HIV & AIDSHIV & AIDS

Claire O’GormanClaire O’Gorman

Claire PettipasClaire Pettipas

Michèle Weir-CotnoirMichèle Weir-Cotnoir

ObjectivesObjectives Describe the pathophysiology of HIV the Describe the pathophysiology of HIV the

consequential infections that occurconsequential infections that occur Understand the Epidemiology of the Understand the Epidemiology of the

disease and the effects of HIV/AIDS on a disease and the effects of HIV/AIDS on a society, including Canadasociety, including Canada

Understand the risk factors associated Understand the risk factors associated with contracting HIV and how to prevent with contracting HIV and how to prevent infectioninfection

Describe how to protect yourself as a HCP Describe how to protect yourself as a HCP from infectious blood borne diseasesfrom infectious blood borne diseases

Understand the nursing management of Understand the nursing management of this terminal illness and the conditions this terminal illness and the conditions associated with it.associated with it.

What Is HIV?What Is HIV?

H – Human

I – Immunodeficiency

V – Virus

What is AIDS?What is AIDS?

A A – Aquired – Aquired II – Immune – ImmuneDD- Deficiency- DeficiencySS- Syndrome- Syndrome

For diagnosis must be:For diagnosis must be:HIV positive, and HIV positive, and CD4 (T-cell) count below 200, or CD4 (T-cell) count below 200, or The presence of one or more opportunistic The presence of one or more opportunistic

infections. infections.

Class ActivityClass Activity

STAND UP!STAND UP!

Global EpidemiologyGlobal Epidemiology

39.5 million39.5 million people living with people living with HIV/AIDS in 2006HIV/AIDS in 2006– 4.3 million newly infected with HIV (more 4.3 million newly infected with HIV (more

than half are younger than 25)than half are younger than 25)– 2.9 million people died from AIDS2.9 million people died from AIDS

More than More than 25 million25 million people have died people have died from AIDS since 1981from AIDS since 1981

Africa has over 12 million AIDS Africa has over 12 million AIDS orphansorphans

Global TrendsGlobal Trends

Xtending HopeXtending Hope

What can you do on campus to address What can you do on campus to address the global AIDS epidemic?the global AIDS epidemic?

Canadian EpidemiologyCanadian Epidemiology

Public Health Agency of Canada. HIV and AIDS in Canada. Public Health Agency of Canada. HIV and AIDS in Canada. Surveillance report to June 30, 2006Surveillance report to June 30, 2006. Surveillance and Risk . Surveillance and Risk Assessment Division, Centre for Infectious Disease Prevention and Assessment Division, Centre for Infectious Disease Prevention and Control, Health Canada, November 2006 Control, Health Canada, November 2006

Health Canada. Health Canada. HIV/AIDS EPI Updates, August 2006HIV/AIDS EPI Updates, August 2006, Surveillance and Risk , Surveillance and Risk Assessment Division, Centre for Infectious Disease Prevention and Assessment Division, Centre for Infectious Disease Prevention and Control, Health Canada, 2006 Control, Health Canada, 2006

58 000 people in Canada with HIV (as of Dec, 2005)

30% of people unaware of their infection

Between 2 300 and 4 500 new HIV infections every year

329 people in Nova Scotia/PEI have AIDS (as of June, 2006)

Canadian EpidemiologyCanadian Epidemiology

Affects ALL races, genders, agesAffects ALL races, genders, ages– Most people who test HIV positive are Most people who test HIV positive are

between the ages of 20-40between the ages of 20-40– Minorities, such as aboriginals and black Minorities, such as aboriginals and black

people, are over representedpeople, are over represented– Women remain around 1/3 of newly Women remain around 1/3 of newly

infected patients (increase since 1995)infected patients (increase since 1995)– Greater risk of infection with high risk Greater risk of infection with high risk

activitiesactivities

Risk FactorsRisk Factors

Transmission: through bodily fluids Transmission: through bodily fluids from an infected personfrom an infected person

Three Conditions:Three Conditions:1. Virus Must be Present1. Virus Must be Present2. There must be a high 2. There must be a high enough concentration of enough concentration of the virus in the infected the virus in the infected personperson3. There must be a way 3. There must be a way for the virus to enter the for the virus to enter the bloodstreambloodstream

Through Blood, Seman, Through Blood, Seman, Vaginal Fluid, or Breast Vaginal Fluid, or Breast milkmilk

TransmissionTransmission

Possible Sources of Transmission: Possible Sources of Transmission: – Blood products/ transfusionsBlood products/ transfusions

Before 1985Before 1985

– Mother to childMother to child Pregnancy, birth, and breastfeedingPregnancy, birth, and breastfeeding

– Contaminated needlesContaminated needles Injection drug use, tattoos, peircings, acupuntureInjection drug use, tattoos, peircings, acupunture

– Sexual contactSexual contact Unprotected sex Unprotected sex Unwashed sexual devicesUnwashed sexual devices Greater risk with other STI due to breaks in skinGreater risk with other STI due to breaks in skin Greater risk with increased number of partnersGreater risk with increased number of partners

