Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS)

Ina, a nurse phlebotomist, is assigned to an HIV-positive patient. She was tasked to withdraw blood from the said patient to be sent to the laboratory. While Ina is withdrawing blood from the patient, he suddenly went berserk, and Ina’s needle plunged deep into her arm. Afraid of being reprimanded, Ina kept the incident from her colleagues. A month after, Ina reported fever and skin rash to her physician. She confessed about the incident of the needle prick with her physician, so he ordered a series of tests to confirm Ina’s diagnosis. The laboratory results showed that Ina is in the primary infection stage of HIV infection.

Description


Since HIV was first identified almost 30 years ago, remarkable progress has been made in improving the quality and duration of life for people living with HIV disease.

  • HIV or human immunodeficiency virus and acquired immunodeficiency syndrome is a chronic condition that requires daily medication.
  • HIV- 1 is a retrovirus isolated and recognized as the etiologic agent of AIDS.
  • HIV-2 is a retrovirus identified in 1986 in AIDS patients in West

Classification


The stages of HIV disease is based on clinical history, physical examination, laboratory evidence of immune dysfunction, signs and symptoms, and infections and malignancies.

  • Primary infection (Acute/Recent HIV Infection). The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection.
  • HIV asymptomatic (CDC Category A). After the viral set point is reached, HIV-positive people enter into a chronic stage in which the immune system cannot eliminate the virus despite its best efforts.
  • HIV symptomatic (CDC Category B). Category B consists of symptomatic conditions in HIV-infected patients that are not included in the conditions listed in category C.
  • AIDS (CDC Category C). When the CD4+ T-cell level drops below 200 cells/mm3 of blood, the person is said to have AIDS.

Pathophysiology


Because HIV infection is an infectious disease, it is important to understand how HIV-1 integrates itself into a person’s immune system and how immunity plays a role in the course of HIV disease.

  • In this first step, the GP120 and GP41 glycoproteins of HIV bind with the host’s uninfected CD4+ receptor and chemokine coreceptors, usually CCR5, which results in fusion of HIV with the CD4+ T-cell membrane.
  • The contents of HIV’s viral core are emptied into the CD4+ T cell.
  • DNA synthesis. HIV changes in genetic material from RNA to DNA through action of reverse transcriptase, resulting in double-stranded DNA that carries instruction for viral replication.
  • New viral DNA enters the nucleus of the CD4+ T cell and through action of integrase is blended with the DNA of the CD4+ T cell, resulting in permanent, lifelong infection.
  • When the CD4+ T cell is activated, the double-stranded DNA forms single-stranded messenger RNA, which builds new viruses.
  • The mRNA creates chains of new proteins and enzymes that contain the components needed in the construction of new viruses.
  • The HIV enzyme protease cuts the polyprotein chain into the individual proteins that make up the new virus.
  • New proteins and viral RNA migrate to the membrane of the infected CD4+ T cell, exits from the cell, and starts the process all over.

Pathophysiology of HIV and AIDS by Osmosis

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Statistics and Epidemiology


In the fall of 1982, after the first 100 cases were reported, the Centers for Disease Control and Prevention (CDC) issued a case definition for AIDS.

  • In 2008, the CDC reported that approximately 56, 300 new HIV infections occurred in the United States in 2006.
  • The figure was roughly 40% higher than their former estimate of 40, 000 HIV infections per year.
  • Almost 7000 people still contract HIV infection every day.
  • An estimated 33 million people are living with HIV/AIDS; however, the number of new infections declined from 3 million in 2001 to 2.7 million in 2007.
  • The global percentage of women among people with HIV/AIDS remains at 50%.
  • Sub-Saharan Africa continues to be most heavily affected by HIV/AIDS, with 67% of all people living with the disease.
  • In 2007, 72% of deaths from HIV/AIDS occurred in the same region.

Causes


HIV is transmitted through body fluids that contain free virions and infected CD4+ T cells.

