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HIV Lecture Handout

Human Immunodeficiency Virus Infection - Infection caused by a retrovirus that results in immunosuppression

 Significance – Global pandemic

 Transmission
 Blood
 Semen
 Vaginal secretion
 Breast milk
o Can transmit HIV to others within a few days of after becoming infected
o Variables that influence if infection will be established after an exposure
 Duration and frequency of contact with the organism
 Volume, virulence and concentration of the organism
 Host immune status
o Large amounts of HIV can be found in the blood and to a lesser extent in the semen during
the first 6 months of infection and again in the last stage of the disease;
o Transmission is possible during all phases of the infection;
o HIV IS NOT SPREAD CASUALLY
o Healthcare workers are at low risk even after a needle stick after injury;
 Sexual transmission
o Most common mode of transmission
o What is sexual activity
 Contact with semen, vaginal secretions, and/or blood
 During sexual intercourse (oral, anal, as well as vaginal) the risk for infection is > for
the partner who receives the semen BUT infection can be transmitted to the
inserting partner
 Sexual activity can cause trauma to local tissues which ↑ risk of transmission;
 Contact with any type of genital lesions
 Contact with Blood and blood products
o Shared IV drug paraphernalia
o Blood transfusions and blood products – testing of donor blood for various viruses
(including HIV) has made the blood supply safer;
o Puncture wounds are the most common means of HIV transmission – 0.3%; 3-4/1000
o Splash exposure to open wounds present some risk;

 Perinatal Transmission
o HIV infected mothers transmit the virus during pregnancy, delivery and breast feeding;
o 25% of infants born to UNTREATED mothers will contract the virus;
o If the mother is treated with antiretroviral drugs the risk is reduced to ≤2%
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Pathophysiology
 HIV is an RNA virus → a retrovirus
 All viruses must reside in a living cell to replicate
o CD4+ T cell (CD4 cell) is the target cell for HIV
o You tube video https://youtu.be/HhhRQ4t95OI
 Fusion – Fig 14.2
 RNA enters the CD4 cell
 Reverse transcriptase – transforms the HIV RNA into a single strand DNA
 DNA copies itself to become a double stranded DNA
 Integrase – allows the newly formed DNA to integrate into the hosts’ genetic structure
 Replication of all genetic material results in all daughter cells being infected, and
 Viral DNA in the genome directs the cell to make new HIV
 Protease – another enzyme involved in HIV replication; cleaves the strands of newly
formed HIV into smaller pieces, new virions are formed and released from the
 The CD4 cells are destroyed after release
 HIV destroys about 1 billion CD4 cells everyday
o For years, the body can make new CD4 cells to replace the ones destroyed
o Healthy CD4 cells have a life span of 100 days but with HIV, these cells die within 2 days
o Eventually the ability of HIV to destroy the CD4 cells exceeds the body’s ability to replace the
cells
 The decline in CD4 cells impairs immune function
o B-cells make HIV specific antibodies→ ↓ viral load; Fig 14.3
o The immune dysfunction with HIV is predominantly the result of damage and destruction of the
CD4 cells
 Normally there are 800 – 1200/microliter CD4 cells
 Immune problems start to occur when CD4 cell count is <500 cell/ microliters
 Severe problems develop with < 200 CD4 cells/microliter
o CD4 cell destruction then results in the inability to regulate immune function Fig 14.3
o This allows opportunistic diseases –
 Disease
 Disability
 Death

 Clinical Manifestations and Complications

o BUT REMEMBER
 Disease progression is highly individualized
 Treatment can significantly alter this pattern
 Individual’ s prognosis is unpredictable
o Acute infection See Figure 14.4
 Mono-like symptoms accompany seroconversion
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 Some people develop neurological complications

 Aseptic meningitis
 Peripheral neuropathy
 Facial palsy
 Guillain- Barre syndrome
 Symptoms are evident in weeks 2-4 of the infection;
 ↑ viral load
 CD4+T-cells fall temporarily but quickly rebound
o Chronic Infection
 Most often the asymptomatic period of the infection
 This is a public health problem – Why?

