HIV

Infection/Impaired Immunity

Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS)

  • Definition:

    • HIV is a bloodborne, sexually transmittable retrovirus that causes AIDS.

    • The disease is characterized by the death of CD4 immune cells, which leaves the body vulnerable to infections and cancer.

Risk Factors for HIV/AIDS

  • Age

  • Race

  • Biological Sex: Men who have sex with men

  • Lack of Safe Sex Habits

  • Injected Drugs and Shared Needles or Works

Gerontologic Considerations

  • Risk Awareness: Some individuals, especially those who are widowed or divorced, may be unaware of risks.

  • Sexual Activity: Many are still sexually active, though they might not use condoms (viewing them as unnecessary for birth control).

  • IV/Injection Drug Use may still be prevalent among older adults.

  • Received HIV-Infected Blood: Vulnerability due to past transfusions.

  • Normal Age-Related Changes to the immune system can exacerbate risks.

  • Increased Rates of Depression and Bereavement: These factors contribute to depressed immune function.

Epidemiology of HIV in the US

Estimated HIV Infections by Age (2019)

  • Total Estimated New HIV Infections: 34,800 in the US in 2019.

  • By Age Group:

    • 13 to 24: 13,800

    • 25 to 34: 7,200

    • 35 to 44: 6,900

    • 45 to 54: 3,800

    • 55 and older: 3,100

  • Note: Data not available for children aged 12 and under.

Estimated HIV Infections by Race and Ethnicity (2021)

  • Black/African American People:

    • Account for 40% of estimated HIV infections despite making up 12% of the US population.

  • Numbers by Group:

    • American Indian/Alaska Native: 470

    • Asian: 190

    • Black/African American: 13,000

    • Hispanic/Latino: 9,300

    • White: 8,200

    • Multiracial: 890

  • Notes on Definitions:

    • “Black” refers to people with origins in any Black racial group in Africa.

    • “Hispanic/Latino” people can belong to any race.

Transmission Categories

  • Transmission Data Notes:

    • Data statistically adjusted for missing transmission categories.

    • “Other” category accounts for 1% or less of cases.

  • Types of Transmission:

    • Heterosexual contact with someone at high risk of HIV infection.

    • Perinatal Transmission: Includes persons whose infections resulted from perinatal transmission, aged 13 years and above.

Drug-Associated HIV Transmission

  • Drug Injections: Associated with the opioid and heroin crisis.

  • Prevention Strategies:

    • Drug abuse treatment

    • Syringe service programs

    • Disinfecting equipment with bleach

  • Modes of Transmission:

    • Contact with blood, semen, vaginal/cervical fluids.

    • Mother-child transmission (in utero or breastfeeding; primarily during delivery).

  • Prevention Measures for Pregnant Women:

    • HIV positive mothers should not breastfeed and should seek treatment.

  • Occupational Exposure:

    • Percutaneous injuries or contact with non-intact skin or mucous membrane with infectious fluids require prevention measures such as assuming all blood/body fluids carry infection and using needle safety measures.

Managing Exposure to HIV

  • Immediate Actions:

    • Wash exposed area thoroughly with soap and water.

    • Alert supervisor or charge RN.

    • File event/injury report and document in employee health record.

  • Consent for Testing and Treatment:

    • Obtain informed consent for blood testing from source patient.

    • Employee consent for testing should occur as soon as possible, preferably within 72 hours after the incident.

  • Post-Exposure Prophylaxis (PEP):

    • Medications (three or more antivirals) should begin as soon as possible and be continued for four weeks.

  • Follow-Up:

    • Testing and counseling post-PEP treatment are critical.

Prophylaxis Strategies

  • Pre-Exposure Prophylaxis (PrEP):

    • For individuals who are HIV negative but at high risk.

    • Reduces risk of HIV transmission from sex by 99%.

    • Available in oral and injection forms, does not replace safer sex practices.

  • Post-Exposure Prophylaxis (PEP):

    • For individuals who are HIV negative but had potential exposure to HIV.

    • Intended for emergent situations only; not for frequent use.

    • Should be administered within 72 hours of exposure.

Stages of HIV Infection

  1. Acute Infection:

    • Initial response occurs approximately four weeks post-infection.

    • Symptoms may include fever, sore throat, rash, night sweats, chills, headache, muscle aches (often mistaken for general viral infections).

    • High viral load in the bloodstream and genital tract increases potential for sexual transmission.

  2. Chronic Infection:

    • This is typically the stage of diagnosis and the initiation of treatment to suppress viral reproduction.

