2. hiv aids lecture ppt

1
HIV/AIDS
Prof. Dr. Ram Sharan Mehta
Medical-Surgical Nursing Department
Dr. RS Mehta, MSND, BPKIHS

2
Human Immunodeficiency Virus
Acquired Immune Deficiency Syndrome

3
Everybody is at risk
of getting HIV.
However certain
Persons have high
risk.

Adults and children estimated to be
living with HIV, 2007
Total: 33.2 million
Western Europe
760 000
North Africa
& Middle East
380 000
Sub-Saharan Africa
22.5 million
Eastern Europe
& Central Asia
1.6 million
South
& South-East Asia
4 million
Oceania
75 000
North America
1.3 million
Caribbean
230 000
Latin America
1.6 million
East Asia
800 000
4Dr. RS Mehta, MSND, BPKIHS

•More than 6 800
new infections &
5700 deaths occur
each day

6
No of Reported Cases
( HIV Infection)
1st case in Nepal --July 1988
Since then increasing
1988 - 4
1992 - 77
1996 - 135
2000 - 700
2004 - 4442
2007 - 10546
2010 - 15639
2011 ->19,118Dr. RS Mehta, MSND, BPKIHS

7
HIV/AIDS status at BPKIHS:
till 2073
• Total HIV Positive = > 1000
• Total ART therapy = > 500
• Regular ART = >350

8
• About 1/3 are aged 15-24 years
• Most people do not know they are
infected
• Gravity of Different mode of
Transmission:
* Sexual intercourse = 80-90 %
* Blood Transfusion ? = 3-15 %
* Injecting Drug users = 5 -10 %
* Equipments/Needles = < 0.1 %
* Perinatal = 0.1%

9
HIV positive to AIDS
– 33 % = Only develop AIDS
– 64 % = Till death live without Symptoms
– 5-10- 20 yrs = A symptomatic
Concentrated epidemic:
Sex workers (4%),
Migrant Population (4-10%) &
IVDUs(51%)
National Prevalence: 0.5%

10
Natural history
&
Pathophysiology
of
HIV/AIDS

11
Human Immunodeficiency Virus
• Acquired Immunodeficiency syndrome first
described in 1981
• HIV-1 isolated in 1984, and HIV-2 in 1986
• Belong to the lentivirus subfamily of the
retroviridae
• Enveloped RNA virus, 120nm in diameter

12
Types and sub-types of HIV
• HIV-1: Sub-type: A to J (based on genetic
Material), very common, rate of replication
very high
• HIV-2: Less common

13
• WBC: N/E/B/L/M (WBC Engulf antigen)
Lymphocytes: produced & mature in stem cells in bone marrow,
regulate immune system, kill cells that bear specific target antigen.
-B: produce antibodies against the pathogen and are
dependent on T-cells for the information of pathogen.
produced in stem cells in bone marrow and travel to mature in thymus gland.
-T:
T=helper (CD4):recognize virus and stimulate B-cell to actively fight infection.
T=Suppressor (CD8): Suppress T & B cell after control of infection.
T= Cytotoxic (killer): recognize virus infected cells and Kill them directly.

14
Structure of the Human Immunodeficiency
Virus HIV is a Retrovirus

15
DNA RNA PROTEIN
HIV IS A RETROVIRUS
Reverse transcriptase

- gp of HIV surface and CD-4 molecule are
similar hence susceptible to infection.
- CD-4 & gp together with CCR5 & CCR4 –
HIV enter cell
(CCR= chemokine coreceptors)
- HIV infected virus half life= 6 hrs
- Daily 108-109 virus particles need for
plasma viaremia
- Infected cell lasts for 2 days (death)

18
•Video show

19
• Window Period: about 2 months, entry
of HIV in body to till not found in test,
transfer rate very high, is also called Healthy
carrier stage.
• Up to 10 million individual virus produce daily
Major S/S (index of suspicion)
• Weight loss more than 10%
• Fever > One months
• Diarrhoea > One months
• Others: Cough, Skin problems

Seroconversion Illness
• Flu-like syndrome: fever, fatigue, myalgia,
weight loss
• Neurological: Headache, aseptic
meningoencephalitis, facial palsy
• GI: nausea and vomiting, mucocutaneous
ulceration, thrush, pharyngitis, diarrhea
• Dermatological: rash, urticaria
• Lymphadenopathy 20Dr. RS Mehta, MSND, BPKIHS

Seroconversion Illness
• Laboratory Findings
• Profound reduction in CD4+ and CD8+
• HIV antigen can be detected
• Antibodies to HIV may not yet be detected
• Management
• Symptomatic

22
0
100
200
300
400
500
600
700
800
900
1000
0 1 2 3 4 5 1 2 3 4 5 6 7 8 9 10 11
CD4+cellCount
Months Years After HIV Infection
CD4+ T cells
VL
Natural Evolution>Severe Symptoms(1)
© 2006
6
CD4 < 200
Severe
Symptoms

23
<3 years
7-10 years
>10-15 yr
90 %
<5%
<10 %
Disease Progression in adults
Typical Progressors
HIV
Infection
Rapid Progressors
Long-term
Non-progressors
© 2006
8

24
WHO Clinical Staging of HIV
Clinical stage 1
Clinical stage 2
Clinical stage 3
Clinical stage 4

WHO Clinical Stage I (APLA)
• Asymptomatic infection
• Persistent generalized
Lymphadenopathy (Lymph
nodes > 1.5 cm in >2
extrainguinal sites of >3
months duration)
• Acute retroviral infection
Performance scale I:
asymptomatic, normal
activity

WHO Clinical Stage II(HUMR)
• Herpes zoster within previous 5 years
• Unintentional weight loss < 10%
• Minor mucocutaneous manifestations
• Recurrent upper respiratory tract
infections
Performance scale II: symptoms, but
nearly fully ambulatory

WHO Clinical Stage III(COUP
VCOSP)
• Chronic diarrhea >1mo
• Oral candidiasis
• Unintentional weight loss >10%
• Prolonged fever >1mo
• Vulvovaginal Candidiasis >1mo
• Oral hairy leukoplakia
• Severe bacterial infections
• Pulmonary tuberculosis (within the last year)
Performance scale III: in bed <50% of normal
daytime, but more than during previous
month. 27Dr. RS Mehta, MSND, BPKIHS

WHO Clinical Stage IV
1) Atypical
mycobacter
iosis
2) Non-
typhoid
Salmonella
septicemia
3) Extra
pulmonary
TB
1) Cytopmegalovir
al disease of
an organ other
than liver,
spleen, or
lymph node
2) Herpes simplex
virus infection
1) Any
disseminated
endemic
mycosis
3) Candidiasis of
the esophagus,
trachea, bronchi,
and lungs
1) Toxoplasma of
the brain
2) Cryptosporidiosi
s with diarrhea
>1mo
3) Isosporiasis with
diarrhea
4) Extrapulmonary
cryptococcosis
1) HIV wasting syndrome
2) HIV encephalopathy
1) Lymphoma
2) Kaposi’s sarcoma
Performance scale IV: in bed >50% of day, over the previous month

