Ch 17 – Infection and HIV Infection

Transmission of HIV
 Fragile virus transmitted only through contact with body fluids
o Blood, semen, vaginal secretions, and breast milk
 Modes of transmission
o Sex with an infected partner
o Exposure to infected blood or blood products
o Prenatally at the time of delivery, or breastfeeding
o Early and Late Stages: High levels of virus in blood during the first 2 to 6 months after
infection and in late stages increase transmission risk.
o Transmission Risk: Unprotected sexual or blood exposure is more risky during these
periods.
Pathophysiology
 Retrovirus: replicate in a backward manner
 Cannot replicate unless it is living within a cell
 Binds to specific CD4 receptor sites and CCR5 and CXCR4 co-receptors on the cell’s surface
 Viral RNA is transcribed into double-stranded viral DNA with the assistance of reverse
transcriptase.
 Viral DNA enters the cell nucleus and splices itself into the genome permanently.
o Integrases its genetic information into that of the host cell it infects.
 Consequence of integration into genetic structure
o All daughter cells from the affected cell will be infected.
o Viral DNA will direct cell to make HIV.
 Viral load in the blood
o Initial infection
o Viremia (large viral levels in blood) for 2–3 weeks
o Transmission is more likely when viral load is high
o Followed by prolonged period (years) of low viral load
 Cells with CD4 receptor sites are infected.
o CD4+ T cells (T helper cells)
o Lymphocytes
o Monocytes/macrophages
o Astrocytes
o Oligodendrocytes
 Immune problems start when CD4+ T-cell counts drop to below 500 cells/mcL.
o Normal range is 800–1 200 cells/mcL.
o Allows for opportunistic diseases
Clinical Manifestations & Complications
 Acute infection
o Flu-like symptoms
 Fever, swollen lymph glands, sore throat, headache, malaise, nausea, muscle
and joint pain, diarrhea, or a diffuse rash
 These symptoms are called acute retroviral syndrome and occur about 1–3
weeks after infection.
 Lasts for 1–2 weeks
 Early chronic infection
 o Generally asymptomatic
o Fatigue, headache, low-grade fever, night sweats, and persistent generalized
lymphadenopathy often occur.
o Most patients are not aware of infected status.
 Intermediate chronic
o CD4+ T cells drop to 200–500 cells/mcL.
o Viral load increases.
o HIV advances to a more active state.
 Intermediate chronic symptoms
o Oropharyngeal candidiasis (thrush)
o Shingles
o Oral hairy leukoplakia
o Persistent vaginal candida infections
o Herpes
o Bacterial infections
o Kaposi’s sarcoma (KS)
 Late chronic or AIDS
o Immune system severely compromised
o Great risk for opportunistic disease
o Possible malignancies, wasting, and dementia
 Several opportunistic diseases may occur at the same time, further compounding the difficulties
of diagnosis and treatment.
 Advances in HIV treatment have led to decreases in opportunistic diseases because successful
treatment maintains a functioning immune system.
Diagnostic Studies
 Most useful screening tests detect HIV-specific antibodies
 May take 2 months (window period) to detect antibodies
 Progression monitored by CD4+ T-cell counts and CD4 fraction
 Viral load
 Abnormal blood tests common
o Neutropenia, thrombocytopenia, and anemia
o Altered liver function tests
 Resistance tests
Interprofessional Care
 Monitoring HIV disease progression and immune function
 Initiating and monitoring antiretroviral therapy (ART)
 Preventing, detecting, and treating opportunistic infections
 Monitoring HIV disease progression and immune function.
 Initiating and monitoring Antiretroviral Therapy (ART).
 Preventing opportunistic diseases.
 Detecting and treating opportunistic diseases.
 Managing symptoms and complications of treatment.
 Providing comprehensive psychosocial and spiritual care.
 Initial visit
o Gather baseline data, conducting a complete history and physical examination that
includes immunization and psychosocial evaluations
 o Education about spectrum of HIV, treatment, preventing transmission, improving
health, and family planning
Medications (pg 337 chart)
Drug Class Medication Mechanism of Action Adverse Effects
Nonnucleoside reverse -Delavirdine Combine with reverse Common: rash, erythema
transcriptase inhibitors -Efavirenz transcriptase to block multiforme, increased liver
-Etravirine the process needed to enzymes, hepatotoxicity
-Nevirapine convert HIV RNA into
-Rilpivirine HIV DNA
Nucleoside reverse -Abacavir Insert a bit of protein (a Common: lactic acidosis with
transcriptase inhibitors -Didanosine nucleoside) into the hepatic steatosis, a rare but
-Emtricitabine developing HIV DNA potentially life-threatening
-Lamivudine chain and leaving the problem; lipodystrophy,
-Zidovudine production of the new especially fat atrophy and
strand of HIV DNA mitochondrial toxicity
incomplete
Nucleotide reverse -Tenofovir Inhibit the action of Nausea, vomiting, diarrhea
transcriptase inhibitors disoproxil reverse transcriptase
fumarate
Protease inhibitors -Atazanavir Prevent the protease Common: dysglycemia,
-Darunavir enzyme from cutting HIV hyperlipidemia, lipodystrophy
-Fosamprenavir proteins into the proper
-Indinavir lengths needed to allow
-Ritonavir viable virions to
-Tipranavir assemble and bud out
-Kaletra from the cell membrane
Integrase inhibitors -Dolutegravir Prevents viral DNA Rash, increased liver enzymes,
-Raltegravir integration into the tiredness, fever, insomnia,
CD4+ cell chromosome headache, diarrhea, nausea
Fusion inhibitors (entry -Enfuvirtide Prevent binding of HIV Fatigue, nausea, diarrhea,
inhibitors) -Maraviroc to cells, thus preventing insomnia, peripheral
entry of HIV into healthy neuropathy, hypersensitivity
cells reaction, pneumonia

