HIV AIDS Education Opportunities

HIV/AIDS Education Opportunities Developed by: Mountain-Plains Regional AIDS Education and Training Center Presented by: New Mexico AIDS ETC Special Project of National Significance HIV/AIDS PREVENTION, EARLY INTERVENTION, & HEALTH PROMOTION HIV PREVENTION Learning Objectives • Assess HIV risk factors • Describe test-decision counseling • Discuss risk reduction counseling • Describe continua of risky behaviors Median Times 11.3 years 2 years 2 months Infection Positive Test AIDS Death HIV gp120 p24 RNA RT reverse transcriptase needed to make copy viral RNA viral DNA CD4 receptor sites human DNA REPLICATION incorporated into cell’s DNA using integrase protease needed to cut strands assembly budding Impact on Immune System CD4+ HIV+/CD4+ CD8+ NK B M CD4+ T Lymphocyte Counts 1000 500 200 Infection Positive Test AIDS Death HIV Antigen Level in blood HIV Antibody HIV Antigen in Tissues Infection Positive Test AIDS Death Major Recent Advances     Ability to assess viral load Multidrug therapy Occupational exposure protocols Treatment to decrease vertical transmission We are now in Santa Rita, a town with 10,000 people. Metro Center, the closest town with a tertiary care hospital, is a 2hour drive from Santa Rita. Imagine that you work here as a health care professional. You suspect that some HIVinfected individuals live here, but you have not yet treated anyone with HIV. MEET PEGGY JONES • 19-year-old female • in your care for 18 years • high school graduate • • • • works at local store lives alone in an apartment parents & brother also live here c/o runny nose and watery eyes Peggy’s health history: • hay fever since age 12 • complete childhood vaccines • birth control pills prescribed last year Peggy has come in because of her hay fever, but she seems distracted. You ask if there is anything else. She says she has a friend who has HIV. She wonders if she is at risk. Transmission Variables       Viral Load Amount of Exposure Frequency of Exposure Duration of Exposure Virulence of Organism Immune Function Transmission Routes     Sexual intercourse with infected partner Sharing used works Blood products Mother to infant You probably already know how HIV is transmitted, but you may have been reluctant to discuss it with your patients. Maybe you feel that your patients are not at risk, or maybe you think it might offend them.  What do patients say about their need for information about HIV infection? Research Findings • Patients want HIV information from their physicians • Only 15% of patients had discussed HIV with their physicians • 72% of HIV discussions initiated by patient, NOT physician Why providers omit HIV risk assessments: • Unaware of shifting demographics • Feel unprepared • Discomfort about sexual & drug use histories After discussing with Peggy how HIV is transmitted, you ask if she has been sexually active or if she has ever used drugs and she says, “yes.”  You decide to do a thorough HIV risk assessment. HIV Risk Assessment  Should be conducted:   during initial exam on every patient periodically to update information    Assesses sex, drug use, & blood contact Assists in early detection of HIV Determines need for prevention education Effective risk assessment interviews are sensitive to: • Sexual identity & practices • Age & learning skills • Cultural values, norms, traditions • Language & communication styles Peggy’s risk assessment shows: • Two sexual partners; inconsistent condom use • No history of injecting drugs  Risk reduction counseling can help Peggy reduce her risk for exposure to HIV & other STDs. Risk Reduction Counseling • Helps patient identify and reduce personal risks for HIV infection • Two essential components: - patient-centered risk assessment - personal risk reduction plan • Basic premise: ANY reduction in risk is beneficial Personal Risk Reduction Plan • Discuss successful and unsuccessful behavior change attempts • Produce plan for practicing safer behaviors • Provide spectrum of low-to-high risk behaviors that are: - less risky than current behaviors - acceptable to patient Peggy’s greatest risk for exposure to HIV is through sexual contact.  How can Peggy decrease her risk? Prevention: SEX     Abstain Delay "Outer"-course Intercourse – Mutual monogamy – Barriers Peggy states that her partners used condoms sometimes, but they were inconsistent.  What should Peggy know about condom use? Condom Use • Efficacy • Types • Correct use: lubrication, placement, consistency • Other barriers You ask Peggy if there is anything else she wants to discuss. She says, “Well, I never used IV drugs, but when I was on the swim team I used steroids a few times. All of us used the same needle.”  