 There is about a 10-12year period between untreated HIV and the development of AIDS
 During this time, the viral load is ↓ and the CD4+T-cell count is ≥500
o Symptomatic Period of the Infection
 CD4 cell count ↓ to 200 – <500
 Viral load ↑
 HIV advances
 Acute symptoms return only worse than before;

o Acquired Immunodeficiency Syndrome – AIDS

 Must meet CDC criteria See Table 14.10
 Opportunistic diseases do not occur in persons with functioning immune systems;
(Table 14.11)
 CD4+ T-cell count falls below 200
o Viral load is high

 One of the following Opportunistic infections

o Bacterial
o Fungal
o Protozoal
o Viral

 One of the following Opportunistic cancers

o Burkitt’s lymphoma
o Immunoblastic lymphoma
o Invasive cervical cancer
o Kaposi sarcoma
o Primary lymphoma of the brain
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 Wasting syndrome

 Diagnostic Studies Table 14. 12

o HIV Antibodies and/or antigens – detected in the blood
 HIV screening can be done using blood or saliva
 For most test to detect acute HIV infection it is about 3 weeks
 Takes 2 – 12 weeks after infection to build antibodies
 The delay is known as the ______________ _____________.
 If tested during the window period may show a false negative
 Standard Antibody Test
 Blood – Enzyme immunoassay (EIA)
 Reports back in 1 – 7 days
 If the test is antibody positive repeat the test;
 If the second test comes back positive the result must be confirmed by a more
specific test called the Western Blot or the Immunofluorescence assay (IFA);
 Rapid HIV test – “ORA Quick” Test
 Results within 20 minutes;
 A Positive result must be confirmed by a more specific test called the Western
Blot or the immunofluorescence assay (IFA);
 A negative result followed by a Risk Assessment
 Combined Antibody/Antigen Test
 Good for testing in the “Window period”

o Laboratory Studies
 Progress monitored by 2 tests:
 CD4 cell count Fig 14.3
 Viral Load
o Reported in real numbers
o Undetectable –

o Other Abnormal Lab Studies

 ↓ WBC especially when looking at the Differential
 ↓ Platelets -
 Anemia of chronic illness and due to ART
 Altered Liver Functions -
 Two Type of Resistance Tests
 Genotype Assay – detects drug resistant viral mutation
 Phenotype Assay - measures the growth of HIV in various concentrations of ART
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HIV Lecture Handout
 Collaborative Care
o Focus is on
 Monitoring immune function and progression of the disease
 Initiating and monitoring ART
 Preventing the development of opportunistic diseases
 Detecting and treating opportunistic diseases Table 14.11
 Managing symptoms
 Preventing or ↓ complications of treatment
 Preventing any further transmission

