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Chapter 16 Care of the Patient with HIV/AIDS Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing and the History of HIV 1979- physicians in New York and California were noting cases of Pneumocystis jiroveci pneumonia (PCP) and Kaposi’s sarcoma (KS). PCP-an unusual pulmonary disease caused by fungus and primarily associated with people who have suppressed immune systems. Kaposi’s-rare cancer of the skin and mucous membranes characterized by red, blue, purple raised lesions These two diseases were occurring at alarming rates in homosexual men whose immune systems were failing. Nursing and the History of HIV June 1981 – CDC reported a HIV epidemic including hemopheliacs, drug users, heterosexual and homosexual patients The cases of HIV infection and AIDS increased rapidly through the 1980s Nursing and the History of HIV In 1986 the virus was named the human immunodeficiency virus (HIV), and two viruses were identified: HIV-1(found throughout the world and responsible for the majority of HIV infection cases) and HIV-2 (found primarily in West Africa) less progressive onset Nursing and History of HIV 1987- CDC reported three cases of occupationally acquired HIV infection in health care providers. “Universal Blood and Body Fluid Precautions” guidelines were then developed for the prevention of occupational exposure. Copyright © 2013, 2009, 2005 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. Slide 5 Trends HIV infections Although infection rates initially declined from 1983-1996, they now remain the same due to many feeling HIV is a chronic/treatable disease and increased high-risk behaviors. African-Americans are estimated to have an incidence rate of new HIV infections that is eight times higher than that of Caucasians Women account for 25% of HIV infections HIV Timeline Transmission of HIV Transmission occurs through sexual practice not preference Worldwide sexual intercourse most common mode of transmission but in US ½ new HIV cases related to injection use Transmitted from human to human Blood Semen Cervicovaginal Breast milk secretions Transmission of HIV HIV is an obligate virus It cannot survive very long outside of the human body Transmitted Infected Vaginal person-to-person through blood secretions Semen Breast Or milk body fluids containing blood Transmission of HIV Other body fluids contain HIV; no evidence they are capable of transmission Saliva Urine Tears Feces 3 Most Common Modes of Transmission of HIV Sexual transmission Anal or vaginal intercourse Parenteral exposure Contaminated drug injecting equipment and paraphernalia Transfusion of blood and blood products (rare) Perinatal (vertical) transmission Transmission from mother to child May occur during pregnancy, delivery, or postpartum breastfeeding HIV Transmission Once infected, individual is capable of transmitting to others at any time throughout the disease spectrum Even when host appears healthy and symptom free Viral load (amount of HIV is blood) is highest immediately after infection and during later stages of disease During these stages, unprotected exposure to infected individual increases likelihood transmission will occur But can still occur during any time in the disease spectrum Sexual Transmission Most common mode of transmission Some individuals become infected after one encounter Others remain free from infection after hundreds of encounters Receptive anal intercourse most risky behavior Rectum is tighter and less lubricated; may become torn and provide portal for virus to enter bloodstream Other factors increasing risk STI can increase risk of transmission through an STI-related lesion Sexual Transmission Females have a greater risk for becoming infected because the vagina has a greater area of mucous membranes than the penis And there is a greater amount of HIV found in semen compared with vaginal secretions Copyright © 2013, 2009, 2005 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. Slide 14 Parenteral Transmission Injecting Drug Use Exposure to injecting equipment and paraphernalia Not limited to illicit drug use; injectable steroids, vitamins, and insulin Additional factors include poor nutrition, hygiene, impaired judgment, Increased risk for Hep B and C, other blood borne illnesses Syringe exchange program availability for persons unable to stop – new sterile syringes and needles Parental Transmission Autologous (one’s own blood) blood transfusion is the safest to prevent HIV infection. . There is a 1 in 1.8 million units chance of HIV transmission from donated blood that is infected but has not yet had time to develop antibodies Copyright © 2013, 2009, 2005 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. Slide 16 Occupational Exposure Occupational HIV transmission is RARE Most infections occur after needlestick injury but risk of contracting HIV is low; about 0.3%. Postexposure to antiviral therapy given to health care workers after documented exposure can result in severe hepatitis and liver transplant. Perinatal Exposure Transmission of infection from mother to infant during pregnancy or through breastmilk 30% infected mothers will transmit HIV to their infants Approximately 50%-70% of the transmissions will occur late in utero or intrapartum Recommended testing during pregnancy Question The physician asks the nurse to talk with a patient about how HIV is transmitted. Which route of transmission should be discussed? 