Out lines : Definition Classification Signs and symptoms Transmission of h.I.

v Role of nurse in :prevention , health education , standard precautions. Diagnosis Treatment :Medical management Pharmacological treatment Non-pharmacological treatment " Nursing role in treatment of H.I.V patients

This acute viremia is associated in virtually all patients with the activation of CD8+ T cells, which kill HIV-infected cells, and subsequently with antibody production, or seroconversion. The CD8+ T cell response is thought to be important in controlling virus levels, which peak and then decline, as the CD4+ T cell counts rebound. A good CD8+ T cell response has been linked to slower disease progression and a better prognosis, though it does not eliminate the virus. During this period (usually 24 weeks post-exposure) many individuals develop an influenza

or mononucleosis-like illness called acute HIV infection, the most common symptoms of which may include fever, lymphadenopathy, pharyngitis, rash, myalgia, malaise, mouth and esophageal sores, and may also include, but less commonly, headache, nausea and vomiting, enlarged liver/spleen, weight loss, thrush, and neurological symptoms. Infected individuals may experience all, some, or none
of these symptoms. The duration of symptoms varies, averaging 28 days and usually lasting at least a week. Because of the nonspecific nature of these symptoms, they are often not recognized as signs of HIV infection. Even if patients go to their doctors or a hospital, they will often be misdiagnosed as having one of the more common infectious diseases with the same symptoms. As a consequence, these primary symptoms are not used to diagnose HIV infection, as they do not develop in all cases and because many are caused by other more common diseases. However, recognizing the syndrome can be important because the patient is much more infectious during this period.

Chronic infection
A strong immune defense reduces the number of viral particles in the blood stream, marking the start of secondary or chronic HIV infection. The secondary stage of HIV infection can vary between two weeks and 20 years. During this phase of infection, HIV is active within lymph nodes, which typically become persistently swollen, in response to large amounts of virus that become trapped in the follicular dendritic cells (FDC) network. The surrounding tissues that are rich in CD4+ T cells may also become infected, and viral particles accumulate both in infected cells and as free virus. Individuals who are in this phase are still infectious. During this time, CD4+ CD45RO+ T cells carry most of the proviral load. During this stage of infection early initiation of antiretroviral therapy significantly improves survival, as compared with deferred therapy.

AIDS
When CD4+ T cell numbers decline below a critical level of 200 cells per L, cell-mediated immunity is lost, and infections with a variety of opportunistic microbes appear. The first symptoms often include moderate and unexplained weight loss, recurring respiratory tract infections (such as sinusitis, bronchitis, otitis media, pharyngitis), prostatitis, skin rashes, and oral ulcerations. Common opportunistic infections and tumors, most of which are normally controlled by robust CD4+ T cell-mediated immunity then start to affect the patient. Typically, resistance is lost early on to oral Candida species and to Mycobacterium tuberculosis, which leads to an increased susceptibility to oral candidiasis (thrush) and tuberculosis. Later, reactivation of

latent herpes viruses may cause worsening recurrences of herpes simplex eruptions, shingles, Epstein-Barr virus-induced B-cell lymphomas, or Kaposi's sarcoma.

Pneumonia caused by the fungus Pneumocystis jirovecii is common and often fatal. In the final stages of AIDS, infection with cytomegalovirus (another herpes virus) or Mycobacterium avium complex

is more prominent. Not all patients with AIDS get all these infections or tumors, and there are other tumors and infections that are less prominent but still significant .
Depressive Manifestations
The prevalence of depression among people with HIV infection is unknown. The causes of depression are multifactorial and may include a history of preexisting mental illness, neuropsychiatric disturbances, and psychosocial factors. Depression also occurs in people with HIV infection in response to the physical symptoms, including pain and weight loss, and the lack of someone to talk with about their concerns. People with HIV/AIDS who are depressed may experience irrational guilt and shame, loss of selfesteem, feelings of helplessness and worthlessness, and suicidal ideation.

Integumentary Manifestations
Cutaneous manifestations are associated with HIV infection and the accompanying opportunistic infections and malignancies. KS (described earlier) and opportunistic infections such as herpes zoster and herpes simplex are associated with painful vesicles that disrupt skin integrity. Molluscum contagiosum is a viral infection characterized by deforming plaque formation. Seborrheic dermatitis is associated with an indurated, diffuse, scaly rash involving the scalp and face. Patients with AIDS may also exhibit a generalized folliculitis associated with dry, flaking skin or atopic dermatitis, such as eczema or psoriasis. Up to 60% of patients treated with the antibacterial agent trimethoprim-sulfamethoxazole (TMP-SMZ) develop a drugrelated rash that is pruritic with pinkish-red macules and papules. Patients with any of these rashes experience discomfort and are at increased risk for infection from disrupted skin integrity.

Endocrine Manifestations
The endocrine manifestations of HIV infection are not completely understood. At autopsy, endocrine glands show infiltration and destruction from opportunistic infections or neoplasms. Endocrine function may also be affected by therapeutic agents.

