Human Immunodeficiency Virus Infection Chapter 14 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Human Immunodeficiency Virus Infection Retrovirus that causes immunosuppression making persons more susceptible to infections > 1 million currently living with HIV About 50,000 new infections occur in United States each year Effective treatment has led to a significant drop in death rates Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) A.O. is a 20-year old Hispanic male college student who comes to the student health center complaining of pain on urination. His urine test is positive for Neisseria gonorrhea. What should you do? Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Transmission of HIV HIV can be transmitted through contact with certain body fluids Blood, semen, vaginal secretions, and breast milk HIV is not spread through casual contact Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Sexual Transmission Unprotected sex with an HIV-infected partner is most common mode of transmission Greatest risk is for partner who receives semen Prolonged contact with infected fluids Women at higher risk Trauma increases likelihood of transmission Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Contact With Blood Sharing drug-using paraphernalia is highly risky Screening measures have improved blood supply safety Puncture wounds are most common means of work-related HIV transmission Copyright © 2017, Elsevier Inc. All Rights Reserved.

Pathophysiology of HIV HIV is a ribonucleic acid virus Called retroviruses because they replicate in a “backward” manner going from RNA to DNA CD4+T cell is the target cell for HIV Type of lymphocyte HIV binds to the cell through fusion Copyright © 2017, Elsevier Inc. All Rights Reserved.

HIV Proteins Bind to Cell 10 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Viral Load in Blood and CD4+ T-Cell Counts Copyright © 2017, Elsevier Inc. All Rights Reserved.

Pathophysiology of HIV Immune problems start when CD4+ T cell counts drop to < 500 cells/μL Severe problems develop when < 200 CD4+ T cells/μL Normal range is 800 to 1200 cells/μL Insufficient immune response allows for opportunistic diseases Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) A.O. informs you he has been sexually active since age 15 with both males and females. He states he is always “on top” (inserting partner). Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) He has had intercourse with 3 people in the last month and doesn’t use protection. What should you do next? Copyright © 2017, Elsevier Inc. All Rights Reserved.

Clinical Manifestations and Complications Acute Infection Flulike symptoms Fever, swollen lymph nodes, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhea, or a diffuse rash Occurs about 2 to 4 weeks after infection Highly infectious Copyright © 2017, Elsevier Inc. All Rights Reserved.

Clinical Manifestations and Complications Asymptomatic Infection Left untreated, a diagnosis of AIDS is made about 10 years after initial HIV infection Symptoms are generally absent or vague High risk behaviors may continue Copyright © 2017, Elsevier Inc. All Rights Reserved.

Clinical Manifestations and Complications Symptomatic Infection CD4+ T cells decline closer to 200 cells/μL Symptoms become worse HIV advances to a more active stage Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Oral Thrush Copyright © 2017, Elsevier Inc. All Rights Reserved.

Clinical Manifestations and Complications Symptomatic Infection Shingles Persistent vaginal candidal infections Herpes Bacterial infections Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Kaposi Sarcoma Copyright © 2017, Elsevier Inc. All Rights Reserved.

Oral Hairy Leukoplakia Copyright © 2017, Elsevier Inc. All Rights Reserved.

Clinical Manifestations and Complications AIDS Diagnostic criteria is established by CDC Immune system severely compromised Infections Malignancies Wasting HIV-related cognitive changes Copyright © 2017, Elsevier Inc. All Rights Reserved.

Pneumocystis jiroveci Pneumonia (From the Centers for Disease Control and Prevention. Courtesy Jonathan W.M. Gold, MD, New York.) Copyright © 2017, Elsevier Inc. All Rights Reserved. 25

Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study A.O. tells you he drinks at weekend parties and has smoked pot but “not recently.” He reports no regular use of injection drugs, tobacco, or anabolic steroids but that sometimes he gets so drunk he doesn’t remember. How would you rate his risk and why? (©iStockphoto/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Diagnostic Studies Most useful screening tests detect HIV-specific antibodies and/or antigens May take several weeks to detect antibodies (window period) Performed using blood or saliva Combination (4th generation) tests can detect HIV earlier Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Laboratory Studies HIV progression is monitored by CD4+ T-cell counts CD4+ T-cell count provides a marker of immune function Viral load The lower the viral load the less active the disease Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Diagnostic Studies Abnormal blood tests are common Caused by HIV, opportunistic diseases, or complications of therapy Decreased WBC counts Low platelet counts Anemia is associated with ART Altered liver function Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Diagnostic Studies Resistance tests can help determine if a patient is resistant to ART Assays help HCPs know which medications may be effective Genotype assay Phenotype assay Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Monitor disease progression, immune function, and manage symptoms Initiate and monitor ART Prevent, detect and/or treat opportunistic infections Prevent or decrease complications of therapies Prevent further transmission of HIV Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Initial patient visit Gather baseline data Begin to establish rapport and use patient input to develop a plan of care Initiate teaching about spectrum of HIV, treatment, preventing transmission, improving health, and family planning Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study A.O. returns to the clinic 3 months later after refusing HIV testing or teaching. He is now concerned as one of his “partners” was just diagnosed with HIV. He wants help. What should you tell him about HIV testing? (©iStockphoto/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Drug Therapy Main goals Decrease viral load Maintain/increase CD4+T counts Prevent HIV-related symptoms and opportunistic diseases Delay disease progression Prevent HIV transmission Copyright © 2017, Elsevier Inc. All Rights Reserved.

Drug Therapy - ART Antiviral Therapy Nucleoside reverse transcriptase inhibitor Protease inhibitor Nonnucleoside analogues Fusion inhibitors – Integrase Inhibitor

Copyright © 2017, Elsevier Inc. All Rights Reserved. Safety Alert Drug interactions Herbal therapies St. John’s wort Commonly used drugs OTC drugs Antacids, proton pump inhibitors, supplements Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Drug Therapy Opportunistic diseases complicate management of HIV infection Prevention is key Onset can be delayed with adequate measures Effective management has significantly increased life expectancy Copyright © 2017, Elsevier Inc. All Rights Reserved.

Preventing Transmission of HIV Pre-exposure prophylaxis (PrEP) Comprehensive strategy to reduce risk of sexually-acquired infection in adults at high risk Used in conjunction with proven prevention interventions Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Assessment Do not make assumptions about who may be at risk Candid conversation is important for effective management of HIV Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Assessment Ask at-risk patients Received blood transfusion or clotting factors before 1985? Shared needles with another person? Had a sexual experience: intercourse, oral or rectal with these areas of another person? Had a sexually transmitted infection? Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Assessment Assess diagnosed patients thoroughly Past health history Medications Functional health patterns Presence of symptoms using a systems review Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Planning Goals for care are aimed at Compliance with drug regimens Adopting a healthy lifestyle Beneficial relationships Spiritual well-being in regard to life and death Coping with the disease and its treatment Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Implementation Primary prevention and health promotion are the most effective strategies for diseases of a chronic nature including HIV When prevention fails Disease results Early intervention is facilitated by health promotion practices Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) A.O. says he will not be abstinent but is willing to use a condom during contact sex. What are the main points you need to cover when teaching about barrier methods of protection? Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Health Promotion HIV infection is preventable Avoid risky behaviors Modify risky behaviors Candid, culturally sensitive, language- appropriate, age-specific information and behavior change counseling Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Health Promotion Prevention of HIV Decreasing risks: Sexual intercourse Abstinence Noncontact safe sex Use of barriers Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Health Promotion Prevention of HIV Decreasing risks: Drug use Do not use drugs Do not share equipment Do not have sexual intercourse under the influence of any impairing substance Refer for help with substance use Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Health Promotion Prevention of HIV Decreasing risks: Perinatal transmission Family planning Prevent HIV in women Appropriately medicate HIV-infected pregnant women Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Health Promotion Prevention of HIV Decreasing risk: Work Adhere to precautions and safety measures to avoid exposure Report all exposures for timely treatment and counseling Post-exposure prophylaxis with combination ART can significantly decrease risk of infection Copyright © 2017, Elsevier Inc. All Rights Reserved.

HIV Testing and Counseling Testing is the only sure method of determining HIV infection CDC recommends universal, voluntary testing as part of routine medical care An estimated 14% of people living with HIV are not aware they are infected Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) As you talk to A.O. about barrier methods of protection, he begins to look away and seems to lose interest. He finally says, “I don’t know if I can do this.” What are some cultural considerations that may be a factor here? Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Acute Intervention Early intervention promotes health and delays disability Reactions to positive HIV test Similar to any life-threatening, chronic illness Panic, anxiety, fear, guilt, depression, denial, anger, hopelessness Copyright © 2017, Elsevier Inc. All Rights Reserved.

