HIV: Prevention and Transmission

HIV Pathophysiology

• HIV is a ribonucleic acid virus, classified as a retrovirus due to its unique replication process from RNA to DNA.
• HIV's target cell is the CD4+ T cell, a type of lymphocyte.
• The virus binds to these cells leading to a decrease in immune function.
• Immune problems typically start when CD4+ T cell counts drop below 500 cells/µL.
• Severe issues arise when levels fall under 200 cells/µL.
• The normal CD4+ T cell range is 800 to 1200 cells/µL.
• A deficient immune response leads to opportunistic diseases.
• The point is eventually reached when so many CD4+ T cells have been destroyed that not enough remain to regulate immune responses
• Patients often succumb to conditions like pneumonia, cytomegalovirus, or varicella zoster.

HIV Health Promotion

• Preventing HIV involves abstaining from or decreasing risks associated with sexual intercourse and drug use.
• Safe sexual practices aim to eliminate risk, while risk-reducing activities lower it.
• Strategies include abstinence, noncontact safe sex, using barriers, and leveraging social support networks.
• For drug use, emphasize abstinence, avoiding shared equipment, and avoiding impaired states during sexual activity.
• Referral for substance use support is also a method for prevention.
• Needle and syringe exchange programs also reduce HIV occurrences.

HIV Workplace and Infection Control

• Preventing HIV transmission in the workplace involves decreasing risk by adhering to precautions and safety measures.
• Post-exposure prophylaxis with combination ART can significantly decrease the risk of infection.
• Nurses should never recap used needles.
• The occupational risk of HIV infection is small but real.
• Post-exposure prophylaxis with combination ART is important should exposure to HIV-infected fluids occur.

HIV Lab Testing

• Monitoring HIV progression involves assessing CD4+ T-cell counts and viral load.
• CD4+ T-cell count serves as an immune function marker.
• Viral load indicates disease activity; the lower the viral load, the less active the disease.
• An "undetectable" viral load means levels are beneath commercial assay detection limits.
• It does not mean the virus is eliminated, just that the viral load is below the level of detection on a commercial assay
• As HIV progresses, numbers of CD4+ T cells typically decrease.
• The normal range for CD4+ T cells is 800 to 1200 cells/μL.
• Viral loads are reported as numbers, and treatment aims to suppress the viral load to undetectable levels.
• "Undetectable" means the circulating HIV amount is below test detection levels, but the individual can still transmit the virus.

TB Treatment Regimen

• Treatment is aggressive and occurs in two phases: initial (8 weeks) and continuation (18 weeks).
• The four-drug regimen consists of Isoniazid, Rifampin (Rifadin), Pyrazinamide, and Ethambutol.
• Treatment lasts 6-9 months.
• Patients require education on side effects and when to seek care.
• Liver function should be monitored.
• Alternatives are available for toxic reactions.
• Directly observed therapy (DOT) addresses noncompliance, ensures adherence, and is essential in combating multi-drug resistance.
• DOT involves healthcare workers watching the patient swallow medications and may be done at a clinic site.

Latent TB Infection

• LTBI drug therapy helps prevent active TB development, usually requiring just one drug because there are fewer bacteria.

TB Treatment Options

• Standard treatment is 9 months of daily Isoniazid, an effective, inexpensive, oral medication.
• A 9-month regimen is more effective, but a 6-month regimen may improve patient compliance.
• A 9-month Isoniazid therapy is recommended for HIV patients or those with fibrotic lesions.
• An alternative 3-month regimen of Isoniazid + rifapentine is available for healthy, non-drug-resistant TB patients.
• A 4-month regimen with rifampin is used for Isoniazid-resistant patients.
• CDC warns that Rifampin + pyrazinamide can cause liver injury and is not recommended for LTBI.
• A live Mycobacterium bovis vaccine is used in high-TB areas for infants.
• Due to low TB risk and variable effectiveness, the BCG vaccine is rarely recommended in the U.S. and can interfere with TB skin tests.
• The BCG vaccine may be considered for select individuals, like healthcare workers exposed to MDR-TB.
• BCG can cause false-positive TST, but IGRA results remain unaffected.

TB Etiology Considerations

• Tuberculosis is usually caused by airborne particles.
• It is the leading cause of death in patients with HIV.
• The transmission of TB requires close, frequent, or prolonged exposure to the bacteria.
• These particles can remain suspended in the air for minutes to hours.
• After entering the body, the TB particles lodge themselves in the bronchioles and alveoli.
• Unlike some other diseases, Tuberculosis is not spread by touching, sharing food utensils, kissing, or other physical contact
• A local inflammatory reaction occurs, causing a Ghon lesion that represents a calcified TB granuloma. (HALLMARK OF TB)
• Infection is walled off, and further spread is stopped
• Only 5%-10% of those infected will develop active TB.
• The TB bacteria is aerophilic (oxygen-loving), causing an affinity for the lungs.
• Infection can spread via lymphatics and grow in other organs, like the cerebral cortex, spine, epiphyses of the bone, and adrenal glands.

