AH II - Immune Conditions (AIDs, HIV, COVID) (13, Final)

HIV infectious process

1. HIV finds its way into host bloodstream

2. Hijacks T cells (T4 cells (CD4 - hyper cells), T8 (killer) cells)

3. Creates more particles

Life cycle of HIV

retrovirus (RNA)

• use antiretroviral therapies to halt replication process

• different drugs work on different cases of life cycle

• ART = antiretroviral therapy 

• HIV-2 = course of progression is slower 

• HIV-1 = mutates quickly 

S/S of antiretroviral therapy

GI disturbances, fatigue, hepatotoxicity, hepatotoxicity, osteopenia, MIs, CV disease

HIV treatment

antiretroviral therapy

• use drugs from different classes to target different places in the replication process

goals of ART

• Suppress HIV replication to a level below which drug-resistant mutations do not emerge

• Reduce HIV-associated morbidity

• Prolong the duration and quality of survival

• Restore and preserve immunologic function

• Maximally and durably suppress plasma HIV viral load

• Prevent HIV transmission

normal CD4 = 500-1500 mcL

increase CD4 and T cell count

when to initiate HAART

recommended for all HIV-infected patients regardless of their viral load or CD4 count

problems with ART (HIV)

• drug resistance

• S/S

• drug toxicity 

• compliance 

• drug interactions 

• IRIS (immune reconstitution inflammatory syndrome)

IRIS (+ S/S and treatment)

rapid restoration of pathogen-specific immune responses to opportunistic infections that cause deterioration of treated infection or new presentation of subclinical infection

• begins in initial months after starting ART

• associated with certain pathogens (e.g. micro bacteria, fungal infections, herpes)

• S/S: fever, respiratory, GI symptoms

• anti-inflammatory meds (E.g. cortisone)

promoting adherence to ART

• Use a multidisciplinary team approach

• Assess pts readiness to start ART

• Evaluate pts knowledge about HIV disease, prevention and treatment

• Identify potential barriers to adherence

• Assess medication management skills before starting

• Involve patient in ART regimen selection

• Assess adherence at every visit

• Use positive reinforcement

• Identify type and reasons for nonadherence

drug resistance causes 

1. genetics 

2. mutations of virus and sub-therapeutic levels of ART 

how to prevent drug resistance

1) TEACH PT TO TAKE EXACT DOSE AT EXACT TIME EACH DAY

2) ADHERE TO REGIMEN CONSISTENTLY, DO NOT MISS   DOSES, FOLLOW RECOMMENDATIONS TO  TAKE WITH FOOD   ETC, CHECK OTHER MEDS FOR INTERACTIONS WITH HAART

3) MISSED DOSES CAN CAUSE SUBTHERAPEUTIC DRUG   LEVELS AND CAN LEAD TO DRUG RESISTANCE

4) RECOGNIZE NEED TO CHANGE TREATMENT AND DRUG   RESISTANCE

5) MANAGE SIDE EFFECTS EFFECTIVELY

transmission of HIV

• Breaks in skin or mucosa increase risk

• HIV is transmitted most often in three ways:

1. Sexual

2. Parenteral (e.g. sharing needles or contaminated blood products)

3. Perinatal (e.g. body fluids/breast milk)

• Transmitted by body fluids containing HIV or infected CD4 lymphocytes:

  • Blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk

• Most prenatal infections occur during delivery

• Casual contact does not cause transmission - use standard precautions

post-exposure prophylaxis (PEP) - occupational exposure 

• Needle stick or “sharps” injuries are the primary means of HIV infection for health care workers – DO NOT RECAP, BEND, BREAK OR HAND MANIPULATE USED NEEDLES.

• Workers can also be infected through exposure of non-intact skin and mucous membranes to blood and body fluids

• The best prevention for health care providers is the consistent use of Standard Precautions.

• Identify patient source, test pt. for HIV (Oraquick), Hep B and C

• Treatment CDC guidelines: Test for HIV, Hep B and C, prophylaxis medication within 2 hours of exposure x 4 weeks. Practice safe sex until f/u testing complete.  HIV testing at baseline, 6 weeks, 12 weeks, 6 months and 1 year f/u, ART x 4 weeks, 2- 3 drug regimen

Risk factors for transmission

• Having sexual relations with infected individuals

• Sharing infected injection equipment

• Infants born or breast fed to mothers with HIV infection

• Organ transplant recipients, blood products (1978 to 1985)

tranmission prevention

• Safer sex practices and safer behaviors

• Abstain from sharing sexual fluids

• Reduce the number of sexual partners to one

• Always use latex condoms; if allergic to latex, use non-latex condoms

• Do not share drug injection equipment

• Blood screening and treatment of blood products

• Standard precautions

• Preexposure prophylaxis (PREP) – 1 pill Truvada:  2HIV medications (tenofovir 300 mg and emtricitabine 200 mg )

Effects of HIV infection

• Everyone who has AIDS has HIV infection. However, not everyone who has HIV infection has AIDS.