Risk FactorsRisk Factors NOT transmitted throughNOT transmitted through

– Casual contact (shaking hands)Casual contact (shaking hands)– HuggingHugging– KissingKissing– SweatSweat– TearsTears– Donating BloodDonating Blood– Swimming PoolsSwimming Pools– Toilet seats Toilet seats – TelephonesTelephones– Sharing bed linens, towels, eating utensils, or Sharing bed linens, towels, eating utensils, or

foodfood– Insect bitesInsect bites

Societal Risk FactorsSocietal Risk Factors

Many determinants of health!Many determinants of health! These, in turn, become consequences of These, in turn, become consequences of

an epidemican epidemic Societal factors that contribute to the Societal factors that contribute to the

epidemic:epidemic:– People on the movePeople on the move– People in conflictPeople in conflict– PovertyPoverty– Stigma and DenialStigma and Denial– Cultural factorsCultural factors

Role of WomenRole of Women

PreventionPrevention

Prevention is the most realistic strategyPrevention is the most realistic strategy– Vaccine or cure unlikely anytime soonVaccine or cure unlikely anytime soon

Prevention is done by decreasing both Prevention is done by decreasing both societal and individual risk factorssocietal and individual risk factors

Barriers to prevention include:Barriers to prevention include:– Political instabilityPolitical instability– Lack of resourcesLack of resources– Existence of other endemic health problems Existence of other endemic health problems

(ie: malaria and childhood diseases)(ie: malaria and childhood diseases)– InefficiencyInefficiency– Apathy and silenceApathy and silence– Misconceptions and lack of knowledgeMisconceptions and lack of knowledge

Decreasing Individual Risk Decreasing Individual Risk FactorsFactors

Nurses are responsible for educating their Nurses are responsible for educating their clients about how to protect themselves clients about how to protect themselves from HIV/AIDS!from HIV/AIDS!

Literacy appropriate teachingLiteracy appropriate teaching Use multiple teaching methodsUse multiple teaching methods

– Provide visual/auditory/written material for Provide visual/auditory/written material for different learning stylesdifferent learning styles

– Provide for kinetic learners, too, such as having Provide for kinetic learners, too, such as having the client demonstrate how put on a condomthe client demonstrate how put on a condom

Direct clients to community resourcesDirect clients to community resources– Where they can be tested for HIV/AIDS and Where they can be tested for HIV/AIDS and

other STI’sother STI’s– Support groupsSupport groups

Community ResourcesCommunity ResourcesAIDS Coalition of Nova Scotia AIDS Coalition of Nova Scotia (ACNS)(ACNS)326-1657 Barrington Street326-1657 Barrington StreetHalifax, Nova Scotia, B3J 2A1Halifax, Nova Scotia, B3J 2A1Phone: 902 425 4882Phone: 902 425 4882Alternate Thursday Evenings Alternate Thursday Evenings 5:00pm–8:00pm5:00pm–8:00pmCall for Schedule - By Call for Schedule - By Appointment OnlyAppointment Only

Mainline Needle ExchangeMainline Needle Exchange5511 Cornwallis Street5511 Cornwallis StreetHalifax, Nova Scotia, B3K 3B4Halifax, Nova Scotia, B3K 3B4Phone: 902 423 9991Phone: 902 423 9991Every Second Monday 9:30am–Every Second Monday 9:30am–11:30am11:30amCall for Schedule - Drop InCall for Schedule - Drop In

Healing Our Nations Healing Our Nations Aboriginal AIDS Task ForceAboriginal AIDS Task Force607-45 Alderney Drive607-45 Alderney DriveDartmouth, Nova Scotia, B2Y 2N6Dartmouth, Nova Scotia, B2Y 2N6Phone: 902 492 4255Phone: 902 492 4255

Halifax Sexual Health Centre Halifax Sexual Health Centre (HSHC)(HSHC)201-6009 Quinpool Road201-6009 Quinpool RoadHalifax, Nova Scotia, B3K 5J7Halifax, Nova Scotia, B3K 5J7Phone: 902 455 9656Phone: 902 455 9656Monday–Friday 8:30am–4:30pmMonday–Friday 8:30am–4:30pmBy Appointment OnlyBy Appointment Only

Lesbian Gay Bisexual Youth Lesbian Gay Bisexual Youth ProjectProject2281 Brunswick Street2281 Brunswick StreetHalifax, Nova Scotia, B3K 2Y9Halifax, Nova Scotia, B3K 2Y9Phone: 902 429 5429Phone: 902 429 5429Every Fourth Thursday 5:00pm-Every Fourth Thursday 5:00pm-8:00pm8:00pmBy Appointment OnlyBy Appointment Only

Teen SceneTeen Scene16 Dentith Road (South Centre Mall)16 Dentith Road (South Centre Mall)Spryfield, Nova Scotia, B3R 2H9Spryfield, Nova Scotia, B3R 2H9Phone: 902 455 9656Phone: 902 455 9656Every Fourth Thursday 3:30pm–Every Fourth Thursday 3:30pm–5:30pm5:30pm

Prevention: Practice SAFER Prevention: Practice SAFER sexsex

Nurses must be Nurses must be comfortable discussing comfortable discussing their clients’ sexual their clients’ sexual activitesactivites– Assess: number of Assess: number of

partners, protection being partners, protection being used, and whether it is used, and whether it is being used properlybeing used properly

– Ask everyone! Don’t Ask everyone! Don’t assume!assume!