What are some vaccination development issues?

Nursing Assessment
4 basic questions:
a)
b)
c)
d)

Past health history: route of infection, hepatitis, other STI’s, TB, foreign travel, frequent viral fungal or
bacterial infections, alcohol use, drug use
  Timely identification can decrease progression
 Ongoing assessments over time as circumstance changes
 A complete history and thorough systems review can help identify and address problems in a
timely manner.
 Using subjective and objective data helps guide care and improve outcomes
Nursing Diagnosis
 Dependent on variables
o Stage (prevention, ongoing infection, terminal phase)
o Presence of specific etiological problems (respiratory distress, depression)
o Social factors (self-esteem, family interactions, finances)
Implementation

Goals Assess Interventions

Health Promotion
1. Prevent HIV infection
2. Detect HIV infection
early
Acute Intervention
1. Promote health and
limit disability
2. Manage problems
caused by HIV infection
Risk factors: what behaviours or
social, physical, emotional,
pathological, and immune
factors place the patient at risk?
Does the patient need to be
tested?
Physical health: Is patient
experiencing problems?
Mental health status: How is
the patient coping?
Resources: Does the patient
have family and social
support? Is the patient
accessing community
services? Is money or
insurance a problem? Does
Education, including
knowledge, attitudes, and
behaviours, with an emphasis
on risk reduction, to
accomplish the following:
• General population:
covering general information
• Pregnant women: covering
general information and
information
specific to HIV infection and
pregnancy; offering prenatal
HIV
testing in the first trimester
Individual patient: specific to
assessed need
Empowering patients to take
control of prevention
measures Providing HIV-
antibody testing with pretest
and post-test counselling
Case management
Education regarding HIV, the
spectrum of infection,
options for care,
signs and symptoms to watch
for, treatment options,
immune enhancement, harm
reduction, and ways to
adhere to treatment
regimens

