HUMAN IMMUNODEFICIENCY

VIRUS (HIV) INFECTION

Zoya Minasyan RN-MSN-Edu

Significance of Problem

Globally 33 million living with HIV 2.7 million new infections each year 2 million HIV-related deaths each year

In the United States• 56,000 new infections 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.

Transmission of HIV Fragile virus transmitted only through

contact with body fluids Blood, semen, vaginal secretions, and breast

milk Sex with infected partner Exposure to infected blood or blood products Pregnancy, delivery, or breastfeeding

Pathophysiology of HIV RNA virus (retrovirus) discovered in 1983 Binds to specific CD4 and chemokine receptors to enter cell

HIV Proteins Bind to Cell

5

HIV has gp120 glycoproteins that attach to CD4 and chemokine CXCR4 and CCR5 receptors on thesurface of CD4+ T cells. Viral RNA then enters the cell, produces viral DNA in the presence of reversetranscriptase, and incorporates itself into the cellular genome in the presence of integrase, causing permanentcellular infection and the production of new virions. New viral RNA develops initially in long strands that are cutin the presence of protease and leave the cell through a budding process that ultimately contributes to cellulardestruction.

Pathophysiology of HIV Reverse transcriptase assists to make

viral DNA. Viral DNA enters cell nucleus and splices

itself into genome permanently. Integrase

Viral Load in the Blood Initial infection

Viremia (large viral levels in blood) for 2 to 3 weeks Transmission is more likely when viral load is

high. Followed by prolonged period (years) of low

viral load

Pathophysiology of HIV

Cells with CD4 receptor sites are infected CD4+ T cells (T helper cells) Lymphocytes Monocytes/macrophages Astrocytes Oligodendrocytes

Immune problems start when CD4+ T-cell counts drop to below 500 cells/μL. Normal range is 800 to 1200

cells/μL. Allows for opportunistic diseases

Clinical Manifestations and Complications

Acute infection Flulike symptoms

Fever, swollen lymph glands, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhea, or a diffuse rash

Occurs about 2 to 4 weeks after infection Lasts for 1 to 2 weeks

Clinical Manifestations and Complications

Early chronic infection Generally asymptomatic

Fatigue, headache, low-grade fever, and night sweats often occur.

Most are not aware of infected status.

Clinical Manifestations and Complications

Intermediate chronic CD4+ T cells drop to 200 to 500 cells/μL.

Viral load increases. HIV advances to a more active state.

Clinical Manifestations and Complications

Intermediate chronic symptoms Thrush Oral hairy leukoplakia Shingles Persistent vaginal candidal infections Herpes Bacterial infections Kaposi sarcoma

Oral Thrush

Oral thrush involving hard and soft palate.

Oral Hairy Leukoplakia

Oral hairy leukoplakia on the lateral aspect of the tongue.

Kaposi Sarcoma

Kaposi sarcoma (KS). Malignant vascular lesions. KS lesions can appear anywhereon the skin surface or on internal organs. Lesions vary in size from pinpoint to very large andmay appear in a variety of shades.

Clinical Manifestations and Complications

Late chronic or AIDS Immune system severely compromised Great risk for opportunistic disease Possible malignancies, wasting, and dementia

Clinical Manifestations and Complications

Common opportunistic diseases Pneumocystis jiroveci pneumonia Cryptococcal meningitis Cytomegalovirus retinitis Mycobacterium avium complex Kaposi sarcoma Influenza virus

Pneumocystis jiroveci

Chest x-ray showing interstitial infiltrates as the result ofPneumocystis jiroveci pneumonia.

Diagnostic Studies Most useful screening tests detect HIV-

specific antibodies May take 2 months (window period) to detect

antibodies

Diagnostic Studies Progression monitored by CD4+ T-cell

counts and viral load Abnormal blood tests common

Neutropenia, thrombocytopenia, and anemia Altered liver function tests

Resistance tests

Collaborative Care Focus Monitoring HIV disease progression and

immune function Initiating and monitoring antiretroviral

therapy (ART) Preventing, detecting, and treating

opportunistic infections

Collaborative Care Focus Managing symptoms Preventing or decreasing complications of

therapies Preventing further transmission

Collaborative Care Initial visit

Gather baseline data Education about spectrum of HIV, treatment,

preventing transmission, improving health, and family planning

Collaborative Care Initial visit

Gather baseline data Education about spectrum of HIV, treatment,

preventing transmission, improving health, and family planning

Drug Therapy Main goals

Decrease viral load. Maintain/raise CD4+ counts. Delay HIV-related symptoms and opportunistic

infections.

