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
2
Q
HIV Prevalence in U.S.
1 in every _______ persons is HIV+
A
250
3
Q
Leading cause of death in persons w/ Advanced HIV disease (AIDS)
A
Opportunistic Infx
4
Q
Which is Contraindicated in a pt w/ Acute Inflammatory Myopathy?
A
PREs
5
Q
Sandy has HIV and Acute Inflammatory Myopathy. You expect to see:
A
Diffuse myalgia and PROXIMAL weakness*
Trunk, shoulder/pelvic girdles
6
Q
Which of the following opportunistic infx’s is the MOST RARE in people w/ HIV?
A
Progressive Multifocal Leukoencephalopathy
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
8
Q
AIDS term coined
A
1982
9
Q
FIRST antiretroviral (ART) drug for AIDS
A
AZT
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
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
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
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
-
all races/genders/sex preferences
- any age, socioeco stat
-
HIV infects people all walks of life. Does NOT discriminate
- FACT:
- Men who have sex w/ men and IV-drug users are at a higher risk for infx (higher # exposures)
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
-
ART drugs can greatly INC life-expect, BUT…
15
Q
1 in ________ Am’s is HIV+
A
250
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
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
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
19
Q
Stigma assocd w/ HIV….WHY?
A
Ignorance/misperceptions, irrational/puritanical judgements, stereotyping, scape-goat/blame-game, bigotry, homophobia
20
Q
How can I REDUCE STIGMA?
A
- Discuss HIV openly
- Educate!
- Non-judgemental
- Resources
- local testing and counseling centers
- Info resources
21
Q
>35 mil living w/ HIV/AIDS
A
Only 53% have access to ART Meds !!!!
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
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
24
Q
Prognosis is ______ in Older individuals
A
WORSE!!!!!
25
Prognosis is **WORSE** in older individuals
## Footnote
**More on this…**
* 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
26
**Delayed Dx in older individuals**
**BIG REASON FOR THIS???**
**\*\*\*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!!!**
27
Older pts w/ HIV have **WORSE prognosis because:**
1. Greater chance of **delayed dx**
2. Presence of **multimorbidity**
3. **Immunosenescence**
28
HIV aka
Human Immunodeficiency (retro) Virus
29
HIV Disease
## Footnote
**Cause and what is it?**
* **Cause→** Infx w/ HIV
* **Suppression of immune system**
* INCd risk for life-threatening **opportunistic infx's**
30
HIV Stages
## Footnote
**AASA\*\*\*\***
**W/OUT ART**
* **A: A**cute infx
* **A: A**symptomatic HIV Dis.
* **S: S**ymptomatic HIV Dis.
* **A: A**dvanced HIV Dis./AIDS
* “**A**cquired **I**mmunodeficiency **S**yndrome"
31
HIV Replication takes how long?
2.6d
32
HIV Replication Steps:
youtube.com/watch?v=RO8MP3wMvqg
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
33
HIV **replicates in,** and **eventually kills:**
CD4 cells\*\*\*
34
Viral replication in a CD4 cell involves **all of the following enzymes**
* Transcriptase
* Integrase
* Protease
**NOTE:** does NOT involve creatine phosphokinase (from pollev.)
35
**#1** HIV Transmission Route:
**Sexual Contact**
36
HIV Transmission routes
* **#1: Sexual contact**
* Sharing needles (IV drug use)
* Blood to blood (or blood derived fluid) contact
* **Mother→ child**
* pregnancy, delivery, breast feeding
37
**Fluids** that transmit HIV
* Semen→ unprotected sex
* Vaginal fluid→ unprotected sex
* Blood
* Breast milk
* Other body fluids w/ blood
38
YOU CANNOT GET HIV FROM HUGGING OR SHAKING HANDS W/ PERSON W/ ADVANCED HIV DISEASE (AIDS) !!!!
**Unless open wound or blood→blood but in general….**
39
**GLOBALLY…..#1 Axis of Transmission for HIV**
**Hetero**sexual sex
40
Heterosexual sex is \_\_\_\_\_\_\_\_\_\_
Globally #1 transmission route of HIV
41
All are routes of transmission for HIV
Sex, blood-blood, mother→baby during childbirth
42
NOT a route of HIV transmission?
Inhalation of airborne particles
43
Why do **Untreated individuals (NOT ON ART)** die from HIV?
Opportunistic infx's
44
Why do **Treated Indiv's (on ART)** die from HIV?