Gynecologic Manifestations
Persistent, recurrent vaginal candidiasis may be the first sign of HIV infection in women. Past or present genital ulcers are a risk factor for the transmission of HIV infection. Women with HIV infection are more susceptible to genital ulcers and venereal warts and have increased rates of incidence and recurrence of these conditions. Ulcerative sexually transmitted diseases (STDs) such as chancroid, syphilis, and herpes are more severe in women with HIV infection. Human papillomavirus (HPV) causes venereal warts and is a risk factor for cervical intraepithelial neoplasia . a cellular change that is frequently a precursor to cervical cancer. Women with HIV are 10 times more likely to develop cervical intraepithelial neoplasia than those not infected with HIV. There is a strong association between abnormal Papanicolaou (Pap) smears and HIV seropositivity. HIV-seropositive women with cervical carcinoma present at a more advanced stage of disease and have more persistent and recurrent disease and a shorter interval to recurrence and death than women without HIV infection. A significant percentage of women who require hospitalization for pelvic inflammatory disease have HIV infection. Women with HIV are at increased risk for pelvic inflammatory disease, and the associated inflammation may potentiate the transmission of HIV infection. Moreover, women with HIV infection appear to have a higher incidence of menstrual abnormalities, including amenorrhea or bleeding between periods, than do women without HIV infection. The failure of health care providers to consider HIV infection in women may lead to a later diagnosis, thereby denying these patients appropriate treatment

HIV Encephalopathy
HIV encephalopathy was formerly referred to as AIDS dementia complex . It is a clinical syndrome that is characterized by a progressive decline in cognitive, behavioral, and motor functions. Substantial evidence exists that HIV encephalopathy is a direct result of HIV infection. HIV has been found in the brain and cerebrospinal fluid(CSF) of patients with HIV encephalopathy. The brain cells infected by HIV are predominantly the CD4_ cells of monocytemacrophage lineage. HIV infection is thought to trigger the release of toxins or lymphokines that result in cellular dysfunction or interference with neurotransmitter function rather than cellular damage. Signs and symptoms may be subtle and difficult to distinguish from fatigue, depression, or the adverse effects of treatment for infections and malignancies. Early manifestations include memory deficits, headache, difficulty concentrating, progressive confusion, psychomotor slowing, apathy, and ataxia. Later stages include global cognitive impairments, delay in verbal responses, a vacant stare, spastic paraparesis, hyperreflexia, psychosis, hallucinations, tremor, incontinence, seizures, mutism, and death Confirming the diagnosis of HIV encephalopathy can be difficult. Extensive neurologic evaluation includes a computed tomography scan, which may indicate diffuse cerebral atrophy and ventricular enlargement. Other tests that may detect abnormalities include magnetic resonance imaging, analysis of CSF through lumbar puncture, and brain biopsy

How H.I.V Transmit

Blood transfusion . Mother-to-child, including pregnancy, childbirth and breastfeeding (without treatment) Mother-to-child, including pregnancy, childbirth and breastfeeding (with optimal treatment) . needle-sharing injection drug use Percutaneous needle stick. Receptive anal intercourse . Receptive anal intercourse . Insertive anal intercourse for uncircumcised men. Insertive anal intercourse for circumcised men . Insertive anal intercourse . Low-income country female-to-male . Low-income country male-to-female . Receptive (female) penile-vaginal intercourse . Insertive (male) penile-vaginal intercourse . Fellating a man . Man being fellated.

Blood transfusion.
In general, if infected blood comes into contact with any open wound, HIV may be transmitted. This transmission route can account for infections in intravenous drug users, hemophiliacs, and recipients of blood transfusions (though most transfusions are checked for HIV in the developed world) and blood products. It is also of concern for persons receiving medical care in regions where there is prevalent substandard hygiene in the use of injection equipment, such as the reuse of needles in Third World countries. Health care workers such as nurses, laboratory workers, and doctors have also been infected, although this occurs more rarely. Since transmission of HIV by blood became known medical personnel are required to protect themselves from contact with blood by the use of universal precautions. People giving and receiving tattoos, piercings, and scarification procedures can also be at risk of infection. HIV has been found at low concentrations in the saliva, tears, and urine of infected individuals, but there are no recorded cases of infection by these secretions and the potential risk of transmission is negligible. It is not possible for mosquitoes to transmit HIV.

Mother-to-child
The transmission of the virus from the mother to the child can occur in utero (during pregnancy), intrapartum (at childbirth), or via breast feeding. In the absence of treatment, the transmission rate up to birth between the mother and child is around 25%.However, where combination antiretroviral drug treatment and Cesarian section are available, this risk can be reduced to as low as one percent. Postnatal mother-to-child transmission may be largely prevented by complete avoidance of breast feeding; however, this has significant associated morbidity. Exclusive breast feeding and the provision of extended antiretroviral prophylaxis to the infant are also efficacious in avoiding transmission. UNAIDS estimate that 430,000 children were infected worldwide in 2008 (19% of all new infections), primarily by this route, and that a further 65,000 infections were averted through the provision of antiretroviral prophylaxis to HIV-positive women.

Multiple infection
Unlike some other viruses, infection with HIV does not provide immunity against additional infections, in particular, in the case of more genetically distant viruses. Both inter- and intraclade multiple infections have been reported, and even associated with more rapid disease progression. Multiple infections are divided into two categories depending on the timing of the acquisition of the second strain. Coinfection refers to two strains that appear to have been acquired at the same time (or too close to distinguish). Reinfection (or superinfection) is infection with a second strain at a measurable time after the first. Both forms of dual infection have been reported for HIV in both acute and chronic infection around the world.