Drug Therapy Nucleoside, non-nucleoside, and

nucleotide reverse transcriptase inhibitors Inhibit the ability of HIV to make a DNA copy

early in replication Protease inhibitors

Interfere with activity of enzyme protease

Drug Therapy Fusion inhibitors

Interfere with HIV CD4 receptor site binding and entry into cells

Drug Therapy Combination antiretroviral therapy

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

Drug Therapy Prophylactic medication given to prevent

opportunistic infection Ongoing research seeks a biochemical

means of preventing HIV transmission.

Nursing Management Assessment

Ask at-risk patients: Received blood transfusion or clotting factors

before 1985? Shared needles, syringes, or other injection

equipment with another person?

Nursing ManagementAssessment

Ask at-risk patients: Had a sexual experience with your penis,

vagina, rectum, or mouth in contact with these areas of another person?

Had a sexually transmitted disease (STD)?

Nursing ManagementAssessment

Assess diagnosed patients Repeat assessments over time as

circumstance changes

Nursing Management Planning

Interventions Adhere to drug regimens. Promote healthy lifestyle. Prevent transmission to others. Have supportive relationships.

Nursing Management Planning

Interventions Maintain productive activity. Explore spirituality. Come to terms with living with disease,

disability, and death. Cope with symptoms and treatments.

Nursing ManagementImplementation

HIV is a highly variable chronic disease. Holistic and individualized approach is best.

Health Promotion 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.

Health Promotion Prevention of HIV

Decreasing risks: Sexual intercourse Use of barriers

Health Promotion Prevention of HIV

Decreasing risks: Drug use Do not use drugs. Do not share equipment. Do not have sexual intercourse under the

influence of any impairing substance.

Health Promotion Prevention of HIV

Decreasing risks: Perinatal transmission Prevent HIV in women. Appropriately medicate HIV-infected pregnant

women.

Health Promotion Prevention of HIV

Decreasing risks: Work Adhere to precautions and safety measures to

avoid exposure. Postexposure prophylaxis with combination ART.

HIV Testing and Counseling 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 All testing should be accompanied by pretest

and posttest education

Acute Intervention 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

Antiretroviral Therapy Multidrug therapy can reduce viral load

and disease progression, but it Is complex Has interactions Does not work for everyone Is expensive

Antiretroviral Therapy When to start therapy

Patient readiness is the most important concern.

To avoid burnout and nonadherence, treatment is recommended when immune suppression is great.

Antiretroviral Therapy Adherence to drug regimens is critical to

prevent Disease progression Opportunistic disease Viral drug resistance

Antiretroviral Therapy Ways to improve adherence

Understand each patient is unique. Provide electronic reminders or timers.

Acute Exacerbations Recurring problems of infection, cancer,

debility, and psychosocial/economic issues affect ability to cope.

Ongoing Care Social stigma

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

Ongoing Care Discrimination causes loss of jobs,

homes, and insurance. Most severe for women Americans with Disabilities Act makes

discrimination illegal.

Disease and Drug Side Effects

Common physical problems Anxiety, fear, depression Diarrhea Peripheral neuropathy Pain Nausea/vomiting Fatigue

Disease and Drug Side Effects

Common metabolic disorders Lipodystrophy Hyperlipidemia Insulin resistance Bone disease Lactic acidosis Cardiovascular disease

Lipodystrophy

FiLipodystrophy manifestations.

Disease and Drug Side Effects

Management of metabolic disorders Early detection Dealing with symptoms Helping to cope

End-of-Life Care Focus of nursing intervention

Patient comfort Promoting acceptance of finite nature of life Helping significant others deal with loss Maintaining safe environment