Nursing Clients with

HIV infection and AIDS

Learning Objectives:
1. Describe the modes of transmission of HIV
infection.
2. Perform a focused assessment to determine the
status of the immune system.
3. Apply the nursing process to a client with HIV/
AIDS.
4. Apply the nursing process to the client receiving
drug therapy for the treatment of HIV/ AIDS.

Hinkle & Cheever

13th ed:
Chapter 37

Cellular Immune Response

Immune Response
Human body has three means of defense
against bacteria, viruses or other
pathogens.
!Phagocytic immune response
!Antibody immune response
!Cellular immune response

T lymphocytes (T-cells)
Killer T Cells

Helper T-Cells (CD4)

Suppressor T-Cells

Pathophysiology of HIV infection

1. HIV retrovirus attaches to the uninfected
CD4 cell.
2. Copies the RNA into cells DNA.
3. New viral particles bud from this cell and
begin the process all over again.

Intracellular parasites through course of HIV infection the

CD4 cells keep replicating and exhausts bodys CD4 cell
5
so that bodys immune system is basically gone.

33.410 HIV

Pathophysiology of HIV-1
Retrovirus carries genetic material in
RNA
CD4+T cell count determines degree
of immune suppression
Opportunistic infections
6

Immunodeficiencies

Nursing Care of the

Client with
HIV/AIDS

Primary or congenital
get in the womb with a mom with HIV aids

Acquired or secondary

10

Origin of HIV in the

United States
HIV first appeared in 1981 in San
Francisco among homosexual men. It
is now believed that the virus
entered the US in the early 1970s

HIV/ AIDS today in the

United States

Prevalence of AIDS in the US

More than 1.2 million people in the United States

are living with HIV infection, and almost 1 in 8
(12.8%) are unaware of their infection.
Gay, bisexual, and other men who have sex with men
(MSMa), particularly young black/African American
MSM, are most seriously affected by HIV.
By race, blacks/African Americans face the most
severe burden of HIV.

11

In 1981, there were 291 reported cases

By 1995, there were 74,180 new cases.
1981-2000: 753,000 cases in the US
438,000 Deaths

2014- CDC estimates that 1,218,400 persons aged

13 years and older are living with HIV infection,
including 156,300 (12.8%) who are unaware of their
infection

12

gay men are more at risk bc the way they have intercourse
is more likely to break skin and have blood and semen
transfer.

33.410 HIV

HIV as a Global epidemic

THE AIDS PANDEMIC

According to estimates by WHO and

UNAIDS, 36.9 million people were living with
HIV globally at the end of 2014. That same
year, some 2 million people became newly
infected, and 1.2 million died of AIDSrelated causes..

13

14

Classification of AIDS
CD4+T cell count determines
degree of immune suppression.
AIDS is defined as clinical
category and those in categories
A3 and B3 and all of category C.

15

CLINICAL CATEGORIES OF HIV DISEASE

1
CD4 count
500
2
CD4 count
200-499
3
CD4 count
< 200

A1

B1

C1

A2

B2

C2

A3

B3

C3

16

Clinical Category A
HIV Positive
Asymptomatic, or
Persistent
lymphadenopathy,
or
Primary (acute)
infection

1 CD4 count
500
2 CD4 count
200-499
3 CD4 count
< 200

17

18

as long as you have enough CD4 cells you dont know

youre sick.

33.410 HIV

Clinical Category B
One or more
conditions
attributed to or
complicated by HIV
infection

Clinical Category C
Considered to have
AIDS (CDC case
definition):
Kaposi s Sarcoma
Taxoplasmosis
Wasting syndrome
Pneumocystis
pneumonia

1 CD4 count
500
2 CD4 count
200-499
3 CD4 count
< 200

1 CD4 count
500
2 CD4 count
200-499
3 CD4 count
< 200

19

When you have one or more of the opportunitist infections.

