Nursing Care of the Client With HIV/AIDS

*Function of the Immune System:
-Defense-against microorganisms, prevents infection by destroying them
-Surveillance-protection from internal invaders, i.e., malignant cells
-Homeostasis-provides the body with clean up operations (removes dead and damaged cells-mutations)

*Specificity: able to discriminate various antigens or other invaders
*Diversity: has extensive number of receptors to recognize invaders
*Memory-able to mount long lasting reactions to antigens
*Self-vs-self recognition-autoimmune disease occurs if this breaks down (body attacks own tissues)

*Thymus: central lymphoid organ in mediastinal area above heart, responsible for differentiation and maturation of T-lymphocytes
*Bone Marrow: undifferentiated stem cells originate here and mature before entering circulation

*Lymph nodes: part of lymphatic system, filters foreign particles, ex. bacteria
*Spleen: largest single collection of lymphocytes, largest filter of foreign tissue
*Liver: filters foreign tissue from blood
*Tonsils: lymphoid tissue
*Peyer's Patches: lymphoid tissue that lines wall of ileum, has macrophages

Immunity
-Innate (inborn) genetic factors
-Acquired
1. Active (own antibodies)
-Natural (exposure to infectious agent)
-Artificial (immunization)
2. Passive (ready-made antibodies)
-Natural (maternal antibodies)
-Artificial (antibodies from other sources)

Tonsils and adenoids
Lymph nodes
Thymus
Spleen
Peyer's Patches
Appendix
Bone Marrow
Appendix

*Humoral: B-lymphocyte mediated, responsible for antibody (immuneglobulin) production antibody-mediated immunity.
*Antibodies, dissolved in blood, lymph, and other body fluids bind the antigen and trigger a response to it. (This form of immunity is also called humoral immunity.)

*Cell-mediated immunity (CMI) T cells (lymphocytes) bind to the surface of other cells that display the antigen and trigger a response. The response may involve
*other lymphocytes and
*any of the other white blood cells (leukocytes)

*Immunodeficiency disorders: incompetent immune system: SCIDS (severe combined immunodeficiency syndrome no T cells or B lymphocytes), AIDS
*Hypersensitivity disorders: allergic reaction, anaphylaxis
*Autoimmune disorders: body doesn't recognize self as self -rheumatoid arthritis, MS, Lupus, diabetes

*Human Immunodeficiency Virus (HIV)
*Discovered in 1983
*No longer considered a death sentence but a chronic disease
-Communicable via blood and body fluids: cerebral spinal fluid, semen, vaginal secretions and breast milk
-Will eventually lead to AIDS
-Occurs as HIV1 (95% of US cases)
-HIV2 (most prevalent in West Africa)

*21st Century Plague - since 1981 worldwide: 58 million people infected with 22 million dying from AIDS
*A disease of disenfranchised by gender, race, sexual orientation, poverty and access to health care
*2005 - 1 million infected in US

Total: 34-46 million

-Unprotected sex with an infected partner
-Sharing needles with infected person

-Transmission from infected mother to fetus
-Infection from blood products (in the US 1 in 12,000,000)

*Sexual transmission - most common
*Blood and blood products - needle sticks, IV drug abuse, potentially transmitted via transfusion
*Pregnancy and delivery
*Breast milk

*Viral load
*Susceptible Host (ex: Hep B or C)
*Virulence of the virus
*Concentration of the virus (viral load)
*Frequency of contact
*Volume of fluid
*Depth of wound
*.3-.4% risk for health care workers

*Extremely fragile virus - hard to keep alive
*Probability of infection is based on:
-concentration and strain of virus
-amount of fluid transmitted
-duration and frequency of exposure as well as host immune system

*Unprotected Sex (most common mode of transmission)
*Multiple partners
*Anal and oral sexual activities
*Improper condom use/breakage
*Open sores, lesions, infections in genital area

*Minute possibility in US for transfusion related transmission-all blood and blood products screened
*Only 20% of world's blood screened
*Health care workers
*Correctional officers and law enforcement personnel
*IV drug abuse, sharing of syringes and drug equipment

