About this course:
This learning activity aims to increase the nurse's knowledge of the background, transmission, diagnosis, staging, treatment, and prevention of human immunodeficiency virus (HIV).
Human Immunodeficiency Virus
This learning activity aims to increase the nurse's knowledge of the background, transmission, diagnosis, staging, treatment, and prevention of human immunodeficiency virus (HIV).
This learning activity is designed to allow the learner to:
- define HIV and acquired immunodeficiency syndrome (AIDS) and understand the impact in the US and globally
- discuss the stages of HIV
- explain HIV testing and patient counseling
- identify the factors that affect transmission and methods to decrease the risk of HIV infection
- consider occupational exposures to bloodborne pathogens and the risks to healthcare providers (HCPs)
- summarize the clinical manifestations and treatment of HIV and AIDS
A diagnosis of HIV infection or AIDS was considered a death sentence just a few decades ago when the disease emerged in the US and worldwide. Today's prognosis and outcomes have significantly improved. Although current data shows that HIV started infecting humans in the 1970s, scientists were unaware of the virus until a decade later. Beginning in the early 1980s, new illnesses were emerging throughout the world. Kaposi's sarcoma (KS), a reasonably harmless cancer previously common among the elderly, started appearing as an aggressive strain in younger patients. At the same time, rare and aggressive types of pneumonia began appearing in other patients. By 1981, scientists began to connect these two new diagnoses and the emergence of other opportunistic infections. By the end of 1981, the first case of AIDS was documented in the medical literature (Public Health, n.d.).
Scientists were aggressively working to figure out the poorly understood new killer. In the early years, all that was known about HIV was that it was viral, deadly, and highly contagious. Fear from both HCPs and the public fueled prejudice and discrimination against those thought to be at the highest risk of contracting the virus. It was noted early in 1981 that young gay men were diagnosed with HIV; therefore, the virus was likely sexually transmitted or caused by sharing needles. Consequently, HIV was labeled as a gay-related illness, immediately stigmatizing the diagnosis. However, other early events, such as the AIDS outbreak in Haiti, the identification of hemophiliac patients as an at-risk population, and mother-child transmission in utero, inspired doctors and scientists to focus on bloodborne in addition to sexual transmission. The stigmatization, however, did not disappear quickly. Television evangelist Jerry Falwell announced that God had sent AIDS as retribution for the sins of drug users and the gay community. HIV patients were ostracized due to mass hysteria, and a young HIV-positive hemophiliac student, Ryan White, was expelled from his middle school (Public Health, n.d.).
Public policy responded by closing gay nightclubs and bathhouses. Law enforcement officers were issued masks and gloves to protect them from exposure to the virus, and needle exchange programs began to address the concerning trend of reusing needles among drug users. The US Food and Drug Administration (FDA) started to consider the safety of the nation's blood bank after a postpartum patient was diagnosed with AIDS just months after their delivery and subsequent blood transfusions. In 1985, the first International AIDS meeting was held, sparked by the appearance of the disease across the globe. By 1986, the first antiretroviral (ARV) drug, zidovudine (Retrovir, AZT), was introduced through clinical trials in the US. Zidovudine (Retrovir, AZT) was initially developed as a chemotherapeutic agent but exhibited beneficial results during the clinical trials for HIV patients. The results were so promising that the FDA halted the trials, stating that it would be unethical to deprive the control patients of the actual drug (Public Health, n.d.).
By 1993, there were more than 2.5 million cases of HIV worldwide, and by 1995, it was the leading cause of death for Americans between the ages of 25 and 44. The United Nations (UN) reported that in 1996, there were more than 3 million new cases in patients under 25. The mortality rate did not improve until 1997. During this time, legislation was passed in the US prohibiting HIV-positive individuals from working in healthcare settings, donating blood, entering the country on a travel visa, or immigrating to the US. Meanwhile, new drugs were being studied, including ACTG 076, saquinavir (Invirase), and nevirapine (Viramune). Combination therapy approaches also demonstrated success, and by 1997, a global treatment guideline was established. Prevention techniques were also identified, including condom use. The condom was rarely discussed before the HIV era, yet its use became a mainstay for prevention. President Bill Clinton aggressively advocated for HIV/AIDS education and allocated many resources toward HIV/AIDS research during his eight years in office. Additionally, the World Health Organization (WHO) AIDS program was replaced by the UN AIDS Global Programme, which is still in place today (Public Health, n.d.).
It wasn't until 2010 that the US removed HIV as an infection preventing non-US citizens from entering the country. In 2011, researchers discovered that antiviral drugs used to treat HIV could also be taken prophylactically to prevent infection in individuals at a high risk of exposure through sex. This is known as pre-exposure prophylaxis (PrEP), and its use was eventually expanded to include more individuals at an increased risk of HIV exposure. Also, new data showed that actively treating HIV reduced transmission by 96%. From 2010 to 2020, numerous campaigns were launched to get more individuals tested and reduce the stigma surrounding HIV. Still, in 2019 the CDC announced that most new HIV cases were a direct result of exposure to an individual who was undiagnosed or diagnosed but not being treated (CDC, 2022b).
HIV is a retrovirus that attacks and depletes the human immune system and limits the body's ability to protect against disease and infections. The former healthy immune system of the affected individual is also unable to stop the progression of HIV. HIV targets CD4+ lymphocytes, also known as T-cells or T-lymphocytes. T-cells work with B-lymphocytes as part of the acquired (adaptive) immune system. HIV integrates its RNA into host-cell DNA through reverse transcriptase, reshaping the host's immune system. By attaching itself to CD4+ cells, the virus can replicate and destroy them, decreasing the number of CD4+ cells available for normal immune system functioning. The host produces extra CD8 cells to compensate for this loss. If untreated, HIV progressively takes over more of the host's immune response (McCance & Huether, 2019).
Strains of HIV
There are many strains of HIV due to the high variability of the virus and its mutational capabilities. HIV is classified into types, groups, and subtypes. The two primary strains are HIV-1 and HIV-2. The predominant strain worldwide is HIV-1, whereas HIV-2 is less common and found predominantly in West Africa. Both strains can progress to AIDS and are transmitted through blood and bodily fluids. Each strain has several subtypes and is evolving continuously. HIV testing detects the two primary strains and all known subtypes (Peruski et al., 2020).
Incidence and Prevalence
The WHO estimates that in 2020, 37.7 million people were living with HIV or AIDS. Of this estimated total, 36 million were over 15 years old, 19.3 million were women, 16.7 were men, and 1.7 were children under 15. It is estimated that over two-thirds of the people living with HIV reside in the African Region. In 2020, there were also an estimated 1.5 million new cases of HIV
...purchase below to continue the course
In the US, approximately 1.2 million people are living with HIV. In 2019, there were 34,800 new cases of HIV diagnosed in the US, an 8% decline from 2015. Overall, there has been a two-thirds reduction in HIV diagnoses since the mid-1980s. New diagnoses are not spread evenly throughout patient demographics. Most new cases occur in the Southern US. HIV is more likely to affect individuals aged 25-34 (30.1%) followed by 35-44 (16.5%), Black/African American (42.1%) followed by Hispanic (21.7%), and male sex at birth (21.0%) which is five times the rate of infection of females. Gay, bisexual, and other men who have sex with men (MSM) remain the population most affected by HIV in the US (Minority HIV/AIDS Fund [MHAF], 2021).
Transmission and Infection Control Guidelines
Viral load refers to the amount of virus detected in a blood sample. The viral load influences the transmission of the virus. For transmission to occur, there must be enough of the virus present in the affected individual. This is referred to as a sufficient dose. A high viral load indicates that the immune system is not effectively fighting the virus, and the individual is more infectious to others. A low viral load is associated with a low transmission rate to sexual contacts. In January 2019, the National Institute of Health (NIH) recognized that an undetectable amount of HIV correlates with the inability to transmit HIV. This concept is called "U=U." There is a campaign to make people aware that compliance with antiretroviral treatment (ART) can lead to an undetectable viral load, indicating that the patient cannot transmit the disease to others. The U=U campaign encourages medication compliance to suppress the viral load to undetectable levels and avoid exposing sexual partners to the infection (Ignatavicius et al., 2018; NIH, 2019, 2022).
Modes of Transmission
HIV must enter an individual's bloodstream and is not passed casually from person to person. Figure 1 depicts the factors affecting the transmission of HIV (CDC, 2020). For an individual to become infected with HIV, the following conditions must be met:
- an HIV source
- enough virus present; high viral load in the affected individual
- contact with the affected individual's blood or bodily fluids (CDC, 2020)
Without these conditions, HIV cannot spread. HIV is transmitted through blood and body fluids, such as semen, saliva, vaginal secretions, and breast milk. In the US, HIV is mainly spread by unprotected anal or vaginal sex with an individual infected with HIV without taking prophylactic medications. For an HIV-negative partner, receptive is the highest-risk sexual behavior, but HIV can also be acquired from penetrative anal sex. During vaginal sex, either partner can contract HIV, though it is less risky than anal sex. The CDC reports that all forms of oral sex have a low risk of transmitting HIV. Still, it is theoretically possible if an HIV-positive individual ejaculates in their partner's mouth during oral sex. Sharing needles or syringes with someone who is HIV-positive is also high-risk behavior. HIV can live in a used needle for up to 42 days, based on storage conditions (CDC, 2020).
