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Chapter 34
HIV/AIDS
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Learning Objectives
• Describe the history of HIV/AIDS.
• Explain the pathophysiology and etiology of HIV
infection.
• List risk factors associated with HIV infection.
• Identify complications associated with HIV infection.
• Identify criteria for diagnosis of AIDS.
• Name the major HIV drugs, indications, side effects, and
nursing considerations.
• Describe appropriate nursing care of the HIV/AIDS
patient.
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Origin of HIV and AIDS
• Might have been as early as the 1940s
• Not recognized as a new pathogen until the
early 1980s
• Immune-deficiency conditions began to show
up among primarily urban, gay men in the
United States
• In 1986, HIV-1 and HIV-2 were isolated as
causal viruses of AIDS
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Origin of HIV and AIDS
• Gay men were just the first to be affected
• Infection soon seen in other populations
• Hemophiliacs
• Patients who received a transfusion with HIVinfected blood or blood products
• Newborns and breast-fed infants of HIV-infected
mothers
• Injection drug users
• Partners having unprotected sex with those infected
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Demographics
• Age
• More than half of new infections in young adults 15
to 24 years of age—at least 27% of these are
women
• Since 1981, HIV/AIDS has affected 123,711 adults
older than 65 years of age
• Race
• 1984
• Whites 49%, African Americans 27%, and Hispanics 12%
• 2004
• Whites 37%, African Americans 40%, and Hispanics 22%
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Pathophysiology
• Retrovirus
• Transcription of genetic material is reversed
• RNA made into deoxyribonucleic acid (DNA) rather than
the normal pattern of DNA to RNA
• Reverse transcriptase
• An enzyme that is responsible for transcribing RNA into
DNA
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Pathophysiology
• The life cycle of HIV
• Penetrates body via blood and body fluids
• Spherical
• Two protein markers protrude from the virus
• gp120 and gp41
• Attach to protein markers found on macrophages and T4
helper cells or CD4 and infuse genetic material into the host
cell
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Pathophysiology
• HIV DNA incorporated into host cell’s DNA
• Billions of copies of HIV are made
• 21 billion new HIV virions are produced daily
• Only about 2 billion new T4 cells are produced
• Eventually, the body is unable to maintain a
healthy immune response and shows
symptoms of HIV/AIDS
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Pathophysiology
• The body’s response to HIV infection
• Mounts a defense against the HIV virus through
antibodies and T cells
• About 12 weeks after infection, the body produces enough
antibodies to be detected by standard HIV test
• HIV viral load begins to drop, indicating partial
effectiveness of the body to rid itself of HIV
• CD8 cells drop drastically in the late stages, and CD4 cells
slowly decline throughout the whole infection
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Stages of HIV Infection
• Initial stage
• Lasts 4 to 8 weeks
• High levels of virus in the blood
• Generalized flulike symptoms
• Latent stage
• Lasts 2 to 12 years
• Virus is inactive
• Levels are high in the lymph nodes but low in the
blood
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Stages of HIV Infection
• Third stage
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Lasts 2 to 3 years
Patient experiences opportunistic infections
TH CD4 cells are usually <500 cells/mm³
Viral levels in the blood increase
Acquired immunodeficiency syndrome (AIDS)
• CD4 cell levels drop <200 cells/mm³
• This stage ends in death, usually within 1 year
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Signs and Symptoms of HIV
Infection
• Initial stage
• Generalized flulike symptoms
• Latent stage
• May have no symptoms initially
• Eventually, frequent and persistent infections
• Fever, night sweats, swollen lymph nodes, headache, skin
lesions, sore throat, dyspnea, burning with urination, or
diarrhea
• Extreme fatigue and weight loss
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Complications
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Opportunistic Infections
• When CD4 cells, CD8 cells, and/or HIV
antibodies fall below normal, infections and
cancers take advantage and cause infection or
cancer in the body
• Causes: parasites, fungi, bacteria, viruses
• Leading cause of death with AIDS is
pneumonia due to unspecified organisms
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Parasitic Infections
• Cryptosporidiosis and isosporiasis
• Fairly common in the environment
• Watery diarrhea; may be severe/persistent
• Nursing care: preventing dehydration and
maintaining fluid and electrolyte balance
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Antidiarrheal drugs
Intravenous fluids
Antimicrobial agents
Teach good hand washing and personal hygiene
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Parasitic Infections:
Toxoplasmosis
• Cats, mammals, and birds serve as hosts
• Humans become infected by ingesting
contaminated, undercooked meats or
vegetables or by contact with cat feces
• Affects any tissue; mainly brain, lungs, eyes
• Toxoplasmosis encephalitis the most common
in immunosuppressed patients
• Dull, constant headache, weakness, seizures
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Parasitic Infections:
Toxoplasmosis
• Pulmonary infection
• Feverish illness that mimics Pneumocystis jiroveci
pneumonia with shortness of breath and
nonproductive cough
• Eye infection
• Loss of visual acuity as well as photophobia
• Wash hands, avoid undercooked raw meats,
and avoid cat litterboxes
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Fungal Infections
• Microsporidiosis
• Source of human infection is unknown
• Watery diarrhea with weight loss, malabsorption,
abdominal cramps, and flatulence
• No curative therapy; treat the symptoms
• Low-fat, low-residue, high-protein, high-calorie diet
• 3 L of fluid per day; avoid milk products
• Teach good hand washing and good hygiene; avoid
ingestion of food or water contaminated with fecal matter
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Fungal Infections
• Pneumocystis jiroveci pneumonia
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Acquired by inhalation
Second leading cause of death in AIDS patients
Cysts prevent the exchange of gases
Shortness of breath on exertion, fever, and a
nonproductive cough
• Treated with Bactrim, dapsone, clindamycin, and
pentamidine
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Fungal Infections
• Aspergillosis
• Lives in soil, water, and air
• Pulmonary infection can develop when spores are
inhaled
• Causes fever, cough, dyspnea, chest pain, and
hemoptysis
• Usually fatal within 8 weeks
• Avoid wet, cool places; decreases risk of infection
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Fungal Infections
• Candidiasis
• Found in most foods, soil, and inanimate objects
• Approximately 80% of HIV patients will develop
candidiasis
• Affects the mouth, vagina, and/or anus
• Thrush: oral form of candidiasis
• Candidal plaques can be scraped off
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Fungal Infections
• Coccidioidomycosis
• Endemic in the southwestern United States and
northern Mexico
• Particles inhaled into the lungs
• Fever, weight loss, fatigue, dry cough, or pleuritic
chest pain
• Dissemination to other organs may occur
• People with HIV should avoid exposure to disturbed
soils in endemic areas
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Fungal Infections
• Cryptococcosis
• Most common systemic fungal infection in AIDS
patients
• Symptoms appear approximately 30 days after
exposure
• Fever, headache, malaise, nausea, vomiting, altered
mental status, and a stiff neck
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Fungal Infections
• Histoplasmosis
• Endemic in the central and southern United States
• Found in soil and bird droppings
• Involves the lungs after spores are inhaled, then can
be disseminated to other organs
• Fever, night sweats, weight loss, and shortness of
breath
• Avoid cleaning bird cages to prevent infection
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Viral Infections
• Cytomegalovirus (CMV)
• Found in semen, cervical secretions, saliva, urine,
blood, and organs
• Mainly transmitted by blood and body fluids through
unprotected sex
• Complications include chorioretinitis, radiculopathy,
subacute encephalitis, colitis, esophagitis, and
pneumonia
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Viral Infections
• Herpes simplex (HSV) and herpes zoster
(HZV)
• Reactivated HSV in HIV patients can cause serious
disease and tissue destruction
• HSV infection follows a predictable pattern
• Primary outbreak, latency, and possible reactivation at
some later point in life
• Most adults carry HZV because of exposure to
chickenpox virus as a child
• Reactivation of HZV usually occurs as shingles
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Viral Infections
• Oral hairy leukoplakia (OHL)
• Thick white patches on the buccal mucosa, soft
palate, floor of mouth, and tongue
• Associated with Epstein-Barr virus
• More common among smokers
• The mouth is often painful
• Advise patient to drink from a straw
• Ice cream or Popsicles can numb the area
• Hot/spicy foods and alcohol may exacerbate mouth pain
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Viral Infections
• Progressive multifocal leukoencephalopathy
• Caused by the Jamestown Canyon virus
• Develops in 2% to 4% of AIDS patients
• Progressive degeneration of white matter of the
brain
• Death within 4-6 months after the onset of
symptoms
• Symptoms include weakness and progressively
impaired speech, vision, and motor function
• No effective treatment
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Bacterial Infections
• Bacillary angiomatosis (BA)
• Causes skin lesions; may affect any organ
• Transmitted by cats and their fleas
• Due to a bite or scratch
• Papules/plaques occur anywhere on the skin
• Advise HIV patient to avoid rough play with cats and
to make sure cats are treated for fleas
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Bacterial Infections
• Mycobacterium avium complex (MAC)
• Found everywhere, including most food, animal, and
soil sources
• May affect any organ of the body
• Causes fever, fatigue, weight loss, night sweats,
abdominal pain, and diarrhea
• Not contagious
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Bacterial Infections
• Mycobacterium tuberculosis (TB)
• HIV patients much more likely than a healthy person
to become infected with TB if exposed, especially
when CD4 counts drop below 200 cells/mm³
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Kaposi’s Sarcoma
• Common neoplasm that develops with AIDS
• Affects the skin first, appearing as a macular
painless, nonpruritic lesion
