au psyc706 final

Running head: MEDICINAL ISSUES: AIDS1

Medicinal Issues: AIDS

Shon Powell

PSYC 706-2 Medical Issues and Introduction to Pharmacology

Bill Heusler, Psy.D.

Antioch University Seattle

December 17, 2010

MEDICINAL ISSUES: AIDS 2

Abstract

Human Immunodeficiency Virus (HIV) is a disease that has risen to

epidemic proportions. Acquired Immunodeficiency Syndrome (AIDS)

is a secondary disorder and a direct result of exposure to the

HIV infection. HIV and AIDS are transmitted between individuals

through bodily fluids via mucous membranes. Opportunistic

infections account for the majority of deaths from AIDS.

Homosexuality has traditionally been associated with the disease,

however, heterosexual intimacy carries equal risk. Heterosexual

men generally do not feel the need to protect themselves from the

disease with condoms during heterosexual intercourse and this

leads to their vulnerability. Although different treatment

modalities are available, the current crop of antiretroviral

drugs are most effective in offering patients longer, healthier

lives.


Medicinal Issues: AIDS The world first became aware of the Human Immunodeficiency

Virus (HIV) in 1981 (Rathbun, Lockhart, & Stephens, 2006). The

disease is now considered a pandemic due to its dispersal through

human populations across the globe. According to Rathbun,

Lockhart, & Stephens (2006), the World Health Organization

estimates that approximately 38 million individuals worldwide had

been infected with HIV in 2003. An additional 4.8 million new

infections occurred in that same year alone. At present an

estimated 20 million persons have died from the HIV infection.

Since the first cases of AIDS were diagnosed more than 25 years

ago, women from the global south came to represent the primary

face of the disease. Conversely, men who have sex with women

remain a forgotten group in the pandemic, and are almost entirely

unaddressed in HIV prevention programs (Higgins, Hoffman, and

Dworkin, 2010).

Symptoms of a Presenting Patient

Tank, Heusser, Schroeder, Luft, & Jordon (2010) discussed a case

study:


A 43 year old man was referred to our syncope–and–

hypotension service because of recurrent “dizziness and

passing out” after a few seconds standing. According to the

patient’s history, a prescription for fludrocortisones and

midodrine had not helped him. He also reported erectile

dysfunction, complete anhidrosis, early satiety, and gastric

distention. His symptoms began 10 years earlier and worsened

gradually. The patient tested positive for human

immunodeficiency virus (HIV) in 1994. (p. 263)

According to Rathbun, Lockhart, & Stephens (2006) the

Acquired Immunodeficiency Syndrome (AIDS) is a disorder in which

the body’s immune system is suppressed as a direct result of

exposure to the human immunodeficiency virus (HIV) infection,

which is transmitted between individuals through bodily fluids

(for example, blood, semen, or vaginal fluids) via mucous

membranes. The vast majority of individuals with an HIV infection

develop AIDS within an average of seven to ten years. Moreover,

Hudson, Kirksey, & Holzemer (2004) reported that HIV positive

women presented with the following most frequently occurring


symptoms: (a) anxiety/fear (17.3%); (b) diarrhea (16.6%); (c)

neuropathy (11.6%); (d) nausea/vomiting (9.7%); (e) depression

(8.1%); and (f) fatigue (7.3%).

Tank, Heusser, Schroeder, Luft, & Jordon (2010) discussed:

The patient was normal weight with warm and dry skin. His

pupils responded slowly to light. Otherwise, his

neurological status was unremarkable. Cardiovascular

autonomic reflex testing was conducted with continuous

finger blood pressure, respiration, heart rate, and cardiac

stroke volume measurements. Respiratory sinus arrhythmia,

which is mediated through vagal modulation of heart rate,

was severely depressed. Blood pressure decreased profoundly

during phase II of the Valsalva manoeuvre and during phase

IV the pressure overshoot was absent. Hand grip and cold

pressure decreased dramatically. He became unconscious after

standing 30 s, which was not enough time to measure upper

arm blood pressure. Systolic and diastolic blood pressure

measured at the finger decreased by -95 and -40 mmHg,

respectively. Heart rate increased insufficiently by 4 beats


per minute. In response to 6.25 µg phenylephrine given

intravenously, his systolic blood pressure increased 20 mmHg

(normal ~ 3 mmHg) suggesting that resistance vessels hyper-

responded to adrenergic stimulation. Together, these

observations are consistent with severe autonomic failure

involving the parasympathetic and sympathetic nervous system

(p. 263)

Patient History

In 1993, the patient had been working as a commercial

trucker driver, and although married, the patient stated that

long periods of time away from his wife made him anxious for

female companionship. Adding to the patient’s restless feelings

was the fact that his marriage was suffering due to his

employment as a truck driver. Because of these circumstances the

patient solicited a commercial sex worker at a truck stop along

his regular route. The patient paid the commercial sex worker an

additional fee to forgo a condom during sexual intercourse. The

patient states that this was the only time that he had had

intercourse with anyone outside of his marriage.


