1. Human Immunodeficiency Virus (HIV) Infection
(relates to Chapter 14, “Human Immunodeficiency Virus Infection,” in the textbook)

2. Significance of Problem
Globally
40 million living with HIV
As of June 2005 in Canada (higher in the USA):
20,146 cases of AIDS diagnosed
13,502 AIDS-related deaths

3. Transmission of HIV
Fragile virus transmitted only through contact with bodily fluids
Blood, semen, vaginal secretions, and breast milk
Transmitted through
Sex with infected partner, exposure to infected blood or blood products, pregnancy, and breast feeding

4. Pathophysiology of HIV
RNA virus discovered in 1983
Virus binds to specific CD4 receptor sites and then enters the cell
Reverse transcriptase assists to make a single viral DNA and it copies itself to make a double-stranded viral DNA

5. Pathophysiology of HIV
Virus enters the cell nucleus
Using integrase the virus splices itself into genome to become part of the cell’s genetic structure

6. Viral Load in the Blood
Fig. 14-1

7. Pathophysiology of HIV
HIV destroys CD4+ cells 3 ways
Viral replication leaves holes in cell membranes
Infected cells fuse with other cells
Combine to form a syncytium that destroys all affected cells
3. Antibodies against HIV bind to the infected cells and activate the complement system, which destroy the infected cells

8. Pathophysiology of HIV
Consequences
All daughter cells from infected cell are infected
Genetic codes can direct the cell to make HIV
Initial infection
Viremia (large amount of virus in blood)
Few clinical symptoms
Steady state of viral load can be maintained for many years

9. Pathophysiology of HIV
HIV destroys about 1 billion CD4+ T cells every day
Immune problems start when CD4+T cell counts drop below 500 cells/μl

10. HIV Cell Counts 1. Normal T4 count: 800-1200 cells/ul
2. T4 count >500; generally healthy
3. T4 count ; minor immune problems
Immune problems start when CD4+T cell counts drop below 500 cells/μl
4. T4 count <200; severe problems
ONCE T4 CELLS INFECTED:
VIRAL REPLICATION!

11. Clinical Manifestations and Complications
Acute infection
Flu-like syndrome
Acute retroviral syndrome

12. Clinical Manifestations and Complications
Chronic HIV infection
Is generally asymptomatic early on
When CD 4+ counts drops to cells/μl, symptoms occur
Oral hairy leukoplakia
Candida infection
Fever, sweats, diarrhea, headaches

13. Aquired Immunodeficiency Syndrome (AIDS)
CDC criteria (Table 14-1 in text)
Immune system severely compromised
Ratio of CD4+ to CD8+ is reversed from 2:1 to 1:2
Opportunistic diseases develop that contribute to disability and death

14. Diagnostic Studies
Screening tests detect HIV-specific antibodies (see Table 14-3 in text)
May take up to 2 months before antibodies can be detected
(window period)
Progression monitored by CD4+ T cell counts
Lab tests measuring viral activity
Assess disease progression, viral load

15. Collaborative Care
Monitoring HIV disease progression and immune function
Initiating and monitoring antiretroviral therapy (ART)
Preventing and detecting opportunistic infections
Preventing and treating complications of therapies
Ongoing health assessment
Baseline data including H&P, immunization history, psychosocial and dietary evaluation
Education about spectrum of HIV, treatment, preventing transmission, improving health, and family planning
Repeating and clarification of information is necessary due to shock and denial

16. Nursing Management Nursing Assessment
Dependent upon the stage of the disease
Prevention
Treatment
Terminal phase

17. Nursing Management Nursing Assessment
Social factors
Self-esteem
Sexuality
Family interactions
Finances
For persons at risk, ask
Received blood transfusion or blood clotting factors before 1985?
Shared needles, syringes, or other injection equipment with another person?
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)?

18. Nursing Management Planning
Adhere to drug regimens
Promote healthy lifestyle
Prevent opportunistic infections
Prevent transmission to others
Have supportive relationships
Maintain productive activity
Come to terms with issues related to living with disease, death, and spirituality

19. Nursing Management Implementation
Drug therapy for opportunistic diseases (Table 14-2 in text)
Delay or treat with adequate antiretroviral therapy
Disease-specific prevention measures
Vaccines?
Development stage, being tested in animals
In HIV-infected person, possibly will boost immune function?

20. Health Promotion Prevention of HIV Decreasing risks related to
Sexual intercourse
Drug use
Perinatal transmission
Work
Decreasing risks related to sexual intercourse
Abstinence
Outercourse
Use barriers (e.g., condoms) when engaging in insertive sexual activity

21. Health Promotion 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

22. Health Promotion 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 ↓ transmission to fetus to less than 2%

23. Health Promotion 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

24. HIV Testing and Counseling
Determine if patient has infection
Negative results relieve anxieties about past behaviors and provide opportunities for prevention education
Positive results provides impetus to seek treatment and to protect sexual and drug-using partners
All testing needs to be accompanied by pre- and post-test education

25. Acute Intervention
Early intervention promotes health and delays disability
Reactions to positive HIV test
Life-threatening, chronic illness
Panic, fear, guilt, depression, denial, thoughts of suicide

26. Antiretroviral Therapy
Multi-drug therapy reduces viral loads, but are complex, have interactions, and do not work for everyone
ART released in 1987
Federal guidelines suggest treatment be delayed until levels of immune suppression are observed
Debate about when to start ART
Adherence to drug regimens is critical to
prevent disease progression
opportunistic disease
viral drug resistance

27. Acute Exacerbations
Infections, cancers, debility, and psychosocial/economic issues affect patient’s ability to cope
Common opportunistic infections
Pneumocysits carinii pneumonia
Cryptococcal meningitis
Cytomegalovirus retinitis
Common type of cancer
Kaposi’s sarcoma

28. Social Constructs Surrounding HIV
Negative social attitudes label patients
Behaviors associated with HIV may be viewed as immoral and sometimes illegal
Infected individuals can transmit the virus to others
Discrimination causes loss of jobs, families, homes, and insurance
Canadian Disabilities Act makes discrimination illegal

29. Ambulatory and Home Care
Often experience anxiety, fear, diarrhea, depression peripheral neuropathy, pain, nausea, vomiting, and fatigue
Symptom management similar to other chronic illness
Metabolic disorders have emerged
Detect early and deal with symptoms
Hyperlipidemia, insulin resistance, and bone disease common

30. Ambulatory and Home Care
Nursing interventions focus on safety, self-care, and to help caregivers support those activities
Prevent confusion by maintaining meaningful environment, frequent reorientation, and stress reduction measures
Emphasis is placed on providing support to family members and significant others who may have difficulty dealing with deterioration of mental and physical status

31. Terminal Care Dementia often present in final stages of HIV
“AIDS-dementia complex” and cognitive motor complex
Results from HIV infection in the brain, CNS lymphoma, toxoplasmosis, CMV, herpes virus, Cryptococcus, progressive multifocal leukoencephalopathy, dehydration, or drug side effects
Dementia in final stages of HIV
Reversible if a cause is diagnosed