Sexual transmission
The majority of HIV infections are acquired through unprotected sexual relations. Complacency about HIV plays a key role in HIV risk. Sexual transmission can occur when infected sexual secretions of one partner come into contact with the genital, oral, or rectal mucous membranes of another. In high-income countries, the risk of female-to-male transmission is 0.04% per act and male-to-female transmission is 0.08% per act. For various reasons, these rates are 4 to 10 times higher in low-income countries. The rate for receptive anal intercourse is much higher, 1.7% per act.

Analysis of studies of condom use showed that the consistent use of latex condoms reduces the risk of sexual transmission of HIV by about 85%.However, spermicide may actually increase the transmission rate. Randomized, controlled trials in which uncircumcised men were randomly assigned to be medically circumcised in sterile conditions and given counseling and other men were not circumcised have been conducted in Some countries showing reductions in female-to-male sexual HIV transmission of 60%, 53%, and 51%, respectively. Among men who have sex with men, there is insufficient evidence that male circumcision protects against HIV infection or other Sexually Transmitted Infections .Studies of HIV among women having undergone female genital cutting (FGC) have reported mixed results, but with some evidence of increased risk of transmission . Programmes that aim to encourage sexual abstinence while also encouraging and teaching safer sex strategies for those who are sexually active can reduce short- and long-term HIV risk behaviour among young people in high-income countries. So HIV has been described from men to men, men to women, women to men, and women to women through vaginal, anal, and oral sex. The best way to avoid sexual transmission is abstinence from sex until it is certain that both partners in a monogamous relationship are not HIV-infected. Because the HIV antibody test can take months to turn positive after infection occurs, both partners would need to test negative for at least 12 and up to 24 weeks after their last potential exposure to HIV. If abstinence is out of the question, condoms should be used for fellatio (oral contact with the penis) and latex barriers (dental dams) for cunnilingus (oral contact with the vaginal area). A dental dam is any piece of latex that prevents vaginal secretions from coming in direct contact with the mouth. Although such dams occasionally can be purchased, they are most often created by cutting a square piece of latex from a condom.

Prevention of HIV Infection

For Health Care Providers
Standard Precautions

Recommendations for Standard Precautions

1. Hand hygiene: Use after touching blood, body fluids, secretions, excretions, or contaminated items; immediately after removing gloves; and between patient contacts. 2. Personal protective equipment (PPE) Gloves: Use for touching blood, body fluids, secretions, excretions, and contaminated items, and for touching mucous membranes and nonintact skin. Gown: Use during procedures and patient care activities when contact of clothing/exposed skin with blood or body fluids, secretions, and excretions is anticipated. Mask, eye protection (goggles), Face Shield*: Use during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids, and secretions, especially suctioning or endotracheal intubation. 3. Soiled patient care equipment: Handle in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; and perform hand hygiene. 4. Environmental control: Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient care areas. 5. Textiles and laundry: Handle in a manner that prevents transfer of microorganisms to others and to the environment. Needles and other sharps: Do not recap, bend, break, or hand-manipulate used needles; if recapping is required, use a one-handed scoop technique only; use safety features when available; and place used sharps in a puncture- resistant container. 6. Patient resuscitation: Use mouthpiece, resuscitation bag, and other ventilation devices to prevent contact with mouth and oral secretions. 7. Patient placement: Prioritize for single-patient room if patient is at increased risk of transmission, is likely to contaminate the environment, does not maintain appropriate hygiene, or is at increased risk of acquiring infection or developing adverse outcome following infection.

8. Respiratory hygiene/cough etiquette (source containment of infectious respiratory secretions in symptomatic patients, beginning at initial point of encounter, such as triage and reception areas in emergency departments and physician offices): Instruct symptomatic people to cover mouth and nose when sneezing or coughing; use tissues and dispose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory secretions; and wear surgical mask if tolerated.

For patients
Until an effective vaccine is developed, nurses need to prevent HIV infection by teaching patients how to eliminate or reduce risky behaviors. Although HIV prevention strategies have focused on individual behaviors, political, economic, and social determinants of risk also need to be considered . A combination of evidence-based prevention strategies that include behavioral, structural, and biomedical approaches tempered by the wisdom and ownership of communities offers the best hope for prevention.

Preventive Education
HEALTH PROMOTION Safer Sexual Behaviors Advise patients to abstain from sharing sexual fluids. Advise patients to reduce the number of sexual partners to one. Advise patients to always use latex condoms. If the patient is allergic to latex, nonlatex condoms should be used. Advise patients to avoid reusing condoms. Advise patients to avoid using cervical caps or diaphragms without using a condom as well. Advise patients to always use dental dams for oral genital or anal stimulation. Advise patients to avoid anal intercourse because this practice may injure tissues. Advise patients to avoid manualanal intercourse (fisting). Advise patients not to ingest urine or semen. Educate patients about nonpenetrative sexual activities, such as body massage, social kissing (dry), mutual masturbation, fantasy, and sex films. Advise patients to avoid sharing needles, razors, toothbrushes, sex toys, or bloodcontaminated articles. Advise HIV-seropositive patients to inform previous, present, and prospective sexual and drug-using partners of their HIVpositive status. If the patient is concerned for his or her safety, advise the patient that many states have established mechanisms through the public health department in which professionals are available to notify exposed people. Advise HIV-seropositive patients to avoid having unprotected sex with another HIVseropositive person. Cross-infection with that persons HIV can increase the severity of infection. Advise HIV-seropositive patients to avoid donating blood, plasma, body organs, or sperm. Evidence-based programs have been used to educate the public regarding safer sexual practices to decrease the risk of transmitting HIV infection to sexual partners . through the HIV/AIDS Prevention Research Synthesis Project, has identified evidence-based behavioral interventions that can be applied in a number of settings. Other than abstinence, consistent and correct use of condoms is the only effective method to decrease the risk of sexual

