AIDS Conference:One World - One HopeHaverfordwest: 14.11.96[Notes taken and webplaced by Ian Hodgson on 17th December 1996] Session 2 - Clinical Diagnosis of HIV disease GP120 and GP41 on protein envelope of CD4 cells are the receptors that attract the HIV. Initial symptoms of fever, sore throat and skin rash can appear within 4 weeks of unprotected sex with a carrier. HIV produces a seroconverting illness: symptoms appear in only 50% of cases, and often means a poor prognosis. Course of the infection: CD4 count = cells per cubic mm, and the usual count is >1000. In an infected person, <200 indicates the necessity for treatment, and <50 represent severe compromisation of the immune system. Manifestation of HIV diseases include:
Treatment = combination of anti-viral drugs [to prevent mutations leading to resistance] Prevention of OI = beginning treatment if CD4 <200, using septrin (for PCP), gancyclovir (for CMV if antibodies raised) General point - on death certificate need to put actual pathology that caused death, not HIV/AIDS (due to confidentiality) Session 3 - Infection control and blood born viruses Mind set required to prevent transmission of blood born virses the same, and therefore applies to HIV, Hep B, C, and others - ?D Sleeping Beauty is an early example of a needlestick injury victim - more modern cases (as least in health care) are via individuals trying to re-sheath needles Protection strategies - * barriers - esp. gloves for blood and body fluids - the recent in the number of people wearing gloves is due to an awareness of HIV and not hep B, though the latter has been around for much longer ! * reporting needlestick injuries and treating as appropriate (at OH/A and E) Sharps injuries can occur with HCW or patients (latter usually via cardiothoracic and gyn. surgery, and dentistry - wherever there are sharp instruments within a confined space) DOH guidelines state that a HCW who is +ve should not take part in traumatic or invasive procedures. Divided carriers into high risk (++ viral bodies) and low risk (++ antibodies). Originally, only high risk were excluded, but in the future the restrictions are likely to apply to all carriers. Hep C (non A/non B) - 10 years old - parenteral route is usual, and while there is a possibility of chronic liver disease following infection, the damage caused by drinking is probably more catastrophic ! Transmission - via blood products; IVDU; sexual (5% risk); mother to baby (5% risk, usually at birth); health care setting (less of a risk than B and HIV, but in Europe cases are in double figures, and 1 cardiothoracic surgeon has passed the virus to a patient) Treatment - interferon; ribovarin (check this ) HIV - elicits fear - needlestick injury should be treated as a medical emergency, and: 1. first aid 2. risk assessment (solid or hollow needle ?; trochar ?) 3. no risk - follow up referral 4. risk - HIV counselling, incident report, blood tests, prophylactic treatment with zidovudine ?? 5. no Z - follow up tests 6. with Z, give within one hour of injury, follow up tests, CDC surveillance [note side effects of zidovudine - nausea, headache, vomiting, aneamia, Seroconversion is rare, though has occurred even with individuals who have taken zidovudine. To maximise preventative effects, a big load of anti-retroviral drugs may be best (research being done in USA) The Florida Dentist ! - spread HIV via a probe, though it was not clear where the probe had been ! He is the only proven case in which HIV has been passed from a HCW to patient. 1100 of the 1800 patient were tested - 8 were found to be HIV +ve, 5 of the 8 had genomes similar to the dentist. DH guidelines (questionable) - HCW who are HIV +ve should not be involved in exposure prone activities; if s/he thinks they may be positive, should get a test; if any other HCW suspects another to be postive, they should report (!!) In future: may be more widespread testing of HCW for HIV; does a HCW demand to have a patient tested following sharps injury; who has repsonsibility for a hospital visitor who suffers a sharps injury. Session 4 - HIV and TB HIV and TB are similar in may ways: both are common in the third world; both have been romanticised in fiction and film; both have involved artists and writers; there is an international day for both New strains of drug resistant TB are emerging; few drugs are effective against HIV TB is now on the increase - in 1993 the WHO stated that TB was again a key global issue. New vectors have been created through increasing world travel that has spread HIV and TB [NB: Bradford has a problem with TB being brought back from Asia] New York has the greatest number of (??) cases of TB in the West, and is also a focus point for HIV TB: reduced since 16thC, but in 20thC - '30s - 35K deaths - '50s - 50K reported - '83 - few reported - '96 - 6k annually Increase prob. associated with poverty, unemployment, homelessness, overcrowding, links to the 3rd world, drug use, immigration, NHS cuts Resistance to drugs: primary = to 1 drug because of spontaneous mutation to 2 or more drugs v. rare (1:10000000000000) secondary = innapropriate therapy or non-compliance Multi-drug resistant TB: Rare until '87, and usually confined to immigrants (90% of cases in West are HIV+ve) Resitance to 2 or more drugs (isoniazid and rifampicin) Portugal and Spain have a serious problem, partly due to poor isolation and increased drug use UK - 0.6% in 1991; 2% in 1994 Spreads in same way as 'normal' TB (ie. via droplet) HIV and MDRTB - can depend on C4 count, and to control infection: * complete isolation (could be up to 4 months) * -ve pressure system * ante-room * telephone * restriction on visitors Problems of depression (because of isolation) and hospitalisation. Role of the nurse is crucial - needs to utilise all communication and counselling skills. Staff exposure: there are cases of transmission to staff, and the bacilus can lay