Human Immunodeficiency Virus

Peggy D. Johndrow

2009

Pathophysiology

Retroviruses carry genetic Information in genetic material RNA instead of DNA

HIV uses enzyme reverse transcriptase to insert itself into cells & reprogram genetic structure; creates HIV

Incubation

Latent period: infected persons (80-90%) develop symptoms of HIV disease or AIDS within 10 years; however varies greatly individually

Modes of TransmissionSexual Genital, anal or oral sexual contact with exposure of

mucous membranes to infected semen or vaginal secretions

Parenteral Sharing needles or equipment contaminated with

infected blood products Needle sticks acquired in healthcare settings

Perinatal Through placenta from contact with maternal blood &

body fluids during birth or from breast milk from infected mother to child

CDC Guidelines for TestingPeople with STI’sIV drug usersPeople who: consider themselves at risk; received a blood transfusion between 1978-1985; planning to marry; undergoing evaluation or treatment for manifestations that may be HIV related; admitted to hospitals; are in correctional institutionsProstitutes and their customersWomen of childbearing age with identifiable risk factors IV drug use, engaged in prostitution or had

sexual partners who were infected, at risk or from countries with high HIV rates

Diagnostic Testing

Need informed consent to perform

Several tests; repeat to confirm

Antibody Testing

Antibodies develop within 3-12 weeks of exposure; can take 6-14 months (may not test positive initially)

Important point, may take time to test positive does not mean client is immune

Enzyme Linked Immunosorbent Assay (ELISA)

Identifies antibodies directed specifically against HIV; not establish diagnosis, indicates exposure; blood contains antibodies called seropositive

Window period” means that test can be negative even if person has HIV if test is performed too soon (i.e. testing one week after unprotected sex w/ith HIV + partner)

False (+) results can occasionally occur

Western Blot Assay

Identify HIV antibodiesUsed to confirm seropositive

Positive ELISA confirmed with Western Blot Analysis

Detects serum antibodies to four specific HIV antigens

Indirect Immunofluorescence Assay (IFA)

Used instead of Western Blot faster & easier to perform

Radioimmunoprecipitation Assay (RIPA)

Detects HIV protein

Client Implication

Positive test antibodies present, HIV probably active, transmit, HIV + (not AIDS), not immune to AIDS

Negative (may not have pronounced antibodies at present); continue precautions body hasn’t produced antibodies yet; continuing present behaviors likely to result in infection with HIV

Diagnostic Studies

Lymphocyte Count Leukcopenia = WBC <3500cells/mm³ Lymphopenia = <1500 lymphocytes/mm³

CD4+ and CD8+ Counts Decreased CD4+ counts & decreased CD4/CD8

ratios associated with increased manifestations of disease

T-helper cells = 800-1000 cells/microL T-suppressor cells = 300-1000 cells/microL CD4/CD8 ratio: >1

Viral Load TestingMeasures presence of HIV RNA in blood Gives quantitative number Indicates level of viral burden Useful in monitoring disease progression & effectiveness

of treatment Quantitative RNA Assays RT-PCR, bDNA, & NASBA: 100% specificity p24 Antigen Assay

Higher viral load the greater risk for transmission; HAART therapy can cause viral load to decrease to undetectable levels, disease transmission risk still present

HIV Tracking

P24 antigen

Quantitative cell culture – viral load

Immune Status

CD4 cells

CD4 cell function test

T cells decreased ability to respond

Basis of Clinical Manifestations

Result from infections, malignancies, or direct effect of HIV in body tissue

Clinical ManifestationsInitial s/s:FeverNight sweats Chills H/AMuscle aches

Decreased CD4+ function r/t HIV infection leads to:Lymphocytopenia Increased production

incomplete & nonfunctional antibodies

Abnormally functioning macrophages

Respiratory Problems

Most common Pneumocystis Carinni pneumonia (PCP), mycobacterium avium, intracellular; legionella species

GI Symptoms

Anorexia, nausea, vomiting, diarrhea, oral esophageal candidiasis, chronic diarrhea

Stool cultures positive for Cryptosporidium muris, Salmonella, Isopora belli, Giardia lamblia, Clostridium difficile

GI DisordersEffects of diarrhea Profound weight loss

>10% body weight, fluid & electrolyte imbalance, perianal skin excoriation, weakness, inability to perform ADL’s

Candidiasis Creamy white patches

on oral membranes, difficulty swallowing, ulcerations, dissemination to other body systems

Wasting syndrome Defined as wt loss>10%

body wt & either chronic diarrhea > 30days, chronic weakness & intermittent or constant fever & absence of disease process

Hypermetabolic state Excessive calories

burned & lean body mass lost

Oncology Problems High incidence of cancer

Kaposi’s sarcoma Malignancy involving

blood & lymphatic vessels; cutaneous lesions on body brownish pink to deep purple lesions; confirm with biopsy

B cell lymphomas Commonly brain,

bone marrow & GI tract; aggressive growth & resistance to treatment; poor prognosis

