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
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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