At the end of the teaching session the student will be enabled to:

Discuss with understanding the immune system and immune response to virus invasion

Describe with reference to the literature HIV disease progression in the spectrum of untreated infection.

Identify the diagnostic criteria for acquired immunodeficiency syndrome (AIDS).

Summarize the characteristics of opportunistic diseases associated with AIDS.

Described as responsiveness to the invasion of foreign substances

Three functions:- Defence protection against micro-organisms Homeostasis Damaged cellular substances

digested and removed Surveillance mutations recognized and removed

Types Innate response within minutes without

prior exposure Acquired Development of immunity active

or passive

Cellular structure simple These cells are small May lay dormant for a long time Viruses do not have specific cellular structure

contains small amount of genetic material encased in protein shell It is considered to be a parasite. But virus' external covering, known as the viral envelope, is almost identical to the host cell's membranes, making them difficult to target.

If our immune system recognises an intruder, it will be destroyed before the virus can gain entry to a cell. If not, the process of infection begins. Viruses such as Herpes and AIDS do not reproduce straight away instead they mix genetic instructions on host genetic instructions and when the host cell replicates viral genetic instructions get copied onto the host cells offspring

Immune system recognition

Symptoms caused by viruses - such as fever, vomiting and tiredness - are a result of the body's defence mechanisms.

Acquired immunity - childhood

Scientists can 'trick' our immune systems into recognising viruses

Immune system recognition - The human immune system is remarkably effective at dealing with viral invaders.Symptoms caused by viruses - such as fever, vomiting and tiredness - are a result of the body's defence mechanisms. In many cases of flu and cold the immune system destroys the infection.Acquired immunity -The immune response leads to something called - the body 'remembers' viruses so that it can quickly destroy them, should they return, and also make us resistant to them in future. A single case of measles as a child, for example, gives us lifelong resistance. Scientists can 'trick' our immune systems into recognising viruses Vaccines for example have been developed against killer viruses eg small pox In 1796, British physician Edward Jenner developed the first vaccine (for smallpox) which led to a complete eradication of the disease by 1980.

Our immune system works by recognising the proteins on the surface of the virus. But in certain types of virus, these proteins keep changing as the virus mutates, so a vaccine developed one year might not work the next.

So why doesnt the human immune system destroy HIV for example?

Viruses like HIV have proved impossible to develop any kind of vaccine for at all.

Similarity of cell walls viral envelope

Viral mutation

So why doesnt the human immune system destroy HIV for example? Drugs are another line of defence. Unfortunately, they are less effective against viruses than they are against bacteria. We can give antibiotics for bacteria for example as antibiotic drugs kill bacteria by disrupting their cell walls. But virus' external covering, known as the viral envelope, is almost identical to the host cell's membranes, making them difficult to target.

Human Immunodeficiency Virus (HIV) is a virus that attacks the body's immune system.

RNA virus -retrovirus

Acquired immune deficiency syndrome(AIDS) A person is considered to have developed AIDS when the

immune system is so weak it can no longer fight off a range of diseases with which it would normally cope.

RNA retrovirus replicates in a backward manner

Human Immunodeficiency Virus (HIV) is a virus that attacks the body's immune system. Specifically the T cells (CD4)In the first cases in the USA , first The T cells, also known as CD4 cells, which help the human body in fighting the diseases were found damaged and their level was lowered in the patients suffering from the mysterious disease.

Over a million people living with HIV in the USA

56,000 new infections every year

Globally

33 million living w/ HIV

2.7 million new infections each year

2 million HIV-related deaths each year

Since the beginning of the epidemic, sub-Saharan Africa has been the most devastated, but the Caribbean, Asia, Eastern Europe, and South America also have growing epidemics.

In developing countries, the major route of transmission is heterosexual sex, and women and children bear a large part of the burden of illness.