29
WHO 1
WHO 2
WHO 3
WHO 4
ADULTS
WHO consultative meeting 1990
Clinical staging of HIV in resource-limited settings
WHO staging
© 2006 23
NEW VERSION 2006!!
See website WHO
asymptomatic
lymphandopathy
Recurrentoralinfections

30
Opportunistic Infections
Fungi:
• Pneumocystis
carinii Pneumonia
• Candidiasis
• Aspergillosis
• Cryptococcosis
• Histoplasmosis
• Coccidioidomycosis
• Microsporidiosis
Bacteria:
• Mycobacterium Avium Complex
• Mycobacterium Tuberculosis
Viruses:
• Varicella-Zoster Virus
• Herpes Simplex Virus
• Cytomegalovirus
Protozoa:
• Coccidiosis (Cryptosporidiosis,
Cyclosporiasis, and Isosporiasis)
• Toxoplasmosis
• Leishmaniasis
• Malaria
Most AIDS-defining conditions are opportunistic infections, which rarely
cause harm in healthy individuals. In people with AIDS, these infections
are often severe

31
African AIDS patient with slim disease
Source: Tropical Medicine and Parasitiology, 1997

32
Opportunistic Oral Yeast Infection by
Candida albicans in an AIDS Patient
Source: Atlas of Clinical Oral Pathology, 1999

33
Extensive tumor lesions of Kaposis’s sarcoma in AIDS patient.
Source: AIDS, 1997

34
Chronic Herpes Simplex infection with lesions on tongue and lips.
Source: Atlas of Clinical Oral Pathology, 1999.

35
Non-Hodgkin’s Lymphoma & ascites in AIDS patient

36
Chest X-Ray of AIDS Patient with
Tuberculosis

37
Perinatal Transmission of AIDS

38
Lab test ( Diagnostic)
1. ELISA ( 90 sample kit)
2. Western Immunoblot test
3. Rapid test: ( Single test)
- Capiilus
- Determine
- Tridot
- Seroda
- Unigold
4. DNA PCR ( After 14 days detect)
ELISA= Enzyme linked immunosorbant assy
PCR = Polymerase chain reaction
Blood bank use single test

Nepal Strategy 1 (Venous Blood Sample)
A1- Negative
A1
A1+ Positive
A2
A1+ A2+
Positive
A1+A2-
A3
A1+A2-A3+
Positive
A1+A2-A3-
Negative

40
Other Investigations :
History taking
Physical examination
Lab. Inv.
• CBC
• Malaria Smear
• Blood C/S
• Widal test for
salmonella
• Typhoid serology
• Rheumatic factor
• K 39 for kala-azar
• Urinanalysis
• Sputum for AFB
• CSF
• Skin scraping
• PPT ( Mantox)
• B.M. aspiration
Radiological Exa.
- Cx R
- USG

41
Association between CD4 & OI
CD4
• 400
• 300
• 200
• 100
• 50
OI
• TB / Herpis Zoster
• Oral Candidasis
• Pneumonia, Mucocutaneous Herpis
• Toxoplasmosis, Cryptococcesis
• Leukoecephalopathy
Early Immune depletion = CD4 > 500
Intermediate depletion = CD4 = 500-200
Advance Immune depletion = CD4 = < 200

42
Association between
CD4 & Lymphocytes
Lymphocytes = CD4
 >2000 = >500
 1000-2000 = 200-500
 < 1000 = < 200

43
Major concerns
• OIs are the main cause of death in AIDS
• Persons who are immunosuppressed may not
have typical features
– Diagnosis may be delayed/overlooked
• Danger of having ARV therapy
– Can be life threatening
– Also can affect liver toxicity
• Interactions with OI drugs and ARV

44
ART-Therapy

• 3TC- lamivudine
• ZDV- zidovudine
• TDF- tenofovir
• NVP- nevirapine
• EFV- efavirenz
• LPV/r- lopinavir/ ritonavir
45

46
Nucleoside
reverse
transcriptase
inhibitors
(NsRTIs)
Nucleotide
reverse
transcriptase
inhibitors
(NtRTI)
Non-
nucleoside
reverse
transcriptase
inhibitors
(NNRTIs)
Protease
inhibitors
(PIs)
•Zidovudine
(ZDV, AZT)
Didanosine
(ddI)
Stavudine
(d4T)
Lamivudine
(3TC)
•Abacavir
(ABC)
•Emtricitibine
(FTC)
Tenofovir
disoproxil
fumarate
(TDF)
•Nevirapine
(NVP)
•Efavirenz
(EFZ)
•Saquinavir/ritonavir
(SQV/r)
•Indinavir (IDV)
•Nelfinavir (NFV)
•Lopinavir/ritonavir
(LPV/r)
•Atazanavir/ritonavir
(ATZ/r)

47
Nepal First Line ARV Regimens
• AZT(ZDV)/3TC/NVP- ‘OR’
• d4T/3TC/NVP- ‘OR’
• ZDV/3TC/EFV- ‘OR’
• d4T/3TC/EFV
• AZT/ZDV - 300 mg bid
• 3TC - 150 bid
• NVP (initial dose) - 200 mg od x 14 days
• NVP (maintenance) - 200 mg od x after 14 days
• EFV - 600 mg once at night
• d4T - 30 mg bid

48
Drugs Side effect
seek care urgently
ZDV
zidovudine
Anemia
Low WBC
NVP
Nevirapine
Skin rash
Itching peeling rash of lips, eyes
Fever
Abdominal pain yellow eyes
hepatotoxicity
d4T
stavudine
Sever abdominal pain
Fatigue & shortness of breath
Tingling, numb or painful feet, hands
3TC Less common
EFV
Efavirenz
Strange dreams
Yellow eyes
Psychosis or confusion
skin rash

Dr. RS Mehta, MSND, BPKIHS 49
Details of ART

Principles of Antiretroviral Therapy
• HAART(highly active antiretroviral therapy) is defined as a
regimen consisting of two nucleoside reverse
transcriptase inhibitors plus a protease inhibitor or a
non-nucleoside reverse transcriptase inhibitor,
• or two protease inhibitors and one other antiretroviral
agent
principles
• Maximal and durable suppression of viral load.
• Restoration and/or preservation of immunologic function.
• Reduction of HIV-related morbidity and mortality.
• Improvement of quality of life of HIV infected persons.
• Prevention of Mother to Child Transmission (PMTCT).
• Post Exposure Prophylaxis (PEP). 50

