HIV

Infection &
AIDS
Prepared By:
Mark Bryan Jeff F. Gagala
BSN 3A
 PRESENTATION OVERVIEW
COMPLEMENTARY,
01 TREATMENT
04 ALTERNATIVE &
INTEGRATIVE HEALTH
THERAPIES

02 CLINICAL MANIFESTATION 05 SUPPORTIVE CARE

03 MEDICAL MANAGEMENT 06 NURSING PROCESS

0
1
Treatment of HIV Infection
The overarching goal of ART is to suppress HIV replication to a level
below which drug-resistant mutations do not emerge; related goals are
to:
(1) Reduce HIV-associated morbidity and prolong the duration and quality
of survival,
(2) Restore and preserve immunologic function,
(3) Maximally and durably suppress plasma HIV viral load, and
(4) Prevent HIV transmission
 Different Drug Classes of ART

Nucleoside/Nucleotide Non-nucleoside Reverse Protease Inhibitors (step

Reverse Transcriptase Transcriptase Inhibitors 6)
Inhibitors (step 3) (step 3)

Fusion Inhibitor CCR5 Antagonist (step Integrase Strand

(step 1) 1) Transfer Inhibitors (step
4)
 Note:
• Psychosocial barriers such as depression and other mental illnesses, neurocognitive
impairment, low health literacy, low levels of social support, stressful life events,
high levels of alcohol consumption and active substance use, homelessness,
poverty, nondisclosure of HIV serostatus, denial, stigma, and inconsistent access to
medications affect adherence to ART.

• Adverse effects associated with all HIV treatment regimens include hepatotoxicity,
nephrotoxicity, and osteopenia, along with increased risk of cardiovascular disease
and myocardial infarction
 
• Many of the antiretroviral agents may cause fat redistribution syndrome and
metabolic alterations such as dyslipidemia and insulin resistance, which put the
patient at risk for early-onset heart disease and diabetes.
FACIAL
WASTING
Facial wasting, characterized as a
sinking of the cheeks, eyes, and
temples caused by the loss of fat
tissue under the skin, may be treated
by injectable fillers such as poly-l-
lactic acid
 DRUG RESISTANCE
• Drug resistance is the ability of pathogens to withstand the effects of
medications that should be toxic to them. There are two major components
of ART resistance:

(1) transmission of drug-resistant HIV at the time of initial infection and

(2) selective drug resistance in patients who are receiving non-suppressive
regimens.

• Genotypic and phenotypic resistance assays are used to assess viral strains
and inform selection of treatment strategies. Genotypic assays detect drug-
resistant mutations present in relevant viral genes while phenotypic assays
measure the ability of a virus to grow in different concentrations of ART
drugs.
 Immune Reconstitution
Inflammatory Syndrome
• Immune reconstitution inflammatory syndrome (IRIS) results from rapid
restoration of organism-specific immune responses to infections that cause
either the deterioration of a treated infection or new presentation of a
subclinical infection.

• This syndrome typically occurs during the initial months after beginning
ART and is associated with a wide spectrum of organisms, most commonly
mycobacteria, herpes viruses, and deep fungal infections.

• Paradoxical tuberculosis-associated immune reconstitution inflammatory

syndrome (TB-IRIS) is a serious complication that arises during successful
ART in patients with HIV-TB co-infection who are receiving TB treatment .
 02
CLINICAL
MANIFESTATIO
N
Respiratory Manifestations
Gastrointestinal Manifestations
Oncologic Manifestations
Neurologic Manifestations
Depressive Manifestations
Integumentary Manifestations
Gynecologic Manifestations
 RESPIRATORY
MANIFESTATION
• Shortness of breath, dyspnea (labored breathing), cough, chest pain, and
fever are associated with various opportunistic infections, such as those
caused by Pneumocystis jirovecii, Mycobacterium avium-intracellulare,
cytomegalovirus (CMV), and Legionella species.