– Educate: know STI status Educate: know STI status of sexual partners, of sexual partners, HIV/AIDS and other STI HIV/AIDS and other STI testing, use of latex testing, use of latex condoms, dental dams, condoms, dental dams, latex gloves, water-based latex gloves, water-based lubricantslubricants

Prevention: Clean NeedlesPrevention: Clean Needles

Risk reduction school of thoughtRisk reduction school of thought Nurse can :Nurse can :

– Direct client to addiction servicesDirect client to addiction services– Direct client to needle exchange program if Direct client to needle exchange program if

quitting is not an option at this timequitting is not an option at this time– Alcohol kills HIVAlcohol kills HIV– Educate! Sharing needles with friends is just Educate! Sharing needles with friends is just

as risky as sharing with strangersas risky as sharing with strangers

Prevention: ScreeningPrevention: Screening

Many STI’s are Many STI’s are tested with gyne tested with gyne exams, but HIV exams, but HIV requires a blood requires a blood testtest

HIV antibody testHIV antibody test

Prevention: EducationPrevention: Education

Many myths and misconceptions ie:Many myths and misconceptions ie:– HIV doesn’t exist within this communityHIV doesn’t exist within this community– HIV only affects sex-trade workers, HIV only affects sex-trade workers,

homosexuals and injection drug usershomosexuals and injection drug users– If you get HIV you will show symptomsIf you get HIV you will show symptoms– Having sex with a virgin will cure you of Having sex with a virgin will cure you of

HIVHIV Nurses play a large role in providing Nurses play a large role in providing

the facts!the facts!

Prevention: PolicyPrevention: Policy

Society contributes to HIV Society contributes to HIV transmission!transmission!– Empowering womenEmpowering women– Promoting JusticePromoting Justice– Addressing PovertyAddressing Poverty– Providing EducationProviding Education– Addressing StigmaAddressing Stigma

What exactly is HIV?What exactly is HIV?

Human Immunodeficiency Virus- a Human Immunodeficiency Virus- a retrovirus belonging to the family of retrovirus belonging to the family of lentiviruses. lentiviruses.

Uses their RNA and host DNA to make viral Uses their RNA and host DNA to make viral DNADNA

Uses CD4+ cell to replicate itself and Uses CD4+ cell to replicate itself and destroying CD4+destroying CD4+

Two types: HIV-1 + HIV-2Two types: HIV-1 + HIV-2 Leads to Acquired Immunodeficiency Leads to Acquired Immunodeficiency

SyndromeSyndrome

HIVHIV

2 types: HIV-1 and HIV-22 types: HIV-1 and HIV-2 Subtypes of HIV-1: A, B, C, D, E, F, G, H, Subtypes of HIV-1: A, B, C, D, E, F, G, H,

O. (No subtypes of HIV-2)O. (No subtypes of HIV-2) HIV-1 subtype C makes up for more HIV-1 subtype C makes up for more

than 50% of all new HIV infections than 50% of all new HIV infections worldwide. worldwide.

HIV-2 progresses slowerHIV-2 progresses slower HIV-2 makes up the majority of cases of HIV-2 makes up the majority of cases of

HIV infection in AfricaHIV infection in Africa

Pathophysiology of Pathophysiology of HIV/AIDSHIV/AIDS

HIV LIFE HIV LIFE CYCLECYCLE

Diagnosis of HIV infectionDiagnosis of HIV infection

EIA (enzyme immunoassay) [formerly EIA (enzyme immunoassay) [formerly ELISA (enzyme-linked immunosorbent ELISA (enzyme-linked immunosorbent assay)] identifies antibodies that are assay)] identifies antibodies that are specifically directed against HIV.specifically directed against HIV.

Western blot assay: used to confirm Western blot assay: used to confirm seropositivity when the EIA is positiveseropositivity when the EIA is positive

Seropositivity: when blood or saliva Seropositivity: when blood or saliva contains HIV antibodiescontains HIV antibodies

Other TestsOther Tests

Viral load tests: used to quantify HIV DNA or Viral load tests: used to quantify HIV DNA or RNA levels in the plasma. These tests RNA levels in the plasma. These tests include: reverse transcriptase polymerase include: reverse transcriptase polymerase chain and nucleic acid sequence-based chain and nucleic acid sequence-based amplification.amplification.

This can help determine response to This can help determine response to treatment. treatment.

Viral load is a significantViral load is a significant

predictor of disease predictor of disease

progression.progression.

Home Testing KitsHome Testing Kits

Home testing kits Home testing kits are available, but are available, but are of concern to are of concern to HCP.HCP.

Why?Why? The lack of The lack of

counselling, as well counselling, as well as the possibility of as the possibility of inaccurate results. inaccurate results.

