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