Anti retroviral drugs
Five categories
1.Nucleotide and nucleoside reverse
transcriptase inhibitors (NRTIs)- constrain HIV
replication by incorporating into the elongating strand of DNA
causing chain termination. S/E- lactic acidosis E,g-abacavir,
didanosine, lamivudine, zidovudine, tenofovir
2.Nonnucleoside reverse transcriptase
inhibitors (NNRTIs)- inhibit HIV by binding noncompetiveily
to the reverse transcriptase. S/E-rash, hepatotoxicity, stevens-
johnson syndrome E.g- efavarinz, nevirapine,
3. Protease inhibitors (PI) block the action of viral protease
required for protein processing. S/E- drug reaction E.g-indinavir,
lopinavir, ritonavir
4.HIV entry inhibitors- target different stages of HIV entry
process. E.g- enfuvirtide 90mg BD, maraviroc 300mg PO BD
5.Integrase inhibitor-eg- raltegravir 400 mg PO BD
51

When to start ART?
National antiretroviral therapy guidelines (MOHP,
Nepal)
If CD4 testing available:
It is recommended to document baseline CD4 counts and to offer
ART to patients with:
• WHO Stage 4 disease, irrespective of CD4 cell count
• WHO Stage 3 disease, irrespective of CD4 cell count
• WHO Stage 1 or 2 disease with CD4 cell counts less than
350/mm3
If CD4 testing unavailable:
• It is recommended to offer ART to patients with:
• WHO Stage 4 disease
• WHO Stage 3 disease
Note: WHO stage 1 and 2, treatment is not recommended
when CD4 testing is not available
• Consider ART initiation in those with active Hepatitis B or C
and those with HIV-related nephropathy
52

In BPKIHS
• CD4 < 500 cells/ mm3
• Acute retroviral illness
• AIDS defining condition (stage III and IV)
• Till date about 700 cases enrolled (ART
started since 2062 BS)
53

The choice of regimen depends on
• Cost of therapy
• Availability
• Affordability of drugs
• Convenience and likelihood of adherence.
• Regimen potency, tolerability and adverse
effect profile
• Possible drug interactions.
Antiretroviral therapy with single or dual drug
regimen is not recommended except for the
prevention of mother to child transmission
and post exposure prophylaxis of HIV.
54

Principle of combination
• 2 NRTI + NNRTI
or
• 2NRTI + PI
or
• 2NRTI + 1NRTI (Abacavir) (triple NRTI
therapy= ZDV+3TC+ABC; do not use
other triple NRTI options) 55

First line ARV regimen in adult and adolescent
ZDV+3TC+NVP
• Use with caution if CD4 count> 250/mm3
(monitor LFT)
• Don’t use if CD4 >350 women or > 400
for men
• Good for pregnant women with CD4 <
250
• Use with caution if on ATT
• Avoid ZDV if anemia (hb <7) 56

TDF+ 3TC+ NVP
• Use with caution if CD4 count> 250, monitor
LFT
• Good to use if anemia
• Don’t use if CD4 >350 women or >400 in men
• Good for pregnant women with CD4 < 250
• Use with caution if on ATT
• Don’t use TDF if renal insufficincy
ZDV+ 3TC+ EFV
• Good choice for TB
• Good choice if high CD4 > 350 women and >
400 for men
• Avoid ZDV if anemia
57

TDF+ 3TC+ EFV
• Good choice for TB
• Good choice if high CD4 count >250
women and >400 men
• Good choice if hepatitis B
• Good choice if CD4 and HB report
unknown
• Do not use TDF if renal insufficiency
ZDV+ 3TC+ LPV/r
• Choice to treat confirmed HIV 2cases
58

Medical management of AIDS done in BPKIHS
ART started in BPKIHS since 2062 BS
• 2 NRTI + 1 NNRTI or 1 or 2 PI
• Life long therapy
• Treatment in OPD basis
• Admission if acute illness and complications
• Medicines free of cost
NRTI
• Zidovudine 600 mg/ day PO OD or 300 mg BD
• Tenofovir 300 mg PO OD
• Lamivudine 300 mg PO OD or 150 mg PO BD
NNRTI
• Nevirapine 200 mg PO OD for first 2 weeks then BD for 2nd 2 weeks
• S/E hepatitis
• Efavirenz 600 mg PO OD
PI
• Ritonavir used in combination
• Atazanavir 400 mg PO OD 59

Coinfection and starting ART
Hepatitis B- start ART in those with chronic active
hepatitis B, irrespective of CD4 or WHO stage
Tuberculosis
• Start ART in all PLHIV with TB, irrespective of CD4
• Start TB treatment first followed by ART as soon as
possible whereafter, but by 8 weeks at the latest
• Use efavirenz as the preferred NNRTI in tb HIV co
infection
• If NVP is used, start with BD doses from initiation
60

Cotrimoxazole Prophylaxis in Adults
• against Tb, Pnuemocyctis xeroviri and
mycobacterium avium
should be given to:
• HIV infected adults with CD4 count <350
cells/mm3
• All adults who have had an episode of PCP
• All adults with symptomatic HIV disease or
Clinical stage 2, 3 or 4
The regimen is:
• 1 DS tablet
(160TMP(trimethoprim)/800SMX(sulfamethox
azole) every day OR
• 2 SS tablets (80TMP/ 400SMX) every day
61

Continue Cotrimoxazole prophylaxis as
follows:
• Lifelong, if not on ART
• If on ART the CD4 is >350 on two
consecutive samples 6 months apart,
Cotrimoxazole can be discontinued.
• Stop prophylaxis for severe cutaneous
reactions, such as Stevens- Johnson
syndrome, renal and/or hepatic failure,
and severe hematological toxicity.
62

Timing of Cotrimoxazole prophylaxis in
relation to ART initiation
• it is recommended to start cotrimoxazole
prophylaxis first and to initiate antiretroviral
therapy two weeks later if the individual is
stable on cotrimoxazole and has no rash.
• For Cotrimoxazole intolerance, consider the
following alternatives:
• Dapsone 100 mg once daily is the first choice.
• OR
• In cases of non-life -threatening adverse
reactions, stop treatment for two weeks; then
re-challenge the client with TMP/ SMX in a
gradually increasing dose of an oral
suspension of TMP/SMX.
63

Medicines for superinfections
• Fungal infections- fluconazole, cotrimazole
64

Antiretroviral treatment failure in adults and
adolescent
Clinical feature- new or recurrent WHO stage 4 condition
CD4 cell failure
• Persistent CD4 count < 100 cells/mm3
• Fall of CD4 count to pretherapy baseline
• 50% fall from on- treatment peak CD4 value
Virological failure- persistent plasma viral load > 5000 copies/ ml
or less than 10 fold reduction of viral load 4- 6 weeks after starting a
new ART regimen, failure to reach an undetectable viral load after
6 months of treatment, detection of virus after initial complete
suppression of viral load
Certain WHO clinical stage 3 conditions like pulmonary TB,
severe bacterial infections may be indications of treatment failure
65

Recommended second line regimen
in adult and adolescent
• For failure on
• ZDV+ d4T+ 3TC +
NVP or EFV
• Change to
• TDF+ 3TC+
LPV/r
• Failure on
• TDF+ 3 TC + NVP or
EFV
• Change to
• ZDV+ 3 TC
+LPV/r
66

67
Cotrimoxazole Prophylaxis
International Guidelines:
1. All PLWHA with Symptomatic HIV (Stage 2,3,4)
Or
2. Asymptomatic individuals who have a CD-4 count of 350 or less
1DS tablet once daily (DS=TMP-160 mg/SM-80mg)

68
Limitations of ART
• ART does not CURE HIV infection
• With currently available medications, the
virus can never be completely eradicated,
so the person should take the drugs
forever, even if symptoms have
disappeared.