S&S of HIV infectionS&S of HIV infection

Often, there are no S&S in the early Often, there are no S&S in the early stages of HIV infectionstages of HIV infection

Why?Why?

The CD4 lymphocytes are still The CD4 lymphocytes are still numerous enough to fight off numerous enough to fight off infectionsinfections

S&S of HIV infectionS&S of HIV infection

There may be slight flu-like symptoms 2-6 There may be slight flu-like symptoms 2-6 weeks after initial infection.weeks after initial infection.

Other S&S (generally advanced infection):Other S&S (generally advanced infection):Lymphadenopathy (often the first sign) Lymphadenopathy (often the first sign)

profuse night sweats, rapid weight loss, profuse night sweats, rapid weight loss, recurrent fever, chronic diarrhea, recurrent fever, chronic diarrhea, unexplained fatigue, persistent headachesunexplained fatigue, persistent headaches

(http://www.mayoclinic.com/health/hiv-(http://www.mayoclinic.com/health/hiv-aids/DS00005/DSECTION=2)aids/DS00005/DSECTION=2)

Stages of HIV diseaseStages of HIV disease

Based on “clinical Based on “clinical history, physical history, physical examination, examination, laboratory evidence of laboratory evidence of immune dysfunction, immune dysfunction, signs and symptoms, signs and symptoms, and infections and and infections and malignancies” malignancies” (Smeltzer & Bare, (Smeltzer & Bare, 2004, 1559)2004, 1559)

3 categories: A, B, C3 categories: A, B, C

Clinical Category AClinical Category A

This category is asymptomatic.This category is asymptomatic. The virus reaches a “set point” level after The virus reaches a “set point” level after

about 6 months. about 6 months. The “set point” generally determines rate The “set point” generally determines rate

of disease progression.of disease progression. In general, 8-10 years can pass before In general, 8-10 years can pass before

HIV-related complications occur. HIV-related complications occur. Why asymptomatic? CD4 levels are high Why asymptomatic? CD4 levels are high

enough to fight off other pathogens (>500 enough to fight off other pathogens (>500 CD4+ T-lymphocytes/mm^3)CD4+ T-lymphocytes/mm^3)

Clinical Category BClinical Category B

CD4 cell level starts dropping (200-CD4 cell level starts dropping (200-499 CD4+ T-lymphocytes/mm^3).499 CD4+ T-lymphocytes/mm^3).

This category consists of conditions This category consists of conditions that are not covered under category that are not covered under category C. The conditions must:C. The conditions must:– Be due to HIV infectionBe due to HIV infection– Require management that is Require management that is

complicated by HIV infectioncomplicated by HIV infection

Clinical Category BClinical Category B

Some of the conditions under this Some of the conditions under this category include:category include:– Candidiasis (oropharyngeal or vulvovaginal)Candidiasis (oropharyngeal or vulvovaginal)– Cervical carcinoma in situCervical carcinoma in situ– Fever (38.5 C), or diarrhea > 1 month Fever (38.5 C), or diarrhea > 1 month

durationduration– Herpes zoster (shingles)Herpes zoster (shingles)– Pelvic inflammatory diseasePelvic inflammatory disease– Peripheral neuropathyPeripheral neuropathy

Clinical Category CClinical Category C

When CD4 T-cell levels drop below When CD4 T-cell levels drop below 200 CD4+ T-lymphocytes/mm^3, the 200 CD4+ T-lymphocytes/mm^3, the client is said to have AIDS. Below client is said to have AIDS. Below 100, the immune system is 100, the immune system is significantly impaired. significantly impaired.

Once a client is classified as having Once a client is classified as having category C infection, s/he remains in category C infection, s/he remains in this category. this category.

Clinical Category CClinical Category C

Some conditions in this category Some conditions in this category include:include:– Candidiasis (bronchi, trachea, lungs, or Candidiasis (bronchi, trachea, lungs, or

esophagus)esophagus)– Cervical cancer, invasiveCervical cancer, invasive– HIV-related encephalopathyHIV-related encephalopathy– Kaposi’s sarcomaKaposi’s sarcoma– Pneumocystis carinii pneumoniaPneumocystis carinii pneumonia– Toxoplasmosis of brainToxoplasmosis of brain– Wasting syndrome due to HIVWasting syndrome due to HIV

Treatment of HIVTreatment of HIV Antiretroviral treatments Antiretroviral treatments Compliance may be Compliance may be

decreased by the side effects decreased by the side effects of the drugs, or by clients of the drugs, or by clients deficiency of knowledge deficiency of knowledge about the treatment. about the treatment.

In developing and transitional In developing and transitional countries, 7.1 million people countries, 7.1 million people are in immediate need of life-are in immediate need of life-saving AIDS drugs; of these, saving AIDS drugs; of these, only 2.015 million (28%) are only 2.015 million (28%) are receiving the drugs. receiving the drugs.

Nucleoside Reverse Nucleoside Reverse Transcriptase Inhibitors Transcriptase Inhibitors

(NRTI’s)(NRTI’s) These were the first antiretrovirals These were the first antiretrovirals

approved by the European and approved by the European and American regulatory agencies. American regulatory agencies.

