CHAPTER 56: CARE OF THE
PATIENT WITH HIV/AIDS
Acute Interventions to Outlook For The Future
Acute Interventions
Acute Interventions




Early intervention after detection of an HIV infection
can promote health and limit or delay disability
Assessment is of primary importance because the course
of HIV is extremely variable
Nursing interventions will be based on and tailored to
any patient needs noted during assessment
Nursing assessment of HIV disease should focus on the
early detection of constitutional symptoms, opportunistic
diseases, and psychosocial problems
Box 56-6: Conducting a Risk
Assessment
Pg 2043
Conducting a Risk Assessment

Risk assessment specific to HIV and sexually
transmitted diseases (STDs), as well as blood borne
diseases, is crucial in health care delivery today.
Risk assessment should be done on a regular basis
with all patients and performed with the evaluation
of any new patient. Sexual and drug use risks
should be determined along with other risks during
routine history taking.
Key Questions To Ask
Any “yes” responses require further assessment and
evaluation:
 Have you ever had a blood transfusion? Have you
ever received any other kind of blood product?
Before 1985?
 Do you now or have you ever shared injection
equipment?
 Are you now or have you ever been sexually active?
Key Points to Consider
Begin by assuring confidentiality and telling the
patient why asking these questions is important:
 “I am going to ask some personal questions. I ask
all my patients these questions so I can provide
better care. All of your responses will be kept
confidential. Is it OK to proceed?”
Key Points to Consider (cont)
Ask direct questions about specific behaviors:
 “When was the last time you….?”
 “How often do you….?”
 “Have you ever exchanged sex for money or
drugs?”
Key Points to Consider (cont)
Exploratory questions may help (especially with
adolescents and young adults):
 “Do your friends use condoms?”
 “What happens at parties?”
 “How easy is it to get drugs?”
Key Points To Consider (cont)
Honest responses may be more forthcoming if the
behaviors are normalized:
 “Some of my patients who use drugs inject them.
Do you inject drugs or other substances?
 “Sometimes people have anal intercourse. Have
you ever had anal intercourse?”
Drug Use Assessment
It is important to be nonjudgmental and nonmoralistic:
 Injection drug use is illegal in the U.S. and many
patients are afraid to be honest unless trust is
established
Drug Use Assessment (cont)
Start with less threatening questions:
 “What over-the-counter (OTC) or prescription
medications are you taking?”
 “How often do you use alcohol? Tobacco?”
 “Have you ever used drugs from a nonmedical
source?”
 “Have you ever injected any kind of drug?”
Drug Use Assessment (cont)
Do not assume anything:
 Drug use occurs in all socioeconomic strata. Do not
forget that people inject substances such as insulin,
steroids, and vitamins. Any sharing, even one time,
can result in HIV exposure
Drug Use Assessment (cont)
Look for other clue in the history and physical exam:
 Antisocial behavior, recurrent criminal arrests,
needle tracks
Drug Use Assessment (cont)
If there is a positive history of drug injection use, get
more information:
 “Do/Did you share needles/other equipment?”
 “Is/Was the equipment you use(d) clean? How did
you know it was clean?”
 “What drugs did you inject?”
Sexual Risk Assessment
Direct and nonjudgmental questions work best:
 “Do you have sex with men, women, or both?”
 “Do you have oral sex? Vaginal sex? Anal sex?”
 “What do you know about the sexual activities of your
partners?”
 “What do you do to protect yourself during sex?
 “Do you use condoms? How often?”
 “Have you ever had sex with someone you didn’t know
or just met?”
Sexual Risk Assessment (cont)
Ask for an explanation of sexual practices:
 “When you say you had sex, what exactly do you
mean?”
 “I don’t know what you mean; could you
explain….?”
Sexual Risk Assessment (cont)
Do not assume anything:
 Marriage does not always mean an individual is
monogamous or heterosexual
 People who identify as homosexual may also have
heterosexual sex
Sexual Risk Assessment (cont)
Use specific terms:
 Use “men who have sex with men” or “women who
have sex with women” instead of gay. Some men
do not consider themselves “gay” if they practice
anal insertive intercourse, but their receptive
partners are considered to be gay (can be
culturally related).
Clinical Risk Assessment
Assess the patient for constitutional signs, history of
chronic infection and HIV, and associated problems:
 Headaches; diarrhea; fatigue; shingles; history of
STD, hepatitis, or TB; fever, chills, night sweats; skin
lesions; weight loss; oral thrush; generalized
lymphadenopathy
Acute Interventions
continuation
Acute Interventions


