HIV 201: What I Wish I Knew as a NEW RN

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Henry Bryant
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1 1 Mountain West AIDS Education and Training Center HIV 201: What I Wish I Knew as a NEW RN Andrea Carriedo, RN The New Hope Clinic NO CONFLICTS OF INEREST OR RELATIONSHIPS TO DISCLOSE This presentation is intended for educational use only, and does not in any way constitute medical consultation or advice related to any specific pa t ie n t. Objectives Describe the natural history of HIV disease progression. Describe adherence management in an HIV positive patient. Identify and differentiate three different clinical manifestations of HIV disease.

2 2 Natural History of HIV Infection Summary HIV multiplies inside the CD4 cells, destroying them. As CD4 cell count decreases and viral load increases, the immune defenses are weakened. People infected with HIV become vulnerable to opportunistic infections. HIV is a chronic viral infection with no known cure. Without ARV treatment, HIV progresses to symptomatic disease and AIDS.

3 3 A person can transmit HIV to others during any of these stages: Acute infection: Within 2 to 4 weeks after infection with HIV, you may feel sick with flu-like symptoms. This is called acute retroviral syndrome (ARS) or primary HIV infection, and it s the body s natural response to the HIV infection. (Not everyone develops ARS, however some people may have no symptoms.) During this period of infection, large amounts of HIV are being produced in your body. Because of this, the CD4 count can fall quickly. Your ability to spread HIV is highest during this stage because the amount of virus in the blood is very high. Eventually, your immune response will begin to bring the amount of virus in your body back down to a stable level. At this point, your CD4 count will then begin to increase, but it may not return to pre-infection levels. Intermediate Progressor

4 4 A person can transmit HIV to others during any of these stages: Clinical latency (inactivity or dormancy): This period is sometimes called asymptomatic HIV infection or chronic HIV infection. During this phase, HIV is still active, but reproduces at very low levels. You may not have any symptoms or get sick during this time. People who are on antiretroviral therapy (ART) may live with clinical latency for several decades, because treatment helps keep the virus in check. If not on ART, this period can last up to a decade, some may progress through this phase faster. Toward the middle and end of this period, your viral load begins to rise and your CD4 cell count begins to drop. As this happens, you may begin to have symptoms of HIV infection as your immune system becomes too weak to protect you. A person can transmit HIV to others during any of these stages: AIDS (acquired immunodeficiency syndrome): This is the stage of infection that occurs when your immune system is badly damaged and you become vulnerable to infections and infectionrelated cancers called opportunistic illnesses. When the CD4 cells falls below 200 cells per cubic millimeter of blood (200 cells/mm3), you are considered to have progressed to AIDS. (Normal CD4 counts are between 500 and 1,600 cells/mm3.) You can also be diagnosed with AIDS if you develop one or more opportunistic illnesses, regardless of your CD4 count. Without treatment, people who are diagnosed with AIDS typically survive about 3 years. Once someone has a dangerous opportunistic illness, life expectancy without treatment falls to about 1 year. People with AIDS need medical treatment to prevent death. Opportunistic Infections Candidiasis of bronchi, trachea, esophagus, or lungs Invasive cervical cancer Coccidioidomycosis Cryptococcosis Cryptosporidiosis, chronic intestinal (greater than 1 month's duration) Cytomegalovirus disease (particularly CMV retinitis) Encephalopathy, HIV-related Herpes simplex: chronic ulcer(s) (greater than 1 month's duration); or bronchitis, pneumonitis, or esophagitis Histoplasmosis

5 5 Opportunistic Infections Continues Isosporiasis, chronic intestinal (greater than 1 month's duration) Kaposi's sarcoma (KS) Lymphoma, multiple forms Mycobacterium avium complex (MAC) Tuberculosis Pneumocystis carinii pneumonia (PCP) Pneumonia, recurrent Progressive multifocal leukoencephalopathy Salmonella septicemia, recurrent Toxoplasmosis of brain Wasting syndrome due to HIV Factors that may shorten the time between HIV and AIDS: Older age HIV subtype Co-infection with other viruses (like tuberculosis or hepatitis C) Poor nutrition Severe stress Your genetic background Factors that may shorten the time between HIV and AIDS Continues: Taking antiretroviral therapy consistently Staying in regular HIV care Closely adhering to your doctor s recommendations Eating healthful foods Taking care of yourself

