Human Immunodeficiency Virus/AIDSBy: Bryan Mae H. Degorio, MAN

Human Immunodeficiency Virus Infection- Results from 1-2 similar retrovirus (HIV 1 and HIV 2) that destroy CD4ᶧ lymphocytes and impaired cell-mediated

immunity thus increasing the risk of infection and cancer.- AIDS (Acquired Immunodeficiency Syndrome)

Is syndrome characterized by immune abnormalities resulting from infection and destruction of CD4ᶧ T-lymphocytes which immunologically compromised the infected person

It is defined by serious opportunistic infection or cancer or a CD4 count of less than 200/ul. All patients with HIV with CD4 count of less than 200/ul as well as HIV related conditions and symptoms

- Modes of TransmissionA. Factors Affecting the Transmission of HIV:

Duration and frequency of contact, volume of fluid, virulence and concentration of organism and the host immune statusThe viral load in the blood, semen, vaginal secretions or breast milk of the donor

B. Sexual transmissionUnprotected sexual intercourse with an HIV infected partner is the most common mode of transmissionSexual activity provide opportunity for contact with semen, vaginal secretions and blood which all have lymphocytes that may contain HIVExamples:

Heterosexual transmission is more prevalent and now the most commonC. Contact with Blood and Blood Products

Exposure to blood through drug using equipments contaminated with HIVTransfusion of Infected blood and blood productsPuncture wounds:

Needle-stick exposure (0.3-0.4%)Notes: The risk increases if the exposure involves blood from the patient, deep puncture wound, needle with a hallow bore, device used for venous and arterial access

Splash exposure of blood through open lesions but poses lower risk than puncture woundD. Perinatal Transmission

Is the most common route of infection to children (25 % of infants born to untreated HIV-infected women will be born with HIVIt can occur during pregnancy, during delivery or during breastfeeding

- Pathophysiology:

Human Immunodeficiency Virus A RNA virus or known as retrovirus because they replicate in a backward manner (from RNA to DNA) It needs a living cell in order to replicate

Note: 1. Replication process is prone to error thus associated to mutation making treatment difficult for HIV2. The amount of virus in the blood (viral load) is highest in the initial infection and followed by prolong period wherein

the virus in the blood remains low and it starts to elevate at the terminal stage3. The virus attack all cell containing CD4 receptor including lymphocytes, monocytes and astrocytes with predominantly

damage and destruction of the CD4ᶧ T-cells or known as T-helper cells or CD4 T-Lymphocytes (because they have more CD4 cells)

4. Normally: the function of the CD4ᶧ T-Cells is for immune system to recognize and defend against infection5. Damage to this cell causes immune suppression leading to the development of Opportunistic Diseases

- Stages and Classification of HIV

A. CDC classification of HIV Infection

CD4 Cell Categories

Clinical Categories

A Asymptomatic, Acute HIV, or PGL

B Symptomatic Conditions,#* not A or C

C AIDS-Indicator Conditions*

(1) ≥500 cells/µL A1 B1 C1

(2) 200-499 cells/µL A2 B2 C2

(3) <200 cells/µL A3 B3 C3

People with AIDS-indicator conditions (clinical category C) and those in categories A3 or B3 are considered to have AIDS.Clinical Category AIncludes one or more of the following in an adult or adolescent withconfirmed HIV infection and without conditions in clinical categoriesB and C:

Clinical Category CExamples of conditions in adults and adolescents include the following:

Candidiasis of bronchi, trachea, or lungs; esophagus Cervical cancer, invasive Coccidioidomycosis, disseminated or extrapulmonary Cryptococcosis, extrapulmonary Cryptosporidiosis, chronic intestinal (exceeding 1 month’s

Human Immunodeficiency Virus- has gp120 knob that attaches to

the CD4 and chemokine receptor of the cell surface

Virus binds to the CD4 as the major receptor and chemokine receptors (CXCR4 and CCR5) as co-receptors

Viral DNA enters the nucleus using enzyme integrase thus

becoming a permanent part of the genetic material

As result:a. All daughter cell will be

infectedb. DNA in the genome will

direct the cell to produce new HIV

HIV replication occurs at a very rapid rate

Viral RNA enters the Cell and transcribed to single strand of viral DNA with the assistance of reverse transcriptase that will

later develop into double strand

The viral RNA is cut into strands with the

enzyme protease during the budding

sequence

Asymptomatic HIV infection Persistent generalized lymphadenopathy (PGL) Acute (primary) HIV infection with accompanying illness

or history of acute HIV infectionClinical Category BExamples of conditions in clinical category B include, but are notlimited to, the following:

