Exam 1: HIV

Question 1

Cell Mediated Immunity (5)

Answer 1

1. Protect against viruses, fungi, and slowly developing bacterial infections (TB)
2. Immune surveillance for malignant cells
3. Timing of response in delayed hypersensitivity reactions (PPD)
4. Rejections of foreign grafts
5. Achieves full function early in life (Helper cells fully developed by 6 yrs. of age)

Question 2

HIV

Answer 2

Acquired cell-mediated immunodeficiency disorder, affects CD4 helper cells
Etiology
*horizontal transmission: sexual transmission, IV usage, etc.
*vertical transmission: from mother to infant

Vertical transmission is decreased with use of ZDV during pregnancy of HIV infected women; there is only 1% ocurrence of it now

Question 3

HIV Pathophysiology

Answer 3

Retrovirus composed of RNA and enzyme reverse transcriptase

1st: Virus gains access into CD4+ cell
2nd: With in cell, reverse transcriptase causes synthesis of HIV DNA
3rd: Integrates with CD4+ cell’s DNA & virus causes CD4+ cell to make more of itself
4th: New virus assembles @ host’s cell surface as they bud through cell membrane, viruses mature and are releases, infecting other CD4+ cells

Results in cell death

Question 4

HIV: Clinical Manifestations (7)

Answer 4

1. Lymphadenopathy
2. Hepatospleenomegaly
3. Oral candidiasis
4. Chronic or recurrent diarrhea
5. Failure to thrive (not developing or growing normally)
6. Developmental delays
7. Parotitis (enlarged gland, gets swollen and inflamed and is very painful)

*Mainly occurs because CD4 cells can no longer do their job

Question 5

HIV: Difference between children and adults (4)

Answer 5

1. Shorter time from infection and AIDS diagnosis
   
   • *Children can develop AIDS in less than a year if positive at birth if they don’t receive any treatment (adults can be up to 10 years)
2. Signs may be physical and developmental failure to thrive
3. Experience earlier opportunistic infections & greater number of bacterial infections from childhood illnesses
4. Perinatally acquired – PCP (Pneumocystis Carineri Pneumonia) can occur much earlier than HIV+ adults. As a result, prophylaxis are started as early as 2 months of age.
   * Adults have longer time of PCP onset
   * Children can get PCP at 4-6 weeks, so start PCP prophylaxis until tests say negative if mother is HIV+!

Question 6

HIV Diagnosis

Answer 6

ELISA or Western blot is not accurate in infants younger than 18 months

USE: HIV DNA – PCR test

• (+) results on 2 separate blood specimens (at birth, at 1-2 months, and at 4-6 months)
• 95% of infected infants diagnosed by 1-3 months

Question 7

Testing for HIV exposed infant with HIV(-) screening results

Answer 7

If screening is negative, repeat at 1-2 months and again at 4-6 months of age.

May confirm absence of HIV infection with HIV antibody assay testing at 12-18 months of age

Question 8

HIV: Clinical Staging (what are the 4 dif stages)

Answer 8

Stage N (infected but not symptomatic)

Stage A (mild symptoms)

Stage B (moderate symptoms)

Stage C (severe symptoms)

Question 9

HIV: Immunological Staging

Answer 9

Stage 1 (no evidence of suppression)

Stage 2 ( evidence of moderate suppression)

Stage 3 (sever suppression)

Question 10

Indicators of AIDS in Children under 13 (11)

Answer 10

1. LIP (Lymphoid Interstitial Pneumonia); similar symptoms to asthma, a reaction the lungs have to a type of infection
2. Serious bacterial infections
3. PCP (pneumonia)
4. CMV (citomegalovirus); not dangerous in healthy people but can cause mono in young children
   * **THIS IS VERY DANGEROUS FOR SOMEONE WHO IS IMMUNOSUPPRESSED
5. Encephalopathy
6. Wasting Syndrome
7. Candidal espophagitis (can get it in lungs, GI tract, etc)
8. Pulmonary candidiasis
9. Herpes simplex disease
10. Cryptosporidiosis (type of parasite)
11. Mycobacterium Avium-Intracellulare Complex infection

