Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome

1. Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome By: Rhian Smith and Whitney Mosher

2. History • 1970s: HIV epidemic became more apparent in the United States and Canada • 1981: Public health officials recognized the presence of new disease now known AIDS • 1985: Routes of transmission were determined and antibody tests were developed • 1987: Drug therapy became available • 1994 to current: New tests to assess viral load have been developed, along with combination drug therapy, and treatment to decrease transmission from mother to baby

3. Statistics • Over 1 million people in North America were infected with HIV in 2004 • Increased rates have been noted in: women, people of color, those who live in poverty, and adolescents • Since the beginning of pandemic, more than 20 million people have died • The most common mode of transmission is unprotected sex with an HIV-infected partner

4. Transmission-General • Transmission can occur through multiple routes: • Sexual intercourse with an infected person • Exposure to infected blood or blood products • Perinatal transmission (at time of delivery or through breast feeding) • Transmission of the disease to others can occur only a few days after becoming infected • Ability to transmit disease is lifelong • Factors affecting transmission: • Duration of contact • Volume of fluid transmitted • Concentration of organism • Immune status of host

5. Transmission-General Continued • Large viral load is found during the first six months, and during the late stages of the disease • Casual transmission is not possible. • HIV cannot be transmitted through: • Tears • Saliva • Urine • Emesis • Sputum • Feces • Sweat • Health care workers are at low risk for developing HIV, even after needle stick injury

6. Sexual Transmission • Most common mode is unprotected sexual contact with an infected partner • Unprotected anal intercourse is the highest risk sexual activity • Risk for infection is greatest for the partner who receives the semen • They receive a high volume of fluid

7. Blood and Blood Product Transmission • Exposure comes from use of drug equipment, which exposes a person to blood • Infection transmission through blood transfusions is low due to current testing standards • Work related transmission is most common through puncture wounds

8. Perinatal Transmission • Most common infection route for children • ¼ infants born to untreated HIV mothers will have HIV transmitted to them

9. Pathophysiology • HIV virus is a ribonucleic acid • The virus must enter a living cell to be allowed to replicate • Once replication process occurs in cell, the virus becomes a permanent part of the genetic structure • Replication occurs at a fast pace, and a continual rate • Rapid replication can cause errors which leads to mutations of the virus • HIV attacks cells with CD4 receptors • CD4 cells are key player in ability of the immune system to function properly

10. Pathophysiology Continued • Normal life span for a CD4 cell averages 100 days • Normal life span for an HIV infected CD4 cell averages 2 days • HIV ability to destroy cells eventually exceeds bone marrow and thymus ability to replace cells • Immune problems develop when CD4 count drops below 500 • Severe immune problems develop when CD4 counts drop below 200

11. Case Study • Deneisha Richards, a 20 year old African American, heterosexual female, presents at the local, free health clinic with flu like symptoms. Further evaluation of symptoms reveal: fever, swollen lymph glands, sore throat, and muscle pain. Deneisha stated, “I feel like I have the flu” • Further assessments were completed

12. Health History • Full health history was taken, and was further noted when sexual history was discussed • Deneisha reported sexual activity beginning at age 18, which included protected and unprotected vaginal and anal intercourse with three different partners • Deneisha reports unprotected anal intercourse 3 months prior with a new partner in which his sexual history is unknown • Many health care provides mistake early HIV symptoms for the flu, but due to the sexually history, HIV testing was ordered

13. Pertinent Health History Questions Related to HIV • The nurse asks Deneisha 4 basic questions to assess for HIV infection • Have you ever had a blood transfusion or used clotting factors? If so, was it before 1985? • Have you shared drug user equipment with another person? • 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? • Have you ever had a sexually transmitted disease? • A positive response to any of these questions requires further evaluation

14. Diagnostic Tests • The health care provider orders an ELISA test • After a period of time, the health care provider tells Deneisha her positive results from the ELISA test • A follow up order is provided for the Western Blot to confirm HIV diagnosis • If she had come in earlier, rapid testing would have been performed.