Progression of HIV

20

Now considered to have AIDS.^^^

-HIV encepholpothy

Exposure Category of HIV

The time from initial infection to the

development of AIDS ranges from months to
years depending on:
How HIV was acquired
Personal factors
Therapeutic intervention

21

Transmission

Men who have sex with men

IV drug users
Male homosexuals who
also inject drugs
Hemophiliacs
Heterosexual contact
Recipient of blood transfusion
Other

25%

47%

10%
1%
10%
1%
9%

women and minorities fastest growing

22

Saliva, Tears, and Sweat

Any body fluid that contains HIV-1 or

CD4+
T lymphocytes

HIV has been found in saliva and tears in

very low quantities from some AIDS
patients.
Contact with saliva, tears, or sweat has
never been shown to result in
transmission of HIV.

Blood

Serum
Seminal fluid
Vaginal secretions, amniotic fluid
Breast milk
fluid surrounding the brain and the spinal cord
fluid surrounding bone joints

23

only a tiny amount of T lymphocytes are found in saliva,

tears, sweat
24

Any body fluid that contains HIV-1 or CD4+ can transmit

this virus

33.410 HIV

Stages of Infection

Post exposure prophylaxis

All health care providers who have
sustained a significant exposure:

AZT, Epivir, 3TC (reverse transcriptase

inhibitors)
Viracept, Crixivan (protease inhibitors)
Within 72 hours after exposure
For 4 weeks post exposure

for 4 weeks you get medication tx.

They day of exposure you get tested for HIV bc
you might have been infected before then again
25
later to see if it has become positive if neg
before.

EIA- Enzyme-Linked Immuno-

(ELISA)

Western blot assay

CD4/CD8 Counts 500-1600
Lymphocyte Counts
OraQuick- In home HIV test
27

ELISA: will become positive btwn 3-12 weeks following

exposure. May be positive as early as 15 days and 6 months.
If positive test you will get a Western Blot test to ensure you
are

26

takes up to 3 weeks-12 weeks for antibodies to show up into

blood and get a positive test result

Used to track the response to treatment for

HIV infection
Used to detect HIV infection before the
development of antibodies
Used to screen neonates
A better predictor of disease progression
than the CD4 count
The lower the viral load, the longer the
time to AIDs diagnosis & the longer the
survival time.
28

better predictor than CD4 count.

Pharmacologic Management of
HIV

ART: AntiRetroviral Therapy

Nucleoside Reverse Transcriptase Inhibitors
(NRTIs)
Zidovudine (AZT) Retrovir

There are many treatments now that can help people with
HIV. As a result, many people with HIV are living much
longer and healthier lives than before.
Currently, medicines can slow the growth of the virus or stop
it from making copies of itself. Although these drugs don't
eliminate the virus from the body, they keep the amount of
virus in the blood low. The amount of virus in the blood is
called the viral load, and it can be measured by a test.

Non-nucleoside Reverse Transcriptase Inhibitors

(NNRTIs)
Efavirenz (EFV) Sustiva
Delavirdine (DLV) Rescriptor
Protease Inhibitors
Fosamprenavir ( Lexiva)
Amprenavir (Agenerase)

aids.

Viral Load Tests

Laboratory Assessment of HIV

Sorbent Assay

INITIAL INFECTION (approx.) 4-12 weeks

ACUTE RETROVIRAL SEROCONVERSION SYNDROME
1-3 weeks
Flu-like symptoms
Full recovery from symptoms
ASYMPTOMATIC INFECTION IS POSSIBLE
SYMPTOMATIC STAGE
CD4 count decreased without tx. will develop into
Lymphadenopathy for 3 mos.
AIDS
CD4 < 200
Opportunistic Infections, TB, Cancer
10% wt. loss, fever, diarrhea

29

30

dont bother learning the names of meds.

alot of these drugs are combined into one pill now so the tx
is less complicated. Compliance is a problem, but less now
that is not as complicated

33.410 HIV

Taking the Drugs

Cost of HIV Medications

HIV medicines have become much easier to take in recent

years. Some newer drug combinations package 3 separate
medicines into only 1 pill, taken once a day, with minimal side
effects.
For the great majority of people, HIV medicines are
tolerable and effective, and let people infected with HIV live
longer and healthier lives.
Still, for some people taking medicine for HIV can be
complicated. Some of the drugs are difficult to take, can
cause serious side effects, and don't work for everyone.
Even when a drug does help a particular person, it may
become less effective over time or stop working altogether.
31

