HIV and Aids

·         Acquired Immune Deficiency Syndrome (AIDS) is a chronic, life threatening condition caused by Human Immunodeficiency Virus (HIV).

·         Characterized by generalized dysfunction of the immune system making individuals susceptible to opportunistic infections & tumors.

·         Pneumocystis carinii pneumonia: most common opportunistic infection. 

·         Incubation period estimates range from 6 months to 9 years.

Pathophysiology:

·         HIV binds with CD4+T cells and replicates by generating a DNA copy by reverse transcriptase.

·         HIV causes AIDS by destroying CD4+T cells which leads to a weak immune system allowing opportunistic infections.

Epidemiology:

·         5^th leading cause of death among ages 25-44 years in the US

·         In the US, it is common among African American, Hispanics and Caucasians. (CDC)

·         Most HIV infections occur in men due to homosexual contact but the incident is already increasing among women who engage in unprotected sexual activities.

Mode of Transmission:

·         Horizontal transmission: Sexual contact (oral, vaginal, anal sex); parenteral exposure to blood or body fluid containing visible blood.

·         Vertical (perinatal) transmission: HIV infected pregnant woman passes the infection to fetus during pregnancy, delivery or breastfeeding.

Clinicl Stages of HIV/AIDS	Signs & Symptoms
Stage I.         Asymptomatic/Primary    HIV infection	Flu-like symptoms ü  Fever ü  Myalgia ü  Persistent generalized lymphadenopathy ü  Headache
Stage II.	ü  Person may experience outbreak of herpes zoster ü  Recurrent respiratory tract infection ü  Chronic diarrhea for longer than 1 month
Stage III.	ü  Integumentary problems ü  Gynecological problems
Stage IV.	ü  HIV wasting syndrome ü  Development of opportunistic infections

Diagnostic Exams:

§  AIDS is present if there is 2 positive results of ELISA confirmed with positive result on Western blot assay.

§  Enzyme –linked immunosorbent assay (ELISA)/ Enzyme immunoassay (EIA)

o Identifies antibodies directed specifically to HIV.

o Useful in children older than 18 months.

§  Western blot assay

o Confirm HIV infection

                        Useful in children older than 18 months

§  Viral load tests: Reverse Transcriptase- Polymerase Chain Reaction (RT-PCR) & Nucleic Acid Sequence-Based Amplification (NASBA)

o < 10,000 copies/mL = low risk AIDS

o > 100,000 copies/mL = High risk for AIDS. (+) viral activity

o Measures HIV RNA in the plasma.

o Measures response to treatment.

o RT-PCR detects HIV in high risk seronegative people before antibodies are measurable, screen neonates, & confirm + EIA result.

§  CD4/CD8 Ratio

o Helper/ suppressor ratio = degree of immune suppression.

o CD4 count of <200/mm3: indicates AIDS

o Normal values depend on age (ratio 0.9 to 3.7 in adults).

§  p24 antigen

o 2 or more positive results are diagnostic for HIV infection

o Used o detect HIV antigen in children younger than 18 months.

§  Nonspecific markers of disease progression: blood counts, albumin levels & ESR

§  Skin biopsy, serum chemistries and imaging studies are indicated depending on organ/system involvement & disease progression.

Treatment:

·         There is no cure; prevention is the only key to control.

·         Highly Active Antiretroviral Therapy (HAART): reduces the number of HIV particles in the blood stream as measured by viral load test.

-    Combination of three (3) drugs belonging to 2 types of antiretroviral agents.

-    Side effects include: lipodystrophy, dyslipidaemia, diarrhea, insulin resistance, an increase in cardiovascular risks and birth defects.

-    n.b: Patient problem with HAART: non-adherence with complex administration leads to drug resistance development.

·         Antiretroviral drugs: inhibit the growth and replication of HIV at various stages of its life cycle.