69
ART : Therapy
• Reduce viral load: halt disease
• Prevent & reduce resistant variant
• Achieve immune reconstitution
( > CD-4)
• Prolong & improve quality of life.

70
Monitor Adverse drug
reactions:
• Anemia
• Rash
• Hepatotoxicity
• CNS effects
• Diarrhoea
• Lipoatrophy
• Fat accumulation
• Diabetes
• Avascular necrosis
• Osteoporosis
• Pancreatitis
• Peripheral
neuropathy
• Hyperlipidemia

71
Do not start ART if:
• The patent is not motivated.
• Without intensive counseling.
• If t/t cannot be continued.
• Patient has poor renal/ hepatic function
• Patient is asymptomatic and there is no
CD4 data.
• During an acute opportunistic infection.
including TB, first treat acute infections.

72
Universal precautions pertain to
the following body fluids
(CDC, 1988):
• Blood
• Semen
• Vaginal Secretions
• Cerebrospinal Fluid
• Synovial Fluid
• Pleural Fluid
• Peritoneal Fluid
• Pericardial Fluid
• Amniotic Fluid
• Body Tissues

73
Universal precautions do not apply to the
following body fluids unless they contain
visible blood (CDC, 1988):
• Feces
• Nasal Secretions
• Sputum
• Sweat
• Tears
• Urine
• Vomitus
• Saliva
Always use barriers to prevent skin and mucous
membrane exposure to blood and body fluids.

Post exposure prophylaxis
• Candidates:
– Health care workers with needle prick injury
– Condom breakage
– Victims of rape
– Relapses in IV drug users
• First dose to be taken as soon as possible
(within hours).

PEP
Post Exposure Prophylaxis 75Dr. RS Mehta, MSND, BPKIHS

76
Principles of PEP Management:
• Exposure Site Management:
• Exposure Reporting:
• Evaluation of transmission Risk:
• Counselling:
• Consideration of PEP:
• Follow up: 6 W, 12W, 6M
Area of Uncertainty: 99.7% occupational
injury involving percutaneous exposure to
HIV do not transmit infection.

PEP
Immediate measures
• Use soap and water
• Antiseptics not better

78
PEP
• Nepal 2005 ART Guidelines (2hrs/<72hrs)
- 2 Drug Combinations
ZDV + 3TC
- 3 Drug Combinations
{2 nucleosides (as above) + IDV or NFV
or other PI’s}
Follow-up: HIV serology at 6 wks, 3 and 6
months

Follow up
• For 6 months.
• Tested at base line, 6Wks, 12 Wks & 6
Months.
• Monitor drug toxicity
• Counseling
• Behavioural precautions.

80
Common Nursing Diagnosis
• Diarrhoea RT enteric pathogens
• Imbalanced nutrition: less than body
requirement RT decreased oral intake and
frequent diarrhoea.
• Risk for infection RT immunodeficiency
status.
• Deficit knowledge RT means of preventing
HIV infection.

81
Health education
• Prevention from infection
• Use of boiled water and well cocked food
• Use of proper/clean latrine, kitchen and
bath-room
• Perform proper hand hygiene
• Avoid play with pets
• Maintain Perineal hygiene

82
• Have safe sex practice
• Treat any infection promptly
• Not to let down self confidence
• Not to depressed with social behaviors
• Eat balanced diet
• Engaged in diversnal activities
• Use of sterile syringe and needles
• Made the family members to accept the
situations

84
Stigma and Psychosocial
aspects Related to HIV/AIDS

85
People with HIV are
stigmatized for Many Reasons:
• HIV is a slow incurable disease, resulting in
illness and death.
• HIV is considered a death sentences.
• People afraid of getting it/transmission
• Often associated with moral violation: sex
• Blame certain groups for spreading : CSWs, IDUs
• Stigma prevents speaking about it.
• Stigma prevent from Seeking care

Comprehensive Care of PLWHA
• HIV counseling including prevention for positive services
• Clinical assessment and staging
• Clotrimoxazole prophylaxis: prevent OI
• Diagnosis of TB
• OI diagnosis and treatment
• Nutrition monitoring and support
• Pre-ART care and ART
• ART adherence counselling
• Referral for VCT
• Supports: NGOs, PMTCT, FP, STI, CHBC etc

Thank You

88
Skin manifestations in HIV

89
Angular
stomatitis

90
Oral thrush

91
Oral hairy leukoplakia

92
Papular pruritic eruption (PPE)
•Anithistaminics
•Potent topical steroids
•Calamine lotion
•HAART

93
PPE

94
Eosininophilic folliculitis
• Anithistaminics
• Potent topical
steroids

95
Bacterial folliculitis
•Local antiseptics
•Cloxacilline 500 mg
4x/d for 10 days

96
Impetigo
•Local antiseptics
•Cloxacilline 500 mg
4x/d for 10 days

97
Herpes Zoster
•Local desinfection
•Acyclovir 800 mg 5x/day,
7-14 days
•Analgetics
•Amitriptyllin

98
Molluscum contagiosum

99
Norvegian Scabies

100
Scabies•Topical benzylbenzoate 20%, 3
days on body (except scalp)
•Chlorpheniramine
•Treatment of family
•Treatment of clothes and bed
sheets
•Antibiotics if surinfection
•Topical steroids for persistent
itching

101
Seborreic dermatitis

102
Seborreic dermatitis
•Whitfields ointment bid OR
•Ketoconazole ointment bid
OR
•Miconazole cream bid
•Local steroid cream added

103
Athlete’s foot
•Clotrimazole or
miconazole cream OR
•Oral griseofulvin 10
mg/day for 4 weeks

105
Tinea cruris

106
Balanitis
•Clotrimazole or miconazole
cream
•Local gentian violet

107
Candida and herpes

108
Cryptococcal skin lesions
Amphotericin B followed
by fluconazole

109
Cryptococcus

110
Secondary syphilis
Benzathin penicillin 2,4 MIU IM
or
erythromycin 4x500 mg
for 4 weeks

111
Chronic mucocutaneous Herpes
Simplex
•Acyclovir 200-400
mg 5x/d for 7-10
days
•Analgetics
•Suppressive therapy
if >6
recurrences/year
(acyclovir 200 mg
2x/d)