*Approximately 120,000 to 160,000 women living in US with HIV infection
*6,000 to 7,000 infected women give birth each year in US
*600,000 babies contract HIV worldwide each year
*Breastfeeding not advised

*Classified as retrovirus, can't make copies of itself on its' own
*Must invade healthy T cell (CD4) in host
*Has a special chemical to allow entrance into CD4 cell
*Releases enzyme reverse transcriptase to convert HIV RNA to DNA

*Inside cell nucleus the DNA replicates the HIV virus using protease
*New copies of virus formed, cell dies
*Up to 10 billion HIV particles produced daily
*Over 2 billion new CD4 cells needed to keep up, not possible for body to do

*Inside CD4, HIV uses 3 enzymes to replicate itself:
-Reverse transcriptase
-Integrase
-Protease
*Treatment based on interfering with enzyme activity, thus preventing replication

*Consequences
-All daughter cells from infected cell are infected
-Genetic codes can direct the cell to make HIV

*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)?
-Have you ever shared (equipment) needles with anyone?

*ELISA (Enzyme-linked immunosorbent assay) most common, confirms presence of HIV antibodies
*Western Blot can identify 1 protein in a mixture of many proteins (looks at antibody classes) more specific
*IFA (Immunofluorescence Assay) tests for p17 and p24 antigen found on HIV (looks at infected cells)
**POSITIVE ELISA, NEED TO HAVE A WESTERN BLOT TO CONFIRM DIAGNOSIS**

*Ora-Sure - Saliva test, approved March, 2004
*Mouth is swabbed, if turns red = positive (confirmed by blood test)
*Home access test - FDA approved, but sample must be sent back to company

*Both ELISA and Western Blot depend on antibody formation
*About 90% of people exposed to HIV will develop antibodies in 6 weeks to 3 months following exposure; it may be as long as 6 months to 1 year
*IFA tests for specific protein
"Window period"" 6 wks to 1 year HIV infected but have not developed antibodies yet

*Viral transmission with Primary HIV infection
*Seroconversion with antibodies
*Asymptomatic chronic infection
*Symptomatic HIV infection
*AIDS - based on CDC definition
*Advanced HIV disease CD4 <50

*ACUTE INFECTION: process of seroconversion (often mistaken for mononucleosis) "flu-like" symptoms acute retroviral syndrome
*May last days to months
*Known as the "WINDOW" period, infectious without antibodies until seroconversion takes place
*Occurs 1-3 weeks post exposure (high viral load in blood)

*SEROCONVERSION
*Majority of those exposed develop antibodies within 3 months
*May take up to a year in small percentage of people
*Body produces antibodies to the HIV virus

*EARLY CHRONIC INFECTION: May last up to 10 years "asymptomatic disease"
*None to minimal symptoms: fatigue, anemia, night sweats, persistent generalized lymphadenopathy
*CD4 counts remain above 500 cells/mm (persistent level)

*INTERMEDIATE CHRONIC INFECTION: More severe symptoms, CD4 count drop to 200-500 cells/mm
*Viral load increases
*More evidence of disease progression with opportunistic diseases: Kaposi's Sarcoma (KS), candida (thrush), shingles, hairy leukoplakia (raised white lesions on tongue)

*LATE CHRONIC INFECTION (AIDS): Diagnosis of AIDS not made until CDC criteria met
*CD4 count declines <200 cells/mm
*Presence of Ol's wasting syndrome with >10% weight loss
*Malignancies and dementia common

*ADVANCED HIV DISEASE OR END STAGE HIV DISEASE: CD4 count <50
*Overwhelming opportunistic infections and diseases that resist treatment
*Period preceding death from AIDS (weeks to months)

*CDC classification for AIDS diagnosis:
1. CD4 count <200
2. Presence of Opportunistic Infection
3. Development of opportunistic cancers
A. Invasive cervical cancer (HPV)
B. Kaposi's sarcoma (KS)
C. Burkitt's lymphoma
4. Wasting Syndrome
5. dementia

