HIV & AIDS

1. Nursing of Adults with Medical & Surgical Conditions HIV & AIDS

2. HIV • Human Immunodeficiency Virus • Type 1 • Found throughout the world • Responsible for the majority of HIV infection cases • Usually progresses to AIDS within 10 years • Type 2 • Found primarily to West Africa and associated countries • Less virulent; does not tend to progress to AIDS as quickly as type 1

3. Transmission of HIV • HIV cannot survive very long outside of the human body • Transmitted from human to human • Blood • Semen • Cervicovaginal secretions • Breast milk

4. Transmission of HIV • Other body fluids contain HIV • No evidence they are capable of transmission • Saliva • Urine • Tears • Feces

5. Transmission of HIV • Most common modes of transmission • Sexual Transmission • Anal or vaginal intercourse • Parenteral Exposure • Contaminated injecting drug equipment and paraphernalia • Transfusion of blood and blood products • 1% of adult and adolescent AIDS cases • 5% of pediatric AIDS cases • Occupational Exposure • Perinatal (vertical) Transmission • Transmission from mother to child • may occur during pregnancy, delivery, or postpartum breastfeeding

6. Pathophysiology of HIV & AIDS • Normal immune response • Foreign antigens interact with B cells • B cells initiate antibody development • B cells and T cells initiate cellular immune response • B cells reduce virus in blood • T cells reduce virus in lymph nodes

7. Pathophysiology of HIV & AIDS • Immune Dysfunction • T- cells or CD4+lymphocytes are destroyed by HIV • HIV is then able to reproduce in the lymphatic system and eventually “spills over” into the blood • Decreases resistance to life-threatening infections • CD4 600-1200 normal • CD4 200-499 minor immune problems • CD4 below 200 severe immune problems

8. Spectrum of HIV • Initial Exposure • Primary HIV Infection • Flulike symptoms • Develop antibodies to HIV in 2 weeks to 6 months • Asymptomatic HIV Infection • HIV seropositivity (seroconversion) • positive HIV antibody test • 95% within 3 months; 99% within 6 months • Infectious; no illness

9. Spectrum of HIV • Early HIV Disease • S/S may not appear until 10-14 years after exposure • Symptomatic infection • persistent, unexplained fever • night sweats • diarrhea • weight loss • fatigue • lymphadenopathy • Advanced HIV Disease • AIDS

10. AIDS Diagnosis • HIV positive AND • CD4 (T4) count below 200 OR • One or more AIDS-Indicator Conditions • Page 672 (category C)

11. Opportunistic Infections • Table 16-6; Pages 685-687 • Most Common Opportunistic Infections • Pneumocystis Carinii Pneumonia (PCP) (Most common infection) • Symptoms • Fever • Night sweats • Productive cough • SOB • Treatment • Bactrim or Septra • Pentamidine • Steroids • Wear gown, mask, and gloves during patient care

12. Opportunistic Infections • Kaposi’s Sarcoma • Symptoms • Reddish-purple spots on the skin • overgrowth of blood vessel cells • Treatment • Radiation • Chemotherapy • Most common neoplasm found in HIV infected patients

13. Opportunistic Infections • Cytomegalovirus (CMV) • Symptoms • Retinitis • blurring of vision • spots in visual field • Colitis • diarrhea • abdomial pain • bloating • Treatment • Gancyclovir • Foscarnet

14. Opportunistic Infections • Cryptococcal Meningitis • Symptoms • Fever • Headache • Treatment • Amphotericin B • Fluconazole

15. Opportunistic Infections • Toxoplasma Encephalitis • Symptoms • Fever • Headache • seizures • mental changes • lethargy • coma • Treatment • Pyrimethamine & folic acid • Sulfadiazine • Clindamyhcin

16. Opportunistic Infections • Mycobacterium (Avium Complex & Tuberculosis) • Symptoms • Fever • Chills • Sweats • Abdominal pain • Bone pain • Fatigue • Diarrhea • Nausea • Weight loss • Treatment • Rifampin • INH • Ciprofloxacin

17. Diagnostic Studies • HIV Antibody Testing • ELISA • Detects the presence of HIV ANTIBODIES • If positive, ELISA is done a second time • Western Blot • Done if second ELISA is positive • More sensitive than ELISA • CD4 Lymphocyte Count • Normally 600-1200 • Decreases as the disease progresses • Viral Load Monitoring • Level of virus in the blood

18. Diagnostic Studies • Seropositive • All three tests are positive • ELISA x 2 and Western blot • Does NOT mean the person has AIDS • Seronegative • Not an assurance that an individual is free from HIV infection • Seroconversion may not have occurred yet • Assurance of seronegativity • All three tests are negative AND no risky behavior for previous 6 months

19. Therapeutic Management • Objectives of Treatment • Monitor HIV disease progression and immune function • Prevent development of opportunistic diseases • Initiate and monitor antiretroviral therapy • Detect and treat opportunistic diseases • Manage symptoms • Prevent complications of treatment