  • Sharing infected drug use equipment such as needles.
  • Having sexual relations with infected individuals (both male and female).
  • Blood transmission. Receiving HIV-infected blood or blood products especially before blood screening.
  • Maternal HIV. Infants born to mothers with HIV infection.

Clinical Manifestations


HIV has four categories with specific manifestations for each stage.

  • This is experienced during the early infection stages.
  • People who are acutely infected with HIV infection experiences this symptom.
  • This symptom is mostly present in category B wherein the patient has already entered the chronic stage.
  • Constitutional symptoms. Fever more than 38.5⁰C or diarrhea exceeding 1 month in duration may also indicate presence of HIV infection.
  • Patients with HIV category C experience wasting syndrome or severe wasting of the muscles.

Prevention


Until an effective vaccine is developed, nurses need to prevent HIV infection by teaching patients how to eliminate or reduce risky behaviors.

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  • Safe sex. Other than abstinence, consistent and correct use of condoms is the only effective method to decrease the risk of sexual transmission of HIV infection.
  • In March 2007, based on the results of three clinical trials, the WHO and UNAIDS recommended that circumcision be recognized as an effective strategy to reduce the risk of HIV acquisition in men.
  • Sex partners. Avoid sexual contact with multiple partners or people who are known to be HIV positive or IV/injection drug users.
  • Blood and blood components. People who are HIV positive or who use injection drugs should be instructed not to donate blood or share drug equipment with others.

Complications


The patient should be monitored for presence of complications and should be managed appropriately.

  • Opportunistic infections. Patients who are immunosuppressed are at risk for opportunistic infections such as pneumocystis pneumonia which can affect 80% of all people infected with HIV.
  • Respiratory failure. Impaired breathing is a major complication that increases the patient’s discomfort and anxiety and may lead to respiratory and cardiac failure.
  • Cachexia and wasting. Wasting syndrome occurs when there is profound involuntary weight loss exceeding 10% of the baseline body weight and it is a common complication of HIV infection and AIDS.

Assessment and Diagnostic Findings


Several screening tests are used to diagnose HIV infection.