transmission of HIV infection . When male condoms are used consistently during vaginal or anal intercourse, their effectiveness can be as high as 95%. Nonlatex condoms made of natural materials such as lambskin are available for people with latex allergy but will not protect against HIV infection. A male condom should be used for oral contact with the penis, and a dental dam (a flat piece of latex used by dentists to isolate a tooth for treatment) should be used for oral contact with the vagina or rectum. The polyurethane female condom, which is an effective contraceptive, provides a physical barrier that also prevents exposure to genital secretions containing HIV such as semen and vaginal fluid . The female condom is the only barrier method that can be controlled by the woman . Microbicides are chemical products such as gels, creams , films, or suppositories that are inserted into the vagina or rectum before sexual intercourse to prevent HIV transmission. (Nonoxynol-9 (N-9) was widely advocated to reduce the risk of HIV infection until a clinical trial conducted in almost 1000 female commercial sex workers in African countries revealed that those who used N-9 intravaginally along with condoms were 50% more likely to be infected with HIV than those who did not use the N-9 gel. Microbicide research is moving in three directions:

(1) new microbicides that contain antiretroviral agents such as tenofovir gel or dapivirine gel and ring (International Partnership for Microbicides, 2009) (2) longacting dispersal methods such as vaginal rings that remain in place or do not require frequent applications (3) combination products with different mechanisms of action .
In March 2007, based on the results of three clinical trials, the World Health Organization (WHO) and UNAIDS recommended that circumcision be recognized as an effective strategy to reduce the risk of HIV acquisition in men because the presence of the foreskin, which harbors HIV target cells, might facilitate survival and entry of the virus . Other topics important in preventive education include the importance of avoiding sexual practices that might cut or tear the lining of the rectum, penis, or vagina and avoiding sexual contact with multiple partners or people who are known to be HIV positive or IV/injection drug users. In addition, people who are HIV positive or who use injection drugs should be instructed not to donate blood or share drug equipment with others. The Harm Reduction Model recognizes that total abstinence from addictive drugs might not be a realistic shortterm goal. This model recommends working with drug users to assist them to increase their healthy behaviors. Needle exchange programs are available in some locations so that IV/injection drug users can obtain sterile drug equipment at no cost. Extensive research has demonstrated that needle exchange programs do not promote increased drug use; on the contrary, they have been found to decrease the incidence of bloodborne infections in people who use IV/injection drugs. Nurses should refer clients to needle exchange programs in their neighborhood whenever available. In the absence of needle exchange programs, IV/injection drug users should be instructed on methods to clean their syringes and advised to avoid sharing cotton and other drug use equipment. Drug users interested in treatment programs should be referred to those programs.
CHART

Diagnosis
Many HIV-positive people are unaware that they are infected with the virus. For example, less than 1% of the sexually active urban population in Africa have been tested and this proportion is even lower in rural populations. Furthermore, only 0.5% of pregnant women attending urban health facilities are counselled, tested or receive their test results. Again, this proportion is even lower in rural health facilities. Since donors may therefore be unaware of their infection, donor blood and blood products used in medicine and medical research are routinely screened for HIV.

HIV-1 testing consists of initial screening with an enzyme-linked immunosorbent assay (ELISA) to detect antibodies to HIV-1. Specimens with a nonreactive result from the initial ELISA are considered HIV-negative unless new exposure to an infected partner or partner of unknown HIV status has occurred. Specimens with a reactive ELISA result are retested in duplicate. If the result of either duplicate test is reactive, the specimen is reported as repeatedly reactive and undergoes confirmatory testing with a more specific supplemental test (e.g., Western blot or, less commonly, an immunofluorescence assay (IFA)). Only specimens that are repeatedly reactive by ELISA and positive by IFA or reactive by Western blot are considered HIV-positive and indicative of HIV infection. Specimens that are repeatedly ELISA-reactive occasionally provide an indeterminate Western blot result, which may be either an incomplete antibody response to HIV in an infected person or nonspecific reactions in an uninfected person. Although IFA can be used to confirm infection in these ambiguous cases, this assay is not widely used. In general, a second specimen should be collected more than a month later and retested for persons with indeterminate Western blot results. Although much less commonly available, nucleic acid testing (e.g., viral RNA or proviral DNA amplification method) can also help diagnosis in certain situations. In addition, a few tested specimens might provide inconclusive results because of a low quantity specimen. In these situations, a second specimen is collected and tested for HIV infection.