What does Peggy need to know about sharing injection equipment? Prevention: DRUG USE      Don't use drugs Don’t inject drugs Don't share works Clean used works Don't use & have sex Peggy says, “My friend found out she had HIV when she got pregnant. I heard that kids can get infected before they’re born.”  What should Peggy know about perinatal HIV transmission? Prevention: Perinatal   Prevent HIV infection in women In HIV-infected women: – use birth control – abort pregnancy   Plan pregnancy early in disease Provide optimal antiretroviral therapy for pregnant women Counseling: ACTG 076 • Encourage at-risk & infected women to determine pregnancy status • Offer test to all pregnant women • If pregnant & HIV+, discuss options: therapy termination All this talk about HIV makes you realize that you and your staff will eventually have a patient with HIV infection.  What does your staff need to know about occupational exposure to HIV? Occupational Exposure • Risk is low: 0.3% - 0.4% • Use precautions for blood & body fluid contact • Post-exposure prophylaxis (PEP) Body Substance Isolation (BSI) Protect yourself from all moist body surfaces & substances. If it's wet & it's not yours, DON'T TOUCH IT! Transfusion Risk Risk of infection through transfusion of blood products in the U.S. is now estimated to be 1 in 400,000. Peggy’s risk assessment confirms a risk for HIV infection. You ask Peggy if she would like to be tested for HIV. Peggy has questions about the test.  HIV Antibody Testing • • • • • Process: EIA + Western blot High positive predictive value Indeterminate results Window period Myth of latency HIV Test Decision Counseling • Decision to test is personal • Test sites • What test does/does not determine • Confidential vs. anonymous testing • Informed consent • Prevention education Peggy returns to the clinic in 2 weeks for her HIV test results. You sit her down and say, “Peggy, I’m afraid your HIV test came back positive. This means you have HIV infection.” EARLY INTERVENTION Learning Objectives • Describe HIV post-test counseling • Discuss the course of HIV infection • Identify elements of HIV-related: - history - physical exam - lab tests During post-test counseling, you need to help Peggy with: • • • • emotional status/support HIV transmission reduction partner notification health-related issues Clients need to understand the chronic nature of HIV: • Slow, variable progression • Treatments available to slow progression • Need for periodic tests & follow-up • Focus on positive Disclosure of HIV Status • Office concerns: – Confidentiality – Informed consent for disclosure – Reporting requirements • Individual concerns: – Liabilities of disclosure – Benefits of disclosure Seronegative Counseling • Review prevention guidelines • Confirm date of last exposure • Provide information: - community support - drug treatment programs - behavior modification education - psychosocial support Peggy is visibly upset with the news. She asks, “What happens now?” You have consulted with an HIVtreatment expert in Metrotown and you explain to Peggy the need for a specific H&P as well as lab work. Since you were aware of Peggy’s diagnosis, you have set aside time for these procedures . . . Initial HIV History Goals • Information on disease stage & risks for future complications • Counseling & education • Partnership building History of Present Illness • Previous HIV-related illnesses • Risk behavior history • • • • • Current sexual history Current level of functioning Emotional status Medications Allergies HIV-related Medical History • TB exposure & PPD testing • Hepatitis & hepatitis testing • STDs & recurrent vaginal candidiasis • GYN, OB, & Pap exams • Immunizations • Dental problems • Hospitalizations, surgeries, transfusions HIV-related Social History • Alcohol, drug, tobacco use • Sexual, physical, emotional abuse • Place of birth, residence, travel • Employment, living situation, support system Peggy’s history is unremarkable: • No other STDs • Not currently sexually active • No current drug use; doesn’t smoke • Travel: only to Maine • Allergies: hay fever • Meds: antihistamines, contraceptives • Not a suicide risk Your next step is the physical exam. You explain that the physical exam will be very similar to other exams that Peggy has experienced. HIV-related Systems Review General: Fever, night sweats, weight loss, anorexia, fatigue Skin: – Rashes, discoloration – Easy bruising – Lesions: Kaposi’s sarcoma, syphilis HEENT: – Eyes – Oropharynx Gastrointestinal: – – – – – Odynophagia or dysphagia Nausea & vomiting Diarrhea Abdominal pain Anal pain Genitourinary: rashes, lesions, discharge, dysuria Pulmonary: Cough, dyspnea Neurological: • Headache • • • • Cognitive dysfunction Peripheral neuropathy Focal