Barbara Weis MS, RN, CCRNFall 2007

HIV/AIDS

History of HIV/AIDS1981

1985

1987

1994

1995-1999

2000-present

Documented presence of new disease

Causative agent identified (HIV)AIDS determined to be end stageAntibody test developedRoutes of transmission determined

Drug therapy availableOK first state to mandate AIDS education

Other advancesDevelopment of lab testsProduction of new drugsCombination drug therapyTest for antiretroviral drug resistanceTreatment to decrease risk of transmission from mother to baby

Protease inhibitors approvedHome testing available; Antigen testing & viral load testing available

New drug formulas approved; 1st generic drug approvedRapid HIV testing availableHIV genotyping approved to begin

Ribonucleic Acid Virus

HIV Replication

CD4+ T Cells

CD4 Receptorslymphocytesmonocytes/macrophages Helper T cellsastrocytesOligodendrocytes

Adults normal800 to 1200 per microliter (µl) of bloodNormal life span: 100 days

Healthy until 500 CD4+ T cells/µlProblems start at 200 to 499 CD4+ T cells/µlSevere problems start at < 200 CD4+ T cells/µl

Transmission of HIVContact with infected

body fluidsBloodSemenVaginal secretionsBreast milk

One of three ways:Sexual intercourse with

infected partnerExposure to HIV-infected

blood or blood products

Perinatal transmissionDuring pregnancyAt time of deliveryBreastfeeding

Factors Affecting Transmission

Duration of contact

Frequency of contact

Volume of fluid

Virulence of virus

Concentration of virus

Host immune status

Sexual TransmissionSexual contact with an HIV-infected partner

Contact with semen, vaginal secretions, and/or bloodLymphocytes containing HIV

MSM account for most cases of sexual transmission

MSW most common method of infection for women

Unprotected anal intercourse most riskyGreatest risk for partner who receives

the semenReceiver has prolonged contact with semenCan be transmitted to inserting partner

Most risky when blood involvedMenstruationTraumaGenital lesions from other STDs

Injection Equipment

Accidental or intended sharingIllegal drugs

All used equipment is potentially contaminated

Only 1% of adult AIDS cases

Blood donationRoutine screening not until 1985

Still possible during first few

months after infection

Clotting FactorsHeat and chemical treated

Healthcare WorkersOccupational exposure57 heath care workers (24

nurses)137 more cases of accidental exposure

Risk of infection after needle-stick

0.3% to 0.4%Deep puncture woundHollow bore needleVisible bloodHigher if patient has high viral

loadPatient dies within 60 days

Risk of infection after splash exposure

Risk much lowerOn skin with open lesion

Employer RequirementsProtect workers from exposure to blood and other potentially infectious materialsPostexposure prophylaxis (PEP)

Combination ART Type of exposureVolume of exposureStatus of source patient

Report exposuresOSHA requirements Isolation needs

Diagnosis of HIVWindow period after infection

Will not test antibody positiveMedian delay of 2 months before antibodies can be

detected

Testing is highly accurate if proper sequence followed (Lewis Table 14-3)

Locations offering free testing Not all tests available everywhere

Sample: Oral mucosa, urine and bloodTime: Standard or rapid (20 minutes)Method: EIA, Western BlotFDA approval and availability

Blood Testing

Standard blood test

First to be developed

Most widely used

May take 2 weeks

Initial assay used (EIA, ELISA)

Confirmed with Western Blot

OMT HIV Antibody TestAlternative to standard blood testSpecially treated pad placed in

mouth and gently rubbed between lower cheek and gum

Collect oral fluid called oral mucosal transudate (OMT)

Must be confirmed with Western Blot

Does not test saliva!FDA approvedRapid Report

Orrasure© OraQuick Advance HIV½ ©

Urine HIV Antibody Test

Painless and NoninvasiveNot as sensitive or specific as blood testing

Urine EIA (ELISA)Confirmed with Western Blot technique

FDA-licensed as alternative to blood testEliminates needle sticks and exposure-

related dangersProtects patient and healthcare worker

Rapid HIV Antibody Test

Results in 5 to 60 minutesCollection

Fingertip lanced for small drop of bloodOral fluid swabbedReactive test result

Must still be confirmed with Western BlotFDA Approved

Reveal G2 HIV-Antibody Tests, manufactured by MedMira, Inc.

