HIV

Objectives

  • Describe methods used to diagnose and monitor HIV infection.

  • Summarize the characteristics of opportunistic diseases associated with AIDS.

  • Describe the potential complications of long-term treatment of HIV infection.

  • Describe the nursing management of patients with HIV and those at risk for HIV infection.

Human Immunodeficiency Virus Infection

  • Definition:

    • HIV is a retrovirus that causes immunosuppression, making individuals more susceptible to infections.

  • Current Statistics:

    • Greater than 1.2 million people are currently living with HIV in the United States.

    • Approximately 36,400 new HIV infections occur each year.

  • Treatment Outcomes:

    • Effective treatment has led to a dramatic drop in death rates from HIV.

    • HIV is now considered a chronic condition once effectively treated.

Case Study (1 of 10)

  • A.O. is a 20-year-old Hispanic male college student who reports pain on urination.

  • Urine test results are positive for Neisseria gonorrhea.

  • Next Steps: What should you do?

Transmission of HIV

  • Modes of Transmission:

    • HIV can be transmitted through specific body fluids:

    • Blood

    • Semen

    • Vaginal secretions

    • Breast milk

    • Not Transmitted By:

    • Tears, saliva, urine, emesis, sputum, feces, sweat, respiratory droplets, or enteric routes.

    • HIV is not spread through casual contact, such as hugging, dry kissing, shaking hands, sharing eating utensils, or using toilet seats.

  • Contact With Blood and Blood Products:

    • Sharing drug-using paraphernalia is highly risky for transmission.

    • Routine screening of blood donors has improved safety of the blood supply.

    • Puncture wounds are the most common means of work-related HIV transmission.

    • Increased risk factors include:

      • Blood of patients with high circulating HIV levels.

      • Deep puncture wounds.

      • Needles with visible blood (hollow bore).

      • Devices used for venous or arterial access.

Perinatal Transmission

  • Transmission can occur during:

    • Pregnancy

    • Delivery

    • Breastfeeding

  • Without treatment, approximately 25% of infants born to women with untreated HIV will be born with the infection.

  • Treatment with ART can reduce this rate of transmission to less than 1%.

Sexual Transmission

  • Unprotected sexual contact with a person who has a high viral load is the most common mode of HIV transmission.

  • Key Concept: "U=U" (Undetectable = Un-transmittable)

    • If a person with HIV has an undetectable viral load, transmission is not possible.

  • Risk for transmission increases due to:

    • Sexual activities causing trauma to local tissues.

    • Presence of lesions from other sexually transmitted infections (STIs).

Pathophysiology of HIV

  • Virus Characteristics:

    • HIV is an RNA virus categorized as a retrovirus because it replicates from RNA to DNA.

  • Cellular Targets:

    • The target cells for HIV are CD4+ T cells, a type of lymphocyte.

    • HIV binds to protein receptors on the cell's surface via fusion.

Components of HIV

  • Key components include:

    • gp120: Attaches to CD4 receptors.

    • Reverse transcriptase enzyme: Facilitates viral DNA production.

    • p24: Protein component of the virus.

    • Viral RNA & DNA: Single and double-stranded forms critical for replication.

  • Mechanism of Viral Replication:

    • CD4 receptors and chemokine receptors (CXCR4 and CCR5) are involved in receptor-mediated endocytosis and incorporation into the host cell's DNA by integrase.

Consequences of Integrase

  • Newly formed double-stranded DNA is infected with HIV, replicating through cell division, leading to production of new HIV.

Pathophysiology of HIV's Impact

  • Over time, HIV destroys CD4 cells faster than they can be replaced:

    • Immune problems start with CD4+ T cell counts dropping below 500 cells/μL.

    • Severe problems develop with counts below 200 cells/μL.

    • Insufficient immune response allows for opportunistic diseases, leading to disease, disability, and death among patients with HIV.

Viral Load in Blood and CD4+ T-Cell Counts

  • Viral Load and CD4 Counts Correlation:

    • Initial high viral load corresponds with acute infections and drops as chronic infection develops.

Case Study (2 of 10)

  • A.O. informs about his sexual activity since age 15 with both males and females. He reports always being the insertive partner.

Case Study (3 of 10)

  • Reports intercourse with three partners in the last month with no protection.

  • Next Steps: What should you do?

Timeline for Untreated HIV Infection

  • Phases of Infection:

    1. Acute infection (1 to 3 weeks)

    2. HIV antibody test becomes positive (3 weeks to 3 months)

    3. Asymptomatic infection

    4. Symptomatic infection

    5. AIDS

Clinical Manifestations and Complications (1 of 5)

  • Acute Infection Symptoms:

    • Mononucleosis-like symptoms: fever, swollen lymph nodes, sore throat, headache, malaise, nausea, joint and muscle pain, diarrhea, diffuse rash.

