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Medcon Rehab IV > HIV Disease: Clinical Implications for PT > Flashcards

HIV Disease: Clinical Implications for PT Flashcards

1
Q

Globally…. # of people who have died of AIDS since start of pandemic

A

30,000,000

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2
Q

HIV Prevalence in U.S.

1 in every _______ persons is HIV+

A

250

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3
Q

Leading cause of death in persons w/ Advanced HIV disease (AIDS)

A

Opportunistic Infx

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4
Q

Which is Contraindicated in a pt w/ Acute Inflammatory Myopathy?

A

PREs

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5
Q

Sandy has HIV and Acute Inflammatory Myopathy. You expect to see:

A

Diffuse myalgia and PROXIMAL weakness*

Trunk, shoulder/pelvic girdles

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6
Q

Which of the following opportunistic infx’s is the MOST RARE in people w/ HIV?

A

Progressive Multifocal Leukoencephalopathy

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7
Q

HIV Hx

A
  • 40s or 50s→ Cameroon, Africa- wild chimpanzees, man either bit or exposed butchering monkey
  • Mid 1970s→ rare illnesses/infx in gay men
    • 5 young men tx for biopsy confirmed P. carinii pneumonia. 2 pts died. All 5 had lab confirmed prev or current CMV infx and candida mucosal infx
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8
Q

AIDS term coined

A

1982

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9
Q

FIRST antiretroviral (ART) drug for AIDS

A

AZT

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10
Q

Routes to a cure

“Functional Cure” vs. “Complete eradication of virus”

A
  • Conventional cure difficult
  • Sustained virologic remission→ “Functional cure”
    • w/out having to continue lifelong ART meds maybe more realistic
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11
Q

Route to a cure:

Currently under study

A
  • Therapeutic vaccine
  • Antibody therapy→ immune system enhancement
    • “Elite controllers”→ have certain killer T cells that keep virus suppressed
  • “Shock and Kill”→ chemo to draw HIV out of reservoir sites and kill it
  • Gene therapy→ mod of receptors (CCR5) on CD4s so HIV cannot get in
  • Gene therapy→ molecular scissors to “snip out” HIV DNA from host cells
  • Combo→ enhance immune system + modify CCR5 receptors + destroy latent reservoirs
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12
Q

Trends in Annual Age-Adjusted Rate of Death w/ HIV Disease as the Underlying Cause

DROP in rate 1995….why?

A

Triple Combo Tx

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13
Q

HIV Myths + Facts

Myth: HIV is an IV-drug abusers disease or a gay male’s disease

FACTS?

A
  • FACT:
    • HIV infects people all walks of life. Does NOT discriminate
      • all races/genders/sex preferences
        • hetero→ 32% cases
    • any age, socioeco stat
  • FACT:
    • Men who have sex w/ men and IV-drug users are at a higher risk for infx (higher # exposures)
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14
Q

HIV Myths + Facts

Myth: HIV can be cured w/ new meds; its not so serious now

FACTS?

A
  • FACT:
    • There is NO CURE for HIV; once infected, HIV cannot be eradicated from body
  • FACT:
    • ART drugs can greatly INC life-expect, BUT…
      • SEs/toxicities
      • Near perfect adherence=critical to success
      • marginalized or underinsured indiv’s have limtd access
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15
Q

1 in ________ Am’s is HIV+

A

250

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16
Q

Why don’t we all say YES to knowing someone w/ HIV?

A
  • Stigma/reluctance to share
  • Person you know hasn’t told you
  • Person doesn’t know
    • 14% of HIV+ Am’s are not aware of HIV stats
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17
Q

Pt w/ prob NOT related to HIV, but is HIV+

referred for tx of MSK prob

Med Hx includes HIV+

A

SAME exam and intervent as any patient: Keep in mind

S/S of possible comorbs, Monitor VS, ART SEs

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18
Q

Pt w/ problem related to HIV disease, comorbs, or ART SEs

A

Exam of and interventions for impairs, functional limits, or disability

  • Example:
    • Balance deficits and gait disturbs due to adv. peripheral neuropathy and CMV
    • Knee pain, impaired ROM and impaired mm perform due to HIV related arthritis
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19
Q

Stigma assocd w/ HIV….WHY?

A

Ignorance/misperceptions, irrational/puritanical judgements, stereotyping, scape-goat/blame-game, bigotry, homophobia

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20
Q

How can I REDUCE STIGMA?

