NRTI regimens
  • Lamivudine/stavudine (36)
  • Didanosine/stavudine (9)
  • Lamivudine/zidovudine (7)
  • Didanosine/zidovudine (7)
  • Stavudine/zidovudine (1)
  • Symptoms included nausea, vomiting, abdominal
    pain, weight loss, malaise, dyspnea

Boxwell DE, Styrt BA. 39th Annual ICAAC
September 2629, 1999San Francisco, California.
Abstract 1284.
33
Hepatotoxicity
  • Severity variable usually asymptomatic, may
    resolve without treatment interruption
  • May occur with any NNRTI or PI
  • Nevirapine risk of severe hepatitis in first 12
    wks of use (monitor LFT), increased risk in
    women,
  • chronic Hepatitis B Hepatitis C
  • PI especially RTV, RTV/SQV increased risk in
    Hepatitis B or Hepatitis C, ETOH, with other
    hepatotoxins

34
Potential Etiology for BodyComposition
Abnormalities
Mitochondrial toxicity 2y to NRTIs
HIV
Protease inhibitors
Etiology?
Age
Genetic predisposition
Immune reconstitution
35
Fat maldistribution
  • Lipodystrophy
  • No uniform definition
  • Mechanism not understood
  • peripheral fat wasting more associated w/ NRTIs
  • central fat accumulation perhaps more associated
    with PIs
  • May be associated with dyslipidemia, insulin
    resistance, lactic acidosis
  • Treatment insufficient data

36
Morphologic ComplicationsFat Loss (Lipoatrophy)
37
Morphologic ComplicationsFat Accumulation
(Lipohypertrophy)
38
Buffalo hump Ultrasound-guided liposuction
BEFORE AFTER RELAPSE
  • Good cosmetic result with buffalo hump, but
    relapse may occur (1/18 in one series, 5/10 in
    another)

Gervason C, 10th CROI, Boston 2003, 723 Piliero
P, et al. ibid, 724 photographs courtesy of Dr
P. Piliero
39
Other Interventions?
  • Aerobic exercise
  • Weight training
  • Anabolic steroids
  • Human growth hormone (Serostim)

40
Hyperglycemia
  • Hyperglycemia and diabetes associated with all
    PIs, especially with chronic use
  • Mechanism not well understood
  • Insulin resistance, relative insulin deficiency
  • Regular screening via fasting glucose

41
Hyperlipidemia
  • Elevations in total cholesterol, LDL, and
    triglycerides
  • Associated w/ all PIs (varies w/ agent)
  • Mechanism unknown
  • Consequences uncertain concern for
    cardiovascular events, pancreatitis
  • Monitor regularly
  • Treatment consider substitution for PI
    lipid-lowering agents (caution w/ PI certain
    statins)

42
Bone abnormalities
  • Osteopenia and Osteoporosis
  • Mechanism ill-defined decreased osteoblast or
    increased osteoclast activity
  • Associated with PIs
  • Dx DEXA in symptomatic pts (no role for
    screening)
  • Prophylaxis No data. Consider calcium/Vit D,
  • weight-bearing exercise, bisphosphonates for
    secondary prevention??

43
Bone abnormalities
  • Osteonecrosis (AVN)
  • Mechanism unknown
  • Associated w/ PIs increased in corticosteroid
    treatment, alcohol abuse, hemoglobinopathies,
    hyperlipidemia, hypercoagulable states
  • Dx CT or MRI

44
Roles of the Nurse
  • Assessment
  • Diagnosis of Nursing Problems
  • Planning
  • Intervention
  • Collaboration with Providers
  • Direct Care
  • Patient Education
  • Evaluation

45
Nursing Actions
  • Patient Education
  • prevent
  • early recognition
  • Assessment of s/s when they present
  • Is it drug related?
  • Is it a side effect or adverse event ?
  • OI related

46
Know the Latest Clinical Data
  • Knowledge of HIV/AIDS changes at a blinding pace
  • Lag time always exists between release of new
    information and publication of Guidelines
  • Sources of new information
  • Internet websites
  • Conferences
  • Teleconferences/webcasts
  • Local organizations

47
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