HIV/AIDS: Part 2, Treatment as Prevention to Precautions Flashcards
1
Q
What are side effects of HIV drugs?
A
- Range from mild and annoying to severe
- Time - weeks to months
- Common - GI disturbances: N&V, diarrhea, bloating, farting - appear within days, less problematic over time
- Around 25% of people who start HAART will experience side effects that are severe enough to modify or stop treatment within the first year
- Peripheral neuropathy and mitochondrial toxicity associated with NRTi’s
2
Q
Describe how long QT is an unusual side effect:
A
- A prolonged QT interval is associated with Torsades de Pointes and potential cardiac arrest
- Associated with PLS and non-nucleosides
- Number of associated meds including antidepressants, psychotropics and methadone as well as HIV
3
Q
What are some non-physical side effects?
A
- Impact on daily activities
- Potential for unplanned disclosure
- Psychological impacts
- Changes in perception of health status
- Treatment focused care - failure to see the whole person
4
Q
What are some ways to reduce discomfort associated with HIV drugs
A
- Manage nausea with anti-emetics, timing (pre-medicating), reassurance it will subside and taking meds with a meal or snack
- CNS side effects (e.g. nightmares), try taking at bedtime or vice versa
5
Q
What are the most common reasons that a person will stop taking ARV’s?
A
- CNS side effects
- GI side effects
- Lipid issues
- Renal impairment
6
Q
What are the four predictors of durability (i.e. no resistance)?
A
1) Potency
2) Adherence *** (MUST take it accurately 95% of the time for success!)
3) Tolerance
4) Gold standard: triple therapy
These factors determine how well a patient does on HAART.
7
Q
Describe the issue of adherence:
A
- The single largest predictor of treatment success is adherence
- Only 30% of people in a study filled their prescriptions > 95% of the time and had 2 serial undetectable plasma viral loads
- Adherence levels of 60 to 90% most associated with resistance - close does not count - worst resistance with adherence levels of around 85%
- Psychological and social barriers need to be evaluated in addition to demographic predictors
- “It is more important to know what type of patient has a disease than what type of disease a patient has.”
8
Q
What are some strategies to support adherence?
A
- Ensure patient ready to start therapy
- Patient education
- Reinforce at each visit
- Simplified regimens when able
- Electronic reminders
- Important to ask HOW people take meds, not IF
- Assess for depression
- Remember that adherence in chronic illness tends to decrease over time
- Treat underlying addiction issues
- Identify and treat side effects - don’t wait for patient to tell you!
9
Q
What are common opportunistic infections?
A
- Fungal infections
- Protozoal infections
- Bacterial infections
- Viral infections
- Cancers
These begin to appear in HIV+ persons as viral load increases and CD4 decreases. These are considered AIDS’s defining illnesses.
10
Q
What are common fungal infections?
A
- Oropharyngeal candidiasis (CD4 < 500)
- Candida esophagitis (CD4 <100)
- Vulvovaginal candidiasis
- Cryptococcus - meningitis/pneumonia
- Pneumocystis pneumonia (PCP)
11
Q
What is significant about pneumocystis Jiroveci Pneumonia?
A
- One of the most common
AIDS related infections ** - First identified about 100 years ago as a protozoa and called pneumocystis carinii
- Reclassified as a fungus in 1988 and renamed in 1999 (pneumocystis jiroveci)
- 50% of hospital admits with PJP are in people who have never been diagnosed with HIV
12
Q
What is the most common bacterial infection in HIV+?
A
- Mycobacterium Avium Complex (MAC), caused by bacteria in food, water and soil, and infects resp. and GI tract
- CD4 <50, AIDS defining
13
Q
What are common cancers in this population?
A
- Kaposi’s sarcoma
- Invasive cervical cancer
- Lymphoma
14
Q
What do most people with AIDS die of?
