HIV and Aids

·         Acquired Immune Deficiency Syndrome (AIDS) is a chronic, life threatening condition caused by Human Immunodeficiency Virus (HIV).

·         Characterized by generalized dysfunction of the immune system making individuals susceptible to opportunistic infections & tumors.

·         Pneumocystis carinii pneumonia: most common opportunistic infection. 

·         Incubation period estimates range from 6 months to 9 years.

Pathophysiology:

·         HIV binds with CD4+T cells and replicates by generating a DNA copy by reverse transcriptase.

·         HIV causes AIDS by destroying CD4+T cells which leads to a weak immune system allowing opportunistic infections.

Epidemiology:

·         5^th leading cause of death among ages 25-44 years in the US

·         In the US, it is common among African American, Hispanics and Caucasians. (CDC)

·         Most HIV infections occur in men due to homosexual contact but the incident is already increasing among women who engage in unprotected sexual activities.

Mode of Transmission:

·         Horizontal transmission: Sexual contact (oral, vaginal, anal sex); parenteral exposure to blood or body fluid containing visible blood.

·         Vertical (perinatal) transmission: HIV infected pregnant woman passes the infection to fetus during pregnancy, delivery or breastfeeding.

Clinicl Stages of HIV/AIDS	Signs & Symptoms
Stage I.         Asymptomatic/Primary    HIV infection	Flu-like symptoms ü  Fever ü  Myalgia ü  Persistent generalized lymphadenopathy ü  Headache
Stage II.	ü  Person may experience outbreak of herpes zoster ü  Recurrent respiratory tract infection ü  Chronic diarrhea for longer than 1 month
Stage III.	ü  Integumentary problems ü  Gynecological problems
Stage IV.	ü  HIV wasting syndrome ü  Development of opportunistic infections

Diagnostic Exams:

§  AIDS is present if there is 2 positive results of ELISA confirmed with positive result on Western blot assay.

§  Enzyme –linked immunosorbent assay (ELISA)/ Enzyme immunoassay (EIA)

o Identifies antibodies directed specifically to HIV.

o Useful in children older than 18 months.

§  Western blot assay

o Confirm HIV infection

                        Useful in children older than 18 months

§  Viral load tests: Reverse Transcriptase- Polymerase Chain Reaction (RT-PCR) & Nucleic Acid Sequence-Based Amplification (NASBA)

o < 10,000 copies/mL = low risk AIDS

o > 100,000 copies/mL = High risk for AIDS. (+) viral activity

o Measures HIV RNA in the plasma.

o Measures response to treatment.

o RT-PCR detects HIV in high risk seronegative people before antibodies are measurable, screen neonates, & confirm + EIA result.

§  CD4/CD8 Ratio

o Helper/ suppressor ratio = degree of immune suppression.

o CD4 count of <200/mm3: indicates AIDS

o Normal values depend on age (ratio 0.9 to 3.7 in adults).

§  p24 antigen

o 2 or more positive results are diagnostic for HIV infection

o Used o detect HIV antigen in children younger than 18 months.

§  Nonspecific markers of disease progression: blood counts, albumin levels & ESR

§  Skin biopsy, serum chemistries and imaging studies are indicated depending on organ/system involvement & disease progression.

Treatment:

·         There is no cure; prevention is the only key to control.

·         Highly Active Antiretroviral Therapy (HAART): reduces the number of HIV particles in the blood stream as measured by viral load test.

-    Combination of three (3) drugs belonging to 2 types of antiretroviral agents.

-    Side effects include: lipodystrophy, dyslipidaemia, diarrhea, insulin resistance, an increase in cardiovascular risks and birth defects.

-    n.b: Patient problem with HAART: non-adherence with complex administration leads to drug resistance development.

·         Antiretroviral drugs: inhibit the growth and replication of HIV at various stages of its life cycle.

Types/Classes:

1.        Nucleotide reverse transcriptase inhibitors/NtRTIs & Nucleoside analogue reverse transcriptase inhibitors/NRTIs (“nukes”): inhibit the replication of an HIV enzyme called reverse transcriptase.

E.g.  idovudine (Retrovir^®) [formerly called AZT azidothymidine], lamivudine (Epivir^®) didanosine (Videx^®), zalcitabine (Hivid^®), stavudine (Zerit^®) and abacavir (Ziagen^®)

2.        Protease inhibitors (PIs): interfere with an enzyme known as HIV protease. This causes HIV particles in your body to become structurally disorganized and noninfectious.

e.g atazanavir/ATV (Reyataz^®), darunavir/DRV (Prezista^®), Fosamprenavir/FPV (Lexiva^®), lopinavir + ritonavir (Kaletra^®), saquinavir/SQV (Invirase^®), tipranavir/TPV (Aptivus^®)

3.        Non-nucleoside reverse transcriptase inhibitors (NNRTIs): bind directly to the enzyme reverse transcriptase. E.g efavirenz (Sustiva^®, Stocrin^®);  nevirapine (Viramune^®); delavirdine (Rescriptor^®); etravirine (Intelence^®)

1.        Fusion inhibitors (entry inhibitors): suppress resistant strains of HIV. e.g maraviroc (Selzentry^®), enfuvirtide (Fuzeon^®)

2.        Integrase inhibitors: aims to treat those who become resistant to other treatments. e.g raltegravir (Isentress^®)

·         CCR5 antagonists: new class of drugs used to treat a particular type of HIV infection called CCR5-tropic HIV-1

E.g. maraviroc (Selzentry^®)

Side effects: liver problems, postural hypotension, inflammation response.

