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HIV and AIDSHIV and AIDS
EpidemiologyEpidemiologyCDC issued case definition of AIDS in
1982Number of people living with AIDS more
than doubled between 1998 and 2003AIDS kills more than 8000 people daily
around the world◦Unsafe sex predominate mode of
transmission; also infected drug injection equipment
◦Racial & ethnic minorities have disproportionately high rates of HIV in US, especially African-American & Hispanics
Transmission of HIVTransmission of HIVBody fluids: Blood, semen, vaginal
secretions, amniotic fluid, breast milk
Not transmitted via casual contactRisk of transmission via
transfusion virtually eliminated due to extensive testing, heat treatment & virus inactivation methods
Transmission to health care Transmission to health care workersworkersStandard precautions used on ALL
patientsPost-exposure treatment reduces risk of
HIV infection◦ Immediately cleanse exposed area; report it!◦Begin tx immediately after exposure, no
longer than 72 hours after◦Baseline testing for HIV, hep. B & C for you &
pt◦Follow-up testing done at 1 month, 3 & 6 mo.◦Antiretroviral therapy x 4 weeks
Can cost $500-$1000; may develop future resistance; S/E
PathophysiologyPathophysiologyHIV is a retrovirus
◦Carry genetic material in RNA instead of DNA
◦Consists of viral core containing the RNA surrounded by an envelope of glycoproteins
◦HIV has complex life cycle of 8 steps HIV attaches to an uninfected CD4 or CD8
cell surface Enzyme “reverse transcriptase” copies the
viral genetic material from RNA into DNA Mutates quickly; now 12 sub-types
identified
Stages of HIV DiseaseStages of HIV DiseaseCDC classification system:3 groups (A, B, C) based on
history, physical exam, lab values, S&S, and infections and malignancies
See Table 52-1 on page 1823
Primary Infection (A)Primary Infection (A)Defined as the period from
infection with HIV to the development of antibodies to HIV◦Intense viral replication◦Symptoms vary from none to flu-like
or “mono” Fever, enlarged lymph nodes, rash, muscle
aches, H/A◦“Window” period exists where
infection has occurred but no antibodies are detected (lasts 3 months up to 1 year)
CDC Category A:CDC Category A:HIV AsymptomaticHIV AsymptomaticBy about 6 months, viral
replication reaches lower but steady state
CD4+ T-cell count greater than 500
Few, if any, symptoms8-10 years can pass before
major HIV-related complication occurs
CDC Category B:CDC Category B:HIV SymptomaticHIV SymptomaticCD4+ T-cells drop to 200 to 499Has developed a condition related
to defect in cellular immunity ◦Candidiasis◦Cervical dysplasia◦Fever or diarrhea lasting more than 1
month◦Hairy leukoplakia of the mouth◦Herpes zoster◦ Idiopathic thrombocytopenic purpura◦PID◦Peripheral neuropathy
CDC Category C:CDC Category C:AIDSAIDSCD4+ T-cell count drops below 200Once classified as category C, patient
remains in Category C (May qualify for entitlements)◦ Candidiasis of esophagus or trachea◦ Coccidioidomycosis◦ Cryptosporidiosis◦ Cytomegalovirus◦ HIV-related encephalopathy◦ Kaposi’s sarcoma◦ Lymphoma ◦ Toxoplasmosis◦ Pneumocystis pneumonia◦ Wasting syndrome
Lab TestsLab TestsEIA (enzyme immunoassay)
◦Antibodies are detected (end of window period)
Western blot◦Also detects antibodies; confirms EIA
Viral load◦Measures HIV RNA in the plasma◦Better predictor of disease
progression than CD4 countCD4/CD8 ratio
Uni-Gold Recombigen
Multispot HIV-1/HIV-2
Reveal G2 OraQuick
Advance
Treatment of HIVTreatment of HIVProtocols change frequentlyCD4 count most important consideration in
starting therapy (less than 350)Treatment should be offered to all patients
with primary infectionTx regimens are complex, have major side-
effects & require adherence to avoid resistance
Viral load/ CD4 counts checked every 3 months◦ Viral load should drop to less than 50 copies
by 16-20 weeks; CD4 count should increase by 100-150 within 3 months