Neurological Problems80% have neurological involvement

Central, peripheral, autonomic function

HIV encephalopathy: ADC(AIDS dementia complex) decline in cognitive, behavioral & motor function; diagnose with CT Scan or MRI, analysis of CSF, brain biopsy

Cryptococcus neoformans: fungal infection; meningitis; diagnose with CSF analysis

Demyelinating CNS disorders

Central & Peripheral Neuropathy Depressive disorders

Integumentary Problems

Kaposi’s Sarcoma

Molluscum contagiosium: viral infection with plague formation (wart like, skin tags)

Seborrheic dermatitis, folliculitis, eczema, psoriasis

Problems Specific to Women

Recurrent vaginal candidiasis Genital warts & ulcersHuman papilloma virus (HPV)Cervical intraepithelial neoplasia (CIN) cellular change precursor to cervical cancer

Women with HIV 10x more likely to develop CIN

Strong correlation between abnormal papanicolaou smear & HIV seropositive

Higher incidence of PID

Higher incidence of menstrual abnormalities

Gerontologic Considerations

10% AIDS occurs in people >50

Under diagnosed; need education for prevention

HIV Classifications

Clinical category A HIV positive

Clinical category B infected with HIV

Clinical category C has AIDS

Category A

Positive HIVMay or may not be symptomaticLymphadnopathy or “flu-like” complaintsSub categoriesA1 = CD4+ ≥500/microLA2 = CD4+ 200-499/microLA3 = CD4+ <200/microL

Category B

One or more problems from column One or more problems from column Table 25-1 presentTable 25-1 presentCaused by HIV infection or indicates deficiency cell mediated immunity; complicated by HIV infectionSub categories

B1, B2, B3CD4+ counts as before

Category C

Any single problem from column C in Table 25-1 Meet criteria for diagnosis of AIDS per CDC guidelinesSub categories

C1, C2, C3CD4+ counts as in A&B

Important Facts

Everyone who has AIDS has HIV infection ; not everyone who has HIV infection has AIDS

Person with HIV infection can transmit virus to others at all stages of disease

Progression from HIV to AIDS range from months to years

Diagnosis of AIDS requires person be HIV (+) & have either a CD4 count <200 cells/microL or an opportunistic infection

Once AIDS diagnosed, even if CD4 count goes above 200 or infection is successfully treated, AIDS diagnosis remains & client does not return to just being HIV (+)

Health Promotion & Prevention

Education most important aspect of prevention

HIV: not transmitted by casual contact; easily transmitted when infected body fluids in contact with mucous membranes or non-intact skin

Sexual Transmission

Abstinence & mutually monogamous sex; only absolute safe methods of preventing HIV through sexual contact

Outercourse: no direct contact with blood, semen or vaginal secretions

Male/Female condom use

See Client Teaching Guidelines

Parental Transmission

Do Not share needles or equipment (aka “works”)

Use full strength household bleach to clean the “works”

Needle exchange programs

See Teaching Guidelines Needle exchange programs

Perinatal Transmission

All women who are pregnant or contemplating pregnancy should be counseled about HIV, informed of their choices, offered HIV testing & provided HAART

Refer to maternal-child course content

Health care Providers Transmission

Needle sticks primary means of HIV infection for healthcare workers If needle stick occurs notify supervisor immediately See Best Practice Guideline for HIV exposure

Contact with infected body fluids Best prevention is consistent use of standard

precautions See prevention guidelines for healthcare workers

Medical Management

Medications: antiretroviral therapy with CD4+ T-cell count< 500/mm3

Measure CD4+ count & viral load 2x before initiating

HAART triple medication regimen 1 protease inhibitor 2 reverse transcriptase

inhibitors

Combination therapies use 3 to 4 medications combinations

Treatment

Post exposure prophylaxis (PEP)

Preferred regime

Reverse transcriptase inhibitors zidovudine (AZT) and lamivudine (Edvir)

Alternate

Stavudine (ZERIT) and didanosine (Videx)

If client has a high viral load or advanced HIV add a Protease inhibitors either

Nelfinavir (Viracept) or indinavir (Crixivan)

Treatment Regimen

Dosage BID for 4 weeks

Must start within 72 hours of exposureMust start within 72 hours of exposure

If not started renders no benefit after 72 If not started renders no benefit after 72 hourshours

MedicationsNucleoside Analog Reverse Transcriptase Inhibitors (NRTI’s): suppress production of RT & inhibit viral DNA synthesis/replication; Retrovir, AZT (zidovudine )Non-Nucleoside Analog Reverse Transcriptase Inhibitors (NNRTI’s): inhibits synthesis of RT & suppresses viral replication; Suvista (efavirenz )

Protease Inhibitors: block protease enzyme preventing viral replication & release of viral particles; Invirase (saquinavir)

Fusion Inhibitors: block ability of gp41 to fuse with CD4+ cell: Fuzeon(enfuvirtide); approved treatment advanced, resistant HIV infection