dormant for 10 years; prevention by isolating patient as soon as condition is known, use of masks, heaf/mantoux tests, ?? respirators Prevention of cross infection: usually via inhalation, therefore no need for disinfection; wah and cook as normal; UV lamps can destroy the bacillus; wash nursing and medical equipment between patients. Ethical issues: confidentiality; directly observed therapy (ie. to prevent non-compliance); fears of staff and refusal to care; support and counselling for staff and patient; sexuality - in USA partner is not allowed contact for 3 months. Conclusion * be aware of where an HIV+ve person has been on holiday * education for staff * support and counselling for staff and patients * prevent negative attitudes Session 5 - The Global View Sun Tzu - military strategist writing 2500 years ago - 'Know your enemy to win....' Do we know about all the aspects of HIV ? HIV = leading cause of death between 14 and 49 years in sub-Saharan Africa Economic implications are enormous - with effects on labour creating a diminishing workforce. The four stages to an epidemic are: seeding; dissemination (eg. through military movement); expansion (where suscepible people succomb to the virus); stabilisation. Different parts of the world are at different stages - Western Erope and Asia are at stage 3. Modes of spread are well known - sexual (link between HIV and other STDs, especially ulcer forming); perinatal (though this depends on viral load in the mother) - can be 20% chance of transmission); parenteral (esp. in Spain, Portugal, Brazil and India - the latter 2 places have a 70% HIV+ve IVDU population) Exposure categories: in UK, predominantly male; in World, ratio 3 (male) : 2(female) - by year 2000 will be 1:1 Figures as at 6/96 UK: Main focus = UK in Nth and Sth Thames RHA Heterosexual HIV spread = 5620 - 72% contact with partner abroad; 11% contact with high risk partner (eg. bisexual and IVDU) IVDU spread - age peaks at 25-29, but in New York there are significant cases of people <20 Europe: homosexual activity = main route of transmission Eastern Europe: Russia - glass syringes transmitting virus to 100s children; Roumania - unsterilised needles infected 1000-2000 in 1989 USA: some plateauing (eg. Baltimore); in NY increase in HOV+ve females, especially Hispanics and AfroAmericans Latin Am: HIV increasing among drug users; Brazil = 60% of IVDU +ve; Carribean = heterosexuality = main cause of spread for last 10 years (in some regions 3% of female population = +ve) Aus/NZ: peaked in 1987, and mainly confined to the homosexual population; IVDU spread has reduced due to lack of availability of syringes Sub Saharan Africa: 16m HIV+ve, 50% are female; 1m children; main spread = heterosexual, and is amplified by poverty, military movements and resettlement (especially men moving to areas without their families, and excessive use of casual sex workers, 80% of whom are HOV+ve; AIDS = leading cause of death between 25 and 34 in SSA Asia: HIV appeared late, but developing rapidly India: 5m HIV+ve, explosive in Thailand and Burma, initially in IVDU population, but later in heterosexual activity, with 50% of casual sex workers being HIV+ve in Bombay Factors for explosive spread: increasing industrialisation and economic status; supplying of narcotics in the Golden Triangle then along trade routes; culture denying condom use (eg. young Thai male); ? circumcision; lowly status of women Long term projections and trends: by 2000 26m people will be HIV+ve (90% of whom will be in developing countries) At the June 1996 Vancouver Conference: HIV epidemic = multiple epidemics at different stages; progress has been made (eg. Baltimore; Uganda); care and support is still grossly inadequate Recommendations: focus on women; improve surveillance Session 6 - Nursing Care and AIDS Using RLT nursing model combined with Henderson Respiration: PCP, CMV, TB, KS, nosocomial infection - usual NC Nutrition: HIV increases metabolic rate by 10% - BUT reduced intake due to malabsorption and drug reaction - therefore need hydration and nutrition - cannabis = good anti-emetic Hydration: reduced fluid intake due to lethargy, diarrhoea, nausea and vomiting. Treat conditions as they appear, encourage fluids Elimination: HIV diarrhoea (due to cryptosporidium), UTI, enteric pathological infection, incontinence. Monitor and treat. Mobility: peripheral neuropathy, generalised weakness and muscule wasting. Care with pressure area care, physiotherapy. Hygiene: oral condition often poor (thrush), night sweats, inability to care for own needs, infections. Assess, plus topical medication and regular hygiene. Safe environment: danger = nosocomial infection, need for infection control, injury possible due to mental/physical state. Communication: impaired communication and isolation. Psychological state: anxiety and social isolation, reduced self esteem, depression, dementia, impaired body image. Need for psychological support, time etc. Working and playing: economic hardship, mental and physical problems. Maybe involve social worker, encouraging flexible visiting. Sexuality: HIV = human disease, not homosexual disease. Person may experience homophobia, reduced libido, grief, changes in sexual practice, children. Provide time, support, empathy. Dying: fear, anxiety, bereavement, physical disability. Give honesty - provide opportunity for closure, last offices, living will. NB: Body bag cannot be opened when it has left hospital. HIV/AIDS has had a positive impact on the nursing profession by raising a number of issues. Session 7 - Role of the GP Key elements = GP often cares for people in the last stages of AIDS related illness. PWA often return to their roots and die soon after arriving (eg. 2 days). Use of universal precautions and risk assessment (cannot take blood properly if vein cannot be held because of glove !). |
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