Exam 1: HIV Flashcards
Cell Mediated Immunity (5)
- Protect against viruses, fungi, and slowly developing bacterial infections (TB)
- Immune surveillance for malignant cells
- Timing of response in delayed hypersensitivity reactions (PPD)
- Rejections of foreign grafts
- Achieves full function early in life (Helper cells fully developed by 6 yrs. of age)
HIV
Acquired cell-mediated immunodeficiency disorder, affects CD4 helper cells
Etiology
*horizontal transmission: sexual transmission, IV usage, etc.
*vertical transmission: from mother to infant
Vertical transmission is decreased with use of ZDV during pregnancy of HIV infected women; there is only 1% ocurrence of it now
HIV Pathophysiology
Retrovirus composed of RNA and enzyme reverse transcriptase
1st: Virus gains access into CD4+ cell
2nd: With in cell, reverse transcriptase causes synthesis of HIV DNA
3rd: Integrates with CD4+ cell’s DNA & virus causes CD4+ cell to make more of itself
4th: New virus assembles @ host’s cell surface as they bud through cell membrane, viruses mature and are releases, infecting other CD4+ cells
Results in cell death
HIV: Clinical Manifestations (7)
- Lymphadenopathy
- Hepatospleenomegaly
- Oral candidiasis
- Chronic or recurrent diarrhea
- Failure to thrive (not developing or growing normally)
- Developmental delays
- Parotitis (enlarged gland, gets swollen and inflamed and is very painful)
*Mainly occurs because CD4 cells can no longer do their job
HIV: Difference between children and adults (4)
- Shorter time from infection and AIDS diagnosis
- *Children can develop AIDS in less than a year if positive at birth if they don’t receive any treatment (adults can be up to 10 years)
- Signs may be physical and developmental failure to thrive
- Experience earlier opportunistic infections & greater number of bacterial infections from childhood illnesses
- Perinatally acquired – PCP (Pneumocystis Carineri Pneumonia) can occur much earlier than HIV+ adults. As a result, prophylaxis are started as early as 2 months of age.
* Adults have longer time of PCP onset
* Children can get PCP at 4-6 weeks, so start PCP prophylaxis until tests say negative if mother is HIV+!
HIV Diagnosis
ELISA or Western blot is not accurate in infants younger than 18 months
USE: HIV DNA – PCR test
- (+) results on 2 separate blood specimens (at birth, at 1-2 months, and at 4-6 months)
- 95% of infected infants diagnosed by 1-3 months
Testing for HIV exposed infant with HIV(-) screening results
If screening is negative, repeat at 1-2 months and again at 4-6 months of age.
May confirm absence of HIV infection with HIV antibody assay testing at 12-18 months of age
HIV: Clinical Staging (what are the 4 dif stages)
Stage N (infected but not symptomatic)
Stage A (mild symptoms)
Stage B (moderate symptoms)
Stage C (severe symptoms)
HIV: Immunological Staging
Stage 1 (no evidence of suppression)
Stage 2 ( evidence of moderate suppression)
Stage 3 (sever suppression)
Indicators of AIDS in Children under 13 (11)
- LIP (Lymphoid Interstitial Pneumonia); similar symptoms to asthma, a reaction the lungs have to a type of infection
- Serious bacterial infections
- PCP (pneumonia)
- CMV (citomegalovirus); not dangerous in healthy people but can cause mono in young children
* **THIS IS VERY DANGEROUS FOR SOMEONE WHO IS IMMUNOSUPPRESSED - Encephalopathy
- Wasting Syndrome
- Candidal espophagitis (can get it in lungs, GI tract, etc)
- Pulmonary candidiasis
- Herpes simplex disease
- Cryptosporidiosis (type of parasite)
- Mycobacterium Avium-Intracellulare Complex infection
CD4+ counts and HIV RNA
- Assess infected immune system’s response to therapy, risk for disease progression and need for PCP prophylaxis after 1 yr. of age
- Measure when clinically stable
- Normally higher in children than adults
- CD4+% have less measurable variability
HIV Management (4: know by heart)
- Elective Cesarean delivery before onset of labor and before rupture of membranes for women with an HIV viral load of > 1000 copies/ml.
* If less than 1,000 copies/mL then she can have normal vaginal birth - Administration of antiretroviral prophylaxis (ZDV) during pregnancy and labor and to the infant for 6 weeks after birth.
* Highly effective
* If mother is HIV+ and hasn’t been taking ZDV, then give post-exposure prophylaxis/IV infusion of ZDV during labor and delivery to diminish transmission - Complete avoidance of breastfeeding in U.S.
- In third world countries, must strictly breastfeed
- PCP prophylaxis @ 4-6 weeks of age and continues until 1 yr. of age or determined to be HIV (-) (Trimethoprine-sulfamethoxazole)
* PCP prophylaxis= Bactrim
Facts about Adolescent HIV (2)
- Percentage of total HIV/AIDS cases among 13-19 year olds has more than quadrupled from 1985 – 2004.
- More than 50% of HIV infected adolescents in the United States are unaware of their infection.
HIV: Drug Dosing for Adolescents (3)
- Based on tanner stages
* Tanner 1 and 2 – Give pediatric dosing
* Tanner 3-5 – Adult dosing - Know if it is perinatal acquired vs new onset
- -> This is because the longer you have the disease, the higher chance you have of non-adherence and then resistance can arise to all drugs in the category - Pregnancy dosing: know whether or not the medication you are giving is safe for pregnant women
UNSAFE MEDICATION= EFAVIRANEZ (causes congenital abnormalities)
CDC recommendations for HIV testing in all patients 13 to 64 years of age.