Antiretrovial AgentsAntiretrovial AgentsNRTIs (nucleoside reverse
transcriptase inhibitors): Retrovir, AZT
NNRTIs (non-nucleoside reverse transcriptase inhibitors): Sustiva
Protease inhibitors: Agenerase, Kaletra
Fusion inhibitors: FuzeonSee Table 52-3 on pages 1827-28
HAARTHAARTHighly active antiretroviral
therapyMore than one antiretroviral
medication taken in order to achieve sustained viral suppression
Medication S/EMedication S/ENausea, vomiting, diarrhea, rash,
pancreatitis, peripheral neuropathyMany cause lipodystrophy
syndrome◦Pseudo-Cushing’s appearance: fat
loss in arms & legs, with build-up of fat in abdomen & neck
◦At risk for early-onset hypercholesterolemia, heart disease & diabetes
Video ClipVideo Clip
http://www.instruction.greenriver.edu/Kmarr/Biology100/Biol%20100%20Lecture%20Notes.htm
Watch “HIV Case Study” Video
Manifestations of HIV Manifestations of HIV InfectionInfectionSx are widespread and can involve
any organ systemFatigue very commonOpportunistic infectionsImmune Reconstitution Syndromes
◦Fever & worsening of the opportunistic infection symptoms
◦Develops weeks after starting antiretroviral therapy Tx with NSAIDs to alleviate inflammatory
reaction
Respiratory InfectionsRespiratory InfectionsMost common infection in AIDS
patients is Pneumocystis pneumonia (PCP)◦Non-productive cough, fever & chills,
SOB, dyspnea, crackles, decreased O2 sats.
◦Will lead to resp. failure without txMycobacterium avium complexTB which can disseminate to CNS,
bone, stomach, peritoneum & scrotum
GI SymptomsGI SymptomsLoss of appetite, N/VDiarrhea occurs in 50-90% of AIDS
pts.◦Cryptosporidium, Salmonella, Giardia,
C. diff. May develop profound weight loss, fluid & electrolyte imbalances, weakness, perianal excoriation
Oral CandidiasisOral CandidiasisOccurs in almost all AIDS ptsMay precede life-threatening
infectionsCreamy white patches in the
mouthCan spread to esophagusDifficulty swallowingMay also have oral lesions
Mucocutaneous Candidiasis:Mucocutaneous Candidiasis: Clinical ManifestationsClinical Manifestations
Erythematous candidiasis
Credit: D. Greenspan, DSC, BDS, HIV InSite
Pseudomembranous candidiasis
Credit: Pediatric AIDS Pictorial Atlas, Baylor International Pediatric AIDS Initiative
Skin ManifestationsSkin ManifestationsHerpes zoster & simplexMolluscum contagiosum (viral
infection)Generalized folliculitis
Wasting SyndromeWasting SyndromeWeight loss of more than 10%Chronic diarrhea more than 1
monthChronic weaknessFeverHypermetabolic state with
protein-energy malnutritionElevated triglycerides
Oncologic ManifestationsOncologic ManifestationsKaposi’s sarcoma is most common
HIV related malignancy◦Skin lesions can occur anywhere on body◦Brownish-pink to deep purple; flat or
raised◦Diagnosis confirmed by skin biopsy
B-cell lymphomas are second most common; resistant to tx
Invasive cervical CA in femalesAlso can get CA in stomach, skin,
pancreas, rectum, bladder
Neurologic ManifestationsNeurologic Manifestations80% of AIDS patients will have
neurologic involvement resulting from direct effects of HIV, opportunistic infections or neoplasms
Cryptococcus meningitisLeukoencephalopathyPeripheral neuropathy R/T
demyelinationDepression
HIV EncephalopathyHIV EncephalopathyFormerly called “AIDS dementia
complex”Progressive decline in cognitive,
behavioral and motor functionsMemory deficits, headache, difficulty
concentrating, confusion, apathy, ataxiaLater stages include global cognitive
impairment, delayed verbal response, vacant stare, spastic paraparesis, hyperreflexia, psychosis, tremor, hallucinations, incontinence, seizures
CT shows diffuse cerebral atrophy & ventricular enlargement
Additional Medical Additional Medical ManagementManagementTreatment of infections
◦T-cell count less than 200 should receive prophylaxis against PCP with Bactrim or Septra (TMP-SMZ)
