Sophomore 2 Test 6 > AIDS > Flashcards

AIDS Flashcards

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1
Q

Pathophysiology of AIDS

A
  1. AIDS is caused by HIV
  2. HIV is a retrovirus
    - These carry genetic material (RNA)
  3. HIV consists of a viral core containing RNA, surrounded by an envelope consisting of protruding glycoproteins
  4. HIV targets CD4 receptors on the surface of T lymphocytes and the chemokine receptor CCR5 or CXCR4
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2
Q

HIV Life Cycle: Attachment

A
  • Glycoproteins of HIV bind with host’s uninfected CD4+

- Results in fusion of HIV with CD4+ T-cell membrane

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3
Q

HIV Life Cycle: Uncoating

A

Contents of HIV viral core empties into CD4+ cell

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4
Q

HIV Life Cycle: DNA Synthesis

A
  • HIV changes its genetic material from RNA to DNA through reverse transcriptase
  • Results in double-stranded DNA that carries instruction for viral replication
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5
Q

HIV Life Cycle: Integration

A
  • New viral DNA enters the nucleus of CD4+ T-cell, resulting in permanent lifelong infection
  • Prior to this step, the person has only been exposed, not infected with HIV
  • At the end of this step HIV is PERMANENT
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6
Q

HIV Life Cycle: Transcription

A

Double stranded DNA forms single stranded RNA (mRNA)

- Builds new virus

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7
Q

HIV Life Cycle: Translation

A

The mRNA creates chains (polyproteins) that have components needed for new virus construction

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8
Q

HIV Life Cycle: Cleavage

A

HIV enzyme protease cuts the polyprotein chain into two individual proteins that make up the new virus

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9
Q

HIV Life Cycle: Budding

A

New proteins and viral RNA migrate to the membrane of the infected CD4+ T-cell, exit from the cell to start the process all over again

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10
Q

Fluids that can transmit HIV infection

A
  1. Blood (tranfusion, needles)
  2. Pre-seminal fluid/semen
  3. Vaginal fluid
  4. Amniotic fluid
  5. Breast milk
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11
Q

HIV can enter the body through:

A
  1. Lining of the anus or rectum
  2. Lining of the vagina and/or cervix
  3. Opening to the penis
  4. Mouth that has sores or bleeding gums
  5. Cuts and sores
  6. Needle sharing
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12
Q

HIV Prevention

A
  1. Male and female condoms
  2. PEP
  3. PMTCT
  4. Male circumcision
  5. Voluntary counseling and testing
  6. Clean injecting equipment
  7. Cervical barriers and vaginal diaphragms
  8. Microbicides
  9. PrEP
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13
Q

PrEP

A

Preventative Exposure Protection

- For high risk groups

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14
Q

Stages of HIV

A
  1. Primary Infection
  2. HIV Asymptomatic Category A
  3. HIV Asymptomatic Category B
  4. AIDS: CDC Category C
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15
Q

HIV Primary Infection

A
  1. The period from infection to the development of HIV specific antibodies
  2. The window period is the time during which an HIV positive person test negative on the HIV antibody test
    • The patient is still highly infectious
    • Viral load is very high during this period
    • After 2-3 weeks the disease can be detected, but the antibodies lack the ability to control the virus
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16
Q

HIV Primary Infection is Characterized by:

A
  1. High levels of viral replication
  2. Normal CD4+ count = 500-1500 cells/mm3 of blood
  3. Widespread dissemination of HIV throughout the body
  4. Destruction of CD4 T-cell counts
  5. Dramatic drop in CD4 count
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17
Q

Why is there a dramatic drop in CD4 count during the HIV primary infection stage?