Treatment of HIV
Protocols on how and when to start treatment for HIV disease change relatively often. The CD4_ T-cell count is usually the most important consideration in deciding whether antiretroviral medications should be started. In general, antiretroviral medications should be offered to people with a T-cell count of less than 350 cells/mm3 or plasma HIV RNA levels exceeding 100,000 copies/mL . Some clinicians and patients, however, are choosing not to start medications until the CD4_ cell count decreases to approximately 200 cells/mm3. Clinicians, in partnership with patients, make treatment decisions based on a number of factors, including CD4 T-cell count, viral load, severity of HIV/AIDS-related symptoms, and willingness of the patient to adhere to the lifelong treatment regimen. The increasing number of antiretroviral agents and the rapid evolution of new information have introduced extraordinary complexity into the treatment of HIV infection. More than 25 agents . Drugs from established classes (nucleoside/nucleotide reverse transcriptase inhibitors
[NRTIs], non-nucleoside reverse transcriptase inhibitors [NNRTIs], and protease inhibitors [PIs]) continue to serve as the mainstays of antiretroviral therapy the integrate inhibitor (raltegravir [Isentress]) and the CCR5 antagonist (maraviroc [Selzentry]), a novel entry inhibitor, were approved and joined the other fusion inhibitors such as enfuvirtide (T-20), which inhibits entry of HIV into the CD4_ T cell (Moyle, Gatell, Perno, et al., 2008). In patients with resistant HIV disease, these new classes of antiretroviral agents offer considerable potential benefit because of the absence of crossresistance To achieve sustained viral suppression, patients must take more than one antiretroviral medication. Although HAART was defined originally as a regimen that included at least one PI, it has evolved to include any regimen with at least two to three different medications. Some pharmaceutical companies have combined two to three agents into one tablet or capsule, such as Kaletra (lopinavir and ritonavir) and Atripla (efavirenz, emtricitabine, and tenofovir) in a single tablet for once-a-day use. Simplifying treatment regimens and decreasing the number of medications that must be taken each day may increase patients adherence to therapy. Adherence to long-term treatment is required to manage HIV infection and many other chronic illnesses; however, overall adherence rates remain low (30% to 50%).

Although antiretroviral regimens have become less complex, side effects create barriers to adherence, and this can lead to viral resistance. The goals of treatment include maximal and sustained suppression of viral load to a nondetectable level, restoration or preservation of immunologic function, improved quality of life, and reduction of HIV-related morbidity and mortality. Viral load testing is recommended at the time of diagnosis of HIV disease and every 3 to 4 months thereafter in the untreated person; T-cell counts should be measured at diagnosis and usually every 3 to 6 months thereafter . In the majority of patients, HAART leads to sustained reductions in HIV replication, a rise in CD4_ T-cell counts with reconstitution of immune function, and significant reductions in morbidity and mortality.

Medical Management
Treatment of Opportunistic Infections

Guidelines for the treatment of opportunistic infections should be consulted for the most current recommendations Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents . Despite the availability of antiretroviral medications, opportunistic infections (OIs) continue to cause considerable morbidity and mortality for three main reasons:

(1) many patients are unaware of their HIV infection and present with an OI as the initial indicator of their disease, (2) some patients are aware of their HIV infection but do not take antiretroviral agents because of psychosocial or economic factors, (3) others receive prescriptions for antiretroviral medications but fail to attain adequate virologic and immunologic response as a result of issues related to adherence, pharmacokinetics, or unexplained biologic factors .
Immune function should improve with initiation of HAART, resulting in faster resolution of the OI. This has been most clearly shown for OIs for which effective therapy does not exist, such as cryptosporidiosis, microsporidiosis, and PML. These conditions may resolve or at least stabilize after the institution of antiretroviral therapy as well as resolution of lesions of KS .

Pneumocystis Pneumonia
TMP-SMZ is the treatment of choice for PCP; it is as effective as parenteral pentamidine and more effective than other regimens. Oral outpatient therapy using TMP-SMZ is highly effective among patients with mild tmoderate PCP. Adjunctive corticosteroids should be started as early as possible and certainly within 72 hours after starting specific PCP therapy. Alternative therapeutic regimens for patients with mild to moderate disease include (1) dapsone and TMP, (2) primaquine plus clindamycin, and (3) atovaquone suspension. Alternatives for patients with moderate to severe disease include (1) primaquine plus clindamycin or (2) IV pentamidine (generally the drug of second choice for severe disease; it can cause severe hypotension if it is administered too rapidly). Aerosolized pentamidine should not be used for the treatment of PCP because of limited efficacy and more frequent relapse. The recommended duration of therapy for PCP is 21 days . Adverse effects, in addition to hypotension, include impaired glucose metabolism leading to the development of diabetes mellitus from damage to the pancreas, renal damage, hepatic dysfunction, and neutropenia.

Mycobacterium Avium Complex

HIV-infected adults and adolescents should receive chemoprophylaxis against disseminated MAC disease if they have a CD4_ count less than 50 cells/_L. Azithromycin (Zithromax) or clarithromycin (Biaxin) are the preferred prophylactic agents. If azithromycin or clarithromycin cannot be tolerated, rifabutin is an alternative prophylactic agent for MAC disease, although drug interactions may make this agent difficult to use Secondary prophylaxis for disseminated MAC may be discontinued in patients who have sustained

increases in CD4 counts (greater than 100 cells/mm3; longer than 3 months) in response to HAART, have completed 12 months of MAC therapy, and have no signs or symptoms attributable to MAC.