Factors Affecting Disease Transmission
HIV cannot reproduce or survive long outside the human body. Therefore, HIV cannot be spread by vectors such as mosquitos or ticks. Handling leftover food, exposure to saliva, or being scratched by an HIV-positive individual cannot cause HIV infection. Tattoo or body piercing equipment can cause an HIV infection, but the risk is low and is directly related to unsanitary practices such as reusing piercing and tattoo needles (CDC, 2020). See Figure 2 for common HIV transmission myths.
HIV Transmission Myths
Social Factors that Influence HIV Transmission
Other factors affecting transmission include infection with other sexually transmitted illnesses (STIs), substance abuse, and relationship equality issues. Less common transmission causes include bites and workplace exposure. STIs increase the risk of infection with HIV due to skin and mucous membrane compromise that allows HIV easier access to the body. Symptomatic herpes and syphilis can cause a break in skin integrity from blisters and sores. Chlamydia causes inflammation, which can increase HIV viral shedding and the viral load in genital secretions. Any genital ulcers, wounds, or inflamed tissues can become an easy entry point for HIV and thus increase the risk of exposure (CDC, 2020).
Substance abuse increases the risk of HIV exposure in several ways. In addition to the injectable drugs that cause exposure through shared needles, the use of alcohol and non-injectable drugs also increases the risk. While under the influence of drugs or alcohol, an individual is more likely to participate in risky behavior and have impaired judgment, leading to an increased risk of infection. Also, substances can alter the pain response and lead to unnoticed sores or open wounds in the mouth or genital area, which increases the risk of HIV infection and other STIs (CDC, 2020).
Domestic violence and cultural implications can create an environment that puts one of the partners in the relationship at risk. For instance, in some cultures, women are not allowed to question their partners and are expected to follow strict rules and restrictions related to sexual activity. They may be unable to ask for protection to be used during intercourse, which places them at increased risk of infection. Women and men who are victims of domestic abuse and sexual abuse may be unable to discuss sexual history or safe sex practices. This problem can exist in all types of relationships, including heterosexual, bisexual, gay, and transgender. Other inequality issues that could lead to HIV transmission include substantial differences in age or wealth. In any situation where one partner has power or control over another, the likelihood of protection and safe sex practices decreases, and the possibility of exposure to HIV or other STIs increases (CDC, 2020).
Human bites should not lead to the transmission of HIV; however, if someone has bleeding gums or open sores in their mouth, there is a small risk of exposure. Other diseases can be transmitted via a human bite, and care should be taken to cleanse the bite wound immediately with soap and water; antibiotic prophylaxis may be indicated (CDC, 2020).
Infection Control Practices in the Workplace
Each healthcare organization should have a bloodborne pathogen policy and procedure that protects employees from exposure to blood and potentially infectious bodily fluids. HCPs are at higher risk of exposure to blood and bodily fluids during the delivery of routine patient care. In addition to healthcare workers, first responders, law enforcement, and public service employees are at increased risk of exposure to bloodborne pathogens such as the hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV in their work roles. Each employer is responsible for training employees on the risk of bloodborne pathogens and providing the equipment to protect them from exposure, including proper personal protective equipment (PPE). Exposure types include occupational exposure and exposure incidents (Ignatavicius et al., 2018).
Occupational exposure is the exposure of the skin, eyes, mucous membrane, or bloodstream to blood or other potentially infectious material (OPIM) that results while an employee performs their routine duties. An exposure incident is a specific eye, mouth, mucous membrane, non-intact skin, or parenteral contact with blood or OPIM resulting from an employee's duties. Non-intact skin would include acne, cuts, abrasions, dermatitis, or hangnails. Examples include needle sticks or splashing of infectious material onto the face (Ignatavicius et al., 2018).
While performing patient care, HCPs are often exposed to bodily fluids. Due to this, they must understand the pathophysiology of the virus, its impact on health care, and the need for protective precautions. While HIV is found in feces, urine, tears, saliva, cerebrospinal fluid, cervical cells, lymph nodes, corneal tissue, and brain tissue, these are not the most common transmission methods. Because HIV cannot live long outside the human body, the risk of transmission is decreased for HCPs. Despite this, careful precautions to protect those caring for individuals with HIV/AIDS must still be taken (CDC, 2020).
The CDC notes that a 0.3% risk exists after percutaneous exposure to HIV and 0.09% after mucous membrane exposure, yet any chance is too much for an individual HCP. Primary prevention for occupationally acquired HIV infection is the most important prevention strategy. Standard precautions with PPE should be meticulously followed to avoid exposure. Infection control includes two tiers of recommended precautions to decrease the risk of exposure to workers and spreading infections within the healthcare system. The first tier consists of standard precautions, which should be maintained for all patients regardless of infection status. The second is transmission-based precautions used with certain known or suspected infections (CDC, 2016; Kuhar et al., 2018). Transmission-based precautions include:
- adherence to standard precautions
- avoiding direct patient care or handling equipment used in invasive procedures if an exudative lesion or weeping dermatitis is present
- performing hand hygiene before and after any patient care
- consistently adhering to work practices such as not recapping needles
- using PPE, such as gloves, gown, mask, protective eyewear, and chin-length plastic face shield when there is a risk of possible exposure to infectious materials
- properly handling, cleaning, and disinfecting all patient care equipment, instruments, or devices
- handling infectious material carefully to avoid exposure
- following safe injection practices
- wearing a surgical mask when performing lumbar punctures and ensuring the safe handling and disposal of sharps and needles (CDC, 2016; Ignatavicius et al., 2018)
It is estimated that 1 in 7 or 15% of individuals with HIV in the US are unaware that they are infected, and these individuals cause 40% of new HIV infections. For this reason, routine screening is recommended. Primary care providers (PCPs) are the front line of screening and testing patients for HIV and preventing the spread. Unfortunately, over 75% of high-risk patients seen by their PCP within the previous 12 months were not offered HIV testing (CDC, 2022a).
Laboratory testing is the only means to verify infection with HIV. The CDC and the US Preventative Services Task Force (USPSTF) recommend that everyone between the ages of 15 and 65 be tested for HIV at least once during routine care. HIV testing should also be included whenever a patient is seeking evaluation for a possible STI. Individuals at a higher risk of contracting HIV (e.g., sexually active gay, bisexual, or other MSM) should be tested annually, with some providers recommending testing as frequently as every 3 to 6 months. Although testing is recommended and beneficial, it should be voluntary, and patients should never be tested without their knowledge. When patients understand their HIV status, it allows them to make fully informed decisions about treatment options and take action to protect their sexual partners (CDC, 2021b).
Diagnosing an HIV infection can involve several steps. Previously, the enzyme-linked immunosorbent assay (ELISA) and Western blot or indirect immunofluorescence assay were performed to confirm a diagnosis. Research and revision to testing strategies have led to more specific and accurate immunoassay tests that can accurately confirm diagnosis sooner. Currently, three tests are used for the diagnosis of HIV: nucleic acid tests (NATs), which detect HIV RNA; antigen/antibody combination tests, which detect HIV p24 antigen and HIV immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies; and antibody tests, which detect HIV IgM or IgG antibodies. These tests use blood, saliva, or urine for results (CDC, 2021a).
The most rapid of the three tests is the antibody test, which is designed for home and rapid point of care (POC) testing. The HIV antibody test identifies HIV antibodies in the blood or saliva. Rapid antibody screening with a fingerstick or saliva can provide results within 20 minutes and is used in most clinical settings. The oral antibody home test kit also provides results within 20 minutes. These kits are available both online and in retail stores. When using a home serum collection kit, the patient pricks their finger and sends the sample by mail to a licensed laboratory for antibody testing. Results are available as quickly as the next day. The manufacturers of these tests provide counseling and referrals for further testing and treatment. If any rapid antibody test is positive, follow-up testing with an antigen/antibody immunoassay is needed to confirm the results (CDC, 2021b).
The CDC recommends that HIV testing begins with a laboratory-based, FDA-approved antigen/antibody immunoassay that detects HIV-1 and HIV-2 antibodies and p24 antigen. This antigen can be detected very early after exposure to the virus, even before antibody formation. Since 2014, the CDC has recommended that when diagnosing HIV, a supplemental HIV-1/HIV-2 differentiation test be performed to confirm the infection type based on the presence of specific antibodies. If the specimen is non-reactive, no further testing is required unless there is a possibility that the patient was recently exposed and virus levels are still undetectable. This is known as the window period. The window period is the time following infection that extends until a substance is produced in enough quantity to be identified by a particular laboratory test. If this is the case, an HIV-1 NAT should be performed or a new specimen obtained and antigen/antibody combination testing repeated after a few weeks (CDC, 2021b; National Center for HIV/AIDS, Viral Hepatitis, and TB Prevention US, 2018; Peruski et al., 2020).