A
  1. Individual is responding to the virus

2. Antibody molecules are trying to remove the virus from the body

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18
Q

Viral Set Point

A

Amount of virus remaining in the body after the initial immune response

- Results in a steady state of infection that last for years
- Varies greatly among individuals
- The higher the viral set point, the poorer the prognosis
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19
Q

Symptoms of Primary HIV Infection

A
  1. Fever
  2. Lymphadenopathy
  3. Pharyngitis
  4. Skin rash
  5. Myalgias/Arthralgias
  6. Flu-like symptoms
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20
Q

HIV Asymptomatic: Category A

A
    • CD4+ count > 500
      1. Occurs after the viral set point is reached
      2. HIV+ individuals enter a chronic state
      3. Immune system cannot eliminate the virus, despite its best effort
      4. On average, 8-10 years pass before the individual develops an HIV related illness
      5. Patients generally feel well, and have few if any symptoms
      6. CD4+ counts remain high enough to preserve immune defensive responses
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21
Q

HIV Asymptomatic: Category B

A
    • CD4+ count 200-499
      1. Over time CD4+ counts fall and the patient becomes ill
      2. The condition must:
      • Be directly caused by HIV infection or defect in cellular immunity
      • Must have a clinical course that requires management of a complicated HIV infection
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22
Q

Examples of conditions that are present in HIV Category B

A
  1. Candidiasis (thrush)
  2. Cervical dysplasia
  3. Cervical carcinoma
  4. Herpes zoster
  5. Idiopathic thrombocytopenia purpura
  6. Peripheral neuropathy
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23
Q

AIDS: CDC Category C

A
    • CD4+ count < 200 cell/mm3
      1. Once a patient enters this stage, the individual remains in this category
      2. As CD4+ levels drop below 100 the immune system is severely impaired
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24
Q

