Human Immunodeficiency Virus C H A P T E R 21 Human Immunodeficiency Virus Archer, Albrecht, Hand Chapter 21

Definition The definition has evolved since 1983 2008 definition (most recent) from the Centers for Disease Control (CDC): HIV antibody test Fewer than 200 CD4+ cells/µl 24 clinical conditions

Table 21.1

Disease Scope Up to 60 million infected worldwide Up to 25 million have died 2002 health care expenditures: $36.4 billion ~50,000 new cases per year in United States ~20% do not know they are infected Initially affected mostly white gays Now affecting lower socioeconomic classes primarily

Pathophysiology Infection from transfer of body fluid (e.g., blood, semen, vaginal secretions, breast milk) Sexual contact, perinatal exposure, IV drug use Not transferred by insects, saliva, or sweat Time course Seroconversion (to greatly increased HIV viral load in blood) illness immediately after transfer for few days to several weeks Symptoms: sore throat, fever, fatigue, lymphadenopathy, rash, myalgia, malaise, oral/esophageal sores Followed by CD4 cell decrease Wasting (unintentional >5% weight loss), typically occurring later in disease process (continued)

Pathophysiology (continued) Metabolic complications—increase in cardiac disease risk Lipodystrophy—loss of subcutaneous fat deposits Cardiac dysfunction—HIV is related to a number of cardiac complications including diastolic dysfunction, arrhythmias, atherosclerosis, vasculitis, pericardial effusion, and others

Clinical Considerations Stage 1: primary infection; asymptomatic and lasts for a few weeks Stage 2: clinically aymptomatic and can last for years Stages 3/4: critically ill and diagnosis presumed based on signs and symptoms Signs and symptoms: vary with degree of illness and treatment Viral illness symptoms (fever, pharyngitis, malaise, rash) within 1 mo of exposure Lipodystrophy Impaired glucose and lipid metabolism CVD risk factors Wasting (continued)

Clinical Considerations (continued) History and physical exam Should focus on: General physical examination Changes in body weight (wasting) Indications of metabolic disorders (lipodystrophy) Motor abnormalities (hyperreflexia, loss of equilibrioception) CV disease (arrhythmias, edema) Peripheral neuropathy (common issue with those on HAART therapy) Behavioral/psychological symptoms: fatigue, malaise, depression anxiety, isolation, lower QOL (continued)

Clinical Considerations (continued) Diagnostic testing HIV blood test: assess for presence of HIV antibodies or viral load Rapid antibody tests are used only for point-of-care testing and are not definitive Exercise testing: Considered safe Can be used to evaluate CVD risk, especially in those at high risk Assess for HAART-related orthopedic complications (osteonecrosis, bone tumors, and so on) Avoid testing if acutely ill Consider assessing body composition, flexibility, strength, and physical functioning/cardiorespiratory fitness (continued)

Clinical Considerations (continued) See table 21.2 for exercise testing and physical fitness and function review.

Treatment 29 drugs are FDA approved to treat HIV. These are in five classes: Protease inhibitors (PIs) Nucleoside reverse transcriptase inhibitors (NRTIs) Non-nucleoside reverse transcriptase inhibitors (non-NRTIs) Fusion inhibitors (FIs) Integrase inhibitors (continued)

Treatment (continued) These medications can result in adverse side effects: Diabetes Hyperglycemia Lipodystrophy Hyperlipidemia Also consider: Nutrition Exercise and physical activity Lifestyle change to control modifiable risk factors

Exercise Prescription Should receive medical clearance Goals: enhance physical functioning and QOL and reduce morbidity Modify for the individual circumstances Strongly consider methods to positively affect adherence For CV training: Reduce initial intensity and volume before beginning exercise training to reduce risk of nonadherence due to effort. (continued)

Exercise Prescription (continued) Resistance training: Adhere to general ACSM guidelines Take into account HIV stage Consider no training or very reduced intensity if: Osteonecrosis Peripheral neuropathies Range of motion training: Follow general flexibility training guidelines from ACSM Slower-progression mild stretching recommended

Exercise Training See table 21.4 for exercise prescription review.

Conclusion Exercise training is safe and beneficial Advances in treatment (HAART) have allowed patients to live longer and develop HIV-related comorbidities that exercise may help to prevent Need to overcome unwillingness to regularly exercise