Multispot, manufactured by Bio-Rad Laboratories Uni-Gold Recombigen, manufactured by Trinity Biotech

Home Testing Kits

Do-it-yourselfFinger-prick

Mailed to laboratory on card

Test results provided over phone

Available at drug stores

FDA approvedHome Access Kit

Rapid tests not accurate

Perinatal and Newborn Testing

HIV-infected Mother identified during pregnancyMedications highly effective if initiated

Reduces risk to 1-2 percent

HIV-infected Mother identified at labor and deliveryMedications initiated at labor and delivery

Reduces risk to 9 to 13 percent

HIV-infected Mother not identifiedRisk of transmission at 25 percent

All babies born to HIV –infected mothers will be positive

Antibodies remain present for up to 18 months

HIV DNA polymerase chair reaction (PCR),, HIV RNA PCR, or viral culture

Laboratory Studies

Decreased white blood cell count (WBC)Low neutrophil count (neutropenia)

Low platelet counts (thrombocytopenia)Anitiplatelet antibodiesDrug therapy

AnemiaChronic disease processAdverse effect of antiretroviral agents

Altered liver function testsDisease ProcessDrug therapy

Co infectionHepatitis B virus (HBV)Hepatitis C virus (HBC)

HIV Staging

Category 1 CD4 count >500

Category AAsymptomatic or acute

HIV infection

Early Chronic Infection

Category 2 CD4 count 200 – 499

Category BSymptomatic disease

Intermediate Chronic

Infection

Category 3CD4 count <200

Category CAIDS Conditions

Late Chronic Infection

Once at C, always at C

Timeline: Untreated HIV

Acute HIV Infection

Acute retroviral syndromeSeroconversion

Occurs in 1 to 3 weeks

Lasts 1 to 2 weeks, to months

High viral load

CD4+ T Cells fall temporarily

Symptoms may be mistaken for fluFever, swollen lymph glands, sore throat, headache, malaise,

nausea, muscle and joint pain, diarrhea, diffuse rash

Neurologic complicationsAseptic meningitis, peripheral neuropathy, facial palsy,

Guillian-Barre syndrome

Early Chronic HIV Infection

10 yearsCD4+ T lymphocyte cells remain above 500

cells/µ/lViral load in blood will be lowAsymptomatic disease or

Fatigue, headache, low-grade fever, night sweats, persistent generalized lymphadenopathy (PGL)

May not be aware of infection

Intermediate Chronic Infection

CD4+ T cell count to 200 - 499 µlViral load risesEarly phase symptoms become worse

persistent fever, frequent drenching night sweats, chronic diarrhea, recurrent headaches, and fatigue severe enough to interrupt normal routines

New symptomslocalized infections, lymphadenopathy, nervous

system manifestations, and opportunistic infections begin

Opportunistic InfectionsOropharyngeal

candidiasis (thrush)

Varicella zoster virus (shingles)

Vaginal candidal infections

Oral or genital herpes

Oral hairy leukoplakia

Epstein-Barr virus

See Lewis Table 14-1 for lists of other infections

Late Chronic Infection (AIDS)

CD4+ count below 200CD4 (helper) to CD8 (suppressor) ratio

reversesAbsolute number of lymphocytes increasePercentage of lymphocytes increases

Development of opportunistic infection (OI)Development of opportunistic cancerWasting Syndrome

loss of 10% or more of body weightDementia

Collaborative Management

Monitoring disease progression

Monitoring immune function

Initiating and monitoring ART (antiretroviral drug therapy)

Preventing development of opportunistic diseases

Detecting and treating opportunistic diseases

Managing symptoms

Preventing or decreasing complications of treatment

Tests for Resistance

Tests for resistance to antiretroviral drugsGenotype assay

Detects drug-resistant viral mutations that are present in the reverse transcriptase and protease genes

Phenotype assay Measures the growth of the virus in various

concentrations of antiretroviral drugs

Starting ART

Old guidelines: “Hit early, hit hard”

New guidelines: Wait for viral load to go up

Consider:

Client readiness

Client ability to adhere to regimen

95% adherence rate required to prevent disease progression, opportunistic disease, viral drug resistance.

Electronic reminders, beepers, timers on pillboxes

Drug Therapy for HIV Infection

Goals:

1. Decreases HIV RNA levels to less than 50 copies/µl

2. Maintain or raise CD4+ T cell counts to greater than 200 cells/µl

Also known as Immune reconstitution

3. Delay development of HIV-related symptoms

Opportunistic diseases

Lewis Table 14-4 Principles of Therapy

National Institutes of Health website

Disease and Drug Side EffectsAnxiety, fear,

depression

Diarrhea

Peripheral neuropathy

Pain, n & v

Fatigue

Skin breakdown

Nursing Assessment

Focus on behaviors:

Have you ever had a blood transfusion or used clotting factors? If so, was it before 1985?

