1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 34 HIV/AIDS.

1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Chapter 34

HIV/AIDS


Origin of HIV and AIDS

• Might have been as early as the 1940s• Not recognized as a new pathogen until the

early 1980s• Immune-deficiency conditions began to show

up among primarily urban, gay men in the United States

• In 1986, HIV-1 and HIV-2 were isolated as causal viruses of AIDS


Origin of HIV and AIDS

• Gay men were just the first to be affected• Infection soon seen in other populations

• Hemophiliacs• Patients who received a transfusion with HIV-

infected blood or blood products• Newborns and breast-fed infants of HIV-infected

mothers• Injection drug users• Partners having unprotected sex with those infected


Demographics

• Age• More than half of new infections in young adults 15

to 24 years of age—at least 27% of these are women

• Since 1981, HIV/AIDS has affected 123,711 adults older than 65 years of age

• Race• 1984

• Whites 49%, African Americans 27%, and Hispanics 12%

• 2004• Whites 37%, African Americans 40%, and Hispanics 22%


Pathophysiology

• Retrovirus• Transcription of genetic material is reversed

• RNA made into deoxyribonucleic acid (DNA) rather than the normal pattern of DNA to RNA

• Reverse transcriptase• An enzyme that is responsible for transcribing RNA into

DNA


Pathophysiology

• The life cycle of HIV• Penetrates body via blood and body fluids• Spherical• Two protein markers protrude from the virus

• gp120 and gp41• Attach to protein markers found on macrophages and T4

helper cells or CD4 and infuse genetic material into the host cell


Pathophysiology

• HIV DNA incorporated into host cell’s DNA• Billions of copies of HIV are made

• 21 billion new HIV virions are produced daily• Only about 2 billion new T4 cells are produced

• Eventually, the body is unable to maintain a healthy immune response and shows symptoms of HIV/AIDS


Pathophysiology

• The body’s response to HIV infection• Mounts a defense against the HIV virus through

antibodies and T cells• About 12 weeks after infection, the body produces enough

antibodies to be detected by standard HIV test• HIV viral load begins to drop, indicating partial

effectiveness of the body to rid itself of HIV• CD8 cells drop drastically in the late stages, and CD4 cells

slowly decline throughout the whole infection


Stages of HIV Infection

• Initial stage• Lasts 4 to 8 weeks• High levels of virus in the blood• Generalized flulike symptoms

• Latent stage• Lasts 2 to 12 years• Virus is inactive• Levels are high in the lymph nodes but low in the

blood


Stages of HIV Infection

• Third stage• Lasts 2 to 3 years• Patient experiences opportunistic infections • TH CD4 cells are usually <500 cells/mm³• Viral levels in the blood increase• Acquired immunodeficiency syndrome (AIDS)

• CD4 cell levels drop <200 cells/mm³

• This stage ends in death, usually within 1 year


Signs and Symptoms of HIV Infection

• Initial stage• Generalized flulike symptoms

• Latent stage• May have no symptoms initially• Eventually, frequent and persistent infections

• Fever, night sweats, swollen lymph nodes, headache, skin lesions, sore throat, dyspnea, burning with urination, or diarrhea

• Extreme fatigue and weight loss


Complications


Opportunistic Infections

• When CD4 cells, CD8 cells, and/or HIV antibodies fall below normal, infections and cancers take advantage and cause infection or cancer in the body

• Causes: parasites, fungi, bacteria, viruses• Leading cause of death with AIDS is

pneumonia due to unspecified organisms


Parasitic Infections

• Cryptosporidiosis and isosporiasis• Fairly common in the environment• Watery diarrhea; may be severe/persistent• Nursing care: preventing dehydration and

maintaining fluid and electrolyte balance• Antidiarrheal drugs• Intravenous fluids• Antimicrobial agents• Teach good hand washing and personal hygiene