Cryptococcal Meningitis
Cryptococcosis among patients with HIV infection most commonly occurs as a subacute meningitis or meningoencephalitis with fever, malaise, and headache. Current primary therapy for cryptococcal meningitis is IV amphotericin B with or without oral flucytosine (5-FC, Ancobon) or fluconazole (Diflucan). Serious potential adverse effects of amphotericin B include anaphylaxis, renal and hepatic impairment, electrolyte imbalances, anemia, fever, and severe chills .

Cytomegalovirus Retinitis

Retinitis caused by CMV is a leading cause of blindness in patients with AIDS. Oral valganciclovir, IV ganciclovir, IV ganciclovir followed by oral valganciclovir, IV foscarnet, IV cidofovir, and the ganciclovir intraocular implant coupled with valganciclovir are all effective treatments for CMV retinitis . A common adverse reaction to ganciclovir is severe neutropenia, which limits the concomitant use of zidovudine (AZT, Compound S, Retrovir). Common adverse reactions to foscarnet are nephrotoxicity, including acute renal failure, and electrolyte imbalances, including hypocalcemia, hyperphosphatemia, and hypomagnesemia, which can be life-threatening. Other common adverse effects include seizures, gastrointestinal disturbances, anemia, phlebitis at the infusion site, and low back pain. Possible bone marrow suppression (producing a decrease in white blood cell and platelet counts), oral candidiasis, and liver and renal impairments require close monitoring.

Chemotherapy
Kaposis Sarcoma Management of KS is usually difficult because of the variability of symptoms and the organ systems involved. KS is rarely life-threatening except when there is pulmonary or gastrointestinal involvement. The treatment goals are to reduce symptoms by decreasing the size of the skin lesions, to reduce discomfort associated with edema and ulcerations, and to control symptoms associated with mucosal or visceral involvement. No one treatment has been shown to increase survival. Radiation therapy is effective as a palliative measure to relieve localized pain due to tumor mass (especially in the legs) and for KS lesions that are in sites such as the oral mucosa, conjunctiva, face, and soles of the feet. Interferon is known for its antiviral and antitumor effects. Patients with cutaneous KS treated with alpha interferon have experienced tumor regression and improved immune system function. Alphainterferon is administered by the IV, intramuscular, or subcutaneous route. Patients may self-administer interferon at home or receive interferon in an outpatient setting.

Lymphoma
Successful treatment of AIDS-related lymphomas has been limited because of the rapid progression of these malignancies. Combination chemotherapy and radiation therapy regimens may produce an initial response, but it is usually short-lived. Because standard regimens for non-AIDS. Lymphoma Successful treatment of AIDS-related lymphomas has been limited because of the rapid progression of these malignancies. Combination chemotherapy and radiation therapy regimens may produce an initial response, but it is usually short-lived. Because standard regimens for non-AIDS

Nutrition Therapy
Malnutrition increases the risk of infection and the incidence of opportunistic infections. Nutrition therapy should be part of the overall management plan and should be tailored to meet the nutritional needs of the patient, whether by oral diet, enteral tube feedings, or parenteral nutritional support, if needed. As with all patients, a healthy diet is essential for the patient with HIV infection. For patients with diarrhea, a diet low in fat, lactose, insoluble fiber, and caffeine and high in soluble fiber is helpful . For all patients with AIDS who experience unexplained weight loss, calorie counts should be obtained to evaluate nutritional status and initiate appropriate therapy. The goal is to maintain the ideal weight and, when necessary, to increase weight. Appetite stimulants have been successfully used in patients with AIDS-related anorexia. Megestrol acetate (Megace), a synthetic oral progesterone preparation, promotes significant weight gain and inhibits cytokine IL-1 synthesis. In patients with HIV infection, it increases body weight primarily by increasing body fat stores. Dronabinol (Marinol), which is a synthetic tetrahydrocannabinol (THC), the active ingredient in marijuana, has been used to relieve nausea and vomiting associated with cancer chemotherapy. After beginning dronabinol therapy, almost all patients with HIV infection experience a modest weight gain. The effects on body composition are unknown. Oral supplements may be used to supplement diets that are deficient in calories and protein. Ideally, oral supplements should be lactose-free (many people with HIV infection are intolerant to lactose), high in calories and easily digestible protein, low in fat with the fat easily digestible, palatable, inexpensive, and tolerated without causing diarrhea. Advera is a nutritional supplement that has been developed specifically for people with HIV infection and AIDS. Parenteral nutrition is the final option because of its prohibitive cost and associated risks, including risk of infections.