* Comps/Comorbs **related to med toxicities and/or chronic infx**
* Poor **adherence** to ART→ disease progresses
45
Treated indiv's ON ART can die from HIV mostly from comps/comorbs or poor adherence to ART
## Footnote
**BUT….**
MOST indiv's successfuly treated w/ ART **expected to live out natural lifespan**
46
Educate/Communicate
1. talk about sex
2. safe sex
3. IV drug use (sterile, no share)
47
Talk about **HIV Prevention:**
* Pre-Exposure Prophylaxis **(PrEP)**
* **Limit exposure:**
* abstinence
* mutual monogamy
* reduce # sexual pahtnas
48
PrEP types:
* Truvada
* **Descovy→ _safer_ than Truvada for _people w/ OP_ or kidney issues**
49
PrEP MOST effective used w/
condoms
50
“**Prevention” as a Cure**
* 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
HIV prevention:
Condoms, communication, PrEP
52
HIV Testing recs:
Routine→ ALL, annually for high risk
ALL pregnant women (early as poss.)
53
HIV Testing
## Footnote
**Rapid Testing**
* Saliva **anti-body tests (mean time 4wks)**
* **Blood→** antibodies **AND virus**
* KNOW THAT BLOOD TESTS CHECK FOR **VIRUS** ITSELF!
54
HIV Testing
## Footnote
**Antibody Tests**
ONLY tests **negative** until point of "**seroconversion)→ mean is 26d**
55
HIV Testing
## Footnote
**Tests detecting actual _virus_**
POSITIVE SOONER than antibody tests → 1wk to 6wks
56
HIV Testing
## Footnote
**Antibody vs Virus detection**
**Which is _positive_ soone?**
Virus detection!!!!
57
+ Rapid test results
Confirm @ **Western blot test** to detect virus
58
After getting infected w/ HIV
## Footnote
**HIV test will be _positive_**
W/in a few wks
59
Why test for HIV?
## Footnote
**2 reasons:**
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
HIV+ people UNAWARE they have HIV
14%
61
Stages of HIV Dis. in an **Untreated Indiv.**
## Footnote
**REMEMBER AASA**
* **Acute:**
* **A: A**cute
* **Chronic**
* **A: A**symptomatic/Clinical latency
* **S: S**ymptomatic
* **A: A**dvanced HIV Disease (AIDS)
62
When you see **Advanced HIV Disease think….**
AIDS
63
Most important parts of the **Acute Infx stage:**
* **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
**Chronic Infx Stage**
**A: A**symptomatic HIV Disease (Clinical Latency)
* 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
**Chronic Infx Stage:**
**Early S: S**ymptomatic HIV Dis.
* Few mos→ 5yrs
* **CD4 cells _decline:_**
* Count @ 200-500
* virus destroys immune/neuroglial cells
* **opportunistic infx's risk**
* **\*persisten lymphodenopathy**
66
**A: A**dvanced HIV Disease (AIDS)
MUST present w/ **one or more of the following:**
* Opportunistic Infx
* LESS THAN 200 CD4 cells
* HIV dementia OR HIV wasting syndrome
67
**Untreated indivs typ progress to AIDS w/in ________ of infx**
w/in 10 yrs
**Leading cause of death→** 2\* Infx's
68
HIV wasting seen in **Advanced HIV Dis./AIDS**
## Footnote
**what does this look like?**
* **Signs:**
* INvoluntary loss of \>10% BW
* Chronic diarrhea
* Weakness/fever
69
Sx's of **Advanced HIV Dis. (AIDS)**
see pics
**NOTE:** Kaposis Sarcoma→ red, brown, pink or purple blotches on skin\*
70
Viral Load and CD4 Count over time in **UNTREATED INDIV'S**
Nat'l progression of disease if **NOT ON ART**
SEE PICS
71
Stages of **Asymptomatic HIV Dis (_Clinical Latency)_ lasts anywhere from:**
1-20yrs
72
**Indicator** of **Adv HIV Dis. (AIDS) is CD4 count _BELOW_**
250
73
Lab tracking of HIV Dis.
* **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
Markers of HIV Dis.
## Footnote
**Goals of ART**
**EARLIER** THE BETTER!!!!!!!!!
REMEMBER THIS!!!!
75
Markers of HIV Dis.
* 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
BIG Goal of ART
**UNDETECTABLE VIRAL LOAD!!!!**
**\*NOTE:** does NOT mean “cured”
77
Goals of ART
## Footnote
**Know bold**
* **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
Why can't HIV be eradicated from body?
