CHAPTER 16. HIV/AIDS
James C. Pace
At the end of the year 2003 approximately 790,000 to 1.2 million Americans were living with human immune deficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and approximately 46 million were living with HIV/AIDS worldwide (World Health Organization, 2003). Prior to the advent of antiretroviral medications (AZT monotherapy first appeared in 1987), HIV/AIDS was viewed as a death sentence—death often occurred less than 1 year after the diagnosis. Once protease inhibitors (PIs) were developed in the mid-1990s, with the concurrent development of highly active antiretroviral therapy (HAART), there were dramatic changes in the trajectory of HIV/AIDS. AIDS-related deaths in the United States declined approximately 70% in the years 1985 through 2001 following the introduction of HAART; death rates from AIDS have only recently begun to show a very slow upward direction due to rapidly developing viral resistance factors (Center for Palliative Care Education, 2003). As a result, post-HAART health care clinicians in HIV/AIDS care have often not been immersed in the historical issues surrounding death and dying as have seasoned clinicians with memories of caring for those with short survival times combined with extremely limited health care options. Since 1997, AIDS has no longer been one of the top 15 causes of death for all age groups combined; however, AIDS remains the fifth leading cause of death among all Americans aged 25 to 40, the leading cause of death among African American men in this age group, and the third leading cause of death among African American women in this age group (Center for Palliative Care Education, 2003).
Currently, HIV/AIDS is perceived as a chronic, manageable disease for those who can take HAART. HIV/AIDS continues to have an unpredictable course, however, related to impaired immune competence, side effects of medications, comorbidities, and issues involving the psychosocial and emotional costs of living with HIV/AIDS (Sherman, 2001). As with other chronic disease states, HIV/AIDS constitutes a continuum of health concerns beginning at initial seroconversion and continuing into its terminal stages. Current statistics reveal that in the absence of therapy, this slowly progressive disease has an average course of 10 to 15 years.
AIDS is often a disease of the disenfranchised and marginalized. In 2004, African Americans accounted for 49% of all AIDS cases although they composed only 13% of the population, and 19% of all AIDS cases occurred in Hispanics although they represented only 14% of the U.S. population (Centers for Disease Control and Prevention [CDC], 2004; Ramirez & de la Cruz, 2003). Many of these patient groups lacked access to medical care, mistrusted the health care system, were involved with the health care of family members to the exclusion of personal health status, or were diagnosed with AIDS during hospitalization when HIV infection was far advanced. It is a well-established fact that minority groups are most often diagnosed with HIV/AIDS later in the disease process than are whites and have significantly greater immunosuppression and symptoms (Sackoff & Shin, 2001). If HAART was made available to many in the above-mentioned groups, adherence was often compromised by such issues as poverty, substance abuse, comorbidities, depression, and lack of sustained support systems (Center for Palliative Care Education, 2003; Jordan, Vaughn, & Hood, 2004). It is important to consider the palliative care implications of HIV/AIDS especially in light of the above scenarios and because HAART therapies are losing their antiviral effectiveness for a select few, are refused entirely by some, and are discontinued by many who tire of the associated pill burden of complex HAART therapies and their often unrelenting drug and metabolic side effects.
PATHOPHYSIOLOGY AND NOMENCLATURE
HIV is a retrovirus that has a particular affinity for the body’s immune system, particularly infecting macrophages and T-lymphocytes (T cells or CD4 cells). Continual destruction of the body’s immune system leaves the body open to more virulent attacks by HIV as well as from opportunistic organisms that would not be able to harm nonimpaired immune systems. Infection with HIV can eventually progress to AIDS. In the term acquired immunodeficiency syndrome, “acquired” means that the illness is not usually inherited from a parent, “immunodeficient” describes the condition of altered immune competence, and “syndrome” means that AIDS cannot be defined by a single disease or illness but rather by a collection of possible health insults. HIV and AIDS are not synonymous terms. HIV describes a living virus; AIDS names a syndrome of health care concerns. Being HIV positive refers to the presence of the virus within a person’s body irregardless of T-cell count; AIDS describes a profound immunocompromised state where the T-cell count falls below 200 cells (or a percentage of <14%) (see below for details). A person can be HIV positive for decades without showing any symptoms of or being diagnosed with AIDS (Sherman, 2001; Zwolski, 2001). Once infected with HIV by means of exposure to infected blood, semen, or bodily fluids, a person will develop antibodies to HIV that can be detected by a blood test. The development of such antibodies may take anywhere from a few weeks to 6 months after exposure. Once antibodies are detected with an HIV test, the person is then diagnosed as being HIV positive.
