Nursing Continuing Education

HIV/AIDS

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This is Your Course on HIV/AIDS


Human immunodeficiency virus (HIV) is a retrovirus that is transmitted through blood and body fluids (semen, vaginal secretions). HIV targets CD4+ lymphocytes, also known as T‑cells or T‑lymphocytes. T‑cells work in concert with B‑lymphocytes. Both are part of specific acquired (adaptive) immunity. HIV integrates its RNA into host cell DNA through reverse transcriptase, reshaping the host’s immune system.

HIV is found in feces, urine, tears, saliva, cerebrospinal fluid, cervical cells, lymph nodes, corneal tissue, and brain tissue, but epidemiologic studies indicate that these are unlikely sources of infection.

All clients who are pregnant are screened for HIV.

Disease Process Stages

HIV infection is one continuous disease process with three stages.

Progression of HIV infection

  • Manifestations occur within 2 to 4 weeks of infection. 
  • Manifestations are similar to those of influenza and can include a rash, night sweats, and a sore throat. 
  • This stage is marked by a rapid rise in the HIV viral load, decreased CD4+ cells, and increased CD8 cells. 
  • The resolution of manifestations coincides with the decline in viral HIV copies. 
  • Lymphadenopathy persists throughout the disease process.

Chronic asymptomatic infection

  • This stage can be prolonged and asymptomatic. 
  • The client can remain asymptomatic for 10 years or more, but can develop generalized lymphadenopathy. 
  • Anti‑HIV antibodies are produced (HIV positive). 
  • Over time, the virus begins active replication using the host’s genetic machinery. 
  • CD4+ cells are destroyed. 
  • The viral load increases. 
  • Dramatic loss of immunity begins. 

AIDS

  • This stage is characterized by life‑threatening opportunistic infections. 
  • This is the end stage of HIV infection. Without treatment, death occurs within 5 years.
All people with AIDS have HIV, but not all people who have HIV have AIDS.


Health Promotion and Disease Prevention

  • The virus is transmitted through blood and body fluids. Ways to prevent infection include the use of condoms, abstinence, and avoiding sharing needles. 
  • Maintain up‑to‑date immunizations, including yearly seasonal influenza and pneumococcal polysaccharide vaccine. 
  • Providers should use standard precautions when caring for the client.

Data Collection

Risk Factors

  • Unprotected sex (vaginal, anal, oral) 
  • Multiple sex partners 
  • Occupational exposure (health care workers) 
  • Perinatal exposure 
  • Blood transfusions (not a significant source of infection in the U.S.) 
  • IV drug use with a contaminated needle 
Older adult clients
  • HIV infection can go undiagnosed in older adult clients due to the similarity of its manifestations to other illnesses that are common in this age group. 
  • Older adults are more susceptible to fluid and electrolyte imbalances, malnutrition, skin alterations, and wasting syndrome than younger adults. 
  • Older adult women experience vaginal dryness and thinning of the vaginal wall, increasing their susceptibility to HIV infection.

Expected Findings

  • Chills 
  • Rash 
  • Anorexia, nausea, weight loss 
  • Weakness and fatigue 
  • Headache and sore throat 
  • Night sweats

Laboratory Tests

CBC and differential: Abnormal (anemia, thrombocytopenia, leukopenia)

Platelet count: Less than 150,000/mm3

Diagnostic Procedures

  • Positive result from an HIV antibody screening test (enzyme‑linked immunosorbent assay [ELISA]) confirmed by a positive result from a supplemental HIV antibody test (Western blot or indirect immunofluorescence assay [IFA]) 
  • Home test kits are also available using a drop of blood. These provide anonymous registration and counseling before the test via a telephone call. 
  • Two noninvasive tests are available using either mucosal fluid or urine. 
  • Client who has a positive result from a confirmatory test, such as Western blot, should then be tested for viral load

HIV RNA quantification (HIV viral load test)

  • Determines viral load before beginning treatment 
  • Can be repeated at intervals to monitor disease progression, identify compliance with treatment and determine HIV medication resistance 
  • Treatment is needed for levels greater than 5,000 to 10,000 copies/mL depending on CD4 counts.