Lee, Salman, and Fitzpatrick (2008) stated that depression

probably diminishes or indirectly affects an individual’s self-

efficacy, which is believed to be a significant factor in the

prediction of condom use during sexual intercourse and refusing

unsafe sexual practices. Furthermore, Solomon et al. (2000) found

that truck drivers are at particular high risk for acquiring HIV

due to long periods at work away from home without access to a

regular sex partner (see Appendix). Of additional note, HIV

infected truck drivers moving along their routes have long been

seen as a root factor in the international spread of HIV.

Higgins, Hoffman, & Dworkin (2010) established that men generally

do not feel the need to protect themselves with condom usage

during unprotected heterosexual intercourse. Moreover, men may be

at a great risk of contracting HIV through sexual intercourse

with small networks of high-risk women, though some other pattern

of sexual behavior may be at play.

Approximately nine months after his encounter with the

commercial sex worker, the patient began to complain of

persistent flu-like symptoms and aching joints. He saw a general


practitioner who did a routine blood screen. After the return of

these test results, the patient was told that he was HIV

positive. The patient confessed to his wife that he contracted

HIV, at which point she underwent testing and received a negative

result. The disclosure of the patient’s condition resulted in a

divorce from his wife and the termination of his employment.

According to Lyketos et al. (1995), there are a number of

findings showing that depressive symptoms develop in the early

and middle stages of HIV infection.

Physiological

The typical course of an HIV infection is defined by three

distinct phases: 1) primary infection phase, 2) chronic

asymptomatic and 3) latency phase/overt AIDS phase (Porth, 2007).

In most cases, the phases present themselves within an eight to

twelve year timeframe.

According to Porth (2007), once an individual is infected

with HIV, an acute mononucleosis will commonly occur much like

the syndrome known as the primary infection phase. The symptoms

of the first phase are often fever, fatigue, myalgias, sore


throat, night sweats, gastrointestinal problems, lymphadenopathy,

maculopapular rash, and headache. In addition, the primary

infection phase will be marked with an increase in viral

replication leading to high viral loads, which sometimes consist

of over 1,000,000 copies/mL and a decrease in CD4+ cell count.

This initial phase usually appears two to four weeks after

exposure to HIV, will usually last for a few days to two weeks,

and is marked by phase signs and the symptoms of the primary HIV

infection. Several weeks later, the immune system acts to curtail

viral replication reducing the viral load to a lesser degree.

This phase often remains at the same level for several years. If

the disease is caught in its beginning stage (primary infection),

infected individuals who are diagnosed with HIV seem to benefit

from early treatment, perhaps reducing the number of long living

HIV infected cells or CD4+ memory cells in their systems. The

latency phase is possibly the most dangerous phase for

transmission of the virus. During this period, individuals

present no outward signs of the virus. Median period for the

latent stage is approximately ten years. During this phase, the


CD4+ cell count falls until it reaches a critically low level

below which there is considerable risk of opportunistic infection

(see Patient Course). Lymphadenopathy develops in some HIV

positive individuals during this phase. Persistent generalized

lymphadenopathy is defined as lymph nodes that are chronically

swollen for more than three months in at least two locations, not

including the groin. The lymph nodes may be sore and/or be

visible externally.

When the CD4+ cell count reach a threshold less than 200

cells/µL, the overt AIDS phase is said to occur and is the

defining point for AIDS as an illness. Porth (2007) assert that

without antiretroviral therapy, this phase can lead to death

within two to three years. The risk of opportunistic (see Patient

Course) infections and death is increased significantly when the

CD4+ cell count reaches this level. In the United States, the

typical adult with overt AIDS presents with fever, diarrhea,

weight loss and the wasting syndrome, generalized

lymphadenopathy, multiple opportunistic infections, and in many

cases, secondary neoplasms.


According to Porth (2007), the clinical course of HIV varies

from person to person. Most (60% to 70%) of those infected with

HIV develop overt AIDS ten to eleven years after the infection -

these people are the typical progressors. Another 10% to 20% of

those infected experience more rapid progression. These

individuals develop overt AIDS in less than five years and are

called rapid progressors. The final 5% to 15% are slow

progressors, who do not experience progression to overt AIDS for

more than 15 years. There is subset of slow progressors, called

long-term nonprogressors, who account for 1% of all HIV

infections. These people have been infected for at least 8 years,

are antiretroviral naïve, have high CD4+ counts, and usually have

very low viral loads.

