Human Immunodeficiency Virus HIV Infection relates to Chapter

Human Immunodeficiency Virus (HIV) Infection (relates to Chapter 14, “Human Immunodeficiency Virus Infection, ” in the textbook)

Significance of Problem l Globally – 40 million living with HIV l As of June 2005 in Canada (higher in the USA): – 20, 146 cases of AIDS diagnosed – 13, 502 AIDS-related deaths

Transmission of HIV l l Fragile virus transmitted only through contact with bodily fluids – Blood, semen, vaginal secretions, and breast milk Transmitted through – Sex with infected partner, exposure to infected blood or blood products, pregnancy, and breast feeding

Pathophysiology of HIV l RNA virus discovered in 1983 l Virus binds to specific CD 4 receptor sites and then enters the cell l Reverse transcriptase assists to make a single viral DNA and it copies itself to make a double-stranded viral DNA

Pathophysiology of HIV l Virus enters the cell nucleus l Using integrase the virus splices itself into genome to become part of the cell’s genetic structure

Viral Load in the Blood Fig. 14 -1

Pathophysiology of HIV l HIV destroys CD 4+ cells 3 ways 1. Viral replication leaves holes in cell membranes 2. Infected cells fuse with other cells Ø Combine to form a syncytium that destroys all affected cells 3. Antibodies against HIV bind to the infected cells and activate the complement system, which destroy the infected cells

Pathophysiology of HIV l Consequences – All daughter cells from infected cell are infected – Genetic codes can direct the cell to make HIV l Initial infection – Viremia (large amount of virus in blood) Few clinical symptoms l Steady state of viral load can be maintained for many years l

Pathophysiology of HIV • HIV destroys about 1 billion CD 4+ T cells every day • Immune problems start when CD 4+T cell counts drop below 500 cells/μl

HIV Cell Counts l l 1. Normal T 4 count: 800 -1200 cells/ul 2. T 4 count >500; generally healthy 3. T 4 count 200 -499; minor immune problems – Immune problems start when CD 4+T cell counts drop below 500 cells/μl 4. T 4 count <200; severe problems ONCE T 4 CELLS INFECTED: VIRAL REPLICATION!

Clinical Manifestations and Complications l Acute infection – Flu-like syndrome l Acute retroviral syndrome

Clinical Manifestations and Complications l Chronic HIV infection – Is generally asymptomatic early on – When CD 4+ counts drops to 200 -500 cells/μl, symptoms occur Ø Oral hairy leukoplakia Ø Candida infection Ø Fever, sweats, diarrhea, headaches

Aquired Immunodeficiency Syndrome (AIDS) l l CDC criteria (Table 14 -1 in text) Immune system severely compromised Ratio of CD 4+ to CD 8+ is reversed from 2: 1 to 1: 2 Opportunistic diseases develop that contribute to disability and death

Diagnostic Studies l Screening tests detect HIV-specific antibodies (see Table 14 -3 in text) – May take up to 2 months before antibodies can be detected (window period) l Progression monitored by CD 4+ T cell counts l Lab tests measuring viral activity – Assess disease progression, viral load

Collaborative Care l Monitoring HIV disease progression and immune function l Initiating and monitoring antiretroviral therapy (ART) l Preventing and detecting opportunistic infections l Preventing and treating complications of therapies l Ongoing health assessment – Baseline data including H&P, immunization history, psychosocial and dietary evaluation l Education about spectrum of HIV, treatment, preventing transmission, improving health, and family planning l Repeating and clarification of information is necessary due to shock and denial

Nursing Management Nursing Assessment l Dependent upon the stage of the disease – Prevention – Treatment – Terminal phase

Nursing Management Nursing Assessment l Social factors – Self-esteem – Sexuality – Family interactions – Finances l For persons at risk, ask – Received blood transfusion or blood clotting factors before 1985? – Shared needles, syringes, or other injection equipment with another person? l For persons at risk, ask – Have you had a sexual experience with your penis, vagina, rectum, or mouth in contact with these areas of another person? – Have you ever had a sexually transmitted disease (STD)?

