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Human Im mun od ef ic ie nc y Vi rus

Ba si c Pri nc ipl es o f Gen etic s
Transmission of HIV

 Exchange of blood or other body fluids containing HIV (blood, semen,

vaginal secretions & breast milk) i.e. unprotected sex or by sharing needles
 HIV- infected individuals can transmit HIV within a few days after becoming
infected; transmit ability lifelong
 Sexual contact with an HIV-infected partner – 75% cases (most common
mode of transmission)
 Accidental needle sticks, needle sharing among IV drug users
 Perinatal Transmission (most common route for infecting children) –
HIV- infected mother to her infant occur during pregnancy in utero or at time
of delivery or after birth through breastfeeding

Pathophysiology (Natural Hx of HIV)

HIV is a ribonucleic acid (RNA) virus (retroviruses – replicate in a
“backward” manner going from RNA to deoxyribonucleic acid (DNA); reverse
flow of genetics)
 Must have living cell to replicate; T lymphocytes (T4 or CD4 cells) (invade
living host cell)

HIV life cycle

 1. HIV binds to the T cells (CD4 lymphocytes, T4 cells, Helper T cells)
 2. Viral RNA is released into the host cell
 3. Reverse transcriptase converts viral RNS into Viral DNA
 4. Viral DNA enters the T cell’s nucleus and inserts itself into the T cell’s
DNA
5. The T cells begins to make copies of the HIV components.
6. Protease (enzyme) helps create new virus particles
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7. The new virion (virus particle is released from the T cell

Clinical Manifestations
 Refer to fig 14-4, pg. 267 typical course of untreated HIV
 Early Stage -First phase of HIV infection; As virus begins to replicate
person develops an acute retroviral syndrome/primary HIV infection (PHI)
 Period of time between initial exposure to virus & appearance of HIV
antibodies
 No test can detect antibodies in early stage
 Fast and furious – amount of virus in peripheral blood increased greater
then 100,000 copies/ml
 Like Van Diesel movie fast and furious – amount of virus in peripheral
blood increased greater than 100,000 copies/ml
 Body starts to produce antibodies
 Flu like symptoms
 Second Phase of HIV infection
 SSx of PHI resolve
 Viral load decreases
 Seroconversion occurs

 Chronic infection
 Patient seems well ( no clinical apparent disease)
 Virus is busy replicating itself and spreading to uninfected cells
 If no treatment – loose T cells – HIV associated infections

 Symptomatic HIV infection

 T-cell count continues to decline
 Patient develops a symptomatic infection (pneumocystis pneumonia
(PCP) or candidiasis)
 HIV infection Dx at this stage
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HIV-associated illnesses appear

 Acquired immunodeficiency syndrome (AIDS)

Meets definition of AIDS established by US center for disease control and
prevention (CDC)
HIV+ & have CD4 cell ct below 200/mm
HIV+ & have AIDS defining illness

Diagnostic Studies
 Most useful screening tests are those that detect HIV-specific antibodies
 Problem – median delay of 2 months after infection before antibodies can be
detected
 Health care providers alerted to do HIV screening based on sexual practices,
IV drug use, receipt of blood transfusions, exposure to body fluid
(needlestick)

 HIV antibody testing

Requires education & counseling – meaning of test & possible results
Informed consent
Privacy
Test results kept confidential

Diagnostic Studies
OralQuick Rapid HIV-1 – (2002)
 Antibody test allow rapid notification of individuals
 Accurate results in 20 minutes
Uni-Gold Recombigen (Dec 2003)
 Results in 10 minutes
Oral Quick Rapid HIV – ½ Antibody test (March 2004)
 99% accurate; results in 20 mins; saliva specimen
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 EIA (enzyme immunoassay) formerly ELISA (enzyme linked

immunosorbent assay)
 Detect serum antibodies that bind to HIV antigen
 Serum & saliva
 Western Blot or immunofluorescence Assay (IFA)
 More specifically confirms HIV
 Viral Load test
 Measure plasma HIV RNA level
 Used to track viral load & response to tx for HIV infection
 CD4 T-cell count to monitor progression of the infection
 WBC count, RBC count, and platelets decrease with progression of HIV
Collaborative Care (Rapidly Changing)
 Protocols change often
 Treat for life
 Highly Active Antiretroviral Therapy (HAART) /Antiretroviral (ARV) regimen
 Treatment based on
HIV RNA (viral load)
CD4T cell count
Clinical condition of patient
 Refer to table 14-6 & 14-7, pg. 273-275 (Lewis)
 Antiretroviral regimens are complex, major side effects, adherence difficult,
carry serious potential consequences from viral resistance r/t lack of
adherence or suboptimal levels of antiretroviral agents