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7 7 Adherence Adherence is about a patient, PHN and their provider coming up with a plan and all parties sticking to the agreement. Compliance is about obeying the rules. Patients are the only ones that can take their pills every day. We need to set them up for success by helping them find ways to make it work. Work medications into their life not the other way around. The patient needs to be in charge. Education about medication side effects is one of the most important parts of adherence. Patients need to call PHN if they are having ANY side effects. DO NOT wait until the next appt to discuss these. Decisions This lesson can help you decide: Whether to start therapy What drugs to take Whether to continue therapy Effective treatment stops or slows the progression of HIV. HIV drugs are recommended for ALL people with HIV infection, whether they are sick or well. That being said not all patients are ready to start ARV s and this is very crucial to adherence. To Start Treatment or Not? Starting treatment is a personal decision. There are some important things to think about before they begin, such as being ready to: Take medication every day Handle possible side effects Schedule ongoing healthcare visits Find stable housing, mental health, or substance use services if they need it HIV treatment is a lifelong commitment. They may need to make changes to your daily life, including: A new routine to take medication at the same time every day Changing what and when they eat Switching other medications they may take

8 8 Physical changes to your body As HIV disease progresses in your body, you may notice physical changes. Some changes may occur as side-effects of medical treatment for HIV. Others may occur as a result of the impact that HIV (or AIDS) has on your body. Body fat changes Some medications you may take to control HIV cause changes in the way your body produces, uses, and stores fat. These changes are called lipodystrophy. This condition causes you to gain or lose fat in particular parts of your body. You can get extra fat in the following places: Abdomen Neck Physical changes to your body Breasts (both men and women) Face In addition, you can also develop small deposits of fat, called lipomas, elsewhere on your body. Other changes can occur when the fat under your skin (called subcutaneous fat) is lost. This can occur in your: Face Arms Legs Buttocks It is important to note that these changes in the way your body handles fat can also coincide with changes in cholesterol, an increase in triglycerides, increases in blood sugar, and lowered sensitivity to insulin, which may lead to diabetes.

9 9 Virologic Failure A type of HIV treatment failure. Virologic failure occurs when antiretroviral therapy (ART) fails to suppress and sustain a person s viral load to less than 200 copies/ml. Factors that can contribute to virologic failure include drug resistance, drug toxicity, and poor treatment adherence. Immunologic Failure A type of HIV treatment failure. There is no consensus on the definition of immunologic failure. However, some experts define immunologic failure as the failure to achieve and maintain adequate CD4 counts despite viral suppression. Treatment Failure When an antiretroviral (ARV) regimen is unable to control HIV infection. Treatment failure can be clinical failure, immunologic failure, virologic failure, or any combination of the three. Factors that can contribute to treatment failure include drug resistance, drug toxicity, or poor treatment adherence.

10 10 Case Study #1 38 year old MM been in the US < 6 months. Wife and kids currently living in Mexico, denies recreational drug use, never used IV drugs, occasional alcohol. Unemployed. Rents a room from a friend. Presents to ED with difficulty breathing, weight loss. Case Study #2 45 year old Hispanic Female Present to ER complaining of vomiting, dizziness, headaches x 1 day. Weight was 42.8 kg. Physical Exam Thrush present All standard ED labs done Contrast CT Abdomen ED visit again this time complaining of feeling faint, cough and weakness x one year. Pain when eating, mouth sores. Weight was 37.9 kg. HIV test done and was positive Past Medical History - Hypothyroidism, Uterine Ablation, GERD, Anemia Referral Oncology RO liver CA Wasting Syndrome Wasting syndrome is the involuntary loss of more than 10% of your body weight, in addition to more than 30 days of either diarrhea or weakness and fever. Wasting refers to a loss of muscle mass, although part of the weight loss may also be due to loss of fat. HIV-associated wasting syndrome is considered an AIDS-defining condition. While this is often a sign of late stage disease, wasting syndrome can be treated by: Proper diet Medications to stimulate appetite Medications to control diarrhea Hormonal therapy to build muscle

11 11 Case Study #3 52 yo Caucasian Male Heterosexual Untreated Mental Health: Bipolar with schizo affective disorder, Depression, Hx of substance abuse w/ IDU Diagnosis HIV+ in 2001, ARV Atripla while being in Seattle. NHC in 2011 still on meds. Medication switch from once a day pill to 3 pills daily possible d/t to MH at that time. stopped ARV s in summer of 2013 d/t untreated MH, restarted about 2 months ago, but about a year prior to restarting he told nurse he was interested in restarting cause he felt sick. Set small goals

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