1. Receiving blood, donating blood 2. Food, water and air 3. Sexual intercourse, sharing needles, mother-tochild transmission 4. Dirty toilets, swimming pools, mosquitoes Answer 3. Sexual intercourse, sharing needles and motherto-child transmission Transmission of HIV Pathophysiology Normal immune response Foreign B antigens interact with B cells cells initiate antibody development B cells and T cells initiate cellular immune response B cells reduce virus in blood T cells reduce virus in lymph nodes Pathophysiology Infection with HIV causes destruction of immune cells “Slow” (long time passes before s/s appear) retrovirus (only has ribonucleic acid – RNA for genetic material) T-cells or CD4+ lymphocytes are the primary targets for HIV infection Because CD4 and T lymphocytes orchestrate all immune functions, HIV’s attack on these cells result in progressive impairment of the body’s immune response Spectrum of HIV Initial exposure Primary HIV infection Flu-like symptoms Develop antibodies to HIV 3 – 6 months after infection HIV seropositivity (seroconversion) Positive 95% HIV antibody test within 3 months; 99% within 6 months HIV Spectrum of HIV Early HIV disease – Clinical latency stage – Symptom-free period Signs and symptoms may not appear until 8 to 12 years after exposure The virus remains in the lymph nodes, liver and spleen and reproduces One in six persons do not know they are infected with the virus Spectrum of HIV Early symptomatic disease CD4+ cell count drops below 500 cells/mcL Persistent, unexplained fevers Drenching night sweats Chronic diarrhea Headaches Fatigue Lymphadenopathy (swollen lymph nodes) Recurrent or localized infections Neurological manifestations (memory impairment, leg weakness, loss of balance) THRUSH most common Diagnostic Studies HIV antibody testing ELISA Enzyme-linked immunosorbent assay Detects the presence of HIV antibodies If positive, ELISA is done a second time Western blot Done if second ELISA is positive More sensitive than ELISA Diagnosis and Testing Diagnostic Studies CD4+ lymphocyte count Normally 600 to 1200 mcL Decreases as the disease progresses Best marker for the immunodeficiency associated with HIV infection Viral load monitoring Level of virus in the blood Provides significant information toward predicting the course of the disease Diagnostic Studies Seropositive All three tests are positive (ELISA 2 and Western blot) Does NOT mean the person has AIDS Seronegative Not an assurance that an individual is free from HIV infection Seroconversion may not have occurred yet Figure 16-1 Viral load in the blood and the relationship to CD4 lymphocyte cell count over the spectrum of HIV disease. HIV viral load Question The purpose of doing a viral load study every 3 to 4 months in the HIV positive person is to determine: 1. the CD4 count 2. the progression of the disease 3. monitor immunosuppression levels 4. the results of the Western blot test Answer 2. the progression of the disease Viral load monitoring shows the level of virus in the blood, provides significant information toward predicting the course of the disease Spectrum of HIV Infection AIDS The end-stage, or terminal, phase of the HIV infection HIV positive and CD4+ (T4) count below 200 or one or more AIDSindicator conditions Therapeutic Management Therapeutic management focus Monitoring HIV disease progression and immune function Preventing the development of opportunistic diseases Initiating and monitoring antiretroviral therapy Detecting and treating opportunistic diseases Managing symptoms Preventing complications of treatment HIV management Therapeutic Management Pharmacological management Most common opportunistic diseases associated with HIV Pneumocystis jiroveci (formerly carinii) pneumonia (PCP) Most common infection Symptoms Fever; night sweats; productive cough; SOB Treatment Bactrim or Septra; pentamidine; steroids Wear gown, mask, and gloves during patient care Therapeutic Management Pharmacological management (continued) Most common opportunistic diseases associated with HIV (continued) Kaposi’s sarcoma Most common neoplasm found in HIVinfected patients Symptoms Reddish-purple Treatment Radiation Chemotherapy spots on the skin Therapeutic Management Pharmacological management (continued) Most common opportunistic diseases associated with HIV (continued) Cytomegalovirus (CMV) Symptoms Retinitis Colitis Treatment Ganciclovir Foscarnet Therapeutic Management Pharmacological