112
Condyloma
accuminata
Podophyllotoxin 0,5%
strictly on the lesions
2x/day for 3 consecutive days per week,
repeat 4 weeks

114
Kaposi Dr. RS Mehta, MSND, BPKIHS

117
Fixed drug reaction
Stop causing agent

118
Fixed drug reaction
Stop causing agent

Tuberculosis in
HIV

Kaposi’s
Sarcoma
• Due to HHV-8
• Features:
– Cutaneous
• Purple, non-pruritic, non-
tender papules
• May ulcerate on feet
• May be associated with
lymphadenopathy
• Sites: nose, Genitals and
lower limbs

• Sites:
– Palate, gum
margins,
• Predictors of GI/
respiratory tract
diseases
Oral

Lipodystrophy in HIV

125
Photographs of Training on HIV/AIDS

Dr. RS Mehta, MSND, BPKIHS 128

129
THANK-YOU

Treatment of AIDS

Classification of Antiretroviral agents
• Nucleoside Reverse Transcriptase Inhibitors
(NRTIs) –Zidovudine, Stavudine, Lamivudine,
Abacavir, Zalcitabine, Didanosine
• Non-Nucleoside Reverse Transcriptase
inhibitors (NNRTIs) –Efavirenz, Nevirapine,
Delavirdine
• Nucleotide Reverse Transcriptase Inhibitors
(NTRTIs) – Tenofovir
• Protease Inhibitors (PIs) – Saquinavir, Indinavir,
Nelfinavir, Amprenavir, Ritonavir, Lopinavir
• Entry/Fusion Inhibitors - Enfuvirtide
• Intergrase inhibitor - Raltegravir

NRTI
• RTIs have cross- inhibition of human DNA
polymerases results in toxicity.
• Compititive inhibitors of viral RT
• Require phosphorylation by cellular kinase to
be activated.
• Most have activity against HIV-1 and HIV-2.
• Lactic acidosis, severe hepatomegaly.
• Women -- obese, alcoholic more prone

NNRTI
• Do not require activation. Bind directly to RT
and inhibit.
• Active against HIV-1 alone.
• Monotherapy leads to resistance
• Cross resistance among NNRTIs, not with
NRTI and PIs
• Potential drug interactions.
• Syergistic action with NRTI or PI
• Skin rashes- SJS, elevated liver enzymes

Protease inhibitors
• PIs render particles noninfectious. Prevent new
infections.
• Effective against both HIV-1 and HIV-2.
• Emergence of resistance to PIs. Combination
required.
• All are inhibitors of CYP3A4. Life threatening
toxicities may occur with cisapride, statins, ergot,
midazolam and triazolam.
• Adverse effects: hyperglycemia, hyperlipidemia,
lipodystrophy, insulin resistance. Increased
bleeding in hemophilia A or B patient 134Dr. RS Mehta, MSND, BPKIHS

HIV treatment guidelines
• Rxof HIV infection is complex.
• HAART with combination of 3 or more drugs.
• Monotherapy is contraindicated.
• None of currently available regimens can
eradicate HIV.
• Goal of therapy is to inhibit viral replication.
• Greater suppression of viral replication,
lesser is chance of emergence of drug
resistant virus.

Initiating antiretroviral therapy
• Treat all symptomatic & asymptomatic HIV
positive pts.
• No long-term benefit in asymptomatic cases
with (CD4 cell count > 350/ul).
• Deleterious effect of anti-HIV drugs on
quality of life.
• Best time to initiate anti-HIV therapy remains
uncertain.
• Various professional bodies and health
authorities have framed t/t guidelines. 136Dr. RS Mehta, MSND, BPKIHS

Current concensus on
Antiretroviral therapy
• CD4 cell count is major determinant of
initiating therapy in asymptomatic cases.
• ↑ed mortality ---- when t/t after CD4 count
<200/ul.
• Serious opportunistic infn, response to anti-
HIV drugs is suboptimal.

Initiating antiretroviral therapy
1. All cases of symptomatic HIV disease—Rx.
2. Asymptomatic HIV disease with CD4 count <
200/ul —Rx
3. Asymptomatic HIV disease with CD4 count >
200/ul —Rx individualized based on:
– CD4 cell count and rate of decline: pts with > 350 CD4
cells/ul need not be treated.
– t/t may be initiated at CD4 count b/w 200-350/ul
– A decline of > 100 CD4 cells/ul per annum is considered
high— indication for initiating therapy.
– HIV-RNA level: > 50,000 copies of HIV-RNA/ml is
considered high.
– Patient's interest.
– Risks of drug toxicity and interactions.

Therapeutic regimens
• HAART ---suppress plasma viral load to
undetectable levels (< 50 copies of HIV-
RNA/ml).
• 3 antiretroviral drugs is considered optimal.
• Addition of a 4th drug to t/t-naive patients no
benefit.
• Variety of combination regimens are possible
and have been employed.
• No specific combination can be considered
optimal initial regimen for all pts. 139Dr. RS Mehta, MSND, BPKIHS

* Only when a NNRTI or
PI cannot be used.

• 3 drugs in the regimen should belong to at
least 2 different classes.
• 3NRTI regimens are clinically less effective
than those which include a NNRTIor a PI.
• 3 NRTI regimen is employed only when a
NNRTI or PI cannot be used.
• PI sparing regimens are more convenient,
better tolerated , <metabolic complications.
• NRTI + NNRTI + PI is reserved for
advanced. 141Dr. RS Mehta, MSND, BPKIHS

• Drug toxicity develops, entire regimen
interrupted or offending drug changed.
• No dose reduction.
• 'Drug holidays' not recommended.
• Rx is practically life-long.
• Pregnancy not contraindicate anti-HIV
therapy.
• Drugs considered relatively safe during
pregnancy : zidoudine, lamivudine,
nevirapine, nelfinavir, saquinavir. 142Dr. RS Mehta, MSND, BPKIHS

Ribavarin not with Zidovidine

• Durability of regimens depends pt
compliance.
• major determinant of outcome.
• Not be discontinued during an acute
opportunistic infection.
• Multiple drugs---Attention for drug
interactions and toxicities.

Changing a failing regimen
• < than 10 fold reduction in plasma viral
load occurs by 4 weeks .
• Failure to suppress plasma viral load to
undetectable level within 6.
• Repeated detection of virus (> 400
copies/ml) in plasma.
• Clinical deterioration,↓in CD4 cell count,
opportunistic infection.
• Rx failures should be anticipate. 145Dr. RS Mehta, MSND, BPKIHS

Changing a failing regimen
• Optimally, regimen should be changed
entirely.
• Known overlapping viral resistance should be
avoided.
• With repeated failures -- difficult to construct
an active combination.
• goal of therapy in this situation is to retard
clinical progression of disease rather than
complete suppression of viraemia.

