Outline

• Statistics (will not be tested on stats)• Viral Reproduction• CDC Classification• Modes of Transmission• Levels of Prevention• Antiretrovirals• Opportunistic Infections goes here

HIV• 1981 was the first reported case of acquired

immune deficiency syndrome diagnosed. (diagnosed through symptoms

• Half a million Americans have died from the condition.

• Since 1981 more than 68 million people worldwide have been infected with the virus.

• Over 55 million people are living with HIV.

• HIV is the leading cause of death in South Africa.

HIV

• Global epidemic– 55 million people living with HIV• 39 million adults• 4.5 million children under 15• 14,000 new infections daily

– 27.8 million dead of AIDS• 22.5 million adults• 5.3 million children under 15• 14 million orphaned: 25 million by 2010

– Estimated cost of $5 million/year

HIV

• During 2003–5 million new infections–3 million people died of AIDS–2.5 million were adults–500,000 were children under 15

HIV

• In the USA– Approx 1 million infected with HIV– ½ are NOT being treated, lack of access or lack

of knowledge (don’t know they are infected) – Approx 40,0000 infected annually (1:12

minutes)– Leading cause of death among African-

American women 25-34

HIV

• Since CDC began tracking cases–More than 95,000 cases in Florida• 1,476 pediatrics

– Annual incidence is more than 2x the national– Florida has the third highest cumulative

number of AIDS cases in the nation (duval co is 2nd county in the state)

– Second highest number of pediatric AIDS cases

New Cases

• Leading cause of death for African American men and women between the ages of 25 and 44.

• Accounted for 64% of AIDS deaths in state, only represent 15% of the state’s population.

New Cases in Florida 5,500-6,000–As of 7/1/97 any new person testing

positive for HIV is reportable

On the brighter side…

• Since the inception of HAART in 1996 the death rate dropped by 70% (highly active… retrovirus treatment??? )

• Incidence of pediatric AIDS has decreased since 1994 (found that it is xmitted through breast milk, also found that if they take antrovirals their chance of passing it on to the baby goes from 30% down to ?????

HIV

• 30% infection rate among inner-city young adults who smoke crack, specially women who exchange sex for drugs.

• More than 10,000 cases of HIV have been attributed to transfusion infected blood or blood components. Current risk is extremely low.

AIDS Rates per 100,000 Women Reported in 1999

US rate: 9.3N=10,780

10+

5 9.9_<<55

Rate per 100,000

<5 cases*

3.0

2.12.5

1.9

1.61.7

1.2

3.6

1.3

2.0

2.0

2.7

2.1

1.81.2

2.5

2.10.9

3.4

9.1

11.0

5.9

30.0

15.0

13.4

23.2

6.3

6.7

7.4

5.51.8

9.2

7.4

0.9 1.54.7

4.6

5.2

1.6PR 21.3 VI 30.1

14.8

21.0

1.2

7.213.019.614.1

93.4

MANH

RICTNJDEMDDC

**

*

*

AIDS rates per 100,000 women

HIV- CDC Classification

• Stage I-Viral Syndrome-Present in 50% of all cases within days to weeks (flu like) virus levels are very high at the very beginning

• Stage II -Asymptomatic- may last up to 10 yrs. (maybe longer, used to call it dormant, it really isn’t dormant, but the immune system is holding it down)

• Stage III-Persistent Generalized Lymphadenopathy (PGL)-greater than 2 extra inguinal nodes for more than 3 months

• (little diff than in the book)

HIV- CDC classification

• Stage IV (what has been called AIDS)

– A-Wasting-Fever > 1 month, weight loss >10% of TBW, diarrhea (the diarrhea is not positive for some bacteria… idiopathic)

– B-Neurologic manifestations-AIDS Dementia Complex (ADC) (has been compared to Alzheimers,), Peripheral Neuropathy (some meds for HIV can cause peripheral neuropathy, need to make sure the PN is not related to those meds, can be so painful that pt is unable to walk)

– C-Opportunistic Infections (OIs) – D-Kaposis Sarcoma (vasculature cancer, almost like blood blisters on

face & belly, some people get them in their GI system), Cervical Cancer (women that were HIV positive have higher incidence of HPV and cervical cancer)

• LOOK at chart in book to see the CDC guidelines… slides not included in this powerpoint!

Transmission

**Can be transmitted only under specific conditions**

HIV is not spread casually, it can not be transmitted through hugging, kissing, shaking hands, sharing utensils, or attending school with an HIV infected person.

Transmission

• It is not transmitted through saliva, tears or sweat.