A NAT identifies HIV RNA in the blood. It is an expensive test and is not recommended for screening except for high-risk or potential exposure with the presence of HIV symptoms. The NAT is very accurate during the early stages of infection, but if negative, an antigen/antibody combination test should be done to confirm the results. For individuals taking PrEP or post-exposure prophylaxis (PEP), the accuracy of a NAT may be compromised (CDC, 2021b).
Following the initial diagnosis of HIV, the patient should undergo an HIV-1 RNA quantification to determine the viral load, an antiretroviral resistance assay to assess for medication sensitivity, and a CD4+ count to assist with staging. These results will guide the patient's treatment plan (CDC, 2021b).
Testing for Drug Resistance
HIV is skilled at mutating and changing its structure, thereby enhancing drug resistance, which occurs when previously effective medications become ineffective. HIV drug resistance testing is recommended at the start of care to guide the selection of the initial ART regimen. Genotypic testing is the preferred resistance testing to guide therapy in ART-naïve patients. ART initiation should not be delayed while awaiting the results of resistance testing. ART can be modified after results are obtained if needed (NIH, 2021, 2022).
The patient might require additional testing to monitor other aspects of health, including a complete blood count (CBC), metabolic profiles (CMP, BMP), lipid profiles, and liver function tests. These tests can assist in monitoring the effects of medications on the body or in detecting the presence of opportunistic infections or complications. Tests to detect secondary conditions can include tuberculin (TB) skin testing; urine, stool, sputum, or drainage culture to identify infectious agents; and screening for additional STIs. Secondary or opportunistic conditions can worsen the outcome of HIV infection. Diagnostic imaging such as MRI and CT scans can help determine changes in the brain or lungs, including HIV/AIDS-related dementia, pneumonia, or neoplasm (CDC, 2021b).
All patients with a suspected or confirmed case of HIV should be counseled after test results are known. Counseling aims to educate patients on behaviors that prevent acquiring or transmitting HIV, treatment, and support services. Historically, when an HIV test was performed, it took several days for results to come back. Due to this delay, comprehensive pre-test counseling was completed in case the individual did not return for their test results. With the widespread use of rapid diagnostic tests, most individuals receive some test results and possibly a diagnosis on the same day. This quick turnaround has eliminated the need for pre-test counseling, which is no longer recommended. Once test results are obtained, and the HCPs have ensured the results are correct, post-test counseling should be provided. Post-test counseling should be individualized and patient-centered. This counseling can be delivered by any HCP or lay person trained to provide HIV counseling (Sax, 2022; WHO, 2015). Post-test counseling should include the following:
- explanation of the test results and diagnosis
- helping the individual cope with the emotional response to the diagnosis
- discussion of any immediate concerns
- information on ART and the importance of medication compliance
- enrollment of the patient into HIV clinical care
- arrangement of follow-up appointments
- information on preventing transmission and the risks and benefits of disclosure – especially among partners
- assessment of potential intimate partner violence, risk of suicide, depression, and changes in mental health following diagnosis
- additional referrals for other services such as access to sterile needles, opioid substitution therapy, and contraception (WHO, 2015)
Absorbing, understanding, and retaining all this information in one counseling session can be overwhelming for an individual just diagnosed with HIV. Follow-up counseling is recommended to reiterate the education provided in the initial post-test counseling session (WHO, 2015).
All testing and results are confidential and cannot be shared with anyone. HCPs who provide HIV testing in public health departments or clinical settings must sign strict confidentiality agreements before employment. The agreements regulate the information shared in counseling and testing sessions. Written HIV test results must be maintained in locked files, and electronic health records must be password protected and meet standards for security (CDC, 2021b).
HIV infection was originally a single, continuous disease process of three stages. Recently the staging guidelines were updated to include a fourth stage, stage 0, which includes the period of initial infection with HIV. The stages progress from initial infection to the development of AIDS (stage 3). Therefore, a patient with HIV does not necessarily have AIDS, but any patient who has AIDS previously acquired the HIV infection. Patients in stage 3 are severely immunocompromised and require complex care. Stages 1, 2, and 3 are determined using the patient's CD4+ count or the CD4+ percentage when the count is unavailable. If neither of these findings is available, the patient is considered "stage unknown," which some experts classify as a separate fifth stage (CDC, 2022e; Selik et al., 2014).
Stage 0 is used to represent early HIV infection. If there was a negative or indeterminate HIV test within 6 months of initial diagnosis, the stage is 0 until 6 months after diagnosis. The classification of stage 0 can also be based on a testing algorithm using laboratory testing that shows the presence of HIV-specific markers such as p24 antigen or nucleic acid within 6 months of a negative antibody test. Even though titers are negative, the patient can transmit the disease during this time. It can take up to 3 months for antibodies to show up on tests, although they typically appear 6 weeks after exposure. Although the stage at diagnosis does not change once the 6 months from diagnosis have elapsed, the stage is classified depending on CD4+ T-lymphocyte test results or whether an opportunistic illness has been diagnosed (CDC, 2021c, 2022e; Selik et al., 2014).
The first manifestations of the disease process will occur within 4 weeks of infection. These manifestations may be mistaken for influenza and can include weakness, fatigue, headache, rash, night sweats, and a sore throat. This stage is marked by a rapid rise in the HIV viral load, decreased CD4+ cell counts, and increased CD8 cell counts. Individuals in stage 1 will have the following characteristics:
- absence of an opportunistic AIDS-defining condition
- CD4+ T-lymphocyte count of 500 cells/mm3 or more
- CD4+ T-lymphocyte percentage of total lymphocytes of 26% or more (CDC, 2021b, 2022; Ignatavicius et al., 2018)
The resolution of the initial viral manifestations of HIV infection is coincidental with the decline in viral HIV copies. However, lymphadenopathy persists throughout the disease process (CDC, 2022e).
Stage 2 is known as the latency stage, as patients are noted to be asymptomatic due to the decline in viral HIV copies. This decline results from the body's immune system attacking and minimizing the virus, not eliminating it. This stage can be prolonged, allowing patients to remain asymptomatic for 10 years without taking medication and for decades if on ART. During this stage, anti-HIV antibodies are produced, and the patient's tests for these will become positive. The viral set point is the amount of virus, or viral load, remaining in the body after the immune system's efforts to eliminate the virus. This set point relates directly to the patient's prognosis, as a high viral set point typically equates to poorer outcomes for the patient (CDC, 2021b, 2022e).
Over time, the virus will use the host's genetic machinery to replicate itself. The viral load increases and CD4+ cells are destroyed. This process results in a dramatic loss of immunity that can have life-threatening consequences for the patient and are a significant concern to health care delivery. This stage has the following characteristics:
- absence of an opportunistic AIDS-defining condition
- CD4+ T-lymphocyte count of 200 to 499 cells/mm3
- CD4+ T-lymphocyte percentage of total lymphocytes of 14% to 25% (CDC, 2022; Ignatavicius et al., 2018)
As evidenced by the decrease in the CD4+ count and CD4+ percentage compared to stage 1, the patient is experiencing a significant loss of immunity secondary to the virus becoming more active. This loss of immunity places the patient in a more vulnerable position as they progress into the third stage of the disease process (CDC, 2021b, 2022e).
Stage 3 is the final stage of HIV infection, and if the patient does not receive treatment, death is likely to occur within 3 years. Stage 3 of the disease process involves the development of AIDS. AIDS is a combination of symptoms and infections stemming from an impaired immune system. HIV-infected individuals become vulnerable to diseases or infections known as "opportunistic," as these illnesses would not impact individuals with a fully-functioning immune system. Modern-day medical treatments significantly delay the progression of HIV and subsequent diagnosis of AIDS (CDC, 2022e; US Department of Veterans Affairs [VA], 2019). This stage is defined through the presentation of the following characteristics:
- presence of an opportunistic AIDS-defining condition
- CD4+ T-lymphocyte count less than 200 cells/mm3
- CD4+ T-lymphocyte percentage of total lymphocytes less than 14% (CDC, 2021b, 2022e; Ignatavicius et al., 2018)
Patients are considered in stage 3 of the disease if an AIDS-defining condition is present, even if the CD4+ count or percentage is higher than expected for this stage. Unlike stages 1 and 2, stage 3 is associated with a range of defining conditions. Stage 3 is associated with severe health challenges for the patient, who is often extremely ill. To plan appropriate care, the nurse should know the pathophysiology and defining conditions related to this stage. Since the patient has the potential to develop more than one AIDS-defining illness, this can present a challenge for the health care team when planning and delivering care (CDC, 2021b, 2022e).