Becomes part of the viral DNA, Becomes part of the viral DNA, stopping the building process. stopping the building process.

These are the cornerstone for HIV These are the cornerstone for HIV therapy.therapy.

Side Effects of NRTI’sSide Effects of NRTI’s Some possible adverse Some possible adverse

effects of this class of drugs:effects of this class of drugs:Peripheral neuropathy, Peripheral neuropathy,

pancreatitis, lactic acidosis, pancreatitis, lactic acidosis, bone marrow suppression, bone marrow suppression, neutropenia, anemia, neutropenia, anemia, arthralgia, myopathy, kidney arthralgia, myopathy, kidney dysfunction, hepatomegaly, dysfunction, hepatomegaly, liver failure, hypersensitivity, liver failure, hypersensitivity, abdominal pain, oral ulcers, abdominal pain, oral ulcers, irritability, anxiety. irritability, anxiety.

(Smeltzer & Bare, 2004, 1563)(Smeltzer & Bare, 2004, 1563)

Non-nucleoside Reverse Non-nucleoside Reverse Transcriptase Inhibitors Transcriptase Inhibitors

(NNRTI’s)(NNRTI’s) Blocks the HIV reverse transcriptase in a Blocks the HIV reverse transcriptase in a

different method from the NRTI’s. different method from the NRTI’s. Attaches to the reverse transcriptase and Attaches to the reverse transcriptase and

prevents conversion of HIV RNA into HIV prevents conversion of HIV RNA into HIV DNA. DNA.

Used in combination with NRTI’s and PI’sUsed in combination with NRTI’s and PI’s. .

Side Effects of NNRTI’sSide Effects of NNRTI’s

Possible adverse reactions of this Possible adverse reactions of this class of drug include:class of drug include:

Abnormal liver function tests, Abnormal liver function tests, hepatitis, stomatitis, numbness, hepatitis, stomatitis, numbness, muscle pain, drowsiness, changes in muscle pain, drowsiness, changes in dreams, trouble concentrating.dreams, trouble concentrating.

Protease Inhibitors (PI’s)Protease Inhibitors (PI’s)

Prevents protease enzyme from cleaving Prevents protease enzyme from cleaving HIV proteins into the smaller, functional HIV proteins into the smaller, functional units. When PI’s are taken, the HIV copies units. When PI’s are taken, the HIV copies that are made cannot infect CD4+ cells that are made cannot infect CD4+ cells and lymphocytes. and lymphocytes.

When taken alone, the virus quickly When taken alone, the virus quickly develops resistance to its effects, so PI’s develops resistance to its effects, so PI’s are always taken with other drugs.are always taken with other drugs.

Missed doses leads to virus resistance and Missed doses leads to virus resistance and drug failure.drug failure.

Side Effects of PI’sSide Effects of PI’s

The following may be some of the The following may be some of the adverse effects associated with PI’s:adverse effects associated with PI’s:

Hemolytic anemia, parasthesia, kidney Hemolytic anemia, parasthesia, kidney stones, asymptomatic stones, asymptomatic hyperbilirubinemia, dyspepsia, hyperbilirubinemia, dyspepsia, altered taste, mood alterations, altered taste, mood alterations, drowsiness.drowsiness.

HAARTHAART

Highly active antiretroviral treatmentHighly active antiretroviral treatment A regimen that consists of 2 NRTI’s + A regimen that consists of 2 NRTI’s +

a PI (or NNRTI) a PI (or NNRTI)

OROR

2 PI’s + one other antiretroviral 2 PI’s + one other antiretroviral agentagent

Decision MakingDecision Making

Treatment Treatment decisions for every decisions for every patient is patient is individualized and individualized and based on 3 factors:based on 3 factors:– Viral loadViral load– CD4 T-cell countCD4 T-cell count– Clinical condition of Clinical condition of

patientpatient

Opportunistic Infections Opportunistic Infections (OI’s)(OI’s)

Infections that Infections that occur because of occur because of the client’s the client’s compromised compromised immune system- immune system- do not occur in do not occur in people with normal people with normal immune systems.immune systems.

Pneumocystis carinii Pneumocystis carinii Pneumonia (PCP)Pneumonia (PCP)

Most common OI which Most common OI which leads to a diagnosis of leads to a diagnosis of AIDS.AIDS.

Without prophylaxis, Without prophylaxis, 80% of all HIV-infected 80% of all HIV-infected clients will develop PCP. clients will develop PCP.

S&S: nonproductive S&S: nonproductive cough, fever, chills, cough, fever, chills, SOB, dyspnea, chest SOB, dyspnea, chest pain. pain.

Untreated, it causes Untreated, it causes respiratory failure.respiratory failure.

Mycobacterium avium complex Mycobacterium avium complex (MAC)(MAC)

MAC is a group of bacilli that usually MAC is a group of bacilli that usually causes respiratory infection. causes respiratory infection.

May also be found in the GI tract, May also be found in the GI tract, lymph nodes, and bone marrow.lymph nodes, and bone marrow.

