Informational Update For SJSU Nursing Students

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Informational Update ForSJSU Nursing Students

• HIV/AIDS 101

Hospice Care Integrative Therapies
Presented By Esther L. Johnson, RN, BSN, PHN,
CHPN Pathways Home Health, Hospice Continuous
Care, Inc.
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Program ObjectivesTo improve understanding of
HIV/AIDS

• Disease Trends
• Current Treatment Strategies
• Opportunistic Infections
• Nursing Implications

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Program ObjectivesTo Introduce

• Hospice Care
• Nursing Career Choices
• Integrative Therapies

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HIV/AIDS Review Update

• Statistics
• Viral Transmission
• Groups at Risk
• Cellular Actions
• Testing
• Disease Progression
• Opportunistic Infections
• Treatment Theories

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Adults and children estimated to be living with
HIV/AIDS
Russian Federation 940,000
Europe 1.1 million

North America 2.1 million
Africa Middle East 26.1 million
Asia 8.5 million
Caribbean 250,000
Latin America 1.7 million
Oceania 81,000
Total 40.1 million http//www.unfpa.org/aids_cloc
k/
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Viral Transmission

• Sexual
• Unprotected or Unsafe Sex
• Parenteral
• IV drug use
• Blood products
• Mother to child transmission (MTCT) aka Vertical
  transmission
• Before birth
• During birth
• After birth during breastfeeding

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Highest At Risk Groups

• Complacent individuals
• Developing Countries are in crisis
• Women
• Minorities People of Color
• Children, Adolescents Young Adults
• Elderly
• Rural Areas

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Prevention of HIV Transmission

• Safer sexual practices
• Parenteral risk reduction behaviors
• Perinatal risk reduction behaviors
• Infection control guidelines practices for
  healthcare workers other service providers
• Contraception and STD prevention/education
• Culturally appropriate HIV prevention programs

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Actions of HIV Antiretrovirals
1
C
HIV enters cell
Protease Inhibitors work here
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E
4
New virus copies leave cell and infect other CD4
cells.
HIV (Virions)
Integrase Inhibitors
Protease cuts chains into smaller pieces to
produce mature HIV copies
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RNA
D
3
HIV uses reverse transcriptase to convert RNA to
DNA
HIV DNA enters nucleus, inserts into cell DNA.
Original virus is copied into long chains of HIV
proteins enzymes
Fusion Inhibitors
A
NRTIs work here
B
NNRTIs work here
CD4 cell (T-cell)
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Review of Testing

• AIDS Test
• CD 4 cell Test
• Viral Load Tests
• Resistance Tests

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AIDS Testing

• Establishes HIV infection by detecting antibodies
  to the virus in the blood
• Results reported as positive, negative or
  indeterminate
• ELISA
• Always done first. If positive, repeat test and
  confirm by performing Western Blot.
• Western Blot
• Confirmation test. If positive, diagnosis made.
  If negative, suspect ELISA was false positive and
  repeat ELISA at future date

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CD 4 Cell (T-cell) Testing

• Assists in staging disease
• Provide guidelines for differential diagnoses
• Assists in making therapeutic treatment decisions
  regarding antiviral treatment and prophylaxis for
  opportunistic infections
• Is a reliable indicator of prognosis when used in
  conjunction with viral load assay.
• Corticosteroids and intercurrent illness will
  influence results

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Viral Load Tests

• Standard for staging and monitoring response to
  retroviral therapy
• Detects acute HIV infection
• Predicts disease progression
• Results are reported in copies/ml. The lower the
  copy the better control available.
• Three types of tests - Use only one test
  consistently
• RT-PCR - Reverse transcriptase polymerase chain
  reaction test. Most sensitive, can detect down
  to 1 - 10 copies
• bDNA - Branched chain DNA test
• Nuclisens HIV-1 QT - Nucleic acid sequence-based
  amplification.

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Resistance Tests

• An in vitro method to measure resistance of HIV
  to antiretroviral agents
• Viral load of 1,000copies/ml required to test
• Assists in selection of appropriate drugs
• Identifies drugs that should be avoided, not
  necessarily drugs that are most likely to be
  active against virus
• Two types of tests
• Genotypic assay - measures mutations at gene site
• Phenotypic assay - measures antimicrobial
  sensitivity, indicating concentration necessary
  to inhibit virus

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Disease Progression

• What is going on with the virus?
• At point of infection
• At CD count of 500
• At CD count of

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Viral Infectious Event - Exposure

• May have no outward symptoms
• Acute Retroviral Syndrome
• Flu like symptoms
• Fatigue
• Fever
• Sore, achy muscles
• Seroconversion
• 6 weeks to 6 months

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Early Symptoms - HIV (CD4 count 500-200)