Patient Course

Opportunistic infections account for the majority of deaths

from AIDS (Porth, 2007). In the United States, the most common

opportunistic infections are Pneumocystis carinii pneumonia

(PCP), oropharyngeal or esophageal candidiasis (thrush),


cytomegalovirus (CMV) infection, and infections caused by

Mycobacterium avium-intracellulare complex (MAC). Additionally,

according to Marcus, Kerns, Rosenfeld, and Breitbart (2000),

HIV/AIDS related pain is a significant clinical problem

associated with functional impairment and psychological distress.

Currently, there is little empirical information available to

guide practitioners in the treatment of patients with HIV/AIDS

related pain. Furthermore, empirical investigations have

indentified numerous barriers to the adequate assessment and

treatment of AIDS pain (Bottonari, Safren, McQuaid, Hsiao, and

Roberts, 2010).

Patient Treatment

Tank, Heusser, Schroeder, Luft, & Jordon (2010) remarked

that patient autonomic failure may be caused by central nervous

system disorders or dysfunction of peripheral autonomic nerves.

They stated:

When we probed the peroneal nerve with a microneurography

electrode, we were unable to record efferent skin or muscle

sympathetic nerve activity. Venous plasma norepinephrine was


profoundly reduced (0.22 nM =37 ng/l; normal ~ 1.18 nM

= 200ng/l). Blood pressure failed to increase with ingestion

of the alph-2 adrenoreceptor antagonist yohimbine, which

normally raises sympathetic activity. These observations and

lack of additional neurological symptoms point to a lesion

involving peripheral autonomic neurons. He had no antibodies

against ganglionic nicotinergic acetylcholine receptors,

which is a rare potentially treatable cause of peripheral

autonomic dysfunction. An earlier report suggested that

orthostatic hypotension can also result from central nervous

system degeneration in HIV patients. (p. 263)

In this case study (Tank, Heusser, Schroeder, Luft, &

Jordon, 2010), the patient was encouraged to drink water

regularly before meals. He was also instructed to elevate the

head of his bed which decreased nocturia and increased

orthostatic symptoms. Additionally, he apply water to his skin to

increase heat tolerance. Finally, the patient continued on the

drug midodrine, which was tailored by the patient to accommodate

his daily activities. At the conclusion of his current battery of


treatment, the patient registered a supine blood pressure of

133/91 and a standing blood pressure of 66/36 mmHg while standing

for 10 minutes, thus affecting a cure for his fainting spells.

Although the patient in the case study did not use any

antiretroviral treatment, there are currently, pharmaceutical

treatments which include twenty antiretroviral medications,

comprised of four classes of antiretroviral (ARV) agents:

nucleoside/tide reverse transcriptase inhibitors (NRTIs), non-

nucleoside reverse transcriptase inhibitors (NNRTIs), protease

inhibitors (PIs) and fusion inhibitors (FIs). (See Table 1

through Table 4.)

Table 1.

Currently Available NRTIsBrand Name Generic Name Abbreviation Manufacturer

Emtriva® Emtricitabine FTC Gilead

Epivir® Lamivudine 3TC GlaxoSmithKline

Hivid® Zalcitabine ddC Roche

Retrovir® Zidovudine AZT ZDV GlaxoSmithKlineVidex EC® Didanosine ddI EC BristolMyersSqu

ibb

Viread® Tenofovir TDF Gilead


Zerit® Stavudine d4T BristolMyersSquibb

Ziagen® Abacavir ABC GlaxoSmithKline

Shibuyama et al., 2000

Table 2.

Currently available NNRTIsBrand Name Generic Name Abbreviation Manufacturer

Sustiva® Efavirenz EFV BristolMyersSquibb

Viramune® Nevirapine NVP Boehringer - Ingelheim

Rescriptor® Delavirdine DLV Pfizer - Agouron

Shibuyama et al., 2000

Table 3.

Currently available PIsBrand Name Generic Name Abbreviation Manufacturer

Lexiva® Fosamprenavir fAPV GlaxoSmithKline-Vertex

Crixivan® Indinavir IDV MerckFortovase® Saquinavir

soft gel SQV- sgc Roche

Invirase® Saquinavir- hard gel

SQV- hgc Roche

Kaletra® Lopinavir + ritonavir

LPV/r Abbott

Norvir® Ritonavir RTV AbbottReyataz® Atazanavir ATV BristolMyersSqu

ibb


Viracept® Nelfinavir NFV AgouronAptivus® Tipranavir TPV Boehringer -

IngelheimShibuyama et al., 2000

Table 4.

