Adult Medical-Surgical Nursing

1. Adult Medical-Surgical Nursing Reproductive Health Module: Sexually Transmitted Diseases 1: HIV/AIDS

2. Sexually Transmitted Disease: Definition • A sexually transmitted disease (STD) is a disease acquired through sexual contact with an infected person

3. STD: Classification • Chlamydia • Human Immunodeficiency Virus • Herpes simplex • Human Papillovirus (HPV) • Cytomegalovirus (CMV) • Gonorrhoea • Syphilis • Hepatitis B (HBV) • Hepatitis C (HCV)

4. STD: Transmission • Portals of entry of STD micro-organisms are the skin and mucosal linings of: • Urethra • Cervix • Vagina • Rectum • Oropharynx

5. STD: Modes of Transmission • Sexual • Perinatal (vertical transmission from mother to foetus/ newborn in utero, at birth, through breastfeeding): HBV, HCV, chlamydia, gonorrhoea, syphilis, HIV • Percutaneous in addition to sexual: HBV, HCV, HIV

6. STD: Risk Factors • High risk behaviours: • Sexual relations with infected persons • Multiple sexual partners • Relations with prostitutes • Oral or anal sex • Using IV injections/ drug abuse (high risk associated behaviour)

7. STD: Prevention • Health education about risk factors/ high risk behaviour • Use of a condom as a protective barrier: reduces but does not eliminate risk of transmission: • “Safer sex” rather than “safe sex”

8. STD: Public Health Challenge • Sexually transmitted diseases may progress without symptoms • Those persons with symptoms often reluctant to disclose and seek help: • Through embarrassment (stigma) • Fear of losing partner • Often more than one STD co-infect • Delay in diagnosis/ treatment risks health complications and transmission to others

9. Human Immunodeficiency Virus (HIV)

10. Human Immunodeficiency Virus: Description • HIV is the causative agent of AIDS • An RNA retrovirus (which transcripts DNA) • Targets CD4-positive (CD4+) T lymphocytes reducing count and function • May progress to severe immune dysfunction: • Acquired Immune Deficiency Syndrome (AIDS) • Immunosuppression leads to: • Opportunistic infections • Neoplasms • Lymphadenopathy

11. HIV: Transmission • Transmitted in body fluids of an infected person: • Blood • Seminal fluid • Vaginal secretions • Amniotic fluid • Breastmilk • Blood transfusion (screening → now rare)

12. HIV/AIDS: Pathophysiology • HIV RNA retroviruses attach to CD4 cell surface receptor/ fuse with cell membrane • Uncoating: viral contents empty into cell • HIV enzyme reverse transcriptase copies viral genetic material to DNA: • Blueprint for replication of viral RNA and repeat process • Dormant infected cells reactivated against any new infection: further replicate virus

13. HIV/AIDS:Clinical Manifestations • Persistent enlargement of lymph nodes • Fatigue (lack of energy) • Weight loss • Frequent fevers and night sweats • Persistent oral or genital candida (thrush) • Persistent skin rash/ flaky skin • Short-term memory loss

14. HIV/AIDS: Complications • Disease progress may involve: • Opportunistic Candidiasis of the bronchial tract, oesophagus • Pneumocystis carinii pneumonia • HIV encephalopathy • Kaposi sarcoma • Invasive cervical cancer/ other neoplasms • Lymphoma • TB • Multiple associated infections • Wasting

15. HIV/AIDS: Diagnosis • Patient history and clinical picture • CD4 positive T cell count: (HIV destroys CD4 T cells) • CD4/ CD8 ratio • EIA (ELISA) enzyme immunoassay ( HIV antibodies detected) • Western blot (antibodies confirm EIA) • Viral load (measures HIV RNA in plasma)

16. HIV Test Result: Patient Education • Positive result: HIV antibodies are present • Patient infected: HIV active in body • Despite HIV infection may not have AIDS • Does NOT indicate immunity to AIDS • Negative result: • No antibodies present at test time • Not infected, or infected but no antibodies as yet (3 weeks to 6 months to develop): takeprecautions

17. HIV: Anti-retroviral Agents • Anti-HIV drugs attempt to block viral replication within the cells • Inhibit reverse transcriptase (interfere and confuse HIV in converting RNA to DNA) • Inhibit HIV protease (enzyme which cuts and disperses viral particles to new CD4+) • Multiple drug protocols used

18. AIDS: Treatment/ Prophylaxis • Anti-retrovirals (HIV) • Antibiotics • Antiviral agents: Amphotericin B (meningitis), Alpha-interferon (Kaposi), Acyclovir, Gancyclovir • Anti-fungal agents: TMP-SMZ (Pneumocystis carinii pneumonia) • Anti-TB medication • Anti-depressants • Anti-diarrhoea medications • Nutrition therapy (wasting)

19. AIDS: Prophylactic Measures in Pregnancy • Anti-retrovirals to pregnant women have reduced risk to the newborn • A caesarian section may be recommended • Breastfeeding should be discouraged

20. HIV: Vaccines • Uniquely difficult to produce HIV vaccine • Usually vaccines activate the humoral immune response: B lymphocytes and production of antibodies (long-term memory IgG) • HIV affects T lymphocytes (and also a retrovirus) • Trials of HIV vaccine were discontinued as detrimental to health of participants • No vaccine available at present time

21. HIV/AIDS: Nursing Considerations • Patient education related to risk factors related to infection and spread of virus • Importance of complying with medication protocol • Importance of maintaining healthy lifestyle, good nutrition, adequate sleep • Psychological support to patient/ family • Management of symptoms/ total care