Diseases:
 Pneumocystis Pneumonia
 Mycobacterium avium
 Tuberculosis
 GASTROINTESTINAL
MANIFESTATION
The gastrointestinal manifestations of HIV infection and AIDS
include loss of appetite, nausea, vomiting, oral and esophageal
candidiasis, and chronic diarrhea. Gastrointestinal symptoms
may be related to the direct inflammatory effect of HIV on the
cells lining the intestines. Some of the enteric pathogens that
occur most frequently, identified by stool cultures or intestinal
biopsy, are Cryptosporidium muris, Salmonella species,
Isospora belli, Giardia lamblia, cytomegalovirus (CMV),
Clostridium difficile, and M. avium-intracellulare.
Diseases:
 Candidiasis
 HIV Wasting Syndrome
 ONCOLOGIC
MANIFESTATION
Those with HIV/AIDS are at greater risk of
developing certain cancers. These include Kaposi
sarcoma (KS), lymphoma, and invasive cervical
cancer. KS and lymphomas are discussed next.
Cervical carcinoma is described later in the
Gynecologic Manifestations section.

Diseases:
 Kaposi Sarcoma
 AIDS-Related Lymphomas
NEUROLOGIC MANIFESTATION
HIV-related brain changes have profound effects on cognition, including motor function,
executive function, attention, visual memory, and visuospatial function. Neurologic
dysfunction results from direct effects of HIV on nervous system tissue, opportunistic
infections, primary or metastatic neoplasm, cerebrovascular changes, metabolic
encephalopathies, or complications secondary to therapy. Immune system response to HIV
infection in the CNS includes inflammation, atrophy, demyelination, degeneration, and
necrosis.
Diseases:
 Peripheral Neuropathy
 HIV Encephalopathy
 Cryptococcus Neoformans
 Progressive Multifocal Leukoencephalopathy
• Other infections involving the nervous system include Toxoplasma gondii, CMV, and
Mycobacterium tuberculosis infections.
 DEPRESSIVE
MANIFESTATION
Depression and apathy are neuropsychiatric complications of HIV
infection. Estimates suggest that the prevalence of current depression
is between 30% and 40% in persons with HIV/AIDS. Similarly,
apathy, which refers to reduced, self-initiated, cognitive, emotional,
and behavioral activity, is also commonly reported among those living
with a diagnosis of HIV with rates as high as 65%. Alcohol and
cocaine use—both current and former—have been associated with
depression and apathy in this population, and depression has been
associated with less adherence with ART.
INTEGUMENTARY
MANIFESTATION
Cutaneous manifestations are associated with HIV
infection and the accompanying opportunistic
infections and malignancies. KS (described earlier)
and opportunistic infections such as herpes zoster and Seborrheic
herpes simplex are associated with painful vesicles dermatitis
that disrupt skin integrity. Molluscum contagiosum is
a viral infection characterized by deforming plaque
formation. Seborrheic dermatitis is associated with an
indurated, diffuse, scaly rash involving the scalp and
face. Patients with AIDS may also exhibit a Molluscum
generalized folliculitis associated with dry, flaking Papules contagiosum
skin or atopic dermatitis, such as eczema or psoriasis.
Many patients treated with the antibacterial agent
trimethoprim–sulfamethoxazole (TMP–SMZ) develop
a drug-related rash that is pruritic with pinkish-red
Macules
macules and papules.
 DEPRESSIVE MANIFESTATION
Persistent, recurrent vaginal candidiasis may be the first sign of HIV infection in women. Past
or present genital ulcers are a risk factor for the transmission of HIV infection. Women with
HIV infection are more susceptible to genital ulcers and venereal warts and have increased
rates of incidence and recurrence of these conditions. Ulcerative STIs such as chancroid,
syphilis, and herpes are more severe in women with HIV infection. Human papillomavirus
(HPV) causes venereal warts and is a risk factor for cervical intraepithelial neoplasia, a cellular
change that is frequently a precursor to cervical cancer.