Risk Factors for TB

• Factors like homelessness, inner-city residence, foreign origin, institutional living, IV drug use, poverty, or immunosuppression heighten TB risk.

TB Classification

• Primary infection occurs when bacteria are inhaled and inflammation starts.
• Encapsulation usually results with no disease progression.
• Latent TB infection means infected but no active disease, a positive skin test, mandatory treatment, and potential progression if conditions are right.

Tuberculosis Symptoms

• LTBI is asymptomatic.
• Pulmonary TB takes 2-3 weeks for symptoms to develop.
• The initial symptom of TB is a dry cough that becomes productive.
• Common constitutional symptoms: fatigue/lethargy, malaise, anorexia, weight loss, low-grade fever, night sweats.
• Dyspnea and hemoptysis are late symptoms.

Tuberculin Skin Test

• Also known as the Mantoux test.
• It involves injecting purified protein derivative (PPD) intradermally.
• Assess for induration in 48–72 hours.
• A presence of induration (not redness) at injection site indicates patients exposure to TB, but doesn't indicate active disease.
• Once the patient is positive for TB, the test will remain positive for life.
• Positive if ≥ 15 mm induration in low-risk individuals,
• • Response decreased in immunocompromised patients; reactions ≥5 mm considered positive

Hepatitis Types

• *ALT alanine aminotransferase enzyme that converts protein into energy
• *AST Aspartate aminotransferase, an enzyme found in the liver, heart, muscles

Hepatitis: Acute vs Chronic

• Acute well balanced diet (high in carbs, low in protein and fat), Rest (reduces the bodies demands on the liver and allows for liver cell regeneration), restrict from donating blood, avoid alcohol and drugs detoxified by the liver
• Chronic: Well balanced diet (high in carbs, low in protein and fat), Rest (reduces the bodies demands on the liver and allows for liver cell regeneration, restrict from donating blood, avoid alcohol and drugs detoxified by the liver

Hepatitis Monitoring

• Elevated ALT, AST, Ascites
• Bleeding problems
• Fatigue/malaise
• Hepatomegaly
• Jaundice
• Joint and muscle pain
• Spider angiomas

Viral Hepatitis Types

• Hepatitis A (HAV) causes mild flu-like symptoms and jaundice. It is self-limiting.
• It is transmitted through the fecal-oral route, most infectious during 2 weeks before symptom onset and infectious until 1-2 weeks after the start of symptoms.
• Hepatitis B (HBV) may cause acute or chronic hepatitis and is a blood-borne pathogen.
• It is infectious before and after symptoms, and carriers continue being infectious.
• Hep C Results in acute and chronic hepatitis, no vaccine
• Hep C S/S are generally mild making people unaware they're infected
• Hep C incubates in 14-180 days, avg. 56

Considerations for Heart Failure

• Anything that disrupts preload, afterload, contractility, or heart rate can cause heart failure.
• Conditions that directly damage the heart
• Conditions that increase the workload of the ventricles

Main Causes of Heart Failure

• Primary causes: coronary artery disease, hypertension, rheumatic heart disease, congenital heart defects, pulmonary hypertension, cardiomyopathy, hyperthyroidism, valvular disorders, myocarditis.
• Precipitating causes: anemia, infection, thyrotoxicosis/hypothyroidism, dysrhythmias, bacterial endocarditis, pulmonary embolism, Paget's disease, nutritional deficiencies, hypervolemia.

Clinical Manifestations of Heart Failure

• Manifestations are dependent on age, underlying type and extent of heart disease, and which ventricle is affected.
• FACES: Fatigue, Limitation of Activities, Chest congestion/cough, Edema, Shortness of breath.
• Chronic Clinical Manifestations: fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachycardia, cough, palpitations.
• Chronic Later Clinical Manifestations: edema, skin changes, mental/behavioral changes, chest pain, weight changes, pleural effusion, dysrhythmias, left ventricular thrombus, hepatomegaly, renal failure, nocturia.

Heart Failure Treatments

• The CardioMems system monitors a patient's pulmonary pressures using a device implanted distal to the pulmonary artery during a right-heart catheterization.
• This device is for NYHA Class III HF patients.
• Patients with <35% EF have increased ventricular tachycardia or fibrillation.
• An ICD is recommended for these patients for SCD prophylaxis.
• Neurohormonal effects and cardiac remodeling in HF can result in dyssynchrony of the LV and RV.
• Biventricular pacing, or cardiac resynchronization therapy (CRT), is recommended for these patients; An extra pacing lead is placed to coordinate right and left ventricular contraction.