A
  • Discuss HIV openly
    • Educate!
    • Non-judgemental
  • Resources
    • local testing and counseling centers
    • Info resources
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21
Q

>35 mil living w/ HIV/AIDS

A

Only 53% have access to ART Meds !!!!

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22
Q

Hispanics→ 27% of new infx’s

Blacks/Af Am’s→ 44% new infx’s

WHY?

A
  • Comm’s of color:
    • greater prevalence HIV→ community incubators
  • Higher poverty
    • limtd access
  • Higher rates of undx’d STD→ inc risk HIV
  • Higher rates incarceration
  • More stigma/homophobia
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23
Q

HIV in “Golden Years” aka older individuals

Prevalence inc’ing indiv’s >50yo

A
  • Incd longevity due to ART: PWHIV living longer
  • New Infx’s: 10% of new infx’s in indivs >55yo
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24
Q

Prognosis is ______ in Older individuals

A

WORSE!!!!!

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25
Q

Prognosis is WORSE in older individuals

More on this…

A
  • Many elderly pts do not receive HIV Dx until they have full blown disease and thus have WORSE prognosis
  • More HIV and non-HIV related comorbs in older pts
  • Immunosenescence→ immune system dysf.
  • Psychosoc, nutritional, lifestyle factors
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26
Q

Delayed Dx in older individuals

BIG REASON FOR THIS???

A

***MANY early sx’s of HIV mimic common presentations of other dis’s or may be attributed to “getting old”

  • Fatigue, wt loss, neuropsycho changes, chronic pain, depression/social iso.

IMPORTANT! KNOW THIS!!!

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27
Q

Older pts w/ HIV have WORSE prognosis because:

A
  1. Greater chance of delayed dx
  2. Presence of multimorbidity
  3. Immunosenescence
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28
Q

HIV aka

A

Human Immunodeficiency (retro) Virus

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29
Q

HIV Disease

Cause and what is it?

A
  • Cause→ Infx w/ HIV
  • Suppression of immune system
    • INCd risk for life-threatening opportunistic infx’s
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30
Q

HIV Stages

AASA****

W/OUT ART

A
  • A: Acute infx
  • A: Asymptomatic HIV Dis.
  • S: Symptomatic HIV Dis.
  • A: Advanced HIV Dis./AIDS
    • “Acquired Immunodeficiency Syndrome”
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31
Q

HIV Replication takes how long?

A

2.6d

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32
Q

HIV Replication Steps:

youtube.com/watch?v=RO8MP3wMvqg

A

Remember steps from pic (see below)

  1. Free virus
  2. Binding and Fusion
  3. Infection
  4. Reverse Transcription
  5. Integration
  6. Transcription (Copies)
  7. Assembly
  8. Budding
  9. Maturation
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33
Q

HIV replicates in, and eventually kills:

A

CD4 cells***

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34
Q

Viral replication in a CD4 cell involves all of the following enzymes

A
  • Transcriptase
  • Integrase
  • Protease

NOTE: does NOT involve creatine phosphokinase (from pollev.)

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35
Q

#1 HIV Transmission Route:

A

Sexual Contact

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36
Q

HIV Transmission routes

A
  • #1: Sexual contact
  • Sharing needles (IV drug use)
  • Blood to blood (or blood derived fluid) contact
  • Mother→ child
    • pregnancy, delivery, breast feeding
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37
Q

Fluids that transmit HIV

A
  • Semen→ unprotected sex
  • Vaginal fluid→ unprotected sex
  • Blood
  • Breast milk
  • Other body fluids w/ blood
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38
Q

YOU CANNOT GET HIV FROM HUGGING OR SHAKING HANDS W/ PERSON W/ ADVANCED HIV DISEASE (AIDS) !!!!

A

Unless open wound or blood→blood but in general….

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39
Q

GLOBALLY…..#1 Axis of Transmission for HIV

A

Heterosexual sex

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40
Q

Heterosexual sex is __________

A

Globally #1 transmission route of HIV

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41
Q

All are routes of transmission for HIV

A

Sex, blood-blood, mother→baby during childbirth

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42
Q

NOT a route of HIV transmission?

A

Inhalation of airborne particles

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43
Q

Why do Untreated individuals (NOT ON ART) die from HIV?

A

Opportunistic infx’s

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44
Q

Why do Treated Indiv’s (on ART) die from HIV?

A
  • Comps/Comorbs related to med toxicities and/or chronic infx
  • Poor adherence to ART→ disease progresses
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45
Q

Treated indiv’s ON ART can die from HIV mostly from comps/comorbs or poor adherence to ART

BUT….