• Color varies: pink, red, purple, and brown
• Tumors may spread to the gastrointestinal
system and lungs
• Treatment: observation, HAART, surgical
removal, cryotherapy, radiotherapy,
chemotherapy
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Lymphomas
• A type of cancer that originates in lymphoid
tissue: bone marrow, spleen, thymus gland
• Two types: Hodgkin’s and non-Hodgkin’s
• Second most common malignancy in AIDS
patients
• Causes fever, night sweats, and weight loss
• Diagnosis based on a biopsy of lymphoid
tissue
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Medical Diagnosis of HIV
• HIV diagnosis
• Positive HIV antibody test
• ELISA
• Done first; 99% reliable
• Western blot
• Used as a confirmation test; 99.99% reliable
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Medical Diagnosis of HIV
• AIDS diagnosis
• CD4 count of <200 cells/mm³; asymptomatic
• CD4 count of <200 cells/mm³; with category B
symptoms
• Category C symptoms regardless of CD4 count
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Medical Treatment: Highly Active
Antiretroviral Therapy (HAART)
• Recommended for HIV viral load of 5000-30,000
copies/mL and CD4 counts of 350-500 cells/mm
• Usual drug combination: 1 protease inhibitor and 2
nucleoside reverse transcriptase inhibitors
• Ability/willingness to comply with therapy
• If patient will not be compliant with the medication regimen,
better to not even start
• GI upset common; reason for noncompliance
• Many side effects; usually subside in a few weeks
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Assessment
• Signs and symptoms of infection
• Most common sites are lungs, mouth, GI tract, skin,
blood, and central nervous system
• Any changes should be reported to a
registered nurse or physician
• Determine how much patient knows about the
disease and treatment
• Assess how patient is coping with disease
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Health History
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Sexually transmitted infection history
Surgical history
Medication history and allergies
Immunization history
Family history
Sexual history
Needle and blood exposure history
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Health History
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Tobacco/alcohol use history
Illegal drug use history
Pet history
Occupational history
Nutritional history
Gynecologic history
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Physical Examination
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Height, weight, vital signs
Skin
Head, ears, eyes, nose, and throat
Lymphatic system
Respiratory system
Cardiovascular system
Abdominal
Musculoskeletal
Neurologic
Genitourinary
Laboratory profile
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Interventions
• Ineffective Therapeutic Regimen Management
• Patient should receive accurate, consistent
information from all members of the health care
team
• Clinical nurse specialist or other specially trained
nurse can provide information about disease and
treatment
• Excellent sources of information on the Internet
• www.thebody.com
• www.hivinsite.ucsf.edu
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Interventions
• Anxiety
• Dealing with emotions of facing a life-threatening
illness
• Encourage patients to ask questions and talk about
their feelings
• Information about disease and treatment may help
patient and family deal with their anxiety
• May need referral to a social worker, chaplain, or
mental health counselor
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Interventions
• Infection
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Early detection and prompt treatment are vital
May be on anti-infective drugs prophylactically
Important to take drugs as prescribed
May need intravenous antibiotics
• Clinic or home administration
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Interventions
• Impaired Oral Mucous Membrane
• Encourage regular teeth and mouth cleaning with
dental floss and a soft toothbrush
• Encourage fluids to maintain hydration to keep
mucous membranes moist
• Topical anesthetics applied before eating
• Regular dental evaluations can help prevent and
manage oral disease and infections
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Interventions
• Imbalanced Nutrition: Less Than Body
Requirements
• Refer to dietitian for nutrition counseling as soon as
the patient is diagnosed
• Oral supplements with Carnation Instant Breakfast,
Ensure, Sustacal, or Resource
• Administer medications
• Improve appetite (megestrol, dronabinol)
• Relieve nausea (prochlorperazine, metoclopramide)
• Control diarrhea (diphenoxylate hydrochloride with atropine
sulfate)
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Interventions
• Disturbed Thought Processes
• Patients with HIV encephalopathy may experience
cognitive and motor impairment
• May withdraw from social activities because of
embarrassment
• May become angry and hostile
• Safety constantly reevaluated based on mental and
physical capabilities
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Interventions
• Pain
• From opportunistic infections, viral invasion into the
nerves and muscles, malignant tumors, and
diagnostic procedures
• Closely monitor pain level and medication use
• Flow sheet of pain reports on a 10-point scale
• Pain and amount of medication used can guide
nurse and physician to the appropriate type and
amount of pain medication
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