• Lymphadenopathy
• Night Sweats
• Diarrhea
• Herpes
• Shingles
• Fatigue
• Hairy Leukoplakia
• Frequent infections
• Thrush
• Molluscum Contagiosum

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Late Stages - AIDS(CD4 count

Wasting Syndrome

CMV Retinitis

Kaposis Sarcoma (KS)

Pneumocystis Carinii Pneumonia (PCP)

Cryptococcal Meningitis

Toxoplasmosis

Tuberculosis (TB)

Mycobacterium Avium Complex (MAC)

Non-Hodgkins Lymphoma

Histoplasmosis

Cervical Cancer

Cognitive Dysfunction

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CDC AIDS Defining Diagnoses

• Candidiasis of bronchi, trachea, or lungs (see
  Fungal Infections)
• Candidiasis, esophageal (see Fungal Infections)
• Cervical cancer, invasive
• Coccidioidomycosis, disseminated (see Fungal
  Infections)
• Cryptococcosis, extrapulmonary (see Fungal
  Infections)
• Cryptosporidiosis, chronic intestinal (1 month
  duration) (see Enteric Diseases)
• Cytomegalovirus disease (other than liver,
  spleen, or lymph nodes)
• Cytomegalovirus retinitis (with loss of vision)
• Encephalopathy, HIV-related (see Dementia)
• Herpes simplex chronic ulcer(s) (1 month
  duration) or bronchitis, pneumonitis, or
  esophagitis
• Histoplasmosis, disseminated (see Fungal
  Infections)
• Isosporiasis, chronic intestinal (1 month
  duration) (see Enteric Diseases)
• Kaposi's sarcoma
• Lymphoma, Burkitt's
• Lymphoma, immunoblastic
• Lymphoma, primary, of brain (primary central
  nervous system lymphoma)
• Mycobacterium avium complex or disease caused by
  M. Kansasii, disseminated
• Disease caused by Mycobacterium tuberculosis, any
  site (pulmonary or extrapulmonary) (see
  Tuberculosis)
• Disease caused by Mycobacterium, other species or
  unidentified species, disseminated

• A diagnosis of AIDS is made whenever a person is
  HIV-positive and
• Has a CD4 cell count below 200 cells per
  microliter
• OR
• CD4 cells account for fewer than 14 percent of
  all lymphocytes
• OR
• That person has been diagnosed with one or more
  of the AIDS-defining illnesses listed to the
  right.
• Additional Illnesses That Are AIDS-Defining in
  Children, But Not Adults
• Multiple, recurrent bacterial infections (see
  Bacterial Infections)
• Lymphoid interstitial pneumonia/pulmonary
  lymphoid hyperplasia

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Effects To Major Systems

• Respiratory System
• PCP - most common
• TB - incidence is increasing
• KS of lungs
• bacterial lung infections
• Skin Mouth infections
• Fungal infections
• Bacterial infections
• Viral infections
• Cancers - KS

• GI System
• Viral, fungal and protozoal infections
• KS of GI tract
• Nervous System
• CNS lymphoma
• AIDS Dementia Complex
• Neuropathies
• Fungal, viral and protozoal parasitic infections
  of the neurological system
• Cancers
• Non-Hodgkin's lymphomas
• Karposis Sarcomas
• Other cancers

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Treatment Theories

• Prior theories
• Do nothing till symptomatic, then treat
• Hit early, hit hard
• Structured Treatment Interruptions
• Latest theories
• Hit hard, when appropriate
• Decrease plasma HIV RNA as much as possible, for
  as long as possible
• Increase survival
• PEP Post Exposure Prophylaxis

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Goal of Antiretroviral TreatmentHAART - Highly
Active Antiretroviral Therapy Help the body
Fight Back by reducing viral load

• As soon as possible
• As low as possible
• As long as possible

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Treatment Strategies

• Combination therapy
• HAART
• Protease Sparing
• Treatment during pregnancy
• AZT
• Other Approved drugs
• Encourage Adherence

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Four Classes of HIV/AIDS Drugs

• Nucleoside Analogs
• Reverse Transcriptase Inhibitors (RTIs)
• Protease Inhibitors (PIs)
• Non-Nucleoside Reverse Transcriptase Inhibitors
  (NNRTIs)
• Fusion Inhibitors

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Nucleoside Analogs Nucleoside Reverse
Transcriptase Inhibitors (NRTIs)

• Retrovir (AZT, ZDV) 1987 Zidovudine
• Videx (ddI) 1991 Videx EC Didanosine
• Hivid (ddC) 1992 Zalcitabine
• Zerit (d4T) 1994 Stavudine
• Epivir (3TC) 1995 Lamivudine
• Combivir (AZT 3TC) 1997 LamivudineZidovudine
• Ziagen 1998 Abacavir sulfate

