HIV

HIV/AIDS 

OVERVIEW 

HIV stands for “human immunodeficiency virus,” and it attacks immune cells called CD4 cells. These are types of T cell  white blood cells that circulate, detecting infections throughout the body and faults and anomalies in other cells. HIV targets and infiltrates CD4 cells, using them to create more copies of the virus. In doing so, it destroys the cells and reduces the body’s ability to combat other infections and diseases. This increases the risk and impact of opportunistic infections and some types of cancer.

AIDS is a disease caused by infection with HIV and is characterized by profound immunosuppression with associated opportunistic infections, malignancies, wasting, and central nervous system degeneration. HIV is a retrovirus that selectively attacks the CD4T lymphocytes, the immune cells responsible for orchestrating and coordinating the immune response to infection. As a consequence, persons with HIV infection have a deteriorating immune system, and thus are more susceptible to severe infections with ordinarily harmless organisms.

SIGNS AND SYMPTOMS 

Early symptoms of HIV may include:

• A fever

• Chills

• Sweating, particularly at night

• Enlarged glands or swollen lymph nodes

• A diffuse rash

• Fatigue

• Weakness

• Pain, including joint pain

• Muscle aches

• A sore throat

• Thrush, or a yeast infection

• Unintentional weight loss, with advancing HIV

STAGES OF HIV DISEASE 

 (for untreated individuals): The four stages of HIV infection can be categorized as acute infection, asymptomatic, symptomatic, and AIDS.

➡️ Acute or primary infection: Period of rapid viral replication during which the person may experience flulike symptoms at the time of seroconversion.

➡️ Asymptomatic stage: Immune system continues to mount a massive response to HIV, causing a drop in viral load but viral replication continues. It may last 10 yr or more, and the person may remain free of symptoms or opportunistic infections.

➡️ Early symptomatic stage: Rate of viral replication remains relatively constant; however, gradual failure of the immune system results in inability to control the virus, causing increased viral load.

➡️ Advanced stage AIDS: The immune mechanism for virus control fails, resulting in large amounts of circulating virus and significant destruction of CD4+ T cells. Clinical manifestations include wasting and opportunistic diseases such as neoplasms and viral, bacterial, and fungal infections. Dementia also can occur, characterized by cognitive impairment and mood changes.

PHYSICAL ASSESSMENT : 

The following indicators are commonly seen with HIV infection.

• General: Fever, night sweats, weight loss.

• Cutaneous: Herpes zoster or simplex lesions, seborrheic or other dermatitis, fungal infections of the skin (moniliasis, candidiasis) or nail beds (onychomycosis), KS lesions, petechiae, warts.

• Head/neck: “Cotton-wool” spots visualized on fundu-scopic examination; oral KS; candidiasis (thrush); hairy leukoplakia; aphthous ulcers; enlarged, hard, and occasionally tender lymph nodes.

• Respiratory: Tachypnea, dyspnea, diminished or adventitious breath sounds (crackles [rales], rhonchi, wheezing).

• Cardiac: Tachycardia, friction rub, gallops, murmurs.

• Gastrointestinal: Enlargement of liver or spleen, nausea, vomiting, diarrhea, constipation, hyperactive bowel sounds, abdominal distention.

• Genital/rectal: KS lesions, herpetic lesions, candidiasis, balanitis, warts, syphilitic chancres, warts, rectal or cervical dysplasia, fistulas.

• Neuromuscular: Flattened affect, apathy, withdrawal, memory deficits, headache, muscle atrophy, speech deficits, gait disorders, generalized weakness, incontinence, neuropathy.

TRANSMISSION 

HIV is transmitted through conditions that facilitate the exchange of blood or body fluids that contain the virus or virus-infected cells.  The major routes of transmission of HIV infection are:

• sexual contact

• contaminated blood

• Sharps

• or passage from infected mothers to their newborns. It is estimated that more than 90% of children living with HIV acquired the virus in utero, during the birth process, or through breast-feeding (to be discussed). HIV is not transmitted through casual contact.

Sexual contact is the most frequent mode of HIV transmission. There is a risk of transmitting HIV when semen or vaginal fluids come in contact with a part of the body that lets them enter the bloodstream. This can include the vaginal mucosa, anal mucosa, and wounds or sores on the skin.

OPPORTUNISTIC INFECTIONS 

Opportunistic infections begin to occur as the immune system becomes severely compromised. The number of CD4T cells directly correlates with the risk of development of opportunistic infections. In addition, the baseline HIV RNA level contributes and serves as an independent risk factor. Opportunistic infections involve common organisms that do not produce infection unless there is impaired immune function. Although a person with AIDS may live for many years after the first serious illness, as the immune system fails, these opportunistic illnesses become progressively more severe and difficult to treat. READ IN FULL

ASSESSMENT 

HIV  risk  assessment:  Because  of  continued  transmission  of HIV  infection  and  incidence  of  new  infections  regardless  of  race,  gender,  sexual  preference,  or  age,  continuous  HIV  risk  assessment  and  prevention  education  within  all  clinical settings is essential. Health care providers have a responsibility to assess each patient’s risk for HIV infection and be sensitive to issues of sexual preferences and practices, as well as cultural values, norms, and traditions. A risk assessment should be used not only for the purpose of recommending testing, but also for development of a “patient-centered” risk reduction plan. Key components of conducting a sexual history:

1. Focus on sexual “behaviors” rather than on categories or labels.

2. Avoid making assumptions about individuals.

3. Ask about specific sexual behavior rather than asking general questions.

• For example, “How many sexual partners have you had?” “In the last 5 years?” “In the last month?”

