Chapter 34

1. Chapter 34 HIV/AIDS

2. 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.

3. 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

4. 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 HIV-infected blood or blood products Newborns and breast-fed infants of HIV-infected mothers Injection drug users Partners having unprotected sex with those infected

5. 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%

6. 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

7. 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

8. 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

9. 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

10. 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

11. Stages of HIV Infection Third stage 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

12. 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

13. Complications

14. 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

15. 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 Antidiarrheal drugs Intravenous fluids Antimicrobial agents Teach good hand washing and personal hygiene

16. 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

17. 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

18. 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

19. Fungal Infections Pneumocystis jiroveci pneumonia 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. Health History Sexually transmitted infection history Surgical history Medication history and allergies Immunization history Family history Sexual history Needle and blood exposure history

39. Health History Tobacco/alcohol use history Illegal drug use history Pet history Occupational history Nutritional history Gynecologic history

40. Physical Examination Height, weight, vital signs Skin Head, ears, eyes, nose, and throat Lymphatic system Respiratory system Cardiovascular system Abdominal Musculoskeletal Neurologic Genitourinary Laboratory profile

41. 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

42. 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

43. Interventions Infection 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

44. 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

45. 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)

46. 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

47. 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