20. Pharmacological Management • Opportunistic Illness Prophylaxis • Table 16-7; Page 688-689 • Medications for HIV Disease • Antiretrovirals • Pages 690-691; List of medications • Combination therapy prevents development of resistance • Must be given around the clock • ie, not three times a day while awake • Usually initiated • CD4 count below 500, or • Viral load greater than 10,000

21. Nursing Interventions • Psychosocial Issues • Uncertainty • Isolation • Fear • Depression • Limited financial resources

22. Nursing Interventions • Assisting with Coping • Educate about HIV • Encourage to participate in their own care • Face life a day at a time; live each day to the fullest • Listen • Maintain sources of psychological support

23. Nursing Interventions • Reducing Anxiety • Clarification & education about HIV & AIDS • disease process • complications • treatment • Include patient and support person in planning care • Encourage talking about feelings or relaxation and meditation • Assess for suicidal ideation • Support groups

24. Nursing Interventions • Minimize Social Isolation • Social Stigma • associate with homosexuality, drug use, and sexual transmission • Sharing diagnosis with others • need to choose carefully • Support groups • patients • significant others

25. Nursing Interventions • Assisting with Grieving • Listening • Explore feelings, fears and treatment options • Significant others and family members • may experience fear, anger embarrassment, and shame

26. Nursing Interventions • Confidentiality • Diagnosis should be carefully protected • Need to know basis • not every health care worker needs to know diagnosis • Universal precautions should be used on every patient

27. Nursing Interventions • Duty to Treat • Healthcare professionals may not pick and choose their patients • Rehabilitation Act of 1973 prohibits discrimination against the handicapped and the disabled • HIV and AIDS are included

28. Nursing Interventions • Early • Good nutritional habits • 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

29. Nursing Interventions • Later • Treat opportunistic diseases • Diarrhea is often a long term problem • Low fat, low fiber, high potassium diet • adequate fluid intake • good skin care • Nutritional • Encourage nutritional supplements • Increase protein • Enteral supplements (NG tube) • TPN

30. Prevention of HIV Infection • Education • Best means of prevention • Counsel about HIV testing, behaviors that put them at risk, and how to reduce or eliminate those risks • Nurse must be able to discuss behaviors • forthright, relaxed, and non-judgemental

31. Prevention of HIV Infection • HIV Testing and Counseling • Pre- and Post-test counseling must be done • Table 16-5; page 683 • Patient should not be pressured to be tested • Informed consent must be obtained before drawing blood • consent laws are established by state laws • Confidential or anonymous testing

32. Prevention of HIV Infection • Risk assessment and Risk Reduction • Minimum risk assessment (Box 16-6; Page 698) • 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? • Positive response to any one of these questions will require further assessment and/or referral

33. Prevention of HIV Infection • Barriers to Prevention • Denial • “it won’t happen to me” • Ignoring risks • Fear, misunderstanding, and potential for social isolation • Cultural and community attitudes, values and norms • opposed to HIV and AIDS education in schools

34. Prevention of HIV Infection • Decreasing Risks Related to Sexual Transmission • Eliminate the risk of exposure to HIV through semen and cervicovaginal secretions • NURSES RESPONSIBILITY IS TO COUNSEL ON SAFE PRACTICES – NOT TO JUDGE THE CHOICE OF PRACTICES! • Abstaining from all sexual activity • Limit sexual behavior in which the mouth, penis, vagina, or rectum come into contact with blood, semen, or cervicovaginal secretions • Massage • Masturbation; mutual masturbation • Telephone sex • Use of barriers • condoms are not 100% effective, but reduce risk • Chart 16-7; Page 704 and Chart 16-8; page 706

35. Prevention of HIV Infection • Decreasing Risks Related to Drug Use • Stop the use of injectable drugs • Provide drug treatment opportunities • If drugs are going to be injected • use sterile needles and equipment • Instructions on cleaning needles and equipment • Deactivation of HIV requires a 30 second exposure to 100% bleach • fill the syringe with bleach two times; empty two times • fill the syringe with clean water two times; empty two times

36. Prevention of HIV Infection • Decreasing Risks of Occupational Exposure • Risk is very rare; only 5% of AIDS cases • Handwashing is the single most effective means of preventing the spread of infection • Universal precautions and body substance isolation • High-risk exposure treatment • Begin antiretroviral medications within 1-4 hours for at least 4 weeks • HIV testing • Baseline, six months and twelve months

37. Prevention of HIV Infection • Other Methods to Reduce Risk • HIV-Infected person should be given the following instructions • Do not give blood, donate organs or donate semen • Do not share razors, toothbrushes, or other household items that may contain blood or other body fluids • shower instead of tub bath • Avoid infecting sexual and needle-sharing partners • Do not breastfeed