Bacillary angiomatosis Candidiasis, oropharyngeal (thrush) or vulvovaginal

(persistent, frequent, or poorly responsive to therapy) Cervical dysplasia (moderate or severe)/cervical

carcinoma in situ Constitutional symptoms, such as fever (38.5°C) or

diarrhea exceeding 1 month in duration Hairy leukoplakia, oral Herpes zoster (shingles), involving at least two distinct

episodes or more than one dermatome Idiopathic thrombocytopenic purpura Listeriosis Pelvic inflammatory disease, particularly if complicated by

tuboovarian abscess Peripheral neuropathy Salmonella septicemia, recurrent Toxoplasmosis of brain Wasting syndrome due to HIV

duration) Cytomegalovirus disease (other than liver, spleen, or lymph

nodes) Cytomegalovirus retinitis (with loss of vision) Encephalopathy, HIV-related Herpes simplex: chronic ulcer(s) (exceeding 1 month’s

duration); or bronchitis, pneumonitis, or esophagitis Histoplasmosis, disseminated or extrapulmonary Isosporiasis, chronic intestinal (exceeding 1 month’s duration) Kaposi’s sarcoma Lymphoma, Burkitt’s (or equivalent term); immunoblastic (or

equivalent term); primary, of brain Mycobacterium avium complex or M. kansasii, disseminated or

extrapulmonary Mycobacterium tuberculosis, any site (pulmonary or

extrapulmonary) Mycobacterium, other species or unidentified species,

disseminated or extrapulmonary Pneumocystis carinii pneumonia Pneumonia, recurrent Progressive multifocal leukoencephalopathy

B. WHO Clinical Staging of HIV/AIDS

Primary HIV InfectionAsymptomaticAcute retroviral syndrome

Clinical Stage 1AsymptomaticPersistent generalized lymphadenopathy

Clinical Stage 2

Moderate unexplained weight loss (<10% of presumed or measured body weight)Recurrent respiratory infections (sinusitis, tonsillitis, otitis media, and pharyngitis)Herpes zosterAngular cheilitisRecurrent oral ulcerationPapular pruritic eruptionsSeborrheic dermatitisFungal nail infections

Clinical Stage 3

Unexplained severe weight loss (>10% of presumed or measured body weight)Unexplained chronic diarrhea for >1 monthUnexplained persistent fever for >1 month (>37.6°C, intermittent or constant)Persistent oral candidiasis (thrush)Oral hairy leukoplakiaPulmonary tuberculosis (current)Severe presumed bacterial infections (eg, pneumonia, empyema, pyomyositis, bone or joint infection, meningitis, bacteremia)Acute necrotizing ulcerative stomatitis, gingivitis, or periodontitisUnexplained anemia (hemoglobin <8 g/dL)Neutropenia (neutrophils <500 cells/µL)Chronic thrombocytopenia (platelets <50,000 cells/µL)

Clinical Stage 4

HIV wasting syndromePneumocystis pneumoniaRecurrent severe bacterial pneumoniaChronic herpes simplex infection (orolabial, genital, or anorectal site for >1 month or visceral herpes at any site)Esophageal candidiasis (or candidiasis of trachea, bronchi, or lungs)Extrapulmonary tuberculosisKaposi sarcoma

Progressive multifocal leukoencephalopathyCandida of the trachea, bronchi, or lungsChronic cryptosporidiosis (with diarrhea)Chronic isosporiasisDisseminated mycosis (eg, histoplasmosis, coccidioidomycosis, penicilliosis)Recurrent nontyphoidal Salmonella bacteremiaLymphoma (cerebral or B-cell non-Hodgkin)Invasive cervical carcinoma

Cytomegalovirus infection (retinitis or infection of other organs)Central nervous system toxoplasmosisHIV encephalopathyCryptococcosis, extrapulmonary (including meningitis)Disseminated nontuberculosis Mycobacteria infection

Atypical disseminated leishmaniasisSymptomatic HIV-associated nephropathySymptomatic HIV-associated cardiomyopathyReactivation of American trypanosomiasis (meningoencephalitis or myocarditis)

- Clinical Manifestations:

A. Acute infection Primary HIV infection may be asymptomatic Seroconversion period- development of HIV-Specific antibodies (HIV antibody test becomes positive after 3 weeks-