The following is a list of AIDS-defining conditions:
- candidiasis of the esophagus, bronchi, trachea, or lungs
- herpes simplex – chronic ulcers (more than one-month duration)
- invasive cervical cancer
- cryptosporidiosis, chronic intestinal (more than one-month duration)
- cytomegalovirus diseases (CMV), particularly retinitis
- encephalopathy, HIV-related
- bronchitis, pneumonitis, or esophagitis
- isosporiasis, chronic intestinal (more than one-month duration),
- Kaposi's sarcoma (KS)
- lymphoma, multiple forms
- tuberculosis (TB)
- Mycobacterium avium complex (MAC), Mycobacterium kansasii, or another Mycobacterium disseminated or extrapulmonary
- Pneumocystis jirovecii pneumonia (PCP), formerly called pneumocystis carinii pneumonia
- recurrent pneumonia
- progressive multifocal leukoencephalopathy
- recurrent Salmonella septicemia
- toxoplasmosis of the brain
- wasting syndrome due to HIV (CDC, 2021b; Ignatavicius et al., 2018)
Primary HIV infection occurs within the first few weeks. A high viral load during this phase indicates that infected individuals are more likely to pass the disease to others, yet they may be unaware of their HIV status. Early HIV symptoms are flu-like and include fever, lymphadenopathy (swollen glands in the neck, armpits, or groin), rash, fatigue, night sweats, chills, muscle aches, and sore throat. The individual may think they have the flu or other viral illness unless they have a reason to suspect HIV. An inaccurate diagnosis may occur as these symptoms are vague and subside in days to weeks (CDC, 2021b; MHAF, 2022).
Seroconversion occurs between the initial exposure and the time antibodies can be detected on an HIV test. Seroconversion can vary but typically occurs between 9 days and 6 months after exposure. Asymptomatic HIV is a term used to describe patients with positive results on their HIV test(s) but no clinical symptoms. This period may last up to 10 years with no outward appearance of illness. Without verification through testing, the individual may be unaware they are infected. There are no specific HIV symptoms; however, HIV affects the normal functioning of the immune system, the kind and number of blood cells, the body's metabolism, the structure and function of the brain, and the amount of fat and muscle distribution in the body (CDC, 2021b). Common symptoms include:
- persistent low-grade fever
- pronounced and rapid weight loss without dieting
- persistent headaches
- difficulty recovering from colds or viruses
- diarrhea lasting more than a week
- illnesses that are more severe than typically experienced
- loss of muscle, tissue, and body weight
- thrush (yeast infection in the mouth)
- vision or hearing loss
- nausea or vomiting
- confusion or dementia
- extreme and unexplained fatigue
- urinary or fecal incontinence
- sores of the mouth, anus, or genitals
- memory loss
- chronic pneumonia, sinusitis, or bronchitis (CDC, 2021b; MHAF, 2022)
HIV in women can lead to several gynecological problems, including pelvic inflammatory disease, abscesses of the fallopian tubes and ovaries, and recurrent yeast infections. Women with HPV are at an increased risk of cervical dysplasia and cancer when co-infected with HIV. Invasive cervical cancer is also an AIDS-defining condition. Routine screening for cervical cancer is recommended for nearly all women, but it is crucial for women with HIV. Women in the US receive fewer healthcare services than men and may not be diagnosed with HIV until later in the disease process, making the disease harder to control (CDC, 2021b).
The progression of HIV to AIDS has been dramatically slowed in the US by ART, yet in less developed countries, the progression can be remarkably rapid. While ART has been shown to slow or temporarily halt disease progression, specific co-factors can exacerbate the advancement of HIV to AIDS (CDC, 2021b). These include:
- advanced age
- drug use
- poor nutrition
- co-infection with any other STI (CDC, 2021b)
The average time lapse from HIV infection to AIDS in untreated patients is 8 to 10 years. After a diagnosis of AIDS, the prognosis varies based on medication compliance and healthy living habits (CDC, 2021b).
According to the WHO, AIDS-related deaths fell by 37% between 2000 and 2018 due to international efforts with ART and education. In 2018, 23 million people were living with HIV and receiving ART therapy globally. For individuals who test positive, starting treatment immediately is vital to control the disease. The CDC recommends that all HIV-positive individuals begin ART upon diagnosis regardless of their health status or duration of HIV infection. HIV is not curable; however, ART can help slow virus replication and reduce viral load (CDC, 2021b; WHO, 2021b).
ART reduces HIV-related morbidity and mortality throughout the disease process, decreases and suppresses the viral load, maintains CD4+ cell counts, delays the progression to AIDS, improves survival rates, and reduces the risk of transmission to others. The nurse should educate the patient on the benefits and risks of ART therapy and the importance of strict and consistent adherence to treatment (CDC, 2021d).
The treatment goals of ART include providing a long, high quality of life, promoting optimal immune function, and minimizing the HIV viral load to lower the risk of transmission to others. Specific medications work at various stages of HIV replication; therefore, most patients must follow a multi-drug HIV regimen. Taking a combination of drugs helps to prevent medication resistance, reduce adverse effects, and decrease the dosage required for each medication. Current recommendations for ART in naïve patients include two nucleoside reverse transcriptase inhibitors (NRTIs) and one drug from one of the following drug classes: integrase strand transfer inhibitor (INSTI), a non-nucleoside reverse transcriptase inhibitor (NNRTI), or a protease inhibitor (PI) with a pharmacokinetic (PK) booster (NIH, 2022). Table 1 outlines the different ARV categories, examples, and implications.
Adverse Reactions (AR)
Nucleoside reverse transcriptase inhibitors (NRTIs): inhibit reverse transcriptase and incorporate it into the viral DNA, resulting in DNA chain termination
abacavir sulfate (Ziagen)
300 mg by mouth twice daily
600 mg by mouth once daily (when used with other antiretrovirals)
Children > 3 months: 8 mg/kg by mouth twice daily or 16 mg/kg by mouth once daily (max dose 600 mg/day when used with other antiretrovirals)
fever, chills, headache, insomnia, anxiety, diarrhea, nausea, vomiting, abdominal pain, lactic acidosis, rash
200 mg capsule or 240 mg oral solution by mouth once daily
Children 3 months to 17 years who cannot swallow capsules: 6 mg/kg up to 240 mg by mouth once daily
Children under 3 months: 3 mg/kg oral solution by mouth once daily
abnormal dreams, dizziness, headache, fatigue, depression, rhinitis, diarrhea, nausea, vomiting, dyspepsia, hepatotoxicity, myalgia, cough, pruritus, maculopapular rash, vesiculobullous rash
300 mg by mouth once daily OR 150 mg by mouth twice daily
dizziness, fatigue, fever, headache, insomnia, anorexia, diarrhea, nausea, vomiting, abdominal cramps, pancreatitis, dyspepsia, neutropenia, thrombocytopenia, anemia, hepatotoxicity, arthralgia, myalgia, cough, rash, paresthesia
Adults and children over 2 weighing 35 kg or more: 300 mg by mouth once daily
Adults and children over 2 weighing 17-34.9 kg:
8 mg/kg by mouth once daily up to 300 mg
headache, pain, fever, peripheral neuropathy, insomnia, dizziness, sinusitis, chest pain, nausea, abdominal pain, anorexia, flatulence, hematuria, neutropenia, hyperglycemia, rash, pruritus, diaphoresis
300 mg by mouth twice daily OR 1 mg/kg IV infused over 1 hour every 4 hours until oral form can be given
Pregnant patients over 14 weeks gestation: 100 mg by mouth five times daily until labor begins, then 2 mg/kg IV over 1 hour, followed by a continuous infusion of 1 mg/kg/hour until the umbilical cord is clamped
dizziness, fever, fatigue, headache, insomnia, paresthesia, irritability, edema, left ventricular dilation, nasal drainage, anorexia, nausea, vomiting, diarrhea, neutropenia, severe bone marrow suppression, lactic acidosis, splenomegaly
Non-nucleoside reverse transcriptase inhibitors (NNRTIs): bind non-competitively to HIV-1 reverse transcriptase and prevents viral RNA conversion to DNA
Adults and children > 3 months and > 40 kg: 600 mg by mouth once daily
abnormal dreams, dizziness, agitation, amnesia, confusion, depression, fatigue, hallucinations, headache, impaired concentration, diarrhea, nausea, abdominal pain, dyspepsia, rash, toxic epidermal necrolysis, pruritus, Stevens-Johnson syndrome (SJS)
200 mg by mouth twice daily given with other antiretrovirals
abnormal dreams, amnesia, anxiety, confusion, fatigue, headache, insomnia, blurred vision, vertigo, abdominal pain, anorexia, constipation, dry mouth, gastritis, flatulence, pancreatitis, retching, renal failure, anemia, hepatomegaly, diabetes, dyslipidemia, dyspnea, rash
200 mg by mouth daily for 14 days, then:
fever, headache, fatigue, nausea, abdominal pain, diarrhea, neutropenia, thrombocytopenia, anemia, hepatitis, elevated liver enzymes, myalgia, arthralgia, blistering, rash, SJS
Protease inhibitors (PIs): inhibit the protease enzyme needed for the virus to replicate