Prophylaxis of HIV infection
Post-exposure prophylaxis (PEP)
• Aim of PEP is to suppress local viral
replication prior to dissemination, so that
infection is aborted.
• Not necessary when contact is only with
intact skin, or with mm by only a few drops
for short duration.
• Not indicated when the source is known to
be HIV -ve.

(NACO, India)
recommends 2
types of regimens

Post-exposure prophylaxis
(PEP)
• Start as soon as possible, preferably
within 1-2 hours of exposure.
• Some guidelines do not recommend
starting after 72 hours of exposure.
• According to others, PEP may even be
started even 1-2 weeks later.
• HIV infection may not be prevented.

Perinatal prophylaxis.
• To decrease risk of mother to child transmission.
• AZT 300mg BD – start in 2nd trimester &
continued through delivery to postnatal period.
• Treat neonate for 6 weeks.
• Not started earlier, AZT administered during
labour and then to infant is also substantially
protective.
• Breastfeeding is discouraged.
• Children – 180 mg/m2 (max. 200 mg) 6-8 hrly….

THANK YOU!!
Visit: www.ncasc.gov.np for recent data

Post exposure prophylaxis
If sustain a needlestick injury, :
• Wash the area with soap and water.
• Alert your supervisor and initiate the injury-reporting
system
• Identify the source patient, who may need to be tested
for HIV, hepatitis B, and hepatitis C.
• Give consent for baseline testing for HIV, hepatitis B, and
hepatitis C.
• Get postexposure prophylaxis for HIV in accordance with
CDC guidelines. Start the prophylaxis medications within
2 hours after exposure.
• Practice safer sex until follow-up testing is complete.
• Follow up with postexposure testing at 6 weeks, 3
months, and 6 months and perhaps 1 year.
152

No risk
• Contact in intact skin
• Contact with non blood containing tear,
saliva, urine and stool
Less risk
• Mucous membrane like eyes, nose and
mouth exposed to body fluids
• Blood spills over abraided skin
• Superficial wound by blunt instruments,
solid needle
• If the source person is asymptomatic
153

High risk
• Contact with heavy amount of infected blood
or wounded by blood stained instruments
• Injured with needles used to aspirate pleural,
pericardial, ascitic, CSF or synovial fluids
• Skin wound exposed to semen, sperm or
amniotic fluid
• Pricked by blood stained needles
• Deep wound by infected articles
• Pricked by hollow needle
• Symptomatic AIDS, viral load
=/>1500copies/ml
• Infected from source in window period
154

When to start PEP
• As soon as possible best if within 2 hours of contact or
at least within 36 hours
Less risk-
• Zidovudine 300 mg + 3 TC 150 mg 1 tab each BD for
28 days
More risk
• Zidovudine 300 mg + 3 TC 150 mg 1 tab each BD and
indinavir 400 mg tab 2 caps TDS or lopenavir/ ritonavir
200 mg/ 50 mg 2 tabs BD for 28 days
Follow up 6 wks, 3 months, 6 months
155

Indication of PEP
• The exposed person is HIV-negative
• The source person is HIV positive, or at high
risk of recent infection and thus likely to be in
the window period.
• The exposure poses a risk of transmission,
that is: Percutaneous exposure to potentially
infectious body fluids,
• Sexual intercourse without an intact condom
• Exposure to non-intact skin or mucus
membranes to potentially infectious body
fluids
• The exposure occurred less than 72 hours
156

Advice to patients for missed ARV
doses:
• take medicine as soon as noticed.
• For the NEXT DOSE
• If the next planned pill-taking time is four
hours away or less, DO NOT take next
dose. Instead wait four hours and then
take next dose. After this follow your
regular dosing schedule.
• Do not take two doses at one time.
• If is it already time for the next dose, just
take that dose and carry on with the
treatment schedule.
157

PMTCT
• Prevent HIV Infection among Women of Child-
bearing age.
• Prevent unintended pregnancies among
women living with HIV
• Prevent HIV transmission from HIV infected
mothers to their infants
• Antiretroviral prophylaxis for mother and baby
• Safer delivery practices
• Safer infant feeding choices
• Provide appropriate treatment, care and
support to women living with HIV and their
children and families
158

When to commence full HAART in pregnancy:
as in other non-pregnant adults
• WHO Stage 4 disease, irrespective of CD4
cell count
• WHO Stage 3 disease, irrespective of CD4
cell count
• WHO Stage 1 or 2 disease with CD4 count
less than 350/mm3*
• Note: ART is even more urgent in the case
of pregnant women, given the potential to
decrease HIV transmission to the infant
159

The standard HAART regimen in
pregnancy
ZDV + 3TC + NVP
• Efavirenz can be used after the first
trimester of pregnancy and may be
preferred in women with higher CD4 counts.
• NVP should not be used in those with CD4
over 350 and only used with caution in those
between 250 and 350 due to risk of liver
toxicity.
• All pregnant women taking NVP need close
monitoring of liver function.
160

Recommended First-Line HAART Regimen for treating Pregnant
Women, and Prophylactic Regimen for Infants
Recipie
nt
Timing Regimen
Mother Start ASAP in
pregnancy and
continue
throughout
pregnancy,
labour
and delivery and
postpartum, for
life
ZDV 300mg + 3TC 150mg twice a day
+ NVP 200mg once a day for 14 days
(if CD4 <250)
If no reaction, continue ZDV + 3TC
and increase NVP to 200mg
twice a day after 14 days
Baby Neonatal Infant ZDV 4 mg/kg twice a day for 7
days
If the mother has received less than 4
weeks of HAART, infant
ZDV should be continued for 4 weeks 161

• Note: EFV is preferred after the first
trimester in women with CD4 >250,
and especially those with CD4 over
350.
• Antiretroviral prophylaxis for mother
and baby (when mother does not yet
need ART)
• The risk of HIV transmission to the
baby can be reduced to 2% or less if 162

Recommendations on infant feeding to babies
born to HIV positive mothers:
• exclusive breastfeeding for six months, is the
ideal way to feed infants and it should be
protected, promoted and supported.
• The rate of mother-to-child transmission of
HIV in the absence of preventive
interventions is about 15-25% without
breastfeeding and 25-40% with
breastfeeding.
• Mixed feeding (defined as breast milk plus
water, other fluids and foods) is associated
with 11-fold increased risk of infant HIV 163

• After 6 months, culturally appropriate
complimentary foods (weaning) is started
and mother is advised to stop breast feeding
as early as possible.
• If a child is diagnosed as HIV-infected, the
mother should be encouraged to continue
breastfeeding the child beyond six months of
age along with the addition of
complementary foods.
164

Ongoing Monitoring and
follow up
• Once ART is started, follow up schedule
should be as follows:
• First month: two visits (every 2 weeks)
• Second + Third month: every month
• Fourth month onwards: one visit every
three months
• More frequent visits will be scheduled, if
the patient develops symptoms or
experiences difficulties in adhering to the
medications
165