• Healthcare workers may be infected with HIV through needlesticks or direct contact with HIV-infected blood

• 1:300 without prompt antiretroviral treatment (24 hrs -7 days)

Transmission

• Modes– Sexual

–Contact with blood/blood products

–Perinatal transmission

HIV- Levels of prevention

Primary Prevention• 1) Safe Sex Counseling-– No sex is safe sex– Proper use of barrier contraception

• 2) High Risk Reduction-– Identification of High Risk groups– Substance abuse counseling– Clean needles and paraphernalia

HIV- Levels of prevention

• 3) Perinatal Transmission-–Gestation –Delivery–Breast feeding – (w/ antiretrovirals & no breastfeeding, the transmission can be

reduced to 10%)

HIV- Levels of prevention

Secondary Prevention• 1) Identification through early screening Tests

currently available• A) Elisa & Western Blott (WB)Antibodies present within 6

weeks, newborns within 18 months.(have to wait 1.5 yrs to find out if baby is pos for HIV, initially ALL babies will test positive)

• B) Rapid oral HIV test 3/20/04 Antibody tests 99.3% effective, 99.8% specificity

• C) Home testing kits (very effective & specific, problem is that the person is tested & then told over the phone that the person is pos… no follow up)

• 2) Drug Cocktails

HIV- Levels of prevention

Tertiary Prevention–1) Medical management for patients

classified as stage IV to prevent complications • Prophylaxis (prevention) against PCP,

MAC, CMV retinitis, candidiasis

Testing Guidelines

• 1985-Blood in blood banks (still not 100%)

• 1987-All patients with STDs• 1993-Inpatients where HIV.1%• 1995-All pregnant women• 2001-Public and private health care settings• 2006-Voluntary screening in all health care

settings

Laboratory Tests

• ELISA• Western Blot• OraQuick Rapid HIV-1/2 Antibody Test• T-cells (about 1000 for most of us, not HIV positive)

• Viral load/viral burden/viral RNA (check number of RNA strands… if below 200 the virus is undetectable, Magic Johnson)

Cases1)Viral load non-detectable (look healthy)

CD4 650

2)Viral load 30,000 (maybe lymphnode problems)

CD4 200

3)Viral load 100,000 (probably sick)CD4 90

Treatments

• Primary factor limiting effectiveness of drugs is the development of resistance–Resistance-the ability of HIV to replicate in

the presence of antiretroviral agent. (don’t take drug as prescribed… )

–HIV replicates frequently with up to 10 bill. copies/day.

Reverse Transcriptase Inhibitors (NRTIs)

– Combivir zido (AZT available in 1985) & lami(AZT & 3TC)

– Emtriva emtricitabine (FTC)– Epivir lamivudine (3TC)– Hivid zalcitabine (ddC)– Retrovir zidovudine (AZT) – Trizivir abacavir+zido+lami – Videx didanosine (ddI)– Viread tenofovir disoproxil (TDF)– Zerit stavudine (d4T)– Ziagen abacavir (ABC)

NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

–Rescriptor delavirdine (DLV)– Sustiva efavirenz (EFV)–Viramune nevirapine (NVP)

• Neuropathies… all meds have their side effects

PROTEASE INHIBITORS– Agenerase amprenavir (APV)– Crixivan indinavir (IDV)– Fortovase saquinavir (SQV-sgc)– Invirase saquinavir (SQV-hgc)– Kaletra lopinavir, ritonavir (LPV)– Lexiva fosamprenavir (FPV)– Norvir ritonavir (RTV)– Reyataz atazanavir (ATZ)– Viracept nelfinavir (NFV)

Entry Inhibitors/ Fusion Inhibitors

• Fuzeon Injectable requires 2 shots/day– Reserved for individuals who are resistant to

PIs, NRTIs and NNRTIs.– Drug binds to gp41 protein on the HIV surface

so it can not bind with T cells– (work on penetration phase, injectable, 2 shots daily, used on pts

w/ resistance to coctails)

HIV-Medications

ANTIMETABOLITE ANTINEOPLASTIC–Hydroxyurea

Current Guidelines for HAART

• Symptomatic Treat• Asymptomatic w/CD4 <200 Treat• Asymptomatic w/CD4 200-350 Offer• Asymptomatic w/CD4>350 Defer

Development of Resistance

• Genotype resistance- mutation of virus• Phenotype resistance-decreased sensitivity to

drug• Cross-resistance-resistance to multiple drugs • Monotherapy-only on one drug• Subtherapeutic levels-not taking full dosage or

not at prescribed intervals

HAART-Associated Adverse Events

• Lactic Acidosis/Hepatic steatosis (fatty liver)• Hepatotoxicity• Hyperglycemia (meds hurt pancreas)• Fat Maldistribution (face loses fat, but develop belly or

back fat)

• Hyperlipidemia (from protease inhibitors)

• Osteopenia/Osteoporosis/Osteonecrosis

Maintenance of HIV-Infected individuals

• CD4< 500 Antiretroviral Therapy

• CD4< 200 P. jiroveci pneumonia prophylaxis

• CD4< 100 M. avium prophylaxis

• CD4< 50 CMV prophylaxis

• Give antibiotics (bactrim) for pneumonia… treatment will be the same as for a non HIV pt.

