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Human
Immunodeficiency
Virus (HIV) Infection
(relates to Chapter 14, “Human
Immunodeficiency Virus Infection,” in the
textbook)
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
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
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
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
Viral Load in the Blood
Fig. 14-1
Pathophysiology of HIV

HIV destroys CD4+ cells 3 ways
1.
2.
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
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

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
HIV Cell Counts




1. Normal T4 count: 800-1200 cells/ul
2. T4 count >500; generally healthy
3. T4 count 200-499; 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!
Clinical Manifestations and
Complications

Acute infection
– Flu-like syndrome
 Acute
retroviral syndrome
Clinical Manifestations and
Complications

Chronic HIV infection
– Is generally asymptomatic early on
– When CD 4+ counts drops to 200-500
cells/μl, symptoms occur
 Oral
hairy leukoplakia
 Candida infection
 Fever, sweats, diarrhea, headaches
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
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
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
Nursing Management
Nursing Assessment

Dependent upon the stage of the disease
– Prevention
– Treatment
– Terminal phase
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?

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)?
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
Nursing Management
Implementation

Drug therapy for opportunistic diseases (Table 142 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?
Health Promotion

Prevention of HIV
– Decreasing risks related to





Prevention of HIV
– Decreasing risks related to sexual intercourse



Sexual intercourse
Drug use
Perinatal transmission
Work
Abstinence
Outercourse
Prevention of HIV
– Decreasing risks related to sexual intercourse

Use barriers (e.g., condoms) when engaging in insertive sexual activity
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
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%
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 postexposure prophylaxis with combination ART
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
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
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
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
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
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
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
Terminal Care



Dementia often present in final stages of HIV
– “AIDS-dementia complex” and cognitive motor
complex
Dementia often present in final stages of HIV
– 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