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HIV & AIDS
Claire O’Gorman
Claire Pettipas
Michèle Weir-Cotnoir
Objectives
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Describe the pathophysiology of HIV the
consequential infections that occur
Understand the Epidemiology of the disease and
the effects of HIV/AIDS on a society, including
Canada
Understand the risk factors associated with
contracting HIV and how to prevent infection
Describe how to protect yourself as a HCP from
infectious blood borne diseases
Understand the nursing management of this
terminal illness and the conditions associated
with it.
What Is HIV?
H – Human
I – Immunodeficiency
V – Virus
What is AIDS?
A – Aquired
I – Immune
D- Deficiency
S- Syndrome
For diagnosis must be:
HIV positive, and
CD4 (T-cell) count below 200, or
The presence of one or more opportunistic infections.
Class Activity
STAND UP!
Global Epidemiology

39.5 million people living with HIV/AIDS in
2006
– 4.3 million newly infected with HIV (more
than half are younger than 25)
– 2.9 million people died from AIDS
More than 25 million people have died
from AIDS since 1981
 Africa has over 12 million AIDS orphans

Global Trends
Xtending Hope

What can you do on campus to address the
global AIDS epidemic?
Canadian Epidemiology
58 000 people in Canada with HIV (as of Dec,
2005)
30% of people unaware of their infection
Between 2 300 and 4 500 new HIV infections every
year
329 people in Nova Scotia/PEI have AIDS (as of
June, 2006)
Public Health Agency of Canada. HIV and AIDS in Canada. Surveillance report to
June 30, 2006. Surveillance and Risk Assessment Division, Centre for
Infectious Disease Prevention and Control, Health Canada, November 2006
Health Canada. HIV/AIDS EPI Updates, August 2006, Surveillance and Risk
Assessment Division, Centre for Infectious Disease Prevention and Control,
Health Canada, 2006
Canadian Epidemiology

Affects ALL races, genders, ages
– Most people who test HIV positive are
between the ages of 20-40
– Minorities, such as aboriginals and black
people, are over represented
– Women remain around 1/3 of newly infected
patients (increase since 1995)
– Greater risk of infection with high risk
activities
Risk Factors

Transmission: through bodily fluids from
an infected person
Three Conditions:
1. Virus Must be Present
2. There must be a high
enough concentration of the
virus in the infected person
3. There must be a way for
the virus to enter the
bloodstream
Through Blood, Seman,
Vaginal Fluid, or Breast
milk
Transmission
Possible Sources of Transmission:
– Blood products/ transfusions
 Before 1985
– Mother to child
 Pregnancy, birth, and breastfeeding
– Contaminated needles
 Injection drug use, tattoos, peircings, acupunture
– Sexual contact




Unprotected sex
Unwashed sexual devices
Greater risk with other STI due to breaks in skin
Greater risk with increased number of partners
Risk Factors

NOT transmitted through
–
–
–
–
–
–
–
–
–
–
–
Casual contact (shaking hands)
Hugging
Kissing
Sweat
Tears
Donating Blood
Swimming Pools
Toilet seats
Telephones
Sharing bed linens, towels, eating utensils, or food
Insect bites
Societal Risk Factors
Many determinants of health!
 These, in turn, become consequences of an
epidemic
 Societal factors that contribute to the epidemic:

–
–
–
–
–
People on the move
People in conflict
Poverty
Stigma and Denial
Cultural factors
 Role of Women
Prevention

Prevention is the most realistic strategy
– Vaccine or cure unlikely anytime soon
Prevention is done by decreasing both societal
and individual risk factors
 Barriers to prevention include:

– Political instability
– Lack of resources
– Existence of other endemic health problems (ie:
malaria and childhood diseases)
– Inefficiency
– Apathy and silence
– Misconceptions and lack of knowledge
Decreasing Individual Risk Factors
Nurses are responsible for educating their clients
about how to protect themselves from HIV/AIDS!
 Literacy appropriate teaching
 Use multiple teaching methods
– Provide visual/auditory/written material for different
learning styles
– Provide for kinetic learners, too, such as having the
client demonstrate how put on a condom