Laboratory Monitoring: first
year
2nd week
• CBC and Liver Function tests
(ALT if on NVP)
Month 1
• CBC
• LFT if on NVP
• Other necessary investigation
if and as required
Month 2
• CBC
• LFT if on NVP
if and as required
Month 3
• CBC
• LFT if on NVP
if and as required
Month 6
• CBC, platelets
• LFTs
• CD4 Cell Count
Month 9
• CBC and LFT
Month-12
• CBC
• LFT
• CD4 Cell count
• Other tests as needed
166

Subsequent Years:
Quarterly
• CBC
Every 6 months
• CD4 Cell count
• LFT
• Other tests as needed
• If viral load testing becomes readily available,
ideal testing schedule would be if virologic
failure is suspected and every 6 months after
starting ART.
• Pregnant women on ART or ARV prophylaxis near
term (36 weeks) who are considering an elective
caesarean section should be offered viral load
testing, if possible.
167

Monitoring in BPKIHS
• CD4 6 monthly
• Viral load 6 months, 12 months then yearly
thereafter
• CBC, LFT, RFT, lipid profile baseline
• G6PD in case of cotrimoxamole
prophylaxis
• TFT, ANA to rule out autoimmune
conditions
• Serology for HbsAg, HCV, sputum AFB 168

prevention
• Education, counseling, and behavior modification
• CDC has recently recommended that HIV testing
become part of routine medical care and that all
individuals between the ages of 13 and 64 years be
informed of the testing and be tested without the need for
written informed consent.
• The practice of “safer sex” is the most effective way for
sexually active uninfected individuals.
• Abstinence from sexual relations is the only absolute way
to prevent sexual ransmission of HIV infection.
• If both are negative, it must be understood that any
divergence from monogamy puts both partners at risk;
open discussion of the importance of honesty in such
relationships should be encouraged.
169

• When the HIV status of either partner
is not known, or when one partner is
positive, Use of condoms can markedly
decrease the chance of HIV
transmission.
• Latex condoms are preferable, since
virus has been shown to leak through
natural skin condoms.
• Petroleum-based gels should never be
used for lubrication of the condom,
since they increase the likelihood of
condom rupture. 170

• Avoid anal intercourse because this practice may injure
tissues.
• Engage in nonpenetrative sex such as body massage,
social kissing (dry), mutual masturbation, fantasy, and sex
films.
• Inform prospective sexual and drug-using partners of your
HIV-positive status.
• Notify previous and present sexual partners if you learn
that you are HIV seropositive.
• If you are HIV seropositive, do not have unprotected sex
with another HIV-seropositive person, because cross-
infection with another HIV strain can increase the severity
of the disease.
• Do not share needles, razors, toothbrushes, sex toys, or
other blood-contaminated articles.
• If you are HIV seropositive, do not donate blood, plasma,
body organs, or sperm.
171

NGO/ INGOs supporting PLWHA in
BPKIHS
• Dharan Positive samuha
• Sunaulo bihani plus
• KYC punarjeevan kendra
• Chhetriya HIV tatha AIDS mahasang
• Bishwas mahila samuha
• Prayas mahila samuha
• Nawajeevan samaj
• Kirat yakthung chumlung punarjeevan
kendra 173

Other organizations in Nepal
• AAN (AIDS ALLIANCE NEPAL) -national community based non-
profit organization representing people living with HIV/AIDS.
• ILO office in Nepal planning to implement a pilot project Employment
Creation for People Living with HIV and AIDS (PLHIV) (October
2008-November 2009), funded by UNAIDS Programme Acceleration
Fund (PAF).
• National Association of People Living with HIV/AIDS in Nepal
(NAP+N) -non-political, non religious, non-governmental, non-
profitable, autonomous network of People Living with HIV/AIDS
established in 2003 with a goal "To unite all those living with the
virus in Nepal and fight back". Since its establishment with 30
members in first NCM from 8 districts of Nepal, it has expanded its
regional office in 5 regions and 40 districts.
• others
174

Nursing assessment
• NUTRITIONAL STATUS- Weight, anthropometric
measurements, and blood urea nitrogen (BUN), serum
protein, albumin, and transferrin levels
• SKIN INTEGRITY- ulceration, or infection, candidiasis.
• RESPIRATORY STATUS- cough, sputum production,
shortness of breath, orthopnea, tachypnea, and chest
pain, x-ray results, arterial blood gas values, pulse
oximetry, and pulmonary function test results.
• NEUROLOGIC STATUS- level of consciousness;
orientation to person, place, and time; and memory
lapses, sensory deficits motor involvement and seizure
activity.
• Knowledge level
176

Nursing diagnosis
• Impaired skin integrity related to cutaneous
manifestations of HIV infection, excoriation,
and diarrhea
• impaired fluid and electrolyte balance, and
hypoxia associated with pulmonary infections
• Disturbed thought processes related to
shortened attention span, impaired memory,
confusion, and disorientation associated with
HIV encephalopathy
• Ineffective airway clearance related to PCP,
increased bronchial secretions, and decreased
ability to cough related to weakness and
fatigue
177

• Pain related to impaired perianal skin
integrity secondary to diarrhea, KS,
and peripheral neuropathy
• Imbalanced nutrition, less than body
requirements, related to decreased oral
intake
• Social isolation related to stigma of the
disease, withdrawal of support
systems, isolation procedures, and fear
of infecting others
• Anticipatory grieving related to 178

PROMOTING SKIN INTEGRITY
• Assess skin and oral mucosa
• change position every 2 hours.
• alternating-pressure mattresses and low-air-loss
beds
• Regular oral care.
• Medicated lotions, ointments, and dressings to
affected skin surfaces.
• Adhesive tape is avoided.
• wear cotton socks and shoes that do not cause
the feet to perspire.
• Antipruritic, antibiotic, and analgesic agents
• Instruct patient to clean perianal region
• If the area is very painful, sitz baths or gentle
irrigation
179

PROMOTING USUAL BOWEL
HABITS
• monitor the frequency and consistency of
stools, stool culture
• Avoid foods that act as bowel irritants, such
as raw fruits and vegetables, popcorn,
carbonated beverages, spicy foods, and
foods of extreme temperatures
• Small, frequent meals.
• antidiarrheal agents
• Antibiotics and antifungal agents
180

PREVENTING INFECTION
• Patients instructed to monitor for signs
and symptoms of infection
• Monitor laboratory values and culture
report of wound drainage, skin lesions,
urine, stool, sputum, mouth and blood
• The patient is instructed to avoid others
with active infections such as upper
respiratory infections.
181

IMPROVING ACTIVITY
TOLERANCE
• Activity tolerance and patient’s ability to
ambulate and perform activities of daily
living.
• Assistance in planning daily routines
that maintain a balance between
activity and rest may be necessary.
• Measures such as relaxation and
guided imagery
• Collaboration with other members of
the health care team
182