Drug Therapy
 Nonnucleoside reverse transcriptase inhibitors (NNRTIs) – attach to
the reverse transcriptase enzyme, preventing the enzyme from converting
HIV RNA to DNA
 Nucleoside reverse transcriptase inhibitors (NRTIs) become part of
HIV’s DNA and derail its building process. (damaged DNA can’t take control
of the cell’s DNA)
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 Protease inhibitors work at later stage in replication process, preventing

the protease enzyme from cutting HIV viral proteins into the virions that
infect new CD4+ cells (new copies of HIV will be defective and unable to
infect other CD4+ cells.
 Fusion Inhibitors – interferes with HIV’s ability to fuse with and enter the
host cell

HAART Therapy
 Combining drugs from above categories allows them to block HIV at several
points in the replication, slowing its spread in the body
 Strategy known as highly active (or highly aggressive) antiretroviral therapy
(HARRT)
 Death rate has dropped because of HARRT
 Initiated during acute HIV infection
 Pregnancy
 Post exposure health care worker, rape victims
 Offered to all patients that are symptomatic
 <350 CD4 or VL > 55,000 (low positives 10,000)
 Barrier – failure to adhere to treatment
 If patient doesn’t take medication as prescribed, virus will mutate
and become resistant to it

Complication & Altered Labs

Protease inhibitor class
Cause lipid abnormalities
Protease inhibitors & NRTIs
Hyperinsulinemia and abnormal glucose metabolism
Lipodystrophy syndrome (lipid abnormalities and /or body fat changes
Facial wasting or atrophy
Intrabdominal fat & fat at dorsocervial area/Visceral fat gain – body
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shape changes
Gynecomastia - rare
Other complications
Common Opportunistic Infections (OIs)
Pneumocystis carinii pneumonia
Cytomegalovirus

Mycobacterium tuberculosis
 Cryptosporidiosis
Toxoplasmosis

Candidiasis

Histoplasmosis

Clinical Manifestations
 Widespread and effect any organ system
 Pneumocystis carinii pneumonia (PCP)
 Most common OI resulting in an AIDS diagnosis
 Fungus – P carinii causes disease only in immunocompromised hosts,
invading and proliferating within pulmonary alveoli with resultant
consolidation of the pulmonary parenchyma

 Nonproductive (dry) cough, fever, chills, shortness of breath, dyspnea, occ.

chest pain, tachypnea, tachycardia
 Treatment
TMP-SMZ drug of choice
Pentamidine(Pentam 300, Nebu-Pent) nebulizer tx.
Dupsone – anti-infective, anti leprosy
Mepron – anti-infective, anti-protozal, antipneumocystic activity

Mycobacterium avium complex (MAC)

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 Group of acid-fast bacilli

 Frequently causes GI tract problems for HIV-infected patients
 SSx – chronic diarrhea, abdominal pain, fever, malaise, weight loss, anemia,
neutropenia, malabsorption syndrome, & obstructive jaundice

Treatment
 clarithromycin (Biaxin)
 azithromycin (Zithromax)
 Rifabutin (Mycobutin) combined with azithromycin more effective but
costly
 Nursing – teach about complicated drug therapy; help deal with
diarrhea

Tuberculosis
Mycobacterium tuberculosis occur in IV drug users & groups with high
preexisting high prevalence to TB infection
Productive cough, fever, night sweats, weight loss
Management complex - taking numerous meds which may interact with
antituberculosis meds - expert consulted
Rifampin
Rifabutin
INH, ethambutol

GI Manifestations
Loss of appetite
Nausea & vomiting
Oral & esophageal candidiasis
Chronic diarrhea
Cryptoporidium muris
Salmonella
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Clostridium difficile

Manage chronic diarrhea - octreotide acetate (Sandostatin)

Candidiasis - clotrimazole (Mycelex) oral troches or nystatin suspension

Kaposi’s Sarcoma (KS)

 Most common HIV-related malignancy - disease involving endothelial layer
of blood and lymphatic vessels -
 Localized cutaneous lesions; disseminated disease involving multiple organ
systems
 Brownish, pink to deep purple cutaneous lesions
Surgical excision of lesions
application of nitrogen
Radiation therapy - palliative to relieve pain
Alpha-interferon

HIV Encephalopathy
Clinical syndrome - progressive decline in cognitive, behavioral, and motor
functions
SSx - (early) memory deficits, headache, difficulty concentrating,
progressive confusion, psychomotor slowing, apathy and ataxia
Later stages - global cognitive impairments, delay in verbal responses, a
vacant state, spastic paraparesis, hyperreflexia,psychosis, hallucination,
tremors, incontinence, seizures, mutism & death