Direct clients to community resources
– Where they can be tested for HIV/AIDS and other
STI’s
– Support groups
Community Resources
AIDS Coalition of Nova Scotia
(ACNS)
326-1657 Barrington Street
Halifax, Nova Scotia, B3J 2A1
Phone: 902 425 4882
Alternate Thursday Evenings
5:00pm–8:00pm
Call for Schedule - By Appointment
Only
Mainline Needle Exchange
5511 Cornwallis Street
Halifax, Nova Scotia, B3K 3B4
Phone: 902 423 9991
Every Second Monday 9:30am–
11:30am
Call for Schedule - Drop In
Healing Our Nations Aboriginal
AIDS Task Force
607-45 Alderney Drive
Dartmouth, Nova Scotia, B2Y 2N6
Phone: 902 492 4255
Halifax Sexual Health Centre
(HSHC)
201-6009 Quinpool Road
Halifax, Nova Scotia, B3K 5J7
Phone: 902 455 9656
Monday–Friday 8:30am–4:30pm
By Appointment Only
Lesbian Gay Bisexual Youth Project
2281 Brunswick Street
Halifax, Nova Scotia, B3K 2Y9
Phone: 902 429 5429
Every Fourth Thursday 5:00pm-8:00pm
By Appointment Only
Teen Scene
16 Dentith Road (South Centre Mall)
Spryfield, Nova Scotia, B3R 2H9
Phone: 902 455 9656
Every Fourth Thursday 3:30pm–5:30pm
Prevention: Practice SAFER sex

Nurses must be comfortable
discussing their clients’
sexual activites
– Assess: number of partners,
protection being used, and
whether it is being used
properly
– Ask everyone! Don’t assume!
– Educate: know STI status of
sexual partners, HIV/AIDS and
other STI testing, use of latex
condoms, dental dams, latex
gloves, water-based lubricants
Prevention: Clean Needles
Risk reduction school of thought
 Nurse can :

– Direct client to addiction services
– Direct client to needle exchange program if quitting
is not an option at this time
– Alcohol kills HIV
– Educate! Sharing needles with friends is just as risky
as sharing with strangers
Prevention: Screening
Many STI’s are tested
with gyne exams, but
HIV requires a blood
test
 HIV antibody test

Prevention: Education

Many myths and misconceptions ie:
– HIV doesn’t exist within this community
– HIV only affects sex-trade workers,
homosexuals and injection drug users
– If you get HIV you will show symptoms
– Having sex with a virgin will cure you of HIV

Nurses play a large role in providing the
facts!
Prevention: Policy

Society contributes to HIV transmission!
– Empowering women
– Promoting Justice
– Addressing Poverty
– Providing Education
– Addressing Stigma
What exactly is HIV?

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
Human Immunodeficiency Virus- a retrovirus
belonging to the family of lentiviruses.
Uses their RNA and host DNA to make viral DNA
Uses CD4+ cell to replicate itself and destroying
CD4+
Two types: HIV-1 + HIV-2
Leads to Acquired Immunodeficiency Syndrome
HIV
2 types: HIV-1 and HIV-2
 Subtypes of HIV-1: A, B, C, D, E, F, G, H,
O. (No subtypes of HIV-2)
 HIV-1 subtype C makes up for more than
50% of all new HIV infections worldwide.
 HIV-2 progresses slower
 HIV-2 makes up the majority of cases of
HIV infection in Africa

Pathophysiology of
HIV/AIDS
HIV LIFE
CYCLE
Diagnosis of HIV infection
EIA (enzyme immunoassay) [formerly
ELISA (enzyme-linked immunosorbent
assay)] identifies antibodies that are
specifically directed against HIV.
 Western blot assay: used to confirm
seropositivity when the EIA is positive
 Seropositivity: when blood or saliva
contains HIV antibodies

Other Tests
Viral load tests: used to quantify HIV DNA or
RNA levels in the plasma. These tests include:
reverse transcriptase polymerase chain and
nucleic acid sequence-based amplification.
 This can help determine response to treatment.
 Viral load is a significant
predictor of disease
progression.

Home Testing Kits
Home testing kits are
available, but are of
concern to HCP.
 Why?
 The lack of
counselling, as well as
the possibility of
inaccurate results.

S&S of HIV infection
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Often, there are no S&S in the early
stages of HIV infection

Why?