·         Oral Progesterone (Megace^®, Winstrol^®): stimulate appetite thereby assisting with the treatment of weight loss (HIV Wasting Syndrome)& loss of taste perception

·         For disease progression: Antibiotic therapy, chemotherapy, analgesic, antiemetic, antifungal & appetite stimulants.

·         Supportive care for chronic illness associated with HIV infection: O2 therapy, IV fluid, electrolyte replacement and mechanical ventilation (end stage AIDS).

Prevention:

If HIV negative:

·         Know the HIV status of your partner.

·         Provide client education regarding safe & protected sex:

o Latex condom: vaginal or anal intercourse

o Dental dam: used for oral contact with the vagina or rectum

o Avoid sexual contact with multiple partners.

·         Consider male circumcision

·         Use sterile needle & avoid needle sharing.

·         Be cautious about blood products.

·         Get routine HIV testing

If HIV positive:

·         Follow safe sex practices.

·         Tell your sexual partner that you have HIV.

·         Don’t share needles or syringes.

·         Don’t donate blood or organ.

·         Don’t share razors, toothbrush, sex toys or blood contaminated articles.

·         Drug users interested in drug treatment programs must be referred.

·         Get immediate medical care if pregnant.

·         Don’t breastfeed the infant.

·         TB testing 

For health workers:

·         Standard precautions: apply to blood, body secretions & excretions.

Nursing Interventions:

·         Use of universal precautions for all clients regardless of diagnosis.

·         Provide ongoing coordination of health care team to afford client the best possible assistance.

·         Provide emotional support, counseling and referral to support group.

·         Protect the client from secondary infections; assess for early signs and report for treatment.

·         Maintain client advocacy and confidentiality.

·         Refer to dietician to analyze nutritional requirements & make recommendations to maintain ideal body weight.

·         Provide high-caloric, high protein diet to prevent weight loss.

·         Encourage intake of foods rich in vitamins A, C & E.

·         Educate on:

o    Importance of compliance to long-term treatment regimen.

o    Stress the need for follow-up check-up & diagnostic tests to monitor response to treatment & disease progression.

Discuss life issues with the client & support system members as disease progresses & prognosis worsens

Antibiotics

·         Drugs derived wholly or partially from certain microorganisms and are used to treat bacterial or fungal infections. They are ineffective against viruses.

·          Antibiotics either kill microorganisms or stop them from reproducing, allowing elimination by the body's natural defense.

o    Aminoglycosides: Inhibit protein synthesis by binding to a portion of the bacterial ribosome. Most of them are bacteriocidal (i.e., cause bacterial cell death).

o    Bacitracin: Inhibits cell wall production by blocking the step in the process (recycling of the membrane lipid carrier) which is needed to add on new cell wall subunits.

o    Beta-lactam antibiotics: A name for the group of antibiotics which contain a specific chemical structure (i.e., a beta-lactam ring). This includes penicillins, cephalosporins, carbapenems and monobactams.

o    Cephalosporins: Similar to penicillins in their mode of action but they treat a broader range of bacterial infections. They have structural similarities to penicillins and many people with allergies to penicillins also have allergic reactions to cephalosporins.

o    Chloramphenicol: Inhibits protein synthesis by binding to a subunit of bacterial ribosomes (50S).

o    Glycopeptides (e.g., vancomycin):  Interferes with cell wall development by blocking the attachment of new cell wall subunits (muramyl pentapeptides).

o    Macrolides (e.g., erythromycin) and Lincosamides (e.g., clindamycin): Inhibit protein synthesis by binding to a subunit of the bacterial ribosome (50S).

o    Penicillins:  Inhibits formation of the bacterial cell wall by blocking cross-linking of the cell wall structure. The cell wall is a needed protective casing for the bacterial cell.

o    Quinolones: Blocks DNA synthesis by inhibiting one of the enzymes (DNA gyrase)

o    Tetracyclines: Inhibit protein synthesis by binding to the subunit of the bacterial ribosome (30S subunit).

o    Trimethoprim and Sulfonamides: Blocks cell metabolism by inhibiting enzymes which are needed in the biosynthesis of folic acid which is a necessary cell compound.