weakness, seizures Autonomic neuropathy Guidelines for HIV-Related Physical Exam Exam Vitals Weight Skin Oropharynx Lymph nodes Initial/ Every baseline visit x x x x x x x x x x by dentist Every 6-12 mo Other Exam Funduscopic Cardiopulmonary Genitourinary Rectal Neurologic Initial/ baseline x Every visit after CD4<50 Every 6-12 mo Other ophthamology consult when indicated x x x x Pap if anal intercourse/ hx of HPV peripheral nerve exam if initiating ddI, ddC, d4T Peggy’s physical exam is unremarkable; everything is within normal limits. You send her to the lab where blood is drawn for tests. Guidelines: CD4 cells Monitoring >600/mm3 Every 3-6 months 500-600/mm3 Every 3 months when considering ART 300-500/mm3 Every 3 months 200-300/mm3 Every 1-3 months in anticipation of PCP prophylaxis 50-200/mm3 Every 1-3 months to anticipate OIs or with ART change <50/mm3 Periodic monitoring & with ART change Course of HIV Disease Progression as it Relates to CD4 Lymphocyte Count 800 600 Thrombocytopenia Lymphadenopathy Bacterial skin infection Herpex simplex, zoster Oral, skin fungal infections 500 400 Kaposi’s sarcoma 400 200 300 200 Lymphoma Hairy leukoplakia Tuberculosis PCP Cryptococcosis Toxoplasmosis 100 CMV MAC 0 Months Years Viral RNA Assays • Measure viral RNA in blood • Use with CD4 counts & clinical status to determine: when to initiate ART treatment effectiveness drug resistance or failure disease progression Guidelines: Viral Load Monitoring • Measure twice to establish baseline • Measure 2-4 weeks after starting or changing ART • Monitor every 3-4 months Guidelines for Laboratory Evaluation Baseline CBC CD4 HIV RNA Chemistry Panel RPR VDRL PPD w/controls Toxoplasma Ab HBV or HCV CXR x x x x x x x x Every 3-6 mo x x x x x unless anergic Annually You tell Peggy that you will be seeing a lot of each other over the next several months. You ask her again about her support system and she assures you that she is o.k. You schedule a follow-up visit ten days later. HEALTH PROMOTION Learning Objectives • Describe management guidelines • Identify common OIs & prophylaxis • State immunization recommendations • Discuss antiretroviral therapy • Discuss wellness counseling Peggy returns in 10 days. She says, “You know, I feel pretty good; no different than before. I can’t believe that I have HIV.” You remind Peggy that she may remain without symptoms for several years. Early signs and symptoms, however, may appear at any time. Asymptomatic HIV infection: • can last many years • generally not entirely asymptomatic  seroconversion illness Symptomatic HIV infection: • clear symptoms, but not enough for an AIDS diagnosis Early Problems in HIV • herpes zoster • • • • • • thrush, vaginal candidiasis PGL thrombocytopenia fevers, night sweats, weight loss minor infections oral lesions Indicators of Progression to AIDS constitutional manifestations • thrush, OHL • multidermatomal zoster • worsening night sweats, diarrhea, fever, fatigue, weight loss • resolution of PGL laboratory indicators • HIV RNA increases • CD4 cell count decreases Diagnostic Criteria for AIDS • • • • • CD4 cells <200mm3 opportunistic diseases HIV dementia wasting syndrome examples of AIDS-indicator conditions include TB, CMV retinitis, Kaposi’s sarcoma, & PCP You tell Peggy that your clinic will work closely with her in the years to come, but that you are not experts in HIV care. You tell her that you have already been in contact with an HIV-care expert and that you will continue getting consultations on her case. Your main goals will be to monitor and maintain Peggy’s health. Comprehensive Care Considerations • monitor initial response and coping skills • manage changing health care requirements • organize a multi-disciplinary team approach • discuss ART early in process • inform patient about side effects & difficult dosing regimens • remember that the patient makes the final decision about initiating therapy • provide ongoing support regardless of therapy decision Antiretroviral Agents Nucleoside RTIs: • Zidovudine (ZDV, AZT, Retrovir) • Didanosine (ddI, Videx) • Zalcitabine (ddC, HIVID) • Stavudine (d4T, Zerit) • Lamivudine (3TC, Epivir) • Abacavir (Ziagen) • Combivir (ZDV + 3TC) • Adefovir (Preveon) Non-nucleoside RTIs: • Nevirapine (Viramune) • Delaviridine (Rescriptovir) • Efavirenz (Sustiva) Protease Inhibitors: • Saquinovir (Fortovase) • Indinavir (Crixivan) • Ritonavir (Norvir) • Nelfinavir (Viracept) • Amprenavir (Agenerase) Highly Aggressive ART (HAART) • when therapy is initiated, combination therapy is standard of care to decrease disease progression • initiation based on CD4, viral load, clinical status, and patient’s desires • expert consultation is appropriate Principles of HAART • maximum viral suppression • continuous viral suppression • change regimen if resistance occurs • may not restore immune function, especially in advanced disease Emerging Treatment Themes    optimal therapy: 2 NRTIs + 1 PI; alternate: 2 NRTIs + 1 NNRTI partial suppression reasonable alternative, but risky resistance common after incomplete viral suppression What is Resistance?     