The CD4 lymphocytes are still numerous
enough to fight off infections
S&S of HIV infection

There may be slight flu-like symptoms 2-6
weeks after initial infection.
Other S&S (generally advanced infection):
Lymphadenopathy (often the first sign) profuse
night sweats, rapid weight loss, recurrent fever,
chronic diarrhea, unexplained fatigue, persistent
headaches
(http://www.mayoclinic.com/health/hivaids/DS00005/DSECTION=2)

Stages of HIV disease
Based on “clinical
history, physical
examination,
laboratory evidence of
immune dysfunction,
signs and symptoms,
and infections and
malignancies”
(Smeltzer & Bare,
2004, 1559)
 3 categories: A, B, C

Clinical Category A
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This category is asymptomatic.
The virus reaches a “set point” level after about
6 months.
The “set point” generally determines rate of
disease progression.
In general, 8-10 years can pass before HIVrelated complications occur.
Why asymptomatic? CD4 levels are high enough
to fight off other pathogens (>500 CD4+ Tlymphocytes/mm^3)
Clinical Category B
CD4 cell level starts dropping (200-499
CD4+ T-lymphocytes/mm^3).
 This category consists of conditions that
are not covered under category C. The
conditions must:

– Be due to HIV infection
– Require management that is complicated by
HIV infection
Clinical Category B

Some of the conditions under this
category include:
– Candidiasis (oropharyngeal or vulvovaginal)
– Cervical carcinoma in situ
– Fever (38.5 C), or diarrhea > 1 month
duration
– Herpes zoster (shingles)
– Pelvic inflammatory disease
– Peripheral neuropathy
Clinical Category C
When CD4 T-cell levels drop below 200
CD4+ T-lymphocytes/mm^3, the client is
said to have AIDS. Below 100, the
immune system is significantly impaired.
 Once a client is classified as having
category C infection, s/he remains in this
category.

Clinical Category C

Some conditions in this category include:
– Candidiasis (bronchi, trachea, lungs, or
esophagus)
– Cervical cancer, invasive
– HIV-related encephalopathy
– Kaposi’s sarcoma
– Pneumocystis carinii pneumonia
– Toxoplasmosis of brain
– Wasting syndrome due to HIV
Treatment of HIV
Antiretroviral treatments
Compliance may be decreased
by the side effects of the
drugs, or by clients deficiency
of knowledge about the
treatment.
 In developing and transitional
countries, 7.1 million people
are in immediate need of lifesaving AIDS drugs; of these,
only 2.015 million (28%) are
receiving the drugs.


Nucleoside Reverse Transcriptase
Inhibitors (NRTI’s)
These were the first antiretrovirals
approved by the European and American
regulatory agencies.
 Becomes part of the viral DNA, stopping
the building process.
 These are the cornerstone for HIV
therapy.

Side Effects of NRTI’s
Some possible adverse effects
of this class of drugs:
Peripheral neuropathy,
pancreatitis, lactic acidosis,
bone marrow suppression,
neutropenia, anemia,
arthralgia, myopathy, kidney
dysfunction, hepatomegaly,
liver failure, hypersensitivity,
abdominal pain, oral ulcers,
irritability, anxiety.
(Smeltzer & Bare, 2004, 1563)

Non-nucleoside Reverse
Transcriptase Inhibitors (NNRTI’s)
Blocks the HIV reverse transcriptase in a
different method from the NRTI’s.
 Attaches to the reverse transcriptase and
prevents conversion of HIV RNA into HIV DNA.


Used in combination with NRTI’s and PI’s.
Side Effects of NNRTI’s
Possible adverse reactions of this class of
drug include:
Abnormal liver function tests, hepatitis,
stomatitis, numbness, muscle pain,
drowsiness, changes in dreams, trouble
concentrating.

Protease Inhibitors (PI’s)
Prevents protease enzyme from cleaving HIV
proteins into the smaller, functional units. When
PI’s are taken, the HIV copies that are made
cannot infect CD4+ cells and lymphocytes.
 When taken alone, the virus quickly develops
resistance to its effects, so PI’s are always taken
with other drugs.
 Missed doses leads to virus resistance and drug
failure.

Side Effects of PI’s
The following may be some of the adverse
effects associated with PI’s:
Hemolytic anemia, parasthesia, kidney
stones, asymptomatic hyperbilirubinemia,
dyspepsia, altered taste, mood alterations,
drowsiness.

