HIV/AIDS

Viral Particle features

▪ Outer envelope with special docking proteins
o gp41 and gp120
§ assists in finding a host
§ inside the virus has protein coatings and enzymes
▪ reverse transcription (RT)
▪ integrase
o HIV particle gets inside a host cell and the CD+4 helper T-cell is
hijacked (this cell directs immune system defenses and regulates
the activities of all immune system cells)
§ More virus particles are created
Virus-Host Interactions
▪ gp120 and gp41 proteins recognize receptors on the CD4+ T-
cells
▪ The gp120 first binds to the primary CD4 receptor, which changes
its shape and allows for the gp41 to bind to one of the co-
receptors, this allow the virus to then enter the CD+4 T-cell
▪ Retrovirus replicates cell’s DNA
o HIV protease
Effects of HIV infection
▪ CD4+ T-cell’s new job is to be an HIV factory
▪ The most important cell is removed from circulation
o Over time the number of HIV particles overwhelms the immune
system
o The number of CD4+ Tcells decreases and the viral load (viral
numbers) increases
▪ HIV leads to these immune system abnormalities:
o Lymphocytopenia
o Increased production fo incomplete and nonfunctional
antibodies
o Abnormally functioning macrophages
▪ As the CD4+ T-cells number drops the patient is at risk for
bacterial, fungal, and viral infections, as well as some
 opportunistic cancers
▪ 10 billion new HIV particles can per produced per day
AIDS=HIV / HIV does not = AIDS
▪ Diagnosis of AIDS = CD4+ T-cell count of < 200 cells/mm3
▪ Opportunistic infection
▪ AIDS diagnosis remains and the patient never reverts to being just
HIV positive

HIV Classification
▪ Clinical Category A:
o HIV positive
o May be asymptomatic
o Person may have persistently enlarged lymph nodes
(lymphadenopathy)
▪ Clinical Category B:
o HIV infection plus
§ Deficiency in cell-mediated immunity
§ Disease complicated by HIV infection
▪ Clinical Category C:
o HIV + opportunistic disease= AIDS
▪ On top of one of the three categories the patient also has a
classification based on the CD4+ T-cell count
o A,B,C either 1,2,3
o 1: when the count is at least 500/mL3
o 2: when the count is between 200 and 499 mL3
o 3: when the count is less than 200mL3
HIV Progression
▪ From infection to AIDS
o Can take form months to years
§ LTNP-long-term non-progressors
▪ 1% of the population
▪ 10 or more years of infection with normal CD4+ Tcells count
▪ Defective co-receptors called delta32
o Dependent upon
§ How acquired- HIV acquired thru blood transfusion, AIDS
progresses quickly
§ Personal factors-frequency of re-exposure, presence of other
STDs, nutritional status, stress
§ Interventions
Incidence/Prevalence
▪ Almost 1 million HIV/AIDS cases diagnosed with over 550k
deaths
▪ 1.1 to 1.8 million estimated infected with HIV
▪ 21-44 year olds hardest hit
▪ Older population is susceptible
o Sex/drug history
o Age-related immune system decline
o Decrease of estrogen in women thins the vaginal tissue and
increases susceptibility to any STD
▪ 26% new cases are women
o Poorer outcome with shorter survival than men
▪ 72% of new infections are in the racial and ethnic minorties in the
US
o Fear/lack of faith in health care system
o Poverty/limited access to drugs
Health Promotion/ Maintenance
Education
▪ HIV is preventable
o Teach modes of transmission
▪ Sexual transmission
o ABCs of safer sex
o Virus concentrates in blood and seminal fluid
▪ Gender
o More easily transmitted to mucous membranes or nonintact
skin
o More easily transmitted from infected male to uninfected female
▪ Sexual Acts
o Anal intercourse is the riskiest route
▪ Viral Load
o Higher the load, greater the risk of infection
Other Modes of Transmission
▪ Parenteral Transmission
o Sharing of needles, syringes, and other drug paraphernalia
§ Clean with water and bleach
§ Needle exchange program
o Donated blood screening
▪ Perinatal Transmission
o Risk of 25% in women not using drug therapy
o 8% risk in women using drug therapy
Transmission and Health Care Workers
▪ Needle stick or “sharpes” injuries are the main means of
occupation-related HIV infection for health care workers
▪ Best prevention for health care workers is the consistent use of
Standard Precautions is recommended by CDC and required
by joint commission