loss of susceptibility of HIV to the inhibitory effects of drugs a common trait of HIV result of alteration of viral genetic structure major cause of treatment failure Potential Causes of Resistance     Partially suppressive drug regimens (including inappropriate prescriptions) High baseline viral load Pharmacological factors (established resistance, poor absorption, poor bioavailability, poor penetration, etc.) Patient non-adherence to therapy **All leading to mutations** Initiating Therapy     CD4+ > 500 & HIV RNA < 5000: ? CD4+ > 500 & HIV RNA > 5000: consider therapy, especially w/sx or HIV RNA > 30,000 CD4+ = 200 - 500: encourage therapy, especially w/sx or HIV RNA > 5,000 CD4+ < 200: therapy strongly encouraged Peggy’s CD4+ T-lymphocyte 3 and her count is 850 cells/mm 3. viral load is 3500 copies/mm She tells you that she isn’t ready to start taking drugs.  What is your best response? Management of HIV: CD4 count >500/mm3       health maintenance dental & oral health care consider/initiate ART visits every 4-6 months repeat CD4 counts & viral load monitor every 3-6 months Pap smears (for women)  Management of HIV: CD4 count = 200-500/mm3  visits every 1-2 months (2-3 months if tolerating therapy) repeat CD4 counts & viral load monitoring every 3 months  Management of HIV: CD4 count < 200/mm3  modify ART if needed PCP prophylaxis visits every 1-6 weeks repeat CD4 counts & viral load monitoring every 3 months    Management of HIV: CD4 count < 50/mm3      modify ART as necessary surveillance for lymphoma, CMV, MAC visits every 4 weeks; more frequently if needed CD4 counts & viral load monitoring as needed for evaluating ART therapy additional prophylaxis Peggy’s health is basically good, but she could benefit from information about preventing opportunistic infections. Immunizations     Give standard adult immunizations Immunize early No live vaccines except MMR Recommended:     Pneumococcal Influenza Hepatitis B MMR if asymptomatic; consider if symptomatic Mycobacterium tuberculosis (TB) prophylaxis needed if patient:    has PPD > 5 mm is anergic with CXR showing latent disease is at high risk for exposure Pneumocystis carinii pneumonia (PCP) prophylaxis needed if patient has:      history of PCP CD4 < 200/mm3 persistent thrush, difficulty swallowing FUO > 2 weeks preferred prophylaxis: TMP/SMX; other choices: Dapsone or Pentamidine Prophylaxis for other Diseases As CD4 cell counts decrease, consider using prophylaxis for:      Mycobacterium avium complex (MAC) Toxoplasma gondii Herpes simplex fungal infections Cytomegalovirus (CMV) On her next visit Peggy is pale, tired, and depressed. She needs comfort, compassion, and guidance. Initial Patient Support     positive, long-term relationship built on mutual trust maintain personal control explore emotional concerns define parameters of relationship, especially provider activities & accessibility Peggy begins to cry. She tells you she is depressed and feels helpless. It is important for Peggy to know that she can influence her own health. Wellness Counseling  mental health • coping skills • stress management • psychiatric evaluation as needed moderation in smoking, alcohol and other drug use • abstinence ideal, but difficult • harm reduction will occur with any decrease in use  Wellness Counseling     exercise for overall health exercise for weight management adequate sleep/rest nutrition is a primary concern   initiate nutrition program ASAP goal: maintain lean body mass Wellness Counseling   sexuality • part of social, mental health • safety concerns complementary/alternate therapies • beneficial therapies • potential problems • access • maintain communication Health Promotion Disease Prevention    Issues change over course of disease Help patient adopt healthy behaviors Assess patient’s readiness to change   offer practical suggestions provide referrals and resources REMEMBER: Behavior change is a slow & sometimes frustrating process. Clinicians can help most by:    providing care in a nonjudgmental & supportive manner understanding the nature of relapse & re-initiation of the change process encouraging movement toward positive change Peggy’s story does not end here. She will need to accommodate life changes and develop strategies to maximize her health and manage her illness.  Her relationship with her caregivers will be an essential component of that process.