HAART
Highly active antiretroviral treatment
 A regimen that consists of 2 NRTI’s + a PI
(or NNRTI)

OR
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2 PI’s + one other antiretroviral agent
Decision Making

Treatment decisions
for every patient is
individualized and
based on 3 factors:
– Viral load
– CD4 T-cell count
– Clinical condition of
patient
Opportunistic Infections (OI’s)

Infections that occur
because of the client’s
compromised immune
system- do not occur
in people with normal
immune systems.
Pneumocystis carinii Pneumonia
(PCP)
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Most common OI which
leads to a diagnosis of
AIDS.
Without prophylaxis, 80%
of all HIV-infected clients
will develop PCP.
S&S: nonproductive
cough, fever, chills, SOB,
dyspnea, chest pain.
Untreated, it causes
respiratory failure.
Mycobacterium avium complex
(MAC)
MAC is a group of bacilli that usually
causes respiratory infection.
 May also be found in the GI tract, lymph
nodes, and bone marrow.

Tuberculosis (TB)
TB tends to occur early in HIV infection.
 If it occurs late in HIV infection, there may
be no response to a tuberculin skin test.
(This is called anergy, which happens due
to the immune system that can no longer
respond to the TB antigen.)

Oral Candidiasis
This is a fungal
infection that occurs
in nearly all patients
with AIDS.
 It commonly precedes
other OI’s.
 Untreated, it
progresses to the
esophagus and
stomach.

Wasting Syndrome
Characterized by
>10% weight loss
and chronic diarrhea
for more than 30 days
OR chronic weakness
and intermittent or
chronic fever.
 Wasting syndrome
can not be managed
by nutritional support
alone.

Kaposi’s Sarcoma (KS)
Most common malignancy in HIV infection.
 Involves the blood and lymphatic vessels.
 AIDS related KS has a more variable and aggressive
course than classic KS.
 It may be characterized by skin lesions, or multiple
organ system involvement.
 Diagnosis comes from biopsy of suspicious lesions.

B-Cell Lymphomas
Second most common malignancy in HIVinfected clients.
 Often occurs in the brain, bone marrow
and GI tract.
 Chemotherapy is not as effective in HIVrelated lymphomas.

HIV Encephalopathy
Formerly referred to as AIDS dementia
complex.
 Clinical syndrome consisting of a
progressive decline in cognitive,
behavioral, and motor function.
 HIV has been found in the CSF of patients
with this syndrome.

S&S of HIV Encephalopathy
Early stage: memory loss, difficulty
concentrating, headache, confusion,
psychomotor slowing, apathy, ataxia.
 Later stage: Global cognitive impairments,
delay in verbal responses, hyperreflexia,
psychosis, hallucinations, tremor,
incontinence, seizures, mutism, death.


(Smeltzer & Bare, 2004, 1567).
Nursing Management
There are many complications associated with
AIDS!
 Nursing interventions remain the same as other
people with those conditions
 Don’t forget about the pyschosocial implications
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Terminal illness
Isolation (physical and emotional)
Coping
Grief
Guilt and anger : associated with transmitting the
disease
– Stigma
Nursing Managment

Don’t contribute to the stigma associated with
AIDS
– Don’t make assumptions
– Don’t treat your patient any different
– Use universal precautions with ALL patients
Nursing Management
Protect Yourself!!!
Healthcare Workers Reported to have AIDS

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Occupational Exposure
DOES occur.
HCP’s reported to
have AIDS:
 Physician
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Lab technician
Dental worker
Surgeon
Nurses
1792
3182
492
122
???
Occupational Exposure to HIV
Exposure to HIV–infected blood via
percutaneous injury:
 3/1000
 Mucocutaneous exposure:
 Less than 1/1000
 Intact Skin:
 No known risk

Post-Exposure Prophylaxis (PEP)
Administration of antiretroviral
medications (ARV’s) after exposure to HIV.
 Given as soon as possible after exposure
 Must be within 72 hours
 4-week treatment with 2-3 different ARV’s
 Standard procedure since 1996.
 Reduces transmission by 79%

PEP cont’d…
Page 2145, Smeltzer
& Bare
 Table 70-5
 Recommended
Algorithm used to
determine PEP

Should a needlestick injury
occur…
What are you going to
do???
Wash area thoroughly with soap and
water
 Alert supervisor, documentation.
 Identify source patient
 Give consent for baseline testing
 PEP
 Follow-up with PEP testing 6 weeks , 3
months and 6 months after beginning
treatment
 Documentation
Day et al., 2007.