HIV drug resistance testing (HIV genotype or HIV tropism)

  • Guides changes in medication therapy when resistance occurs 
  • Useful with CD4 counts fall despite therapy

Liver profile, biopsies, and testing of stool for parasites

Nursing Actions
  • Prepare the client for the test. 
  • Inform the client about the details of the test (length, what to expect). 
  • Allow the client time to ask questions or express emotions.
Client Education
  • A positive Western blot or IFA test means the AIDS virus is in the body but does not mean the client has clinical AIDS. 
  • Use safe sexual practices.

Brain or lung MRI or CT scan

Detailed image of the brain or lung to detect abnormalities

Nursing Actions

Prepare the client for the procedure.

Client Education

The test takes up to 1 hour.

CD4+ cell count

  • Used to confirm progression from HIV infection to AIDS. 
  • The expected reference range for the CD4+ count is 800 to 1,200 mm3. A CD4+ count less than 200/mm3 or a percentage of CD4 lymphocytes less than 14% indicates AIDS.

Patient-Centered Care

Nursing Care

  • Collect data on risk factors (sexual practices, IV drug use). 
  • Monitor fluid intake/urinary output. 
  • Obtain daily weights to monitor weight loss. 
  • Monitor nutritional intake. 
  • Monitor electrolytes. 
  • Monitor skin integrity (rashes, open areas, bruising). 
  • Monitor pain status. 
  • Monitor vital signs (especially temperature). 
  • Check lung sounds/respiratory status (diminished lung sounds). 
  • Check neurological status (confusion, dementia, visual changes). 
  • Encourage activity alternated with rest periods. 
  • Administer supplemental oxygen as needed. 
  • Provide analgesia as needed. 
  • Provide skin care as needed. 
  • Reinforce client teaching. 
    • Transmission, infection control measures, and safe sex practices 
    • Importance of maintaining a well‑balanced diet 
    • Self‑administration of prescribed medications and potential adverse effects 
    • Findings that need to be reported immediately (infection) 
  • Assist the client with identifying primary support systems.

Medications

Highly active antiretroviral therapy involves using three to four HIV medications in combination with other antiretroviral medications to reduce medication resistance, adverse effects, and dosages.

Fusion inhibitors: Enfuvirtide blocks the fusion of HIV with the host cell

Entry inhibitors: Maraviroc

Nucleoside reverse transcriptase inhibitors: Zidovudine interferes with the virus’s ability to convert RNA into DNA.

Non‑nucleoside reverse transcriptase inhibitors: Delavirdine and efavirenz inhibit viral replication in cells.

Protease inhibitors: Atazanavir, nelfinavir, saquinavir, and indinavir inhibit an enzyme needed for the virus to replicate.

Integrase inhibitors: Raltegravir

Antineoplastic medication: Interleukin is an immunostimulant that enhances the immune response and reduces the production of cancer cells (used commonly with Kaposi’s sarcoma).


Nursing Actions

  • Monitor laboratory results (CBC, WBC, liver function tests). Antiretroviral medications can increase alanine aminotransferase, aspartate aminotransferase, bilirubin, mean corpuscular volume, high‑density lipoproteins, total cholesterol, and triglycerides. 
  • Monitor total CD4+ T lymphocyte count, CD4 percentage, and ratio of CD4 to CD8 cells. 
    • Normal CD4‑to‑CD8 ratio is 2. A ratio less than 1 indicates more severe disease manifestations 
    • Low CD4 T lymphocyte counts and steadily decreasing counts indicate poor prognosis or medication resistance. 
  • Reinforce teaching to the client about the adverse effects of the medications and ways to decrease the severity of adverse effects.

Client Education

Take medications on a regular schedule and do not miss doses. Missed medication doses can cause medication resistance.

