HIV Disease Complications

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HIV Disease Complications

• Patricia P. Gilliam, MEd, MSN, ARNP, BC
• Nurse Practitioner, HIV Services
• Tampa General Hospital Infectious Disease Center
• Hillsborough County HD- Specialty Care Center
• Faculty, Florida/Caribbean AETC
• Tampa, Florida

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Learning Objectives

• 1. Identify potential complications of the
• progression of HIV Disease when
• CD4 is
• 2. Identify and discuss potential complications
  related drug therapy

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Stages of HIV Disease Progression

• Acute Retroviral Syndrome
• Asymptomatic HIV infection
• Symptomatic HIV infection
• AIDS defining illnesses
• AIDS

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Each Patient is Unique!

• Each patient is a person, not simply a CD4 count
  and viral load.
• The uniqueness of the HIV-infected patient
  creates many issues to address.
• Medical issues surrounding a chronic disease with
  many unknowns
• Psychosocial and economic issues which will
  impact health disease progression
• Pharmacogenomics / Genetic Polymorphisms

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Roles of the Nurse

• Assessment
• Diagnosis of Nursing Problems
• Planning
• Intervention
• Collaboration with Providers
• Direct Care
• Patient Education
• Evaluation

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Clinical Categories
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Updated DHHS Guidelines (Oct. 2004)When to Start
Treatment
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HIV Disease Complications

• HIV Disease Progression
• Related to declining CD4 cell counts as they
  approach

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Evidence of Mild Immune Deficiency (CD4 cell
count 200-500 cells/ml)

• Oral candidiasis or thrush
• Recurrent vaginal candidiasis
• Recurrent herpes zoster
• Especially 1 dermatome
• Recurrent herpes simplex
• Tuberculosis
• Neurological abnormalities
• Bells Palsy

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Clinical Categories
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Category B conditions

• Listeriosis
• Pelvic Inflammatory disease
• Idiopathic thrombocytopenic purpura
• Recurrent bacterial endocarditis, meningitis, or
  sepsis
• Persistent or resistant vulvovaginal candidiasis

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Category B conditions (cont.)

• Constitutional symptoms, such as fever 38.5 C
  or diarrhea lasting 1 month
• Nocardiosis
• Peripheral neuropathy
• Oropharyngeal candidiasis
• Herpes Zoster involving at least 2 episodes of
  more than 1 dermatome

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Clinical Categories
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AIDS Defining IllnessesAKA AIDS-Indicator
Conditions

• Bacterial pneumonia
• Cervical CA, invasive
• Candidiasis of bronchi, trachea, lungs or
  esophagus
• Coccidioidomycosis (disseminated or
  extrapulmonary)

• Cryptococcosis, extrapulmulmonary
• Cryptosporidiosis, chronic intestinal (1 month)
• CMV Disease (other than liver, spleen or nodes)
• CMV retinitis (with loss of vision)

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AIDS Defining Illnesses cont.

• Kaposis sarcoma
• Lymphoma, Burkitts
• Lymphoma, immunoblastic
• Lymphoma, primary in brain

• HIV encephalopathy
• Herpes simplex chronic ulcers 1 month or
  bronchitis, pneumonitis, or esophagitis
• Histoplasmosis (dissem. or extrapulmonary
• Isosporiasis, chronic intestinal (1 month)

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AIDS Defining Illnesses cont.

• Mycobacterium avium complex or M. kansasii
  (disseminated or extrapulmonary)
• Mycobacterium, other species, disseminated or
  extrapulmonary
• Pneumocystis pneumonia
• Progressive multifocal leukoencephalopathy

• Salmonella septicemia, recurrent
• Toxoplasmosis of brain
• Wasting syndrome (wt. loss 10 baseline body
  weight, associated with chronic diarrhea or
  fever)

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Incidence of AIDS Indicator Conditions