Ambulatory and Home Care
1. Maximize quality of life
2. Resolve life and death
issues
the patient have access to
spiritual support?
Physical health: Are new
symptoms developing? Is the
patient experiencing drug
adverse effects or
interactions?
Mental health: How is the
patient coping? What
adjustments have been
made?
Finances: Can the patient
maintain health care and
basic standards of living?
Family, social, and
community supports:
Are these available? Is the
patient using supports in an
effective manner? Do family
or significant others need
education, encouragement,
Referral to needed resources
Establishing long-term,
trusting relationship with
patient, family, and
significant others
Providing emotional and
spiritual support
Providing care during acute
exacerbations: recognition of
life-
threatening developments,
life support, rapid
intervention with treatments
and drugs, patient and family
emotional support during
crisis, comfort, and hygiene
needs
Developing resources for
legal needs: discrimination
prevention, wills and powers
of attorney, child care wishes
Empowering patient to
identify needs, direct care,
and seek services
Continuing case management
Educating about changing
treatment options and
continued
adherence
Empowering patient to
continue to direct care and to
make desires
known to family members
and significant others
Continuing physical care for
chronic disease process:
treatments,
drugs, comfort, and hygiene
needs
Supporting patient and
family and significant others
in a trusting
relationship
 or stress relief?
Spirituality issues: Does the
patient desire support from a
religious organization? Are
spirituality issues private and
personal? What assistance
does the patient need?
Referral to resources that will
assist in meeting identified
needs Promoting health
maintenance measures
Assistance with end-of-life
issues: resuscitation orders,
comfort
measures, funeral plans, and
the like Referral to palliative
care

Health Promotion
 Major goals: Prevention of disease and early detection
o Safer, healthier, and less risky behaviours
o Most new HIV infections were transmitted by individuals who were not aware that they
were infected.
 Prevention of HIV
o Decreasing risks: Sexual intercourse
 Abstinence
 Outercourse
 Use of barriers
o Insertive sex
o Decreasing risks: Substance use
 Do not use illegal or illicit substances.
 Do not share equipment.
 Do not have sexual intercourse under the influence of any impairing substance.
o Decreasing risks: Perinatal transmission
 Prevent HIV in women
 Appropriately medicate HIV-infected pregnant women
o Decreasing risks: Work
 Adhere to precautions and safety measures to avoid exposure.
 Postexposure prophylaxis with combination ART

Why do we test for HIV and give counselling?

Acute Intervention
 Early intervention
o Promote health and limit/delay disability
o Assessment is so important
 Initial response to a diagnosis of HIV
o Similar to any life-threatening, chronic illness
o Ranges from immediate acceptance to grief, denial, and suicidal thoughts
  Antiretroviral therapy
o Reduce viral loads and reverse clinical progression

o Interventions include:
 A)
 B)
 C)
 D)
 E)
o When to start therapy
 All people with HIV regardless of CD4+ T-cell count
 Assess patient readiness
 Treatment should be initiated at the time of diagnosis
o Adherence to regimens is critical
 Improve adherence by understanding each patient is unique and providing
electronic reminders/timers
o Missing even a few doses can lead to resistance

Health Promotion
• Disease progression can be delayed by promoting a healthy immune system.
• Nutritional support
• Moderation or elimination of alcohol
• Adequate rest and activity
• Stress reduction
• Avoidance of exposure to new infections
• Mental health counselling
• Support groups and community activities
Acute Exacerbations
• Recurring problems of infection, cancer, debility, and psychosocial/economic issues affect the
ability to cope.
Ongoing Care
• Social constructs
• May be seen as lacking control to resist urges to have risky sex or substance use
• Behaviours may be viewed as immoral, illegal, or uncontrolled by infected person
• Social stigmatization can lead to discrimination.
• According to Canadian Human Rights Commission policy on HIV/AIDS, all Canadians have the
right to equality and dignity without discrimination, regardless of HIV/AIDS status.
Disease and Medication Adverse Effects
• A new set of metabolic disorders has emerged among HIV-infected patients, especially those
who have been infected for a long time and who have been receiving ART.
• Include changes in body shape, dyslipidemia, insulin resistance and hyperglycemia, bone
disease, lactic acidosis, and cardiovascular disease
• Management of metabolic disorders
• Early detection
• Dealing with symptoms
• Helping to cope
End-of-Life Care
 • Focus of nursing intervention
• Patient comfort
• Promoting emotional and spiritual acceptance of finite nature of life
• Helping significant others deal with loss
Evaluation
• At risk:
• Analyze personal risk factors
• Develop and implement a personal plan to decrease risks
• Get tested
 Patient with infection:
o Describe basic aspects of the effects of HIV on the immune system
o Compare and contrast various treatment options for HIV disease
o Work with a team of health care providers to achieve optimal health
o Prevent transmission of HIV to others
Textbook Questions