Can only be transmitted via: Infected blood, semen vaginal secretions and breast

milk

Through sexual intercourse with an infected partner Exposure to HIV infected blood or blood products Perinatal during pregnancy ,delivery or via breast

milk

You have to have large amount of virus which enters the body of a susceptible host Duration and frequency of contact, volume virulence and concentration of the organism and host immune status all affect whether the infection is established after exposure. The viral load is an important variable

What are the risks of passing on the infection?

It is not spread casually!

Health care workers have a low risk!

Most common transmission route for adults unprotected sex with HIV infected partner

Contact with blood and blood products

(CDC 2006;2007;2009 Marcelin et al 2008;NIAID 2009)

Large amounts of HIV are found in the blood and lesser extent in the semen during the first few months of infection and again in the later stages of the infection so increasing the risk of passing on infection, although it can be passed on at any time during all phases of the illness.

HIV-infected individuals can transmit HIV to others within a few days after becoming infected.

Transmission of HIV is subject to the same requirements as other microorganisms (i.e., a large enough amount of the virus must enter the body of a susceptible host).

Duration and frequency of contact, volume, virulence and concentration of the organism, and host immune status all affect whether infection will be established after an exposure.

HIV is not spread casually you cannot catch it from hugging dry kissing, shaking hands sharing eating utensils using toilet seats tears saliva, urine, faeces, toilet seats emesis, sputum etc.

Health care workers have a low risk even after needle stick injury It has been estimated that the risk of infection from a needlestick injury is less than 1 percent. In the UK for instance, there have been five documented cases of HIV transmission through occupational exposure in the healthcare setting, the last being in 1999. In the US, there were 57 documented cases of occupational HIV transmission up to 2006. Avert(Averting HIV and AIDS) Accessed 204/22/13 http://www.avert.org/

Risk is greater for the person receiving the semen

Easier to infect women than men in heterosexual partnerships because semen stays in the vagina and the women has prolonged contact with the semen.

Presence of herpes for example increases the chance of infection transmission ! (Tobian AA and Quinn TC (2009)

Contact with blood and blood products can be transmitted via infected syringes and transfusion of infected blood Currently however only 1% of people infected with transfusions because of the routine screening of donors instigated in 1985

The risk of HIV transfusion through infected blood products exceeds that of any other risk exposure.

An estimated 14,262 persons have been diagnosed with AIDS as a result of transfusing contaminated blood or blood products pre 1985

Testing for most developed countries commenced 1985 with few exceptions

The risk of HIV transfusion through infected blood products exceeds that of any other risk exposure. Ninety percent of recipients transfused with HIV antibody-positive blood are found to be HIV infected at follow-up CDC HIV Statistics. www.cdc.gov/hiv/stats.htm#exposure(accessed March 23, 2003)

France began HIV antibody testing in June 1985, Canada began testing in November 1985, and Switzerland began testing in May 1986. Germany inconsistently tested plasma products between 1987 and 1993, as did Japan in 1985 and 1986. These delays led to criminal investigations in France, Germany, Switzerland, and Japan, which in some cases led to criminal conviction of those persons found to be responsible. At least 20 countries initiated compensation programs for at least some individuals infected by transfusion of HIV-contaminated blood and blood products. Weinberg PD, Hounshell J, Sherman LA, Godwin J, Ali S, TomoriC, Bennett CL. (2002) Legal, financial, and public health consequences of HIV contamination of blood and blood products in the 1980s and 1990s. Ann Intern Med. Feb;136(4):312-9.[PubMed ID: 11848729]

Pozen A. (2003) Contamination of the blood supply in the 1980s and 1990s. Ann Intern Med ;138(1):78-9

[PubMed ID: 12513058]

Initial infection

Viremia (large viral levels in blood) for 2 - 3 weeks

Transmission is more likely when viral load is high

Followed by prolonged period (years) of low viral load

Even without symptoms HIV replication

occurs a rapid and constant rate *

During the time of low viral load, which may last for 10 to 12 years or longer, clinical symptoms can be limited. Even without symptoms, however, HIV replication occurs at a rapid and constant rate in the blood and lymph tissues.

*A major consequence of rapid replication is that errors can occur in the copying process, causing mutations that contribute to treatment difficulties.