    • With treatment, a stable viral load can be maintained, often leading to an undetectable load.

  3. AIDS:

    • Defined as CD4 T lymphocyte count < 200 cells/mm³.

    • Significant immune system impairment correlates with increased risk for opportunistic infections including:

    • Candidiasis

    • Cytomegalovirus

    • Pneumocystis pneumonia

    • Tuberculosis (TB)

    • Mycobacterium avium complex

Disease Development Impact

  • Other Body Systems Impacted by HIV/AIDS:

    • Cardiovascular Issues: Including coronary artery disease (CAD), heart failure (HF), and hyperglycemia.

    • Endocrine Disorders

    • Gastrointestinal Problems: Such as anorexia, malabsorption, weight loss, and diarrhea.

    • Dermatological Manifestations: Including Kaposi sarcoma and rashes.

    • Neurocognitive Disorders: Leading to gait changes and neuropathies.

    • Renal Issues: Nephropathy.

    • Respiratory Conditions: Chronic obstructive pulmonary disease (COPD).

    • Psychological Concerns: Increased incidence of depression and suicidal ideation.

Progression Rate and Predictors

  • Progression Rate:

    • HIV/AIDS is characterized by a variable progression rate among individuals.

  • Key Predictor of Opportunistic Infections:

    • CD4 cell counts are the most significant predictor of opportunistic infections.

HIV Testing Recommendations

  • Universal Testing Recommendations:

    • Individuals aged 13-64 years should receive universal testing.

    • Those at higher risk should be tested more frequently.

Types of HIV Testing

  1. Nucleic Acid Tests (NAT):

    • Detect specific amounts of the virus (viral load test).

  2. Antigen/Antibody Test:

    • Detects early acute infection by identifying HIV antigens and antibodies.

  3. Antibody Test:

    • Detects specific HIV antibodies in the blood or oral fluid.

    • Includes the only FDA approved HIV self-test.

Treatment Goals for HIV/AIDS

  • Overall Goals:

    • Reduce HIV-related morbidity and mortality.

    • Improve quality of life for patients.

    • Restore and preserve immunological function.

    • Achieve long-term viral suppression.

Treatment Strategies

  • Antiretroviral Treatment (ART):

    • ART should be offered to all individuals regardless of CD4 cell count to reduce morbidity, mortality, and transmission.

  • Factors Influencing Treatment Decisions:

    • CD4+ count

    • Viral load

    • Presence of severe symptoms

    • Willingness to adhere to a lifelong treatment regimen.

Drug Resistance Considerations

  • Common Causes of Drug Resistance:

    • Serial monotherapy during early clinical trials.

    • Inadequate suppression of virus replication due to suboptimal treatment regimens.

    • Late initiation of therapy in the HIV disease course.

Importance of Medication Adherence

  • Benefits of Adherence:

    • Reduces viral load.

    • Prevents transmission of HIV to others.

    • Achieving an undetectable viral load helps prevent drug resistance.

Barriers to Adherence

  • Side Effects:

    • Include nausea/vomiting/diarrhea, difficulty sleeping, dry mouth, headaches, dizziness, fatigue, and pain at the injection site.

  • Challenges Related to Daily Life:

    • Having a busy schedule or personal responsibilities can hinder adherence.

  • Mental Health/Substance Use Issues:

    • These can also complicate adherence.

Classes of ARV Medications

  • Major Classes:

    • There are ten major classes of antiretroviral therapies that attack HIV at different stages of its replication cycle.

    • Multi-modality Therapy:

    • Recommended to use at least three medications from at least two classes for effective treatment.

Monitoring of HIV Progression

  • CD4/CD8 Ratio and CD4 Count:

    • Regular checks are essential as HIV kills CD4 cells, typically every 3-6 months.

  • Viral Load:

    • Measures the amount of HIV in the blood (plasma HIV RNA).

    • A lower viral load indicates less HIV in the body and a longer time until an AIDS diagnosis; typically checked every 3-4 months.

    • Testing before starting a new HIV medicine and 2-8 weeks after starting or changing medications is required.

  • Lymphocyte Counts:

    • Important for assessing stage III HIV infection, which presents with low white blood cell counts.

Care Coordination

  • Interdisciplinary Care Team Includes:

    • Pharmacy professionals

    • Chronic disease specialists focusing on comorbidities

    • Dieticians

    • Infectious disease specialists

    • Social workers

    • Wound care specialists

    • Pain management specialists