Chapter 52 Management of Patients With HIV Infection and AIDS

1. Chapter 52Management of Patients With HIV Infection and AIDS

2. Epidemiology • United States • Approx 1.1 million infected at end of 2006 (CDC) • 21% undiagnosed • African Americans accounted for 44% of all cases through 2007, but make up only 12% of the population • Minority groups disproportionately affected • Males accounted for 72% of all cases in 2003 • Most common routes: • MSM, heterosexual contact, IVDA • Fastest growing infection rate among women, minorities and adolescents

4. Epidemiology • Wordwide • AIDS kills 8,000 people/day • 33.4 million people infected worldwide • 22.4 million of these in Subsaharan Africa • In underdeveloped countries, heterosexual transmission is primary route

5. Transmission of HIV • Transmitted by body fluids containing HIV or infected CD4 lymphocytes • Blood, seminal fliud, vaginal secretions, amniotic fluid, and breast milk • Most prenatal infections occur during delivery • Risk via blood transfusion in developed countries is very low • Casual contact does not cause transmission • Breaks in skin and mucosa increase risk

6. High-Risk Behaviors (USA) • Sharing infected injection equipment • Having sexual relations with infected individuals • Gerontologic considerations

7. Prevention • Standard precautions for healthcare providers • Practice safe activities and risk-reducing activites • Abstain from sharing sexual fluids • Reduce the number of sexual partners to one • Always use latex condoms; if allergic to latex, use nonlatex condoms (male or female) • Avoid sexual practices that may cause tears in mucous membranes

8. Prevention • Practice safe activities and risk-reducing activities • Do not use drugs • If drugs are used, do not share equipment • Do not have sex under the influence of any drug • Needle exchange programs • Clean equipment properly (bleach) • See table 15-21

9. Prevention • Perinatal transmission • Treatment during pregnancy reduces transmission to less than 2%

10. Transmission to healthcare providers • Standard precautions • Risk of seroconversion after needlestick about 0.3% • Postexposure prophylaxis • Baseline testing within 72 hours and testing at 1, 3, 6 months • If needed: start prophylaxis meds within 24 hours of exposure • Documentation

11. Structure of HIV-1 (retrovirus)

12. Life Cycle of HIV-1

13. Pathophysiology • HIV is a retrovirus; it makes DNA from RNA • Replicates via reverse transcription and viral DNA is integrated into the host DNA • Target cells • T cells (CD4 or CD8) • B cells • Natural killer cells

14. Categories • The three CD4+ T-lymphocyte categories are defined as follows: • Category 1: greater than or equal to 500 cells/mL • Category 2: 200-499 cells/uL • Category 3: less than 200 cells/uL • Clinical categories

15. Stages of HIV Disease • Acute infection • Early chronic infection • Intermediate chronic infection • AIDS

16. Primary Infection • Acute HIV infection/acute HIV syndrome • Part of CDC category A • Symptoms: none to severe flu-like syndrome • Occurs about 3 weeks after exposure, lasts 1-3 weeks • Window period: lack of HIV antibodies • Period of rapid viral replication and dissemination through the body • Viral set point: balance between amount of HIV and the immune response

17. Early Chronic Infection • CD4 remains above 500 • Viral load is low • Asymptomatic disease • May have persisten generalized lymphadenopathy, fatigue, mild symptoms

18. Intermediate Chronic Infection • CD4 drops to 200-500 • Viral load increases • Symptoms may include persistent fever, night sweats, chronic diarrhea, headaches, fatigue, infection • Most common infection oropharyngeal candidiasis; also shingles, vaginal candidiasis, increase in herpes, oral hairy leukoplakia

19. AIDS - Late Chronic Infection • CDC criteria for AIDS (table 15-10) • CD4 <200 • Certain opportunistic infection • Certain opportunistic cancers • Wasting syndrome • AIDS dementia complex

20. Diagnosis • Includes detailed history and physical exam • HIV antibody tests • Informed consent - state specific laws • Antibodies detected within 3-12 wks of infection • ELISA performed; confirmation by Western Blot • Rapid HIV • Viral load tests • “undetectable”

21. Treatment • Treatment and protocols are continually evolving • Most current recommendations include early, aggressive treatment • Antiretroviral agents: see 15-14) • Nucleoside reverse transcriptase inhibitors (NRTIs) • Non-nucleoside reverse transcriptase inhibitors (NNRTIs) • Protease inhibitors (PIs) • Use of combination therapy

22. Treatment • Management focuses upon: • Preservation of the immune system-maintain or raise CD4 counts • Suppression of viral load • Improved quality of life • Reduction of HIV-associated morbidity and mortality • Treatment of specific manifestations and conditions related to the disease • Viral load is monitored (may become undetectable), as well as T cell count

23. Treatment • Adverse effects vary by medication, but may include: • Lipodystophy syndrome • Fat redistribution syndromes • Facial wasting • Liver dysfunction • GI intolerance • Drug resistance • Immune reconstitution syndromes