**It hides. It waits.**
**“Sanctuary sites”/Reservoirs of HIV**
* Cellular
* latent CD4's, macrophages, follicular dendritic cells
* Anatomical
* CNS
* Lymph nodes
79
A person living w/ HIV **who has an UNDETECTABLE VIRAL LOAD _DOES NOT_ TRANSMIT THE VIRUS TO THEIR PARTNERS\*\*\*\*\*\*\***
U=U
## Footnote
**Undetectable=Untransmittable**
80
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?**
Virus, Patients, Drugs
See pics
81
**Adherence** issues to ART may be MORE pronounced in _________ and \_\_\_\_\_\_\_\_
Adolescents and older indiv's
82
LOW adherence to ART
## Footnote
**Cascade of events?**
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
HIV+ pts on ART
Tech's to use
see pics
84
Drug interactions **in the process of HIV invading CD4 cells**
## Footnote
**Know the drug option “Functions” @ ea. phase!!!**
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)**
1. Protease Inhibitors work here\*
85
LABEL THIS PICTURE!!!!
## Footnote
**What works where?**
1. Entry Inhibitors
2. Non-Nucleoside Reverse Transcriptase Inhibitors
3. Nucleoside/Nucleotide Reverse Transcriptase Inhibitors
4. Integrase Inhibitors
5. Protease Inhibitors
86
Current ART Guidelines:
**When to begin:**
Just know that answer should always be **ASAP after + dx \*\*\***
* 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
FIRST **TRIPLE COMBO TX**
**ATRIPLA**
88
ART
## Footnote
**Monthly injection option**
Cabenuva
## Footnote
**KNOW IT IS AN OPTION**
89
GOAL OF ART:
**UNDETECTABLE VIRAL LOAD**
**U=U\*\*\***
90
Risk of HIV infx from **unprotected anal sex w/ HIV+ partner NOT ON ART**
HIGH!!!
91
Would have a **higher viral load** and **likely to infect others via _unprotected sex_**
**HIV+ person _unaware they have HIV_**
92
Risk of infx thru sex w/ HIV+ partner **on ART and _Undetectable viral load_?**
Negligible/none
## Footnote
**U=U\*\*\***
93
When does PT become involved?
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
What do I *do* for PT for pt w/ HIV?
SAME THING YOU DO W/ ANYONE ELSE!!!
**\*be aware of dis. + comorbs**
95
PT Exam for Indiv's w/ HIV Disease
## Footnote
**Some useful tools/outcome measures**
FYI….use w/ pts!!!
see pics
96
Communication w/ Interdisciplinary team mbrs===**CRITICAL!!!**
Lab vals, phys/mental health stat, comorbs, psycho issues, progress to goals/outcomes, insurance, **compliance w/ ART**
97
**Aerobic Exercise** in PWHIV
Summary of findings
* 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
**PRE's** in PWHIV
Summary of findings:
* Research shows:
* **improved LBM (lean body mass), inc mm girth, improved mm function, retardation of wasting, Cardiopulm bennies, improved psycho status**
99
When you see **ASYMPTOMATIC HIV DIS.**
## Footnote
**THINK……**
1-20yrs AND **“Clinical Latency”**
100
Exercise for pts w/ **Asymptomatic HIV Disease (Clinical Latency)** ***1-20yrs***
* UNrestricted ex/activity
* PREs, aerobic, flex/balance, sports, recreation
* Metabolic parameters WNL
* Competitive sports OK
101
Exercise fo pts w/ **Early Symptomatic HIV Disease (step above asympto.)**
* 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
Exercise for pts w/ **Advanced HIV Disease (AIDS)**
* 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
Occupational Exposure in Healthcare Personnel
## Footnote
**MOST COMMON???**
**Percutaneous injury (ex. needlestick or cut w/ sharp obj)**
104
Occupational Exposure in HC Personnel
## Footnote
**Risk of transmission is real, but gen VERY low**
* **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
What do I do if i get a pts blood on my intact skin?
**Stabilize pt**
**Wash off w/ soap/water**
**Do NOT worry!**
106
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?
**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
No validated cases of HIV transmission via sport
\*\*\*\*\*
108
Participation in sports by a student athlete who is HIV+
* 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
Working w/ HIV+ pt
Standard Precautions
Awareness of comorbs/ART SEs
Systems screening/monitor VS!
110
CHECK OUT MG CASE STUDY!!!!
SLIDE 140 ON!!!
TEST YOURSELF FIRST _THEN_ CHECK OUT ANSWER KEY!!!!