300 mg once daily plus 100 mg ritonavir (Norvir) by mouth once daily
headache, depression, dizziness, fatigue, fever, insomnia, peripheral neuropathy, prolonged PR interval, 1st and 2nd-degree heart block, peripheral edema, nasal congestion, rhinorrhea, abdominal pain, diarrhea, nausea, vomiting, neutropenia, jaundice/scleral icterus, hypoglycemia, arthralgia, myalgia, cough, wheezing, rash
600 mg by mouth twice daily
To reduce gastrointestinal effects, begin with 300 mg by mouth twice daily and increase by 100 mg twice daily at 2 to 3-day intervals
anxiety, paresthesia, confusion, depression, dizziness, fatigue, headache, peripheral neuropathy, somnolence, taste perversion, hypotension, edema, flushing, blurred vision, diarrhea, nausea, vomiting, pancreatitis, urinary frequency, anemia, hepatitis, hyperglycemia, arthralgia, cough, rash, acne, pruritus
500 mg by mouth twice daily with 200 mg of ritonavir (Norvir) by mouth twice daily
dizziness, fatigue, headache, insomnia, epistaxis, diarrhea, pancreatitis, abdominal pain, nausea, vomiting, renal insufficiency, neutropenia, anemia, hepatic failure, hepatitis, anorexia, dehydration, diabetes mellitus, facial wasting, muscle cramps, cough, dyspnea, rash, pruritus, flu-like illness, reactivation of herpes simplex or varicella-zoster
Treatment naïve: 800 mg with ritonavir (Norvir) 100 mg by mouth once daily OR
800 mg with cobicistat (Tybost)
150 mg by mouth daily
Treatment experienced: 600 mg with 100 mg ritonavir (Norvir) by mouth every 12 hours
skin rash, hyperlipidemia, diarrhea, abdominal pain, nausea, vomiting, anorexia, fatigue
Fusion inhibitors: blocks the fusion of HIV with the host cell
90 mg subcutaneously twice daily
For children weighing at least 11 kg: 2 mg/kg subcutaneously twice daily up to a maximum of 90 mg
fatigue, insomnia, anxiety, depression, conjunctivitis, taste disturbance, diarrhea, nausea, abdominal pain, constipation, dry mouth, anorexia, myalgia, bacterial pneumonia, injection-site reactions, pruritus
CCR5 Antagonists: block the CCR5 receptor on CD4+ T-cells to prevent the entry of HIV into the cell
When combined with CYP3A4 inhibitors: 150 mg by mouth twice daily
When combined with a potent CYP3A inducer: 600 mg by mouth twice daily
When combined with any drug that is not a potent CYP3A inhibitor or inducer: 300 mg by mouth twice daily
anxiety, dizziness, paresthesia, sensory abnormalities, depressive disorders, pain, unstable angina, acute cardiac failure, endocarditis, otitis media, nasal congestion, abdominal pain, constipation, dyspepsia, flatulence, vomiting, anemia, neutropenia, cirrhosis, jaundice, joint and muscle pain, rhabdomyolysis, cough, rash, pruritus
Integrase strand transfer inhibitor (INSTI): blocks the enzyme integrase, which in turn keeps HIV from inserting its DNA into the host DNA
raltegravir potassium (Isentress)
1,200 mg by mouth once daily OR 400 mg by mouth twice daily OR 300 mg (chewable tablets) by mouth twice daily if unable to swallow a whole tablet
Treatment experienced: 400 mg by mouth twice daily
headache, dizziness, fatigue, insomnia, abnormal dreams, depression, nightmares, nausea, abdominal pain, vomiting, diarrhea, flatulence, decreased appetite, anemia, neutropenia, thrombocytopenia, hyperglycemia, rhabdomyolysis
Post attachment inhibitors: block CD4+ receptors on the surface of specific immune cells that HIV needs to enter the cells
2,000 mg IV infusion loading dose followed by 800 mg IV infusion maintenance dose every 2 weeks
nausea, dizziness, diarrhea, rash,
PK enhancer (CYP3A Inhibitor): increase the effectiveness and systematic exposure of other HIV drugs, including atazanavir or darunavir
150 mg by mouth daily WITH atazanavir 300 mg by mouth daily OR darunavir (Prezista) 800 mg by mouth daily
jaundice, ocular icterus, nausea, rash
(NIH, 2022; Woods, 2023)
Combination products containing more than one ARV medication are also available. Additionally, the patient might require drugs to treat secondary or opportunistic conditions, such as antineoplastic medications, antivirals, or antifungals, or to combat adverse effects, such as antiemetic or antidiarrheal medications. If the patient has depression, antidepressants such as imipramine (Tofranil) and fluoxetine (Prozac) might be prescribed. These also have secondary beneficial effects, such as reducing fatigue and lethargy. Methylphenidate (Ritalin) can improve neuropsychiatric impairment (NIH, 2022).
ART adherence and viral suppression drives the successful outcomes of ART therapy. Proper administration of the medication regime leads to viral suppression, and undetectable levels of the virus are possible. As previously mentioned, the concept of U=U has been recognized as scientifically sound among most experts. The NIH's National Institute of Allergy and Infectious Disease (NIAID) reviewed the extensive scientific evidence behind U=U, leading to widespread acceptance of the concept. The validation of HIV treatment as a prevention strategy adds additional rationale for compliance with ART among HIV-positive patients and further decreases the stigma surrounding an HIV diagnosis. For the virus to remain undetectable, strict compliance with ART is required (CDC, 2021d; NIH, 2019).
In the few months following ART initiation, some patients may develop immune reconstitution inflammatory syndrome (IRIS) due to the sudden boost in the body's immune capabilities. IRIS results in an exaggeration of symptoms associated with opportunistic pathogens that might be present in the patient's body (e.g., tuberculosis, hepatitis, and cytomegalovirus). Treatment with corticosteroids may be required to reduce inflammation and resolve this condition (NIH, 2022).
Treatment with ART can cost well over $1,000 per month. Government insurance programs offer coverage for HIV-related medical visits and medications. Private health insurance is required to pay for many of the medications used to treat HIV; however, the co-pays may be high, causing the patient financial hardship. For the patient who does not have health insurance, assistance is available through government programs, including Medicaid, Medicare, the Ryan White AIDS Program, and other resources such as the AIDS Drug Assistance Program (ADAP; CDC, 2021d).
While patients are being treated for HIV, the HCP should:
- review laboratory findings to monitor for adverse medication effects (e.g., alanine aminotransferase, aspartate aminotransferase, bilirubin, mean corpuscular volume, high-density lipoproteins, total cholesterol, and triglycerides)
- monitor total CD4+ T-lymphocyte count, CD4 percentage, and the ratio of CD4 to CD8 cells to monitor disease progression and effectiveness of the medication regimen
- reinforce patient teaching about the potential adverse effects of the medications and explore ways to decrease the severity of adverse effects to promote adherence to the prescribed treatment regimen
- obtain a list of the patient's prescribed, over-the-counter, or herbal medications to check for possible interactions (CDC, 2021d; NIH, 2022)
Patient Education for Medication Issues
As a patient advocate, the nurse should educate the patient on the following (CDC, 2021d; NIH, 2022):
- Medications should be taken on a regular schedule without missing doses. Missed medication doses can cause medication resistance. The goal is on-time dosing 90% of the time to maintain effectiveness.
- Protocols for missed doses specific to the medications prescribed should be followed.
- Medication administration timing, restrictions, and potential interactions with food or other substances should be thoroughly explained.
Patients may choose to use alternative and complementary therapies to supplement prescribed therapies to alleviate the manifestations of HIV (NIH, 2022). Common treatments may include the following:
- supplements such as vitamin D to promote bone health
- herbal products such as echinacea and ginseng for their effects on improving immunity
- shark cartilage used in the treatment of Kaposi's sarcoma
- physical therapy, occupational therapy, yoga, massage, and acupuncture
- relaxation techniques to alleviate stress and fatigue, such as meditation, visualization, guided imagery, and hypnosis
- selenium supplements to slow the progression of HIV (NIH, 2022)
When patients adhere to the regimen, PrEP can reduce the risk of acquiring HIV by 90%. Before initiation, the HCP must determine if the benefits outweigh the risks. The HCP should obtain a detailed sexual and drug use history and assess the risk of infection, evaluate the patient for the presence of conditions that could lead to adverse outcomes (i.e., kidney failure, active HBV infection, osteoporosis), and determine whether the patient can adhere to the medication regimen. PrEP uses combination ART to prevent HIV. Combination oral emtricitabine/tenofovir disoproxil fumarate (TDF-FTC; Truvada) and emtricitabine/tenofovir alafenamide (TAF-FTC; Descovy) are effective at reducing HIV infection. When taken as prescribed, TDF can reduce the risk of HIV infection by almost 100%. Side effects are mild and include nausea and diarrhea; however, TDF can lead to bone and renal toxicity when used long-term. TAF has shown less renal and bone toxicity incidence, but side effects include weight gain and dyslipidemia (Mayer & Krakower, 2022).