o To accomplish
 Ongoing Assessment

 Close clinician-patient interaction

 Ongoing patient teaching

 Support

 Drug Therapy – Antiretroviral Therapy (ART) See Table 14.13

o Also called HAART -Highly Active Antiretroviral Therapy https://youtu.be/e85nerRGfWw
o Goals of Treatment
 ↓ viral load
 Maintain or ↑ CD4 cell count
 Prevent HIV related symptoms and opportunistic diseases
 Delay disease progression
 Prevent HIV transmission
o Cannot be cured but with ART:
 Drugs must be taken absolutely, as directed and consistently
 Can ↓ viral load by 90-99%
o Major advantages to having several different classes of drugs to treat HIV is that combination
therapy can inhibit viral replication in several different ways
 Making viral recovery more difficult
 Decreasing the possibility of drug resistance developing due to mutation
o A combination of 3 or more drugs, each from a different class, should be used;
o See Table 14.13 https://youtu.be/GR9d9wrOl5E
 Attachment Inhibitors (AI) – blocks HIV envelope from attaching to the cell membrane;
this prevents HIV from entering the CD4 cell of the immune system
 Entry Inhibitors (EI) – prevents binding of HIV to cells; preventing entry into the cell
where replication would occur
 CCR5 Antagonists – blocks the CCR5 co-receptor on the surface of some immune
cells, like the CD4 T lymphocytes and prevents entry into the cell.
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HIV Lecture Handout
 Reverse Transcriptase Inhibitor
 Nucleoside Reverse Transcriptase Inhibitor (NRTI) – inserts a piece of DNA into
the developing HIV DNA chain, blocking further development of the chain and
leaving the production of the new strand of HIV DNA incomplete
 Non-nucleoside Reverse Transcriptase Inhibitor (NNRTI) – inhibits the action of
reverse transcriptase
 Nucleotide Reverse Transcriptase Inhibitor (NtRTI) – combines with reverse
transcriptase enzyme to block the process needed to convert HIV RNA into HIV
DNA:
 Integrase Inhibitors – bind with integrase enzyme and prevent HIV from incorporating
its genetic material into the host cell; prevents HIV from replicating.
 Integrase Strand Transfer Inhibitors (INSTI) – blocks integrase (an HIV enzyme, which is
used to insert (integrate) its viral DNA into the host DNA of the host CD4 cell. Prevents
HIV from replicating.
 Protease Inhibitors (PIs) – prevent the protease enzyme from cutting HIV proteins into
the proper length needed to allow viable virions to assemble and bud out from the cell
membrane
 Fixed Dose Combination Products - more than one drug combined into a single tablet;
drugs may be from the same or different classes

o Many of these drugs have dangerous and potentially lethal interactions with other common
drugs, OTC drugs and herbal therapies; See SAFETY ALERT pg 221
 Encourage patient to discuss any other Rx medication or OTC drugs and herbal therapies
with their HIV practitioner prior to starting

 Drug Therapy for Opportunistic Diseases

o HIV treatment is complicated by the many opportunistic diseases that develop as the immune
system deteriorates Table 14.11
o Prevention is the preferred though not possible to totally eradicate once they occur
o Prophylactic medication can decrease the morbidity and motality
o Advances in prevention, diagnosis, and treatment have contributed significantly to increased
life expectancy

Preventing Transmission
 Pre-exposure Prophylaxis (PrEP) – a comprehensive HIV prevention strategy to reduce the risk of
transmission in high risk individuals; includes See the CDC Handout
o safe sex practices
o risk reduction counselling
o regular HIV testing
o the use of Etricitabine + tenofovir DF (Truvada)(Descovy)
Nursing Assessment
 The non-infected patient – focus on behaviors that are high risk for HIV
o Assess on a regular basis;
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HIV Lecture Handout
o Don’t judge – the church lady may be just as much at risk!
o Build a trusting rapport with each patient
o Questions to ask:
 Have you had a transfusion of blood or clotting factors?
 If so, was it before 1985?
 Have you shared drug using equipment with another person?
 Have you ever had a sexual experience in which your penis, vagina, rectum or mouth
came in contact with someone else’s penis, vagina, rectum or mouth?
 Have you ever had a sexually transmitted disease/infection?
 For the person already diagnosed with HIV see the full assessment Table 14.15

Health Promotion
See Promoting Population Health Pg 224
 Prevention is the only way to control the epidemic – HIV is preventable
o Teaching how to avoid and/or modify risky behavior
o Teaching needs to be culturally sensitive, language appropriate and age-specific;
o Develop a comfort level when talking about sexuality and drug use;
o Teach about safe sexual activities and risk reducing sexual activities;
Decreasing Risk Related to Sexual Intercourse
 Abstinence is not the only answer, but it is the only absolute 100%
o Masturbation, mutual masturbation
 Risk reducing sexual activities, through the use of barriers
o Male condoms –
 100% efficacy under ideal circumstances
 >90% effective in real life circumstances

o Female condoms (Dental Dams) –

 Also 100% efficacy
 94 – 97% effective in real life circumstances
Decreasing Risk Related to Drug Use
 Sharing equipment is where the risk lies; this includes all paraphernalia including coke straws and
pipes;
 Access to sterile equipment is an important risk elimination tactic
 OR having unsafe sexual experiences which would include any sex while under the influence of drugs
or ETOH
Decreasing Risk at Work
 PPE’s ↓ the risk of direct contact with blood and body fluids Table 14.8
 Should exposure occur
o Post Exposure Prophylaxis (PEP) See the CDC Handout
 ART must be started within 72hrs. of the exposure;
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HIV Lecture Handout
 And must be taken exactly as prescribed for 28 days;
 Significant ↓ in risk of contracting HIV but is not 100%;