15. Video-Rapid Testing http://www.youtube.com/watch?v=IKdw7tsDQic

16. Physical Exam Findings • After completing a physical exam on Deneisha, the following was discovered: • Flu-like symptoms included: • *Fever • *Swollen lymph glands • *Sore throat • Headache • Malaise • Nausea • *Muscle and joint pain • Diarrhea • Diffuse rash • Anorexia • Weight loss • Night sweats • The starred items were Deneisha’s symptoms

17. Additional Diagnostic Tests Completed • Monitoring of CD4 lymphocyte count • Complete blood count (CBC) • Viral load • The lower the viral load, the less active the disease • Skin test anergy • Common antigen is injected under the skin, with the purpose being to see if a patient’s immune system is reacting properly to antigens in general

18. Normal Lab Values • CD4 count: 800-1200 ul • CBC • White Blood Cells: 4000-11,000 cells/mm3 • Neutrophils: 1800-7800 cells/mm3 • Platelets: 150,000-400,000 cells/mm3 • Viral Load: Undectable • Skin Test Anergy: Nonreactive

19. Pertinent Lab Values • CD4 count: 600 cells/ul • Viral load: undetectable at this time • Does not indicate the virus is not present, just undetectable by a test at this time • Skin test Anergy: nonreactive • This proves the immune system is functioning adequately • CBC: • White blood cells: 3,500 cell/mm3 • Neutrophil count: 1,500 cells/mm3 • Platelets: 130,000 cells/mm3

20. A follow up appointment was made to discuss management of disease process with Deneisha • Upon arrival to the appointment, Deneisha was crying hysterically • She stated, “I’m so afraid of dying”

21. Nursing Diagnosis #1 • Acute pain related to acute infection of HIV as evidence by previous client statement of muscle and joint pain, along with a headache • Goal: Client will state proper management of pain • Interventions: • Assess pain in client by using self-report through numerical scale (0= no pain, 10= extreme pain) • Administer pain medication PRN or around the clock per physician order • Teach and implement non-pharmacological interventions, like deep breathing ad imagery, to help decrease pain • Ask client to describe appetite, bowel elimination, and patterns of sleep related to medication administration

22. Nursing Diagnosis #2 • Fear related to impending premature death as evidence by client stating, “I’m so afraid of dying” • Goal: Client will identify, verbalize, and demonstrate coping behaviors that reduce fear • Interventions: • Stay with client when they express fear • Provide verbal and non-verbal re-assurance to client • Explore coping skills previously used by client to deal with fear, and reinforce these skills and explore other outlets • Teach of appropriate community resources involving fear and HIV infection

23. Home Care Instructions • Drug Regimes: • Antiretroviral medications are not started at this time, because great immune suppression has not occurred as noted in previous lab values • Continual monitoring of lab values will determine when antiretroviral therapy will initiate

24. Home Care Instructions Continued • Promotion of a healthy lifestyle: • Nutritional support to help maintain an appropriate vitamin and mineral balance • Elimination of tobacco and alcohol use • Keep immunizations up to date • Adequate rest, exercise, and stress reduction • Avoid exposure to new infectious agents • Teach patients to recognize symptoms of disease progression

25. Home Care Instructions Continued • Sex Education: • Tell client to have protected sex using a male condom • “Male condoms are more effective against sexually transmitted infections such as gonorrhea, Chlamydia, Trichomoniasis, and HIV” (Healthy Sexuality, 2006) • Notify partners of HIV infection prior to any sexual encounter • This protects future partners from HIV infection! • Patient should have as much information as needed to guide care at home!!

26. Routine Visit • Deneisha returns for routine visits, in which physical assessments are completed, lab values are monitored, and education is reinforced • During this visits, Deneisha is started on 2 antiretroviral medications, because her labs reveal a drop in CD4 levels, and an increase in viral load

27. Antiretroviral Therapy • The goal of antiretroviral medications include: decrease opportunistic infections, delay the development of HIV-related symptoms, decrease viral load, and maintain and raise CD4 counts • Multiple medications are started, because HIV can quickly become resistant to one medication, thus defeating the purpose • Combination therapy can be very expensive, so many patients are unable to maintain the financial expense

28. Antiretroviral Therapy Continued • Nonnucleoside Reverse Transcription Inhibitors: Works by blocking the process for HIV RNA to convert into HIV DNA • Nucleoside Reverse Transcriptase Inhibitors: Works by inserting DNA into developing strand thus causing the incomplete formation of HIV DNA • Nucleotide Reverse Transcriptase Inhibitors: Works by inhibiting reverse transcription • Protease Inhibitors: Works by preventing HIV proteins formation thus preventing formation of HIV DNA • Entry Inhibitors: Works by preventing binding of HIV onto cells