In 1993, the CDC developed a revised HIV classification system and an expanded AIDS surveillance definition for adolescents and adults. The CDC system provides a clinically based definition of AIDS that includes categories A, B, and C. These categories are briefly summarized as follows (Zwolski, 2001):
▪ Category A includes patients with acute primary HIV illness (acute retroviral syndrome), asymptomatic HIV infection, or persistent generalized lymphadenopathy.
▪ Category B includes a number of symptomatic conditions that are either directly attributable to HIV infection or have a clinical course or management complicated by the presence of HIV. Examples of these symptomatic conditions include oropharyngeal candidiasis, vulvovaginal candidiasis, constitutional symptoms to include fever and diarrhea, herpes zoster, oral hairy leukoplakia, pelvic inflammatory disease, peripheral neuropathy, and cervical dysplasia.
▪ Category C comprises AIDS indicator conditions, including bronchial, tracheal, pulmonary, or esophageal candidiasis; invasive cervical cancer; cryptococcosis; cryptosporidiosis; cytomegalovirus disease (CMV, including CMV retinitis); encephalopathy; persistent herpes simplex (HSV); Kaposi’s sarcoma; lymphomas (Burkitt’s, immunoblastic, primary of brain); Mycobacterium avium complex (MAC) and Mycobacterium tuberculosis; Pneumocystis jiroveci (formerly carinii) pneumonia (PCP); toxoplasmosis of brain; and HIV wasting disease.
TRAJECTORY AND ASSOCIATED CLINICAL SYMPTOMS
Primary HIV infection (acute retroviral syndrome), the period immediately after infection with HIV (2 to 8 weeks), is characterized by high levels of viremia and is accompanied by such symptoms as fever (97%), myalgia or arthralgia (58%), lethargy and malaise (common), lymphadenopathy (70%, particularly in the groin and head and neck), pharyngitis (73%), and an erythematous, nonpruritic, maculopapular rash affecting most often the face or trunk (70%).
Chronic HIV infection is divided into categories based on the CD4 count:
▪ Early: CD4 count > 500. Although the virus is actively reproducing at this stage, there is generally a period of clinical latency in terms of visible symptoms. Minor infections may take longer times to heal, depending upon the patient. Patients often report symptoms such as mild diarrhea, cough, fatigue, night sweats, minor skin rashes, weight loss, oral problems, and persistent or recurrent vaginal yeast infections.
▪ Middle (intermediate): CD4 count 200 to 500. Features present in early HIV disease often worsen (e.g., diarrhea, recurrent HSV, oral or vaginal candidiasis). There is an increased incidence of bacterial infections of sinuses, respiratory tract, and skin; there is also an increased disruption of lymphoid tissue.
▪ Late (AIDS): CD4 count < 200. Appearance of opportunistic infections—any or a combination of the AIDS indicator conditions as described by CDC (see category C on p. 234). Lymphoid tissue is mostly replaced by fibroid tissue (Sherman, 2001; Zwolski, 2001).
DIAGNOSTICS AND ASSESSMENT
HIV-positive status is tested by means of an ELISA (enzyme-linked immunosorbent assay) (which measures antibody to HIV) and, if reactive, is then confirmed with the Western blot. Once positive status is documented, the clinician looks at various laboratory diagnostic tools for the establishment of a long-term treatment plan that includes medical management combined with nutritional, emotional, and behavioral health supportive care.
▪ CD4 cell count or percentage: A normal CD4 count is 600 to 1200 cells per microliter (or 30% to 60%). AIDS is diagnosed when the CD4 cell count drops below 200 (<14%). At this time, prophylaxis against various opportunistic infections (PCP, cryptococci, MAC) should be initiated (Table 16-1).
| CMV, Cytomegalovirus; HAV, hepatitis A virus; HBc, hepatitis B core antibody; HBV, hepatitis B virus; MAC, | ||
| Mycobacterium avium complex; PCP, Pneumocystis jiroveci (formerly carinii) pneumonia; TB, tuberculosis; TMP-SMX, trimethoprim-sulfamethoxazole. | ||
| Pathogen | Indication | First Choice |
|---|---|---|
| PCP | CD4 <200 | TMP-SMX |
| Toxoplasmosis | CD4 <100 | TMP-SMX |
| MAC | CD4 <50 | Azithromycin or clarithromycin |
| CMV | Secondary prophylaxis | Ganciclovir |
| Valganciclovir | ||
| Foscarnet | ||
| Cidofovir | ||
| Cryptococcosis | Secondary prophylaxis after history of cryptococcal meningitis | Fluconazole |
| Tuberculosis | Positive PPD (≥5 mm induration) | INH |
| Recent contact with TB case | ||
| History of inadequately treated TB | ||
| Streptococcus pneumoniae | All patients | Pneumovax |
| HBV | Antibody HBc negative | HBV vaccine series |
| Influenza | ||