In rich countries, highly active antiretroviral therapy (HAART) which usually comprises three drugs, has reduced the mother-to-child transmission rates to around 1-2%, but HAART is not always available in low- and middle-income countries. In these countries, various simpler and less costly antiretroviral regimens have been offered to pregnant women or to their newborn babies, or to both.

HIV infects human cells with CD4 receptors on their surfaces binding to specific CD4 & chemokine receptors to enter cell. It attacks lymphocytes, monocytes/macrophages, astrocytes and oligodendrites Immune dysfunction in HIV predominantly as the result of damage to the T helper cells otherwise known as CD4. HIV destroys about billion CD4 cells every day. The body is generally able to make enough new cells to replace these eventually however the ability to destroy the cells exceeds the bodys ability to replace them.

T Helper cells - It is thought these cells are targeted because they have CD4 receptors sites on their surfaces

This diagram shows the HIV virus attacking and entering the cells. HIV has gp120 glycoproteins that attach to CD4 and chemokine CXCR4 and CCR5 receptors on the surface of CD4+ T cells. Viral RNA then enters the cell, produces viral DNA in the presence of reverse transcriptase, and incorporates itself into the cellular genome in the presence of integrase, causing permanent cellular infection and the production of new virions. New viral RNA develops initially in long strands that are cut in the presence of protease and leave the cell through a budding process that ultimately contributes to cellular destruction.Reverse transcriptase (RNA) assists to make viral DNAViral DNA enters cell nucleus & splices itself into genome permanentlyIntegrase phase is the consequence of integration into genetic structureAll daughter cells are infectedViral DNA will direct cell to make HIV

Highly individualised experience Acute infection Seroconversion (HIV antibody

development) The acute stage may be accompanied by neurological

complication such as Guillan Barre. After the initial infection symptoms generally occur about 2

4 weeks lasts for 7 14 days. Can be mistaken for a bad case of flu!

An important point to make here is that it is an highly individualised experience and treatments can alter the pattern and progression. Acute infection Seroconversion (HIV antibody development) mononucleosis like syndrome of fever, swollen lymph glands, sore throat, headache, malaise,nausea,muscle and joint pain, diarrhoea sometimes a diffuse rash.

Early chronic infection - approx 11 years before this occurs Generally known as asymptomatic phase. Individuals with disease

can be a public health risk to others WHY? Intermediate chronic infective stage most common

manifestation is orophyrangeal thrush Other infections include shingle or varicella zoster persistent

episodes of thrush,oral or genital herpes.

Generally known as asymptomatic phase although the individual can have fatigue headache, low grade fever, night sweats etc.During this time people may carry on normal behaviour which could include risky sexual behaviour therefore contaminating other people Intermediate chronic infective stage as the T cell count drops to 200- 500uL the viral load increases. HIV advances to an active stage. Fever, night sweat, sore throat, headache, malaise, nausea, muscle and joint pain increases together with swollen lymph glands. These are now severe enough to disrupt normal routines. May also include localised infection neurological involvement. most common manifestation is

Fig. 15-5. Oral thrush involving hard and soft palate.

Fig. 15-7. Oral hairy leukoplakia on the lateral aspect of the tongue

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Fig. 15-6. Kaposi sarcoma (KS). Malignant vascular lesions. KS lesions can appear anywhere on the skin surface or on internal organs. Lesions vary in size from pinpoint to very large and may appear in a variety of shades.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

. 15-9. Lipodystrophy manifestations.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

At this stage the immune system is extremely compromised

Decrease in the absolute number and % of lymphocytes

Risk of opportunistic diseases occurring is greater

These contribute towards the persons disability and chance of death increases

However! advances in treatments have led to a decrease in these

Common opportunistic diseases Candida Albicans

Pneumocystis jiroveci pneumonia

Cryptococcal meningitis fungal infection from soil Cytomegalovirus (CMV) Retinitis Esophagitis/stomatitus Pneumonitis Neurological disease

Mycobacterium avium complex -late stages of AIDS persistent cough, fever, anorexia, diarrhoea