    • Symptoms often mistaken for the flu.

    • Possible neurologic problems (aseptic meningitis, peripheral neuropathy, facial palsy, Guillain-Barré syndrome).

    • Highly infectious due to high viral load in blood.

    • Temporary drop in CD4 cell counts which return to baseline.

Clinical Manifestations and Complications (2 of 5)

  • Chronic HIV Infection:

    • Asymptomatic initially.

    • Untreated, AIDS diagnosis approximately 10 years post-infection.

    • Early years typically asymptomatic or with limited infection signs.

Clinical Manifestations and Complications (3 of 5)

  • Symptomatic Infection:

    • CD4+ T cells decline near 200 cells/μL, with increased viral load.

    • Symptoms worsen: persistent fever, night sweats, chronic diarrhea, recurrent headaches, severe fatigue.

    • Common infections include oropharyngeal candidiasis (thrush).

Clinical Manifestations and Complications (4 of 5)

  • Infection Occurrences During Symptomatic Phase:

    • Shingles (varicella-zoster virus)

    • Vaginal candidal infections

    • Oral/genital herpes

    • Bacterial infections

    • Kaposi sarcoma (human herpesvirus 8)

    • Oral hairy leukoplakia (Epstein-Barr virus infection).

Clinical Manifestations and Complications (5 of 5)

  • AIDS:

    • Diagnostic criteria established by CDC:

    • Immune system severely compromised

    • Infections and various cancers

    • Wasting issues

    • HIV-related cognitive changes

    • Non-severe organisms cause debilitating infections.

    • Advances in treatment have reduced opportunistic diseases occurrence.

Case Study (4 of 10)

  • A.O. discusses alcohol use: reports no regular drug, tobacco, or steroid use, but drinks enough to not remember.

  • Risk Assessment: What is the risk level, and why?

Diagnostic Studies (1 of 3)

  • Screening Tests:

    • Most useful tests detect HIV-specific antibodies and/or antigens.

    • May take several weeks for antibodies to be detectable (window period of about 3 weeks).

    • Tests during the window period may yield false negatives (using blood or saliva).

Laboratory Studies Monitoring HIV Progression

  • Key Indicators:

    • CD4 Cell Count:

    • Provides a marker for immune function. Normal range: 800 to 1200 cells/μL. Generally decreases with disease progression.

    • Viral Load:

    • Lower viral load indicates less disease activity. Goal is to suppress viral load to the lowest level possible.

    • "Undetectable" simply means HIV is below the threshold of test detection, not a cure.

Diagnostic Studies (2 of 3)

  • Common Abnormal Results:

    • Decreased WBC counts (lymphopenia, neutropenia)

    • Low platelet counts (thrombocytopenia)

    • Anemia from chronic disease and ART

    • Altered liver function from HIV infection, drug therapy, and co-infections (e.g., hepatitis B or C).

  • Early detection of abnormalities is critical.

Diagnostic Studies (3 of 3)

  • Resistance Tests:

    • Determine if patient is resistant to ART drugs, guiding effective medication selection.

    • Types of assays:

    • Genotype assay

    • Phenotype assay (similar to culture and sensitivity testing for antibiotics).

Interprofessional Care (1 of 2)

  • Focus of Care:

    • HIV cannot be cured; primary focus is on managing the disease:

    • Monitor disease progression and immune function.

    • Initiate and monitor ART.

    • Prevent and manage opportunistic diseases.

    • Manage symptoms and treatment complications.

    • Prevent further transmission.

Interprofessional Care (2 of 2)

  • Strategies for Goals of Care:

    • Conduct ongoing assessments.

    • Foster clinician-patient interactions and teaching.

    • Provide support.

Case Study (5 of 10)

  • A.O. returns three months later after refusing HIV testing. He is now concerned due to a partner's recent HIV diagnosis and seeks help.

  • Discussion: What should you inform A.O. about HIV testing?

Drug Therapy (1 of 3)

  • ART (Antiretroviral Therapy):

    • Combination of medications to control and suppress HIV replication.

    • Effective treatments require adherence to therapy.

  • Main Goals:

    • Decrease viral load

    • Maintain/increase CD4 counts

    • Prevent HIV-related symptoms and opportunistic diseases

    • Delay disease progression

    • Prevent HIV transmission.

Drug Therapy (2 of 3)

  • Combination Therapy Principles:

    • Utilize drugs from different classes targeting various steps in the HIV replication cycle.

    • Helps prevent viral recovery and reduces drug resistance potential.

    • Single-tablet combination therapies available.

  • Side Effects & Expenses:

    • Side effects and treatment costs can be disadvantages to ART.

Safety Alert

  • ART interactions can occur with:

    • Herbal therapies (e.g., St. John’s Wort)

    • Common drugs (OTC medications and supplements).