Nursing Interventions
Promoting Skin Integrity

The skin and oral mucosa are assessed routinely for changes in appearance, location and size of lesions, and evidence of infection and breakdown. The patient is encouraged to maintain a balance between rest and mobility whenever possible. Patients who are immobile are assisted to change position every 2 hours. Devices such as alternating-pressure mattresses and low-air-loss beds are used to prevent skin breakdown. Patients are encouraged to avoid scratching; to use nonabrasive, nondrying soaps; and to apply nonperfumed skin moisturizers to dry skin. Regular oral care is also encouraged. Medicated lotions, ointments, and dressings are applied to affected skin surfaces as prescribed. Adhesive tape is avoided. Skin surfaces are protected from friction and rubbing by keeping bed linens free of wrinkles and avoiding tight or restrictive clothing. Patients with foot lesions are advised to wear cotton socks and shoes that do not cause the feet to perspire. Antipruritic, antibiotic, and analgesic agents are administered as prescribed. The perianal region is assessed frequently for impairment of skin integrity and infection. The patient is instructed to keep the area as clean as possible. The perianal area is cleaned after each bowel movement with nonabrasive soap and water to prevent further excoriation and breakdown of the skin and infection. If the area is very painful, soft cloths or cotton sponges may be less irritating than washcloths. In addition, sitz baths or gentle irrigation may facilitate cleaning and promote comfort. The area is dried thoroughly after cleaning. Topical lotions or ointments may be prescribed to promote healing. Wounds are cultured if infection is suspected, so that the appropriate antimicrobial treatment can be initiated. Debilitated patients may require assistance in maintaining hygienic practices

Promoting Usual Bowel Patterns

Bowel patterns are assessed for diarrhea. The nurse monitors the frequency and consistency of stools and the patients reports of abdominal pain or cramping associated with bowel movements. Factors that exacerbate frequent diarrhea are also assessed. The quantity and volume of liquid stools are measured to document fluid volume losses. Stool cultures are obtained to identify pathogenic organisms. The patient is counseled about ways to decrease diarrhea. The physician may recommend restriction of oral intake to rest the bowel during periods of acute inflammation associated with severe enteric infections. As the patients dietary intake is increased, foods that act as bowel irritants, such as raw fruits and vegetables, popcorn, carbonated beverages, spicy foods, and foods of extreme temperatures, should be avoided. Small, frequent meals help to prevent abdominal distention. Medications, such as anticholinergic agents, antispasmodic, agents, or opioids, can be prescribed to decrease diarrhea by decreasing intestinal spasms and motility. Administering antidiarrheal agents on a regular schedule may be more beneficial than administering them on an as-needed basis. Antibiotics and antifungal agents may also be prescribed to combat pathogens identified by stool cultures. Assessment of self-care strategies being used is essential.

Preventing Infection
The patient and caregivers are instructed to monitor for signs and symptoms of infection: fever; chills; night sweats; cough with or without sputum production; shortness of breath; difficulty breathing; oral pain or difficulty swallowing; creamy-white patches in the oral cavity; unexplained weight loss; swollen lymph nodes; nausea; vomiting; persistent diarrhea; frequency, urgency, or pain on urination; headache; visual changes or memory lapses; redness, swelling, or drainage from skin wounds; and vesicular lesions on the face, lips, or perianal area. The nurse also monitors laboratory test results that indicate infection, such as the white blood cell count and differential. Cultures of specimens from wound drainage, skin lesions, urine, stool, sputum, mouth, and blood are obtained to identify pathogenic organisms and the most appropriate antimicrobial therapy. The patient is instructed to avoid others with active infections such as upper respiratory infections.

Improving Activity Tolerance

Activity tolerance is assessed by monitoring the patients ability to ambulate and perform activities of daily living . Patients may be unable to maintain their usual levels of
activity because of weakness, fatigue, shortness of breath, dizziness, and neurologic involvement. Assistance in planning daily routines that maintain a balance between activity and rest may be necessary. In addition, patients benefit from instructions about energy conservation techniques,such as sitting while washing or while preparing meals. Personal items that are frequently used should be kept within the patients reach. Measures such as relaxation and uided imagery may be beneficial because they decrease anxiety, which contributes to weakness and fatigue. Collaboration with other members of the health care team may uncover other factors associated with increasing fatigue and strategies to address them. For example, if fatigue is related to anemia, administering epoetin alfa (Epogen) as prescribed may relieve fatigue and increase activity tolerance.

Maintaining Thought Processes

The patient is assessed for alterations in mental status that may be related to neurologic involvement, metabolic abnormalities,infection, side effects of treatment, and coping mechanisms. Manifestations of neurologic impairment may be difficult to distinguish from psychological reactions to HIV infection, such as anger and depression.

If the patient experiences altered mental or cognitive status, family and support network embers are instructed to speak to the patient in simple, clear language and give the patient sufficient time to respond to questions. The patients support network is encouraged to orient the patient to the daily routine by talking about what is taking place during daily activities and encouraged to provide the patient with a regular daily schedule for medication administration, grooming, meal times, bedtimes, and awakening times. Posting the schedule in a prominent area (eg, on he refrigerator), providing night lights for the bedroom and bathroom, and planning safe leisure activities allow the patient to maintain a regular routine in a safe manner. Activities that the patient previously enjoyed are encouraged. These should be easy to accomplish and fairly short in duration. The nurse encourages the social support network to remain calm and not to argue with the patient while protecting the patient from injury. Around-the-clock supervision may be necessary, and strategies can be implemented to prevent the patient from engaging in potentially dangerous activities, such as driving, using the stove, or mowing the lawn. Strategies for improving or maintaining functional abilities and for providing a safe environment are used for patients with HIV encephalopathy

Care of the Patient With HIV Encephalopathy

Disturbed Thought Processes
Assess mental status and neurologic functioning. Monitor for medication interactions, infections, electrolyte imbalance, and depression. Frequently orient the patient to time, place, person, reality, and the environment. Use simple explanations. Teach the patient to perform tasks in incremental steps. Provide memory aids (clocks and calendars). Provide memory aids for medication administration. Post activity schedule. Give positive feedback for appropriate behavior. Teach caretakers how to orient patient to time, place, person, reality, and the environment. Encourage the patient to designate a responsible person to assume power of attorney.