• Pneumocystis carinii Pneumonia 38
• AIDS Wasting Syndrome 18
• Candidiasis (esophageal, tracheal) 16
• Kaposis sarcoma 7
• HIV-associated dementia 5
• Recurrent bacterial CAP
• Mycobactium avium, disseminated
• Cryptococcosis, extrapulmonary
• (Bartlett, 2004)

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Prevention of Disease Progression

• Prevention of Immune System Deterioration
• HAART
• Prevention of OIs
• Prophylactic medications
• Patient Education

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Preventing Exposure to OIs

• Sexual exposure
• IVDU exposure
• Environmental and occupational exposure
• Child-care provider and parental exposure
• Pet related exposures Food and Water-related
  exposure
• Travel related exposure

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• 2001 USPHS/IDSA Guidelines for the
• Prevention of Opportunistic Infections in
  Persons Infected with Human Immunodeficiency
  Virus. Recommendations to Help Patients Avoid
  Exposure to or Infection with Opportunistic
  Pathogens. Appendix pp. 61-65
• http//www.aidsinfo.nih.gov/guidelines/op_infectio
  ns/OI_112801.html

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Clinical Management of the HIV-Infected Adult A
Manual for Midlevel Clinicians (March, 2003)

• This manual is available in both print and
  compact disk formats from the Southeast AIDS
  Training and Education Center (SEATEC) and from
  the Midwest AIDS Training and Education Center
  (MATEC), through the communication channels
  below. In addition, the manual is downloadable
  from the Internet site of the AIDS Education and
  Training Center National Resource Center at
• http//www.aids-etc.org/pdf/tools/se_midlevel_2003
  .pdf

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Prophylaxix to Prevent OIs

• PCP pneumonia
• Toxoplasmosis
• Mycobacterium Avium Complex

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PCP pneumonia

• Given to prevent a primary episode or a
  recurrence of infection
• Recommended to all HIV patients with a CD4
  
• Prophylactic Treatment Recommendations
• TMP-SMX
• Dapsone
• Aerosolized pentamidine

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Toxoplasmosis

• Test for presence of Toxo IgG Ab
• If IgG negative, counsel to avoid sources of
  infection
• Raw or undercooked meats
• Garden soil
• Avoid stray cats
• Keep pet cats indoors and feed commercially
  prepared cat food
• Prophylactic treatment is recommended to all HIV
  Toxoplasmosis IgG positive patients with a CD4
  
• Prophylactic Treatment Recommendations
• TMP-SMX
• Pyrimethamine Dapsone Leukovorin
• Dapsone alone is ineffective

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DMACdisseminated mycobacterium avium complex

• Prophylactic treatment is recommended to all HIV
  patients with a CD4
• Prophylactic Treatment Recommendations
• Azithromycin 1200 mg/week

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HIV Disease Complications

• Complications R/T drug therapy
• Assess for development of signs symptoms
• Manage the problems to allow continuation of
  therapy if possible

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HAART-Associated Side Effects

• Rash
• GI symptoms
• NV
• Diarrhea
• Headache
• Malaise

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HAART AssociatedAdverse Events

• Stevens-Johnsons Syndrome
• Lactic acidosis/hepatic steatosis
• Hepatotoxicity
• Hyperglycemia
• Fat maldistribution
• Hyperlipidemia
• Osteopenia, osteoporosis
• Osteonecrosis

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Stevens-Johnsons Syndrome

• Disseminated Rash
• Fever
• Cutaneous sloughing

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Lactic acidosis / Hepatic Steatosis

• Possibly due to mitochondrial toxicity
• Associated w/ NRTIs
• Clinical presentation variable have high index
  of suspicion
• Lactate 2-5 mmol/dL plus symptoms
• Treatment d/c NRTI, supportive care

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Lactic acidosis / Hepatic Steatosis

• Rare, but high mortality
• The combination of stavudine didanosine was
  associated with several maternal deaths due to
  lactic acidosis. This antiretroviral combination
  should be used during pregnancy only when other
  NRTI drug combinations have failed or have caused
  unacceptable toxicities.