  • Ensure a comprehensive and accurate patient history is taken.

Drug Therapy (3 of 3)

  • Opportunistic Diseases & Management:

    • Prevention is essential due to complications from HIV management.

    • Effective management has significantly increased life expectancy for HIV patients.

Nursing Management Assessment (1 of 3)

  • Risk Assessment:

    • Do not make assumptions about who may be at risk for HIV.

    • Open and candid conversation is crucial for effective HIV management.

  • Establish rapport during initial visits to gather baseline data.

Nursing Management Assessment (2 of 3)

  • For those without infection, inquire about:

    • Receipt of blood transfusions or clotting factors before 1985.

    • Sharing of drug-using equipment.

    • Sexual experiences involving contact with others' genitals.

    • History of STIs.

    • Sexual contact with an HIV-positive individual.

  • Ensure follow-ups for affirmative answers.

Nursing Management Assessment (3 of 3)

  • For diagnosed patients:

    • Conduct thorough health history and physical assessments.

    • Assess immunization history and psychosocial factors.

    • Evaluate dietary habits and conduct periodic assessments for timely interventions.

Clinical Problems

  • Common problems include:

    • Risk for infection

    • Deficient knowledge

    • Difficulty coping

    • Nutritionally compromised.

Nursing Management Planning

  • Goals for Nursing Care:

    • Adherence to ART

    • Encourage a healthy lifestyle

    • Manage relationships to protect others from HIV

    • Maintain productivity and explore spiritual concerns

    • Coping with disease and treatment symptoms.

Nursing Management Implementation

  • Effective Strategies:

    • Prioritize primary prevention & health promotion, especially for chronic diseases including HIV.

    • Address early interventions when prevention fails.

Case Study (6 of 10)

  • A.O. expresses willingness to use condoms but not abstain from sex.

  • Teaching Points: What are essential elements to cover regarding barrier methods of protection?

Health Promotion Preventing HIV Infection

  • HIV infection is preventable through:

    • Development of safer behaviors.

    • Consistent and correct application of preventive measures.

  • Tailor nursing interventions to individual risk behaviors.

  • Provide culturally sensitive and appropriate education regarding sexuality and drug use.

Biomedical Prevention (1 of 2)

  • Preexposure Prophylaxis (PrEP):

    • Comprehensive strategy for reducing HIV acquisition risk in high-risk persons.

    • Used alongside other preventive methods (e.g., condoms, counseling, regular testing).

  • Address disproportionate access to PrEP.

  • Nurse's role includes education and promotion of PrEP.

Biomedical Prevention (2 of 2)

  • Non-occupational Post-exposure Prophylaxis (nPEP):

    • Combination ART delivered within 72 hours after potential exposure, continued for 28 days.

    • Situations include unanticipated exposure such as needlestick, sexual contact, or other bloodborne exposures.

    • Ongoing monitoring with subsequent HIV testing is necessary.

Promoting Population Health

  • Focus on prevention and early detection.

  • Offer resources and education about behavior modification.

  • Assist individuals in selecting methods that align with their needs.

  • Encourage combination prevention methods for increased effectiveness.

Decreasing Risks Related to Sexual Intercourse (1 of 2)

  • Safe Sexual Activities:

    • Aim to eliminate risks for HIV exposure through semen and vaginal secretions.

    • Effective methods include:

    • Abstinence

    • Limiting contact between genital areas.

    • Engaging in safer sexual activities such as manual or no-contact stimulation.

Decreasing Risks Related to Sexual Intercourse (2 of 2)

  • Risk-reducing Strategies:

    • Use of protective barriers during insertive activities:

    • Male condom.

    • Female condom.

    • Dental dams for oral sex.

Decreasing Risks Related to Drug Use (1 of 2)

  • Major risks include:

    • Sharing equipment and engaging in unsafe sex while under the influence.

  • Basic Risk Reduction Rules:

    • Avoid drug use altogether.

    • Do not share drug paraphernalia.

    • Avoid sex while impaired by drugs.

Decreasing Risks Related to Drug Use (2 of 2)

  • Preferred Methods:

    • Avoid drug use altogether or use sterile equipment.

    • Adopt needle and syringe exchange programs (NSEPs).

    • Prevent increases in drug use while controlling rates of other infections.

Decreasing Perinatal Transmission

  • Prevent HIV in infants by preventing HIV in women:

    • Discuss reproductive desires and family planning.

    • Provide voluntary HIV antibody testing and counseling if affected.

    • Administer ART to mothers during pregnancy.

    • Perinatal transmission decreases from 25% to less than 1% with ART.

Decreasing Risks At Work

  • Occupational Safety:

    • OSHA mandates protection for workers against HIV.

    • Post-Exposure Prophylaxis (PEP) with ART reduces infection risk after exposure.

    • Immediate reporting of exposures is key for timely treatment and counseling.