A

MOST indiv’s successfuly treated w/ ART expected to live out natural lifespan

46
Q

Educate/Communicate

A
  1. talk about sex
  2. safe sex
  3. IV drug use (sterile, no share)
47
Q

Talk about HIV Prevention:

A
  • Pre-Exposure Prophylaxis (PrEP)
  • Limit exposure:
    • abstinence
    • mutual monogamy
    • reduce # sexual pahtnas
48
Q

PrEP types:

A
  • Truvada
  • Descovy→ safer than Truvada for people w/ OP or kidney issues
49
Q

PrEP MOST effective used w/

50
Q

“Prevention” as a Cure

A
  • 14% of people who do not know they’re HIV+ → 30% of new infx’s
  • Those who KNOW HIV+ but not successfully tx’d (have a viral load)→ 60% new infx’s
  • IF we could get them all treated (viral load to undetectable) → new infx’s DROP over 90%!
51
Q

HIV prevention:

A

Condoms, communication, PrEP

52
Q

HIV Testing recs:

A

Routine→ ALL, annually for high risk

ALL pregnant women (early as poss.)

53
Q

HIV Testing

Rapid Testing

A
  • Saliva anti-body tests (mean time 4wks)
  • Blood→ antibodies AND virus
  • KNOW THAT BLOOD TESTS CHECK FOR VIRUS ITSELF!
54
Q

HIV Testing

Antibody Tests

A

ONLY tests negative until point of “seroconversion)→ mean is 26d

55
Q

HIV Testing

Tests detecting actual virus

A

POSITIVE SOONER than antibody tests → 1wk to 6wks

56
Q

HIV Testing

Antibody vs Virus detection

Which is positive soone?

A

Virus detection!!!!

57
Q

+ Rapid test results

A

Confirm @ Western blot test to detect virus

58
Q

After getting infected w/ HIV

HIV test will be positive

A

W/in a few wks

59
Q

Why test for HIV?

2 reasons:

A
  1. Seek medical care and initiate ART earlier*
    1. ART:
      1. reduces risk of progression, dec’s timing living w/ high viral load,
      2. Pregnancy→ reduce risk mother→ newborn
  2. Prevent transmission
    1. Transm rates from unaware is 3x higher
60
Q

HIV+ people UNAWARE they have HIV

61
Q

Stages of HIV Dis. in an Untreated Indiv.

REMEMBER AASA

A
  • Acute:
    • A: Acute
  • Chronic
    • A: Asymptomatic/Clinical latency
    • S: Symptomatic
  • A: Advanced HIV Disease (AIDS)
62
Q

When you see Advanced HIV Disease think….

63
Q

Most important parts of the Acute Infx stage:

A
  • HIGH viral loads, HIGHLY contagious***
    • mono sx’s, flu-like sx’s after 1-6wk incubtion
  • HIV test negative until:
    • Antibody tests→ 2wks-6mos (26d)
    • Viral detection tests→ 1-6wks
64
Q

Chronic Infx Stage

A: Asymptomatic HIV Disease (Clinical Latency)

A
  • 1-20 yrs, + antibody test
  • CD4 count >500 cells/mm3
  • Viral load @ set point, BUT dynamic process of viral replication is occurring→ esp lymph tissue
65
Q

Chronic Infx Stage:

Early S: Symptomatic HIV Dis.

A
  • Few mos→ 5yrs
  • CD4 cells decline:
    • Count @ 200-500
    • virus destroys immune/neuroglial cells
    • opportunistic infx’s risk
  • *persisten lymphodenopathy
66
Q

A: Advanced HIV Disease (AIDS)

MUST present w/ one or more of the following:

A
  • Opportunistic Infx
  • LESS THAN 200 CD4 cells
  • HIV dementia OR HIV wasting syndrome
67
Q

Untreated indivs typ progress to AIDS w/in ________ of infx

A

w/in 10 yrs

Leading cause of death→ 2* Infx’s

68
Q

HIV wasting seen in Advanced HIV Dis./AIDS

what does this look like?

A
  • Signs:
    • INvoluntary loss of >10% BW
    • Chronic diarrhea
    • Weakness/fever
69
Q

Sx’s of Advanced HIV Dis. (AIDS)

A

see pics

NOTE: Kaposis Sarcoma→ red, brown, pink or purple blotches on skin*

70
Q

Viral Load and CD4 Count over time in UNTREATED INDIV’S

Nat’l progression of disease if NOT ON ART

71
Q

Stages of Asymptomatic HIV Dis (Clinical Latency) lasts anywhere from:

72
Q

Indicator of Adv HIV Dis. (AIDS) is CD4 count BELOW

73
Q

Lab tracking of HIV Dis.