Aminoglycosides
·           ·	·           ·         Amikacin        ·         Gentamicin ·         Kanamycin ·         Neomycin ·         Netilmicin ·         Streptomycin ·         Tobramycin		Infections caused by gram-negative bacteria, such as Escherichia coli and Klebsiella	Hearing loss ·         Dizziness         Kidney         damage
Carbapenems
	Ertapenem        Imipenem/  cilastatin		Gangrene, sepsis,  pneumonia, abdominal and urinary infections, and (except for ertapenem)Pseudomonas infections	Seizures         Confusion
Cephalosporins, 1st generation
	·              Cefadroxil ·               Cefazolin Cephalexin		Skin and soft tissue   infections	Gastrointesti-nal upset and diarrhea        Nausea        Allergic reactions
Cephalosporins, 2nd generation
	·         Cefaclor ·         Cefamandole ·         Cephalexin ·         Cefoxitin ·         Cefprozil      Cefuroxime		Some respiratory and abdominal infections	Gastrointesti -al upset and diarrhea       Nausea        Allergic reactions
Cephalosporins, 3rd generation
	·         Cefixime ·         Cefdinir ·         Cefditoren ·         Cefoperazone ·         Cefotaxime ·         Cefpodoxime ·         Ceftazidime ·         Ceftibuten ·         Ceftizoxime         Ceftriaxone	Broad coverage of many bacteria for people with mild-to-moderate infections (oral) and serious illness (by injection		Gastrointesti -al upset and diarrhea       Nausea        Allergic  reactions

Cephalosporins, 4th generation
	Cefepime	Serious infections, particularly in people with a weakened immune system	Gastrointesti -al upset and diarrhea        Nausea        Allergic  reactions
Macrolides
	·         Azithromycin ·         Clarithromycin ·         Dirithromycin ·         Erythromycin Troleandomy- cin	Streptococcal infections, syphilis, respiratory infections, myoplasmal infections, Lyme disease	·         Nausea, vomiting, and diarrhea (especially at higher doses) Jaundice
Monobactam
	Aztreonam	Infections caused by gram-negative bacteia	Allergic reactions
Penicillins
	·         Amoxicillin ·         Ampicillin ·         Carbenicillin ·         Cloxacillin ·         Dicloxacillin ·         Nafcillin ·         Oxacillin ·         Penicillin G ·         Penicillin V ·         Piperacillin Ticarcillin	Wide range of infections; penicillin used for streptococcal infections, syphilis, and Lyme disease	·         Nausea, vomiting, and diarrhea ·         Allergy with serious anaphylactic reactions         Brain and kidney damage (rare)
Polypeptides
	·         Bacitracin ·         Colistin         Polymyxin B	Ear, eye, skin, or bladder infections; usually applied directly to the skin or eye; rarely given by injection	Kidney and nerve damage (when given by injection)
Quinolones
	·         Ciprofloxacin ·         Enoxacin ·         Gatifloxacin ·         Levofloxacin ·         Lomefloxacin ·         Moxifloxacin ·         Norfloxacin ·         Ofloxacin Trovafloxacin	Urinary tract infections, bacterial prostatitis, bacterial diarrhea, gonorrhea	·         Nausea (rare) ·         Nervousness, tremors, seizures        Inflammation or rupture of tendons
Sulfonamides
	·         Mafenide ·         Sulfacetamide ·         Sulfamethizole ·         Sulfasalazine ·         Sulfisoxazole         Trimethoprim- sulfamethoxazole	Urinary tract infections (except sulfasalazine, sulfacetamide, and mafenide); mafenide is used topically for burns	·         Nausea, vomiting, and diarrhea ·         Allergy (including skin rashes)
Tetracyclines
	·         Demeclocycline ·         Doxycycline ·         Minocycline ·         Oxytetracycline        Tetracycline	Syphilis, chlamydial infections, Lyme disease, mycoplasmal infections, rickettsial infections	·         Gastrointestinal upset ·         Sensitivity to sunlight ·         Staining of teeth         Potential toxicity to mother and fetus during pregnancy

General Nursing Considerations:

ü  Instruct patient that antibiotics are for bacterial infections and are not effective in treating viral infections.

ü  Emphasize importance of asking questions about antibiotic prescription.

ü  Use the correct method to instill medications.

ü  Monitor laboratory values.

ü  Intruct the patient to complete the prescribed medication regimen as ordered, regardless of whether the patient feels relief quickly or not.

ü  Teach instructions to avoid such foods or supplements within several hours of taking the antibiotic dose for some antibiotics are less effective when taken with supplements or foods that are high in minerals such as iron or calcium.

ü  Provide patient teachings:

o    Specific antibiotic should not be taken if a previous allergic reaction has been experienced.

o    Take at evenly spaced intervals around the clock to maintain blood levels.

o    Do not take the medication after the expiration date.

o    Do not expose the drug to light, heat, or humidity.

o    Do not breast feed while taking Macrolide antibiotic.

o    Women on birth control pills need to use another form of birth control.

o    Most oral agents are taken on empty stomach as food decreases absorption.

o    Take oral agents with full glass of water to ensure drug is dissolving in the stomach.

o    Do not take left-over medications from previousi infection or those prescribed for another person.

ü  Provide teachings regarding potential side effects and their management, including the manifestations that necessitate stopping the drug, and notifying physician.