Nursing Assessment of the Client

with HIV & AIDS
Clinical Manifestations

32

Respiratory Manisfestations
PCP- Pneumocystis carinii pneumonia

most common - also in pt who did not know they

were HIV positive

HIV/AIDS affects any organ system

Diseases associated with HIV/AIDS result
from infection, malignancies, or the direct
effect of HIV on body tissues

MAC- mycobacterium avium complex

Tuberculosis

HIV is now considered a chronic disease and not a death

sentence. virus can affect any part of your body with
33
infections or malignancies.

34

PCP: fever, SOB

TB: seen in mostly IV drug users

Drug therapy: Antibiotics/Anti-infectives

GI Manisfestations:

Musosal candidiasis: thrush

Azythromycin (Zithromax)
Trimethoprim-sulfamethoxazole
(Bactrim) make sure to drink like 4L of h20 a day!
Ciprofloxacin
Ceftriaxone (Rocephin)
Metronidazole (Flagyl)
35

33.410 HIV

36

Pharmacologic Management of
Fungal Infections

Common sites for Candidal

infection

Candidiasis

Oropharynx
Esophagus
Mammary folds
Axillae
Buttock fold
Vaginal & labial
inguinal
nails

Clortrimazole (Mycelex) troches or

vaginally tid
Nystatin swish and swallow

Coccidioidomycosis, Cryptococcosis
& Histoplasmosis
37

Amphotericin B IV antifungal drug

Fluconazole, p.o.or i.v.

38

you can get thrush anywhere! tx nystatin.

GI Manifestations: Wasting
Syndrome

Amphotericin B
Adverse reactions:

MAJOR:, seizures, arrhythmias,, permanent renal

impairment, acute liver failure, thrombocytopenia,
hemorrhagic gastroenteritis
MINOR: Fever, chills, malaise, phlebitis,
burning, tissue damage with extravasation, pain at
injection site

usually pretreat pt with benydrl and tylenol for

fever and chills.
Given slowly and monitor for severe s/e. Drug
is very toxic to kidney.

The wasting syndrome

of
AIDS
"Anorexia
"Diarrhea
"GI malabsorption
"Lack of nutrition
"Drug of choice:
"Megestrol acetate
(megace)

39

40

body is using all of its fat and muscle. Wasting syndrome is part of
definition of AIDS where someone has involuntary weight loss, and
serve diarrhea for 30 days. You have no appetite and start wasting away.
Causes malabsorption of nutrients. You want to make sure they are
eating high biologic valued foods. No wasting calories. Low ANC.
Avoid raw fruits and veggies (undercooked meat). sometimes you get
TPN

GI Manifestations:
Opportunistic infections causing diarrhea

Oncologic Manisfestations
AIDS related Kaposi s Sarcoma

Cryptosporidiosis gastroenteritis
Salmonella typhimurium
Shigella

used to be only old men.

Hodgkin s lymphoma
Non-Hodgkin s lymphoma
Cervical Cancer
41

33.410 HIV

42

Kaposi s Sarcoma

Neurologic manifestations
HIV encephalopathy or AIDS dementia
complex develop blindness.
Peripheral neuropathy

43

Opportunistic infection: Protozoal

Toxoplasmosis encephalitis
CNS lesions

44

toxoplasmosis (preggos dont touch kitty litter): Can get it from

feces.

Reproductive Manifestations:
Human Papilloma Virus: HPV

Integumentary Manifestations
Herpes simplex
virus:
Chronic ulcers in
HIV disease
get when youre
immunosuppressed

45

Integumentary Manifestations:
Varicella zoster: in HIV disease

46

Cryptoccosis disseminated: in HIV

Cryptoccosis
disseminated: in
HIV
fungal infection.

47

33.410 HIV

48

Pharmacologic Management of
Fungal Infections

Candidiasis
Clortrimazole (Mycelex) troches or
vaginally tid
Nystatin swish and swallow

Coccidioidomycosis, Cryptococcosis &

Histoplasmosis
Amphotericin B
Fluconazole, p.o.or i.v.