*FUNGAL: candidiasis of respiratory tract, Pneumocystis carinii pneumonia (PCP)-treated with bactrim
*VIRAL: cytomegalovirus (CMV) retinitis - loss of vision, herpes simplex - chronic
*PROTOZOAL: toxoplasmosis of the brain
*BACTERIAL: Mycobacterium tuberculosis, Salmonella septicemia

*MALIGNANCIES OFTEN SEEN:
-AIDS associated lymphomas
-Invasive cervical cancer
-Kaposi's sarcoma

*Chills and fever
*Night sweats
*Productive cough
*Dyspnea
*Lethargy/fatigue
*Confusion
*Stiff neck
*Headache
*Diarrhea
*Persistant vaginal candida
*Oral candida
*Oral lesions
*Abdominal pain
*Weight loss
*Neuropathies
*Lymphadenopathy
*Skin rash

*PULMONARY SYSTEM
*Often first manifestation of HIV infection
*TB in HIV infection global problem
*Pneumocystis carinii pneumonia (PCP) common Ol
*Has both prophylaxis and treatment: Trimethoprin-sulfamethoxazole (Bactrim)

*GASTROINTESTINAL SYSTEM
*Cryptosporidium (parasite) most widely recognized pathogen in AIDS infection
*Causes massive diarrhea (dehydration)
*Candida may be first sign of suppressed immune system, can affect entire GI tract mouth to anus

*NERVOUS SYSTEM
*HIV crosses blood-brain barrier
*Can cause encephalopathy with loss of cognitive and motor function
*Peripheral neuropathy is common
*CNS lymphoma-resistant to treatment (brain tumor associated with impending death)
*AIDS Dementia Complex (ADC) confussion, agitation whole spectrum of mental status changes

INTEGUMENTARY SYSTEM
*Kaposi's sarcoma - common in men, aggressive in HIV disease (lungs, oral mucosa, entire GI tract)
*Herpes zoster-resistant to treatment
*Rashes - seborrheic dermatitis psoriasis

*HEMATOLOGIC SYSTEM:
*Anemia, thrombocytopenia and neutropenia due to decreased blood production and increased lymphocyte destruction
*Body not able to keep up with losses
*Medications can be immunosuppressive

*GYNECOLOGICAL SYSTEM
*Vaginal candida may be first sign of HIV disease in women
*Human papilloma virus (HPV)
*Cervical dysplasia
*Cervical cancer

*CARDIOVASCULAR - OI of pericardium (OI = opportunistic infection)
*MUSCULOSKELETAL - arthralgias, weakness
*RENAL - renal failure
*ENDOCRINE - risk of diabetes with HIV medications (antiviral drugs)
*SENSORY - CMV retinitis, neuropathies

*CD4 and T cell counts are measured to determine extent of immune damage
*Viral load determines "viral burden" or amount of virus particles per mL of blood
*Both should be measured at diagnosis and routinely after - depends on client and treatment

*There is no cure for AIDS
*Current medical management is:
-Treating/preventing infections
-Treating malignancies
-Administration of medications that block or inhibit replication

*1. HIV fusion inhibitors (inhibit HIV from binding on CD4 cell)
*2. Reverse transcriptase inhibitors
-Nucleoside reverse transcriptase inhibitors (NRTI)
-Non-nucleoside reverse transcriptase inhibitors (NNRTI) (prevent RNA-DNA conversion
*3. Protease inhibitors
ALL DRUGS DECREASE REPLICATION WHICH IN TURN DECREASES VIRAL LOAD

*NRTI: Zidovudine (AZT), Stavudine (Zerit)
*NNRT: Efavirenz (Sustiva), Nevirapine (Viramune)
*Fusion Inhibitor: Enfuvirtide (Fuzeon) (BID Subcutaneous very expensive)

*Maximal HIV suppression
*Undetectable viral load (<50 copies)
*Effective combination therapy (3 agents)
*Select tolerable regimen
*Individualize treatment
*Educate client
*Assure adherence
*Consider viral genotyping
*Prevent development of viral resistance
*Maintain or raise CD4 T cell counts to >200
*Reduce HIV related morbidity & mortality
*Improve quality of life