Cardiac Rhythm Observations

• Normal sinus starts in the SA node at a rate of 60-100 bpm.
• Sinus bradycardia pathway is same as normal sinus, only at a rate less than 60 bmp; a permanent pacemaker is placed.
• Sinus tachycardia pathway is same as normal sinus, only at a rate of 101-180 bmp

Meniere's Disease

• Disorder of the inter ear causes accumulation of excess endolymph in the membranous labyrinth
• This builds up and ruptures
• Then the High-K+ endolymph mixes with Low-K+ perilymph
• Can lead to episodic vertigo, tinnitus, hearing loss, and aural fullness
• Triggers sudden attacks of vertigo, feelings, dropping, or whirling.
• Patients must learn to live with its unpredictability.
• This condition can be extremely debilitating
• Patients need supportive nursing care following surgical intervention.

Eye Injury

• Eye Injury Intervention includes:
• Ensure ABC's
• Ocular irrigations immediately assess for chemical exposure
• Asses visual acuity
• No pressure on eye
• Interprofessional Care; Oral/IV hyperosmotic, Laser peripheral iridotomy/Surgical iridectomy

Glaucoma

• Acute angle-closure glaucoma is an ocular emergency.
• Treatments involve miotics and oral or IV hyperosmotic agents like glycerin liquid (Ophthalgan).
• Isosorbide solution (Ismotic) and mannitol solution (Osmitrol) are usually successful in immediately lowering the IOP.
• Miotics and oral or IV hyperosmotic agents including glycerin liquid (Ophthalgan), isosorbide solution (Ismotic), and mannitol solution (Osmitrol) are usually successful in immediately lowering the IOP. Examples of miotics include pilocarpine, acetylcholine.
• Primary open-angle glaucoma (POAG) is the most common type
• Outflow of aqueous humor is↓ in trabecular meshwork Like a "clogged drain" • Primary angle-closure glaucoma (PACG) is the Angle closure the flow of aqueous humor: Caused by age, pupil dilation: Possibly drug induced

Cataract

• Opacity within the lens
• May occur in one or both eyes
• Influencing factors: Age, Blunt trauma, Congenital factors, radiation/UV exposure, long term corticosteroid use, ocular inflammation Cataracts clinical manifestations: • Decrease in vision, Abnormal color perception: Glaring of vision: Significantly worse at night
• Visual decline is gradual, but the rate of cataract development varies by patient.
• The patient will receive dilating drops and a nonsteroidal antiinflammatory eye drop to reduce inflammation. An a-adrenergic agonist that produces pupillary dilation by contraction of the iris dilator muscle. One type of drug used for dilation is a mydriatic, an a-adrenergic agonist that produces pupillary dilation by contraction of the iris dilator muscle. • Another type of drug is cycloplegic, an anticholinergic agent that produces paralysis of accommodation (cycloplegia) by blocking the effect of acetylcholine on the ciliary body muscles.

Rheumatoid Arthritis vs Osteoarthritis

• The joints are painful and stiff and appear warm, tender, and swollen with fluid.
• Blood tests confirming RA show widespread inflammation that affects the body in general, often causing anemia, weight loss, and fatigue.
• X-ray images in rheumatoid arthritis show bones that are thin and eroded.

Rheumatoid Arthritis Manifestations

• Typical distortions of the hand include ulnar drift ("zigzag deformity”), swan neck, and boutonnière deformities: RA: CLINICAL MANIFESTATIONS, EXTRA ARTICULAR MANIFESTATIONS • Rheumatoid nodules develop in about half the patients with RA. These nodules appear subcutaneously as firm, nontender, granuloma-type masses. They are often located on bony areas exposed to pressure, such as fingers and elbows. Nodules at the base of the spine and back of the head are common in older adults. Treatment is usually not needed. However, these nodules can break down, similar to pressure ulcers. Cataracts and vision loss can result from scleral nodules. Sjögren's syndrome

Gout

• This condition is a type of recurring acute arthritis characterized by the accumulation of uric acid crystals in one or more joints.
• Gout is caused by an increase in uric acid production, under excretion of uric acid, or increased intake of foods containing purines, which are metabolized to uric acid by the body.
• Risk factors include obesity and excessive alcohol consumption.
• Sardines, herring, mussels, liver, kidney, goose, venison, sweetbreads (organ meats) Bacon, pork, beef, ham Alcohol is high in purine and obesity increases serum uric acid levels and decreases renal excretion of urate: MANIFESTATIONS: GOUT • Acute phase, arthritic pain, Occurs in one or more joints Usually less. Than 4 Triggers

Systemic Lupus Erythematosis

• Lupus is marked by an unpredictable cause with alternating times of remissions and worsening disease and a complex disorder of multifactorial origin
• It is more common in african americans than in whites, usually manifested by dermatologic skin problems
• Severe skin reactions can occur in people who are sensitive to sunlight (photosensitivity)
• Can cause increased susceptibility to infections caused by the defects with ability to phagocytizes bacterias

Explore effective strategies for HIV prevention, including harm reduction for injection drug users and post-exposure protocols. Understand viral load, risk reduction during sexual activity, and implications of declining CD4+ T-cell counts. Identify activities with the lowest risk of HIV transmission.