Tuberculosis (TB)Tuberculosis (TB)

TB tends to occur early in HIV TB tends to occur early in HIV infection. infection.

If it occurs late in HIV infection, there If it occurs late in HIV infection, there may be no response to a tuberculin may be no response to a tuberculin skin test. (This is called anergy, skin test. (This is called anergy, which happens due to the immune which happens due to the immune system that can no longer respond to system that can no longer respond to the TB antigen.)the TB antigen.)

Oral CandidiasisOral Candidiasis

This is a fungal This is a fungal infection that infection that occurs in nearly all occurs in nearly all patients with AIDS.patients with AIDS.

It commonly It commonly precedes other OI’s. precedes other OI’s.

Untreated, it Untreated, it progresses to the progresses to the esophagus and esophagus and stomach.stomach.

Wasting SyndromeWasting Syndrome

Characterized by Characterized by >10% weight loss and >10% weight loss and chronic diarrhea for chronic diarrhea for more than 30 days OR more than 30 days OR chronic weakness and chronic weakness and intermittent or intermittent or chronic fever.chronic fever.

Wasting syndrome Wasting syndrome can not be managed can not be managed by nutritional support by nutritional support alone. alone.

Kaposi’s Sarcoma (KS)Kaposi’s Sarcoma (KS)

Most common malignancy in HIV infection.Most common malignancy in HIV infection. Involves the blood and lymphatic vessels.Involves the blood and lymphatic vessels. AIDS related KS has a more variable and aggressive course than AIDS related KS has a more variable and aggressive course than

classic KS.classic KS. It may be characterized by skin lesions, or multiple organ system It may be characterized by skin lesions, or multiple organ system

involvement. involvement. Diagnosis comes from biopsy of suspicious lesions. Diagnosis comes from biopsy of suspicious lesions.

B-Cell LymphomasB-Cell Lymphomas

Second most common malignancy in Second most common malignancy in HIV-infected clients.HIV-infected clients.

Often occurs in the brain, bone Often occurs in the brain, bone marrow and GI tract. marrow and GI tract.

Chemotherapy is not as effective in Chemotherapy is not as effective in HIV-related lymphomas.HIV-related lymphomas.

HIV EncephalopathyHIV Encephalopathy

Formerly referred to as AIDS Formerly referred to as AIDS dementia complex.dementia complex.

Clinical syndrome consisting of a Clinical syndrome consisting of a progressive decline in cognitive, progressive decline in cognitive, behavioral, and motor function.behavioral, and motor function.

HIV has been found in the CSF of HIV has been found in the CSF of patients with this syndrome.patients with this syndrome.

S&S of HIV EncephalopathyS&S of HIV Encephalopathy

Early stage: memory loss, difficulty Early stage: memory loss, difficulty concentrating, headache, confusion, concentrating, headache, confusion, psychomotor slowing, apathy, ataxia.psychomotor slowing, apathy, ataxia.

Later stage: Global cognitive Later stage: Global cognitive impairments, delay in verbal impairments, delay in verbal responses, hyperreflexia, psychosis, responses, hyperreflexia, psychosis, hallucinations, tremor, incontinence, hallucinations, tremor, incontinence, seizures, mutism, death.seizures, mutism, death.

(Smeltzer & Bare, 2004, 1567).(Smeltzer & Bare, 2004, 1567).

Nursing ManagementNursing Management

There are many complications associated There are many complications associated with AIDS! with AIDS!

Nursing interventions remain the same as Nursing interventions remain the same as other people with those conditionsother people with those conditions

Don’t forget about the pyschosocial Don’t forget about the pyschosocial implicationsimplications– Terminal illnessTerminal illness– Isolation (physical and emotional)Isolation (physical and emotional)– CopingCoping– GriefGrief– Guilt and anger : associated with transmitting Guilt and anger : associated with transmitting

the diseasethe disease– StigmaStigma

Nursing ManagmentNursing Managment

Don’t contribute to the stigma associated Don’t contribute to the stigma associated with AIDSwith AIDS– Don’t make assumptionsDon’t make assumptions– Don’t treat your patient any differentDon’t treat your patient any different– Use universal precautions with ALL patientsUse universal precautions with ALL patients

Nursing ManagementNursing Management

Protect Yourself!!!Protect Yourself!!!

Healthcare Workers Reported to have Healthcare Workers Reported to have AIDSAIDS

Occupational Occupational Exposure DOES occur.Exposure DOES occur.

HCP’s reported to HCP’s reported to have AIDS:have AIDS: Physician 1792Physician 1792 Lab technician 3182Lab technician 3182 Dental worker 492Dental worker 492 Surgeon 122Surgeon 122 Nurses ???Nurses ???

Occupational Exposure to Occupational Exposure to HIVHIV

Exposure to HIV–infected blood via Exposure to HIV–infected blood via percutaneous injury:percutaneous injury:

3/10003/1000 Mucocutaneous exposure:Mucocutaneous exposure:

Less than 1/1000Less than 1/1000 Intact Skin:Intact Skin:

No known riskNo known risk

Post-Exposure Prophylaxis Post-Exposure Prophylaxis (PEP)(PEP)

Administration of antiretroviral Administration of antiretroviral medications (ARV’s) after exposure to medications (ARV’s) after exposure to HIV.HIV.