30. AIDS Diagnosis • Deneisha continues her routine visits for the next 8 years, and one routine visit presents progression of the disease • Labs are drawn, and reveal that Deneisha’s CD4 count has dropped to 150 (normal 800-1200 ul), and the viral load has increased dramatically • For AIDS diagnosis regarding CD4 Count: needs to be below 200 ul

31. AIDS Diagnosis Continued • Physical assessment findings reveal: • A persistent high fever • Chronic diarrhea • Extreme weight loss • Chronic fatigue that is interrupting normal ADLs • Further assessment reveals the following: • Candidiasis (Thrush) • Kaposi Sarcoma • Pneumocystis Carinii Pneumonia

32. Video-Opportunistic Infections http://www.youtube.com/watch?v=68I7JlVhuhY

33. Candidiasis • Whiteish lesions in the mouth and on the tongue • Not common among adults unless HIV positive • Treatment: Nystatin mouth wash

34. Kaposi Sarcoma • Purplish red lesions of the internal organs and skin • Can vary in size and appear in a variety of shades • Treatment: Cryotherapy for skin lesions

35. Pneumocystis Carinii Pneumonia • Nonproductive cough, shortness of breath, fever, fatigue • Treatment: Bactrim, increase in fluids, encourage movement

36. Nursing Diagnosis #1 • Impaired oral mucous membrane related to immunosupression as evidence by whiteish lesions on the mouth and tongue • Goal: Client will demonstrate ways to maintain an intact, moist, mucous membrane • Interventions: • Teach client to inspect oral cavity and monitor for signs of infection • Teach client how to use Nystatin mouthwash • Instruct client in ways to soothe oral cavity (use popsicles, cold beverages)

37. Nursing Diagnosis #2 • Impaired skin integrity related to immunosupression as evidence by purplish red lesions on skin surface • Goal: Client will describe measures to protect and care for lesions • Interventions: • Educate client on importance of adequate nutrition • Teach client signs and symptoms of infection • Monitor client’s continent status and minimize moisture exposure

38. Nursing Diagnosis #3 • Fatigue related to progression of immunocompromised status as evidence by client statement of decreased ability to accomplish ADLs • Goal: Client will utilize strategies to promote and relieve fatigue • Interventions: • Teach client the importance of prioritizing activities • Teach client strategies for energy conservation, like sitting instead of standing • Teach the importance of following a healthy lifestyle with adequate nutrition

39. End of Life Care/Evaluation • Deneisha is sent home with Hospice care to provide adequate comfort and care during the end stages of her life • Focus is placed on physical and emotional care to provide holistic care for Deneisha • Deneisha died quietly at her home

40. Video on AIDS Awareness http://www.youtube.com/watch?v=COfdnY27LP4

41. Famous People who had HIV/AIDS • Freddie Mercury (Lead Singer of Queen) • Magic Johnson (Basketball Player) • Liberace (Pianist) • Pedro Zamora (MTV’s Real World Cast Member)

42. More Famous People with HIV/AIDS • Tom McBride (Marlboro Man) • Anthony Perkins (Norman Bates in Psycho) • Rock Hudson (Actor) • Robert Reed (Mike Brady on The Brady Bunch)

43. References • Ackley, B., & Ladwig, G. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis, MO: Mosby. • Avert (n.d.) Introduction to hiv and aids drug treatment. Retrieved from http://www.avert.org/treatment • Blonna, R., & Levitan, J. (2006). Healthy Sexuality. Belmont, CA: Wadsworth. • HIV InfoSource (2009) Understanding your hiv test results. Retrieved from http://www.hivinfosource.org • Lewis, S., Heitkemper, M., & Dirksen, S. (2007). Medical surgical nursing: Assessment and management of clinical problems (7th ed. Volume II). St. Louis, MO: Mosby. • Mayo Clinic (2010) HIV/AIDS. Retrieved from http://www.mayoclinic.com/health/hiv-aids • Medline Plus (2010) Early symptomatic hiv infection. Retrieved from http://www.nlm.nih.gov • Silvestri, L.A. (2008). Saunders comprehensive review for the nclex-rn examination (4thed.). St. Louis, MO: Saunders. • The New York Times (2010) Skin test anergy. Retrieved from http://www.health.nytimes.com/health • World Health Organization (2010) HIV/AIDS. Retrieved from http://www.who.int • Images Retrieved from Google Images • Videos Retrieved from Youtube