Disturbed Sensory Perception

Assess sensory impairment. Decrease amount of stimuli in the patients environment. Correct inaccurate perceptions. Provide reassurance and safety if the patient displays fear. Provide a secure and stable environment. Teach caregivers how to recognize inaccurate sensory perceptions. Teach caregivers techniques to correct inaccurate perceptions. Teach the patient and caregivers to report any changes in the patients vision to the patients health care provider.

Risk for Injury

Assess the patients level of anxiety, confusion, or disorientation. Assess the patient for delusions or hallucinations. Remove potentially dangerous objects from the patients environment. Structure the environment for safety (ensure adequate lighting, avoid clutter, provide bed rails if needed). Supervise smoking. Do not let the patient drive a car if confusion is present. Instruct the patient and caregiver in home safety. Provide assistance as needed for ambulation and in getting in and out of bed. Pad headboard and side rails if the patient has seizures.

Self-Care Deficits
Encourage activities of daily living within the patients level of ability. Encourage independence but assist if the patient cannot perform an activity. Demonstrate any activity that the patient is having difficulty accomplishing. Monitor food and fluid intake. Weigh patient weekly. Encourage the patient to eat, and offer nutritious meals, snacks, and adequate fluids. If patient is incontinent, establish a routine toileting schedule. Teach caregivers how to meet the patients self-care needs

Relieving Pain and Discomfort

The patient is assessed for the quality and severity of pain associated with impaired perianal skin integrity, the lesions of KS, and peripheral neuropathy. In addition, the effects of pain on elimination, nutrition, sleep, affect, and communication are explored, along with exacerbating and relieving factors. Cleaning the perianal area, as previously described, can promote comfort. Topical anesthetic medications or ointments may be prescribed. Use of soft cushions or foam pads may increase comfort while sitting. The patient is instructed to avoid foods that act as bowel irritants. Antispasmodic and antidiarrheal medications may be prescribed to reduce the discomfort and frequency of bowel movements. If necessary, systemic analgesic agents may also be prescribed Pain from KS is frequently described as a sharp throbbing pressure, and heaviness, if lymphedema is present .Pain management may include use of nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids plus nonpharmacologic approaches such as relaxation techniques.When NSAIDs are administered to patients who are receiving zidovudine, hepatic and hematologic status must be monitored. The patient with pain related to peripheral neuropathy frequently describes it as burning, numbness, and pins and needles. Pain management approaches may include opioids, tricyclic antidepressants, and anti-embolism stockings to equalize pressure. Tricyclic antidepressants have been found to be helpful in controlling the symptoms of neuropathic pain. They also potentiate the actions of opioids and can be used to relieve pain without increasing the dose of the opioid.

Improving Nutritional Status

Nutritional status is assessed by monitoring weight, dietary intake, and serum albumin, BUN, protein, and transferring levels. The patient is also assessed for factors that interfere with oral intake, such as anorexia, oral and esophageal candidal infection, nausea, pain, weakness, fatigue, and lactose intolerance . Based on the results of assessment, the nurse can implement specific measures to facilitate oral intake. The dietitian is consulted to determine the patients nutritional requirements. Control of nausea and vomiting with antiemetic medications administered on a regular basis may increase the patients dietary intake. Inadequate food intake resulting from pain caused by oral lesions or a sore throat may be managed by administering prescribed opioids and viscous lidocaine (the patient is instructed to rinse the mouth and swallow). Additionally, the patient is encouraged to eat foods that are easy to swallow and to avoid rough, spicy, or sticky food items and foods that are excessively hot or cold. Oral hygiene before and after meals is encouraged. If fatigue and weakness interfere with intake, the nurse encourages the patient to rest before meals. If the patient is hospitalized, meals should be scheduled so that they do not occur immediately after painful or unpleasant procedures. The patient with diarrhea and abdominal cramping is encouraged to avoid foods that stimulate intestinal motility and abdominal distention, such as fiber-rich foods or lactose, if the patient is intolerant to lactose. The patient is instructed about ways to enhance the nutritional value of meals. Adding eggs, butter, or fortified milk (milk to which powdered skim milk has been added to increase the caloric content) to gravies, soups, or milkshakes can provide additional calories and protein. Supplements such as puddings, powders, milkshakes, and Advera (previously described) may also be useful (Dudek, 2006). Patients who cannot maintain their nutritional status through oral intake may require enteral feedings or parenteral nutrition.

Brunner & Suddarths textbook of medical-surgical nursing. 12th ed

http://en.wikipedia.org/wiki/HIV http://www.avert.org/hiv.htm http://www.cdc.gov/hiv/ http://hivinsite.ucsf.edu/