BOTTOM LINE= NEW RECOMMENDATION IS THAT EVERYONE GETS TESTED FOR HIV UNLESS THEY SAY THEY DO NOT WANT TO BE TESTED
Goals of HIV Therapy (5)
- Slowing growth of HIV
- Promoting or restoring normal growth and development
- Preventing complicating infections and cancers (there is an increased risk of lymphoma in adolescents with HIV)
- Improving quality of life
- Prolonging survival
*A lot of children with vertical transmitted HIV will be in the hospital not because of the HIV but because of lymphoma they have developed secondary to the HIV
Antiretroviral Therapy Goal
maximum suppression of viral replication in an attempt to preserve immune function and delay disease progression
Antiretroviral Therapy HAART
Highly active antiretroviral therapy (dosage in adolescents based on Tanner stage)
*Medication may be changed in response to worsening immune function, mild intolerance, toxicity or development of newer or better regime.
Types of HIV Medications with commonly use regime
- Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
- Protease inhibitors
- Non-Nucleoside Reverse Transcriptase Inhibitors
Regime: 2(NRTI) + PI or NNRRTI
Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
Targets the reverse transcriptase phase
Includes 2 nucleoside analogs
- ZDV (zidovudine) & ddl (didanosine)
Protease Inhibitors
Targets replication @ different phase
*Retonavir, nelfinavir
Non-Nucleoside Reverse Transcriptase Inhibitors
Blocks HIV protein reverse transcriptase
* Nivirapine, efavirenz
EFAVIRENZ IS NOT SAFE WITH PREGNANCY; if someone is on it then they need to take pregnancy tests frequently
Side Effects of HIV Medication (8)
- Nausea, Vomiting
- Headache
- Diarrhea
- Anorexia
- Rash
- Fever
- Abdominal pain
- Anemia
*Side effects are another reason that people are non-adherent
When to initiate combination therapy
With HIV infected infants younger than 1 yr. as soon as diagnosis confirmed
- As soon as 4-6 months old test comes back +, infant should be started on combination therapy
- If test is negative then take infant off ZDV and do not start combination therapy
Treatment for Asymptomatic HIV Infected Children Older than 1 yr.
Defer treatment for those with normal immune status, a low viral load and medical compliance risk
- need frequent monitoring of virologic, immunologic and clinical status
- Treatment is delayed due to the risk of non-adherence and developing resistance to treatment
Prophylactic Medications (4)
- For PCP: Trimethoprim-sulfamethoxazole
- For Candidiasis, Herpes Simplex, and MAC: IVIG (monthly infusion)
- For LIP: Corticosteroids
- Immunizations
Medication Adherence (with 5 Barriers)
Failure results in development of drug resistance & treatment failure
Barriers:
- palatability
- adjusting medication routine to existing routines
- denial
- embarrassment with diagnosis
- financial
Nursing Dx for Adolescent HIV
- Deficit knowledge
- Risk for Infection
- Imbalanced nutrition
- Impaired Gas exchange
- Ineffective airway clearance
- Risk for impaired skin integrity
- Delayed growth & development
- Acute & chronic pain
- Anxiety
- Ineffective Therapeutic Regimen
T Helper Cells
CD4+ Cells
Secrete cytokines and stimulate B cells
*Affected cells from HIV
How does HIV look on electron microscope image
Small spheres on surface of white blood cells
Category N
Not Symptomatic
Children who have no signs or symptoms considered to be the result of HIV infection OR who have only one of the conditions listed in category A
*Would defer treatment in this case
Category A
Mildly Symptomatic
Two or more of the following conditions (and none from category B or C)
- Lymphadenopathy
- Hepatomegaly
- Splenomegaly
- Dermatitis
- Parotitis
- Recurrent or persistent upper respiratory infection, sinusitis, or otitis media
Category B
Moderately Symptomatic
Symptomatic conditions other than those listed in category A or C, that are attributed to HIV
Some examples: Anemia, pneumonia or sepsis (single episode), meningitis, candidiadis, hepatitis, HSV, herpes, nephropathy, varicella, fever lasting >1 month
*LIP is in this category
Category C
Severely Symptomatic
AIDS CATEGORY
Immunological Staging
Stage 1: No evidence of suppression
Stage 2: evidence of moderate suppression
Stage 3: severe suppression; AIDS
- This staging is dependent on the age of the child! (dif from how adults get staged)
- Based on CD4+ Cell Count and Percentage
Immunological Staging, Stage 1
1,500 or >25%
1-5 years: >1,000 or >25%
6-12 years: >500 or >25%
*Would defer treatment in this case
Immunological Staging, Stage 2
Immunological Staging, Stage 3
Myobacterium Avium Intracellular Complex Infection
“MAC”
One of the most severe indicators of AIDS in children
- A non-TB lung infection that has very similar characteristics as TB
- Can present with a rash and papillary/nodular lesions on body
Child will be VERY SICK with this
When to defer treatment
1-5 years old: if patient is asymptomatic or mild symptoms and has CD4 >25% AND HIV RNA 5 years old: asymptomatic or mild symptoms and CD4 >350 AND HIV RNA
Immunizations for HIV+ Adolescents
HIV+ children get immunizations, but not all of them
If total CD4 count is equal to or less than 15%, then give immunizations other than live virus ones, which are:
- Varicella for chicken pox
- MMR
- Flumis
*If count is above 15% then give all immunizations