1. What are nursing responsibilities regarding emerging and re-emerging infections? (Select all that
apply)
a. Educating clients about risks of developing emerging and re-emerging infections
b. Maintaining awareness of unusual disease patterns
c. Participating in immunization programs
d. Using infection control procedures
e. Examining prescribing practices to ensure appropriate anti- biotic use

2. Which of the following antibiotic-resistant organisms are resistant to normal hand soap?
a. Vancomycin-resistant enterococci
b. Methicillin-resistant Staphylococcus aureus
c. Penicillin-resistant Streptococcus pneumoniae
d. β-Lactamase–producing Klebsiella pneumoniae

3.How is human immunodeficiency virus (HIV) transmitted?

a. Most commonly as a result of sexual contact
b. In all infants born to women with HIV infection
c. Only when there is a large viral load in the blood
d. Frequently in health care workers with needle-stick exposures

4.Which is the common physiological change after HIV infection?

a. The virus replicates mainly in B lymphocytes before spreading to CD4+ T cells in lymph nodes.
b. The immune system is impaired predominantly by infection and destruction of CD4+ T cells.
c. Infection of monocytes may occur, but these cells are destroyed by antibodies produced by
oligodendrocytes.
d. A long period develops during which the virus is not found in the blood and there is little viral
replication.

5. Which of the following statements is false?

a. “Infection with HIV results in a chronic disease with acute exacerbations.”
b. “Untreated HIV infection can remain in the early chronic stage for a decade or more.”
c. “Late-stage infection is often called acquired immune deficiency syndrome (AIDS).”
d. “Opportunistic diseases occur more often when the CD4+ T-cell count is high and the viral load is
low.”

6.When is AIDS diagnosed in an HIV-infected person?

a. When an AIDS-defining illness develops.
b. When the amount of HIV in the blood increases.
c. When the CD4:CD8 ratio is reversed to less than 2 : 1.
d. When the person has oral hairy leukoplakia, an infection caused by Epstein-Barr virus.

7.What does screening for HIV infection generally involve?

a. Laboratory analysis of blood to detect HIV antigen
b. Electrophoretic analysis of HIV antigen in plasma
c. Laboratory analysis of blood to detect HIV antibodies
d. Analysis of lymph tissues for the presence of HIV RNA

8. What is the indication for use of antiretroviral drugs?

a. Cure acute HIV infection
b. Treat opportunistic diseases
c. Decrease viral RNA levels
d. Supplement radiation therapy and surgery

9. Which statement about metabolic adverse effects of ART is true? (Select all that apply)
a. “These are annoying symptoms that are ultimately harmless.”
b. “ART-related body changes include central fat accumulation and peripheral wasting.”
c. “Lipid abnormalities include increases in triglycerides and decreases in high-density cholesterol.”
d. “Insulin resistance and hyperlipidemia can be treated with drugs to control glucose and cholesterol.”
e. “Insulin resistance and hyperlipidemia are more difficult to treat in HIV-infected clients than in
uninfected people.”

10. Which of the following descriptions of opportunistic diseases in HIV infection is correct?
a. Usually occur one at a time
b. Generally slow to develop and progress
c. Occur in the presence of immuno-suppression
d. Curable with appropriate pharmacological intervention

11. Of the following, which is the most appropriate nursing intervention to help an HIV-infected client
adhere to the treatment regimen?
a. Give the client a DVD and a brochure to view and read at home.
b. Volunteer to “set up” a drug pillbox for a week at a time.
c. Inform the client that the adverse effects of the drugs are bad but that they go away after a while.
d. Assess the client’s lifestyle and find adherence cues that fit into the client’s lifestyle.

12. Which strategy can the nurse teach the client to eliminate the risk of transmission of HIV?
a. Using sterile equipment to inject drugs
b. Cleaning equipment used to inject drugs
c. Taking zidovudine (azidothymidine [AZT], ZDV, Retrovir) during pregnancy
d. Using latex barriers to cover genitals during sexual contact

1. a, b, c, d, e; 2. a; 3. a; 4. b; 5. d; 6. a; 7. c; 8. c; 9. b, c, d; 10. c; 11. d;