Amphotericin B

Used for life threatening fungal infections.

Give drug through a separate line, if possible.
Use volumetric pump and an in-line filter.
Adverse reactions:
Nephrotoxicity- monitor Creatinine level
May decrease K+ levels; Monitor for
hypokalemia
Assess IV site for phlebitis
Premedicate with antipyretics, antihistamines
and/or steroids.

49

50

tylenol, bendryl, prednisone

What are the high risk sexual

behaviors?

Nursing Diagnosis:
Knowledge Deficit r/t preventing HIV transmission

Anal sex without condom (active

or passive).
Manual-anal intercourse
(fisting).
Oral-genital sex involving
contact with semen or vaginal
secretions.
Oral-anal sex.
Vaginal intercourse without
condom.
Sharing of sex toy.
Use of saliva as lubricant.
Blood contact of any kind
including menstrual blood

Perinatal HIV exposure can occur during

pregnancy, during vaginal delivery, and
postpartum through breast-feeding.
Women exposed to HIV should consult
physician before becoming pregnant;
consider use of antiviral agents if pregnant
(AZT prophylaxis).
51

52

What changes in laboratory studies are seen as

the disease process of human immunodeficiency
virus (HIV) progresses?

Which evidence supports a nursing diagnosis of high

risk for infection related to immuno-deficiency?

a. Decreased
leukocyte count
b. Decreased serum
globulin level
c. Increased serum
hemoglobin level
d. Increased number
of T-Helper cells

a. Platelet count decreases

B. CD-4 lymphocyte count
decreases
C. CD-4 lymphocyte count
increases
d. Erythrocyte
sedimentation rate
decreases.

33.410 HIV

A client with HIV is receiving antiviral agent

zidovudine. What laboratory studies need to be
monitored in the client receiving this medication?

A Client with HIV has been hospitalized. During your

initial assessment of the client, you observe cheesylooking white patches in the client s mouth. When the
patches are rubbed, erythema and bleeding occur. You
suspect:

a. Serum glutamic-pyruvic
transaminase
b. BUN
c. Erythrocyte
sedimentation rate
d. Red blood cell count

A. Herpes simplex
B. Candidiasis
C. Leukoplakia
D. Karposi s Sarcoma

The client with HIV has begun therapy with

zidovudine (AZT, Retrovir). The nurse carefully
monitors which of the following laboratory results

The client exposed to HIV about 3 months ago has

seroconverted to an HIV positive status. The nurse
anticipates that the client will experience which of
the following at this time?

a.
b.
c.
d.

during treatment with this medication?

a. Complete blood
count
b. BUN
c. Blood culture
d. Blood glucose level

Oral lesions
Purplish skin lesions
Chronic cough
No signs or
symptoms
d

Does person with HIV infection

have to be treated for the rest
of their life?
Right now, there is no cure for HIV infection
or AIDS. So, once one starts treatment, they
have to continue to be sure the virus doesn't
multiply out of control.
medication has to be continued forever.
59

33.410 HIV

I am a nurse who was exposed to vomit or sputum

from an end stage AIDS patient which contacted a
small area of non-intact skin (less than 1 cm) on my
finger. What is the risk of infection from this
incident?
There is no evidence of a health care worker getting
infected with HIV through contact with vomit or
sputum. The real risk for transmission is partly
determined by the presence of blood in the vomit or
sputum; otherwise, those fluids only pose a
theoretical risk for infection. Given the fact that
these fluids also came into contact with a small area
of nonintact skin, your risk for infection is quite
small.

60

10

Deaths from HIV/ AIDS today in the

United States

Further website exploration

Living with HIV/ AIDS

Deaths: An estimated 13,712 people with an

AIDS diagnosis died in 2014, and
approximately 658,507 people in the United
States with an AIDS diagnosis have died
overall.

http://www.cdc.gov/hiv

AIDS Action Council

http://www.aidsaction.org

National Aids Treatment Advocacy Project

www.natap.org

61

62

Source:

63

33.410 HIV

11