HIV Testing
 14% of those living with HIV do not know they have the virus
 They are huge risk for transmission
 CDC recommendation – not a requirement
o Universal voluntary testing of all people 13-64yrs of age regardless of risk;
 CDC Goal:
o Normalize the test
o ↓ stigma related to HIV testing
o Find hidden cases
o Get infected people into care
o Prevent new cases of infection

Acute Interventions
 Goal: Early intervention to promote health and limit disability
Table 14.15,
o Initial response to the diagnosis – anxiety, panic, fear, anger, guilt ….
o Then comes the stigma and the discrimination
o These all include the family, friends & caregivers;
o Thoughts may then go to powerlessness, depression, the possibility of death and/or thoughts of
suicide;

 Antiretroviral Therapy – slows the clinical progression of HIV Table 14.17

o Adherence often is a problem
 Treatments are complex;
 Drugs have big side effects;
 ART does not work for everyone;
 ART is expensive;
o When adherence is poor it causes a high risk of developing drug resistance;
 MUST be taken at the right time and at the right dose; Table 14.18

 Delays Disease Progression – promote a healthy immune system

o Adequate nutritional support;
o Moderating or eliminating ETOH, tobacco and drugs;
o Keeping up to date with vaccines;
o Reduce stress
o Avoid exposure to new infectious agents;
o Accessing mental health counselling;
o Getting involved with support groups;
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HIV Lecture Handout
o Most importantly: developing a consistent relationship with HCP & keeping all regular
appointments

 Acute Exacerbation – common with all chronic diseases Table 14.16

o Nursing care is important when opportunistic diseases or difficult treatment side effects
develop, symptom management, teaching and emotional support are needed;
o Best way to prevent opportunistic infections is to follow the ART regime exactly and to take any
prophylactic meds that are ordered;
o Pneumocystis jiroveci pneumonia (PCP) – just as in any pneumonia – assure a clear airway and
adequate oxygenation;
o Cryptococcal meningitis – maintain a safe environment for a confused patient;

 Disease and Drug Side Effects

o HIV patients frequently experience these problems, and they are worsened by the drug
therapy:
 Anxiety Fear
 Depression Diarrhea
 Peripheral neuropathy Fatigue
 Pain Nausea/vomiting

 Frequent Side Effects of ART

o Developing a set of metabolic disorders that include:
 Lipodystrophy - A change in body shape (fat deposits in the abdomen, upper back,
breasts; and fat loss in the face and extremities)due to lipodystrophy;
 Insulin resistance -
 Hyperglycemia -
 hyperlipidemia -
 bone diseases - (osteopenia, osteoporosis, and AVN),
 lactic acidosis -
 renal disease - kidney stones
 cardiovascular disease –
o Frequently the ART must be changed to minimize the more serious d/o
o Early recognition of metabolic problems is important so that appropriate treatment may be
started; esp. with lactic acidosis which can be fatal
 Patient Education See Tables 14.17, 14.18, and 14.19

 End of Life Care

o HIV is not curable though people are living a lot longer the disease progresses to disability and
eventually death
o As a nurse you are the perfect care provider during this phase
 Keeping the patient comfortable
 Facilitate the spiritual and emotional acceptance of the finite nature of life
 Helping the significant others deal with grief and loss
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Gerontological Considerations
 The number of older adults who have HIV is increasing.
o HIV treatment has been effective in reducing the number of deaths from opportunistic diseases
o The number of people 60 and older are being infected at an increased rate
 Remember that older people with HIV are still susceptible to the same diseases that non-HIV infected
people are:
o The HIV patient may develop these conditions earlier
 Another consideration is the impact of polypharmacy
 Older adults may be ashamed and therefore hesitate to tell anyone they have HIV