HIV DEFINE: It’s a retrovirus that causes immunosuppression. People with HIV are more susceptible to infections that are normally controlled through immune responses. STATISTICS: In North America HIV is most prevalent among men (MSM). However, increasing numbers of new HIV infections are occurring in women, people of color, people that live in poverty, and young adults TRANSMISSION OF HIV: HIV transmissions occurs thorough sexual intercourse with an infected partner (SEMEN and VASINAL SECRETION), exposure to HIV-infected blood or blood products (BLOOD), and perinatal transmission during preggo…at delivery…or through breastfeeding (BREAST MILK). SEXUAL TRANSMISSION: - Sexual activity involves contact with semen, vaginal secretions, and/or blood, all of which have lymphocytes that may contain HIV. - Risk of infection is greater for the partner who receives the semen, although infection can also be transmitted to the inserting partner - Sexual activities that cause trauma to the local tissues can increase the risk of transmission - Genital lesions from other sexually transmitted infections (herpes and syphilis) greatly increase the likelihood of transmission CONTACT WITH BLOOD: - Needles, syringes, straws, and other equipment may be contaminated with HIV or other blood borne organisms, and sharing this equipment can result in disease transmission - Screening of blood donors and testing donated blood for presence of HIV have approved the safety of the blood supply - The risk of infection after a needle stick exposure to HIV-infected blood is 0.3%-0.4% (3-4 out of 1000) - The risk is higher is the exposure involves blood from a patient with a high level of circulating HIV, a deep puncture wound, a needle with a hollow bore and visible blood, or a device used for venous or arterial access. - Splash exposures of blood on skin with an open lesion present some risk, but it is much lower than from a puncture wound PARINATAL TRANSMISSION: - Occurs during preggo, delivery, or breastfeeding - The risk of transmission can be reduced to less than 2% in settings in which preggo women are routinely tested for HIV infection and, if found to be infected, treated with ANTIRETROVIRAL THERAPY (ART), a combination of medication used to control and suppress HIV replication PATHO: HIV is an RNA virus CD4+ T cell is the target cell for HIV (destroys 1 billion every day) (decrease in CD4+T impairs immune function) CLINICAL MANIFESTATIONS: It is important to remember that (1) disease progression is highly individualized, (2) treatment can significantly alter this pattern, and (3) an individual’s prognosis is unpredictable ACUTE INFECTION (most infectious): 2-4 weeks after someone becomes newly infected with HIV (flu like symptoms). During this time a high VIRAL LOAD is noted, and CD4+T cell counts decrease temporarily but quickly returns to baseline or near baseline. - Fever - Swollen lymph nodes - Sore throat - Headache - Malaise - Nausea - Muscle and joint pain - Diarrhea - Diffuse rash - NUERO complications: aseptic meningitis, peripheral neuropathy, facial palsy, or Guillain-Barre syndrome ASMPTOMATIC INFECTION: - Left untreated, a diagnosis of AIDS is made about 10 years after initial HIV infection - Symptoms are generally absent or vague - High risk behaviors may continue SYMPTOMATIC INFECTION: The CD4+T cell count declines closer to 200 and the viral load increases, HIV advances to a more active stage - persistent fever - Night sweats - Chronic diarrhea - Headaches - Severe fatigue - Oropharyngeal candidiasis (thrush) (MOST COMMON) - Shingles - Persistent vaginal candida infections - Oral or genital herpes - Bacterial infections - Kaposi sarcoma (KS) - Oral hairy leukoplakia AIDS: a diagnosis of AIDS is made when an HIV-infected patient meets criteria established by CDC - AIDS is diagnosed when an individual with and HIV develops at least one of the following conditions: - - 1. CD4+T cell count drops below 200 2. One of the following opportunistic infections: fungal, viral, protozoal, bacterial 3. One of the following opportunistic cancers: invasive cervical cancer, KS, Burkitt’s lymphoma, or primary lymphoma of the brain 4. Wasting syndrome wasting is defined as a loss of 10% or more of ideal body mass Opportunistic diseases generally do not occur in the presence of a functioning immune system. Organisms that do not cause diseases in functioning immune systems can cause life threatening diseases during this stage. Advances in HIV treatment have decreased the occurrence of opportunistic diseases DIAGNOSTIC STUDIES: HIV screening test can detect HIV specific antibodies or antigens - may take several weeks to detect antibodies (window period) - using blood or saliva - combination antibodies and antigen test (4th generation test) can detect HIV earlier. Decreases the window period to within 3 weeks following infection 2 lab tests are used for monitoring the progression of HIV - CD4+T provides a marker of immune function. As HIV progresses, the number of cells decreases (normal range 800-1200) - Viral load is reported as real numbers (1260 copies/uL). The goal is to suppress the viral load to the lowest level possible, which is below the level of detection a commercial assay. Abnormal blood test is common - Decreased WBCs - Low platelet counts, may be cause by HIV, antiplatelet antibodies, or drug therapy - ANEMIA is an adverse effect of ART - Altered liver function INTERPROFESSIONAL CARE: The care focuses on 1. Monitoring HIV disease progression and immune function 2. Initiating and monitoring ART 3. Preventing the development of opportunistic diseases 4. Detecting and treating opportunistic diseases 5. Managing symptoms 6. Preventing or