PULMONARY DISEASE MANAGEMENT

LECTURE

MODULE

Human Immunodeficiency Virus (HIV)

and
Acquired Immunodeficiency Syndrome (AIDS)

Ina, a respiratory therapist, is assigned to an HIV-positive patient. She was tasked to

withdraw arterial blood from the said patient to be sent to the laboratory. While Ina is
withdrawing blood from the patient, he suddenly went berserk, and Ina’s needle plunged deep
into her arm. Afraid of being reprimanded, Ina kept the incident from her colleagues. A
month after, Ina reported fever and skin rash to her physician. She confessed about the
incident of the needle prick with her physician, so he ordered a series of tests to confirm Ina’s
diagnosis. The laboratory results showed that Ina is in the primary infection stage of HIV
infection.

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Description

Since HIV was first identified almost 30 years ago, remarkable progress has been
made in improving the quality and duration of life for people living with HIV disease.
● HIV or human immunodeficiency virus and acquired immunodeficiency syndrome
is a chronic condition that requires daily medication.
● HIV- 1 is a retrovirus isolated and recognized as the etiologic agent of AIDS.
● HIV-2 is a retrovirus identified in 1986 in AIDS patients in West.

Classification

The stages of HIV disease are based on clinical history, physical examination,
laboratory evidence of immune dysfunction, signs and symptoms, and infections and
malignancies.
● Primary infection (Acute/Recent HIV Infection). The period from infection with
HIV to the development of HIV-specific antibodies is known as primary infection.
● HIV asymptomatic (CDC Category A). After the viral set point is reached,
HIV-positive people enter into a chronic stage in which the immune system cannot
eliminate the virus despite its best efforts.
● HIV symptomatic (CDC Category B). Category B consists of symptomatic
conditions in HIV-infected patients that are not included in the conditions listed in
category C.
● AIDS (CDC Category C). When the CD4+ T-cell level drops below 200
cells/mm3 of blood, the person is said to have AIDS.

Pathophysiology

Because HIV infection is an infectious disease, it is important to understand how

HIV-1 integrates itself into a person’s immune system and how immunity plays a role in the
course of HIV disease.
● In this first step, the GP120 and GP41 glycoproteins of HIV bind with the host’s
uninfected CD4+ receptor and chemokine coreceptors, usually CCR5, which
results in fusion of HIV with the CD4+ T-cell membrane.
● The contents of HIV’s viral core are emptied into the CD4+ T cell.
● DNA synthesis. HIV changes in genetic material from RNA to DNA through
action of reverse transcriptase, resulting in double-stranded DNA that carries
instruction for viral replication.
● New viral DNA enters the nucleus of the CD4+ T cell and through the action of
integrase is blended with the DNA of the CD4+ T cell, resulting in permanent,
lifelong infection.
● When the CD4+ T cell is activated, the double-stranded DNA forms
single-stranded messenger RNA, which builds new viruses.
● The mRNA creates chains of new proteins and enzymes that contain the
components needed in the construction of new viruses.
● The HIV enzyme protease cuts the polyprotein chain into the individual proteins
that make up the new virus.

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 ● New proteins and viral RNA migrate to the membrane of the infected CD4+ T cell,
exits from the cell, and starts the process all over.

Pathophysiology of HIV and AIDS by Osmosis

Check out this awesome pathophysiology and easy to understand video by Osmosis.
https://www.youtube.com/watch?v=5g1ijpBI6Dk&feature=emb_title

Statistics and Epidemiology

In the fall of 1982, after the first 100 cases were reported, the Centers for Disease
Control and Prevention (CDC) issued a case definition for AIDS.
● In 2008, the CDC reported that approximately 56, 300 new HIV infections
occurred in the United States in 2006.
● The figure was roughly 40% higher than their former estimate of 40, 000 HIV
infections per year.
● Almost 7000 people still contract HIV infection every day.
● An estimated 33 million people are living with HIV/AIDS; however, the number of
new infections declined from 3 million in 2001 to 2.7 million in 2007.
● The global percentage of women among people with HIV/AIDS remains at 50%.
● Sub-Saharan Africa continues to be most heavily affected by HIV/AIDS, with
67% of all people living with the disease.
● In 2007, 72% of deaths from HIV/AIDS occurred in the same region.

Causes

HIV is transmitted through body fluids that contain free virions and infected CD4+
T cells.
● Sharing infected drug use equipment such as needles.
● Having sexual relations with infected individuals (both male and female).
● Blood transmission. Receiving HIV-infected blood or blood products especially
before blood screening.
● Maternal HIV. Infants born to mothers with HIV infection.

Clinical Manifestations

HIV has four categories with specific manifestations for each stage.
● This is experienced during the early infection stages.
● People who are acutely infected with HIV experience this symptom.
● This symptom is mostly present in category B wherein the patient has already
entered the chronic stage.
● Constitutional symptoms. Fever more than 38.5⁰C or diarrhea exceeding 1 month
in duration may also indicate presence of HIV infection.
● Patients with HIV category C experience wasting syndrome or severe wasting of
the muscles.

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Prevention

Until an effective vaccine is developed, nurses need to prevent HIV infection by

teaching patients how to eliminate or reduce risky behaviors.
● Safe sex. Other than abstinence, consistent and correct use of condoms is the only
effective method to decrease the risk of sexual transmission of HIV infection.
● In March 2007, based on the results of three clinical trials, the WHO and UNAIDS
recommended that circumcision be recognized as an effective strategy to reduce the
risk of HIV acquisition in men.
● Sex partners. Avoid sexual contact with multiple partners or people who are
known to be HIV positive or IV/injection drug users.
● Blood and blood components. People who are HIV positive or who use injection
drugs should be instructed not to donate blood or share drug equipment with others.