Opportunistic Diseases (OI)

• Fungal Infections– Candidiasis-(thrush) frequently first sign of disease (soil, food, on

the skin, mouth, vagina, large intestine) Most infections are endogenous.

– Clinical presentation is dependent on site of infection• Esophagitis-dysphagia• Thrush-oral legions• Intertrigo (folds in body… under breasts or fat folds)-cutaneous lesions• Vaginitis-vulvovaginal lesions and discharge• Disseminated disease (throughout the body)-constitutional symptoms

– Treated with clotrimazole, miconazole, ketoconazole, fluconazole or itraconazole. Disseminated- Amphoteracin B

– “zole” is antifungal– Amphoteracin… “amphoterrible” bad side effects, sometimes w/

steriods, gives chills & fever just from IV infusion, will get rid of the infection but it has rough side effects.

Opportunistic Diseases (cont)

• Protozoal– Pneumocystis jiroveci (formerly PCP)(Airborne,

found in lungs) – 7% are asymptomatic, coughing, non-productive

cough, fever, DOE (dry cough)– Treated with TMP-SMX (Bactrim)not for pt w/ sulfa allergy,

pentamidine, atovaquone, dapsone (also given for malaria), clindamycin-primaquin

– Maintenance therapy on TMP-SMX, pentamidine aerosol, atovaquone, dapsone

– Toxoplasmosis (injestion of contaminated foods)• Usually CNS symptoms (brain), presents like meningitis

Opportunistic Diseases (Cont)

• Bacterial – Fever, night sweats, fatigue, anorexia, weight loss,

abdominal pain, diarrhea– Mycobacterium Avium Complex (MAC) (soil, water,

animals, eggs, unpasteurized dairy)– May require 2-6 drug to treat including

Azithromycin (Z pack, drug of choice), clarithromycin, ethambutol, ciprofloxacin, rifabutin, and amikacin.

– Mycobacteria Tuberculosis (airborne)

Opportunistic Diseases (Cont)• Viral

– Cytomegalovirus (CMV). Almost everyone becomes infected with CMV which is transmitted through direct contact with infected secretions including saliva, cervical fluid, urine, semen, breast milk, feces, and blood. Infection can be asymptomatic or not. Medications used include gancyclovir, foscarnet and cidofovir. Treatment may also include intraocular gancyclovir implants or intravitrial injections of ganciclovir, foscarnet or cidofovir. Maintenance lifetime suppressive therapy is required. (a lot of children have this, often seen in the eyes “CMV retinitis”, can become blind from this)

– Herpes Simplex (often same meds as for CMV)

Opportunistic Diseases (Cont)

– Progressive Multifocal Leukoencephalopathy (PML)

Caused by the JC virus, ubiquitous in nature and infects most middle-aged people. Active disease results in limb weakness, ataxia, cognitive impairment, vision loss, speech impairment, and headache. In latter stages it progresses to dementia, blindness, paralysis and death.

There is no effective therapy.

Opportunistic Diseases (Cont)

• Cancers– Kaposis Sarcoma (KS)

• Classic KS- Older Black, Mediterranean or certain Jewish men• African KS- Seen in Africa• Transplant KS- people who receive transplanted organs• HIV-related KS- disseminated throughout the body, resulting

in shorter survival

– Initial patch is flat and pink, looks like a bruise, symmetrical on both sides of the body. Later dark violet • Localized or systemic- Chemotherapy such as: bleomycin,

alpha-interferon, daunorubicin

Opportunistic Diseases (Cont)

– Cervical Cancer-occurs at a high rate, progresses more rapidly, less responsive to therapy, related to low CD4 counts.• Early- asymptomatic• Diagnosed by Pap Smear• Post-coital bleeding, blood-tinged vaginal discharge• Late-stage Back, pelvic, leg apin, weight loss, vaginal

bleeding, anemia. Lymphadenopathy, edema of legs.• Treatment-conization, laser therapy, cryosurgery,

electrocautery, or hysterectomy

Opportunistic Diseases (Cont)

• Central Nervous System– Dementia-HIV encephalopathy-affects mostly the

very young and older clients• Cognitive dysfunction, motor problems, behavioral

changes (Five stages of progression)

– Peripheral Neuropathies• Greatly debilitating, interfereing with ability to

ambulate

Opportunistic Diseases (Cont)

• HIV Wasting Syndrome-profound involuntary weight loss (>10%) with either chronic diarrhea or chronic weakness and fever.– Primary causes: decreased food intake,

malabsorption, altered metabolism– Treatment usually results in only partial recovery– Megace and Dronabinol, Human growth hormone.

Critical Thinking

• Your HIV-infected client tells you “I don’t have HIV anymore. The doctor just told me my viral load was undetectable.”

• How would you respond?

Critical Thinking

• Explain how you can decrease your risk of occupational exposure to HIV.