Parasitic Infections: Toxoplasmosis

• Cats, mammals, and birds serve as hosts• Humans become infected by ingesting

contaminated, undercooked meats or vegetables or by contact with cat feces

• Affects any tissue; mainly brain, lungs, eyes• Toxoplasmosis encephalitis the most common

in immunosuppressed patients• Dull, constant headache, weakness, seizures


Parasitic Infections: Toxoplasmosis

• Pulmonary infection• Feverish illness that mimics Pneumocystis jiroveci

pneumonia with shortness of breath and nonproductive cough

• Eye infection• Loss of visual acuity as well as photophobia

• Wash hands, avoid undercooked raw meats, and avoid cat litterboxes


Fungal Infections

• Microsporidiosis• Source of human infection is unknown• Watery diarrhea with weight loss, malabsorption,

abdominal cramps, and flatulence• No curative therapy; treat the symptoms

• Low-fat, low-residue, high-protein, high-calorie diet• 3 L of fluid per day; avoid milk products• Teach good hand washing and good hygiene; avoid

ingestion of food or water contaminated with fecal matter


Fungal Infections

• Pneumocystis jiroveci pneumonia• Acquired by inhalation • Second leading cause of death in AIDS patients• Cysts prevent the exchange of gases• Shortness of breath on exertion, fever, and a

nonproductive cough• Treated with Bactrim, dapsone, clindamycin, and

pentamidine


Fungal Infections

• Aspergillosis• Lives in soil, water, and air• Pulmonary infection can develop when spores are

inhaled• Causes fever, cough, dyspnea, chest pain, and

hemoptysis• Usually fatal within 8 weeks• Avoid wet, cool places; decreases risk of infection


Fungal Infections

• Candidiasis• Found in most foods, soil, and inanimate objects• Approximately 80% of HIV patients will develop

candidiasis• Affects the mouth, vagina, and/or anus• Thrush: oral form of candidiasis• Candidal plaques can be scraped off


Fungal Infections

• Coccidioidomycosis• Endemic in the southwestern United States and

northern Mexico• Particles inhaled into the lungs• Fever, weight loss, fatigue, dry cough, or pleuritic

chest pain• Dissemination to other organs may occur • People with HIV should avoid exposure to disturbed

soils in endemic areas


Fungal Infections

• Cryptococcosis• Most common systemic fungal infection in AIDS

patients• Symptoms appear approximately 30 days after

exposure• Fever, headache, malaise, nausea, vomiting,

altered mental status, and a stiff neck


Fungal Infections

• Histoplasmosis• Endemic in the central and southern United States• Found in soil and bird droppings• Involves the lungs after spores are inhaled, then can

be disseminated to other organs• Fever, night sweats, weight loss, and shortness of

breath• Avoid cleaning bird cages to prevent infection


Viral Infections

• Cytomegalovirus (CMV)• Found in semen, cervical secretions, saliva, urine,

blood, and organs• Mainly transmitted by blood and body fluids through

unprotected sex• Complications include chorioretinitis, radiculopathy,

subacute encephalitis, colitis, esophagitis, and pneumonia


Viral Infections

• Herpes simplex (HSV) and herpes zoster (HZV)• Reactivated HSV in HIV patients can cause serious

disease and tissue destruction• HSV infection follows a predictable pattern

• Primary outbreak, latency, and possible reactivation at some later point in life

• Most adults carry HZV because of exposure to chickenpox virus as a child

• Reactivation of HZV usually occurs as shingles


Viral Infections

• Oral hairy leukoplakia (OHL)• Thick white patches on the buccal mucosa, soft

palate, floor of mouth, and tongue• Associated with Epstein-Barr virus• More common among smokers• The mouth is often painful

• Advise patient to drink from a straw• Ice cream or Popsicles can numb the area• Hot/spicy foods and alcohol may exacerbate mouth pain


Viral Infections

• Progressive multifocal leukoencephalopathy

• Caused by the Jamestown Canyon virus• Develops in 2% to 4% of AIDS patients• Progressive degeneration of white matter of the

brain• Death within 4-6 months after the onset of

symptoms• Symptoms include weakness and progressively

impaired speech, vision, and motor function• No effective treatment


Bacterial Infections

• Bacillary angiomatosis (BA)• Causes skin lesions; may affect any organ• Transmitted by cats and their fleas

• Due to a bite or scratch

• Papules/plaques occur anywhere on the skin• Advise HIV patient to avoid rough play with cats and

to make sure cats are treated for fleas



• Mycobacterium avium complex (MAC)• Found everywhere, including most food, animal, and

soil sources• May affect any organ of the body• Causes fever, fatigue, weight loss, night sweats,

abdominal pain, and diarrhea• Not contagious



• Mycobacterium tuberculosis (TB)• HIV patients much more likely than a healthy person

to become infected with TB if exposed, especially when CD4 counts drop below 200 cells/mm³