Available Fusion InhibitorBrand Name Generic Name Abbreviation Manufacturer

Fuzeon® Enfuvirtide T-20 Roche-TrimerisShibuyama et al., 2000

Conclusion

Antiretroviral drugs have been an important innovation in the

treatment of HIV/AIDS (Shibuyama et al., 2000). Due to the

current crop of antiretroviral drugs patients are living longer,

healthier lives. For HIV patients, the symptoms of their disease

have not varied greatly. However, according to a sample study

(Heckman, Somiai, Sikkema, Kelly, & Franzoi, 1997) respondents

with high levels of life satisfaction indicated a higher level of

physical and functional well being than did individuals with low

life satisfaction. It was shown that a high level of social

support vastly improved the quality of life for HIV/AIDS infected


individuals. Yet, the stigma of homosexuality looms large in the

psychosocial aspects of HIV/AIDS within world culture.

Repudiation of homosexuality is a fundamental characteristic of

masculinity that can place men at greater risk for HIV (Higgins,

Hoffman, and Dworkin, 2010).


References

Bottonari, K. A., Safren, S. A., McQuaid, J. R., Hsiao, C., &

Roberts, J. E. (2009). A longitudinal investigation of the

impact of life stress on HIV treatment adherence. Journal of

Behavioral Medicine, 33, 486-495. doi:10.1007/s10865-010-9273-9

Heckman, T. G., Somlai, A. M., Sikkema, K. J., Kelly, J. A., &

Franzoi, S. L. (1997). Psychosocial predictors of life

satisfaction among persons living with HIV infection and

AIDS. Journal of the Association of Nurses in AIDS Care, 8(5), 21-30.

Higgins, J. A., Hoffman, S., & Dworkin, S. L. (2010). Rethinking

gender, heterosexual men, and women’s vulnerability to

HIV/AIDS. American Journal of Public Health, 100(3), 435-445.

doi:10.2105/AJPH.2009.159723

Hudson, A., Kirksey, K., & Holzemer, W. (2004). The influence of

symptoms on quality of life among HIV-infected women. Western

Journal of Nursing Research, 26(1), 9-23.

doi:10.1177/0193945903259221

Lee, Y., Salman A., & Fitzpatrick, J. J. (2009). HIV/AIDS

preventive self-efficacy, depressive symptoms, and risky


sexual behavior in adolescents: A cross-sectional

questionnaire survey. International Journal of Nursing Studies, 46, 653-

660. doi:10.1016/j.ijnurstu.2008.11.007

Lyketsos, C. G.., Hoover, D. R., Guccione, M., Dew, M. A., Wesch,

J., Bing, E. G., & Treisman, G. J. (1996). Depressive

symptoms over the course of HIV infection before AIDS. Social

Psychiatry and Psychiatric Epidemiology, 31, 212-219.

Marcus, K. S., Kerns, R. D., Rosenfeld, B., & Breitbart, W.

(2000). HIV/AIDS-related pain as a chronic pain condition:

Implications of a biopsychosocial model for comprehensive

assessment and effective management. Pain Medicine, 1(3), 260-

263.

Porth, C. M. (2007). Essentials of pathophysiology: Concepts of altered health

states. USA: Lippincott, Williams, & Wilkins

Rathbun, R. C., Lockhart, S. M., & Stephens, J. R. (2006).

Current HIV treatment guidelines – An overview. Current

Pharmaceutical Design, 12, 1045-1063.

Shibuyama, S., Gevorkyan, A., Yoo, U., Tim, S., Dzhangiryan, K.,

& Scott, J. (2006). Understanding and avoiding


antiretroviral adverse events. Current Pharmaceutical Design,

12,1075-1090.

Solomon, S., Ganesh, Al, Ekstrand, M., Barclay, J., Kumarasamy,

N., Mandel, J., & Lindan, C. (2000). High HIV seropositivity

at an anonymous testing site in Chennai, India: Client

profile and trends over time. AIDS and Behavior, 4(1), 71-81.

Tank, J., Heusser, K., Schroeder, C., Luft, F. C., & Jordan, J.