Testing
▪ All sexually active people should know their HIV status
o Pre/posttest counseling
Assessment
▪ History
o Age
o Gender
o Occupation
o Living situation
o Blood transfusions between 1978-85
o Sexual practices/STDs
▪ Opportunistic Infections
o Protozoal infections
§ PCP- most common opportunistic infections in HIV patients
§ Toxoplasmosis encephalitis- acquired through contact with
contaminated cat feces or by ingesting infected, undercooked meat
§ Crytosporidiosis- manifestations range from a mild diarrhea to a
severe wasting with electrolyte imbalance
o Fungal Infections
§ Candida albicans- part of the natural flora of the intestinal tract,
occurs because the weakened immune system can no longer control
fungal growth
§ Cryptococcosis- debilitating memingitis and is sometimes a
widely spread infection in AIDS patients
§ Histoplamosis- begins as a respiratory infection and progresses
to a wide spread infection in the AIDS patient
o Bacterial Infections
§ Mycobacterium avium complex (MAC)- most common bacterial
infection in AIDS patients, infects the respiratory or GI tract, is a
systemic infection
§ Tuberculosis- anergy- inability to mount an immune response to
the antigen when having a TB test done
o Viral infections
§ Cytomegalovirus- can infect many sites in a person with AIDS
including the eye, respiratory and GI tracts, and the CNS
§ Herpes simplex virus (HSV)- manifestations are more widespread
and of longer duration among AIDS patients
§ Varicella-zoster virus (VZV)- usually not a new infection for
people with AIDS

Malignancies
▪ Kaposi’s sarcoma- most common AIDS-related malignancy
o Small, purplish brown, raised lesions that are usually not painful
or itchy
o Diagnosed by a biopsy and histologic examination of the lesion
▪ Hodgkin’s/non-Hodgkin’s lymphoma
▪ Invasive cervical cancer
Endocrine Changes
▪ Gonadal dysfunction
o Men have low testosterone levels
o Women often have irregular menstrual cycles
o Both have decrease in body muscle mass and a change in libido
▪ Adrenal dysfunction
o Adrenal insufficiency resulting in
o Fatigue
o Weight loss
o Nausea
o Vomiting
o Low BP
o Electrolyte disturbances
▪ Pancreatic changes
Other Affected Systems
▪ AIDS dementia complex (ADC)
o 70% of people with AIDS
o Result of infection of the CNS by HIV
o Causes cognitive, motor, and behavioral impairments
▪ AIDS wasting syndrome
o May be a result of altered metabolism from cancer or infection
o Persistent and sometimes extreme weight loss, the patient may
appear quite emaciated
▪ Skin changes
o Dry, itchy, irritated skin and many types of rashes
Laboratory Assessment
▪ Leukocyte counts
o Patients are usually leukopenic, with a WBC count of less than
3500 cells/mm3 and lymphopenic
▪ Antibody tests- measure the patient’s response to the virus
o Antibodies usually made in 3 wweks-3months
o ELISA or Western blot analysis
o Viral Load testing
§ Quantitative RNA assays
§ Monitor therapy effectiveness
▪ Other lab tests
o Blood chemistries
o CBC with diff
o LFTs
▪ Testing stool
▪ Chest xrays
Planning/Implementation
§ Risk for infection
o Drug “cocktail”
§ HAART- Highly active antiretroviral therapy. Important to ensure
that these drugs are not missed, delayed, or administered in lower
than prescribed doses it he inpatient setting.
▪ Nucleoside Analog Reverse Transcription Inhibitors (NARTIs)-
have similar structure to the four nucleoside bases of DNA,
they compete with the actual nucleotide for placement in the
DNA. Thus they suppress production of reverse transcriptase
and inhibit viral DNA synthesis and replication
EX.
§ Combivir
§ Stavudine
§ Zidovudine
▪ Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)- inhibit
synthesis of reverse transcriptase, suppress viral replication
obut do not kill the virus
EX.
§ Etravirine
§ Nevirapine
▪ Protease Inhibitors- block HIV protease enzyme, preventing viral
replication and relrease of viral particles. Make the protrease
enzzyume work on the drug rather than ton the initial large
protein
EX.
§ Fosamprenavir
§ Darunavir
§ Kaletra
▪ Fusion Inhibitors- block the fusion of HIV with a host cell by
blocking the ability of gp41 to fuse with the host cell.
Infection of new cells does not occur
▪ Entry Inhibitors- prevent infection by blocking the CCR5 receptor
on CD4+ Tcells, prevent cellular infection with HIV
▪ Integrase Inhibitors- prevent infection by inhibiting the enzyme
integrase, viral proteins are not made and viral replication in
inhibited
Community-Based Care
▪ Home care management
o Assess status and ability to perform ADLs
o Assess available resources
o Help family make arrangements for careif needed
▪ Health Teaching
o Modes of transmission and prevention
o Infection control measures
o Diet teaching
o Social strategies
▪ Psychosocial Prep
o Support and strategies for social stigma and rejection
▪ Health Care Resources
o Community outreach
o Respite care
o Referral services
o Mental health/behavioral health
o Support groups
Evaluation/Outcomes
▪ Adherence to prescribed drug therapy regimen
▪ Safe sex practices
▪ Remain free from OIs
▪ Adequate respiratory function
▪ Acceptable level of comfort
▪ Adequate weight
▪ Maintain skin integrity
▪ Remain oriented
▪ Maintain self-esteem
Maintain support system