Examples of conditions associated with ADIS category C

A
  1. Mycobacterium tuberculosis
  2. Invasive cervical carcinoma
  3. HIV encephalopathy
  4. Kaposi’s sarcoma
  5. Wasting syndrome related to HIV
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25
Diagnostic Tests: Monitoring of HIV Infection
1. Viral load test | 2. CD4+ Count
26
Viral Load Test
1. Measures plasma HIV RNA levels in the blood 2. Viral load testing at initial diagnosis and every 3-4 months 3. Viral load is a better predictor of the risk of HIV disease progression than CD4+ count 4. The lower the viral load, the longer the time until AIDS diagnosis and the longer the survival time
27
CD4+ Count
1. The number of helper T cells per cubic mm of blood 2. AIDS patients get CD4+ counts every 3-4 months to assess response to ART or HAART 3. One of the key factors in determining both the urgency of antiretroviral therapy (ART) initiation and the need for prophylaxis for opportunistic infections 4. It is also the strongest predictor of subsequent disease progression and survival 5. Indicator if they need a medication change
28
ELISA/EIA
Enzyme-linked immunosorbent assay OR enzyme immunoassay 1. Identifies antibodies directed specifically against HIV in the blood 2. If test is positive, a 2nd test is done to verify the results = Western Blot Assay
29
Western Blot Assay
Identifies specific antibodies or proteins in blood. The proteins are separated by electrophoresis, transferred to nitrocellulose, and reacted with antibody ** Used to confirm seropositivity when EIA/ELISA result is positive
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OraSure Test
Uses saliva to perform EIA antibody test
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OraQuick Rapid HIV-1 Antibody Test
Uses > 1 drop of blood to quickly (20 minutes) and reliably detect antibodies to HIV-1
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Respiratory Manifestations of AIDS
1. SOB 2. Dyspnea 3. Cough 4. Chest pain 5. Fever 6. Pneumocystis pneumonia 7. Mycobacterium Avium Complex 8. Tuberculosis
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Pneumocystis pneumonia
- This is the most common infection in people with AIDS | - Without prophylactic treatment, 80% of all patients with HIV develop PCP
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S/Sx of Pneumocystis pneumonia (Initial Symptoms)
1. Non-productive cough 2. Fever 3. Chills 4. SOB 5. Chest pain 6. ABGs show mild hypoxemia
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S/Sx of Pneumocystis pneumonia (Dramatic Presentation)
1. Severe hypoxemia 2. Cyanosis 3. Tachypnea 4. Altered mental status 5. Death (can result in 2-3 days from respiratory failure)
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How is Pneumocystis pneumonia diagnosed?
1. Fiber optic bronchoscopy | 2. CXR may also show changes
37
Treatment for Pneumocystis pneumonia
1. TMP-SMZ (bactrim PO) - Highly effective with mild-moderate PCP 2. Adjunctive corticosteroids started within 72 hours of treatment 3. Pentamidine is 2nd line treatment - given IV
38
Pentamidine
2nd line treatment for PCP - Given to patients who are allergic to sulfa drugs - Highly nephrotoxic (25% will develop toxicity) - Common SE are fatal arrhythmias/CHF
39
Gastrointestinal Manifestations of AIDS
1. Diarrhea is a problem in majority of AIDS patients 2. GI symptoms may be related to the direct effect of HIV on cells lining the intestines 3. Loss of appetite 4. N/V 5. Oral and esophageal candidiasis
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Oral Candidiasis
1. Occurs in almost every patient with AIDS 2. Creamy white patches in the oral cavity, may progress to esophagus if left untreated 3. Difficult and painful swallowing 4. Ulcerating lesions 5. May spread to other body sustems
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Oral Candidiasis Treatment
1. Ketoconazole | 2. Fluconazole
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Criteria for Wasting Syndrome
1. Weight loss exceeding 10% of baseline body weight 2. And either chronic diarrhea for more than 30 days or chronic weakness and documented intermittent/constant fever in the absence of any concurrent illness that explains these findings * * For category C of AIDS
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Symptoms that lead to Wasting Syndrome
1. Anorexia 2. Diarrhea 3. GI malabsorption 4. Lack of nutrition
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Antidiarrheal Therapy in HIV
1. Somatostatin inhibits GI motility and increases secretion of water and electrolytes 2. Octreotide acetate is a synthetic analogue of somatostatin; effective in managing chronic diarrhea
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Nursing Plan of Care for GI Symptoms
1. BRAT diet 2. Avoid bowel irritants: fatty/fried foods, raw vegetables, and nuts 3. Fluid intake of at least 3 L/day 4. Small, frequent meals for daily nutritional needs
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BRAT diet
B - bananas R - rice A - apple sauce T - toast
47
Oncological Manifestations of HIV
Certain types of cancers are considered AIDS-defining conditions 1. Kaposi's sarcoma 2. Lymphoma - Non Hodgkin's - Primary CNS lymphoma - Invasive cervical carcinoma
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Kaposi's Sarcoma
- The most common HIV related malignancy - Involves the endothelial layer of blood and lymphatic vessels - Very aggressive, but rarely life-threatening except with pulmonary or GI involvement - Ranges from localized cutaneous lesions to disseminated disease involving multiple organs
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How is Kaposi's sarcoma diagnosed
Diagnosis is dependent on biopsy of suspected lesions
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S/sx of Kaposi's Sarcoma
1. Cutaneous lesions are the first manifestations 2. Correlates to low CD4+ counts (< 200) 3. Can appear anywhere on the body 4. Usually brownish pink to deep purple 5. Can be flat or raised and surrounded by ecchymoses and edema 6. Most common sites are lymph nodes, GI tract, and lungs
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Kaposi's sarcoma lesions can lead to what?
1. Venous stasis 2. Lymphedema 3. Pain 4. Ulcerative lesions disrupt skin integrity, increase discomfort, and susceptibility to infection
52
Treatment for Kaposi's sarcoma