Given as soon as possible after exposureGiven as soon as possible after exposure Must be within 72 hoursMust be within 72 hours 4-week treatment with 2-3 different 4-week treatment with 2-3 different

ARV’sARV’s Standard procedure since 1996.Standard procedure since 1996. Reduces transmission by 79%Reduces transmission by 79%

PEP cont’d…PEP cont’d…

Page 2145, Page 2145, Smeltzer & Bare Smeltzer & Bare

Table 70-5Table 70-5 Recommended Recommended

Algorithm used to Algorithm used to determine PEPdetermine PEP

Should a needlestick injury Should a needlestick injury occur…occur…

What are you going What are you going to do???to do???

Wash area thoroughly with soap and Wash area thoroughly with soap and waterwater

Alert supervisor, documentation.Alert supervisor, documentation. Identify source patientIdentify source patient Give consent for baseline testingGive consent for baseline testing PEPPEP Follow-up with PEP testing 6 weeks , Follow-up with PEP testing 6 weeks ,

3 months and 6 months after 3 months and 6 months after beginning treatmentbeginning treatment

DocumentationDocumentation Day et al., 2007.Day et al., 2007.

PEP use for non-occupation PEP use for non-occupation exposureexposure

Non-occupational HIV exposures, Non-occupational HIV exposures, commonly related to unsafe commonly related to unsafe behaviors.behaviors.

Would PEP encourage unsafe Would PEP encourage unsafe behaviors?behaviors?

No research indicated PEP works for No research indicated PEP works for non-occupational exposure.non-occupational exposure.

PEP not a ‘morning after’ pillPEP not a ‘morning after’ pill

Preventative Strategies:Universal Preventative Strategies:Universal PrecautionsPrecautions

Routine use of barriers (gloves, gowns, Routine use of barriers (gloves, gowns, masks, goggles)masks, goggles)

Washing skin surfaces immediately after Washing skin surfaces immediately after contact with blood or body fluids.contact with blood or body fluids.

Disinfecting instruments and contaminated Disinfecting instruments and contaminated equipment.equipment.

Properly handling soiled linensProperly handling soiled linens Careful handling/disposal of sharp Careful handling/disposal of sharp

instruments.instruments. Documentation of sterilization quality Documentation of sterilization quality

following procedures.following procedures. page 1557 Smeltzer & Bare, Chart 52-3page 1557 Smeltzer & Bare, Chart 52-3

Building Better Prevention Building Better Prevention ProgramsPrograms

Administrative EffortsAdministrative Efforts Development/ Promotion of the use of safety Development/ Promotion of the use of safety

devices.devices. Sharp disposal containersSharp disposal containers Disposable instrument useDisposable instrument use

Monitoring of the effectiveness of PEP.Monitoring of the effectiveness of PEP.

Pre-Exposure Prophylaxis for Pre-Exposure Prophylaxis for HIVHIV

““Various studied have shown that Various studied have shown that antiretroviral treatment given at or shortly antiretroviral treatment given at or shortly after HIV exposure can reduce likelihood of after HIV exposure can reduce likelihood of transmission…”transmission…”

“…“…this lead to the hypothesis that this lead to the hypothesis that transmission may be decreased even transmission may be decreased even further if treatment were delivered before further if treatment were delivered before exposure to HIV” – Paxton, 2007).exposure to HIV” – Paxton, 2007).

TenofirTenofir Safety/ effectiveness still unknown.Safety/ effectiveness still unknown.

Ethics - TenofirEthics - Tenofir

Think about…Think about… Obligations of gov’t to provide pre-Obligations of gov’t to provide pre-

exposure prophylaxisexposure prophylaxis Appropriate indications for prescribing Appropriate indications for prescribing

Tenofir ( think high-risk populations)Tenofir ( think high-risk populations) Who should have priority for pre-exposure Who should have priority for pre-exposure

prophylaxis?prophylaxis? Stigmatization: Stigmatization:

- Stigma attached to engagement in risky behaviors- Stigma attached to engagement in risky behaviors - Decision making clouded by underlying beliefs- Decision making clouded by underlying beliefs

CASE STUDYCASE STUDYTalia is a 23 year old female from Halifax. She is an arts Talia is a 23 year old female from Halifax. She is an arts

student at StFX university in her third year. She likes to go to student at StFX university in her third year. She likes to go to the pub on Saturdays and is the hockey team’s biggest fan. the pub on Saturdays and is the hockey team’s biggest fan. Talia is single but had dated several boys since her first year. Talia is single but had dated several boys since her first year. She used a condom most of the time and goes for regular She used a condom most of the time and goes for regular pap smears.pap smears.