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Frequency of Lactic AcidosisWith Different NRTIs

• 60 cases reported to FDA through June 30, 1998
• Number of cases on different NRTI regimens
• Lamivudine/stavudine (36)
• Didanosine/stavudine (9)
• Lamivudine/zidovudine (7)
• Didanosine/zidovudine (7)
• Stavudine/zidovudine (1)
• Symptoms included nausea, vomiting, abdominal
  pain, weight loss, malaise, dyspnea

Boxwell DE, Styrt BA. 39th Annual ICAAC
September 2629, 1999San Francisco, California.
Abstract 1284.
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Hepatotoxicity

• Severity variable usually asymptomatic, may
  resolve without treatment interruption
• May occur with any NNRTI or PI
• Nevirapine risk of severe hepatitis in first 12
  wks of use (monitor LFT), increased risk in
  women,
• chronic Hepatitis B Hepatitis C
• PI especially RTV, RTV/SQV increased risk in
  Hepatitis B or Hepatitis C, ETOH, with other
  hepatotoxins

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Potential Etiology for BodyComposition
Abnormalities
Mitochondrial toxicity 2y to NRTIs
HIV
Protease inhibitors
Etiology?
Age
Genetic predisposition
Immune reconstitution
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Fat maldistribution

• Lipodystrophy
• No uniform definition
• Mechanism not understood
• peripheral fat wasting more associated w/ NRTIs
• central fat accumulation perhaps more associated
  with PIs
• May be associated with dyslipidemia, insulin
  resistance, lactic acidosis
• Treatment insufficient data

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Morphologic ComplicationsFat Loss (Lipoatrophy)
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Morphologic ComplicationsFat Accumulation
(Lipohypertrophy)
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Buffalo hump Ultrasound-guided liposuction
BEFORE AFTER RELAPSE

• Good cosmetic result with buffalo hump, but
  relapse may occur (1/18 in one series, 5/10 in
  another)

Gervason C, 10th CROI, Boston 2003, 723 Piliero
P, et al. ibid, 724 photographs courtesy of Dr
P. Piliero
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Other Interventions?

• Aerobic exercise
• Weight training
• Anabolic steroids
• Human growth hormone (Serostim)

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Hyperglycemia

• Hyperglycemia and diabetes associated with all
  PIs, especially with chronic use
• Mechanism not well understood
• Insulin resistance, relative insulin deficiency
• Regular screening via fasting glucose

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Hyperlipidemia

• Elevations in total cholesterol, LDL, and
  triglycerides
• Associated w/ all PIs (varies w/ agent)
• Mechanism unknown
• Consequences uncertain concern for
  cardiovascular events, pancreatitis
• Monitor regularly
• Treatment consider substitution for PI
  lipid-lowering agents (caution w/ PI certain
  statins)

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Bone abnormalities

• Osteopenia and Osteoporosis
• Mechanism ill-defined decreased osteoblast or
  increased osteoclast activity
• Associated with PIs
• Dx DEXA in symptomatic pts (no role for
  screening)
• Prophylaxis No data. Consider calcium/Vit D,
• weight-bearing exercise, bisphosphonates for
  secondary prevention??

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Bone abnormalities

• Osteonecrosis (AVN)
• Mechanism unknown
• Associated w/ PIs increased in corticosteroid
  treatment, alcohol abuse, hemoglobinopathies,
  hyperlipidemia, hypercoagulable states
• Dx CT or MRI

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Roles of the Nurse

• Assessment
• Diagnosis of Nursing Problems
• Planning
• Intervention
• Collaboration with Providers
• Direct Care
• Patient Education
• Evaluation

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Nursing Actions

• Patient Education
• prevent
• early recognition
• Assessment of s/s when they present
• Is it drug related?
• Is it a side effect or adverse event ?
• OI related

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Know the Latest Clinical Data

• Knowledge of HIV/AIDS changes at a blinding pace
• Lag time always exists between release of new
  information and publication of Guidelines
• Sources of new information
• Internet websites
• Conferences
• Teleconferences/webcasts
• Local organizations

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