Kaposi’s Sarcoma

• Common neoplasm that develops with AIDS• Affects the skin first, appearing as a macular

painless, nonpruritic lesion• Color varies: pink, red, purple, and brown• Tumors may spread to the gastrointestinal

system and lungs• Treatment: observation, HAART, surgical

removal, cryotherapy, radiotherapy, chemotherapy


Lymphomas

• A type of cancer that originates in lymphoid tissue: bone marrow, spleen, thymus gland

• Two types: Hodgkin’s and non-Hodgkin’s • Second most common malignancy in AIDS

patients• Causes fever, night sweats, and weight loss• Diagnosis based on a biopsy of lymphoid

tissue


Medical Diagnosis of HIV

• HIV diagnosis• Positive HIV antibody test

• ELISA• Done first; 99% reliable

• Western blot• Used as a confirmation test; 99.99% reliable


Medical Diagnosis of HIV

• AIDS diagnosis• CD4 count of <200 cells/mm³; asymptomatic• CD4 count of <200 cells/mm³; with category B

symptoms• Category C symptoms regardless of CD4 count


Medical Treatment: Highly Active Antiretroviral Therapy (HAART)

• Recommended for HIV viral load of 5000-30,000 copies/mL and CD4 counts of 350-500 cells/mm

• Usual drug combination: 1 protease inhibitor and 2 nucleoside reverse transcriptase inhibitors

• Ability/willingness to comply with therapy• If patient will not be compliant with the medication regimen,

better to not even start

• GI upset common; reason for noncompliance• Many side effects; usually subside in a few weeks


Assessment

• Signs and symptoms of infection• Most common sites are lungs, mouth, GI tract, skin,

blood, and central nervous system

• Any changes should be reported to a registered nurse or physician

• Determine how much patient knows about the disease and treatment

• Assess how patient is coping with disease


Health History

• Sexually transmitted infection history• Surgical history• Medication history and allergies• Immunization history• Family history• Sexual history• Needle and blood exposure history


Health History

• Tobacco/alcohol use history• Illegal drug use history• Pet history• Occupational history• Nutritional history• Gynecologic history


Physical Examination

• Height, weight, vital signs• Skin• Head, ears, eyes, nose, and throat• Lymphatic system• Respiratory system• Cardiovascular system• Abdominal• Musculoskeletal• Neurologic• Genitourinary• Laboratory profile


Interventions

• Ineffective Therapeutic Regimen Management• Patient should receive accurate, consistent

information from all members of the health care team

• Clinical nurse specialist or other specially trained nurse can provide information about disease and treatment

• Excellent sources of information on the Internet• www.thebody.com• www.hivinsite.ucsf.edu


Interventions

• Anxiety• Dealing with emotions of facing a life-threatening

illness• Encourage patients to ask questions and talk about

their feelings• Information about disease and treatment may help

patient and family deal with their anxiety• May need referral to a social worker, chaplain, or

mental health counselor


Interventions

• Infection• Early detection and prompt treatment are vital• May be on anti-infective drugs prophylactically • Important to take drugs as prescribed• May need intravenous antibiotics

• Clinic or home administration


Interventions

• Impaired Oral Mucous Membrane• Encourage regular teeth and mouth cleaning with

dental floss and a soft toothbrush• Encourage fluids to maintain hydration to keep

mucous membranes moist• Topical anesthetics applied before eating• Regular dental evaluations can help prevent and

manage oral disease and infections


Interventions

• Imbalanced Nutrition: Less Than Body Requirements• Refer to dietitian for nutrition counseling as soon as

the patient is diagnosed• Oral supplements with Carnation Instant Breakfast,

Ensure, Sustacal, or Resource• Administer medications

• Improve appetite (megestrol, dronabinol)• Relieve nausea (prochlorperazine, metoclopramide)• Control diarrhea (diphenoxylate hydrochloride with atropine

sulfate)


Interventions

• Disturbed Thought Processes• Patients with HIV encephalopathy may experience

cognitive and motor impairment• May withdraw from social activities because of

embarrassment• May become angry and hostile• Safety constantly reevaluated based on mental and

physical capabilities


Interventions

• Pain• From opportunistic infections, viral invasion into the

nerves and muscles, malignant tumors, and diagnostic procedures

• Closely monitor pain level and medication use• Flow sheet of pain reports on a 10-point scale• Pain and amount of medication used can guide

nurse and physician to the appropriate type and amount of pain medication

1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 34 HIV/AIDS.

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