  • Confirming Diagnosis: Signs and symptoms may occur at any time after infection, but AIDS isn’t officially diagnosed until the patient’s CD4+ T-cell count falls below 200 cells/mcl or associated clinical conditions or disease.
  • CBC: Anemia and idiopathic thrombocytopenia (anemia occurs in up to 85% of patients with AIDS and may be profound). Leukopenia may be present; differential shift to the left suggests infectious process (PCP), although shift to the right may be noted.
  • PPD: Determines exposure and/or active TB disease. Of AIDS patients, 100% of those exposed to active Mycobacterium tuberculosis will develop the disease.
  • Serologic: Serum antibody test: HIV screen by ELISA. A positive test result may be indicative of exposure to HIV but is not diagnostic because false-positives may occur.
  • Western blot test: Confirms diagnosis of HIV in blood and urine.
  • Viral load test:
    • RI-PCR: The most widely used test currently can detect viral RNA levels as low as 50 copies/mL of plasma with an upper limit of 75,000 copies/mL.
    • bDNA 3.0 assay: Has a wider range of 50–500,000 copies/mL. Therapy can be initiated, or changes made in treatment approaches, based on rise of viral load or maintenance of a low viral load. This is currently the leading indicator of effectiveness of therapy.
    • T-lymphocyte cells: Total count reduced.
    • CD4+ lymphocyte count (immune system indicator that mediates several immune system processes and signals B cells to produce antibodies to foreign germs): Numbers less than 200 indicate severe immune deficiency response and diagnosis of AIDS.
    • T8+ CTL (cytopathic suppressor cells): Reversed ratio (2:1 or higher) of suppressor cells to helper cells (T8+ to T4+) indicates immune suppression.
    • Polymerase chain reaction (PCR) test: Detects HIV-DNA; most helpful in testing newborns of HIV-infected mothers. Infants carry maternal HIV antibodies and therefore test positive by ELISA and Western blot, even though infant is not necessarily infected.
  • STD screening tests: Hepatitis B envelope and core antibodies, syphilis, and other common STDs may be positive.
  • Cultures: Histologic, cytologic studies of urine, blood, stool, spinal fluid, lesions, sputum, and secretions may be done to identify the opportunistic infection. Some of the most commonly identified are the following:
    • Protozoal and helminthic infections: PCP, cryptosporidiosis, toxoplasmosis.
    • Fungal infections: Candida albicans (candidiasis), Cryptococcus neoformans (cryptococcus), Histoplasma capsulatum (histoplasmosis).
    • Bacterial infections: Mycobacterium avium-intracellulare (occurs with CD4 counts less than 50), miliary mycobacterial TB, Shigella (shigellosis),Salmonella (salmonellosis).
    • Viral infections: CMV (occurs with CD4 counts less than 50), herpes simplex, herpes zoster.
  • Neurological studies, e.g., electroencephalogram (EEG), magnetic resonance imaging (MRI), computed tomography (CT) scans of the brain; electromyography (EMG)/nerve conduction studies: Indicated for changes in mentation, fever of undetermined origin, and/or changes in sensory/motor function to determine effects of HIV infection/opportunistic infections.
  • Chest x-ray: May initially be normal or may reveal progressive interstitial infiltrates secondary to advancing PCP (most common opportunistic disease) or other pulmonary complications/disease processes such as TB.
  • Pulmonary function tests: Useful in early detection of interstitial pneumonias.
  • Gallium scan: Diffuse pulmonary uptake occurs in PCP and other forms of pneumonia.
  • Biopsies: May be done for differential diagnosis of Kaposi’s sarcoma (KS) or other neoplastic lesions.
  • Bronchoscopy/tracheobronchial washings: May be done with biopsy when PCP or lung malignancies are suspected (diagnostic confirming test for PCP).
  • Barium swallow, endoscopy, colonoscopy: May be done to identify opportunistic infection (e.g., Candida, CMV) or to stage KS in the GI system.

Medical Management


Medical management focuses on elimination of opportunistic infections.

  • Treatment of opportunistic infections. For Pneumocystis pneumonia, TMP-SMZ is the treatment of choice; for mycobacterium avian complex, azithromycin or clarithromycin are preferred prophylactic agents; for cryptococcal meningitis, the current primary treatment is IV amphotericin B.
  • Prevention of opportunistic infections. TMP-SMZ is an antibacterial agent used to treat various organisms causing infection.
  • Antidiarrheal therapy. Therapy with octreotide acetate (Sandostatin), a synthetic analog of somatostatin, has been shown to be effective in managing severe chronic diarrhea.
  • Antidepressant therapy. Treatment for depression in patients with HIV infection involves psychotherapy integrated with imipramine, desipramine or fluoxetine.
  • Nutrition therapy. For all AIDS patients who experience unexplained weight loss, calorie counts should be obtained, and appetite stimulants and oral supplements are also appropriate.

Nursing Management


The nursing care of patients with HIV/AIDS is challenging because of the potential for any organ system to be the target of infections or cancer.

Nursing Assessment

Nursing assessment includes identification of potential risk factors, including a history of risky sexual practices or IV/injection drug use.

  • Nutritional status. Nutritional status is assessed by obtaining a diet history and identifying factors that may affect the oral intake.
  • Skin integrity. The skin and mucous membranes are inspected daily for evidence of breakdown, ulceration, or infection.
  • Respiratory status. Respiratory status is assessed by monitoring the patient for cough, sputum production, shortness of breath, orthopnea, tachypnea, and chest pain.
  • Neurologic status. Neurologic status is determined by assessing the level of consciousness; orientation to person, pace, and time; and memory lapses.
  • Fluid and electrolyte balance. F&E status is assessed by examining the skin and mucous membranes for turgor and dryness.
  • Knowledge level. The patient’s level of knowledge about the disease and the modes of disease transmission is evaluated.