3 months) Acute retroviral syndrome

Transient non-specific manifestationsUsually begins 1-4 weeks after the infection and usually lasts for 3-14 daysFever. malaise, rash, arthralgia, generalized lymphadenopathy and sometimes aseptic meningitis, diarrhea

B. Specific Manifestations Pulmonary manifestations

Persistent cough with and without sputum production, shortness of breath, chest pain, feverFrom Pneumocystis carinii pneumonia (PCP) (most common), bacterial pneumonia (community-acquired pneumonia), Mycobacterium tuberculosis, disseminated Mycobacterium avium complex, cytomegalovirus (CMV), Histoplasma, Kaposi's sarcoma, Cryptococcus, Legionella, and other pathogens

GI manifestationsDiarrhea, weight loss, anorexia, abdominal cramping, rectal urgency (tenesmus)From enteric pathogens including Salmonella, Shigella, Campylobacter, Entamoeba histolytica, C. difficile, CMV, M. avium complex, herpes simplex, Strongyloides, Giardia, Cryptosporidium, Isospora belli, Chlamydia, and others

Oral manifestationsAppearance of oral lesions, white plaques on oral mucosa, particularly in the posterior pharynx and angular cheilitis from Candida albicans of mouth and esophagusVesicles with ulceration from herpes simplex virusWhite, thickened lesions on lateral margins of tongue from hairy leukoplakiaOral warts due to human papillomavirus and associated gingivitisPeriodontitis progressing to gingival necrosisAphthous ulcers of unclear etiology, painful, solitary lesions with raised margins

Central nervous system (CNS) manifestationsCognitive, motor, and behavioral symptoms (AIDS dementia complex/HIV encephalopathy)Demonstrated by mental slowing, impaired memory and concentration, loss of balance, lower extremity weakness, ataxia, apathy, and social withdrawalMay be caused by CNS toxoplasmosis, cryptococcal meningitis, herpesvirus infections, CMV encephalitis, progressive multifocal leukoencephalopathy, and CNS lymphoma.May also have sensory symptoms (distal symmetric polyneuropathy)demonstrated by numbness, tingling, and neuropathic pain.

Ocular manifestationsRetinopathy due to CMV retinitisVisual impairment that progresses to blindness, if untreated

MalignanciesKaposi's sarcoma (aggressive tumor involving skin, lymph nodes, GI tract, and lungs)Non-Hodgkin's lymphoma and lymphomasCervical carcinoma

- Diagnostic Evaluations:

1. HIV Antibody Testa. Enzyme Immunoassay Test or Enzyme Linked Immunoabsorbent Assay

A serological test used in detecting antibodies for HIV But it rarely produced a false positive result and therefore should be confirmed with Western

Blot When the result is negative, the test is reported as negative If recent risk is found, encourage retesting 3 weeks, 6 weeks and 3 months

b. Western Blot or Immunoflourescent Assay Used to confirm positive result of the ELISA

c. Nursing Care: patients who test positive may need ongoing counseling as well as referrals for social, financial,

medical, and psychological support services. Patients whose test results are seronegative may develop a false sense of security, possibly resulting

in continued high-risk behaviors or feelings that they are immune to the virus. They may need ongoing counseling to help them modify high-risk behaviors and to return for

repeated testing. Other patients may experience anxiety regarding the uncertainty of their status.2. CD4 Count

It provides marker for immune functioning As the disease progresses, CD4 count is usually decreasing Normal: 750 ± 250/μl.

3. Viral Loads Is use the measure the amount of HIV in the blood using the plasma HIV RNA level High viral loads are usually found in the acute seroconversion and late disease and also among

patients who have infection Viral result is presented in actual number (ex: 1260 copies/μl) or as undetectable (below 50 copies/μl) Undetectable doesn’t mean that the patient is negative HIV

- Management of HIV

1. Preventive Education and Reproductive Health Education Safer sexual practice to prevent the transmission of HIV

Condom should be used during vaginal and anal intercourseCondoms should be used for oral contact with the penis and dental dam should be used for oral contact with vagina and rectum

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 injection drug users.