AIDS – dementia complex (ADC)

 Dementia that accompanies final stage of AIDS
 Caused by HIV infection in brain, or HIV related CNS problems caused by
lymphoma, toxoplasmosis, CMV, herpes virus, Cryptococcus, PML,
dehydration or drug SE
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 SSx – decreased ability to concentrate, apathy, depression, inattention,

forgetfulness, social withdrawal, personality changes, insomnia, confusion,
hallucinations, slowed response rates, clumsiness and ataxia
 Progresses – global dementia, paraplegia, incontinence and coma
 Nursing intervention – focus on safety; issues r/t assistance devices, home
environment, and smoking; encourage self-care as long as possible & help
caregiver

Cryptocococcal meningitis
 Fungal infection
 Fever, headache, malaise, stiff neck, nausea & vomiting, mental status
changes, seizures
IV amphotericin B
flucytosine or Diflucan

Cytomegalovirus Retinitis (CMV)

Leading cause of blindness - retinal lesions
Blurred or loss of vision, floaters
Oral ganciclovir - prophylaxis with T-cell counts less than 50
foscarnet (Foscavir) -
Does not kill the virus but control growth - requires lifelong tx

Depressive Manifestation
Multifactorial causes
May experience irrational guilt and shame, loss of self-esteem, feeling of
helplessness and worthlessness, and suicidal ideation
Psychotherapy

Antidepressants

imipramine (Tofranil
fluoxetine (Prozac)
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 desipramine (Norpramin)
 Relieve fatigue & lethargy

Skin Manifestations
OIs - herpes zoster & herpes simplex - painful vesicles disrupt skin integrity
Seborrheic dermatitis - indurated, diffuse, scaly rash involving scalp & face
Generalized folliculitis - dry,flaking skin or atopic dermatitis (eczema or
psoriasis)
Gynecologic Manifestations
Persistent, recurrent vaginal candidiasis - first sign in HIV infection in
women
Ulcerative STDs - chancroid syphilis, herpes more severe in women
PID

Older Adults & HIV

 Seniors are a growing segment pf the HIV + population and AIDS diagnoses
among seniors are on the rise
 Between 11 and 15% of U.S. AIDS cases occur in people over age 50
 Referred to as an “overlooked epidemic” and “forgotten population”
 Older adults do not use condom; view as means of unneeded birth control &
do not consider themselves at risk
 Modes of transmission identical as for other age groups
 Teach safe sex practices to prevent sexually transmitted diseases

Nursing Care
Very challenging – organ system target for infection & Cancer
Complicated by emotional, social & ethical issues
Refer to Table 14-10, pg. 277 (Lewis) Nursing Dx
Refer to Table 14-11, pg. 278 (Lewis) interventions
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Prevention of HIV Infection

 Effective educational program to eliminate & reduce risk behaviors
 Safer sexual practices – use of latex or non-latex condoms during vaginal &
anal intercourse, and oral contact with penis
 Dental Dams used for oral contact with vagina & rectum
 Avoid sexual practices that might cut, tear, lining of rectum, penis or vagina
 Avoid contact with multiple partners or people know HIV infection and use
injection drugs
 Avoid donating blood & sharing drug equipment
Family planning issues need to be addressed
 Estrogen in oral contraceptives increase risk of HIV infection
 Use estrogen in HIV + women increase shedding in vagina & cervical
secretion
 IUD string serves as means to transmit HIV & causes penile abrasion
Female condom- 1st barrier method that can be controlled by women

Transmission to Health Care Providers

Standard Precautions
 Applies to all patients receiving care in hospital regardless of Dx or
presumed infection status
 Goal – prevent transmission of nosocominal infection
 Refer to chart 52-3 pg. 1551
Transmission Base Precautions
 Used for pt with documented or suspected infections
 Airborne precautions
 Droplet precautions
 Contact precautions
2000 Needlestick Injury & Prevention Act
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Nursing Interventions
 Promoting skin integrity
Assess
Balance rest and mobility
Immobile – turn Q 2 hrs
Pressure relieving devices; low air loss beds (Clinitron)
Avoid scratching & nonabrasive soaps
Medicated lotions, ointments & dressings
Avoid adhesive tape
Regular oral care
Perianal area – clean after each BM; soft cloth or sponge less irritating;
Sitz bath or gentle irrigation
Wounds cultured for infection