VAGINAL
YEAST
INFECTION
 03

MEDICAL
MANAGEMENT
Treatment of Opportunistic Infections
Antidiarrheal Therapy
Chemotherapy
Antidepressant Therapy
Nutrition Therapy
 Treatment of Opportunistic Infections
Although ART is highly effective in keeping the CD4+ cell count high, opportunistic infections
continue to cause considerable morbidity and mortality for three main reasons:

(1) many patients are unaware of their HIV infection and present with an opportunistic
infection as the initial indicator of their disease,
(2) some patients are aware of their HIV infection but do not take antiretroviral agents because
of psychosocial or economic factors, and
(3) others receive prescriptions for antiretroviral medications but fail to attain adequate
virologic and immunologic response as a result of issues related to adherence,
pharmacokinetics, or unexplained biologic factors.
 Pneumocystis Mycobacterium avium
Pneumonia Complex
Initial treatment of MAC disease
Persons in stage 3 HIV infection should consist of two or more
should receive chemoprophylaxis antimycobacterial drugs to
to prevent PCP with prevent or delay the emergence
trimethoprim–sulfamethoxazole of resistance.
(TMP–SMX) if they have CD4+
counts less than 200 cells/ mm3 ● Clarithromycin (Biaxin)
or a history of oropharyngeal *Arithromycin (Zithromax)
candidiasis ● Ethambutol
 Cryptococcal Cytomegalovirus
Meningitis Retinitis
The preferred induction treatment for
cryptococcal meningitis and other Oral valganciclovir (Valcyte), IV
forms of extrapulmonary ganciclovir (Cytovene), IV
cryptococcosis is the IV lipid ganciclovir followed by oral
formulation of amphotericin B in valganciclovir, IV foscarnet
combination with fluconazole (Foscavir), IV cidofovir
(Diflucan). Follow up or c (Vistide), and a ganciclovir
consolidation therapy is then initiated intraocular implant coupled with
with oral fluconazole daily which valganciclovir are all effective
should continue for at least 8 weeks treatments for CMV retinitis
ANTIDIARRHEAL THERAPY
Although many forms of diarrhea respond to treatment, it
is not unusual for this condition to recur and become a
chronic problem for the patient with HIV infection.
Therapy with octreotide acetate (Sandostatin), a synthetic
analog of somatostatin, has been shown to effectively
manage chronic severe diarrhea. High concentrations of
somatostatin receptors have been found in the
gastrointestinal tract and in other tissues. Somatostatin
inhibits many physiologic functions, including
gastrointestinal motility and intestinal secretion of water
and electrolytes.
 CHEMOTHERAPY
Kaposi Sarcoma
KS can be treated with local therapy,
radiation therapy, chemotherapy, and
biologic therapy depending upon the
location of the lesions.
 
Lymphoma
There is no standard treatment for AIDS-
related peripheral or systemic lymphoma. The
treatment plan is adjusted for each patient and
usually includes one or more of combination
chemotherapy, high-dose chemotherapy and
stem cell transplant.
ANTIDEPRESSANT THERAPY

If depressive symptoms are severe and of sufficient duration,

treatment with antidepressants may be initiated.
Antidepressants such as imipramine (Tofranil), desipramine
(Norpramin), and fluoxetine (Prozac) may be used, because
these medications also alleviate the fatigue and lethargy that
are associated with depression. A psychostimulant such as
methylphenidate (Ritalin) may be used in low doses in
patients with neuropsychiatric impairment.
NUTRITION THERAPY
Appetite stimulants have been successfully used in patients with
AIDS related anorexia.

 Megestrol acetate (Megace)

 Dronabinol (Marinol)

Oral supplements may be used when the diet is deficient in

calories and protein. Nutritional supplements have been
developed specifically for people with HIV infection and AIDS.
Parenteral nutrition is the final option because of its prohibitive
cost and associated risks, including possible infection.
 Complementary, Alternative, and
Integrative Health Therapies
 The nurse should ask about the patient’s use of complementary, alternative, and
integrative therapies.
 Patients may need to be encouraged to report their use of these therapies to their
primary provider.
 The nurse needs to become familiar with the potential adverse side effects of these
therapies.
 The nurse who suspects that complementary, alternative, and integrative therapies is
causing a side effect needs to discuss this with the patient, the alternative therapy
provider, and the primary provider.
 The nurse needs to view complementary, alternative, and integrative therapies with an
open mind and try to understand the importance of this treatment to the patient.
 SUPPORTIVE CARE
 Nutritional support may be as simple as providing assistance in obtaining or preparing
meals.
 Imbalances that result from nausea, vomiting, and profuse diarrhea often necessitate
IV fluid and electrolyte replacement.
 To combat pain associated with skin breakdown, abdominal cramping, peripheral
neuropathy, or KS, the nurse administers analgesic agents at regular intervals around
the clock.
 Pulmonary symptoms, such as dyspnea and shortness of breath, may be related to
opportunistic infections, KS, or fatigue. (oxygen therapy, relaxation training, and
energy conservation techniques)
 Nurses should anticipate that patients as well as family and friends will need support
and time to share concerns. In some family systems, more than one person might be
living with HIV/AIDS.
NEW DRUGS
 CABENUVA & VOCABRIA
 FDA approved CABENUVA (cabotegravir extended-release injectable suspension; rilpivirine
extended-release injectable suspension), co-packaged for intramuscular use. This is the first FDA-
approved injectable, complete regimen for HIV-1 infected adults that is administered once a month.