Other Therapies

Immune enhancement In research stages

Hypothesis: immune system may be enhanced or replenished

Bone marrow transplantLymphocyte transfusionInterleukin-2 infusion

Complementary/Alternative therapiesUsefulness not yet established; however, used

by many clients with HIV/AIDSVitamins, shark cartilage, botanicals

Immunomodulator Therapy

Alfa-interferon (stimulate macrophages, lymphocytes & T cells)

Colony stimulating factorEpoetin alfa recombinant/EpogenFilgrastim/Neupogen

Other Medications

General infections

Bactrim/Septra

PCP pentamidine (antiprotozoal) IV slow infusion

Steroid

Medications for Specific Disorders

Mycobacterium avium: Biaxin, Zithromax, Rifampin, mycobutin, lamprene, Ethambutal, Cipro & Amikacin

Meningitis: Amphotericin B, Diflucan

Other infections Acyclovir & Foscarent for herpes encephalitis Daraprim, Sulfadiazine, Clindamycin for toxoplasmosis Myclex, Nystatin for candidiasis Ketoconazole, fluconazole for chronic candidiasis

Nursing ImplicationsSee Chart 25-8 for side effects & nursing considerationsAntiretroviral therapy only inhibits viral replication; it does not kill virusCombination therapy uses; monotherapy promotes resistance , not improve duration or quality of life “Cocktails” combination of different types of antiretroviral medications HAART (highly active antiretroviral therapy) shows good results as evidenced by decreased viral load & increased CD4+ counts

Problems r/t Therapy

Expense of medications

Distressing side effects

Food & timing requirements

Amount of pills that must be taken daily

Treatment is lifelong & burdensome

Nursing

Assessment

History sexual practices, IV drug use, physical status, psychological status & all factors affecting immune system

Teaching

Nutritional

Balanced nutrition required for proper immune function

Diet history

Assess factors interfering with intake

Weight, BUN, serum protein, albumin, and transferrin levels

Skin integrity

Inspect daily for breakdown, excoriation and infection

Keep clean and dry

Respiratory

Monitor cough, sputum, dyspnea, tachypnea, chest pain

Evaluate CXR, PFT’s, ABG’s, O2 saturation

Neurological

LOC, orientation

Mental status exam

Motor and sensory deficits

Fluid and Electrolytes

Monitor labs, hydration, vital signs, signs and symptoms of electrolyte imbalance

I&O

Skin turgor

Mucus membranes

Health Teaching

Client, family, and support systems

About disease and transmission

Use of alternative therapies

Prevention

Integumentary Nursing Interventions

Turn q 2hrs

Use nonabrasive, non-drying soaps, non-perfumed moisturizers

Avoid adhesive tape

Cleanse after BM with soap and water

Sitz bath for comfort

Promote Usual Bowel Habits Monitor frequency & consistency of stoolsMeasure quantity & volume of liquid stools to document fluid lossAvoid bowel irritants raw fruits & vegetables, popcorn, carbonated beverages, spicy foods, extreme temperatures of foodsSmall frequent mealsAnti diarrheal agents administered on regular schedule

 

Prevent Infections

Monitor symptoms for infection

Monitor labs and cultures

Screen visitors; avoid others with infections

No live plants; fresh fruits

All use good handwashing

Promote client hygiene

Improve Activity Tolerance

Assist clients to plan daily routine that maintain a balance between activity and rest

Teach techniques of energy conservation

Cluster nursing actions

Maintain Thought Processes

Teach family to speak in simple terms, clear language and give client time to respond

Orient to daily routine

Provide a regular schedule / routine

Improve Airway Clearance

Respiratory assessment

Postural drainage

Cough and deep breathe q 2hrs

Place HOB in semi or high fowlers

Adequate hydration (3L/fluid per day)

Suction as needed

Relieve Pain and Discomfort

Assess

Provide skin care

Assistive devices for comfort

Medications NSAIDS, Opioid, tricyclic antidepressants

Improve Nutrition Status

Oral care

Monitor daily weight & dietary intake

Monitor labs

Control nausea & vomiting with

anti-emetics on regular basis

Oral soreness opioids, viscous lidocaine

Bland diet, avoid temperature extremes in foods

Rest before meals

Dietary teaching,

supplements

Decrease Sense of Isolation

Acceptance and understanding

AIDS support groups and family support

Educate client’s families, friends and staff

Medications

Teach side effects of medication

Instruct on importance of taking medications as ordered

Explain what to report

Home and Community Based

Safe sexual practices

Avoid infections & infectious people

Kitchens & bathrooms surfaces cleansed with disinfectants

Avoid contact with pet waste, if necessary client must use gloves

Ethical

With appropriate techniques minimal transmission in providing careConfidential information disclosure issuesPrivacyHigh mortality rateSelf-assessment & awareness of personal value & belief system regarding HIV & AIDS