Types/Classes:

1.        Nucleotide reverse transcriptase inhibitors/NtRTIs & Nucleoside analogue reverse transcriptase inhibitors/NRTIs (“nukes”): inhibit the replication of an HIV enzyme called reverse transcriptase.

E.g.  idovudine (Retrovir^®) [formerly called AZT azidothymidine], lamivudine (Epivir^®) didanosine (Videx^®), zalcitabine (Hivid^®), stavudine (Zerit^®) and abacavir (Ziagen^®)

2.        Protease inhibitors (PIs): interfere with an enzyme known as HIV protease. This causes HIV particles in your body to become structurally disorganized and noninfectious.

e.g atazanavir/ATV (Reyataz^®), darunavir/DRV (Prezista^®), Fosamprenavir/FPV (Lexiva^®), lopinavir + ritonavir (Kaletra^®), saquinavir/SQV (Invirase^®), tipranavir/TPV (Aptivus^®)

3.        Non-nucleoside reverse transcriptase inhibitors (NNRTIs): bind directly to the enzyme reverse transcriptase. E.g efavirenz (Sustiva^®, Stocrin^®);  nevirapine (Viramune^®); delavirdine (Rescriptor^®); etravirine (Intelence^®)

1.        Fusion inhibitors (entry inhibitors): suppress resistant strains of HIV. e.g maraviroc (Selzentry^®), enfuvirtide (Fuzeon^®)

2.        Integrase inhibitors: aims to treat those who become resistant to other treatments. e.g raltegravir (Isentress^®)

·         CCR5 antagonists: new class of drugs used to treat a particular type of HIV infection called CCR5-tropic HIV-1

E.g. maraviroc (Selzentry^®)

Side effects: liver problems, postural hypotension, inflammation response.

·         Oral Progesterone (Megace^®, Winstrol^®): stimulate appetite thereby assisting with the treatment of weight loss (HIV Wasting Syndrome)& loss of taste perception

·         For disease progression: Antibiotic therapy, chemotherapy, analgesic, antiemetic, antifungal & appetite stimulants.

·         Supportive care for chronic illness associated with HIV infection: O2 therapy, IV fluid, electrolyte replacement and mechanical ventilation (end stage AIDS).

Prevention:

If HIV negative:

·         Know the HIV status of your partner.

·         Provide client education regarding safe & protected sex:

o Latex condom: vaginal or anal intercourse

o Dental dam: used for oral contact with the vagina or rectum

o Avoid sexual contact with multiple partners.

·         Consider male circumcision

·         Use sterile needle & avoid needle sharing.

·         Be cautious about blood products.

·         Get routine HIV testing

If HIV positive:

·         Follow safe sex practices.

·         Tell your sexual partner that you have HIV.

·         Don’t share needles or syringes.

·         Don’t donate blood or organ.

·         Don’t share razors, toothbrush, sex toys or blood contaminated articles.

·         Drug users interested in drug treatment programs must be referred.

·         Get immediate medical care if pregnant.

·         Don’t breastfeed the infant.

·         TB testing 

For health workers:

·         Standard precautions: apply to blood, body secretions & excretions.

Nursing Interventions:

·         Use of universal precautions for all clients regardless of diagnosis.

·         Provide ongoing coordination of health care team to afford client the best possible assistance.

·         Provide emotional support, counseling and referral to support group.

·         Protect the client from secondary infections; assess for early signs and report for treatment.

·         Maintain client advocacy and confidentiality.

·         Refer to dietician to analyze nutritional requirements & make recommendations to maintain ideal body weight.

·         Provide high-caloric, high protein diet to prevent weight loss.

·         Encourage intake of foods rich in vitamins A, C & E.

·         Educate on:

o    Importance of compliance to long-term treatment regimen.

o    Stress the need for follow-up check-up & diagnostic tests to monitor response to treatment & disease progression.

Discuss life issues with the client & support system members as disease progresses & prognosis worsens