 Adverse Reaction: Inj site reactions, pyrexia, fatigue, headache, musculoskeletal pain, nausea,
sleep disorders, dizziness, rash; hepatotoxicity, depressive disorders.

 FDA also approved VOCABRIA (cabotegravir) 30 mg tablets which should be taken in combination
with oral rilpivirine (EDURANT) for one month prior to starting treatment with Cabenuva to ensure
the medications are well-tolerated before switching to the extended-release injectable formulation.

 Adverse Reaction: Headache, nausea, abnormal dreams, anxiety, insomnia; hepatotoxicity,

depressive disorders.
 NURSING
PROCESS
 ASSESSMENT
 Nutritional Status
 Skin Integrity
 Respiratory Status
 Neurologic Status
 Fluid and Electrolyte Balance
 Knowledge Level
 DIAGNOSIS
 Impaired skin integrity related to cutaneous manifestations
of HIV infection, excoriation, and diarrhea
 Diarrhea related to enteric pathogens or HIV infection
 Risk for infection related to immune deficiency
 Activity intolerance related to weakness, fatigue,
malnutrition, impaired fluid and electrolyte balance, and
hypoxia associated with pulmonary infections
 Chronic confusion related to cognitive changes associated
with HIV encephalopathy
 Ineffective airway clearance related to infection, increased
bronchial secretions, and decreased ability to cough related
to weakness and fatigue
 DIAGNOSIS
 Acute and chronic pain related to impaired
perianal skin integrity secondary to diarrhea, KS,
and peripheral neuropathy
 Imbalanced nutrition: less than body requirements
related to decreased oral intake
 Social isolation related to stigma of the disease,
withdrawal of support systems, isolation
procedures, and fear of infecting others
 Grieving related to changes in lifestyle and roles
and unfavorable prognosis
 Deficient knowledge related to HIV infection,
means of preventing HIV transmission, ART, and
self-management strategies
COLLABORATIVE
PROBLEMS/
POTENTIAL COMPLICATIONS
 Opportunistic infections
 Impaired breathing or respiratory
failure
 Wasting syndrome and fluid and
electrolyte imbalance
 Adverse effects of medications
 Body image changes
 Achievement and maintenance of skin integrity
 Resumption of usual bowel patterns
 Absence of infection PLANNING
 Improved activity tolerance
 Coherent thought processes
AND GOALS
 Improved airway clearance
 Increased comfort
 Improved nutritional status
 Increased socialization
 Expression of grief
 Increased knowledge regarding disease prevention and self-care
 Absence of complications.
 NURSING INTERVENTION
 Promoting skin integrity
 Promoting usual bowel patterns
 Preventing infection
 Improving activity intolerance
 Maintaining coherent thought processes
 Improving airway
 Improving nutritional status
 Decreasing the sense of isolation
 Coping with grief
 Improving knowledge of HIV
 Monitoring and managing potential complications
 Promoting, home, community-based and transitional care
EVALUATION
 Maintains skin integrity
 Resumes usual bowel habits
 Experiences no infections
 Maintains adequate level of activity tolerance
 Maintains usual thought processes
 Maintains effective airway clearance
 Experiences increased sense of comfort and less pain
 Maintains adequate nutritional status
 Experiences decreased sense of social isolation
 Progresses through grieving process
 Reports increased understanding of AIDS, prevention of HIV transmission,
and ART, and participates in self-management strategies as possible
 Remains free of complications
THANKS
FOR
LISTENING!
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