At the end of 2021, the FDA approved cabotegravir (Cabenuva) for use as PrEP. Cabotegravir (Cabenuva) requires an intramuscular injection of 600 mg every 2 months with an optional 30 mg daily 4-week course of the oral formulation of the drug before starting injections. Injections should only be administered into the gluteal muscle as the pharmacokinetics of the medication are unknown if administered in a different muscle. Other ART should not be used while being treated with cabotegravir (Cabenuva). Self-administration is not currently approved; therefore, the patient must have injections administered by an HCP. Side effects include pain, redness, and induration at the injection site (US Public Health Service, 2021).
PEP involves using ART to prevent an HIV infection in an HIV-negative individual with high-risk exposure to HIV (e.g., sex or sharing needles). HIV can establish infection within 24 to 36 hours after exposure; therefore, patients seeking care within 72 hours of exposure should be evaluated quickly for PEP initiation. PEP is a 28-day course of a three-drug ART regimen. The drugs used include TDF-FTC 300 mg/200 mg once daily, raltegravir (RAL; Isentress) 400 mg twice daily, and dolutegravir (DTG; Tivicay) 50 mg once daily. Compliance with the drug regimen is necessary for effectiveness. Treatment is well tolerated (CDC, 2022c).
The HCP should be knowledgeable about common complications that can affect a patient diagnosed with AIDS. Four significant issues related to the care of patients with AIDS are:
- opportunistic infections
- wasting syndrome
- fluid and electrolyte imbalance
- seizures (HIV encephalopathy; Hinkle et al., 2021)
- Tuberculosis (TB): pulmonary or extrapulmonary (may be lymphatic); negative skin testing does not necessarily rule out TB; a false-negative can occur if the patient's immune system is not strong enough to elicit a response to the injected purified protein derivative solution.
- Bacterial pneumonia: may impact the airway; the patient may report pain, chills, and shivering and exhibit wheezing and coughing.
- Septicemia/sepsis: can be caused by various infectious organisms, and due to a depleted immune system, the organism can proliferate and cause sepsis (Hinkle et al., 2021).
- Kaposi's sarcoma (KS): purple-blue lesions on the skin that usually occur on the extremities; there may be an invasion into the gastrointestinal system, lymphatic system, lungs, and brain; diagnosis is confirmed through biopsy antineoplastic medications are used for treatment.
- Lymphoma: may cause psychomotor slowing and changes in mental status, resulting in seizures and apathy; standard lymphoma treatment is usually ineffective for patients with AIDS.
- Squamous cell carcinoma: more aggressive forms are associated with HIV infection (Hinkle et al., 2021).
- Cytomegalovirus: a significant cause of morbidity and mortality; usually affects the retina and commonly causes blindness in patients with AIDS; if the eyes are affected, the patient will report visual impairment along with weight loss, fatigue, and fever.
- Herpes simplex virus – can affect the oral, perirectal, or genital areas; the course of illness is more severe than for healthy patients.
- Varicella-zoster virus – lesions may be painful or necrotic (Hinkle et al., 2021).
- Pneumocystis jirovecii pneumonia (PCP): initial manifestations are mild (dry cough, fever, chills) but can progress to respiratory failure within several days.
- Candidiasis (Candida albicans): occurs due to overgrowth of normal intestinal flora; commonly found in the oral cavity and esophagus, producing thick white exudate in the mouth with possible ulcerations; affected individuals report altered taste and may experience retrosternal burning (Hinkle et al., 2021).
- Toxoplasmosis (Toxoplasmosis gondii) – can result in toxic encephalitis and is accompanied by headache, altered mental status, and fever.
- Microsporidiosis – caused by a parasite; clinical findings depend on the organism, but diarrhea is the most common symptom.
- Cryptosporidiosis - a parasite in the small bowel mucosa; it can cause chronic, watery diarrhea in patients with AIDS; for patients who are not immunocompromised, the infection usually lasts only 1 to 2 weeks.
- Isosporiasis – a parasite found in feces; symptoms include stomach cramps, watery diarrhea, weakness, and weight loss.
- Leishmaniasis – is transmitted by sandflies and has been correlated with inadequate environmental resources and a weakened immune system; usually found in underdeveloped areas; clinical manifestations are associated with cutaneous, mucocutaneous, and visceral lesions (Hinkle et al., 2021).
Interventions for opportunistic infections often include:
- maintain treatment with ART
- antineoplastic, antibiotic, analgesic, antifungal, or antidiarrheal medications as indicated
- monitor for skin breakdown
- monitor fluid intake and electrolyte status
- maintain adequate nutrition, consult a dietician if needed, and provide supplementation and appetite stimulants as indicated
- protect the patient from acquiring other infectious conditions during treatment
- educate the patient on signs that should be reported immediately to the HCP since recovery is often much longer, and the risk of complications is higher (Hinkle et al., 2021)
In 1987, the CDC recognized "wasting" as an AIDS-defining condition. Current guidelines define the condition as unintended weight loss of more than 10% in a year, more than 5% in 6 months, or a body mass index (BMI) of less than 20. Disease progression and mortality are related to weight loss in patients with AIDS and are characterized by depletion of fat and muscle tissue. Wasting may be due to multiple factors such as malignancy, malabsorption, decreased appetite and intake, and diarrhea. The HCP should address these underlying conditions to promote adequate intake and monitor the patient for weight loss. Sufficient intake is essential, and measures must be implemented to stimulate appetite (Dudek, 2018; Hinkle et al., 2021). Interventions for wasting syndrome are likely to include:
- maintain nutrition orally or through total parenteral nutrition (TPN) if necessary
- monitor weight, calorie counts, intake, and output
- medications to control diarrhea, increase appetite, and combat gastrointestinal tract infections (Hinkle et al., 2021)
The HCP should be sure to educate the patient regarding wasting syndrome. Education should include:
- report weight loss immediately
- eat at least six small meals daily
- decrease the fat content of foods to prevent complications of fat intolerance
- incorporate between-meal supplements and snacks into the diet
- consume more calories and protein to prevent loss of muscle mass by adding the following foods: instant breakfast drinks, eggs, cheese, milkshakes, dried beans, peas, peanut butter, and cream-based soups and sauces
- perform mouth care several times daily to reduce pain and increase appetite
- engage in strength-building exercises such as resistance exercises and modified weight training as tolerated (Hinkle et al., 2021)
Fluid and Electrolyte Imbalance
Patients with AIDS can develop a wide variety of fluid and electrolyte disturbances. This may be secondary to the disease or related to adverse medication effects. The patient might experience an imbalance of calcium, magnesium, phosphorus, potassium, or sodium. When monitoring the patient for these conditions, the HCP should monitor for findings associated with hyper or hypo-electrolyte levels (Hinkle et al., 2021). Interventions for fluid/electrolyte imbalance typically include:
- monitor fluid status, particularly for indicators of dehydration
- monitor kidney function and electrolyte levels and report abnormal laboratory data promptly
- observe the patient for physiological manifestations of electrolyte imbalance (changes in neuromuscular ability, vital signs, or deep tendon reflexes)
- encourage the patient to drink two to three liters of fluid daily
- make dietary adjustments to reduce diarrhea
- inform the patient that electrolyte monitoring might be required every 3 to 6 months
- ensure the patient is aware of potential electrolyte disturbances associated with each HIV stage and treatment option, and what to monitor for and when to report abnormalities (Hinkle et al., 2021)
As AIDS develops, the patient may experience HIV-associated neurocognitive disorders (HAND). When HIV cells infect the brain, they secrete neurotoxins, and the patient may begin to experience impairment with motor dysfunction, speech problems, and behavioral changes. Cognitive impairment may be marked by mental slowness/psychomotor slowing, memory problems, lack of concentration, depression/apathy, incontinence, and diminished spontaneity. These cognitive and behavioral symptoms may accompany a similar reduction in motor abilities, such as loss of fine motor control with associated clumsiness or lack of balance. The condition can progress to the absence of verbal response (mutism), spastic paraparesis, hallucinations, psychosis, seizure, and death. However, the specific symptoms of HIV dementia may vary from person to person. The patient can deteriorate to the point where they are dependent and require 24/7 care (Hinkle et al., 2021).
