HIV Infectionw/CDC Slide show

Presented by Felecia Briggs MS, APRN-CPre-Junior Clinical’sJune 4th, 2010

Surveillance According to the Centers for Disease Control and

Prevention (CDC) which reports annually on the prevalence and incidence of HIV and AIDS in the United States and its territories, there were an estimated 1,051,875 cumulative AIDS cases between 2004 and 2007.

Since the beginning of the epidemic, certain ethnic and other minority groups have comprised a disproportionate number of HIV/AIDS cases in the United States.

Surveillance con’t

The Association for Nurses in AIDS Care (ANAC) released a statement August 3rd, 2008, requesting that the government increase funding in the area HIV/AIDS prevention.

Furthermore, they noted that the CDC had released a new annual rate of 56,000 new cases per year versus the incidence rate of 40,000 since the 80’s.

ANAC stated that disparities still exist – approx. 70% of individuals living with HIV in the US are from communities of colors particularly in the Latino & AA population.

Meanwhile, MSM’s still comprise the largest group affected by HIV.

Trends

Trends indicate that the number of new infections is rising among men who have sex with men (MSM) amongst Hispanics and non-Hispanic whites as well as heterosexuals.

Also, in the past 15 years, there has been a growth in the proportion of AIDS cases among black residents of the southern United States.

Trends con’tIncreased incidence of STD’s, such as syphilis

and chlamydia serve as biological markers of these rising trends.

For instance, syphilis rates fell 90% between 1990 and 2000, but the number of reported primary and secondary cases rose by 12.4% between 2001-2002 with rates of infection 3.5x higher in men than in women.

HIV Defined

Human Immunodeficiency Virus (HIV) is the virus that causes AIDS (Acquired Immune Deficiency Syndrome).

HIV is most commonly acquired from exposure to bodily fluids infected with HIV (i.e., blood, semen, or breast milk). Once the virus enters the body, it begins breaking down the immune system, at first producing no symptoms but ultimately for some, producing AIDS.

HIV Transmission

HIV enters the body – HIV is transmitted from an HIV-infected person to another individual, usually during sex or by sharing needles during drug use.

During sex, HIV in the semen, vaginal fluid or blood stream of an infected person travels to the bloodstream of another through the tissue lining in the rectum, vagina, penis, or mouth.

In IV drug use, HIV enters the bloodstream through a puncture made by a needle contaminated with infected blood (AAHIVM, pgs. 19-23)

Unprotected Sex

Unprotected sexual intercourse means vaginal, anal, or oral intercourse without a condom or other barrier protection to prevent contact with the other persons bodily fluids.

Because HIV is commonly found in an HIV-infected person’s semen or vaginal secretions, sexual contact may allow the virus to enter the uninfected persons body and establish an infection

Transmission Con’t:

Mother to baby via transplacental transmission during pregnancy, through exposure to genital tract fluids during birth, or through breast milk.

HIV may also be transmitted through blood transfusion (highest rates in developing/3rd world countries). Meanwhile, in the US since donated blood is now tested, the risk is very small.

HIV entry is facilitated by the presence of cuts, sores, or ulcers (including microscopic abrasions or ulcerative STD’s) in the vagina, rectum, penis or mouth

Risk factors

Anyone sexually active (greater prevalence now amongst heterosexual teens and Gay youth)

IV drug users Multiple sex partners w/o use of condoms & other

barrier methods Children born to IV drug using mothers Those with recurrent STD’s, especially ulcerative

diseases (i.e., HSV, Syphilis, and Traumatic sex). Anything that increases the risk of cuts, sores or

ulcers increase the risk of HIV transmission

IV Drug Use

Using needles or syringes that have previously been used by an infected person can also transmit HIV, even if the infected needle is only shared once.

Sharing of needles may take place during injection drug use but also can occur during other injections, tattooing or piercing

Sharing needles or syringes may transmit other serious infections, including Hepatitis B and C virus

After HIV enters the body:

After HIV enters the bloodstream, the immune system tries to fight the virus by developing antibodies to destroy it. But HIV enters a special immune cell (T cell) where it can hide from the antibodies (because it really attaches to the T-Cell acting as an imposter, like a T-Cell, but its an HIV cell). The virus may lie dormant for an indefinite time causing no symptoms. After a while it becomes active and manufactures many copies of itself.

Then the new virus burst from the T-Cell and moves into other immune cells to repeat the process of duplication and destruction.

As more and more immune cells are destroyed, the body becomes less able to fight other germs (i.e., immunocompromised)

The Weakened Immune System

As his or her immune system weakens the individual may develop persistent symptoms (i.e., swollen lymph glands, night sweats, fever, cough, diarrhea, and/or weight loss). The persons symptoms may be relatively mild at first.

Eventually the virus destroys almost all the disease fighting cells of the immune system (T-Cells & other white blood cells) thereby giving a number of uncommon infections the opportunity to overwhelm the body.

When these opportunistic infections appear, the person is considered to have AIDS

Classification of HIVThe current CDC classification uses three

ranges of CD4 cell counts (>500, 200-499, and <200mm3) and a matrix of nine mutually exclusive categories. Category B includes most conditions previously classified as AIDS related complex.

See next slide

Classification made easier

CD4 cell categories

AAsymptomatic, PGL

BSymptomatic(not A or C)

CAIDS Indicator

Conditions

>500mm3/> 29%

A1 B1 C1

200-499mm3/14-28%

A2 B2 C2

<200mm3 or <14%

A3 B3 C3

Diagnosis

*Seroconversion generally takes 3-5 weeks after exposure to HIV

HIV antibody test- Enzyme linked immunoabsorbent assay) the Elisa test as a screening test, and the Western Blot as the confirmation test.