Antiretroviral Therapy ART can significantly slow HIV progression, but it Is complex Has side effects Does not work for everyone Is expensive Copyright © 2017, Elsevier Inc. All Rights Reserved.

Antiretroviral Therapy When to start therapy Patient readiness is most important concern To avoid burnout and non-adherence, treatment is recommended when immune suppression is great Copyright © 2017, Elsevier Inc. All Rights Reserved.

Antiretroviral Therapy Adherence to drug regimens is critical to prevent Disease progression Opportunistic disease Tx: antifungals, antibiotics Viral drug resistance An individualized approach is best Copyright © 2017, Elsevier Inc. All Rights Reserved.

Delaying Disease Progression Supporting a healthy immune system Adequate nutrition Current vaccinations Health habits Avoiding risky behaviors Supportive relationships Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) A.O. tells you he “really cares” about one of his partners. What do you tell him about informing his previous sexual partners about his gonorrhea? What should he tell them about the HIV infection if he tests positive? Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Acute Exacerbations HIV infection Has no cure Continues for life Causes physical disability Impairs social, emotional, economic, and spiritual wellbeing Ultimately leads to death Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Ambulatory Care Stigma can lead to discrimination and result in social isolation, dependence, frustration, low self-image, loss of control, and economic pressures This, in turn, could lead to further involvement in risky behaviors Copyright © 2017, Elsevier Inc. All Rights Reserved.

Disease and Drug Side Effects Common physical problems Anxiety, fear, depression Diarrhea Peripheral neuropathy Pain Nausea/vomiting Fatigue Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Metabolic Disorders Lipodystrophy Hyperlipidemia Insulin resistance Hyperglycemia Bone disease Lactic acidosis Renal disease Cardiovascular disease Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Lipodystrophy Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) One year later A.O. returns to the clinic with complaints of night sweats and a productive cough for 1 week. His CD4+ lymphocyte count is 76 cells/µL. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) He has lost 13 pounds in the last month. His record shows a history of a positive PPD. What do you think is happening? Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved. End-of-Life Care Focus of nursing intervention Patient comfort Promoting acceptance of finite nature of life Helping significant others deal with loss Maintaining safe environment Copyright © 2017, Elsevier Inc. All Rights Reserved.

Gerontologic Considerations Increasing rates of HIV disease among older adults Death rate from opportunistic infections reduced People 60 and older are increasingly being infected Copyright © 2017, Elsevier Inc. All Rights Reserved.

Audience Response Question A diagnosis of AIDS can be made for a patient with HIV with a CD4+ T-cell count <500/µL. a WBC count <3000/µL (3 × 109/L). development of oral candidiasis (thrush). onset of Pneumocystis jiroveci pneumonia. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Audience Response Question The nurse is teaching a newly diagnosed 34-year-old male about his HIV infection. Which statement by the patient would indicate the patient needs additional education? “I will need to take my HIV medication daily for the rest of my life.” “Although I only take one pill, it has multiple medications combined into a single tablet.” “I should notify my HIV provider if I get fevers that do not go away with Tylenol or aspirin.” “Once my viral load is undetectable I don’t have to worry about taking my medication every day.” Copyright © 2017, Elsevier Inc. All Rights Reserved.

Audience Response Question The nurse is caring for a patient who is receiving antiretroviral therapy (ART) for treatment of AIDS. Which assessment best indicates that the patient’s condition is improving? Decreased viral load Increased drug resistance Decreased CD4+ T-cell count Increased aminotransferase levels Copyright © 2017, Elsevier Inc. All Rights Reserved.

Audience Response Question The nurse informs the patient with a bacterial pneumonia that the most important factor in antibiotic treatment is antibiotics should have been used to prevent pneumonia. all of the supplied antibiotics should be taken even when symptoms have resolved. enough antibiotics for 2 days’ treatment should be reserved in case symptoms recur. patients should request antibiotics for upper respiratory infections to prevent development of streptococcal-related diseases. Copyright © 2017, Elsevier Inc. All Rights Reserved.