Deterioration may be a prolonged and gradual process with varying levels of impairment as the disease process progresses. It is essential to encourage the patient to maintain self-care and participate in ADLs for as long as possible. The HCP should attempt to engage them in skills and exercises to maintain and promote their cognitive and physical functioning. The level of care required will increase as the level of neurocognitive disorder worsens (Hinkle et al., 2021). Interventions may include the following:
- maintain patient safety, including fall and seizure precautions
- promote self-care
- encourage cognitive exercises
- promote psychomotor skills
- address worsening manifestations, especially if the ability for self-care is a concern
- discuss the effects of HIV on the brain leading to impairment in thinking, emotions, and movement
- validate the patient's feelings of frustration that can result from muscle weakness and clumsiness (Hinkle et al., 2021)
Nursing care for a patient diagnosed with HIV in the acute care setting should be prioritized according to need. Each body system is affected by either the pathophysiology of HIV or secondary conditions. The patient's respiratory status might be affected due to fatigue or secondary infection. Confusion is possible if the brain has been affected. Pain is often a problem, so the nurse should advocate for pharmacological and non-pharmacological measures to promote comfort. Changes to the endocrine system can affect nutrition, gonads, and hormone production. Nutrition is another area of concern for a patient who has HIV. The nurse should intervene to ensure the patient maintains or gains weight, drinks adequate fluid, and demonstrates laboratory evidence of proper nutrition and electrolyte stability. Diarrhea is a common problem, and the nurse should promote regular, formed bowel movements and prevent complications from fluid or electrolyte imbalances. Skin integrity can be compromised easily, so skincare and preventing breakdown are essential nursing strategies (Hinkle et al., 2021). Specifically, the nurse should:
- provide a private room if the patient is immunocompromised and keep fresh plants, fruits, and vegetables out of the room
- monitor fluid intake and output as well as nutritional intake
- obtain daily weights
- monitor electrolytes
- assess skin for rashes, open areas, redness, or bruising
- monitor pain and implement interventions to promote comfort
- monitor vital signs (especially temperature as an indicator of infection)
- auscultate lung sounds
- assess neurological status and monitor for confusion, dementia, or visual changes
- monitor bowel sounds and administer antidiarrheal medications as indicated
- encourage activity alternated with rest periods
- administer supplemental oxygen as needed
- reinforce patient teaching
- assist the patient in identifying primary support systems
- employ the principles of asepsis when performing venipunctures or other invasive procedures
- maintain strict adherence to standard precautions (Hinkle et al., 2021)
The nurse should demonstrate sensitivity in addressing psychological issues with the patient. The nurse can use therapeutic communication techniques to encourage the patient to express concerns and identify positive self-characteristics (Hinkle et al., 2021). Other strategies include the following:
- promote patient independence and self-care
- advocate for patient decision-making
- assist the patient in setting goals
- determine a baseline for the patient's typical social patterns and monitor for changes (Hinkle et al., 2021)
Because HIV changes the course of the patient's life, the patient faces many challenges in learning to manage the disease and maintain their preferred lifestyle. HIV affects the entire body and impacts the patient financially and psychologically. The patient may require recurrent hospitalizations when complications or illness occur (Hinkle et al., 2021). The nurse should assist with care coordination by connecting members of the interprofessional team that can address patient needs related to HIV diagnosis and disease progression:
- infectious disease services can manage ART
- respiratory services can improve the respiratory status and provide portable oxygen
- a registered dietician can recommend dietary supplementation
- rehabilitation services can increase strength and improve the patient's level of independence
- support groups for HIV/AIDS patients, family members, and support persons can assist with psychological coping and grieving
- home health services are indicated for patients who need continued occupational or physical therapy or skilled nursing care to manage dressing changes and TPN
- transfer to a long-term care facility and hospice services may be required for patients with end-stage AIDS
- community programs might be able to provide patient assistance with housekeeping, shopping, and transportation
- a social worker can assist the patient with financial support and resources
- a case manager can coordinate services for the patient across the continuum of care (Hinkle et al., 2021)
The nurse plays an essential role in assisting the patient with self-management by discussing topics related to the prevention of transmission of HIV to others and protecting the patient from acquiring opportunistic infections. Education should be targeted around prolonging life and preventing complications. Patients may or may not be aware of the potential risk of transmission from blood. Therefore, protecting close contacts from exposure to contaminated blood or other body secretions is essential. Another vital role for the nurse concerning health promotion and disease prevention relates to ensuring the patient is up to date with immunizations. Vaccination timing is crucial and should be completed before exposure to an opportunistic infection. Most patients should obtain the seasonal influenza vaccine and the pneumococcal polysaccharide vaccine. Some immunizations may be appropriate, even with a CD4+ count below 200 cells/mm3. Older adult patients may be at increased risk for complications due to age-related changes and conditions, such as decreased resistance to infection, fluid and electrolyte imbalances, malnutrition, skin alterations, and loss of muscle tissue. Also, the nurse must emphasize medication compliance, as missed doses can cause medication resistance (Hinkle et al., 2021). Self-care education should also include:
- report manifestations of infection immediately to the provider (cough, shortness of breath, pain in the mouth, difficulty swallowing, swollen lymph nodes, gastrointestinal upset, difficulty urinating, mental changes, or edema)
- practice good hygiene, including frequent hand hygiene; bathe daily using an antimicrobial soap; if a full bath isn't possible, at least clean the armpits, genitals, groin, and anus
- avoid raw foods (fruits, vegetables, paprika, black pepper) and undercooked foods (meat, fish, eggs)
- do not drink liquids that have been sitting for over 1 hour, and rewash cups before use
- sanitize your toothbrush weekly in the dishwasher or by pouring bleach solution over it and rinsing with hot, running water
- avoid crowds, and do not travel to countries with poor sanitation
- identify positive coping mechanisms and seek support to manage feelings of grief or loss
- return to the provider as scheduled for monitoring of CD4+ levels, percentages, and viral load to ensure medications are working
- talk to the HCP about managing adverse medication effects; do not begin any new prescription, over-the-counter, or botanical supplements without discussing it with the provider that manages ART
- maintain a well-balanced diet; monitor for and report any significant weight loss
- avoid sharing items that may contain bodily fluids, such as eating utensils, razors, or toothbrushes
- avoid exposure to sick individuals (Hinkle et al., 2021)
Caring for a Patient who has AIDS
In general, the nurse should implement many of the care strategies previously mentioned; however, the patient with AIDS has a more complicated disease status, so the nurse may need to be more aggressive regarding symptom management and coordinate with a larger team of HCPs to provide comprehensive management of the patient's condition. A patient diagnosed with AIDS may be eligible for government benefits, including housing and disability assistance that is not available with an initial HIV diagnosis. When planning the care priorities of patients with AIDS, it is vital to address potential problems and comfort measures. While treating existing conditions, the nurse must also be proactive in preventing the development of a new infection. The primary need categories are addressed as life-threatening, physical, and psychological (Hinkle et al., 2021).
Life-Threatening Care Needs
The nurse can use the prioritization principle of airway, breathing, and circulation to address life-threatening patient needs. Some patients experience problems with airway clearance and could develop respiratory distress. The nurse should have suction equipment and oxygen available if this is anticipated. Rigorous monitoring of vital signs, including lung sounds, is imperative. Bronchodilators and antibiotics should be given as prescribed, and the patient should be monitored for symptoms of secondary infections. Electrolyte disturbances could lead to arrhythmias or alterations in blood pressure, and neurological changes place the patient at increased risk for injury (Hinkle et al., 2021).
Physical Care Needs
Patients with AIDS are immunocompromised and susceptible to developing a range of diseases. Standard infection control precautions should be reinforced with the patient and family. They should be regularly assessed for dehydration and have their weight monitored. Nutritional supplements should be encouraged as required. As the disease progresses, the patient may experience fatigue and require assistance with ADLs. They should be encouraged to relax, rest, and restrict visitation from family and friends when needed. The patients should be regularly assessed for pain and given prescribed medication for pain relief (Hinkle et al., 2021).
Emotional Care Needs
An HIV diagnosis is life-changing for the patient and their loved ones. Depression, hopelessness, and anger are typical emotional responses, and the healthcare team should provide support through the early stages of disease diagnosis and treatment. An HIV support group can be an excellent way for patients to share feelings and work through new challenges. Seeing how others have managed their diagnosis and live with the disease can provide empowerment and encouragement for patients. Nurses should remind the patient that having HIV does not mean they have AIDS, and they may never progress to this stage. Patients may be embarrassed about their situation and should be encouraged to express their feelings and discuss their concerns. The responsibilities and expectations of the patient should be addressed. A discussion on lifestyle choices should be handled in a non-judgmental manner. In addition to using therapeutic communication techniques, the nurse can offer referrals to counselors or spiritual advisors if the patient expresses a desire to talk further (Hinkle et al., 2021).
The nurse should ask if the patient is taking herbal products, as botanicals can alter the effects of prescribed medications. For example, St. John's Wort is commonly used to treat depression; however, this herbal medicine is processed via the liver and can alter the efficacy of some ARVs, such as protease inhibitors and NNRTIs. Ask the patient about the use of therapies that might not be approved or have evidence to demonstrate effectiveness, as these treatments might cause harm to the patient. Encourage the patient to discuss preferences about alternative therapies with the provider (NIH, 2022).
Laws that protect HIV and AIDS patients include the Americans with Disabilities Act (ADA) of 1990 and the Federal Rehabilitation Act of 1973, which protects patients with HIV/AIDS from discrimination. It is unlawful to discriminate against anyone with suspected or known HIV/AIDS. Anyone with HIV/AIDS who feels discriminated against based on their disease should file a complaint with the Office for Civil Rights of the US Department of Health and Human Services or the appropriate agency within their state (US Department of Justice, 2020).
Several national support services are available for individuals living with HIV/AIDS. Patients need to understand their rights and resources within the medical system. Those rights include safety, competent medical care, and confidentiality. The following resources are listed on the CDC (2022d) website:
- Ryan White HIV/AIDS program. This resource assists people with HIV/AIDS after exhausting all other resources. They can get medical care and other services, regardless of their ability to pay. The website lists available resources: https://targethiv.org/community/program-locator.