HIV disease progression may be delayed by promoting
a healthy immune system
Useful interventions for the HIV infected patient include
the following:

Nutritional changes that maintain lean body mass, increase
weight, and ensure appropriate levels of vitamins and
micronutrients; Elimination of smoking and drug use;
Elimination or moderation of alcohol intake; Regular
exercise; Stress reduction; Avoidance of exposure to new
infectious agents; Mental health counseling; Involvement in
support groups; Safer sexual practices
Acute Interventions (cont)


Nurse needs to help patients gain control of the
situation and their emotions
Facilitating empowerment is particularly important,
because the individual with an HIV infection often
experience loss, including an overwhelming feeling
of loss of control
 Empowerment
is facilitated through education and
honest discussions about the patient’s health status
Acute Interventions (cont)

Patient should be taught to recognize clinical
manifestations that may indicate progression of the
disease
 This

will ensure that prompt medical care is initiated
Early manifestations that need to be reported:
 Unexplained
weight loss, night sweats, diarrhea,
persistent fever, swollen lymph nodes, oral hairy
leukoplakia (OHL), oral candidiasis (thrush), persistent
vaginal yeast infections
Acute Interventions (cont)

Patients should also report:
 Unusual
headaches, changes in vision, nausea and
vomiting, numbness and tingling in the extremities

Patient should be given as much information as
needed to make health care decisions
 Decisions
will dictate the appropriate medical and
nursing interventions
Acute Interventions (cont)


Nursing interventions become more complicated as
the patient’s immune system deteriorates and new
problems arise to compound existing difficulties
Nursing focus should be on quality-of-life issues and
symptom management, rather than on issues
regarding a cure
Acute Interventions (cont)

When opportunistic diseases develop, symptomatic
nursing interventions, education, and emotional support
are necessary

Example: acute case of PCP


Interventions include monitoring the respiratory status,
administering medications and oxygen, positioning the patient to
facilitate breathing, managing anxiety, promoting nutritional
support, and helping the patient conserve energy to decrease
oxygen demand
Because the potential for death is associated with
advanced HIV disease, emotional support for the
patient, caregiver, or significant other is particularly
important
Nursing Care Plan Box
Pg 2044 to 2045
Nursing Diagnosis #1
Risk for caregiver role strain, r/t advancing disease in
care receiver, lack of caregiver
 Patient Goals/Expected Outcomes:
 Caregiver
will use available community and personal
resources
 Caregiver will have the ability to complete necessary
care giving tasks
 Effective support for caregiver
Nursing Diagnosis #1 (cont)

Nursing Intervention:
 Assess
needs and capabilities of patient and caregiver
 Assess factors that contribute to caregiver strain
(unrealistic expectations, poor insight, inability to use
resources, unsatisfactory relationship with care receiver,
insufficient financial and psychosocial resources)
 Develop supportive and trusting relationship with
caregiver
Nursing Diagnosis #1 (cont)

Nursing Interventions (cont):
 Enlist
help of other family members or friends to assist
 Teach caregiver to perform care activities in a safe,
efficient, and energy-conserving manner
 Teach stress-reduction techniques
 Encourage caregiver to attend to own personal and
health needs
Nursing Diagnosis #1

Evaluation:
 The
caregiver:
 Provides
safe, supportive care to the HIV-infected patient
 Acknowledges need for personal support and accesses
resources in family and community
 Shares frustrations about difficulty of care for significant
other
 Receives assistance from family members and/or
professional caregivers
Nursing Diagnosis #2
Imbalanced nutrition: less than body requirements, r/t
chronic infections and/or malabsorption,
nausea/vomiting/diarrhea, fatigue, or side effects
of medications as e/b 10% or greater loss of ideal
body mass
 Patient Goals/Expected Outcomes:
 Patient’s
weight will remain stable
 Patient’s nutritional intake will exceed metabolic needs
 Patient will regain lost weight
Nursing Diagnosis #2 (cont)

Nursing Intervention:
 Assist
with diagnosis of underlying opportunistic
infections
 Assess patient’s knowledge of optimal nutritional intake
 Increase protein, calorie, and fat intake
 Offer nutritional supplements (Carnation Instant
Breakfast, Boost, Sustacal, etc.)
Nursing Diagnosis #2 (cont)