24. Manifestations of AIDS—Respiratory • Pneumocystis carinii pneumonia (PCP) • Most common infection resulting in AIDS diagnosis • Initial symptoms may be nonspecific and may include nonproductive cough, fever chills, dyspnea, and chest pain • If untreated, progresses to pulmonary impairment and respiratory failure • Treatment: TMP-SMZ or pentamidine; prophylactic TMP-SMZ • Mycobacterium avium complex (MAC) • May cause respiratory or GI infection • Tuberculosis

25. Manifestations of AIDS—GI • Oral candidiasis • May progress to esophagus and stomach • Treatment with Mycelex troches or nystatin and ketoconazole • Diarrhea related to HIV infection or enteric pathogens (50-90%) • Octreotide acetate for severe chronic diarrhea • Wasting syndrome • 10% weight loss and chronic diarrhea or chronic weakness and fever with absence of other cause • Protein energy malnutrition • Anorexia, diarrhea, GI malabsorption, and lack of nutrition may contribute

26. Manifestations of AIDS—Oncologic • Kaposi's sarcoma • Cutaneous lesions but may involve multiple organ systems • Lesions cause discomfort, disfigurement, ulceration, and potential for infection • Death may result from tumor progression • B cell lymphomas • Second most common HIV associated malignancy

27. Lesions of Kaposi’s Sarcoma

28. Manifestations of AIDS—Neurologic • HIV encephalopathy • Progressive cognitive, behavioral, and motor decline • Probably directly related to the HIV infection • Signs/symptoms may be difficult to distinguish from depression, fatigue/ • Includes headaches, memory deficit, apathy, confusion, psychomotor deficits • HIV - related peripheral neuropathy • Cryptococcus neoformans (fungal infection) • Other neurologic disorders (often infectious) • Depression

29. Manifestations of AIDS- gynecologic • Invasive cervical cancer

30. Nursing Process—Assessment of the Patient With AIDS • Assess physical and psychosocial status • Identify potential risk factors: IV drug abuse and risky sexual practices • Assess immune system function • Assess nutritional status • Assess skin integrity • Assess respiratory status and neurologic status • Assess fluid and electrolyte balance • Assess knowledge level

31. Nursing Process—Diagnosis of the Patient With AIDS • Impaired skin integrity • Diarrhea • Risk for infection • Activity intolerance • Disturbed thought processes • Ineffective airway clearance • Pain • Imbalanced nutrition • Social isolation • Anticipatory grieving • Deficient knowledge

32. Collaborative Problems/Potential Complications • Opportunistic infections • Impaired breathing or respiratory failure • Wasting syndrome • Fluid and electrolyte imbalance • Adverse reaction to medication

33. Nursing Process—Planning the Care of the Patient With AIDS • Goals may include: • Achievement and maintenance of skin integrity • Resumption of usual bowel patterns • Absence of infection • Improved activity tolerance • Improved thought processes • Improved airway clearance • Effective coping

34. Nursing Process—Planning the Care of the Patient With AIDS (cont.) • Goals may include (cont.) • Increased comfort • Improved nutritional status • Increased socialization • Expression of grief • Increased knowledge regarding disease prevention and self-care • Absence of complications

35. Skin Integrity • Conduct frequent routine assessment of skin and mucosa • Encourage patient to maintain balance between rest and activity • Reposition at least every two hours and as needed • Use pressure reduction devices • Instruct patient to avoid scratching • Use gentle, nondrying soaps or cleansers • Avoid adhesive tape • Provide perianal skin care

36. Promoting Usual Bowel Pattern • Assess bowel pattern and factors that may exacerbate diarrhea • Avoid foods that act as bowel irritants, such as raw fruits and vegetables, carbonated beverages, spicy foods, and foods of extreme temperatures • Small, frequent meals • Administer medications as prescribed • Assess and promote self-care strategies to control diarrhea

37. Activity Intolerance • Maintain balance between activity and rest • Instruction regarding energy conservation techniques • Relaxation measures • Collaboration with other members of the health care team

38. Maintaining Thought Processes • Assess mental and neurologic status • Use clear, simple language if mental status is altered • Establish and maintain a daily routine • Use orientation techniques • Ensure patient safety and protect from injury • Implement strategies to maintain and improve functional ability • Instruct and involve family in communicationand care

39. Nutrition • Monitor weight, I&O, dietary intake, and factors that interfere with nutrition • Provide dietary consultation • Control nausea with antiemetics • Provide oral hygiene • Treat oral discomfort • Administer dietary supplements • May require enteral feedings or parenteral nutrition

40. Decreasing Isolation • Promote an atmosphere of acceptance and understanding • Assess social interactions and monitor behaviors • Allow patient to express feelings • Address psychosocial issues • Provide information related to the spread of infection • Educate ancillary personnel, family, and partners

41. Other Interventions • Improve airway clearance • Use semi-Fowler's or high-Fowler’s position • Pulmonary therapy; coughing and deep breathing; postural drainage; percussion; and vibration • Ensure adequate rest • Pain • Administer medications as prescribed • Provide skin and perianal care

42. The Nursing Process - Evaluation • Maintains skin integrity • Resumes usual bowel habits • Experiences no infections • Maintains adequate level of activity tolerance • Maintains usual level of thought processes • Experiences increased sense of comfort • Maintains adequate nutritional status • Reports understanding of AIDS and participates in self-care activities