Diagnosis

The list of potential nursing diagnoses is extensive because of the complex nature of the disease.

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  • Impaired skin integrity related to cutaneous manifestations of HIV infection, excoriation, and diarrhea.
  • Diarrhea related to enteric pathogens of HIV infection.
  • Risk for infection related to immunodeficiency.
  • Activity intolerance related weakness, fatigue, malnutrition, impaired F&E balance, and hypoxia associated with pulmonary infections.
  • Disturbed thought processes related to shortened attention span, impaired memory, confusion, and disorientation associated with HIV encephalopathy.
  • Ineffective airway clearance related to PCP, increased bronchial secretions, and decreased ability to cough related to weakness and fatigue.
  • Pain related to impaired perianal skin integrity secondary to diarrhea, KS, and peripheral neuropathy.
  • Imbalanced nutrition, less than body requirements related to decreased oral intake.

Planning & Goals

Main Article: 13 AIDS (HIV Positive) Nursing Care Plans

Goals for a patient with HIV/AIDS may include:

  • Achievement and maintenance of skin integrity.
  • Resumption of usual bowel pattern.
  • Absence of infection.
  • Improve activity intolerance.
  • Improve thought processes.
  • Improve airway clearance.
  • Increase comfort.
  • Improve nutritional status.
  • Increase socialization.
  • Absence of complications.
  • Prevent/minimize development of new infections.
  • Maintain homeostasis.
  • Promote comfort.
  • Support psychosocial adjustment.
  • Provide information about disease process/prognosis and treatment needs.

Nursing Interventions

The plan of care for a patient with AIDS is individualized to meet the needs of the patient.

  • Promote skin integrity. Patients are encouraged to avoid scratching; to use nonabrasive, nondrying soaps and apply nonperfumed moisturizers; to perform regular oral care; and to clean the perianal area after each bowel movement with nonabrasive soap and water.
  • Promote usual bowel patterns. The nurse should monitor for frequency and consistency of stools and the patient’s reports of abdominal pain or cramping.
  • Prevent infection. The patient and the caregivers should monitor for signs of infection and laboratory test results that indicate infection.
  • Improve activity intolerance. Assist the patient in planning daily routines that maintain a balance between activity and rest.
  • Maintain thought processes. Family and support network members are instructed to speak to the patient in simple, clear language and give the patient sufficient time to respond to questions.
  • Improve airway clearance. Coughing, deep breathing, postural drainage, percussion and vibration is provided for as often as every 2 hours to prevent stasis of secretions and to promote airway clearance.
  • Relieve pain and discomfort. Use of soft cushions and foam pads may increase comfort as well as administration of NSAIDS and opioids.
  • Improve nutritional status. The patient is encouraged to eat foods that are easy to swallow and to avoid rough, spicy, and sticky food items.

Evaluation

Expected patient outcomes may include:

  • Achieved and maintained of skin integrity.
  • Resumption of usual bowel pattern.
  • Absence of infection.
  • Improved activity intolerance.
  • Improved thought processes.
  • Improved airway clearance.
  • Increased comfort.
  • Improved nutritional status.
  • Increased socialization.
  • Absence of complications.

Discharge and Home Care Guidelines

Before discharge, the nurse should educate the patient and the family about precautions and the transmission of HIV/AIDS.

  • Patients and their families or caregivers should receive instructions about how to prevent disease transmission, including hand-washing techniques and methods for safely handling and disposing of items soiled with body fluids.
  • Patients are advised to avoid exposure to others who are sick or who have been recently vaccinated.
  • Medication administration. Caregivers in the home are taught how to administer medications, including IV preparations.
  • The patient’s adherence to the therapeutic regimen is assessed and strategies are suggested to assist with adherence.
  • Infection prevented/resolved.
  • Complications prevented/minimized.
  • Pain/discomfort alleviated or controlled.
  • Patient dealing with current situation realistically.
  • Diagnosis, prognosis, and therapeutic regimen understood.
  • Plan in place to meet needs after discharge.

