HIV (INSTI-based regimens, baseline labs: viral load, CD4 count, resistance testing, hepatitis panel, TB test, CBC, CMP, lipids, and pregnancy test)

🧬 HIV – Nurse Practitioner Clinical Guide

🧠 What Is HIV?

HIV is a retrovirus that attacks the immune system, specifically CD4+ T-cells, leading to progressive immunosuppression. If untreated, it can progress to AIDS (Acquired Immunodeficiency Syndrome).

🦠 Pathophysiology:

  • HIV enters CD4+ cells and integrates into the host genome

  • Gradual depletion of CD4 cells → immune dysfunction

  • Increases risk of opportunistic infections, malignancies

🔄 Modes of Transmission:

Mode

Examples

Sexual

Anal, vaginal (most common worldwide)

Blood

Needle sharing, transfusions (rare now)

Perinatal

During pregnancy, delivery, or breastfeeding

Occupational

Needle-stick injuries (low but possible risk)

📊 Epidemiology:

  • Over 1.2 million people in the U.S. living with HIV

  • 1 in 8 don’t know they have it

  • Most new infections in the U.S. occur in:

    • MSM (men who have sex with men)

    • People of color

    • People who inject drugs

🩺 Clinical Presentation

🧪 Acute HIV Infection ("Seroconversion")

  • Occurs ~2–4 weeks after exposure

  • Flu-like illness: fever, sore throat, rash, myalgias, lymphadenopathy

  • Often mistaken for viral syndrome

  • Very high viral load, highly infectious

📉 Chronic HIV (Asymptomatic)

  • CD4 count gradually declines

  • May last years without symptoms

⚠ AIDS (CD4 < 200 cells/mm³ or AIDS-defining illness)

  • Opportunistic infections: PCP, toxoplasmosis, CMV, cryptococcal meningitis

  • AIDS-defining cancers: Kaposi sarcoma, lymphoma, invasive cervical cancer

🧪 HIV Testing: What NPs Need to Know

Test

Use

HIV 1/2 Antigen/Antibody (4th gen)

Preferred screening test – detects p24 antigen and antibodies

HIV RNA (viral load)

Detects virus directly – useful in early/acute infection or to confirm diagnosis

Western Blot

No longer routinely used

✅ NP Tip: Everyone aged 13–64 should be screened at least once; high-risk individuals annually.

📋 NP Role in HIV Diagnosis & Care

  • Provide pre- and post-test counseling

  • Link newly diagnosed patients to HIV-specialized care

  • Monitor adherence, labs, side effects

  • Promote stigma-free, holistic care

  • Screen and vaccinate for Hep A, B, HPV, flu, pneumococcal, etc.

💊 Antiretroviral Therapy (ART)

Goals:

  • Suppress HIV viral load to undetectable

  • Restore and preserve immune function (CD4 count)

  • Prevent transmission

Standard Regimen:

  • Usually 3-drug combination: 2 NRTIs + 1 INSTI

    • E.g., Biktarvy (bictegravir + emtricitabine + tenofovir alafenamide)

✅ U = U: Undetectable = Untransmittable
If viral load is suppressed, no risk of sexual transmission

📅 Monitoring:

  • CD4 count: Gauge immune function

  • HIV RNA (viral load): Treatment efficacy

  • Resistance testing: At baseline and treatment failure

  • STI screening, mental health, substance use

🛡 HIV Prevention Strategies

1. PrEP (Pre-exposure prophylaxis)

For HIV-negative individuals at high risk

Med

Who

Truvada (daily pill)

MSM, IV drug users, heterosexuals at risk

Descovy

Approved for MSM (not for vaginal sex)

Apretude

Injectable PrEP every 2 months

✅ Check HIV status, renal function, and STI screen before starting

2. PEP (Post-exposure prophylaxis)

  • Start within 72 hours of exposure

  • 28-day regimen (e.g., Truvada + Tivicay)

⚠ Common Opportunistic Infections (OIs) to Know:

CD4 Count

Risk

< 200

Pneumocystis jirovecii pneumonia (PCP) – TMP-SMX prophylaxis

< 100

Toxoplasmosis, Cryptococcus

< 50

MAC (Mycobacterium avium complex), CMV retinitis

🗣 Patient Education Key Points

  • ART is lifelong, but modern meds are well-tolerated

  • Adherence = viral suppression = no transmission

  • Keep regular appointments to monitor labs and health

  • Discuss mental health, stigma, and sexual health

  • Encourage partner testing and PrEP if negative

✅ NP Clinical Pearls

  • Screen all patients aged 13–64

  • 4th gen test is the best screening tool

  • HIV is manageable and treatable—early diagnosis saves lives

  • Always think about STIs, Hep B/C co-infection, substance use, and mental health

  • Stay updated on PrEP/PEP guidelines!