Promoting bowel habits

 Assess for diarrhea
 Monitor frequency & consistency of stools & report abdominal pain &
cramping
 Measure quantity & volume of liquid stools
 Obtain stool cultures
 Oral fluid restriction (NPO) acute inflammation
 Avoid foods that act as irritants, i.e. raw fruits & vegetables, popcorn,
carbonated beverages, spicy foods, and foods extreme temperature
 Small frequent meals – prevent abdominal distention
 Administer anticholinergic antispasmodics or opioids which decrease
diarrhea by decreasing intestinal spasms & motility
 Antibiotics & antifungal Rx to combat pathogens (stool cultures)

Preventing Infection
Monitor for SSx infection; fever, chills, night sweats, cough with or without
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sputum production; SOB; difficulty breathing, oral pain or difficulty

swallowing…
Monitor labs, CBC with differential
Obtain culture specimens as ordered
Avoid others with active infections i.e. upper respiratory infection

Maintaining thought process

 Assess alteration in mental status
 Speak to patient in simple, clear language & give pt time to respond to
questions
 Orient to daily routines
 Provide regular daily schedule for med administration, grooming meal
times, bedtimes, and awakening
 Provide nightlights
 Remain calm, not to argue with the patient while protecting patient from
injury
 Sitter – around the clock supervision

Activity intolerance
Monitor ability to ambulate and perform ADLs
Balance activity & rest
Personal items kept within pt’s reach
Relaxation and guided imagery beneficial to decrease anxiety which
contributes to weakness and fatigue
Collaborate with Health care team
Fatigue R/T anemia – administer Epogen as ordered

Relieving pain and discomfort

 Assess pain quality and severity associated with impaired perianal skin
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integrity, KS lesions, peripheral neuropathy

 Keeping perianal area clean – promote comfort
 Soft cushions or foam pads
 Pain from KS – described as sharp, throbbing pressure & heaviness if
lymphedema present
 Pain management – NSAIDS and opioids + nonpharmacological approach
(relaxation techniques)
 NSAIDS + zidovudine – monitor hepatic & hematologic status
 Pain R/T peripheral neuropathy – burning, numbness, & “pins & needles”
Opioids, tricyclic antidepressants, gabapentin (Neurontin), elastic
compression stockings

Nutritional Status
 Monitor weight, dietary intake; anthropometric measurements, serum
albumin, BUN, protein, and transferrin levels
 Control nausea & vomiting – adm antiemetic
 Inadequate intake from pain caused by mouth sores or sore throat
administer Opioids; Viscous lidocaine – rinse and swallow
 Eat foods easy to swallow
 Provide oral care before and after eating
 Encourage rest before eating
 Avoid fiber rich foods or lactose if lactose intolerant
 Add eggs, butter, margarine, and fortified milk to gravies, soups or
milkshakes to provide additional calories & protein
 Supplement – puddings, powders, milkshakes
 Advera – nutritional supplement designed for people with HIV infection or
AIDS
 May require enteral or parenteral nutrition

Decreasing sense of Isolation

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 AIDS patients at risk for double stigmatization – “dread disease” & lifestyle
considered unacceptable
 Overwhelmed with emotions like anxiety, guilt, shame and fear
 Multiple losses
 Guilt R/T lifestyle & having infected someone else
 Anger toward sexual partner who transmitted virus
 Infection control measures used further contribute to emotional isolation
 Nurse provide atmosphere of acceptance and understanding
 Nonjudegmental, establish trusting relationship
 Allow verbalization of feelings of isolation and loneliness
 Assure that feelings are not unique or abnormal
 Therapeutic touch
 Spirituality – assess spiritual needs; provide spiritual support; resources –
Chaplin, Minister

Coping with Grief

Anticipatory grief
Help patients verbalize feelings and explore and identify resources for
support and ways of coping
Encourage contact with family and friends, coworkers
Use local and national AIDS support groups and hotlines, chatline
Continue activities whenever possible
Mental health consult
Monitor for Complications
Immunosuppressed – at risk for OIs
Impaired breathing major complication
Wasting syndrome and fluid & electrolyte imbalance & dehydration
common complication
Cachexia – state of ill health, malnutrition, wasting
Antiretroviral drugs can cause severe toxic effects & concurrent use with
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many other meds

Terminal Care
Nursing Care should focus on
 Keeping patient comfortable
 Facilitate emotional and spiritual acceptance of death
 Help pt & pt significant other deal with grief and loss
 Choose terminal care at home (Hospice Care)
 Refer to Chapter 10 End-of-live care
 Physical Care – See Table 10-8, pg. 170-171

Resources
www.aidaction.org

www.aidinfonet.org

www.anacnet.org

http://hab.hrsa.gov

www.napwa.org

www.nmac.org

www.dhh.state.la.us

www.oph.state.la.us
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