Kaposi sarcoma

Influenza virus

Pneumonia, non productive cough, hypoxia, progressive shortness of breath fever, night sweats, fatigue

Cryptococcal meningitis - a fungal infection of the tissues covering the brain and spinal cord. Most often affects people with a weakened immune system. Comes from soil all over the world, and unlike bacterial meningitis, this form of meningitis comes on more slowly, over a few days to a few weeks. Medline plus (Accessed 19/04/2013) http://www.nlm.nih.gov/medlineplus/ency/article/000642.htm

CMV retinitus, lesions, blurred vision, loss of vision. Esophagitis/stomatitis difficulty swallowing, colitis, gastritis weight loss ,pain and bloody diarrhoea

Mycobacterium avium complex is an atypical mycobacterial infection which can occur in the later stages of AIDS. Presenting as a persistent cough. Causes fevers, diarrhoea, malabsorption and anorexia, and can disseminate to the bone marrow. This type of bacteria is common in the environment. Symptoms are similar to that of tuberculosis (TB), including fever, fatigue, and weight loss if bone marrow is involved there will also be anemia and neutropenia. Pulmonary involvement is similar to TB, while diarrhoea and abdominal pain are associated with gastrointestinal involvement.

Hepatitis B jaundice, fatigue, abdominal pain, loss of appetite, nausea. Joint pain

Hepatitis C - jaundice, fatigue, abdominal pain, loss of appetite, nausea. Dark urine

Herpes simplex vesticular and ulcerative lesions

CNS Lymphoma cognitive dysfunction. Motor impairment, seizure, headache

Coccidioides immitis pneumonia, fever weight loss , persistent cough

Cryptosporidium muris gastroenteritis watery diarrhea, abdominal pain, weight loss

CD4 + T cell count drops below 200 cells uL One of the following opportunistic criteria Fungal infections Viral CMV Bacterial Mycobacterium kansasii Protozol

One of the following opportunistic cancers Invasive cervical cancer, KS, Burkitts lymphoma,

immunoblastic lymphoma or primary lymphoma of the brain

Wasting syndrome 10% or more of ideal b9ody mass

AIDS dementia complex -

1. a CD4+ T-cell count of

1. antibiotics should have been used to prevent the pneumonia.

2. all of the supplied antibiotics should be taken even when symptoms have resolved.

3. enough antibiotics for 2 days treatment should be reserved in case symptoms recur.

4. patients should request antibiotics for upper respiratory infection to prevent development of streptococcal-related diseases.

Answer: 2 Rationale: To prevent the emergence of antibiotic-resistant

organisms, the patient needs to take the entire prescription even if symptoms have resolved. Antibiotics should not be used routinely to prevent bacterial pneumonia.

EIA -serum antibodies that bind to HIV antigens Risky behaviour test again 3, 6,weeks and 6

months May take 2 months to detect antibodies Abnormal blood tests are common in HIV Positive result and the test is repeated Western Blot for confirming results IFA (immunofluorescence assay ) - infected HIV

cells Progression monitored by CD4+ T-cell counts

and viral load Neutropenia, thrombocytopenia, and anemia Altered liver function tests

Rapid testing 20 minutes

Rapid testing is highly reliable and provides immediate feedback to patients who can then be counselled about treatment and prevention. This is an important advantage because many people do not return to get their test results when other testing methods (take longer to obtain the results) are used. They are screening tests testing for antibodies not antigen, negative results shoulfd be followed by risk assessment to determine need for retesting

The patient will also have to be tested for WB or IFA with a positive result

NB Rapid test kits have short shelf life. Abnormal blood tests are common in HIV and can be due

to opportunistic infections, HIV itself Low white cells blood counts and platelet counts are also often seen. Anemia is also often associated with the chronic disease process.