A
  • CD4+ counts
    • HIV neg.→ healthy immune system: Norm=700-1100 cells/mm3
    • HIV+→ precarious decline over time if not on ART
  • CD4:CD8 ratio (CD4 %)
  • Viral Load→ strength of virus in body
74
Q

Markers of HIV Dis.

Goals of ART

A

EARLIER THE BETTER!!!!!!!!!

REMEMBER THIS!!!!

75
Q

Markers of HIV Dis.

A
  • Lab values assess effectiveness of ART
    • ART Goals: earlier the better*
      • UNdetectable viral load
      • Improve CD4 # and CD4/CD8 ratio
  • Lab vals DO NOT predict phys impair, functional stat, or disability***
76
Q

BIG Goal of ART

A

UNDETECTABLE VIRAL LOAD!!!!

*NOTE: does NOT mean “cured”

77
Q

Goals of ART

Know bold

A
  • Maximally and durably suppress HIV viral load
    • GOAL→ UNDETECTABLE viral load (<20copies/mL)
  • stop progression
  • reduce HIV-related morbidiy/mortality
  • restore/preserve immunologic function
  • prevent transmission
  • improve QoL
78
Q

Why can’t HIV be eradicated from body?

A

It hides. It waits.

“Sanctuary sites”/Reservoirs of HIV

  • Cellular
    • latent CD4’s, macrophages, follicular dendritic cells
  • Anatomical
    • CNS
    • Lymph nodes
79
Q

A person living w/ HIV who has an UNDETECTABLE VIRAL LOAD DOES NOT TRANSMIT THE VIRUS TO THEIR PARTNERS*******

A

U=U

Undetectable=Untransmittable

80
Q

If HIV can be treated w/ one pill/1x/day, why do 44% of people w/ HIV in US still have detectable lvls of virus?

A

Virus, Patients, Drugs

See pics

81
Q

Adherence issues to ART may be MORE pronounced in _________ and ________

A

Adolescents and older indiv’s

82
Q

LOW adherence to ART

Cascade of events?

A
  1. Virus starts replicating/mutating→ accel’d resistance to ART drugs pt was on
  2. Virological failure of salvage regimes
  3. Progression of HIV dis.
83
Q

HIV+ pts on ART

Tech’s to use

84
Q

Drug interactions in the process of HIV invading CD4 cells

Know the drug option “Functions” @ ea. phase!!!

A
  1. Entry of HIV
    1. Entry Inhibitors work here*
  2. RNA release
    1. NON-Nucleoside Reverse Transcriptase Inhibitors work here*
  3. Reverse transcriptase (trying to release DNA)
    1. Nucleoside/Nucleotide Reverse Transcriptase Inhibitors work here*
  4. Trying to integrate into Nucleus
    1. Integrase Inhibitors work here*
  5. Protease (“Budding” off phase)
  6. Protease Inhibitors work here*
85
Q

LABEL THIS PICTURE!!!!

What works where?

A
  1. Entry Inhibitors
  2. Non-Nucleoside Reverse Transcriptase Inhibitors
  3. Nucleoside/Nucleotide Reverse Transcriptase Inhibitors
  4. Integrase Inhibitors
  5. Protease Inhibitors
86
Q

Current ART Guidelines:

When to begin:

Just know that answer should always be ASAP after + dx ***

A
  • ASAP after +Dx, sooner the better
  • ALWAYS begin if:
    • any AIDS defining illness (opportunistic infx; dementia) or HIV-related comorbs
    • rapidly declining CD4 count (esp if BELOW 350 cells/mm3) and/ or high viral load (>100,000 copies/mL)
    • sexually active AND/OR pregnant
87
Q

FIRST TRIPLE COMBO TX

88
Q

ART

Monthly injection option

A

Cabenuva

KNOW IT IS AN OPTION

89
Q

GOAL OF ART:

A

UNDETECTABLE VIRAL LOAD

U=U***

90
Q

Risk of HIV infx from unprotected anal sex w/ HIV+ partner NOT ON ART

91
Q

Would have a higher viral load and likely to infect others via unprotected sex

A

HIV+ person unaware they have HIV

92
Q

Risk of infx thru sex w/ HIV+ partner on ART and Undetectable viral load?

A

Negligible/none

U=U***

93
Q

When does PT become involved?

A

ASAP!!!