Interprofessional Care

  • Infectious disease services can manage HIV. 
  • Respiratory services can improve respiratory status and provide portable oxygen. 
  • Nutritional services can be consulted for dietary supplementation. Food services are indicated for clients who are homebound and need meals prepared. 
  • Rehabilitation services can be consulted for strengthening and improving the client’s level of energy. 
  • Refer the client to local AIDS support groups as indicated. 
  • Home health service are indicated for clients who need help with strengthening and assistance regarding ADLs. Home health services can also provide assistance with IVs, dressing changes, and total parenteral nutrition (TPN). 
  • Long‑term care facilities can be indicated for clients who have chronic HIV. 
  • Hospice services are usually indicated for clients who have a late stage of HIV.

Alternative therapy

Vitamins, herbal products, and shark cartilage can help alleviate manifestations of HIV. Ask if the client is taking herbal products. These can alter the effects of prescribed medications.

Client Education

  • Practice good hygiene (including frequent hand hygiene) to reduce the risk of infection. 
  • Avoid crowded areas or traveling to countries with poor sanitation. 
  • Avoid raw foods (fruits, vegetables) and undercooked foods (meat, fish, eggs). 
  • Avoid cleaning pet litter boxes to reduce the risk of toxoplasmosis. 
  • Keep the home environment clean and avoid being exposed to family and friends who have colds or flu viruses. 
  • Wash dishes in hot water using a dishwasher if available. 
  • Bathe daily using antimicrobial soap. 
  • Adhere to the antiretroviral dosing schedules. 
  • Frequent follow‑up monitoring of CD4+ and viral load counts is needed. 
  • Use constructive coping mechanisms. 
  • Report manifestations of infection immediately to the provider.

Complications

Opportunistic infections

  • Bacterial diseases, such as tuberculosis, bacterial pneumonia, and septicemia (blood poisoning) 
  • HIV‑associated malignancies, such as Kaposi’s sarcoma, lymphoma, and squamous cell carcinoma 
  • Viral diseases, such as those caused by cytomegalovirus, herpes simplex, and herpes zoster virus 
  • Fungal diseases, such as Pneumocystis jirovecii pneumonia (PCP), candidiasis, cryptococcosis, and penicilliosis 
  • Protozoal diseases, such as PCP, toxoplasmosis, microsporidiosis, cryptosporidiosis, isosporiasis, and leishmaniasis
Nursing Actions
  • Implement and maintain antiretroviral medication therapy. 
  • Administer antineoplastics, antibiotics, analgesics, antifungals, and antidiarrheals. 
  • Administer appetite stimulants (to enhance nutrition). 
  • Monitor for skin breakdown. 
  • Maintain fluid intake. 
  • Maintain nutrition.
Client Education

Report indications of infection immediately to the provider.

Wasting syndrome

Nursing Actions
  • Maintain nutrition orally or by TPN. 
  • Monitor weight, calorie counts, and I&O. 
  • Provide between‑meal supplements/snacks. 
  • Decrease fat content of foods to prevent complications of fat intolerance. 
  • Rinse the client’s mouth several times daily with saline or sodium bicarbonate and sterile water to reduce mouth pain and increase appetite. 
  • Serve at least six small feedings with high protein value per day.

Fluid/electrolyte imbalance

Nursing Actions
  • Monitor fluid/electrolyte status. 
  • Report abnormal laboratory data promptly. 
  • Encourage the client to drink 2,000 to 3,000 mL fluid daily. 
  • Make dietary adjustments to reduce diarrhea.

Seizures (HIV encephalopathy)

Nursing Actions
  • Maintain client safety. 
  • Implement seizure precautions.

References

  1. Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, Sexual Transmitted Diseases and Tuberculosis Prevention, Centers for Disease Control and Prevention August 3, 2017
  2. ATI Adult Medical Surgical Nursing REVIEW MODULE EDITION Copyright © 2017 Assessment Technologies Institute, LLC. All rights reserved

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