HIV Infection and AIDS Dr. Belal M. Hijji, RN. PhD May 25 & 28, 2011

2 By the end of this lecture, students will be able to: Describe the transmission and prevention of HIV Discuss the importance of preventive education Describe the standard precautions of infection prevention, and measure that healthcare providers need to take postexposure prophylaxis Identify the main stages of HIV Recognise some of the drugs used in HIV treatment Use the nursing process as a framework to address a nursing problem related to HIV Learning Outcomes

3 HIV Transmission HIV-1 is transmitted in body fluids containing HIV and/or infected CD4+ (or CD4) T lymphocytes. These fluids include blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk. Breaks in the skin or mucosa results in the increased probability of exposure to HIV.

4 CD4 molecule CD4 (cluster of differentiation 4) is a glycoprotein expressed on the surface of T helper cells, regulatory T cells, monocytes, macrophages, and dendritic cells.

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6 Prevention of HIV Infection Eliminating or reducing risk behaviors. Primary prevention efforts through effective educational programs are vital for control and prevention.

7 Preventive Education Public education regarding safer sexual practices. Latex condoms should be used during intercourse. Nonlatex condoms for people with latex allergy. Avoiding sexual practices that might cut or tear the lining of the rectum, penis, or vagina and avoiding sexual contact with multiple partners. In the absence of needle exchange programs, injection drug users should be instructed on methods to clean their syringes and to avoid sharing cotton and other drug use equipment.

8 Transmission to Health Care Providers Standard precautions are guidelines that were developed to prevent the transmission of infection during patient care for all patients, regardless of known or unknown infectious status. Attention needs to be given to the following aspects: –Hand washing after touching blood, body fluids, secretions, excretions, and contaminated items. Wash hands immediately after removing gloves, and between patient contacts to avoid transfer of microorganisms to other patients. Wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites.

9 –Gloves: Wear clean gloves when touching blood, body fluids, secretions, excretions, contaminated items, and just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same patient after contact with materials that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient. –Mask, eye protection, face shield: Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.

10 –Patient care equipment: Handle used patient care equipment soiled with blood or body fluids in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. Ensure that disposable items are discarded properly. –Environmental control: Hospitals should have adequate procedures for cleaning and disinfection of environmental surfaces, beds, bed rails, and bedside equipment. –Linen: Handle, transport, and process used linen soiled with blood fluids in a manner that prevents skin and mucous membrane exposures and contamination of clothing and that avoids transfer of microorganisms to other patients and environments.

11 –Occupational health and blood-borne pathogens: Take care to prevent injuries when using sharp instruments such as needles and scalpels after procedures, when cleaning used instruments, and when disposing of used needles. Never recap used needles. Do not remove used needles from disposable syringes by hand. Place used disposable syringes and needles and scalpel blades in appropriate containers close to the area in which the items were used. Use mouthpieces or resuscitation bags as an alternative to mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable. –Patient placement: Place a patient who contaminates the environment or who does not or cannot be expected to assist in maintaining appropriate hygiene or environmental control in a private room. Otherwise, consult with infection control professionals regarding patient placement or other alternatives.

12 Postexposure Prophylaxis For Health Care Providers If you sustain a needle stick injury, take the following actions immediately: – Wash the area with soap and water. –Alert your supervisor and initiate the injury-reporting system used in the setting. –Identify the source patient for possible testing. –Have your blood tested for HIV, hepatitis B, and hepatitis C. –Start the prophylaxis medications for HIV within 2 hours after exposure. –Practice safer sex until follow-up testing is complete. –Follow up with postexposure testing at 6 weeks, and at 3, 6, and 12 months.

13 Stages of HIV Disease Primary Infection –The period from infection with HIV to the development of antibodies to HIV. –There is intense viral replication and widespread dissemination of HIV throughout the body. Symptoms range from none to severe flu-like symptoms. –The person is infected with HIV but tests negative on the HIV antibody blood test.

14 HIV Asymptomatic –By about 6 months, the rate of viral replication reaches a lower but relatively steady state. –8 to 10 years pass before a major HIV-related complication develops. –In this prolonged, chronic stage, patients feel well and show few symptoms. –Apparent good health continues because CD4 T-cell levels remain high enough to preserve defensive responses to other pathogens.

15 HIV Symptomatic –Over time, the number of CD4 T cells gradually falls. –This stage consists of symptomatic conditions in HIV- infected patients including, but not limited to, candidiasis, cervical carcinoma, fever, diarrhea exceeding 1 month in duration, oral herpes zoster, idiopathic thrombocytopenic purpura, pelvic inflammatory disease, and peripheral neuropathy.

16 AIDS –When CD4 T-cell levels drop below 200 cells/mm3 of blood, patients are said to have AIDS. –One complication of advanced HIV infection is anemia, which may be caused by HIV, opportunistic diseases, and medications. –Complex conditions are present such as candidiasis of bronchi, trachea, or lungs, cervical cancer, cytomegalovirus retinitis (with loss of vision), encephalopathy, HIV-related herpes simplex, bronchitis, pneumonitis, or esophagitis, lymphoma, mycobacterium tuberculosis, pneumocystis carinii pneumonia, recurrent Salmonella septicemia, recurrent toxoplasmosis of brain

17 Assessment and Diagnostic Findings Obtain patient history in relation to his/ her sexual practices, injection drug use, and receipt of blood transfusions. Assess exposure to body fluids containing infected blood while providing care to others with HIV infection, such as through needle sticks. Patients who are in later stages of HIV infection may have a variety of symptoms related to their immuno-suppressed state. Several screening tests are used to diagnose HIV infection. These are EIA (enzyme immunoassay), Western blot, viral load, and CD4/CD8 ratio.

18 Treatment of HIV Infection Treatment is carried out using antiretroviral drugs. These include: –Zidovudine (AZT, Retrovir), lamivudine (3TC, Epivir), d4t (Zerit, stavudine), ddc (Hivid, zalcitabine), abacavir (Ziagen). –Nevirapine (Viramune), delavirdine (Rescriptor), efavirenz (Sustiva), tenofovir (Viread). –Nelfinavir (Viracept), ritonavir (Norvir), saquinavir (Invirase,Fortovase)

19 Applying the Nursing Process to Manage a Nursing Problem Related to HIV Nursing Diagnosis: Deficient knowledge related to means of preventing HIV transmission Goal: Increased knowledge concerning means of preventing disease transmission

20 Instruct patient and family about routes of HIV transmission. Instruct patient and family about means of preventing transmission of HIV: –Avoid sexual contact with multiple partners. Use condoms during sexual intercourse. –Avoid sex with prostitutes. –Do not use injection drugs; if addicted and unable or unwilling to change behavior, use clean needles and syringes. –Women at risk of exposure to AIDS through sexual or drug practices should consult with a physician before becoming pregnant. Nursing Interventions

21 Patient and family state means of transmission. Reports and demonstrates practices to reduce exposure of others to HIV Avoids intravenous drug use Demonstrates knowledge of safer sexual practices Identifies means of preventing disease transmission States that sexual partners are informed about positive HIV antibodies in blood Avoids IV/injection drug use and sharing of drug equipment with others Outcomes