Resistance tests include Two types of resistance tests to determine if a patients HIV is resistant to drugs used in ART: the genotype assay and the phenotype assay. Especially useful to decide on new drug combinations

Monitoring HIV disease progression and immune function

Initiating and monitoring antiretroviral therapy (ART)

Preventing, detecting, and treating opportunistic infections

Managing symptoms

Preventing or decreasing complications of therapies

Preventing further transmission

As you would expect this is geared towards Monitoring HIV disease progression and immune function

Initiating and monitoring antiretroviral therapy (ART)

Preventing, detecting, and treating opportunistic infections

Gather baseline data

Education about spectrum of HIV, treatment, preventing transmission, improving health, and family planning

Perform complete history and physical examination. These findings will determine the patients needs.Ensure that case reports required by the state health department have been completed. Remember that a newly diagnosed patient may be in a state of shock or denial and be unable to retain or understand information. You should be prepared to repeat and clarify information over the course of several months.

Clinical category CD4+ T cell count Recommendations

History of AIDS Any Treat

Asymptomatic 500 Recommended versus optional

Decrease viral load.

Maintain/raise CD4+ counts.

Delay HIV-related symptoms and opportunistic infections.

Recommendations for starting therapy in the chronically infected patient are summarized in Table on previous slide.

HIV cannot be cured, but ART can decrease viral replication and delay progression of disease in most patients.

When taken consistently and correctly, ART can reduce viral loads by 90% to 99%, which makes adherence to treatment regimens extremely important. The major advantage of using drugs from different drug groups is that combination therapy can attack viral replication in several different ways, making it more difficult for the virus to recover and decreasing the likelihood of drug resistance. In rich countries, highly active antiretroviral

therapy (HAART) which usually comprises three drugs, has reduced the mother-to-child transmission rates to around 1-2%, but HAART is not always available in low- and middle-income countries. In these countries, various simpler and less costly antiretroviral regimens have been offered to pregnant women or to their newborn babies, or to both.

Nucleoside, non-nucleoside, and nucleotide reverse transcriptase inhibitors

Inhibit the ability of HIV to make a DNA copy early in replication

Examples efavirenz (Sustiva), etravirine (Intelence) and nevirapine (Viramune).

Protease inhibitors Interfere with activity of enzyme protease Examples - tazanavir (Reyataz), darunavir (Prezista),

fosamprenavir (Lexiva) and ritonavir (Norvir).

NB resistance develops quickly when used alone so they tend to use a combination and in large doses as small doses are found to ineffective also. Efavirenz (sustiva) do not use in pregnancy large doses can cause fetao abnormalities, one a day dose should be taken before bed to help patient cope with side effects of dizziness

Fusion inhibitors

Interfere with HIV CD4 receptor site binding and entry into cells

Examples include enfuvirtide (Fuzeon) and maraviroc (Selzentry).

Integrase inhibitors- Raltegravir (Isentress) works by disabling integrase, a protein that HIV uses to insert its genetic material into CD4 cells.

Combination antiretroviral therapy

Three or more drugs from different groups are prescribed at full strength

Prophylactic medication given to prevent opportunistic infection

On-going research seeks a biochemical means of preventing HIV transmission.

HIV lives inside cells, where it can hide from circulating immune factors. HIV also mutates rapidly, so that infected individuals develop HIV variants that may not respond to simple vaccines or microbicides. In addition, two strains of HIV (HIV-1 and HIV-2) cause infection, and at least nine clades (subtypes) of HIV may be found around the world.

Common metabolic disorders

Lipodystrophy

Hyperlipidemia

Insulin resistance

Bone disease

Lactic acidosis

Cardiovascular disease

It mutates rapidly

Can hide from circulating immune factors

Two strains cause infection

Nine subsets exist around the world

Social economic and ethical issues related to vaccination and microbocide

Ask at-risk patients:

Received blood transfusion or clotting factors before 1985?

Shared needles, syringes, or other injection equipment with another person?

Ask at-risk patients about sexual experiences and any sexually transmitted disease (STD)?