The usual Western Blot criteria are p24 plus glycoprotein (gp) 120/160 or gp 41 plus gp 120/160. Sensitivity is 99.3% and specificity is 99.7%

Alternative Diagnostic tests Home access test, one drop of blood is placed on a lancet and

specimen sent off anonymously for testing Salivary test- OraSure- a cotton pad is used to obtain saliva, which

is placed in a vial and submitted to lab for EIA and WB testing Urine testing must be substantiated by blood serology Rapid tests- SUDS (Single Unit Diagnostic Test) is the 1st FDA

approved rapid test in the US. Must be done in licensed lab, centrifuge specimen and look for subtle blue color change- problem was false positives

Oraquick was FDA approved on Nov. 2002, it uses whole blood from a finger stick, very high sensitivity (99.6%) and Specificity (100%) should be confirmed w/a Western Blot test. The results are ready in 20 minutes.

Reveal- approved in 2003, must be done in licensed lab

Types of results and their significance

Positive

Negative

Indeterminate- most common cause of a n indeterminate result is a positive Elisa and a single band on a Western Blot, this may represent seroconversion, so the test should be repeated in 3-4 months

Laboratory Test

HIV serology- should be repeated if no actual blood test can be identified

CD4 count- lets us know how fast the virus is progressing in your body. In healthy controls, mean levels for most labs are 800-1050/mm3. The count represent three variables WBC count, percent lymphocytes, and percent lymphocytes that bear CD4 receptor

Viral load (Quantitative HIV/Plasma RNA)-If a person has started medication, it allows us to see if the medication is effective in slowing the replication of the virus (i.e., response to therapy) and prognosis (range from undetectable to greater than a million copies)

Toxoplasmosis titers, cytomegalovirus (CMV) titers, Hep B & C, HLA-B 5701 r/t Abacavir, along with initial workup CBC, Lipid panel, Complete metabolic panel, RPR, and UA

Testing doesn’t always work

According to AAHIVM (2007) many of those with new infections are unaware of their status.

Nearly one-third of those who test positive do not return for their lab results—so without a confirmed diagnosis they continue some of their negative behavior and the virus continues to be spread

**Discuss 65 year old newly diagnosed Pt.

AIDS

Years ago it took approximately 10 years before a persons immune system decompensates to the point where they were diagnosed with AIDS, but now with people transmitting resistant virus and people getting into care much later—people are being diagnosed with AIDS much earlier now.

For the purpose of AIDS Surveillance, an adult or adolescent (older than 12yrs) is considered to have AIDS if at least 2 major signs are present in combination w/1 minor sign (AAHIVM, 2007, pgs. 13-15).

AIDS Surveillance Criteria

Major Signs (2 or more required):

Weight loss of at least 10% of body weight Chronic diarrhea for >1 month Prolonged fever for longer than 1 month (intermittent or constant)

AIDS Surveillance con’t

Minor Signs (1 or more required): Persistent cough for > 1 month Generalized pruritic dermatitis History of Herpes Zoster Oropharyngeal Candidiasis Chronic progressive or disseminated HSV infection Generalized lymphadenopathy

Epidemiological Surveillance

An adult or adolescent is considered to have AIDS if a test for HIV antibody is positive and 1 or more of the following are present:

10% body wt. loss or cachexia w/diarrhea, fever or both not known to be d/t a condition unrelated to HIV

Cryptococcal meningitis, pulmonary or extra-pulmonary tuberculosis, Kaposi Sarcoma, invasive cervical cancer

Neurologic impairment sufficient to interfere with ADL (i.e., activities of daily living)

Candidiasis of the esophagus Clinically diagnosed life threatening or recurrent episodes of

pneumonia

National Recommendation for HIV testing in pregnant Women

CDC recommends the following: Prenatal- routine HIV testing for all pregnant women using the

opt out approach Women will be notified that they will be tested unless they

decline Labor and Delivery- routine rapid testing for women whose HIV

status is unknown Post-natal- Rapid testing for all infants whose mother’s status is

unknown Regulations, laws and policies about HIV vary state by state *

Look up NJ Testing should be voluntary with appropriate counseling

provided.

Prevention

Abstinence Use of Condoms (male and female) Decrease use of drugs and alcohol

during sexual intercourse Education

Condom usageCondoms when used properly remain the most

effective barrier against the transmission of HIV and most other STD’s for individuals who choose not to be abstinent and who are not in a monogamous relationship with an uninfected partner

Most condoms are made of very thin latex, for those w/latex allergy polyurethane condoms are available

Condoms con’t

Avoid all oil based lubricants Avoid use of nonoxynol-9 because it irritates the

mucosal tissue & makes HIV transmission more likely Polyurethane female condoms are also available-fits

inside the vagina w/rubber ring to hold it in place If not lubricated use a water based lubricant and roll all

the way down to shaft; after ejaculation, hold penis while pulling out to avoid leaking ejaculate into or onto partner

Treatment

Nonnucleoside Reverse Transcriptase Inhibitors (NNRTI’s)- NNRTI’s bind to and disable reverse transcriptase, a protein that HIV needs to make more copies of itself

Nucleoside Reverse Transcriptase Inhibitors (NRTI’s)- NRTI’s are faulty blocks that HIV needs to make more copies of itself, When HIV uses an NRTI instead of a normal building block, reproduction of the virus is stalled.

Protease Inhibitors- PI’s disable protease, a protein that HIV needs to make more copies of itself

Fusion Inhibitors- Fusion inhibitors work by blocking HIV entry into the cell

References

American Academy of HIV Medicine (2007). AAHIVM Fundamentals of HIV Medicine for the HIV Specialist. Washington, DC: American Academy of HIV Medicine

www.cdc.gov