Nursing Intervention (cont):
 Schedule
procedures that are painful, stressful, or
nauseating so they do not interfere with mealtimes
 Eat several small meals throughout day as opposed to
three larger meals
 Provide referrals to dietitians, social workers, and case
managers
 Weigh patient daily
Nursing Diagnosis #2 (cont)

Evaluation:
 Weight
will remain stable or increase
 Patient reports increased energy level
 Patient able to complete ADLs
 Patient experiences increase in lean muscle mass
Acute Interventions
continuation
Acute Interventions

Nursing interventions for diarrhea, which is a long-term
problem for HIV-infected people include:
Recommending dietary interventions
 Encouraging adequate fluid intake to prevent dehydration
 Instructing the patient about skin care
 Managing excoriation around the perianal area
 In some cases, nurse must administer antidiarrheals to help
control and prevent further complications
 Recommend use of incontinence products to prevent soiling
of the clothes and bed linens

Table 56-11: Nutritional
Management for HIV Infection
Pg 2045
Dietary Recommendation

Diarrhea
 Lactose-free,
low-fat, low-fiber, and high-potassium
foods

Constipation
 High-fiber

Nausea and Vomiting
 Low-fat

foods
foods
Candidiasis
 Soft
or pureed foods
Dietary Recommendation (cont)

Fever
 High-calorie,

Altered Taste
 Diet

as tolerated
Anemia
 High-iron

high-protein foods
foods
Fatigue
 High-calorie
foods
Intervention

Diarrhea
 Avoid
dairy products, red meat, margarine, butter,
eggs, dried beans, peas, raw fruits and vegetables.
Cooked or canned fruits and vegetables will provide
needed vitamins. Eat potassium-rich foods such as
bananas and apricot nectar. Discontinue foods,
nutritional supplements, and medications that may make
diarrhea worse (Ensure, antacids, stool softeners). Avoid
gas-producing foods. Serve warm, not hot foods. Plan
small, frequent meals. Drink plenty of fluids between
meals.
Intervention (cont)

Constipation


Eat fruits and vegetables (beans, peas), cereal, and whole
wheat breads. Gradually increase fiber. Drink plenty of
fluids. Exercise.
Nausea and Vomiting

Avoid dairy products and red meat. Plan small, frequent
meals. Prepare nonodorous foods. Eat dry, salty foods.
Serve food cold or at room temperature. Drink liquids
between meals. Avoid gas-producing, greasy, spicy foods.
Eat slowly in a relaxed atmosphere. Rest after meals with
head elevated. Take antiemetics 30 minutes before meals.
Intervention (cont)

Candidiasis
 Serve
moist foods. Drink plenty of fluids. Avoid acidic
and spicy foods. Use straw and tilt head back and
forth when drinking. To decrease discomfort, eat soft
foods, such as puddings and yogurt.

Fever
 Use
nutritional supplements. Increase fluid intake.
Intervention (cont)

Altered Taste
 Try
herbs and spices. Marinate meat, poultry, and fish.
Serve food cold or at room temperature. Drink plenty
of fluids. Add salt or sugar. Introduce alternative
protein sources.

Anemia
 Eat
organ meats and raisins. Drink orange juice when
taking iron supplements to facilitate absorption.
Intervention (cont)

Fatigue
 Cook
in large quantities and freeze in meal-size
packets. Use microwave and convenience foods. Use
easy-to-fix snack foods. Use social support system to
assist with meal planning and preparation. Access inhome homemaker services. Access community Meals on
Wheels programs.
Acute Intervention
Wasting and Lipodystrophy Syndromes
Wasting and Lipodystrophy Syndromes



AIDS wasting has been a common clinical manifestation
of HIV disease since early in the epidemic
Wasting is due to disturbances in metabolism, which
interferes with the effective use of nutrients, resulting in
the loss of lean (muscle) body mass
Wasting is characterized by depletion of lean body
mass, without reduction of body fat

This loss of lean body mass is a primary cause of functional
decline in wasting
Wasting and Lipodystrophy Syndromes
(cont)


Loss of lean body mass increases the risk for opportunistic
infections, reduces quality of life, and reduces survival
Causes of Wasting