*Probably most difficult aspect of HAART therapy (30,40,50,60 drugs/day)
*Missed dose(s) lead to viral replication and resistance
*Eventually no adequate treatment left due to multi-drug resistance

*3 classes of antiretrovirals used
*May be as many as 60 pills per day
*Must be taken at specific times, with and without food
*Prescribed at full strength
*Potentially lethal side effects when combined with OTC and herbal therapy

*Lipodystrophy and lipoatrophy
*Development of Type II Diabetes (protease inhibitors)
*Hyperlipidemia
*Resistance
*Nausea/vomiting/diarrhea
*Neuropathies
*Osteonecrosis and osteoporosis
*Cardiomyopathy
*Hepatic Steatosis
*Myelosuppression
*Lactic Acidosis

*Complication of long term HAART
*Affects Caucasian men over 40 who had HIV infection >7 years
*Affects those with higher viral load
*AZT (NRTI) and protease inhibitors are implicated
*Cause still not known, just suspected

*HAART in HIV positive population raises risk of diabetes by nearly 2-3 times over non HIV infected males
*No single drug implicated, cause not known
*HAART therapy changes glucose metabolism, raises blood sugars

*Elevated cholesterol and triglycerides increase risk of heart attack, stroke and PVD
*More HIV infected clients dying from side effects of medications - rather than from AIDS

*High rate of virus mutation with drug resistance
*The earlier resistance occurs, the more likely treatment will fail
*Resistance is one reason it's important to continue developing new drugs
*Research to develop a vaccine against resistance

*Nausea/vomiting/diarrhea
*Neuropathies
*Osteonecrosis and osteoporosis
*Cardiomyopathy
*Hepatic Steotosis

*Measure viral load-goal is for undetectable level-client still infectious <50 copies
*Measure CD4 count
*Monitor CBC, LFT's, amylase, lipids, cholesterol and glucose

*Cost: up to $12,000/year in MA
*Pill burden and adherence
*End of life issues
*Planned pregnancies
*Aging issues
*Substance abuse issues

STAGE: ACUTE RETROVIRAL INFECTION
CD4 CELL/mm = 750-1000
STAGE: ASYMPTOMATIC HIV/EARLY
CD4 CELL/mm = 500-750
STAGE: INTERMEDIATE
CD4 CELL/mm = <500
STAGE: LATE
CD4 CELL/mm = <200 = AIDS
STAGE: ADVANCED HIV
CD4 CELL/mm = <50

**See Handout**

*Smoking education
*Teach relaxation and stress reduction
*Encourage routine exercise
*Nutritional education
*Infection control guidelines
*Avoid all animal droppings/cat litter, etc.
*Teach safe/safer sex

*Prevention of HIV
-Decreasing risks related to:
Sexual intercourse
Drug use
Perinatal transmission
Work

*Prevention of HIV
-Decreasing risks related to sexual intercourse
*Abstinence
*Outercourse

*Prevention of HIV
-Decreasing risks related to sexual intercourse
*Use barriers (e.g., condoms) when engaging in insertive sexual activity

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

*Prevention of HIV
-Decreasing risks related to perinatal transmission
*Prevent HIV infection in women
*Treat HIV pregnant women with zidovudine (ZDV, AZT, Retrovir)
*Combination ART for the mother's HIV infection can decrease transmission to fetus to less than 2%
*Viral load >1000 = C Section

*Prevention of HIV
-Decreasing risks related to work
*Greatest risk is through puncture wounds
*Splash exposure of blood on skin with open lesion present some risk, though much lower than puncture
*Exposure to HIV-infected fluids require post-exposure prophylaxis with combination ART (2-3 drugs for 4 weeks - trying to prevent seroconversion)

*CDC will soon recommend every American aged 13-64 to have HIV testing as part of routine exam
*? Vaccine to prevent or slow progression of HIV within a decade (Dr. Tony Fauci, NIH)
*Darunavir - accelerated approval by FDA as a new protease inhibitor for clients with resistance to other protease inhibitors