- Housing Opportunities for Persons with AIDS (HOPWA) is a federal program dedicated to the housing needs of people living with HIV/AIDS. This program is funded by the Housing and Urban Development Department (HUD). It makes grants available to local communities, states, and non-profit organizations to serve the housing needs of those impacted by HIV/AIDS. Their website can be found at https://www.hudexchange.info/programs/hopwa/.
- The Affordable Care Act (ACA) is the national healthcare law and has provisions to expand medical coverage for those with HIV/AIDS. Each state will have varying coverage, and social workers or healthcare providers (HCPs) in a local area can guide the patient through available options. This website can help explain the ACA services for each state: https://www.greaterthan.org/campaigns/health-coverage-hiv-you/.
Children with HIV will have a different progression of the disease. Most pediatric HIV is due to maternal transmission and a significant impetus for maternal screening campaigns. Most HIV-positive children will exhibit symptoms by age 7 if ART is not initiated, so the current recommendation is to start medications as soon as an HIV-positive status is determined. Children with HIV may have developmental delays, pneumonia, failure to thrive, or recurrent bacterial infections. Uninfected children born to HIV-positive mothers should receive 6 weeks of ART to reduce the possibility of HIV transmission (CDC, 2021b).
Pregnancy has its own risks and exposes HCPs and the fetus to the possibility of infection. All pregnant women should be counseled on their risk for HIV. It is recommended that all pregnant patients are screened for HIV. The HCP should discuss their options for testing. All pregnant patients should be tested for HIV during the first prenatal appointment, and those at high risk should be tested again at 36 weeks of gestation. Treatment can begin immediately to reduce the risk of transmission to the fetus. In some states, HCPs caring for pregnant women must ensure HIV counseling and testing for each woman seeking prenatal care. While less common, HIV can be spread from mother to child during pregnancy, birth, or breastfeeding. If mothers are screened early, treatment with ARVs can decrease the risk of transmission to their babies. During treatment, PK enhancers such as cobicistat (Tyboost) are not recommended for use in pregnant patients (CDC, 2021b).
As treatment options improve, patients diagnosed with HIV are living longer. At the end of 2016, 48% of individuals diagnosed with HIV were over 50, and 8% were over 65. HIV treatment in older patients comes with additional challenges. Older individuals are more likely to experience serious non-HIV complications. As the individual ages, they also acquire more comorbid conditions increasing the need for medical intervention. Due to physiological changes, older adults are more susceptible to side effects and adverse drug effects. Polypharmacy is also more prevalent as an individual ages, increasing the risk of drug-drug interactions (NIH, 2022).
Although many older adults engage in risky behavior that puts them at risk of HIV exposure, most HCPs perceive this population to be at low risk of HIV infection, delaying testing. In this population, a late diagnosis of HIV leads to delayed initiation of ART. In 2016, 36% of individuals over 55 met the criteria for AIDS at the time of HIV diagnosis. This is compared to 16% of adults 25-34 and 27% of adults 35-44 (NIH, 2022).
Centers for Disease Control and Prevention. (2016). Infection control. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html
Centers for Disease Control and Prevention. (2020). HIV transmission. https://www.cdc.gov/hiv/basics/transmission.html
Centers for Disease Control and Prevention. (2021a). Diagnostic tests: Newer, improved HIV tests allow for earlier HIV detection. https://www.cdc.gov/hiv/clinicians/screening/diagnostic-tests.html
Centers for Disease Control and Prevention. (2021b). HIV infection: Detection, counseling, and referral. https://www.cdc.gov/std/treatment-guidelines/hiv.htm
Centers for Disease Control and Prevention. (2021c). Monitoring selected national HIV prevention and care objectives by using HIV surveillance data United States and 6 dependent areas, 2019: Technical notes. https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-26-no-2/content/technical-notes.html
Centers for Disease Control and Prevention. (2021d). Treatment, care, and prevention for people with HIV. https://www.cdc.gov/hiv/clinicians/treatment/treatment-clinicians.html#TASP
Centers for Disease Control and Prevention. (2022a). Benefits of routine screening. https://www.cdc.gov/hiv/clinicians/screening/benefits.html
Centers for Disease Control and Prevention. (2022b). HIV and AIDS timeline. https://npin.cdc.gov/pages/hiv-and-aids-timeline#1980
Centers for Disease Control and Prevention. (2022c). Post-exposure prophylaxis (PEP). https://www.cdc.gov/hiv/clinicians/prevention/pep.html
Centers for Disease Control and Prevention. (2022d). Resources for people with HIV. https://www.cdc.gov/hiv/basics/livingwithhiv/resources.html
Centers for Disease Control and Prevention. (2022e). Terms, definitions, and calculations used in CDC HIV surveillance publications. https://www.cdc.gov/hiv/statistics/surveillance/terms.html
Dudek, S. G. (2018). Nutrition essentials for nursing practice (8th ed.). Wolters Kluwer.
Hinkle, J. L., Cheever, K. H., & Overbaugh, K. (2021). Brunner & Suddarth's textbook of medical-surgical nursing (15th ed.). Wolters Kluwer.
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care (9th ed.). Elsevier.
Kuhar, D. T., Henderson, D. K., Struble, K. A., Heneine, W., Thomas, V., Cheever, L. W., Gomaa, A., Panlilio, A. L., US Public Health Service Working Group on Occupational Postexposure Prophylaxis, National Center for Emerging and Zoonotic Infectious Diseases, & US Division of Healthcare Quality Promotion. (2018). Updated US public health service guidelines for the management of occupational exposures to HIV and recommendations for post-exposure prophylaxis. The Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/20711
Mayer, K. H., & Krakower, D. (2022). Administration of pre-exposure prophylaxis against HIV infection. UpToDate. Retrieved July 23, 2022, from https://www.uptodate.com/contents/administration-of-pre-exposure-prophylaxis-against-hiv-infection
McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Elsevier.
Minority HIV/AIDS Fund. (2021). U.S. statistics. https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics
Minority HIV/AIDS Fund. (2022). About HIV & AIDS. https://www.hiv.gov/hiv-basics/overview/about-hiv-and-aids/symptoms-of-hiv
National Center for HIV/AIDS, Viral Hepatitis, and TB Prevention. (2018). 2018 quick reference guide: Recommended laboratory HIV testing algorithm for serum or plasma specimens. https://stacks.cdc.gov/view/cdc/50872
National Institute of Health. (2019). The science is clear: With HIV, undetectable equals untransmittable. https://www.nih.gov/news-events/news-releases/science-clear-hiv-undetectable-equals-untransmittable
National Institute of Health. (2021). Drug resistance. https://hivinfo.nih.gov/understanding-hiv/fact-sheets/drug-resistance
National Institute of Health. (2022). What to start: Initial combination regimens for the antiretroviral-naïve patient. https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/whats-new-guidelines
Peruski, A. H., Wesolowski, L. G., Delaney, K. P., Chavez, P. R., Owen, S. M., Granade, T. C., Sullivan, V., Switzer, W. M., Dong, X., Brooks, J. T., & Joyce, P. (2020). Trends in HIV-2 diagnosis and use of the HIV-1/HIV-2 differentiation test - United States, 2010-2017. Morbidity and Mortality Weekly Report (MMWR), 69(3), 63-66. https://doi.org/10.15585/mmwr.mm6903a2
Public Health. (n.d.). HIV and AIDs: An origin story. Retrieved July 20, 2022, from https://www.publichealth.org/public-awareness/hiv-aids/origin-story/
Sax, P. E. (2022). Acute and early HIV infection: Clinical manifestations and diagnosis. UpToDate. Retrieved July 23, 2022, from https://uptodate.com/contents/acute-and-early-hiv-infection-clinical-manifestations-and-diagnosis
Selik, R. M., Mokotoff, E. D., Branson, B., Owen, S. M., Whitmore, S., & Hall, H. I. (2014). Revised surveillance case definition for HIV infection - United States, 2014. Morbidity and Mortality Weekly Report (MMWR), 63(RR03), 1-10. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm
US Department of Justice. (2020). A guide to disability rights laws. https://www.ada.gov/cguide.htm
US Department of Veterans Affairs. (2019). Glossary of HIV terms. https://www.hiv.va.gov/provider/glossary/index.asp
US Public Health Service. (2021). Pre-exposure prophylaxis for the prevention of HIV infection in the United States - 2021 update: A clinical practice guideline. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf
Woods, A. D. (2023). Nursing 2023 drug handbook. Wolters Kluwer.
World Health Organization. (2015). Consolidated guidelines on HIV testing services 5Cs: consent, confidentiality, counseling, correct results, and connection. https://ncbi.nlm.nih.gov/books/NBK316021
World Health Organization. (2021a). HIV/AIDS key facts. https://www.who.int/news-room/fact-sheets/detail/hiv-aids
World Health Organization. (2021b). Summary of the global HIV epidemic, 2020. https://www.who.int/data/gho/data/themes/hiv-aids