PEP use for non-occupation exposure
Non-occupational HIV exposures,
commonly related to unsafe behaviors.
 Would PEP encourage unsafe behaviors?
 No research indicated PEP works for nonoccupational exposure.
 PEP not a ‘morning after’ pill

Preventative Strategies:Universal
Precautions
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Routine use of barriers (gloves, gowns,
masks, goggles)
Washing skin surfaces immediately after
contact with blood or body fluids.
Disinfecting instruments and contaminated
equipment.
Properly handling soiled linens
Careful handling/disposal of sharp
instruments.
Documentation of sterilization quality
following procedures.
page 1557 Smeltzer & Bare, Chart 52-3
Building Better Prevention Programs
Administrative Efforts
 Development/ Promotion of the use of safety
devices.
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Sharp disposal containers
Disposable instrument use
Monitoring of the effectiveness of PEP.
Pre-Exposure Prophylaxis for HIV
“Various studied have shown that antiretroviral
treatment given at or shortly after HIV exposure
can reduce likelihood of transmission…”
 “…this lead to the hypothesis that transmission
may be decreased even further if treatment
were delivered before exposure to HIV” –
Paxton, 2007).
 Tenofir
 Safety/ effectiveness still unknown.

Ethics - Tenofir
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Think about…
Obligations of gov’t to provide pre-exposure
prophylaxis
Appropriate indications for prescribing Tenofir (
think high-risk populations)
Who should have priority for pre-exposure
prophylaxis?
Stigmatization:
- Stigma attached to engagement in risky behaviors
- Decision making clouded by underlying beliefs
CASE STUDY
Talia is a 23 year old female from Halifax. She is an arts student
at StFX university in her third year. She likes to go to the pub
on Saturdays and is the hockey team’s biggest fan. Talia is
single but had dated several boys since her first year. She used
a condom most of the time and goes for regular pap smears.
Around Christmas Exams Talia noticed that she is feeling tired all
the time. She wakes up in the middle of the night with night
sweats and has a rash. She is having a really hard time
studying for her exams. Her mom thought that she was
probably stressed about exams. But when Talia got her second
yeast infection since September she decided to seek medical
attention from her friendly neighborhood nurse.
Upon examination Talia’s nurse noticed that she had lost 8lbs
since her last visit in September. Her gums appear swollen and
so are her lymph nodes. She is anxious to get back to studying.
Case Study
How should the nurse tell Talia that an HIV
test is required?
If the results are positive, what should the
nurse tell her? What additional education
is needed?
What can the nurse tell Talia to expect?
How can the nurse be supportive to Talia?
Should any other risk reduction actions be
taken?
Nursing Care of the HIV positive client:
THE NURSING PROCESS
ASSESSMENT
-identify risk factors
- unsafe sexual practices
- IV drug use
- Physical Assessment – focus on Immune system
- Psychological status
- Nutritional status
- Skin integrity
- Respiratory status
- Neurological status
- Fluid and electrolyte balance
- Knowledge level
NSG DIAGNOSIS
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Impaired skin integrity r/t percutaneous
manifestations of HIV infection.
Risk for fluid volume deficit r/t diarrhea
Risk for infection r/t immunodeficiency
Activity intolerance r/t weakness, fatigue.
Pain r/t impaired skin integrity
Anticipatory greiving r/t changes in lifetsyle 2°
diagnosis of AIDS
Social isolation r/t stigma of the disease, fear of
infecting others
Ineffective A/W clearance r/t increased bronchial
secretions, decreased ability to cough.
PLANNING
Goals for Patient???
Achievement/Maintenance of skin
integrity
 Maintenance of usual bowel habits
 Absence of infection
 Improved activity tolerance
 Increased comfort
 Increased socialization
 Improved nutritional status
 Increased knowledge base
 Absence of complications

NSG INTERVENTIONS

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
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Promote skin integrity
Promote usual bowel habits
Prevent infections
Improve activity intolerance
Maintaining health
Improving A/W clearance
Relieving pain.increasing comfort
Nutritional status
Coping
Monitor for complications
EVALUATION
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Expected Patient Outcomes:
Maintains skin integrity
Experiences no infections
Maintains adequate activity tolerance
Experiences increased sense of comfort
Progresses through grieving process
Remains free of complications
Ethical considerations
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Many patients with HIV have engaged in
‘stigmatized’ behaviors.
Challenges traditional, religious and moral
values of HCP’s.
Fear and anxiety re: disease transmission.
The impact of an epidemic on a
culture/society (lost generation, orphans, etc)
Nurses encouraged to examine own personal
beliefs / values clarification.
Challenges legal and political systems
End of Life Care
Pg. 1584, Smeltzer & Bare Chart 52-10