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HIV & AIDS

What Is HIV?

H Human
I Immunodeficiency
V Virus
What is AIDS?

A Aquired
I Immune
D- Deficiency
S- Syndrome
For diagnosis must be:
HIV positive, and
CD4 (T-cell) count below 200, or
The presence of one or more opportunistic infections.
Global Epidemiology
39.5 million people living with HIV/AIDS in
2006
4.3 million newly infected with HIV (more
than half are younger than 25)
2.9 million people died from AIDS

More than 25 million people have died


from AIDS since 1981
Africa has over 12 million AIDS orphans
Global Trends
Canadian Epidemiology

58 000 people in Canada with HIV (as of Dec,


2005)
30% of people unaware of their infection
Between 2 300 and 4 500 new HIV infections every
year
329 people in Nova Scotia/PEI have AIDS (as of
June, 2006) Public Health Agency of Canada. HIV and AIDS in Canada. Surveillance report to
June 30, 2006. Surveillance and Risk Assessment Division, Centre for
Infectious Disease Prevention and Control, Health Canada, November 2006
Health Canada. HIV/AIDS EPI Updates, August 2006, Surveillance and Risk
Assessment Division, Centre for Infectious Disease Prevention and Control,
Health Canada, 2006
Canadian Epidemiology
Affects ALL races, genders, ages
Most people who test HIV positive are
between the ages of 20-40
Minorities, such as aboriginals and black
people, are over represented
Women remain around 1/3 of newly infected
patients (increase since 1995)
Greater risk of infection with high risk
activities
INDONESIAN EPIDEMIOLOGY

How about Indonesian?


Until 2016, 7.148 people wit HIV in
indonesia (january-march 2016)
Most people wit HIV positive are
between the age of 25 49
HIV ratio between man and women are
2:1
Risk Factors
Transmission: through bodily fluids from
an infected person
Three Conditions:
1. Virus Must be Present
2. There must be a high
enough concentration of the
virus in the infected person
3. There must be a way for
the virus to enter the
bloodstream
Through Blood, Seman,
Vaginal Fluid, or Breast
milk
Transmission
Possible Sources of Transmission:
Blood products/ transfusions
Before 1985
Mother to child
Pregnancy, birth, and breastfeeding
Contaminated needles
Injection drug use, tattoos, peircings, acupunture
Sexual contact
Unprotected sex
Unwashed sexual devices
Greater risk with other STI due to breaks in skin
Greater risk with increased number of partners
Risk Factors
NOT transmitted through
Casual contact (shaking hands)
Hugging
Kissing
Sweat
Tears
Donating Blood
Swimming Pools
Toilet seats
Telephones
Sharing bed linens, towels, eating utensils, or food
Insect bites
Societal Risk Factors
Many determinants of health!
These, in turn, become consequences of an
epidemic
Societal factors that contribute to the epidemic:
People on the move
People in conflict
Poverty
Stigma and Denial
Cultural factors
Role of Women
Prevention
Prevention is the most realistic strategy
Vaccine or cure unlikely anytime soon
Prevention is done by decreasing both societal
and individual risk factors
Barriers to prevention include:
Political instability
Lack of resources
Existence of other endemic health problems (ie:
malaria and childhood diseases)
Inefficiency
Apathy and silence
Misconceptions and lack of knowledge
Decreasing Individual Risk Factors
Nurses are responsible for educating their clients
about how to protect themselves from HIV/AIDS!
Literacy appropriate teaching
Use multiple teaching methods
Provide visual/auditory/written material for different
learning styles
Provide for kinetic learners, too, such as having the
client demonstrate how put on a condom
Direct clients to community resources
Where they can be tested for HIV/AIDS and other
STIs
Support groups
Prevention: Practice SAFER sex
Nurses must be comfortable
discussing their clients
sexual activites
Assess: number of partners,
protection being used, and
whether it is being used
properly
Ask everyone! Dont assume!
Educate: know STI status of
sexual partners, HIV/AIDS and
other STI testing, use of latex
condoms, dental dams, latex
gloves, water-based lubricants
Prevention: Clean Needles
Risk reduction school of thought
Nurse can :
Direct client to addiction services
Direct client to needle exchange program if quitting
is not an option at this time
Alcohol kills HIV
Educate! Sharing needles with friends is just as risky
as sharing with strangers
Prevention: Screening
Many STIs are tested
with gyne exams, but
HIV requires a blood
test
HIV antibody test
Prevention: Education
Many myths and misconceptions ie:
HIV doesnt exist within this community
HIV only affects sex-trade workers,
homosexuals and injection drug users
If you get HIV you will show symptoms
Having sex with a virgin will cure you of HIV
Nurses play a large role in providing the
facts!
Prevention: Policy
Society contributes to HIV transmission!
Empowering women
Promoting Justice
Addressing Poverty
Providing Education
Addressing Stigma
What exactly is HIV?
Human Immunodeficiency Virus- a retrovirus
belonging to the family of lentiviruses.
Uses their RNA and host DNA to make viral DNA
Uses CD4+ cell to replicate itself and destroying
CD4+
Two types: HIV-1 + HIV-2
Leads to Acquired Immunodeficiency Syndrome
HIV
2 types: HIV-1 and HIV-2
Subtypes of HIV-1: A, B, C, D, E, F, G, H,
O. (No subtypes of HIV-2)
HIV-1 subtype C makes up for more than
50% of all new HIV infections worldwide.
HIV-2 progresses slower
HIV-2 makes up the majority of cases of
HIV infection in Africa
Pathophysiology of
HIV/AIDS
HIV LIFE
CYCLE
Diagnosis of HIV infection
EIA (enzyme immunoassay) [formerly
ELISA (enzyme-linked immunosorbent
assay)] identifies antibodies that are
specifically directed against HIV.
Western blot assay: used to confirm
seropositivity when the EIA is positive
Seropositivity: when blood or saliva
contains HIV antibodies
Other Tests
Viral load tests: used to quantify HIV DNA or
RNA levels in the plasma. These tests include:
reverse transcriptase polymerase chain and
nucleic acid sequence-based amplification.
This can help determine response to treatment.
Viral load is a significant
predictor of disease
progression.
Home Testing Kits
Home testing kits are
available, but are of
concern to HCP.
Why?
The lack of
counselling, as well as
the possibility of
inaccurate results.
S&S of HIV infection
Often, there are no S&S in the early
stages of HIV infection