Question 11

CD4+ counts and HIV RNA

Answer 11

1. Assess infected immune system’s response to therapy, risk for disease progression and need for PCP prophylaxis after 1 yr. of age
2. Measure when clinically stable
3. Normally higher in children than adults
4. CD4+% have less measurable variability

Question 12

HIV Management (4: know by heart)

Answer 12

1. Elective Cesarean delivery before onset of labor and before rupture of membranes for women with an HIV viral load of > 1000 copies/ml.
   * If less than 1,000 copies/mL then she can have normal vaginal birth
2. Administration of antiretroviral prophylaxis (ZDV) during pregnancy and labor and to the infant for 6 weeks after birth.
   * Highly effective
   * If mother is HIV+ and hasn’t been taking ZDV, then give post-exposure prophylaxis/IV infusion of ZDV during labor and delivery to diminish transmission
3. Complete avoidance of breastfeeding in U.S.
   
   • In third world countries, must strictly breastfeed
4. PCP prophylaxis @ 4-6 weeks of age and continues until 1 yr. of age or determined to be HIV (-) (Trimethoprine-sulfamethoxazole)
   * PCP prophylaxis= Bactrim

Question 13

Facts about Adolescent HIV (2)

Answer 13

1. Percentage of total HIV/AIDS cases among 13-19 year olds has more than quadrupled from 1985 – 2004.
2. More than 50% of HIV infected adolescents in the United States are unaware of their infection.

Question 14

HIV: Drug Dosing for Adolescents (3)

Answer 14

1. Based on tanner stages
   * Tanner 1 and 2 – Give pediatric dosing
   * Tanner 3-5 – Adult dosing
2. Know if it is perinatal acquired vs new onset
   - -> This is because the longer you have the disease, the higher chance you have of non-adherence and then resistance can arise to all drugs in the category
3. Pregnancy dosing: know whether or not the medication you are giving is safe for pregnant women
   UNSAFE MEDICATION= EFAVIRANEZ (causes congenital abnormalities)

Question 15

CDC recommendations for HIV testing in all patients 13 to 64 years of age.

Answer 15

BOTTOM LINE= NEW RECOMMENDATION IS THAT EVERYONE GETS TESTED FOR HIV UNLESS THEY SAY THEY DO NOT WANT TO BE TESTED

Question 16

Goals of HIV Therapy (5)

Answer 16

1. Slowing growth of HIV
2. Promoting or restoring normal growth and development
3. Preventing complicating infections and cancers (there is an increased risk of lymphoma in adolescents with HIV)
4. Improving quality of life
5. Prolonging survival

*A lot of children with vertical transmitted HIV will be in the hospital not because of the HIV but because of lymphoma they have developed secondary to the HIV

Question 17

Antiretroviral Therapy Goal

Answer 17

maximum suppression of viral replication in an attempt to preserve immune function and delay disease progression

Question 18

Antiretroviral Therapy HAART

Answer 18

Highly active antiretroviral therapy (dosage in adolescents based on Tanner stage)

*Medication may be changed in response to worsening immune function, mild intolerance, toxicity or development of newer or better regime.

Question 19

Types of HIV Medications with commonly use regime

Answer 19

1. Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
2. Protease inhibitors
3. Non-Nucleoside Reverse Transcriptase Inhibitors

Regime: 2(NRTI) + PI or NNRRTI

Question 20

Nucleoside Reverse Transcriptase Inhibitors (NRTIs)

Answer 20

Targets the reverse transcriptase phase

Includes 2 nucleoside analogs

• ZDV (zidovudine) & ddl (didanosine)

Question 21

Protease Inhibitors

Answer 21

Targets replication @ different phase

*Retonavir, nelfinavir

Question 22

Non-Nucleoside Reverse Transcriptase Inhibitors

Answer 22

Blocks HIV protein reverse transcriptase
* Nivirapine, efavirenz

EFAVIRENZ IS NOT SAFE WITH PREGNANCY; if someone is on it then they need to take pregnancy tests frequently

Question 23

Side Effects of HIV Medication (8)

Answer 23

1. Nausea, Vomiting
2. Headache
3. Diarrhea
4. Anorexia
5. Rash
6. Fever
7. Abdominal pain
8. Anemia

*Side effects are another reason that people are non-adherent

Question 24

When to initiate combination therapy

Answer 24

With HIV infected infants younger than 1 yr. as soon as diagnosis confirmed

• As soon as 4-6 months old test comes back +, infant should be started on combination therapy
• If test is negative then take infant off ZDV and do not start combination therapy

Question 25

Treatment for Asymptomatic HIV Infected Children Older than 1 yr.