Medications use of immunosuppressive drugs

Assess diagnosed patients Repeat assessments over time as

circumstance changes These patients fall into three groups Uninfected Newly diagnosed Chronically infected

It is complex and each person must be treated individually

Diagnosis depends on the disease process and variables such as opportunistic disease processes

Ask about Health perception of the illness, alcohol and drug use Nutrition weight loss, anorexia, nausea, vomiting, lesions,

bleeding, or ulcerations of mouth, gums, tongue, or throat. Sensitivity to acidic, salty or spicy foods, difficulty swallowing, abdominal cramping, skin rashes, lesions or color changes , non healing wounds

Elimination painful voiding persistent diarrhoea, change in the character of stools or low back pain.

Activity exercise chronic fatigue, muscle weakness, difficulty in walking, cough and shortness of breath

Sleep rest night sweats, insomnia, fatigue Cognitive perception headaches, stiff neck, chest pain rectal

pain, retrosternal pain, blurred vision, photophobia, diplopia, loss of vision, hearing impairment, confusion, memory loss, , personality change, hypersensitivity on feet, para thesis

Role relationship support systems, work, finances Sexuality reproductive lesions on genitalia, puritis and burning

in the vagina, penis, anus, painful sexual intercourse, rectal pain or bleeding, changes in menstruation, vaginal/penile discharge, use of birth control, pregnancies and desire for future children

Coping stress tolerance stress levels, previous losses, coping patterns

In groups please discuss the assessment process both subjective and objective coming up with a nursing diagnosis for at least three problems

Objective data lethargy, persistent fever, lymphadenopathy, peripheral wasting fat deposits in truncal areas and upper back, social withdrawal.

Integumentary decreased skin turgor, dry skin, diaphoresis, pallor, cyanosis, lesions, eruptions, discoloration, bruises of skin, or mucous membranes alopecia, delayed wound healing.

Eyes presence of exudates, retinal lesions or hemorrhage, papilledema

Respiratory Tachypnea, dyspnea, intercostal reactions, wheezing cough

Cardiovascular- Pericardial rub, murmur, bradycardia, tachycardia Gastrointestinal- mouth lesions, blisters, white gray patches,

,painless white lesions known as hairy leukoplakia, discolorations, tooth decay or loose teeth gingivitis, redness or patchy lesions of the throat , vomiting, diarrhea, incontinence, rectal lesions, hyperactive bowel sounds, abdominal masses, hepatomegaly

Musculoskeletal muscle wasting and weakness Neurological Ataxia, tremors, lack of co-ordination, sensory

loss, slurred speech, peripheral neuropathy, apathy, agitation, depression, inappropriate behaviors, decreasing conscious level, seizures, paralysis, coma .

Reproductive Genital lesions or discharge, abdominal tenderness secondary to pelvic inflammatory disease for example.

Positive HIV assay EIA confirmed by WB or IFA)

Detectable viral load levels

Decrease in CD4+ cell count and decrease in WBC count

Lymphopenia

Anemia

Thrombocytopenia

Electrolyte imbalances

Abnormal Liver Function Tests

Rise in cholesterol, triglyceride and blood glucose

Assess- rate, rhythm , depth, accessory muscle use, adventitious sounds, cough, color of sputum, cyanosis

O2 sat keep > 92% (humidified) ABG-hyperventilation if indicated -CO2 < 35, pH >7.40 Prevent pneumonia, remove mucus & excess fluids Uninterrupted rest periods Report dyspnea or cough Sedatives/analgesics judiciouslyrespiratory depression Activate universal precautions for contact

http://www.livestrong.com/article/143186-hiv-universal-precautions/#ixzz2R1QeMtHJ

Medical personnel should wear disposable gloves when the potential for contact with blood or other hazardous fluids exists. They should wear a mask and goggles or other protective eyewear when the potential for the splashing of fluids is present. They should wear a gown or apron to protect the skin and clothing.Read more: http://www.livestrong.com/article/143186-hiv-universal-precautions/#ixzz2R1QeMtHJ