• The distinction rests with the number of CD4+ T-cells the patient has and whether any opportunistic infections have occurred.

diagnosis of AIDs

• HIV postiive AND

• CD4 and T cell count of <200 cells per mm OR opportunistic infections

opportunistic infections

• occur due to profound immune infection

HIV Classification: stage 1

• primary infection

• Period when HIV positive patients test negative on HIV antibody test, yet highly infectious with high viral load

• Period of rapid viral replication and dissemination throughout the body

• Viral set point - balance between amount of HIV and the immune response (after viral set point is reached, they enter chronic state and the immune system cannot get rid of the virus)

• > 500 CD4+ and T lymphocytes mcL OR

• 40-80% of pts. develop clinical symptoms of nonspecific viral illness: rash, fatigue, fever

• After 2-3 weeks,  antibodies detected in the sera

HIV Classification: stage 2

• early HIV infection

• NO opportunistic infections

• 200-499 CD4 lymphocytes mcL

• CD4 cells gradually fall

• can last up to 12 years without major symptoms

HIV Classification: stage 3

• less than 200 CD4+ and lymphocytes mcL

• <100 cell/mm = immune system significantly impaired 

• documentation of an AIDs. defining condition with laboratory confirmation of HIV infection 

HIV Classification: stage 4

< 50 CD4 and T lymphocytes

high risk for AIDs related infections

HIV diagnostic tests

1. antibody tests - detect antibodies (not HIV itself)

2. antigen-antibody tests - antigen and RNA test directly detect HIV

3. nucleic acid RNA tests

• blood tests detect infection before fluid tests

• RNA tests detect infection before blood tests

risk for opportunistic infections

assess: 

• Respiratory status

• Neurologic status

• GI status

• Nutritional status

• Skin integrity

• Immune System function

• Knowledge level

• Social and Emotional status

opportunistic infection: pneumocystis pneumonia (PCP) - ineffective airway clearance

• high risk with CD4<200

• S/S:  fever, dyspnea, cough, chest discomfort, increased RR and HR, rales, hypoxemia

• Dx: CXR, bronchoscopy for sputum culture

• Interventions: ART, IV Bactrim or Pentamidine, semi or high Fowlers, ensure rest,  TCDB, postural drainage, percussion, and vibration

• Prophylaxis:  Bactrim double strength daily

• Incidence declined with widespread use of PCP prophylaxis

opportunistic infection: mycobacterium avian complex (MAC)

• bacteria inhaled or   ingested, risk CD4<50, fever, night sweats, fatigue, weight loss,   diarrhea and abdominal pain

• Diagnosis: blood cultures, lymph nodes, bone marrow

• Treatment: ART,  Antibiotics e.g. Clarithromycin and Ethambutol,   manage symptoms

• Prophylaxis – Azithromycin and Clarithromycin when CD4 count   <50, d/c prophylaxis when CD4 >100

• S/S: respiratory, GI symptoms

tuberculosis

• lethal infectious disease

• can cause pneumonia and spread to rest of body 

• opportunistic respiratory infection (but not technically)

Increased risk with HIV

PPD every 6-12 months

Reading a PPD

Induration > 15 mm (low risk) 

Induration > 10 mm (HCW, immigrants)

Induration > 5 mm (HIV, immunosuppressed)

• Treatment: Isoniazid (INH) Side Effects

  Hepatotoxic: Assess for S/S, LFTs

  Peripheral Neuritis: pyridoxine (B6)

If Active TB, Prevent Spread to Others

opportunistic infection: toxoplasmosis gondii encephalopathy

• High risk when CD4<100

• S/S: fever, headache, confusion or motor weakness, progressive cognitive, behavioral, and motor decline

• Diagnosis: IgG antibody to T gondii, brain CT or MRI, brain biopsy

• Treatment: ART,  Pyrimethamine, Sulfadiazine, Leucovorin, and treat symptomatically

disturbed thought processes interventions

Assess mental and neurologic status

*Use clear, simple language if mental status is altered

*Establish and maintain a daily routine

*Orientation techniques

*Ensure patient safety and protect from injury

*Strategies to maintain and improve functional ability

*Instruct and involve family in communication and care 

opportunistic infections: candidiasis (thrush)

• can progress to esophagus and stomach

• S/S: Painless, yellow-white, plaque-like lesions, occur on buccal surface

• Treated with nystatin and ketoconazole

opportunistic infections: C. Diff

• bacteria

• S/S: severe diarrhea

Tx: antibiotics e.g. Vancomycin, Fidaxomicin, Metronidazole

opportunistic infections: cryptosporidium

• caused by protozoa

• S/S” profuse, watery diarrhea, low abdominal cramping

• Treatment: ART to increase CD4 count, rehydrate with electrolyte solutions, treat with octreotide or loperamide to manage chronic diarrhea

impaired bowel function interventions

• Assess bowel pattern and factors that may exacerbate diarrhea

• Avoid foods that act as bowel irritants, such as raw fruits and vegetables, carbonated beverages, spicy foods, and foods of extreme temperatures