• “Do you have sex with men, women, or both?”

• “When is the last time you had sex while under the influence of drugs or alcohol?”

4. Ask non judgmentally about traditional and nontraditional sexual practices.

• “What type of sexual intercourse (vaginal, anal, oral) do you have with your partner(s)?”

• “When you have anal or oral intercourse, are you the insertive or receptive partner?”

5. It is essential that clinicians provide patients with risk reduction information in a consistent and continuous process within the clinical care relationship. This intervention should include development of specific skills and ongoing monitoring of the patient’s successes and continued challenges.} Key components of conducting a drug history:

6. Focus on specific drug-using behaviors. For example:

• “Do you use alcohol or tobacco?” If so, ask how much and how often.

• “What drugs do you use?” “What drugs do you inject?”

• “When did you last inject drugs?” “When did you last share needles?”

• “Do you clean your works?” “How do you do this?”

7. Avoid making assumptions about individuals because drug use occurs in all socioeconomic groups.

8. Convey a nonjudgmental attitude.

AIDS 

When CD4 cells are severely depleted, at fewer than 200 cells per cubic millimeter, AIDS is diagnosed. The presence of certain opportunistic infections, involving bacteria, viruses, fungi, or mycobacteria, also help to identify AIDS.

SYMPTOMS OF AIDS  INCLUDES:

• Blurred vision

• A dry cough

• Night sweats

• White spots on the tongue or mouth

• Shortness of breath, or dyspnea

• Swollen glands lasting for weeks

• Diarrhea, which is usually persistent or chronic

• A fever of over 100°F (37°C) that lasts for weeks

• Continuous fatigue

• Unintentional weight loss

DIAGNOSTIC TESTS

A variety of diagnostic tests are used for specific reasons in the course of HIV disease. The following tests are used to deter-mine HIV infection. Because it can take up to 6 month to develop enough antibodies to trigger a reactive result, the person may be infected but test negative. This is often referred to as the “window period” for HIV infection. Individuals who test negative should be retested in 3-6 month to confirm seronegativity. The CDC currently recommends routine HIV screening for all individuals 13-64 yr old, regardless of risk factors.

• Enzyme-linked immunosorbent assay (ELISA): The standard test for HIV. ELISA tests for the presence of HIV anti-body. An initially reactive ELISA should be repeated on the same specimen. If reactive, a confirmatory Western blot (WB) is performed. A positive ELISA with a confirmatory WB signals infection with HIV.

• Western blot: A confirmatory test used to detect immune response to the specific viral proteins of HIV. A reactive WB is defined by a specific pattern of protein bands separated by electrophoresis on a strip of nitrocellulose paper; three of the following bands must be present for reactivity. 

• P24 antigen test: Detects HIV p24 antigen in serum, plasma, and cerebrospinal fluid (CSF) of infected individuals Its advantage is that it may detect viral antigen (HIV p24) early in the course of infection before seroconversion.

• Immunofluorescence assay: Tests for HIV antibody and is equivalent to the WB.

• Rapid tests: Several relatively new Food and Drug Administration (FDA) approved rapid antibody tests indicate presence of HIV antibodies in oral fluid, serum, and/or whole blood within approximately 20-40 min.

MONITORING TESTS 

With use of Anti Retroviral Therapy(ART) in the clinical management of HIV disease, monitoring tests have become increasingly essential in assessing for immune reconstitution and monitoring for treatment failure or resistance.

• CD4+ T cell count: A measure of the amount of CD4+ T cells per milliliter in the blood. It is a marker for the impact of HIV infection on the immune system and the individual’ susceptibility to infections. With increased viral load there is a reduction in CD4+ T-cell counts because of destruction of these lymphocytes by HIV. A CD4+ T-cell count of less than 200 is diagnostic of AIDS.

• Viral load testing: Only 3%-4% of the virus is located in the plasma. The remaining 90+% is located in lymphoid tissues and other blood cells. The viral load test measures the free virus in the plasma but not in these other areas. It is used to determine response of antiretroviral treatment, monitor development of drug resistance, and determine need to change antiretroviral treatment. When a patient is on ART, the viral load should be undetectable.

• Viral resistance testing: Testing for viral resistance to specific antiretroviral drugs. Before initiating treatment, this test is used to determine if the virus is already resistant to a specific agent. It is also used to assess treatment failure and help deter-mine appropriate changes in the introduction of new or alter-native antiretroviral agents. The different types of resistance testing include genotypic assays, phenotypic assays, and virtual phenotype.

NURSES DIAGNOSIS 

1. Risk for Infection related to inadequate immune system function, malnutrition, or side effects of chemotherapy evidence by onset of infections

2. Imbalanced Nutrition: Less Than Body Requirements related to diarrhea and nausea associated with side effects of medications, malabsorption, anorexia, dysphagia, and fatigue

3. Impaired Gas Exchange related to altered oxygen supply occurring with pulmonary infiltrates, hyper-ventilation, and sepsis

4. Deficient Knowledge related to unfamiliarity with the disease process, prognosis, lifestyle changes, and treatment plan

5. Anxiety related to threat of death, significant life changes, and social isolation