Nursing Management Planning • • Adhere to drug regimens Promote healthy lifestyle Prevent opportunistic infections Prevent transmission to others Have supportive relationships Maintain productive activity Come to terms with issues related to living with disease, death, and spirituality

Nursing Management Implementation l Drug therapy for opportunistic diseases (Table 142 in text) – Delay or treat with adequate antiretroviral therapy – Disease-specific prevention measures l Vaccines? – Development stage, being tested in animals – In HIV-infected person, possibly will boost immune function?

Health Promotion l Prevention of HIV – Decreasing risks related to Ø Ø l Prevention of HIV – Decreasing risks related to sexual intercourse l l l Sexual intercourse Drug use Perinatal transmission Work Abstinence Outercourse Prevention of HIV – Decreasing risks related to sexual intercourse l Use barriers (e. g. , condoms) when engaging in insertive sexual activity

Health Promotion l Prevention of HIV – Decreasing risks related to drug use l Do not use drugs l Do not share equipment l Do not have sexual intercourse when under the influence of any drug (including alcohol) that impairs decision making ability

Health Promotion l Prevention of HIV – Decreasing risks related to perinatal transmission l Prevent HIV infection in women l Treat HIV pregnant women with zidovudine (ZDV, AZT, Retrovir) l Combination ART for the mother’s HIV infection can ↓ transmission to fetus to less than 2%

Health Promotion l Prevention of HIV – Decreasing risks related to work l Greatest risk is through puncture wounds l Splash exposure of blood on skin with open lesion present some risk, though much lower than puncture l Exposure to HIV-infected fluids require postexposure prophylaxis with combination ART

HIV Testing and Counseling l Determine if patient has infection – – l Negative results relieve anxieties about past behaviors and provide opportunities for prevention education Positive results provides impetus to seek treatment and to protect sexual and drug-using partners All testing needs to be accompanied by pre- and post-test education

Acute Intervention l Early intervention promotes health and delays disability l Reactions to positive HIV test – Life-threatening, chronic illness l Panic, fear, guilt, depression, denial, thoughts of suicide

Antiretroviral Therapy l Multi-drug therapy reduces viral loads, but are complex, have interactions, and do not work for everyone – ART released in 1987 – Federal guidelines suggest treatment be delayed until levels of immune suppression are observed – Debate about when to start ART l Adherence to drug regimens is critical to – prevent disease progression – opportunistic disease – viral drug resistance

Acute Exacerbations l Infections, cancers, debility, and psychosocial/economic issues affect patient’s ability to cope l Common opportunistic infections – Pneumocysits carinii pneumonia – Cryptococcal meningitis – Cytomegalovirus retinitis l Common type of cancer – Kaposi’s sarcoma

Social Constructs Surrounding HIV l l Negative social attitudes label patients Behaviors associated with HIV may be viewed as immoral and sometimes illegal Infected individuals can transmit the virus to others Discrimination causes loss of jobs, families, homes, and insurance – Canadian Disabilities Act makes discrimination illegal

Ambulatory and Home Care l l Often experience anxiety, fear, diarrhea, depression peripheral neuropathy, pain, nausea, vomiting, and fatigue Symptom management similar to other chronic illness Metabolic disorders have emerged Detect early and deal with symptoms – Hyperlipidemia, insulin resistance, and bone disease common

Ambulatory and Home Care l l l Nursing interventions focus on safety, self-care, and to help caregivers support those activities Prevent confusion by maintaining meaningful environment, frequent reorientation, and stress reduction measures Emphasis is placed on providing support to family members and significant others who may have difficulty dealing with deterioration of mental and physical status

Terminal Care l l l Dementia often present in final stages of HIV – “AIDS-dementia complex” and cognitive motor complex Dementia often present in final stages of HIV – Results from HIV infection in the brain, CNS lymphoma, toxoplasmosis, CMV, herpes virus, Cryptococcus, progressive multifocal leukoencephalopathy, dehydration, or drug side effects Dementia in final stages of HIV – Reversible if a cause is diagnosed