decreasing complications of treatment 7. Preventing further transmission of HIV INITIAL PATIENT VISIT: - A complete history and physical examination (immunization, psychosocial, and dietary) - Assessment - Laboratory test - Complete the case reports required by the state health department Initiate teaching about spectrum of HIV, treatment, preventing transmission, improving health, and family planning - Develop a plan of care DRUG THERAPY FOR HIV: HIV cannot be cured but ART can delay disease progression by decreasing viral replication - THE GOAL: 1. Decrease viral load 2. Maintain/increase CD4+T counts 3. Prevent HIV-related symptoms and opportunistic diseases 4. Delay disease progression 5. Prevent HIV transmission - MAJOR PROBLEM: resistance can develop rapidly when they are used alone (monotherapy) or taken on inadequate doses. Combination of 3-4 drugs should be used - SAFETY ALERT: o Many ARTs have interactions with other commonly used drugs and herbal therapies (St. John’s wort) o Significant interactions with ARTs also occur with OTC drugs, including antacids, PPI, and supplements PREVENTING TRANSMISSION OF HIV: - Pre-exposure prophylaxis (PrEP): Comprehensive strategy to reduce risk of sexually acquired infection in adults at high risk - Condoms - Risk reduction counseling - Regular HIV testing NURSING MANAGMENT: NURSING ASSESMENT Do not make assumptions about who may be at risk/Candid conversation is important for effective management of HIV ASK AT-RISK PATIENTS: - Received blood transfusion or clotting factors before 1985? - Shared needles with another person? - Had a sexual experience with another person? - Had a sexually transmitted infection? ASSESMENT FOR HIV PATIENTS: - Past health history - Medications - Functional health patterns - Presence of symptoms using a systems review PLANNING Nursing interventions can help the patient to (GOALS) 1. Compliance with drug regimens 2. Adopting a healthy lifestyle 3. Protect others from HIV 4. Maintain or develop healthy relationships 5. Maintain activities and productivity 6. Spiritual well-being in regard to life and death 7. Come to terms with issues related to disease, disability, and death 8. Cope with symptoms caused by HIV and its treatments NURSING IMPLEMENTATION Primary prevention and health promotion are the most effective health care strategies HEALTH PROMOTION - Even with the recent success in HIV treatment, prevention remains a critical component to control the epidemic - Health promotion encourages early detection of the disease so that, if primary prevention has failed, early intervention can be initiated PREVENTION OF HIV - Decreasing the risk related to sexual intercourse: abstaining from all sexual activity is an effective way to accomplish this goal but there are safe options for those who cannot or will not - Decreasing risks related to drug use: sharing equipment or having unsafe sexual experiences while under the influences - Decreasing the risk for perinatal transmission: family planning, prevent HIV in women (best way), and appropriately medicate HIV-infected pregnant women - Decreasing risk at work: if exposure to HIV infected fluids occur, postexposure prophylaxis (PEP) with combination ART can decrease the risk to affection PREVENTION AND EARLY DETECTION OF HIV: Increase safer sexual practices, including condom use Decrease equipment sharing among IV drug users Increase clinician skills to assess for risk factor for HIV infection, recommend HIV testing, and provide counseling for behavior change Make voluntary HIV testing a routine part of health care Increase access to new HIV testing technology, especially rapid testing Increase access to HIV testing facilities in traditional health care setting, as well as in alternative sites such as drug and alcohol treatment facilities Increase risk assessment and individualized behavior change messages to people with HIV to prevent new infections Decrease perinatal HIV infection by offering voluntary HIV testing as a part of routine prenatal care Provide counseling and appropriate HIV therapy to those that are affected ACUTE INTERVENTION The nursing assessment in HIV disease should focus on early detection of symptoms, opportunistic diseases, and psychosocial problems INITIAL RESPONSE TO DIAGNOSIS: - Anxiety, panic, fear, depression, denial, hopelessness, anger, and guilt Stigma can lead to discrimination and result in social isolation, dependence, frustration, low self-image, loss of control, and economic pressures - This, in turn, could lead to further involvement in risky behaviors ANTIRETROVIRAL THERAPY: An individualized approach is best - ART can significantly slow HIV progression, but …. o its complex and has side effects o does not work for everyone o is expensive - When to start therapy: o Patient readiness is most important concern o To avoid burnout and non-adherence…. treatment is recommended when immune suppression is great - Adherence to drug regimens is critical to prevent o Disease progression o Opportunistic disease o Viral drug resistance DISEASE AND DRUG SIDE EFFECTS Physical problems: - Anxiety, fear, depression - Diarrhea - Peripheral neuropathy - Pain, N/V, fatigue Metabolic disorders: - Lipodystrophy - Hyperlipidemia - Insulin resistance - Hyperglycemia - bone disease - Lactic acidosis - Renal disease - Cardiovascular disease END OF LIFE CARE Focus of nursing intervention - Patent comfort - Promoting acceptance of finite nature of life - Helping significant others deal with loss - Safe environment GERONTOLOGIC CONSIDERATIONS People 60 and older are increasingly being infected Death rate from opportunistic infections reduced Multiple medications that could interact with ART