◦PCP treated with Septra; pentamidine used if Septra ineffective Aerosolized pentamidine no longer used
◦Prophylaxis against Mycobacterium avium with Biaxin or azithromycin, for T-cell counts less than 50
Additional Medical Additional Medical ManagementManagementTx of cryptococcal meningitis with
amphotericin B, with or without Diflucan◦Diflucan also used for suppressive therapy
Retinitis due to Cytomegalovirus (leading cause of blindness in AIDS patients): tx prophylactically with ganciclovir for T-cell counts less than 50◦Tx for retinitis must be taken for life◦Common adverse reaction is neutropenia
May be given intravitreally
Additional Medical Additional Medical ManagementManagementHerpes infections treated with
acyclovir or famciclovirOral or esophageal Candidiasis
treated with Mycelex, nystatin, Nizoral or Diflucan
Chronic diarrhea treated with Sandostatin
Kaposi’s sarcoma treated with alpha-interferon, surgical excision, liquid nitrogen, radiation
Lymphoma treated may be treated with chemo & radiation but usually has limited effect
Additional Medical Additional Medical ManagementManagementDepression treated with Tofranil,
Prozac◦ECT used for severe cases not responsive
to medsAppetite stimulants such as Megace Dronabinol (synthetic THC) used to
control N/VNutritional supplements usually
lactose-free: Advera specifically for AIDS◦Parenteral nutrition is final option due to
risk of infections
Nursing AssessmentNursing AssessmentPotential risk factors: IV drug use,
risky sexual behaviorNutritional status: anorexia, N/V,
oral pain, diarrhea, weight pattern, serum protein & albumin levels
Skin & mucous membranes: Look for breakdown, ulcerations, peri-anal excoriation
Fluid & electrolyte status: Turgor, V/S, urine output, electrolyte values
Nursing AssessmentNursing AssessmentRespiratory Status: cough,
sputum, SOB, chest pain, pulse-ox, breath sounds, CXR
Neuro Status: LOC, orientation, memory, H/A, neuropathy, seizures, visual changes, depression
Knowledge level: transmission, psychological reaction, ability to manage treatments
Nursing Diagnoses for Nursing Diagnoses for HIV/AIDSHIV/AIDSRisk for infectionDiarrheaIneffective airway clearanceImbalanced nutritionDeficient knowledgeSocial isolation*See Care Plan pages 1838-44
Nursing InterventionsNursing InterventionsMonitor for S&S of infectionBalance activities with restPrevent skin breakdown;
administer treatments as orderedPromote usual bowel patterns
◦Avoid bowel irritants; small frequent meals
◦Anti-diarrheals on routine basisImprove airway clearance
◦Cough/ deep breathe, postural drainage
Nursing InterventionsNursing InterventionsNutritional support
◦Anti-emetics, soft foods, topical Lidocaine◦Supplements & high-cal foods
Pain management◦NSAIDs, opioids, tricyclics for neuropathy
Social isolation: Many feel guilt, shame, suffer loss normal roles, anger◦Offer accepting attitude◦Reassure that HIV not transmitted casually
Nursing InterventionsNursing InterventionsMonitoring for medication side-effectsTeaching self-care: preventing
transmission of HIV & other infections (safe sexual practices, handling soiled items, handwashing, personal and environmental hygiene)◦Avoid exposure to sick people◦Avoid alcohol, tobacco◦Avoid cleaning bird cages & cat litter boxes◦Medication administration◦Nutrition◦ Importance of keeping follow-up
appointments◦Community resource referrals
Ethical Considerations Ethical Considerations Must protect patient’s right to privacyThis sometimes conflicts with sexual or
drug partners’ right to know about their exposure
State laws vary as to whether contacts are notified & who is responsible for notification
Indiana law requires that persons infected with HIV who know their status, warn past & present sexual or needle-sharing partners of their HIV status & need to seek testing◦Court can order restrictive limitations on
person who presents a danger to public health