Most likely multifactorial
Food intake may be inadequate because of mechanical
difficulties
Loss of appetite
Psychological factors such as depression and anxiety
Decreased absorption in intestines due to infections and a
damaged mucosal barrier
Some patients just stops eating to decrease the number of bowel
movements per day
Wasting and Lipodystrophy Syndromes
(cont)

Wasting causes disturbances in self-concept and self
image
 Useful
interventions for these disturbances
 Creating
an atmosphere of acceptance and reassurance
 Encouraging a focus on past accomplishments and personal
strengths
 Facilitating the use of positive affirmation

Decreased levels of testosterone have been
reported in 35 to 50% of HIV-infected men
Wasting and Lipodystrophy
Syndromes (cont)

Testosterone has two distinct biologic properties:
Virilizing activity (androgenic effect)
 Protein building (anabolic effect)


A deficiency of testosterone may cause a loss of body
cell mass, contributing to HIV wasting


Women


Due to testosterone being an anabolic hormone
Lose a significant amount of body fat, but body cell mass is
not significantly decreased
Men

Tend to lose a significant amount of lean body mass (skinny
arms and legs) with the preservation of fat
Wasting and Lipodystrophy Syndromes
(cont)

With the advances in HIV treatment and
opportunistic infection prophylaxis, serious
malnutrition is less evident
 However,
nutrition does not return to normal after antiHIV treatment begins, and a syndrome of increased
truncal obesity (abdomen), and metabolic
abnormalities are developing
Wasting and Lipodystrophy Syndromes
(cont)

Characteristic alterations in body composition of
both men and women include:
 Development
of truncal (visceral, abdominal) obesity
 Subcutaneous fat loss on the extremities and face
 Also
called lipoatrophy
 Hyperlipidemia
 Insulin
resistance
Wasting and Lipodystrophy Syndromes
(cont)

3 hypotheses to explain the mentioned changes:
 Changes
are a side effect of either protease inhibitors
or nucleoside reverse transcriptase inhibitors (AZT, d4T)
 Changes may represent an altered stress response, with
mild chronic hypercortisolism in some patients
 Changes are part of long-term HIV disease and have
only been noticed in recent years because of increased
survival time
Wasting and Lipodystrophy Syndromes
(cont)

The management of wasting and lipodystrophy is
difficult



Requires multiple interventions
Nurse can assist by assessing for and documenting the
presence of diminished appetite and weight
Nursing interventions include:

Encouraging nutritional supplementation; increasing protein
intake; providing enteral supplements (through nasogastric
or gastric tubes if necessary); and, assisting with total
parenteral nutrition (TPN)
Wasting and Lipodystrophy Syndromes
(cont)

May use appetite stimulants such as Megestrol
(Megace) or Dronabinol (Marinol)



These medications tend to increase body fat and not lean
muscle mass unfortunately
Testosterone (anabolic steroid) can be administer PO,
IM, or transdermally to increase lean body mass and
weight
Effect of testosterone can be enhanced by the addition
of a low-weight resistance-training program
(weightlifting) because it maintains muscle tone and
improves appetite
Wasting and Lipodystrophy Syndromes
(cont)



Nutritional counseling is vital to ensure that individuals
with HIV disease maintain a well balanced diet and
include supplements if necessary
Teaching about food safety is of paramount concern
because enteric infections (cryptosporidiosis,
microsporidiosis, and amebas) in HIV diseases are often
not treatable or are relapsing
In some cases, enteral and parenteral feeding becomes
necessary
Wasting and Lipodystrophy Syndromes
(cont)


Management of elevated triglycerides and lipids
(cholesterol) is becoming common in HIV disease
These elevations can lead to:
Cardiac and vascular diseases
 Some cases, diabetes



Lipid-lowering agents such as the statins may be
effective in treating this complication
A program of diet control, exercise, and medications
can safely lower lipids and reduce the chances of a
cardiovascular event occurring
Wasting and Lipodystrophy Syndromes
(cont)

Insulin resistance and/or diabetes sometimes
responds to oral hypoglycemic agents
 Some
cases, anti-HIV therapy needs to be changed to a
protease-sparing combination

Managing diet, stopping smoking, weight loss, and
exercise can help control the elevated blood sugars
that can occur with the use of anti-HIV medication
Wasting and Lipodystrophy Syndromes
(cont)