• Trizivir 2000 (AZT 3TC Abacavir )
• Viread 2001 Tenofovir
• Emtriva (FTC) 2003 Emtricitabine
• Epzicom 2004 (Abacavir 3TC)
• Truvada 2004 (Viread Emtriva)
• Atripla 2006 (Sustiva Viread Emtriva)

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Actions of Nucleoside Analogs

• Incorporate themselves into the DNA of the virus,
  thereby stopping the building process

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Protease Inhibitors (PIs)

• Invirase 1995 Saquinavir
• Norvir 1996 Ritonavir
• Crixivan 1996 Indinavir
• Viracept 1997 Nelfinavir
• Agenerase 1999 Amprenavir, APV
• Kaletra 2000 (tablets or capsules) Lopinivir
  Ritonavir
• Reyataz 2003 Atazanavir
• Lexiva 2003 Fosamprenavir
• Aptivus 2005 Tipranavir
• Prezista 2006 Darunavir, TMC-114

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Actions of Protease Inhibitors

• Prevent HIV from being successfully assembled and
  released from the infected CD 4 cell

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Non-Nucleoside Reverse Transcriptase Inhibitors
(NNRTIs)

• Viramune 1996 Nevirapine
• Rescriptor 1997 Delavirdine
• Sustiva 1998 Efavirenz
• Atripla 2006 (Sustiva Viread Emtriva)
• Action Stops HIV production by binding directly
  onto reverse transcriptase and preventing the
  conversion of RNA to DNA

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Fusion Inhibitors

• Fuzeon (T-20) 2003 Enfuvirtude (SQ injection)
• Action Fusion inhibitors work by blocking the
  HIV virus from entering human cells.

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Combination Therapy Drug Cocktails

• Combining classes of drugs effectively to fight
  HIV infection
• Inhibits virus growth ability to mutate
• Most common combinations
• RTIs NNRTIs (Protease Sparing)
• 3,4,5 or 6 drug combinations (Salvage Therapy)

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NRTI NNRTI Combo

• Atripla 2006 (Efavirenz Tenofovir DF
  Emtricitabine)
• Combines 2 NRTIs 1 NNRTI
• Atripla is considered to be a complete one-pill,
  once-daily anti-HIV treatment regimen, at least
  for people starting anti-HIV treatment for the
  first time. It does not need to be combined with
  other anti-HIV drugs
• Atripla is a tablet taken once a day. It should
  be taken without food, preferably at bedtime.

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In the Pipeline

• Integrase Inhibitors Drugs that will prevent
  the integration of the virus once the RNA has
  been converted to DNA by reverse transcriptase.
• Immune Based Therapies drugs that will help the
  bodys immune system fight the virus on its own.

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LIPODYSTROPHY

• Redistribution of fat
• Peripheral fat wasting
• Buffalo hump
• Truncal obesity
• Breast enlargement
• Elevated cholesterol triglycerides
• Insulin resistance
• Increased risk of Heart Disease or Diabetes
  Mellitus

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Factors to consider

• Baseline evaluation
• Physical exam, health history, psycho-social
  history, lab tests, nutritional assessment,
  classification system, special needs (cultural,
  gender issues, age, dual diagnoses, chronic
  conditions)
• Planning care follow up
• Health teaching
• Nutritional teaching
• Antiretroviral therapy/Medication adherence
• Symptom management of OIs/other conditions
• Management of psychosocial /or neuropsychiatric
  dysfunction
• Referrals for support /or interventions
• Legal /or ethical issues

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Nursing Implications

• Follow Clinical Parameters
• Keep Abreast of New Treatments
• Monitor Nutritional Status
• Monitor lab tests
• Promote Adherence to Medication Regimen
• Promote Communications with MDs, RNs,
  Pharmacists, and Other Resources
• Practice Standard Precautions Consistently
• Educate your patient their caregivers
• Practice with Compassion Always Offer
  Hope

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Hospice Care

• Focus on Comfort Care
• Medications and treatments as appropriate
• Provided in patient home
• Team approach
• Paid for by Medicare, Medical, Insurance
• Visits, equipment and some meds covered
• Sign up or Revoke benefit
• 911 versus DNR

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Integrative Therapies

• Non pharmacologic methods of pain symptom
  management
• Mind-Body (guided imagery, relaxation skills,
  hypnosis)
• Bio-energetic techniques (Reiki, Healing Touch,
  Acupressure)
• Music
• Aromatherapy
• Animals
• Creative Expression
• Within scope of RN practice with education
  training
• Easy to learn, cost effective, can be used by
  everyone
• More research and education in Nursing and
  Medical school

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Where Will Your Career Take You?
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Wrap Up Summary

• Questions
• Other Issues
• Evaluation