    • Promote voluntary HIV testing as standard medical care to reduce stigma and improve early detection.

Case Study (7 of 10)

  • While discussing barrier methods, A.O. exhibits signs of disinterest.

  • Cultural Factors: What considerations may contribute to his reaction?

Acute Care Early Intervention

  • Early intervention encourages health and limits disability:

    • Use patient input for care planning and referrals.

    • Patient reactions to positive HIV diagnoses include panic, anxiety, guilt, depression, denial, anger, and hopelessness.

    • Be prepared to clarify repeated information to address stigma and discrimination concerns.

Antiretroviral Therapy (1 of 3)

  • Importance of ART:

    • Slows HIV progression considerably but can be complex and may not work for everyone:

    • Understanding ART is crucial for patients and caregivers regarding follow-up care.

Antiretroviral Therapy (2 of 3)

  • Education on ART:

    • Discuss the advantages and disadvantages:

    • Stress adherence importance.

    • Provide guidance on how and when to take medications and avoid interactions.

    • Education on reporting side effects to healthcare providers is critical to avoid disease progression and drug resistance.

Antiretroviral Therapy (3 of 3)

  • Individualized Approaches:

    • Support networks (group support and counseling) aid in adherence.

    • Understand patient lifestyles to facilitate adherence strategies.

Delaying Disease Progression

  • Promote healthy immune function through:

    • Nutritional support.

    • Moderating or eliminating substance use.

    • Staying up-to-date with vaccinations.

    • Encouraging adequate rest and exercise.

    • Providing counseling and support groups.

Case Study (8 of 10)

  • A.O. expresses care for a partner; discuss informing previous partners about gonorrhea and potential HIV infection if he tests positive.

Acute Exacerbations

  • Care complexity increases as the immune system declines:

    • New issues compound existing health concerns.

    • Focus on assisting adherence to ART.

    • Ensure treatment for opportunistic infections and provide symptom management and support.

Pneumocystis jiroveci Pneumonia

  • A common opportunistic infection among HIV patients.

Ambulatory Care

  • HIV affects every aspect of a person's life:

    • Include physical health, social, emotional, economic, and spiritual well-being.

    • Nurses often form close connections with patients living with HIV.

Psychosocial Care

  • Patients may face complex treatment choices:

    • Feelings of loss, anger, and depression can be overwhelming.

    • Address potential social isolation and suicidal thoughts.

    • Providing education, referrals, and support is essential.

Stigma

  • Negative attitudes surrounding HIV include:

    • Misconceptions about personal control over urges and self-inflicted illness.

    • Stigma leads to discrimination, social isolation, and economic hinderances.

Disease and Drug Side Effects

  • Common physical challenges:

    • Anxiety, depression, diarrhea, neuropathy, nausea/vomiting, and fatigue.

    • These symptoms can hinder the ability to maintain a desired lifestyle.

Gerontologic Considerations HIV Infection (1 of 2)

  • HIV rates are increasing among older adults:

    • Effective treatments have reduced HIV-related mortality in older adults.

    • Those over 60 may be more susceptible due to underlying health issues and changes from ART.

Gerontologic Considerations HIV Infection (2 of 2)

  • Early problem detection and managing modifiable risk factors are vital:

    • Support for older HIV patients includes coping strategies, ART adjustments for associated conditions, and managing polypharmacy issues.

Case Study (9 of 10)

  • A.O. reports night sweats and productive cough; CD4+ lymphocyte count is 76 cells/µL.

Case Study (10 of 10)

  • A.O. loses 13 pounds in a month; prior record indicates a history of positive PPD test.

End-of-Life Care

  • Despite treatment advances, disease progression, disabilities, and mortality from HIV remain prevalent:

    • Focus on patient comfort and emotional/ spiritual acceptance of life’s challenges.

    • Assist loved ones with grief and loss management.

Evaluation

  • Patients at risk for HIV infection will:

    • Develop and implement personal plans to reduce risks.

    • Be proactive in testing for HIV.

  • Patients living with HIV will:

    • Adhere to treatment plans.

    • Collaborate with the healthcare team to achieve optimal health and prevent transmission.

Audience Response Question (1 of 2)

  • AIDS Diagnosis Criteria:

    • Can be diagnosed if:

    • WBC count < 3000/µL.

    • CD4+ T-cell count < 500/µL.

    • Development of oral candidiasis (thrush).

    • Onset of Pneumocystis jiroveci pneumonia.

Audience Response Question (1 of 2)

  • Indication for Additional Education:

    • Patient Statement: "Once my viral load is undetectable, I don’t have to worry about taking my medication."

  • Correct answer: D, as continual medication is necessary regardless of undetectable viral status.

Audience Response Question (2 of 2)

  • Best Indicator of Improvement for ART Patient:

    • Decreased viral load is a sign of improving condition.