Human Immunodeficiency Virus

Transmission of HIV
Exchange of blood or other body fluids containing HIV (blood, semen, vaginal & cervical
secretions & breast milk, and cerebrospinal fluid (CSF) ) 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 (anal, vaginal, oral) 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
HIV life cycle
5.The T cells begins to make copies of the HIV
components.

6. Protease (enzyme) helps create new virus particles

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
 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

Clinical Manifestations (cont.)

Second Phase of HIV infection
SSx of PHI resolve
Viral load decreases
Seroconversion occurs ( converting from HIV negative to HIV positive)

Seroconversion
The process by which a newly infected person develops antibodies to HIV.
These antibodies are then detectable by an HIV test. Seroconversion may
occur anywhere from days to weeks or months following HIV infection.
(CDC definition)

Clinical Manifestations (cont.)

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

Clinical Manifestations (cont.)

Symptomatic HIV infection
T-cellcount continues to decline
Patient develops a symptomatic infection (pneumocystis pneumonia (PCP) or
candidiasis)
HIV infection Dx at this stage
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 or less than 14% of all lymphocytes
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

Diagnostic Studies
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

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)
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
Intrabdominalfat & fat at dorsocervial area/Visceral fat gain – body 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, breath sounds may initially be normal, sputum may be present
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)

Group of acid-fast bacilli
Occurs late in course of disease CD4 count less then 50
Major cause of “wasting syndrome”
Frequently causes GI tract problems for HIV-infected patients
SSx – chronic diarrhea, abdominal pain, chills 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, purulent sputum, fever, fatigue, night sweats, weight loss,
lymphadenopathy
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
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
Clinicalsyndrome - 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) & Neurologic Effect
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
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
Sensory neuropathies – numbness, tingling and pain in lower extremities; progress to
weakness and paralysis
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)
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)
Skin Manifestations
Gynecologic Manifestations
Persistent, recurrent vaginal candidiasis - first sign in HIV
infection in women
Ulcerative STDs - chancroid syphilis, herpes more severe
in women
PID
Cervical Cancer
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
Verychallenging – organ system target for infection &
Cancer
Complicated by emotional, social & ethical issues

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

Prevention of HIV Infection

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

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 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 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

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 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)