Why?

The CD4 lymphocytes are still numerous


enough to fight off infections
S&S of HIV infection
There may be slight flu-like symptoms 2-6
weeks after initial infection.

Other S&S (generally advanced infection):


Lymphadenopathy (often the first sign) profuse
night sweats, rapid weight loss, recurrent fever,
chronic diarrhea, unexplained fatigue, persistent
headaches
(http://www.mayoclinic.com/health/hiv-
aids/DS00005/DSECTION=2)
Stages of HIV disease
Based on clinical
history, physical
examination,
laboratory evidence of
immune dysfunction,
signs and symptoms,
and infections and
malignancies
(Smeltzer & Bare,
2004, 1559)
3 categories: A, B, C
Clinical Category A
This category is asymptomatic.
The virus reaches a set point level after about
6 months.
The set point generally determines rate of
disease progression.
In general, 8-10 years can pass before HIV-
related complications occur.
Why asymptomatic? CD4 levels are high enough
to fight off other pathogens (>500 CD4+ T-
lymphocytes/mm^3)
Clinical Category B
CD4 cell level starts dropping (200-499
CD4+ T-lymphocytes/mm^3).
This category consists of conditions that
are not covered under category C. The
conditions must:
Be due to HIV infection
Require management that is complicated by
HIV infection
Clinical Category B
Some of the conditions under this
category include:
Candidiasis (oropharyngeal or vulvovaginal)
Cervical carcinoma in situ
Fever (38.5 C), or diarrhea > 1 month
duration
Herpes zoster (shingles)
Pelvic inflammatory disease
Peripheral neuropathy
Clinical Category C
When CD4 T-cell levels drop below 200
CD4+ T-lymphocytes/mm^3, the client is
said to have AIDS. Below 100, the
immune system is significantly impaired.
Once a client is classified as having
category C infection, s/he remains in this
category.
Clinical Category C
Some conditions in this category include:
Candidiasis (bronchi, trachea, lungs, or
esophagus)
Cervical cancer, invasive
HIV-related encephalopathy
Kaposis sarcoma
Pneumocystis carinii pneumonia
Toxoplasmosis of brain
Wasting syndrome due to HIV
Treatment of HIV
Antiretroviral treatments
Compliance may be decreased
by the side effects of the
drugs, or by clients deficiency
of knowledge about the
treatment.
In developing and transitional
countries, 7.1 million people
are in immediate need of life-
saving AIDS drugs; of these,
only 2.015 million (28%) are
receiving the drugs.
Nucleoside Reverse Transcriptase
Inhibitors (NRTIs)
These were the first antiretrovirals
approved by the European and American
regulatory agencies.
Becomes part of the viral DNA, stopping
the building process.
These are the cornerstone for HIV
therapy.
Side Effects of NRTIs
Some possible adverse effects
of this class of drugs:
Peripheral neuropathy,
pancreatitis, lactic acidosis,
bone marrow suppression,
neutropenia, anemia,
arthralgia, myopathy, kidney
dysfunction, hepatomegaly,
liver failure, hypersensitivity,
abdominal pain, oral ulcers,
irritability, anxiety.
(Smeltzer & Bare, 2004, 1563)
Non-nucleoside Reverse
Transcriptase Inhibitors (NNRTIs)
Blocks the HIV reverse transcriptase in a
different method from the NRTIs.
Attaches to the reverse transcriptase and
prevents conversion of HIV RNA into HIV DNA.
Used in combination with NRTIs and PIs.
Side Effects of NNRTIs
Possible adverse reactions of this class of
drug include:
Abnormal liver function tests, hepatitis,
stomatitis, numbness, muscle pain,
drowsiness, changes in dreams, trouble
concentrating.
Protease Inhibitors (PIs)
Prevents protease enzyme from cleaving HIV
proteins into the smaller, functional units. When
PIs are taken, the HIV copies that are made
cannot infect CD4+ cells and lymphocytes.
When taken alone, the virus quickly develops
resistance to its effects, so PIs are always taken
with other drugs.
Missed doses leads to virus resistance and drug
failure.
Side Effects of PIs
The following may be some of the adverse
effects associated with PIs:
Hemolytic anemia, parasthesia, kidney
stones, asymptomatic hyperbilirubinemia,
dyspepsia, altered taste, mood alterations,
drowsiness.
HAART
Highly active antiretroviral treatment
A regimen that consists of 2 NRTIs + a PI
(or NNRTI)