Metabolic needs of the HIV-infected individual increase
by as much as 40%



Results in the need for a higher energy expenditure than is
provided by the number of calories taken in by the patient
Malnutrition, weight loss, and generalized wasting are
common problems in patients with HIV disease
Estimated that as many as 70 to 90% of patients with
HIV disease will experience wasting
Wasting and Lipodystrophy Syndromes
(cont)


When a patient’s weight is reduced to 60% of his or her
ideal body weight, death can occur, regardless of the
underlying condition
Malnutrition may influence morbidity and mortality in
several ways


Malnutrition contributes to wasting, and wasting hastens the
negative immune consequences of HIV infection. HIV wasting
contributes to slower recovery from infection, impaired wound
healing, increased risk of secondary infection and decreased
cardiac and respiratory function, and can lead to death
Although typically seen in later stages HIV disease,
malnutrition and wasting can occur in the early stages of HIV
infection
Acute Intervention
Neurological Complications
Neurological Complications: AIDS
Dementia


HIV-associated cognitive motor complex
(previously known as AIDS dementia) is the term
preferred by the WHO and the American Academy
of Neurology (AAN) to describe a common CNS
complication of HIV disease
Frequency:
 Being
anywhere between 20 and 33% of all adults
and up to 50% of children with end-stage disease
Neurological Complications: AIDS
Dementia (cont)

This condition is a complex combination of signs and
symptoms:



Dementia; impaired motor function; and, at times,
characteristic behavioral changes that resemble an injury
similar to a stroke or head trauma
Generally does not cause alterations in the level of
consciousness or psychiatric disturbances
Usually described as a triad of cognitive, motor, and
behavioral dysfunction that slowly progresses over a
period of weeks to months
Neurological Complications: AIDS
Dementia (cont)

Cognitive changes:
 Primarily
involve a mental slowing and inattention.
Patients typically lose their train of thought and
complain of a slowness of thinking.

Motor dysfunction:
 Develops
after those of cognitive impairment. Includes
poor balance and coordination (falling and tripping,
dropping things); slower hand activities (writing,
eating); and ultimately, leg weakness that can limit
ambulation
Neurological Complications: AIDS
Dementia (cont)


Diagnosis of this type of dementia can be made by
conducting a simple physical examination, neurological
testing, MRI/CT exams, and CSF analysis
Nursing interventions for the treatment of neurocognitive
dysfunction:

Administration of anti-HIV medications and psychotropic
medications (cautiously); supervise patient (this includes a home
safety assessment); ensure that orientation cues such as clocks and
calendars are present, hallways and living areas are brightly lit,
walkways are clear of electrical cords or throw rugs, and
potentially dangerous objects (knives, poisons) are safely stored
away
Neurological Complications: AIDS
Dementia (cont)



Caring for patients with dementia is a collaborative
effort between health care provider and family
It is advisable to seek advise from a social worker,
home health care department, and a psychologist in
developing a plan to care for an impaired
individual
AIDS-dementia complex (ADC), caused by HIV
infection in the brain, is a common neurological
disorder associated with HIV
Neurological Complications: AIDS
Dementia (cont)


Dementia symptoms are sometimes reversible if a
treatable cause can be diagnosed
Treatable causes include:
 Dehydration
 Depression
 Medication

toxicity or side effects
Clinical manifestations
 Cognitive,
behavioral, and motor abnormalities
Neurological Complications: AIDS
Dementia (cont)

Symptoms:
 Decreased
ability to concentrate, apathy, depression,
social withdrawal, personality changes, confusion,
hallucinations, altered levels of consciousness, slowed
response rates


ADC can lead to coma
Nursing interventions are focused on patient safety
and caregiver support
Neurological Complications: Peripheral
Neuropathy




Diseases that affect the peripheral nervous system
They can affect sensory, motor, or autonomic nerves
Cause of neuropathies can be related to HIV disease
itself, or more frequently, the side effects of many antiHIV medications
Symptoms:

Numbness, localized tingling, hypesthesia (diminished
sensitivity to stimulation) or anesthesia, loss of vibration and
position sense (proprioception), and decreased or increased
sensitivity to pain
Neurological Complications: Peripheral
Neuropathy (cont)



Most cases, patient complains of numbness in the
fingers, hands and feet, and pain on walking
May also experience autonomic neuropathy
Symptoms such as mild positional hypotension to
cardiovascular collapse, as well as chronic diarrhea,
are suggestive of autonomic neuropathy
Neurological Complications:
Management of OIs