A
- non-AIDS related cancers
- liver failure
- infections unrelated to AIDS
- complications arising from substance use
- suicide
- heart attacks
15
Q
Describe AIDS vs. Cancer:
A
- AIDS differs from cancer in some significant ways:
- predominantly impacts on a younger population; poorly housed; low income; mental health and/or substance use issues
- Diseases of the marginalized
- multisystem disease with multisysystem problems
- unpredictable trajectory
- polypharmacy
- Informal caregivers are often HIV+ themselves
16
Q
What are some issues for caregivers in the post-HAART era?
A
- The timing of death has become even more uncertain
- Decline and death most often seen in non-adherent clients or those who choose not to take HAART
- There is a gap between caregivers’ preferences and patient’s wishes
- Unpredictable course means that palliative care referrals should be made relatively early
- Some treatments (i.e. for CMV retinitis) may be continued until death
- People living with AIDS face a complex set of symptoms and conditions
17
Q
How is HIV different from other complex, chronic illnesses?
A
- Stigma
- Young age of clients/patients
- Fear of contagion
- Unpredicatable course of illness
- Lack of resources, support
- Multiple losses, death
- Ethical and legal dilemmas
18
Q
Our attitudes, beliefs and experiences about ____ impact how we treat HIV+ individuals.
A
- sexuality, sexual orientation
- drug use
- sex work
- illness
- death
- professional omnipotence
19
Q
How do we as caregivers take care of ourselves?
A
- Be reflective- seek out supervision or therapy
- Do grief work for self
- Limit caseload; use case mix
- Set clear boundaries
- Use stress management skills
- Cultivate a healthy personal lifestyle
20
Q
What are significant exposures to HIV?
A
- Any percutaneous exposure to infectious body fluids
- Mucous membrane or non-intact skin exposure to a splash of blood (more than a few drops) and/or duration of exposure of a few minutes or more
- Consider prophylaxis of large prolonged exposure on intact skin
21
Q
What are negligible exposures to HIV?
A
- Minor percutaneous, mucous membrane or skin exposure to non-infectious body fluid (whether source is positive or negative)
- Intact skin exposure to a small quantity of blood (< 3 drops) or fluid visibly contaminated with blood for short duration (< 3 minutes)
- Bites unless there has clearly been a transmission of infected blood
- A superficial scratch that does not bleed
- Injuries received in fights would rarely be appropriate indications for prophylaxis unless it is clear that transfer of infected blood has occurred
22
Q
What are factors affecting degree of risk?
A
- Prevalence of HIV/HCV
- Source characteristics
- Type of source fluid
- Type of exposure - deep injury, visible blood on device, needle was placed in vein or artery
- Illness of source patient - terminal AIDS = higher viral load = greater infectivity
23
Q
What do you do if you have an accidental exposure?
A
- Wash area of exposure with warm, soapy water (for eyes and other mucous membranes just rinse with water)
- Attend the nearest emergency department IMMEDIATELY - if you are determined to have a significant risk for HIV transmission the drugs should be started within 2 hours of exposure (PEP)
- Take someone with you to advocate if you are feeling particularly anxious or distressed
- Misc. such as supportive counseling, avoidance of sex/pregnancy/breastfeeding ~6 months, post-exposure blood-work, WCB claim, documentation and GP follow-up within 5 days
24
Q
What are some personal precautions?
A
- Ensure you and sexual partners have open discussions about risks during intercourse
- Insist on condoms
- Never share needles
- Get tattoos/piercing only in established businesses that follow best practice guidelines
25
Q
What are some routine work precautions?
A
- Protect yourself from exposure to blood and body fluids from any and all sources
- Hand-washing
- NEVER recap needles
- Gloves whenever there is a potential for handling blood or body fluids
- Long-sleeved gowns and goggles PRN
- Use PPE as designed and whenever available
26
Q
What are COMMON side effects that ART’s present with?
A
- CNS disturbance (insomnia, nightmares)
- Peripheral neuropathy
- Hepatotoxicity
- Renal failure
- Lipid changes = increased risk of CAD
- Hypersensitivity reactions
- GI disturbances