OR

2 PIs + one other antiretroviral agent


Decision Making
Treatment decisions
for every patient is
individualized and
based on 3 factors:
Viral load
CD4 T-cell count
Clinical condition of
patient
Opportunistic Infections (OIs)
Infections that occur
because of the clients
compromised immune
system- do not occur
in people with normal
immune systems.
Pneumocystis carinii Pneumonia
(PCP)
Most common OI which
leads to a diagnosis of
AIDS.
Without prophylaxis, 80%
of all HIV-infected clients
will develop PCP.
S&S: nonproductive
cough, fever, chills, SOB,
dyspnea, chest pain.
Untreated, it causes
respiratory failure.
Mycobacterium avium complex
(MAC)
MAC is a group of bacilli that usually
causes respiratory infection.
May also be found in the GI tract, lymph
nodes, and bone marrow.
Tuberculosis (TB)
TB tends to occur early in HIV infection.
If it occurs late in HIV infection, there may
be no response to a tuberculin skin test.
(This is called anergy, which happens due
to the immune system that can no longer
respond to the TB antigen.)
Oral Candidiasis
This is a fungal
infection that occurs
in nearly all patients
with AIDS.
It commonly precedes
other OIs.
Untreated, it
progresses to the
esophagus and
stomach.
Wasting Syndrome
Characterized by
>10% weight loss
and chronic diarrhea
for more than 30 days
OR chronic weakness
and intermittent or
chronic fever.
Wasting syndrome
can not be managed
by nutritional support
alone.
Kaposis Sarcoma (KS)

Most common malignancy in HIV infection.


Involves the blood and lymphatic vessels.
AIDS related KS has a more variable and aggressive
course than classic KS.
It may be characterized by skin lesions, or multiple
organ system involvement.
Diagnosis comes from biopsy of suspicious lesions.
B-Cell Lymphomas
Second most common malignancy in HIV-
infected clients.
Often occurs in the brain, bone marrow
and GI tract.
Chemotherapy is not as effective in HIV-
related lymphomas.
HIV Encephalopathy
Formerly referred to as AIDS dementia
complex.
Clinical syndrome consisting of a
progressive decline in cognitive,
behavioral, and motor function.
HIV has been found in the CSF of patients
with this syndrome.
S&S of HIV Encephalopathy
Early stage: memory loss, difficulty
concentrating, headache, confusion,
psychomotor slowing, apathy, ataxia.
Later stage: Global cognitive impairments,
delay in verbal responses, hyperreflexia,
psychosis, hallucinations, tremor,
incontinence, seizures, mutism, death.

(Smeltzer & Bare, 2004, 1567).