Around Christmas Exams Talia noticed that she is feeling tired Around Christmas Exams Talia noticed that she is feeling tired all the time. She wakes up in the middle of the night with all the time. She wakes up in the middle of the night with night sweats and has a rash. She is having a really hard time night sweats and has a rash. She is having a really hard time studying for her exams. Her mom thought that she was studying for her exams. Her mom thought that she was probably stressed about exams. But when Talia got her probably stressed about exams. But when Talia got her second yeast infection since September she decided to seek second yeast infection since September she decided to seek medical attention from her friendly neighborhood nurse.medical attention from her friendly neighborhood nurse.

Upon examination Talia’s nurse noticed that she had lost 8lbs Upon examination Talia’s nurse noticed that she had lost 8lbs since her last visit in September. Her gums appear swollen since her last visit in September. Her gums appear swollen and so are her lymph nodes. She is anxious to get back to and so are her lymph nodes. She is anxious to get back to studying.studying.

Case StudyCase Study

How should the nurse tell Talia that an How should the nurse tell Talia that an HIV test is required?HIV test is required?

If the results are positive, what should If the results are positive, what should the nurse tell her? What additional the nurse tell her? What additional education is needed?education is needed?

What can the nurse tell Talia to expect?What can the nurse tell Talia to expect?How can the nurse be supportive to How can the nurse be supportive to

Talia?Talia?Should any other risk reduction actions Should any other risk reduction actions

be taken?be taken?

Nursing Care of the HIV positive Nursing Care of the HIV positive client:client:

THE NURSING PROCESS THE NURSING PROCESS

ASSESSMENTASSESSMENT

-identify risk factors-identify risk factors - unsafe sexual practices- unsafe sexual practices - IV drug use- IV drug use- Physical Assessment – Physical Assessment – focus on Immune focus on Immune

systemsystem

- Psychological statusPsychological status- Nutritional statusNutritional status- Skin integritySkin integrity- Respiratory statusRespiratory status- Neurological statusNeurological status- Fluid and electrolyte balanceFluid and electrolyte balance- Knowledge levelKnowledge level

NSG DIAGNOSISNSG DIAGNOSIS

Impaired skin integrity r/t percutaneous Impaired skin integrity r/t percutaneous manifestations of HIV infection.manifestations of HIV infection.

Risk for fluid volume deficit r/t diarrheaRisk for fluid volume deficit r/t diarrhea Risk for infection r/t immunodeficiencyRisk for infection r/t immunodeficiency Activity intolerance r/t weakness, fatigue.Activity intolerance r/t weakness, fatigue. Pain r/t impaired skin integrityPain r/t impaired skin integrity Anticipatory greiving r/t changes in Anticipatory greiving r/t changes in

lifetsyle 2lifetsyle 2° diagnosis of AIDS° diagnosis of AIDS Social isolation r/t stigma of the disease, Social isolation r/t stigma of the disease,

fear of infecting othersfear of infecting others Ineffective A/W clearance r/t increased Ineffective A/W clearance r/t increased

bronchial secretions, decreased ability to bronchial secretions, decreased ability to cough.cough.

PLANNINGPLANNING

Goals for Patient???Goals for Patient???

Achievement/Maintenance of skin Achievement/Maintenance of skin integrityintegrity

Maintenance of usual bowel habitsMaintenance of usual bowel habits Absence of infectionAbsence of infection Improved activity toleranceImproved activity tolerance Increased comfortIncreased comfort Increased socializationIncreased socialization Improved nutritional statusImproved nutritional status Increased knowledge baseIncreased knowledge base Absence of complicationsAbsence of complications

NSG INTERVENTIONSNSG INTERVENTIONS

Promote skin integrityPromote skin integrity Promote usual bowel habitsPromote usual bowel habits Prevent infectionsPrevent infections Improve activity intoleranceImprove activity intolerance Maintaining health Maintaining health Improving A/W clearanceImproving A/W clearance Relieving pain.increasing comfortRelieving pain.increasing comfort Nutritional statusNutritional status CopingCoping Monitor for complications Monitor for complications

EVALUATIONEVALUATION

Expected Patient Outcomes:Expected Patient Outcomes: Maintains skin integrityMaintains skin integrity Experiences no infectionsExperiences no infections Maintains adequate activity toleranceMaintains adequate activity tolerance Experiences increased sense of Experiences increased sense of

comfortcomfort Progresses through grieving processProgresses through grieving process Remains free of complicationsRemains free of complications

Ethical considerationsEthical considerations Many patients with HIV have engaged in Many patients with HIV have engaged in

‘stigmatized’ behaviors.‘stigmatized’ behaviors. Challenges traditional, religious and moral Challenges traditional, religious and moral

values of HCP’s.values of HCP’s. Fear and anxiety re: disease transmission.Fear and anxiety re: disease transmission. The impact of an epidemic on a The impact of an epidemic on a

culture/society (lost generation, orphans, culture/society (lost generation, orphans, etc)etc)

Nurses encouraged to examine own Nurses encouraged to examine own personal beliefs / values clarification.personal beliefs / values clarification.

Challenges legal and political systemsChallenges legal and political systems End of Life CareEnd of Life Care Pg. 1584, Smeltzer & Bare Chart 52-10Pg. 1584, Smeltzer & Bare Chart 52-10