Zoya Minasyan RN-MSN-Edu

 Globally  33 million living with HIV  2.7 million new infections each year  2 million HIV-related deaths each year  In the United States 56,000 new infections each year Since the beginning of the epidemic, sub-Saharan Africa has been the most devastated, but the Caribbean, Asia, Eastern Europe, and South America also have growing epidemics. In developing countries, the major route of transmission is heterosexual sex, and women and children bear a large part of the burden of illness.

 Fragile virus transmitted only through contact with body fluids  Blood, semen, vaginal secretions, and breast milk  Sex with infected partner  Exposure to infected blood or blood products  Pregnancy, delivery, or breastfeeding

 RNA virus (retrovirus) discovered in 1983  Binds to specific CD4 and chemokine receptors to enter cell

5 HIV has gp120 glycoproteins that attach to CD4 and chemokine CXCR4 and CCR5 receptors on the surface of CD4 + T cells. Viral RNA then enters the cell, produces viral DNA in the presence of reverse transcriptase, and incorporates itself into the cellular genome in the presence of integrase, causing permanent cellular infection and the production of new virions. New viral RNA develops initially in long strands that are cut in the presence of protease and leave the cell through a budding process that ultimately contributes to cellular destruction.

 Reverse transcriptase assists to make viral DNA.  Viral DNA enters cell nucleus and splices itself into genome permanently.  Integrase

 Initial infection  Viremia (large viral levels in blood) for 2 to 3 weeks  Transmission is more likely when viral load is high.  Followed by prolonged period (years) of low viral load

 Cells with CD4 receptor sites are infected  CD4 + T cells (T helper cells)  Lymphocytes  Monocytes/macrophages  Astrocytes  Oligodendrocytes  Immune problems start when CD4 + T-cell counts drop to below 500 cells/ μL.  Normal range is 800 to 1200 cells/ μL.  Allows for opportunistic diseases

 Acute infection  Flulike symptoms  Fever, swollen lymph glands, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhea, or a diffuse rash  Occurs about 2 to 4 weeks after infection  Lasts for 1 to 2 weeks

 Early chronic infection  Generally asymptomatic  Fatigue, headache, low-grade fever, and night sweats often occur.  Most are not aware of infected status.

 Intermediate chronic  CD4 + T cells drop to 200 to 500 cells/ μL.  Viral load increases.  HIV advances to a more active state.

 Intermediate chronic symptoms  Thrush  Oral hairy leukoplakia  Shingles  Persistent vaginal candidal infections  Herpes  Bacterial infections  Kaposi sarcoma

Oral thrush involving hard and soft palate.

Oral hairy leukoplakia on the lateral aspect of the tongue.

Kaposi sarcoma (KS). Malignant vascular lesions. KS lesions can appear anywhere on the skin surface or on internal organs. Lesions vary in size from pinpoint to very large and may appear in a variety of shades.

 Late chronic or AIDS  Immune system severely compromised  Great risk for opportunistic disease  Possible malignancies, wasting, and dementia

 Common opportunistic diseases  Pneumocystis jiroveci pneumonia  Cryptococcal meningitis  Cytomegalovirus retinitis  Mycobacterium avium complex  Kaposi sarcoma  Influenza virus

Chest x-ray showing interstitial infiltrates as the result of Pneumocystis jiroveci pneumonia.

 Most useful screening tests detect HIV-specific antibodies  May take 2 months (window period) to detect antibodies

 Progression monitored by CD4 + T-cell counts and viral load  Abnormal blood tests common  Neutropenia, thrombocytopenia, and anemia  Altered liver function tests  Resistance tests

 Monitoring HIV disease progression and immune function  Initiating and monitoring antiretroviral therapy (ART)  Preventing, detecting, and treating opportunistic infections

 Managing symptoms  Preventing or decreasing complications of therapies  Preventing further transmission

 Initial visit  Gather baseline data  Education about spectrum of HIV, treatment, preventing transmission, improving health, and family planning

 Initial visit  Gather baseline data  Education about spectrum of HIV, treatment, preventing transmission, improving health, and family planning

 Main goals  Decrease viral load.  Maintain/raise CD4 + counts.  Delay HIV-related symptoms and opportunistic infections.

 Nucleoside, non-nucleoside, and nucleotide reverse transcriptase inhibitors  Inhibit the ability of HIV to make a DNA copy early in replication  Protease inhibitors  Interfere with activity of enzyme protease

 Fusion inhibitors  Interfere with HIV CD4 receptor site binding and entry into cells

 Combination antiretroviral therapy  Three or more drugs from different groups are prescribed at full strength.

 Prophylactic medication given to prevent opportunistic infection  Ongoing research seeks a biochemical means of preventing HIV transmission.

 Ask at-risk patients:  Received blood transfusion or clotting factors before 1985?  Shared needles, syringes, or other injection equipment with another person?

 Ask at-risk patients:  Had a sexual experience with your penis, vagina, rectum, or mouth in contact with these areas of another person?  Had a sexually transmitted disease (STD)?

 Assess diagnosed patients  Repeat assessments over time as circumstance changes

 Interventions  Adhere to drug regimens.  Promote healthy lifestyle.  Prevent transmission to others.  Have supportive relationships.

 Interventions  Maintain productive activity.  Explore spirituality.  Come to terms with living with disease, disability, and death.  Cope with symptoms and treatments.

 HIV is a highly variable chronic disease.  Holistic and individualized approach is best.

 Major goal: Prevention  Four strategies  Use testing as routine health care.  Use rapid testing.  Work to modify risky behaviors.  Offer tests universally to pregnant women.

 Prevention of HIV  Decreasing risks: Sexual intercourse  Use of barriers

 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.

 Prevention of HIV  Decreasing risks: Perinatal transmission  Prevent HIV in women.  Appropriately medicate HIV-infected pregnant women.

 Prevention of HIV  Decreasing risks: Work  Adhere to precautions and safety measures to avoid exposure.  Postexposure prophylaxis with combination ART.

 Testing is only sure method to determine infection.  Negative results: Opportunity for prevention education  Positive results: Treatment and education to protect sexual and drug-using partners  All testing should be accompanied by pretest and posttest education

 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

 Multidrug therapy can reduce viral load and disease progression, but it  Is complex  Has interactions  Does not work for everyone  Is expensive

 When to start therapy  Patient readiness is the most important concern.  To avoid burnout and nonadherence, treatment is recommended when immune suppression is great.

 Adherence to drug regimens is critical to prevent  Disease progression  Opportunistic disease  Viral drug resistance

 Ways to improve adherence  Understand each patient is unique.  Provide electronic reminders or timers.

 Recurring problems of infection, cancer, debility, and psychosocial/economic issues affect ability to cope.

 Social stigma  Behaviors may be viewed as immoral, illegal, or uncontrolled by infected person.

 Discrimination causes loss of jobs, homes, and insurance.  Most severe for women  Americans with Disabilities Act makes discrimination illegal.

 Common physical problems  Anxiety, fear, depression  Diarrhea  Peripheral neuropathy  Pain  Nausea/vomiting  Fatigue

 Common metabolic disorders  Lipodystrophy  Hyperlipidemia  Insulin resistance  Bone disease  Lactic acidosis  Cardiovascular disease

FiLipodystrophy manifestations.

 Management of metabolic disorders  Early detection  Dealing with symptoms  Helping to cope

 Focus of nursing intervention  Patient comfort  Promoting acceptance of finite nature of life  Helping significant others deal with loss  Maintaining safe environment