Nursing Management
There are many complications associated with
AIDS!
Nursing interventions remain the same as other
people with those conditions
Dont forget about the pyschosocial implications
Terminal illness
Isolation (physical and emotional)
Coping
Grief
Guilt and anger : associated with transmitting the
disease
Stigma
Nursing Managment

Dont contribute to the stigma associated with


AIDS
Dont make assumptions
Dont treat your patient any different
Use universal precautions with ALL patients
Nursing Management

Protect Yourself!!!
Healthcare Workers Reported to have AIDS

Occupational Exposure
DOES occur.
HCPs reported to
have AIDS:
Physician 1792
Lab technician 3182
Dental worker 492
Surgeon 122
Nurses ???
Occupational Exposure to HIV
Exposure to HIVinfected blood via
percutaneous injury:
3/1000
Mucocutaneous exposure:
Less than 1/1000
Intact Skin:
No known risk
Post-Exposure Prophylaxis (PEP)
Administration of antiretroviral
medications (ARVs) after exposure to
HIV.
Given as soon as possible after exposure
Must be within 72 hours
4-week treatment with 2-3 different ARVs
Standard procedure since 1996.
Reduces transmission by 79%
PEP contd
Page 2145, Smeltzer
& Bare
Table 70-5
Recommended
Algorithm used to
determine PEP
Should a needlestick injury
occur

What are you going to


do???
Wash area thoroughly with soap and
water
Alert supervisor, documentation.
Identify source patient
Give consent for baseline testing
PEP
Follow-up with PEP testing 6 weeks , 3
months and 6 months after beginning
treatment
Documentation
Day et al., 2007.
PEP use for non-occupation exposure

Non-occupational HIV exposures,


commonly related to unsafe behaviors.
Would PEP encourage unsafe behaviors?
No research indicated PEP works for non-
occupational exposure.
PEP not a morning after pill
Preventative Strategies:Universal
Precautions
Routine use of barriers (gloves, gowns,
masks, goggles)
Washing skin surfaces immediately after
contact with blood or body fluids.
Disinfecting instruments and contaminated
equipment.
Properly handling soiled linens
Careful handling/disposal of sharp
instruments.
Documentation of sterilization quality
following procedures.
page 1557 Smeltzer & Bare, Chart 52-3
Building Better Prevention Programs

Administrative Efforts
Development/ Promotion of the use of safety
devices.
Sharp disposal containers
Disposable instrument use
Monitoring of the effectiveness of PEP.
Pre-Exposure Prophylaxis for HIV
Various studied have shown that antiretroviral
treatment given at or shortly after HIV exposure
can reduce likelihood of transmission
this lead to the hypothesis that transmission
may be decreased even further if treatment
were delivered before exposure to HIV
Paxton, 2007).
Tenofir
Safety/ effectiveness still unknown.
Ethics - Tenofir
Think about
Obligations of govt to provide pre-exposure
prophylaxis
Appropriate indications for prescribing Tenofir (
think high-risk populations)
Who should have priority for pre-exposure
prophylaxis?
Stigmatization:
- Stigma attached to engagement in risky behaviors
- Decision making clouded by underlying beliefs
Nursing Care of the HIV positive client:
THE NURSING PROCESS

ASSESSMENT
-identify risk factors
- unsafe sexual practices
- IV drug use
- Physical Assessment focus on Immune system
- Psychological status
- Nutritional status
- Skin integrity
- Respiratory status
- Neurological status
- Fluid and electrolyte balance
- Knowledge level
NSG DIAGNOSIS
Impaired skin integrity r/t percutaneous
manifestations of HIV infection.
Risk for fluid volume deficit r/t diarrhea
Risk for infection r/t immunodeficiency
Activity intolerance r/t weakness, fatigue.
Pain r/t impaired skin integrity
Anticipatory greiving r/t changes in lifetsyle 2
diagnosis of AIDS
Social isolation r/t stigma of the disease, fear of
infecting others
Ineffective A/W clearance r/t increased bronchial
secretions, decreased ability to cough.
PLANNING

Goals for Patient???


Achievement/Maintenance of skin
integrity
Maintenance of usual bowel habits
Absence of infection
Improved activity tolerance
Increased comfort
Increased socialization
Improved nutritional status
Increased knowledge base
Absence of complications
NSG INTERVENTIONS

Promote skin integrity


Promote usual bowel habits
Prevent infections
Improve activity intolerance
Maintaining health
Improving A/W clearance
Relieving pain.increasing comfort
Nutritional status
Coping
Monitor for complications
EVALUATION

Expected Patient Outcomes:


Maintains skin integrity
Experiences no infections
Maintains adequate activity tolerance
Experiences increased sense of comfort
Progresses through grieving process
Remains free of complications
Ethical considerations
Many patients with HIV have engaged in
stigmatized behaviors.
Challenges traditional, religious and moral
values of HCPs.
Fear and anxiety re: disease transmission.
The impact of an epidemic on a
culture/society (lost generation, orphans, etc)
Nurses encouraged to examine own personal
beliefs / values clarification.
Challenges legal and political systems
End of Life Care
Pg. 1584, Smeltzer & Bare Chart 52-10