  • Gen public: health promotion
  • Asymptomatic HIV Dis (Clinical Latency): fitness&wellness
  • Early Symptomatic HIV Dis: mng concomitant probs, impairments/functional limits
  • Advanced HIV Dis (AIDS): function/QoL, palliative
94
Q

What do I do for PT for pt w/ HIV?

A

SAME THING YOU DO W/ ANYONE ELSE!!!

*be aware of dis. + comorbs

95
Q

PT Exam for Indiv’s w/ HIV Disease

Some useful tools/outcome measures

A

FYI….use w/ pts!!!

see pics

96
Q

Communication w/ Interdisciplinary team mbrs===CRITICAL!!!

A

Lab vals, phys/mental health stat, comorbs, psycho issues, progress to goals/outcomes, insurance, compliance w/ ART

97
Q

Aerobic Exercise in PWHIV

Summary of findings

A
  • NO studies show detrimental effect of immune function
  • Some show inc CD4 count (@ early stage)
  • improved aerobic fitness markers, psycho bennies, stress mgmt, nutritional adjustments**
98
Q

PRE’s in PWHIV

Summary of findings:

A
  • Research shows:
    • improved LBM (lean body mass), inc mm girth, improved mm function, retardation of wasting, Cardiopulm bennies, improved psycho status
99
Q

When you see ASYMPTOMATIC HIV DIS.

THINK……

A

1-20yrs AND “Clinical Latency”

100
Q

Exercise for pts w/ Asymptomatic HIV Disease (Clinical Latency) 1-20yrs

A
  • UNrestricted ex/activity
    • PREs, aerobic, flex/balance, sports, recreation
  • Metabolic parameters WNL
  • Competitive sports OK
101
Q

Exercise fo pts w/ Early Symptomatic HIV Disease (step above asympto.)

A
  • Continue exercise
    • well-designed rx
    • Submax aerobic testing
      • YMCA Bike Submax Test, Bruce Protocol
  • Avoid intense, exhaustive
  • Obtain med clearance
  • IF +DSPN (distal polyneuropathy)→ foot care/shoes for WB acts
102
Q

Exercise for pts w/ Advanced HIV Disease (AIDS)

A
  • Remain phys active, respect reduced VC, VO2max, O2 pulse max
  • Ex on a sx limtd basis, avoid strenuous over-training
    • microtrauma/injury risk→ MSK tissue more vulnerable to injury
  • Avoid occasional bouts→ have reg freq.
  • Monitor/adjust program as needed***
103
Q

Occupational Exposure in Healthcare Personnel

MOST COMMON???

A

Percutaneous injury (ex. needlestick or cut w/ sharp obj)

104
Q

Occupational Exposure in HC Personnel

Risk of transmission is real, but gen VERY low

A
  • Percutaneous injury** (MOST COMMON)
  • Contact of your mucous memb’s or non-intact skin w/ pts:
    • blood (fluids, tissues), semen/vaginal secretions,
    • Pot infx→ CSF, synovial, pleural, peritoneal, pericardial, amniotic
    • NOT infx (unless bloody)→ feces, nasal, saliva, sputum, sweat/tears/urine, vomit)
  • Bites
  • Direct contact to conc’d virus in lab
105
Q

What do I do if i get a pts blood on my intact skin?

A

Stabilize pt

Wash off w/ soap/water

Do NOT worry!

106
Q

What should I do if i get a pts blood in my eye or mouth (mucosal memb), or on non-intact skin, or get stuck by contaminated needle?

A

PEP (Post-Exposure Prophylaxis)

Rec’d when source is HIV+ or risk factors unknown

  • ASAP!!! (w/in hrs after exposure)→ 81% reduction in transm. rate if initiated w/in first 72hrs after exposure***
  • 4wk 28d regimen of ART
107
Q

No validated cases of HIV transmission via sport

108
Q

Participation in sports by a student athlete who is HIV+

A
  • Should be based on indivs general health status (NOT HIV status)
  • Take steps to minimize risk of transmission of blood borne pathogens during athletic events
    • “Standard Precautions”
      • Care of injured/bleeding athlete
      • Care of environmental surfs.
109
Q

Working w/ HIV+ pt

A

Standard Precautions

Awareness of comorbs/ART SEs

Systems screening/monitor VS!

110
Q

CHECK OUT MG CASE STUDY!!!!

SLIDE 140 ON!!!

A

TEST YOURSELF FIRST THEN CHECK OUT ANSWER KEY!!!!

Medcon Rehab IV (18 decks)

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