Diarrhea, nausea-meds,

Malabsorption, anorexia, dysphagia, fatigue

Weight, caloric intake, protein & albumin levels

Facilitate wound healing & ability to withstand infection

Progressive weight loss, wasting muscle tissue, loss of skin tone

Small, frequenthigh calorie , high protein diet and supplements

Late stages - TPN; Vitamin & minerals

Tube feeds prn

Oral hygiene Food from home to encourage patients to eat

Antiemetic's

Cachexia, malnourishment, chemo, negative Nitrogen balance, decreased mobility

Skin integrity (ROM & Weight bearing)

Kopi Sarcoma lesions Herpes Diarrhea treatment? Fecal incontinence bags,

rectal tubes, barrier creams Pressure relief mattress(soft

sheets) Mild, non drying products;

soft tooth brush

Pain Social Isolation

Social rejection Loss of support Guilt & punishment

Fatigue Changed sexual expression

Peripheral neuropathy

Immobilitychemoinfections

Pain scalebaseline for comparison

Analgesics

Moist heatvasodilates/relaxes

Cold-reduces swelling & pain

Diversion therapy

Keep viral load low.

Maintain immune function.

Improve quality of life.

Prevent opportunistic disease and new infections.

Reduce disability.

Prevent new infections.

Interventions

Adhere to drug regimens.

Promote healthy lifestyle.

Prevent transmission to others.

Have supportive relationships.

Major goal: Prevention Four strategies Use testing as routine health care.

Use rapid testing.

Work to modify risky behaviors.

Offer tests universally to pregnant women.

Prevention of HIV Decreasing risks: Sexual intercourse

Abstinence

Use of barriers

Safe-dry, wet kiss

-hug, massage

Questionable Latex barriers with anal/oral/vaginal

Mouth to penis-no ejaculation

Unsafe Anal/vaginal/oral contact without condoms

Sharing sexual aids/needles

Blood contact

Decreasing risks: Drug use Do not use drugs.

Do not share equipment.

Do not have sexual intercourse under the influence of any impairing substance.

Decreasing risks: Perinatal transmissionPrevent HIV in women.

Appropriately medicate HIV-infected pregnant women.

Decreasing risks: WorkAdhere to precautions and safety measures to avoid exposure.

Postexposure prophylaxis with combination ART.

Injecting equipment (works) includes needles, syringes, cookers (spoons or bottle caps used to mix the drug), cotton, and rinse water. Equipment used to snort (straws) or smoke (pipes) drugs can also be contaminated with blood. None of this equipment should be shared.

Some communities have needle and syringe exchange programs (NSEPs) that provide sterile equipment to users in exchange for used equipment.

Cleaning equipment before use is a risk-reducing activity. It decreases the risk when sharing equipment, but it takes time and may be difficult for a person in drug withdrawal.

*If HIV-infected pregnant women are appropriately treated during pregnancy, the rate of perinatal transmission can be decreased from 25% to less than 2%.

Testing is only sure method to determine infection.

Negative results: Opportunity for prevention education

Positive results: Treatment and education to protect sexual and drug-using partners

The CDC has recommended that all people ages 13 to 64 should be tested. The CDC recommends universal, voluntary testing in these age groups, regardless of the patients risk or perceived risk.

To decrease the barriers to testing, the CDC recommends an opt out process in which the patient is given the opportunity to decline a test, but it is offered as routine.

Early intervention promotes health and delays disability. Reactions to positive HIV test Similar to any life-threatening, chronic illness Panic, anxiety, fear, guilt, depression, denial, anger,

hopelessness The nursing assessment in HIV disease should focus on

early detection of symptoms, opportunistic diseases, and psychosocial problems.

As time passes, patients and their loved ones must confront common issues associated with any life-threatening illness. These include complex treatment decisions; feelings of loss, anger, powerlessness, depression, and grief; social isolation imposed by self or others; altered concepts of the physical, social, emotional, and creative self; thoughts of suicide; and the possibility of death.

Multidrug therapy can reduce viral load and disease progression, but

It is complex and has interactions

Does not work for everyone and is expensive

When to start therapy? Patient readiness is the most important concern.

To avoid burnout and non-adherence, treatment is recommended when immune suppression is great.

How can you encourage adherence?