MAINTAINING THOUGHT PROCESSES
• assess for alterations in mental status
• Instruct Family member to speak to the patient in
simple, clear language and give the patient
sufficient time to respond to questions and orient
the patient to the daily routine by talking about
what is taking place during daily activities.
• The nurse encourages the family to remain calm
and not to argue with the patient while protecting
the patient from injury.
• Around the- clock supervision may be necessary,
and strategies can be implemented to prevent the
patient from engaging in potentially dangerous
activities, such as driving, using the stove
183

IMPROVING AIRWAY CLEARANCE
• Assess Respiratory status, including rate, rhythm,
use of accessory muscles, and breath sounds;
• Pulmonary therapy (coughing, deep breathing,
postural drainage, percussion, and vibration)
every 2 hours
• high Fowler’s or semi-Fowler’s position
• Adequate rest to prevent excessive fatigue.
• adequate hydration 3 L daily Unless
contraindicated
• Humidified oxygen
• nasopharyngeal or tracheal suctioning, intubation,
and mechanical ventilation as necessary
184

RELIEVING PAIN AND DISCOMFORT
• The patient is assessed for the quality and
severity of pain
• Cleaning the perianal area
• avoid foods that act as bowel irritants.
• Antispasmodics and antidiarrheal
medications.
• Pain management -nonsteroidal anti-
inflammatory drugs (NSAIDs) and opioids
plus nonpharmacologic approaches such as
relaxation techniques.
185

IMPROVING NUTRITIONAL STATUS
• Assess Nutritional status
• Control of nausea and vomiting with
antiemetic medications
• patient is encouraged to eat foods that
are easy to swallow and to avoid
rough, spicy, or sticky food items and
foods that are excessively hot or cold.
• Oral hygiene before and after meals.
• enteral feedings or parenteral nutrition
for those who cannot take orally.
186

DECREASING THE SENSE OF
ISOLATION
• provide an atmosphere of acceptance and
understanding of people with AIDS and their
families and partners.
• Patients are encouraged to express feelings of
isolation and loneliness,
• Providing information about how to protect
themselves and
• others may help patients avoid social isolation.
• Patients, family, and friends must be assured that
AIDS is not spread through casual contact.
• Patients are encouraged to maintain contact with
family, friends, and coworkers and to use local or
national AIDS support groups and hotlines.
• Consultations with mental health counselors
187

MONITORING AND MANAGING POTENTIAL COMPLICATIONS
Opportunistic Infections
• anti-infective agents.
• Report Signs and symptoms of OIs
Respiratory Failure
• The respiratory rate, pattern, abnormal
breath sounds.
• Suctioning and oxygen therapy
• Mechanical ventilation as necessary
188

Cachexia and Wasting
• Assess nutritional and electrolyte status
• help patient to select foods that will replenish
electrolytes, such as oranges and bananas
(potassium) and cheese and soups (sodium).
• A fluid intake of 3 L or more, unless contraindicated,
• administer IV fluids and electrolytes as prescribed.
Side Effects of Medications
• Instruct Patients and their caregivers need to know
which signs and symptoms and report immediately
• planning the medication schedule to promote
adherence to the medication regimen.
189

Teaching Patients Self-Care
• Guidelines about infection and infection control,
medication follow-up care, diet, rest, and activity
• Patients are advised to avoid exposure to others who are
sick or who have been recently vaccinated.
• Patients with AIDS and their sexual partners are strongly
urged to avoid exposure to body fluids during sexual
activities and to use condoms for any form of sexual
intercourse.
• Injection drug use is strongly discouraged
• The importance of avoiding smoking and maintaining a
balance between diet, rest, and exercise is also
emphasized.
• If the patient requires enteral or parenteral nutrition,
instruction is provided to patients and families about how
to administer nutritional therapies at home.
• Patients who are HIV positive or who inject drugs are
instructed not to donate blood.
190

Mortality, AIDS-morbidity and loss to follow-up by current CD4 cell
count among HIV-1 infected adults receiving antiretroviral therapy
in Africa and Asia: data from the ANRS 12222 collaboration
J Acquir Immune Defic Syndr. 2013 Apr 15; 62(5): 555–
561.
• We pooled data from 13 research cohorts in five sub-
Saharan African (Benin, Burkina Faso, Cameroon,
Cote d'Ivoire and Senegal) and two Asian (Cambodia
and Laos) countries. HIV-infected adults (≥18 years)
who received ART in 1998-2008 and had at least one
CD4 count available were eligible. Changes in CD4
counts over time were estimated by a linear mixed
regression. CD4-specific incidence rates were
estimated as the number of first events occurring in a
given CD4 stratum divided by the time spent within the
stratum.
191

Results
• Overall 3,917 adults (62% women) on ART were
followed-up during 10,154 person-years. In the ≤50, 51-
100, 101-200, 201-350, 351-500, 501-650 and
>650/mm3 CD4 cells strata, death rates were: 20.6, 11.8,
6.7, 3.3, 1.8, 0.9 and 0.3 per 100 person-years; AIDS
rates were: 50.5, 32.9, 11.5, 4.8, 2.8, 2.2 and 2.2 per 100
person-years; and loss to follow-up rates were: 4.9, 6.1,
3.5, 3.1, 2.9, 1.7 and 1.2 per 100 person-years,
respectively. Mortality and morbidity were higher during
the first year following ART initiation.
Conclusion
• In these resource-limited settings, death and AIDS rates
remained substantial after ART initiation, even in
individuals with high CD4 cell counts. Ensuring earlier
ART initiation and optimizing case finding and treatment
for AIDS-defining diseases should be seen as priorities.
192

Rates and risk factors associated with the progression of HIV to
AIDS among HIV patients from Zhejiang, China between 2008 and
2012
(AIDS Res Ther. 2015; 12: 32).
• retrospective cohort to identify the specific
factors involved in the progression of human
immunodeficiency virus (HIV) to AIDS
• The AIDS progression rates were 33.9 %
(2008), 33.6 % (2009), 38.1 % (2010), 30.6 %
(2011) and 25.9 % (2012)
• Compared with patients infected with HIV by
homosexual transmission, patients infected
with HIV by heterosexuals transmission or
blood transfusion had a reduced hazard ratio
(HR) for progression to AIDS (heterosexual
transmission: HR = 0.695, 0.524,P = 0.007;
blood transfusion: HR = 0.524, P = 0.015).
193

• Patients with a CD+ T-cell count of 200–
350 cells/mm3 or greater than 350
cells/mm3 were less likely to develop AIDS
following HIV diagnosis than were those
patients without HAART treatment.
• HIV progression to AIDS was affected by
the patient’s age at diagnosis,
transmission routes and baseline CD4+ T-
cell counts. Early HAART treatment in
patients with a higher CD4+ T-cell count 194

references
• Harrison
• Washinton manual of medicine
• Brunner
• Black
• davidson
195

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