Have you ever shared needles, syringes, or other injecting equipment with another person?

Have you ever had a sexual experience in which your penis, vagina, rectum, or mouth came into contact with another person's penis, vagina, rectum, or mouth?

Have you ever had an STD?

Positive response requires in-depth exploration!

Nursing Diagnosis

Nursing Outcomes

Patient Education

1. Adhere to drug regimens

2. Promote a healthy lifestyle

3. Prevent opportunistic disease

4. Protect others from HIV

5. Maintain or develop healthy, supportive relationships

6. Maintain activities and productivity

7. Come to terms with issues related to disease, death, and spirituality

Illicit Drug Use

Sharing injecting equipmentUnsafe sexual experiences while under influence of drugsThe basic rules are as follows:

1. Do not use drugs2. If you use drugs, do not share equipment;

Use alternatives (smoking, snorting, ingesting)Needles, syringes, cookers (spoons or bottle caps

used to mix drugs), cotton, rinse waterCommunity Needle and Syringe Exchange Programs

3. Do not have sexual intercourse when under the influence of any drug (including alcohol) that impairs decision-making ability

Initial Response to Diagnosis

Empowerment

Education

Honest discussions

Health status

Treatment Options

Referrals

Local agencies

Web resources

Literature

Groups

Health Promotion

Promote healthy immune systemNutritional Support

• Maintain lean body mass• Ensure appropriate levels of vitamins and

micronutrientsModeration or elimination of alcohol, nicotine, and drug

useAdequate rest and exerciseStress reductionAvoidance of exposure to new infectious agentsMental Health counselingInvolvement in support groups and community activities

Pneumocystis Carinii Pneumonia

CD4 counts < 200

Prevent with antibiotics

S/S:

SOB, fever, night sweats, fatigue, weight loss, non-productive cough

May require intensive therapy

Cryptococcus Neoformans6 to 10% of all HIV-infected clientsMeningitis

Prolonged waxing and waning period of fever Headache and malaise Nausea & vomiting

Altered Mental Status Stiff neck

Visual disturbances, papilledema Light sensitivity

SeizuresAphasiaAtaxia

Relapse rate: 50-75%Maintenance therapy

Cytomegalovirus Retinitis

RetinitisDecreased vision

floatersOne-sided visual

field lossblindness

"Blue Yonder," Elliott Linwood

Kaposi's sarcoma

Skin

Lesions flat or raised

Variety in color and shape

Lungs and GI Tract

Bleeding

Respiratory distress

Palliative care

Lesions resolved with ART

Mycobacterium Avium complex

Gastrointestinal tract problems

Can also infect blood, spleen, lymph nodes, bone marrow, liver.

Chronic diarrhea, abdominal pain, fever, malaise, weight loss, anemia, neutropenia, malabsorption syndrome, obstructive jaundice

Teach about drug therapy

Teach how to deal with diarrhea, n & v

Metabolic Disorders

Changes in body shape

Fat redistribution to abdomen, upper back, breasts

Wasting in arms, legs and face

Hyperlipidemia• Elevated triglycerides• Decreases in high-density lipoproteins

Insulin resistance and Hyperglycemia

Bone disease • osteoporosis, osteopenia, avascular necrosis

Lactic Acidosis

Cardiovascular disease

AIDS-Dementia Complex

Cognitive, behavioral motor abnormalitiesDecreased ability to concentrate, apathy, depression,

inattention, forgetfulness, social withdrawal, personality change, insomnia, confusion, hallucinations, slowed response rates, clumsiness, ataxias

HIV-Associated Cognitive Motor ComplexLymphoma, toxoplasmosis, CMV, herpes virus,

Cryptococcus, Progressive multifocal leukoencephalopathy, dehydration, drug side effects

Reversible if treatable cause identifiedInterventions: Safety, maintaining meaningful environment,

frequent reorientation, stress reduction, family support

Terminal phase

Disease progresses toward disability and death

Calculated decision to forego further treatment

Comfort care, facilitate emotional and spiritual acceptance of finite nature of life

Help SO’s deal with grief and loss

Hospice

Suicide Rates

66 times greater

than that of others

Art from:

thebody.com

Untitled (self-portrait), c. 1993-96, Nelson Edwin Rodriguez