These factors contribute to problems with adherence to treatment, a dangerous situation because of the high risk of developing drug resistance.

Interventions include education about (1) advantages and disadvantages of new treatments, (2) dangers of nonadherence to therapeutic regimens, (3) how and when to take each drug, (4) drug interactions to avoid, and (5) side effects that must be reported to the health care provider.

Table 15-12 provides the recommendations for treatment.

Adherence to drug regimens is critical to prevent, Disease progression, Opportunistic disease, Viral drug resistance

How might you encourage adherence? Group supports and individual counseling can also help, but the best approach is to learn about the patients life and assist with problem solving within the confines of that life.

Table 15-18 lists strategies to help your patients adhere to their medications.

Ensure patient understands the importance of adherence and is ready to start treatment.

Provide education on medication dosing Review potential side effects of drugs Assure the patient side effects can be treated so they should not stop taking

the drugs Use teaching and memory aids including pictures, pillboxes and calendars Engage family in the education process. Simplify where possible the regimes dosing and food requirements ]Use a

team approach with nurses pharmacists and counselors PROVIDE ACCESS TO A HEALTH CARE TEAM THE PATIENTS TRUSTS Help the patient integrate the medication regime into their life and work

schedules 2 4 weeks after starting the viral load will be tested to see how the

medicines are working NB an undetectable viral load does not mean that the infection is gone

Missing even a few doses can lead to viral mutations, that allows HIV to become resistant to the drugs.NB an undetectable viral load does not mean that the infection is gone the

patient must be told to continue to take the drugs and use contraceptives and not share needles

Recurring problems of infection, cancer, debility, and psychosocial/economic issues

Social stigma - Behaviors may be viewed as immoral, illegal, or uncontrolled by infected person.

Discrimination causes loss of jobs, homes, and insurance. Most severe for women

Nursing care becomes more complex as the patients immune system deteriorates and new problems arise to compound existing difficulties. When opportunistic diseases or difficult side effects of treatment develop, symptom management, education, and emotional support are necessary.The best way to prevent opportunistic disease is to provide adequate treatment for the underlying HIV infection. In addition to assisting the patient to adhere to medications prescribed for opportunistic diseases, you will need to provide appropriate supportive care.

Focus of nursing intervention

Patient comfort

Promoting acceptance of finite nature of life

Helping significant others deal with loss

Maintaining safe environment

Sometimes the patients HIV becomes resistant to all available drug therapies. In other cases, a patient may make a decision to forego further treatment, allowing the disease to progress toward death.

A client with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jirovecipneumonia. Which measure should the nurse include in the plan of care to assist the client in performing activities of daily living?

1) provide supportive care with hygiene needs 2) provide meals and snacks with high-protein, high calorie, and

high-nutritional value 3) provide small, frequent meals 4) offer low microbial foods1- Providing supportive care with hygiene needs as needed reduces the client's physical and emotional energy demands and conserves energy resources for other functions such as breathing. Options B, C, and D are important interventions for the client with AIDS but do not address the subject of activities of daily living. Option B will assist the client in maintaining appropriate weight and proper nutrition. Option C will assist the client in tolerating meals better. Option D will decrease the client's risk of infection.

A client who was tested for human immunodeficiency virus (HIV) after a recent exposure had a negative result. During the post-test counseling session, the nurse tells the client which of the following?

1) the test should be repeated in 6 months 2) this ensures that the client is not infected with the HIV

virus 3) the client no longer needs to protect himself from sexual

partners 4) the client probably has immunity to the acquired

immunodeficiency virus

1- A negative test result indicates that no HIV antibodies were detected in the blood sample. A repeated test in 6 months is recommended because false-negative test results have occurred early in the infection. Options 2,3,4 , are incorrect.

BBC Science (2013) Why cant we beat viruses ( accessed 04/16/2013)

http://www.bbc.co.uk/science/0/21143412

Centers for Disease Control & Prevention (CDC) (2007)[online] Universel prcautions (Accessed04/20/2013)

http://www.cdc.gov/niosh/topics/bbp/universal.html

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