With the advent of effective antiretroviral therapy and
better understanding of OI prophylaxis, the frequency
of OIs has decreased dramatically
OIs still occur in the severely immunocompromised
patients


Nurses must be familiar with the recognition, treatment, and
prophylaxis of these diseases
OIs typically seen in:

Those who are not adherent to their antiretroviral therapy,
not adherent to OI prophylactic regimens, or at the end
stage of HIV and in those who do not consistently access the
health care system
Neurological Complications: Health
Promotion


Because patients with HIV disease are living longer, more
productive lives, attention to the promotion of health and
healthy behaviors is important
Patients should be encouraged to:

Eat well-balanced meals, stop or at least reduce the number of
cigarettes smoked, get adequate sleep and rest periods, use
stress-reduction modalities (biofeedback, referral for counseling),
obtain dental care regularly, keep scheduled appointments with
all health care providers, get all immunizations and keep them up
to date, female patients should regularly receive gynecologic
care, participation of the patient and significant others in
treatment decision making and arrange for home care follow-up
if indicated
Neurological Complications: Health
Promotion Considerations (p 2048)

Patient infected with HIV
Remind patients that a positive diagnosis is not an
immediate “death sentence”. Patients are living increasingly
longer after diagnosis because of medications, more
specialized care, and decreased morbidity and mortality
related to opportunistic diseases
 Stress the importance of health-promoting behaviors to
reduce the risk of comorbidity
 Encourage patients to maintain good nutritional status by
eating regular, well-balanced meals that are high in protein
and calories. Increased protein is necessary for cell and
tissue repair- especially in patients who may be
hypermetabolic

Neurological Complications: Health
Promotion Considerations (cont)
Encourage patients to limit their intake of alcoholic
beverages and avoid the use of illicit or recreational drugs
 Encourage patients to maintain an adequate sleep schedule
 Encourage patients to use stress reduction practices such as
biofeedback, massage, or progressive relaxation. Engage in
relaxing or pleasurable activities
 Encourage patients to use safer sexual practices to avoid
reinfection and exposure to other sexually transmitted
diseases

Neurological Complications: Health
Promotion Considerations (cont)
 Encourage
patients to establish an exercise regimen
that includes aerobic activity as well as low-resistance
weightlifting of possible
 Most important, support patients in setting short- and
long-term goals and assist them in achieving those
goals
Prevention of HIV Infection
HIV Testing and Counseling to Other Methods to
Reduce Risk
Prevention of HIV Infection




HIV disease is preventable
Prevention takes cooperation and efforts of public
health care providers, medical providers, nurses in all
specialties, families, communities, churches, and schools
Education on prevention is the only truly effective
“vaccine” available to curb the HIV pandemic
Nurses have a responsibility to assess each patient’s risk
for HIV infection and counsel those at risk about HIV
testing and the behaviors that put them at risk, and
about how to reduce or eliminate those risks
Prevention of HIV Infection




Today, every nurse is in an HIV nurse, implying that all
nurses are responsible for teaching methods to reduce
risk of transmission
Nurse must be able to discuss the details of behaviors
relating to sexual activity and drug use in a forthright,
relaxed, and nonjudmental manner
Nurse must be able to establish rapport before asking
sensitive, explicit questions and one must be
comfortable with the discussion of risk-reduction
techniques
Harm-reduction education is a fundamental element of
HIV prevention methods
Prevention of HIV Infection

Harm reduction does not completely eliminate the
risk of HIV transmission. Instead, it focuses on
minimizing the personal and social harms and costs
associated with these activities
HIV Testing and Counseling





This is an integral part in the prevention of HIV transmission
Patients should not be pressured to be tested
Test decision counseling is the process of assisting patients in
making decisions about when, if, and how to be tested
It is important that the nurse takes every opportunity to
provide pretest counseling
Aside from providing the testing information, the nurse must
also explain and obtain an informed consent before actually
drawing blood

This involves explaining the purpose, possible uses, limitations, and
meaning of the test results
HIV Testing and Counseling
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Consent policies are established by state laws and
vary from state to state
The most common and acceptable policy is to obtain
informed written consent before HIV antibody
testing
All states have some exceptions to informed consent,
usually relating to critical or emergency situations
However, these situations are rare and every effort
should be made to obtain consent
HIV Testing and Counseling