management (continued) Most common opportunistic diseases associated with HIV (continued) Cryptococcal meningitis Symptoms Fever Headache Treatment Amphotericin Fluconazole B Therapeutic Management Pharmacological management (continued) Most common opportunistic diseases associated with HIV (continued) Toxoplasma encephalitis Symptoms Fever; headache; seizures Mental changes Treatment Pyrimethamine and folic acid Sulfadiazine Clindamycin Therapeutic Management Pharmacological management (continued) Most common opportunistic diseases associated with HIV (continued) Mycobacterium (avium complex and tuberculosis) Symptoms Fever; chills; sweats Abdominal pain; bone pain Fatigue; diarrhea; nausea; weight loss Treatment Rifampin; INH; ciprofloxacin Therapeutic Management Pharmacological management (continued) Antiretroviral therapy Combination therapy prevents development of resistance Must be given around the clock Usually initiated CD4+ Viral count below 350 mcL, or load greater than 30,000 copies/mL Therapeutic Management Pharmacological management (continued) Alternative and complementary therapies Massage Acupuncture Acupressure Biofeedback Nutritional Herbal supplements remedies Nursing Interventions Adherence Adhering to a prescribed regimen is of paramount importance to survival and the success of treatment Palliative care The active, total care of patients whose disease is not responsive to curative treatment Nursing Interventions Psychosocial issues Uncertainty Isolation Fear Depression Limited financial resources Nursing Interventions Assisting with coping Educate about HIV Encourage patients to participate in their own care Encourage patients to face life a day at a time; live each day to the fullest Listen Maintain support sources of psychological Nursing Interventions Reducing anxiety Clarification and education about HIV and AIDS Include patient and support person in planning care Encourage talking about feelings or relaxation and meditation Assess for suicidal ideation Support groups Nursing Interventions Minimize social isolation Social stigma Associated with homosexuality, drug use, and sexual transmission Sharing Need Support diagnosis with others to choose carefully groups Patients Significant others Nursing Interventions Assisting with grieving Listening Explore feelings, fears, and treatment options Significant others and family members May experience fear, anger, embarrassment, and shame Nursing Interventions Confidentiality Diagnosis should be carefully protected Need-to-know basis Not every health care worker needs to know diagnosis Universal precautions should be used with every patient Nursing Interventions Duty to treat Health care professionals may not pick and choose their patients Ethical and legal principles Rehabilitation Act of 1973 prohibits discrimination against the handicapped and the disabled HIV and AIDS are included Nursing Interventions Good nutritional habits Elimination of smoking and drug use Elimination or moderation of alcohol intake Regular Stress exercise reduction Avoidance of exposure to new infectious agents Mental health counseling Involvement Safer in support groups sexual practices Nursing Interventions Later interventions Treat opportunistic diseases Diarrhea is often a long-term problem Low-fat, low-fiber, high-potassium diet Adequate fluid intake Good skin care Nutritional Encourage Increase Enteral TPN nutritional supplements protein supplements (NG tube) Prevention of HIV Infection Education Best means of prevention Counsel about HIV testing, behaviors that put people at risk, and how to reduce or eliminate those risks Nurse must be able to discuss behaviors Forthright, relaxed, and nonjudgmental Prevention of HIV Infection HIV testing and counseling Pre- and posttest counseling must be done Patient should not be pressured to be tested Informed consent must be obtained before drawing blood Consent laws are established by state laws Confidential or anonymous testing Prevention of HIV Infection Barriers to prevention Denial “It won’t happen to me” Ignoring risks Fear, misunderstanding, and potential for social isolation Cultural and community attitudes, values, and norms Opposed schools to HIV and AIDS education in Prevention of HIV Infection Decreasing risks related to drug use Stop the use of injectable drugs Provide If drug treatment opportunities drugs are going to be injected Use sterile needles and equipment Instructions equipment on cleaning needles and Prevention of HIV Infection Decreasing risks of occupational exposure Risk is very low Handwashing is the single most effective means of preventing the spread of infection Universal Precautions and body substance isolation High-risk exposure treatment Begin antiretroviral medications within 1 to 4 hours for at least 4 weeks HIV testing: Baseline, 6 months, and 12 months Prevention of HIV Infection Other methods to reduce risk HIV-infected person should be given the following instructions: Do not give blood, donate organs, or donate semen Do not share razors, toothbrushes, or other household items that may contain blood or other body fluids; shower instead of tub bath Avoid infecting sexual and needle-sharing partners Do not breastfeed Chapter 13 Antivirals, Antiretrovirals, and Antifungal Medications Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 63 Antiretrovirals Action Interfere with the ability of a retrovirus to reproduce or replicate Two types: Reverse transcriptase inhibitors • Act early in viral life cycle Protease inhibitors • Act later in viral life cycle Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 64 Antiretrovirals (cont.) Uses Slow advance of AIDS Maintain immunity Prevention of HIV in infants born to HIVinfected mothers Prevention of HIV in health care workers exposed to HIV Drug Interactions Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 65 Antiretrovirals (cont.) Nursing Implications and Patient Teaching Adherence is essential Medications do not cure Report all drugs and supplements used, including OTC and CAM Signs and symptoms of pancreatitis Signs and symptoms of peripheral neuropathy Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 66 Antiretrovirals (cont.) Nursing Implications and Patient Teaching (cont.) Routes of disease transmission Need for social and financial support Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 67 Williams' Basic Nutrition & Diet Therapy 14th Edition Chapter 23 Nutrition Support in Cancer and HIV/AIDS Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 68 Lesson 23.2: Nutrition Support in HIV/AIDS Nutrition problems affect the nature of the disease process and the medical treatment methods in patients with cancer or AIDS. The progressive effects of the human immunodeficiency virus (HIV), through its three stages of white T-cell destruction, have many nutrition implications and often require aggressive medical nutrition therapy. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 69 Process of AIDS Development (p. 485) Evolution of human immunodeficiency virus First case identified in 1959 By late 1970s and early 1980s had spread to Europe and United States Underlying infectious agent identified in 1983 Parasitic nature Viruses contain only shreds of genetic material They invade a host cell and use it to make copies of itself Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 70 Transmission and Stages of Disease Progression (p. 487) Modes of transmission Three distinct stages Primary infection and extended latent period of HIV incubation HIV-related diseases AIDS Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 71 CD4+ T-Lymphocyte Conditions (p. 487) Terminal stage of HIV infection: AIDS Rapidly declining T-lymphocyte counts Kaposi’s sarcoma Protozoan parasites Cytomegalovirus Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 72 Medical Management of Patient with HIV/AIDS (p. 489) Delay progression of the infection and improve the immune system Prevent opportunistic illnesses Recognize the infection early Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 73 Drug Therapy (p. 489) Effective drug therapy is difficult because of highly evolved nature of virus Several drugs approved by FDA Highly active antiretroviral therapy is current primary drug regimen Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 74 Medical Nutrition Therapy (cont’d) (p. 493) Intervention No specific nutrient recommendations for patient with HIV Reduce or eliminate malnutrition Correct nutrition problems identified in assessment Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 75 Complications of HIV/AIDS AIDS Wasting Syndrome – involuntary loss of more than 10% baseline body weight and chronic weakness/fever/diarrhea for more than 30 days HIV Neurocognitive Disorder – HIV associated dementia – HIV infection in the brain or other parts of the Central Nervous System –memory impairment, loss of balance, slower responses, hallucinations Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 76 Causes of Body Wasting (p. 494) Inadequate food intake Malabsorption of nutrients Disordered metabolism Lean tissue wasting Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 77 Nutrition Counseling, Education, and Supportive Care (p. 495) Should focus on: Appropriate, adequate food intake – encourage small meals Food behaviors Symptoms that may affect food intake Benefits and risks of supplemental nutrients Nutritional strategies for symptom management Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 78 Counseling Principles (p. 495) Motivation for dietary changes Rationale for nutrition support Provider-patient agreement on plan Development of manageable steps for change Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 79 Personal Food Management Skills (p. 495) Identify community programs (e.g., Meals on Wheels) Provide psychosocial support Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 80