Answer 25

Defer treatment for those with normal immune status, a low viral load and medical compliance risk * need frequent monitoring of virologic, immunologic and clinical status * Treatment is delayed due to the risk of non-adherence and developing resistance to treatment

Question 26

Prophylactic Medications (4)

Answer 26

1. For PCP: Trimethoprim-sulfamethoxazole 2. For Candidiasis, Herpes Simplex, and MAC: IVIG (monthly infusion) 3. For LIP: Corticosteroids 4. Immunizations

Question 27

Medication Adherence (with 5 Barriers)

Answer 27

Failure results in development of drug resistance & treatment failure Barriers: 1. palatability 2. adjusting medication routine to existing routines 3. denial 4. embarrassment with diagnosis 5. financial

Question 28

Nursing Dx for Adolescent HIV

Answer 28

1. Deficit knowledge 2. Risk for Infection 3. Imbalanced nutrition 4. Impaired Gas exchange 5. Ineffective airway clearance 6. Risk for impaired skin integrity 7. Delayed growth & development 8. Acute & chronic pain 9. Anxiety 10. Ineffective Therapeutic Regimen

Question 29

T Helper Cells

Answer 29

CD4+ Cells Secrete cytokines and stimulate B cells *Affected cells from HIV

Question 30

How does HIV look on electron microscope image

Answer 30

Small spheres on surface of white blood cells

Question 31

Category N

Answer 31

Not Symptomatic Children who have no signs or symptoms considered to be the result of HIV infection OR who have only one of the conditions listed in category A *Would defer treatment in this case

Question 32

Category A

Answer 32

Mildly Symptomatic Two or more of the following conditions (and none from category B or C) 1. Lymphadenopathy 2. Hepatomegaly 3. Splenomegaly 4. Dermatitis 5. Parotitis 6. Recurrent or persistent upper respiratory infection, sinusitis, or otitis media

Question 33

Category B

Answer 33

Moderately Symptomatic Symptomatic conditions other than those listed in category A or C, that are attributed to HIV Some examples: Anemia, pneumonia or sepsis (single episode), meningitis, candidiadis, hepatitis, HSV, herpes, nephropathy, varicella, fever lasting >1 month *LIP is in this category

Question 34

Category C

Answer 34

Severely Symptomatic AIDS CATEGORY

Question 35

Immunological Staging

Answer 35

Stage 1: No evidence of suppression Stage 2: evidence of moderate suppression Stage 3: severe suppression; AIDS * This staging is dependent on the age of the child! (dif from how adults get staged) * Based on CD4+ Cell Count and Percentage

Question 36

Immunological Staging, Stage 1

Answer 36

1,500 or >25% 1-5 years: >1,000 or >25% 6-12 years: >500 or >25% *Would defer treatment in this case

Question 37

Immunological Staging, Stage 2

Question 38

Immunological Staging, Stage 3

Question 39

Myobacterium Avium Intracellular Complex Infection

Answer 39

"MAC" One of the most severe indicators of AIDS in children * A non-TB lung infection that has very similar characteristics as TB * Can present with a rash and papillary/nodular lesions on body Child will be VERY SICK with this

Question 40

When to defer treatment

Answer 40

1-5 years old: if patient is asymptomatic or mild symptoms and has CD4 >25% AND HIV RNA 5 years old: asymptomatic or mild symptoms and CD4 >350 AND HIV RNA

Question 41

Immunizations for HIV+ Adolescents

Answer 41

HIV+ children get immunizations, but not all of them If total CD4 count is equal to or less than 15%, then give immunizations other than live virus ones, which are: 1. Varicella for chicken pox 2. MMR 3. Flumis *If count is above 15% then give all immunizations