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When obtaining consent, explain the applicable limits
of confidentiality in the office, clinic, or hospital setting
where the patient is being tested
Patient should be told who will have access to the test
results, such as the health department or insurance
company, and what will be done with that information


Ex: contact tracing or partner notification
HIV antibody testing may take place in a physician’s
office or at a designated HIV counseling and testing
sites
HIV Testing and Counseling


Nurses must be aware of the various options for HIV
antibody testing in their state or community in order
to advise patients appropriately
HIV testing can be done in one of two ways:
confidentially or anonymously
 Confidential
testing: individuals are asked to provide
identifying information, including a name, address, and
often demographics such as sex, age, race, and
occupation
HIV Testing and Counseling
 Anonymous
testing: individuals are not asked to provide
identifying information. Records are kept through
assigned numbers, and the patient must retain this
number to obtain results

In either form of testing, pretest and posttest
counseling can be performed by the nurse
Risk Assessment and Risk Reduction

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Nurse should encourage early detection of HIV infection
Testing for HIV is important part of the public health
response to HIV disease
Risk assessment should be patient centered, a joint
process between nurse and patient
Patient should take “ownership” of the risk for HIV
infection
Patients need to be assessed for manifestations that
would be indicative of risky behaviors, such as STDs
Risk Assessment and Risk Reduction

Basic Questions
 Have
you ever had a transfusion or used clotting
factors? Was it before 1985?
 Have you ever shared needles, syringes, or other
injecting equipment with anyone?
 Have you ever had a sexual experience in which your
penis, vagina, rectum, or mouth came into contact with
another person’s penis, vagina, rectum, or mouth?
Risk Assessment and Risk Reduction


Positive response to any of the mentioned questions
will require the nurse to investigate further with the
patient
Nurse should be prepared to refer patient to
centers that provide testing and counseling services
Barriers to Prevention

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There are numerous barriers to HIV prevention, not the
least of which is a denial of risk, an attitude that “it
won’t happen to me”
Fear, misunderstanding, and the potential for social
stigma are significant barriers
Cultural and community attitudes, values, and norms can
affect the success of prevention efforts
Prevention of HIV transmission requires a commitment to
change behaviors that put one at risk
Education to alter behaviors is a long-term process
Risk Assessment and Risk Reduction



Nurses need to take every opportunity to educate
their patients on how to avoid or reduce the risk for
HIV infection
Collective efforts will have the greatest effect
Fear of alienation and discrimination are significant
additional barriers to prevention
Reducing Risks Related to Occupational
Exposure



Risk of acquiring HIV through occupational exposure is quite
rare
CDC and OSHA have instituted policies to ensure that
employees are protected from exposure to blood and other
potentially infectious fluids
Use of standard precautions and body substance isolation
have been shown not only to reduce the risk of bloodborne
pathogens, but also to reduce the risk of transmission of
other diseases between patient and health care worker


This also reduces the risk of transmission between patients
Handwashing still remains the single most effective means of
preventing the spread of infection
Reducing Risks Related to Occupational
Exposure

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

Recommendations for an occupational exposure is to
begin antiretroviral therapy with at least 2 or 3
medications
Exposed health care worker should begin therapy
within 1 to 4 hours following a high-risk exposure
For best prophylactic effect, initiation of postexposure
prophylaxis must occur within 36 hours
Completion of a 4 week course of therapy after an
occupational exposure is essential
Reducing Risks Related to Occupational
Exposure

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

Hospitals or agencies should have policies in place that
specifically address occupational HIV exposure because
instituting chemoprophylaxis needs to occur immediately
Optional HIV testing may be done at 6 wks and 3
months after exposure
Maintaining of confidentiality for both exposed health
care worker and source patient is of utmost importance
Appropriate counseling and necessary referrals should
be made for the health care worker and patient when
HIV testing is indicated
Outlook for the Future
Outlook for the Future

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As we enter the third decade of the HIV pandemic, much has been
learned about transmission and ways to prevent infection
With no cure in sight, prevention of infection through education,
prevention of mother-to-child transmission, and in some cases
postexposure prophylaxis can limit the effect this disease has on the
human population
The field of HIV and AIDS nursing changes frequently, and nurses
must constantly refresh their base of knowledge
As new therapies emerge, the nurse will be in the unique position to
educate patients and the public regarding what is undoubtedly the
most challenging infectious disease discovered in the 20th century