Complications

The patient should be monitored for presence of complications and should be managed
appropriately.
● Opportunistic infections. Patients who are immunosuppressed are at risk for
opportunistic infections such as pneumocystis pneumonia which can affect 80% of
all people infected with HIV.
● Respiratory failure. Impaired breathing is a major complication that increases
the patient’s discomfort and anxiety and may lead to respiratory and cardiac failure.
● Cachexia and wasting. Wasting syndrome occurs when there is profound
involuntary weight loss exceeding 10% of the baseline body weight and it is a
common complication of HIV infection and AIDS.

Assessment and Diagnostic Findings

Several screening tests are used to diagnose HIV infection.

● Confirming Diagnosis: Signs and symptoms may occur at any time after infection,
but AIDS isn’t officially diagnosed until the patient’s CD4+ T-cell count falls
below 200 cells/mcl or associated clinical conditions or disease.
● CBC: Anemia and idiopathic thrombocytopenia (anemia occurs in up to 85% of
patients with AIDS and may be profound). Leukopenia may be present; differential
shift to the left suggests infectious process (PCP), although shift to the right may be
noted.
● PPD: Determines exposure and/or active TB disease. Of AIDS patients, 100% of
those exposed to active Mycobacterium tuberculosis will develop the disease.
● Serologic: Serum antibody test: HIV screen by ELISA. A positive test result may
be indicative of exposure to HIV but is not diagnostic because false-positives may
occur.
● Western blot test: Confirms diagnosis of HIV in blood and urine.

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 ● Viral load test:
○ RT-PCR: The most widely used test currently can detect viral RNA
levels as low as 50 copies/mL of plasma with an upper limit of 75,000
copies/mL.
○ bDNA 3.0 assay: Has a wider range of 50–500,000 copies/mL. Therapy
can be initiated, or changes made in treatment approaches, based on rise
of viral load or maintenance of a low viral load. This is currently the
leading indicator of effectiveness of therapy.
○ T-lymphocyte cells: Total count reduced.
○ CD4+ lymphocyte count (immune system indicator that mediates several
immune system processes and signals B cells to produce antibodies to
foreign germs): Numbers less than 200 indicate severe immune
deficiency response and diagnosis of AIDS.
○ T8+ CTL (cytopathic suppressor cells): Reversed ratio (2:1 or higher) of
suppressor cells to helper cells (T8+ to T4+) indicates immune
suppression.
○ Polymerase chain reaction (PCR) test: Detects HIV-DNA; most helpful
in testing newborns of HIV-infected mothers. Infants carry maternal HIV
antibodies and therefore test positive by ELISA and Western blot, even
though the infant is not necessarily infected.
● STD screening tests: Hepatitis B envelope and core antibodies, syphilis, and other
common STDs may be positive.
● Cultures: Histologic, cytologic studies of urine, blood, stool, spinal fluid, lesions,
sputum, and secretions may be done to identify the opportunistic infection. Some
of the most commonly identified are the following:
○ Protozoal and helminthic infections: PCP, cryptosporidiosis,
toxoplasmosis.
○ Fungal infections: Candida albicans (candidiasis), Cryptococcus
neoformans (cryptococcus), Histoplasma capsulatum (histoplasmosis).
○ Bacterial infections: Mycobacterium avium-intracellulare (occurs with
CD4 counts less than 50), miliary mycobacterial TB, Shigella
(shigellosis),Salmonella (salmonellosis).
○ Viral infections: CMV (occurs with CD4 counts less than 50), herpes
simplex, herpes zoster.
● Neurological studies, e.g., electroencephalogram (EEG), magnetic resonance
imaging (MRI), computed tomography (CT) scans of the brain;
electromyography (EMG)/nerve conduction studies: Indicated for changes in
mentation, fever of undetermined origin, and/or changes in sensory/motor function
to determine effects of HIV infection/opportunistic infections.
● Chest x-ray: May initially be normal or may reveal progressive interstitial
infiltrates secondary to advancing PCP (most common opportunistic disease) or
other pulmonary complications/disease processes such as TB.
● Pulmonary function tests: Useful in early detection of interstitial pneumonias.
● Gallium scan: Diffuse pulmonary uptake occurs in PCP and other forms of
pneumonia.

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 ● Biopsies: May be done for differential diagnosis of Kaposi’s sarcoma (KS) or other
neoplastic lesions.
● Bronchoscopy/tracheobronchial washings: May be done with biopsy when PCP
or lung malignancies are suspected (diagnostic confirming test for PCP).
● Barium swallow, endoscopy, colonoscopy: May be done to identify opportunistic
infection (e.g., Candida, CMV) or to stage KS in the GI system.

Medical Management

Medical management focuses on elimination of opportunistic infections.

● Treatment of opportunistic infections. For Pneumocystis pneumonia, TMP-SMZ
is the treatment of choice; for mycobacterium avian complex, azithromycin or
clarithromycin are preferred prophylactic agents; for cryptococcal meningitis, the
current primary treatment is IV amphotericin B.
● Prevention of opportunistic infections. TMP-SMZ is an antibacterial agent used
to treat various organisms causing infection.
● Antidiarrheal therapy. Therapy with octreotide acetate (Sandostatin), a synthetic
analog of somatostatin, has been shown to be effective in managing severe chronic
diarrhea.
● Antidepressant therapy. Treatment for depression in patients with HIV infection
involves psychotherapy integrated with imipramine, desipramine or fluoxetine.
● Nutrition therapy. For all AIDS patients who experience unexplained weight loss,
calorie counts should be obtained, and appetite stimulants and oral supplements are
also appropriate.

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