Documentation Guidelines

The focus of documentation in a patient with HIV/AIDS should include:

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  • Characteristics of lesions or condition.
  • Impact of condition in personal image and lifestyle.
  • Assessment findings including characteristics and pattern of elimination.
  • Individual risk factors including recent or current antibiotic therapy.
  • Signs and symptoms of infectious process.
  • Breath sounds, presence and character of secretions, use of accessory muscles for breathing.
  • Caloric intake.
  • Individual cultural or religious restrictions and personal preferences.
  • Plan of care.
  • Teaching plan.
  • Response to interventions, teaching, and actions performed.
  • Attainment or progress toward desired outcomes.
  • Modifications to plan of care.
  • Long term needs.

Practice Quiz: HIV/AIDS


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1. A widely used laboratory test that measures HIV-RNA levels and tracks the body’s response to HIV infection is the:

A. CD4/CD8 ratio.
B. EIA test.
C. Viral load test.
D. Western blot.

2. The most debilitating gastrointestinal condition found in up to 90% of all AIDS patients is:

A. Anorexia.
B. Chronic diarrhea.
C. Nausea.
D. Vomiting.

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3. Abnormal laboratory findings seen with AIDS include:

A. Decreased CD4 and T cell count.
B. P24 antigen.
C. Positive EIA test.
D. All of the above.

4. The most common infection in persons with AIDS (80% occurrence) is:

A. Cytomegalovirus.
B. Legionnaire’s disease.
C. Mycobacterium tuberculosis.
D. Pneumocystis pneumonia.

5. A diagnosis of wasting syndrome can be initially made when involuntary weight loss exceeds what percentage of baseline body weight?

A. 10%
B. 15%
C. 20%
D. 25%

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Answers and Rationale


1. Answer: C. Viral load test.

  • C: Viral load test measures plasma RNA levels.
  • A: CD4/CD8 ratio measures the number of CD4 T cells in the body.
  • B: EIA test identifies antibodies directed specifically against HIV.
  • D: Western blot is used to confirm seropositivity when the EIA result is positive.

2. Answer: B. Chronic diarrhea.

  • B: Chronic diarrhea occurs in up to 90% of patients with AIDS.
  • A: Anorexia is not as incapacitating as chronic diarrhea.
  • C: Nausea is not as incapacitating as chronic diarrhea.
  • D: Vomiting is not as incapacitating as chronic diarrhea.

3. Answer: D. All of the above.

  • D: All of the mentioned laboratory results are seen in an AIDS patient.
  • A: Decreased CD4 and T cell count is seen in an AIDS patient.
  • B: P24 antigen is seen in an AIDS patient.
  • C: Positive EIA test is seen in an AIDS patient.

4. Answer: D. Pneumocystis pneumonia.

  • D: Pneumocystis pneumonia can affect 80% of all people infected with HIV.
  • A: Cytomegalovirus is not the most common infection in AIDS patients.
  • B: Legionnaire’s disease is not the most common infection in AIDS patients.
  • C: Mycobacterium tuberculosis is not the most common infection in AIDS patients.

5. Answer: A. 10%

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  • A: Wasting syndrome occurs when there is profound involuntary weight loss exceeding 10% of the baseline body weight.
  • B: It is not 15%, but 10% of the baseline body weight.
  • C: It is not 20%, but 10% of the baseline body weight.
  • D: It is not 25%, but 10% of the baseline body weight.

See Also


Posts related to HIV/AIDS:

Bloodborne Pathogens: Occupatioons at Risk Infographics
Bloodborne Pathogens: Occupations at Risk Infographics

Further Reading and Recommended Resources


Recommended books and reading materials:
  1. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
  2. Medical-Surgical Nursing: Assessment and Management of Clinical Problems
  3. Medical-Surgical Nursing: Patient-Centered Collaborative Care
  4. Saunders Comprehensive Review for the NCLEX-RN Examination
  5. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing
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