KAYLEE MCBRAYER, DIETETIC INTERNAPRIL 22 , 2015

NUTRITION IN HIV AND END STAGE AIDS

Part 1 Part 2

Disease StateHistory3 Ts Nutrition &

HIV/AIDSBarriersRelevant Research

Patient CJNutrition Care PlanOutcome Conclusion

Overview

PART 1

WHAT IS HIV

CD4 or “HELPER” T CELLS

LymphocyteReleases CytokinesWorks with CD8

Cells & B Cells

WHAT IS AIDS?

Acquired Immunodeficiency SyndromeFinal Stage of HIVCD4 count is <200 cells/mm3 AND/OR1 Opportunistic Infection (OI)High Viral Load in Blood*

It is false to think that everyone who has HIV will get AIDS

AIDS DEFINING OI’s

Candidiasis *Cervical CancerCoccidioidomycosisCryptoccosisCrytosporidiosisCMV RetinitisHIV EncephalopathyChronic Herpes SimplexHistoplasmosisIsosporiasisLymphoma

Kaposi’s Sarcoma *Mycobacterium Avium

Complex *TuberculosisPneumocystis Carinii

Pneumonia (PCP) *Recurrent Pneumonia *Progressive

LuekoencephalopathySalmonella SepticemiaToxoplasmosisHIV Wasting Syndrome *

AIDS DEFINING OIs

HISTORY

1884-1924

1966/1970

1981/1982

1983/1984

1990

1996

2012

Today

HIV is no longer a death sentence, dealing with new HIV health complications

STATS/ PROGNOSIS

1,201,100 aged 13 and older living with HIV

# of ppl living increases but infection rate is stable

MSM most effected (in US), African American MSM, African Americans

2013- 47,352 diagnosed

Prognosis is individual

3 Ts - TRANSMISSION

TRUE HIV can’t survive for long in air Blood Sex Secretions/Delicate

Membranes Breastmilk* Spinal Cord Fluids HIV has to get into bloodstream

NOT TRUE Daily Activities Animals Human Touch Kissing HAART Therapy = Safe

3 T’s TRANSMISSION

1. HIV is carried to CD4

2. Binding & Fusion3. Reverse

Transcription4. Integration5. Transcription6. Assembly7. Budding8. Cycle RepeatsThis concept is important because

of HAART

3Ts -TREATMENT

HAART THERAPYPrEPoPEPnPEP

5 Different HIV drug classes

Generally take 3 ART drugs from 2 classes

Important for Drug Resistance

Genotype/ Phenotype Testing

Can be complicatedMANY interactionsMANY side-effects

3Ts-THERAPY

Mental HealthNutrition TherapyEmotional Support

COMPLIANCE BARRIERS

Side Effects of DrugsSchedulingSize of PillAIDS StigmaFear of Seeking Healthcare“Sentenced” to MedsCAMReligion/ Conspiracy TheoriesCentral Nervous System IssuesSupport

NUTRITION IN HIV

Nutrition & ImmunityPreserve Lean Body Mass Aid with LipodystrophyPrevent/Reverse

DeficienciesFood SecurityFood SafetyQuality of LifeSupport Medication

RegimenCAMComorbidities and Meds

LIPODYSTROPHY

Lipohypertrophy – More common with womenLipoatrophy – More common with men

NUTRITION RELATED SIDE EFFECTS

Metabolic ChangesInsulin ResistanceNauseaVomitingDiarrhea/

MalabsorptionLoss of AppetiteBone Mineral DensitySwallowing

Ability/Sores

Mitochondrial ToxicitiesHormone Changes

KEY NUTRIENTS

Multivitamins & Trace ElementsB-Vitamins Vitamin C, E, ASeleniumZincIronCalcium/ Vitamin D/ Phosphorous

ADDITIONAL SUPPLEMENTS OF BENEFIT*

ProbioticsWhey ProteinAntioxidantsAlpha Lipoic AcidN-Acetyl Cysteine

ACADEMY POSITION PAPER SUMMARY, 2010

Prevent & reverse wt loss and wasting

Maintain energy balance ALWAYS support

medication goals Physical Activity No evidence of

supplementation effecting morbidity or mortality

MCT aids with fewer stools/absorbtion

BMI, protein stores, wt loss of any kind, LBM

HIV increases REE Higher Protein Diets seem

to be beneficial Fiber intake Alterations of zinc, Fe, Se,

B-vitamins, CHO, Fat may be shunted in HIV whether altered metabolism or inflammatory response or both

RESEARCH # 1

RESEARCH #1

RESEARCH # 2

RESEARCH #2

NUTRITION CARE PROCESS IN END STAGE AIDS

PATIENT CJ

PART 2

HOSPITAL COURSE OVERVIEW

LOS – 10 DaysInitial Assessment (Screen & Consult)2 Follow Ups, Visited OftenNutrition Education – Very Limited

Patient Overview

22 y/o MEthnicity UnknownAdmit for SOB, Coughing w/ Sputum,

Hypoxia, Tachycardia, Severe Respiratory Distress

Recent Hospitalization at University for PCP PNA

At ER, Disclosed not taking PCP or HAART Therapy

Unsure of last CD4 count or Viral LoadIntial Dx: Respiratory Failure/Distress

Patient Overview, cont.