• Small, frequent meals

• Administer medications as prescribed

• Assess and promote self-care strategies to control diarrhea

imbalanced nutrition, wasting syndrome, cachexia

• wasting syndrome = unintentional weight loss of more than 10% of body weight while experiencing diarrhea, fever, weakness for 30+ days; loss of muscle mass

• Monitor weight, I&O, dietary intake, and factors that interfere with nutrition, electrolytes

• Dietary consult

• Control of nausea with antiemetics

• Oral hygiene

• Treatment of oral discomfort   

• Dietary supplements

• May require enteral feedings or parenteral nutrition

altered skin integrity interventions 

• Frequent routine assessment of skin and mucosa

• Encourage patient to maintain balance between rest and activity

• Reposition at least every 2 hours and as needed

• Pressure reduction devices (e.g. cushions)

• Instruct patient to avoid scratching

• Use gentle, nondrying soaps or cleansers

• Avoid adhesive tape

• Perianal skin care

activity intolerance interventions

• Maintain balance between activity and rest

• Instruction regarding energy conservation techniques

• Relaxation measures

• Collaboration with other members of the health care team

isolation interventions

• Promote an atmosphere of acceptance and understanding

• Assess social interactions and monitor behaviors

• Allow patient to express feelings

• Address psychosocial issues

• Provide information related to the spread of infection (to decrease fear)

• Educate ancillary personnel, family, and partners

opportunistic infections: malignancies 

• Kaposi's sarcoma

Cutaneous lesions, but may involve multiple organ systems

Lesions cause discomfort, disfigurement, ulceration, and potential for infection, ART, treat with Interferon

• B-cell lymphomas

• Treatments:

ART, Chemotherapy

and radiation

opportunistic infections: STIs

• recurrent vaginal candidiasis (yeast infections)

• genital ulcers

• VENEREAL WARTS

• HERPES

• HPV

• CERVICAL CANCER

• PELVIC INFLAMMATORY DISEASE

risk factors for contracting serious case of COVID

• age

• immunocompromised

• smoking

• obesity

• pregnancy

  • low SES, racial disparities

COVID testing: PCR tests

• performed in lab

• detect viral genetic material

• most reliable tests

COVID testing: antigen tests

• rapid, at home tests

• detect viral antigens

• not as reliable - should repeat 48 hours later 

how to swab patient with COVID

• told head back 70 degrees

• insert swab parallel to nose until resistance is met

• swirl swab for 15 secs

COVID S/S: mild

Mild COVID = fever, nonproductive cough, sore throat, fatigue, muscle aches, congestion, N/V, anosmia and ageusia (loss of smell and taste)

• Managed outpatient

COVID S/S: moderate

Moderate COVID = mild COVID symptoms plus evidence of viral pneumonia AMB clinical examination, CXR/CT scan findings

• Will have adequate SPO2 levels on room air

• Recommended to be inpatient

COVID S/S: severe 

Severe COVID = mild and moderate symptoms plus SPO2 < 93% on room air with tachypnea and dyspnea

• inadequate oxygenation 

• CXR will show diffuse opacities (lungs look solid instead of clear)

• Inpatient

nursing interventions: mild COVID

• patient education

• home therapy (rest, hydration, monitor symptoms)

nursing interventions: moderate COVID

• lab testing: CBC, CMP, lactate (monitor for sepsis), CRP, ferritin, D-dimer

• DVT prophylaxis

• airborne precaution rooms

• symptom monitoring

nursing interventions: severe COVID

• supplemental oxygen

• potentially ET intubation and ventilation + sedation

• patient positioning

• skin care, ROM 

COVID complications: hypoxia

• monitor for respiratory distress

• supportive therapy to prevent worsening of COVID

• initially use nasal cannula - non-rebreather - high flow/CPap

COVI complications: shock and respiratory failure

• hypotension and septic shock

• often seen in those who are unvaccinated or not receiving adequate treatment

COVID complications: pleural effusion

• accumulation of fluid between pleura of lung - treated with thoracentesis 

• detected on CXR

• chest tube may be needed to establish adequate drainage 

post covid conditions / PCC / long COVID

• can happen to anyone

• wide range of new, returning, or ongoing health problems

• e.g. fatigue, fever, SOB, headache, cough… feeling like COVID doesn’t go away

COVID vaccine

• Interact with T and B lymphocytes to produce antibodies to the virus

• Takes a few weeks for vaccine to be effective

• mRNA vaccines = Pfizer-BIoNtech or Moderna

  • Teach our cells to make a protein that triggers immune response

  • Side effects are a sign of this immune response (e.g. fatigue, weakness)

• Debunking vaccine myths/patient education

  • Do not use any live virus

  • Cannot cause COVID infection

  • Do not affect or interact with our DNA

  • Do not include: preservative, antibiotics, therapeutics, tissues from any animal, food proteins, metals or latex

COVID prevention

• vaccines! 

• improving ventilation

• getting tested (especially if symptomatic)

• if exposed: wear mask for 10 days, test regularly

• clinical: isolation gowns, N95, respirators, face shields/goggles, gloves