(2009). Automatic failure in a HIV-infected patient. Clinical

Autonomic Research, 20(4), 263-265. doi:10.1007/s10286-010-0063-

9


Critique

Bottonari, K. A., Safren, S. A., McQuaid, J. R., Hsiao, C., &

Roberts, J. E. (2009). A longitudinal investigation of the

impact of life stress on HIV treatment adherence. Journal of

Behavioral Medicine, 33, 486-495. doi:10.1007/s10865-010-9273-9

Participants were 87 treatment seeking HIV positive clients from an inner-city health clinic. Life stress is associated with poor outcomes in HIV treatment. Study seeks to example effects of psychosocial factors on life stress, depression, and coping skills. This article is valuable in its demonstration of patient’s ability to affect treatment outcomes.

Lyketsos, C. G.., Hoover, D. R., Guccione, M., Dew, M. A., Wesch,

J., Bing, E. G., & Treisman, G. J. (1996). Depressive

symptoms over the course of HIV infection before AIDS. Social

Psychiatry and Psychiatric Epidemiology, 31, 212-219.

Study describes the prevalence and course of symptoms before AIDSin HIV-infected homosexual men. The Center for Epidemiologic Studies Depression Scale (CES-D) is addressed in its primary roleas the measure of depressive symptoms. Depressive symptoms suffered most often by homosexual men are investigated. This article was used to describe the stigma felt by all men diagnosedwith AIDS.

Tank, J., Heusser, K., Schroeder, C., Luft, F. C., & Jordan, J.

(2009). Automatic failure in a HIV-infected patient. Clinical


Autonomic Research, 20(4), 263-265. doi:10.1007/s10286-010-0063-

9

Case report of severe autonomic failure in a 43-year-old well-controlled HIV patient was showcased. Clinical and pharmacological autonomic function testing and diagnosis of peripheral autonomic failure were demonstrated. Physiological maneuvers required to improve patient’s symptoms was addressed. This case study was the actual one used to complete the assignment.


Appendix

Solomon, S., Ganesh, Al, Ekstrand, M., Barclay, J., Kumarasamy,

N., Mandel, J., & Lindan, C. (2000). High HIV seropositivity

at an anonymous testing site in Chennai, India: Client

profile and trends over time. AIDS and Behavior, 4(1), 71-

81.

The study took place in Chennai, India, between the years of

1994 to 1998, during a rapidly escalating epidemic, and looked at

trends of various demographic groups among the sample of 1,745

male and female clients. It was found that 74% of the infections

were due to heterosexual transmission, but this figure was likely

skewed due to the social stigma and illegality of homosexual and

bisexual conduct in India.

The clients that were most often defined as HIV-seropositive

were commercial sex workers and their husbands, truck drivers and

their wives, migrant workers and their wives, and children who

were at risk primarily from prenatal transmission or blood

transfusions. The majority of clients were at risk due to their

sexual behavior, such as low condom use with the 64% having never


used one. Only a fraction of those infected were aware of their

condition. Absent from the study’s list of health center clients

were intravenous drug users.

In 1998, the U.S. Agency for International Development

community-based survey documented overall community HIV infection

rates of 1.8%. Higher documented rates were recorded in rural

areas (21%) than in urban areas (0.7%). Correlates of being HIV-

positive included occasional condom use, being married, being

referred by an HIV-positive sex partner, working as a truck

driver or migrant, or having a spouse in these professions.

Differing rates of infection have resulted from male migrant

workers who brought the epidemic back to their wives in rural

villages. Tamil Nadu accounted for 15% reported HIV infections

and 32% of its reported AIDS cases in India.

Forty three percent of the women came to the center after

exposure through an HIV-positive partner. HIV prevalence among

housewives (47%) was greater than amongst women who admitted to

being a commercial sex worker (32%) and was contrasted by only 4%

of men who sought testing because of partner referral. Women were


more likely to be infected by a regular partner, while the men

had been engaging in behaviors that they were aware would have

placed them at risk for HIV infection. Commercial sex workers

were the most likely to use condoms regularly but the study still

speculated that husbands of these commercial sex workers were

still at risk due to their wives employment.

Several factors may have contributed to the high rural

prevalence of HIV found in Tamil Nadu. It was found that the

occupational groups in which men were most likely to be HIV-

infected were truck drivers (82% HIV seropositive) and migrant

workers (68%). It was theorized that HIV infections moved along

the truck routes where drivers sought out commercial sex workers

or non-regular sex partners. Migrant workers sought out

alternative partners because they were often working in urban

centers for long periods away from their regular sex partners.

The prevalence of HIV in this sample was 51%, indicating

that the clinics had been successful in their outreach to at-risk

individuals. The increasing number of clients over time as well

as the change in demographic (most notably HIV-uninfected woman


and pregnant woman as well as older, married and uneducated men)

suggested that the clinic had been well-received by the

community. The success of the clinic served as a model for

similar centers in India, and signaled the widespread need for

anonymous testing and counseling.

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