PCP PNA* – recurrent*, on steroidsEsophageal Thrush*AIDS Cachexia, 15 lb wt loss in 2 mos.*Swallowing Difficulties, not taking oral medsConstipation

Medical History & Social Background

HIV+ (AIDS)Bipolar disorder, depression, no drug or

alcohol abuse, cachexia, insomniaUnemployedLives w/ Brother, who is deaf

ANTHROPOMETRICS

63 inches32 kgBMI: 12.5% IBW: 57IBW: 56 kg82% of Usual BW, UBW: 39 kg% Wt Loss: Severe

LAB DATA

LAB Value NormalGlucose 129BUN 6Na 134HCO3 21Albumin 2.1Lactate 5.6Mg 1.7WBC 2.8

LAB ValueCD4 Count <20LCD4% 2LCD4/CD8 Ratio .10LCD 8% 74H

• Glucose, Lactate, Albumin, HCO3 remained abnormal

• NS @ 75ml/hr – d/c when I saw him

MEDICATIONS

AzithromycinCefepimeEnoxaparinFluconazoleNystatinProtonixSulfamethox-TMPSolu-medrolVancomycin

AcylovirMirtazapineProtonixPrednisoneSeptraRatepravir

HOME MEDICATIONS

AcyclovirAzithromycinCyproheptadineIsentressVitamin D3AbilifyDepakoteHydroxyzine PamoateNexium

PrednisoneZofranZyprexaRaltegravirErgocalcifeol

ENN

• 1440-1600 kcal (45-50kcal/kg of BW) • 64-74 g pro (2-2.3g/kg of BW)• 1ml/kcal fluid

INTITAL ASSESSMENT

Per pt, appetite is fine but says swallowing is difficult for his PO meds, very lethargic

Follows a normal diet, occasionally drinks Boost that is provided – hates it. Prefers Ensure, Food Security, Received some nutr edu

Denies wt loss, says always thinRegular DietPES: Increased Protein/Energy Needs

Related to Metabolic Stressors/Current Condition AEB by BMI of 12.5, 57% IBW, Severe Wt Loss

Intervention Monitoring/Evaulation

1. Continue w/ current diet, will send Ensure TID along w/ HP Milkshakes TID/ HNS Snacks

2. Recommend swallow study to assess dysphagia prescence – pt may benefit from nutrition support

3. Request PAB4. Provide edu as

appropriate

Preserve LBMMaintain Skin

Integrity

INTIAL ASSESSMENT, Cont

First Follow Up

PAB of 21! Suspected PellagraMitochondrial Toxicity 2/2 to AZTMetabolic Acidosis w/ Primary Respiratory

AlkalosisPlaced on Thiamine & B-Vitamin ComplexNepro 1 can BID ? (Renal Fxn normal)Thrush is responding to treatmentInfectious Disease to re-evaluate for new

HAART

First Follow Up, Cont

Eating fine, Nursing reporting eating fine, Very hungry

Reports he can’t swallow HAART, uncomfortable

Denies N/V/Diarrhea – BMSome Stomach PainPES: REMAINS

Intervention Monitoring/Evaluation

1. Continue w/ current diet and supplements. Will honor food prefs

2. D/C Nepro3. Revaluate

medication regimen if feasible for swallowing

Preserve LBMMaintain skin

integrity

First Follow Up, Cont.

NUTRITION EDUCATION

Fortification of FoodsBrief Food SafetyTouched on Importance of Meds and

Following Instructions

SECOND FOLLOW UP

Nursing Staff to Check for Outside DrugsStill not taking HAART, but taking all other PO medsMD had spoke w/ pt regarding Meds*Pt wishes for DNR status, contemplating hospice PCP not responding to treatmentLeft Pneumothroax discovered- chest tubeLactic Acidosis resolved (d/c AZT)Metabolic Acidosis continues, cause unclearAdd some chipsPES Remains

Intervention Monitoring/Evaluation

1. Continue w/ current care plan, will honor food prefs

Preserve LBMMaintain skin

integrity

Second Follow Up, cont

OUTCOME

Home Care HospiceLife expectancy, few days or weeks – per MD

PERSONAL IMPRESSION

HORRIBLERecommended Vitamin A or B-Vitamin

Complex in BeginningBetter, more in-depth Nutrition EducationOutreach assistance, websites

REFERENCES