* Prognosis depends on the extent of tumor, presence of other symptoms, and CD4+ count 1. Goal is to decrease size of the lesions and reduce discomfort 2. No treatment has been found to increase survival 3. Radiation therapy 4. Interferon
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Treatment for Kaposi's sarcoma: Radiation Therapy
* Effective as a palliative measure - Relieves localized pain (esp. legs) - Sites such as oral mucosa, conjunctiva, face, and soles of the feet
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Treatment for Kaposi's sarcoma: Interferon
* Known for antiviral and antitumor effects | - Facilitates tumor regression and improves immune system function
55
B-cell Lymphomas (Non-Hodgkins)
- Second most common malignancy in patients with AIDS - Tends to develop outside the lymph system (brain, bone marrow, GI tract) - Standard regimens for non-AIDS patients have been ineffective in AIDS patients
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B-cell Lymphomas (Non-Hodgkins) Treatment
- Chemotherapy and radiation therapy are the best treatment | - Response to treatment is short-lived because of their diminished immune system it will keep coming back
57
Immune system responses to HIV infection in the CNS include:
1. Inflammation 2. Atrophy 3. Demyelination 4. Degeneration 5. Necrosis
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Peripheral Neuropathy
- Very common in HIV/AIDS patients - Distal symmetric polyneuropathy occurs in advanced HIV disease - Leads to significant pain and decreased function
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HIV Encephalopathy
- Progressive decline in cognitive functions - Progressive decline in behavioral and motor functions - HIV found in brain and CSF; triggers release of toxins and cytokines which leads to cellular or neurotransmitter dysfunction
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Early Symptoms of HIV Encephalopathy
1. Memory deficits 2. HA 3. Difficulty concentrating 4. Progressive confusion 5. Psychomotor slowing 6. Apathy/ataxia
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Late Symptoms of HIV Encephalopathy
1. Global cognitive impairments 2. Delay in verbal response 3. A vacant stare 4. Spastic paraparesis 5. Hyperreflexia 6. Psychosis 7. Hallucinations 8. Tremor 9. Incontinence 10. Seizures 11. Mutism 12. Death
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Treatment for HIV Encephalopathy
No treatment
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Diagnostic Testing HIV Encephalopathy
1. CT 2. MRI 3. Lumbar puncture 4. Brain biopsy (post-mortem)
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Gynecological Manifestations
- Persistent, recurrent vaginal candidiasis may be the first sign of HIV in women - Ulcerative STDs are more severe in women (ulcers, warts, syphilis, herpes) - Women with HIV are 10 times more likely to develop cervical cancer than non-HIV women - HPV is strongly associated with cervical carcinoma in HIV+ women
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Goals of ART Treatment
1. Reduce HIV-associated morbidity and prolong the duration and quality of survival 2. Restore and preserve immunologic function 3. Maximally and durably suppress plasma HIV viral load 4. Prevent HIV transmission
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How to decide how to treat HIV
- Protocol on how and when to start treatment; usually changed often - CD4+ count is usually the most important consideration when deciding on antiretroviral medications (ARTs) - Currently ARTs are recommended when CD4+ counts are 350-500 - Decision is based on CD4+ count, viral load, severity of symptoms, and willingness of patient to adhere to lifelong therapy
67
Antiretroviral Therapy (ART) Drug Classes
1. Protease inhibitors (mainstay of therapy) 2. Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) 3. Non-nucleoside reverse transcriptase inhibitors (NNRTIs) 4. Fusion inhibitors 5. Entry inhibitors 6. Integrase strand transfer inhibitors
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Highly Active Antiretroviral Therapy (HAART)
- Therapy includes 2-3 antiviral medications for treatment regimen (to sustain viral suppression) - Try to affect several different points of the life cycle of the virus - Overall adherence levels to therapy remains low (30-50%)
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HAART is recommended for the following patient groups:
Symptomatic from HIV, regardless of CD4+ count, including any of the following conditions - HIV associated neurocognitive disorder (HAND) - Severe thrombocytopenia - HIV associated nephropathy - HIV related malignancies * * To achieve viral suppression, patients must take more than one antiretroviral medication
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Long-Term Management of HAART
1. Monitoring of HAART therapy requires viral load testing and CD4 regularly - Viral load should decline over time if therapy is successful - T cells should rapidly increase 2. Drug resistance is a huge issue
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Immune Reconstitution Inflammatory Syndrome (IRIS)
Is a syndrome that results from rapid restoration of pathogen-specific immune responses to opportunistic infections - Causes the deterioration of a treated infection OR - New presentation of a subclinical infection * * Most often occurs during the initial months after starting ART
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S/Sx of IRIS
1. Fever 2. Respiratory symptoms 3. Abdominal symptoms 4. Worsening clinical manifestations 5. Opportunistic infections
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If HIV infected blood splatters into your eyes...
1. Rinse eyes with water 2. Report to supervisor 3. Go to employee health 4. ER to test patient and you and possibly begin PEP
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Post Exposure Prophylaxis (PEP)
1. PEP must begin within 72 hours of exposure (ASAP), before the virus has time to rapidly replicate in the body 2. PEP involves taking antiretroviral drugs as soon as possible after you have been exposed to HIV 3. PEP consists of 2-3 antiretroviral medications and should be taken for 28 days. - Medications have serious side effects and can make it difficult to finish regimen 4. Follow up testing at 3 months, 6 months, and 1 year. 5. PEP is not 100% effective 6. PEP can also be used to treat people who have been exposed to HIV by accident or sexual assault
Sophomore 2 Test 6
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