Women considering pregnancy need to have adequate information about the risks of transmitting HIV infection to themselves, their partner, and their future children and about the benefits of antiretroviral agents in reducing perinatal HIV transmission

Other than abstinence, the condom has been the only method that has proved to decrease the risk of sexual transmission of HIV infection

female condom is also effective in preventing the transmission of HIV infection and sexually transmitted diseases (STDs)

Notes:a. Estrogen in oral contraceptives may increase a women’s risk for HIV infectionb. The intrauterine contraceptive device (IUD) may also increase the risk for HIV transmission

because the device’s string may serve as a means to transmit HIV infection.2. Post-Exposure Prophylaxis

Is the response to exposure of health care personnel to blood or other body fluids has been proven to reduce the risk for HIV infection (Worthington, 2001).

The CDC (1998) recommends that all health care providers who have sustained a significant exposure to HIV be counseled and offered anti-HIV post exposure prophylaxis, if appropriate.

Ideally, prophylaxis needs to start immediately after exposure; therapy started more than 72 hours after exposure is thought to offer no benefit.

The recommended course of therapy involves taking the prescribed medications for 4 weeks. Guidelines:

a. Wash the area with soap and water.b. Alert your supervisor and initiate the injury-reporting system used in the setting.c. Identify the source patient, who may need to be tested for HIV, hepatitis B, and hepatitis

C. (State laws will determine if written informed consent must be obtained from the source patient prior to his or her testing.)

d. Report to the employee health services, the emergency department, or other designated treatment facility.

e. Give consent for baseline testing for HIV, hepatitis B, and hepatitis C.f. Get post exposure prophylaxis for HIV in accordance with CDC guidelines. Start the

prophylaxis medications within 2 hours after exposure. Make sure that you are being monitored for symptoms of toxicity. Practice safer sex until follow-up testing is complete.

g. Follow up with post exposure testing at 6 weeks, 3 months, and 6 months and perhaps 1 year.

h. Document the exposure in detail for your own records as well as for the employer.3. Standard Precautions4. Retroviral Therapy (ART)

They act to prevent HIV replication at four different points along the replication process. The standard for ART is to take a minimum of three different drugs from at least two different drug

classifications. Guidelines for ART:

a. Women should receive optimal ART regardless of pregnancy statusb. Treatment decision should be individualized by the risk of disease progression indicated by higher

viral loads and lower CD4 T-cells count and the patient’s desires for therapyc. Combination ART suppresses HIV replication and limit the potential for retroviral resistance which is

the major factor limiting treatment effectd. HIV infected person even when viral loads are below detectable level and those on effective ART

should be considered infectious and should avoid behavior associated with transmission of HIV Goals of Antiretroviral Therapy

a. Prolong life and improve quality of life.b. Reduce viral load to as low as possible for as long as possible.c. Increase the CD4+ count to allow immune reconstitution.d. Maintain options for future treatment by preventing the development of treatment-resistant virus.e. Avoid drug toxicities.

Specific Drug Therapy:a. Nonnucleoside reverse transcriptase inhibitor

Act by attaching to the reverse transcriptase enzyme, which prevents it from converting HIV RNA into HIV DNA (Gracia Jones, 2001). Possible adverse reactions for this group of agents include abnormal liver function test results, hepatitis, stomatitis, numbness, muscle pain, drowsiness, changes in dreams, trouble concentrating, severe psychiatric symptoms in rare cases (severe depression, suicidal thoughts, angry behavior) (Gracia Jones, 2001). Rare cases of Stevens-Johnson syndrome have been reported with the use of this class of medications (Panel on Clinical Practices, 2000, 2001). Drug resistance develops very easily, which makes adherence essential.

b. Nucleoside reverse transcriptase inhibitorAct by becoming part of HIV’s DNA and derail its building process. As a result, the damaged viral DNA cannot take control of the host cell’s DNA (Gracia Jones, 2001). Possible adverse reactions associated with medications that act through this mechanism include peripheral neuropathy, pancreatitis, lactic acidosis, bone marrow suppression, neutropenia, anemia, arthralgia, myopathy, kidney dysfunction, hepatomegaly, liver failure, vision changes, neuropathy, hypersensitivity reaction, abdominal pain, fever, chills, sore throat, oral ulcers, dry mouth, muscle and joint pain, irritability, anxiety, nervousness (Gracia Jones, 2001). Lactic acidosis with hepatic steatosis (fatty degeneration of the liver) is a rare but potentially life-threatening toxicity with this classification of medications (Panel on Clinical Practices, 2000, 2001).

c. Nucleotide reverse transcriptase inhibitorInhibit the action of reverse trancriptase

d. Protease inhibitorWork at a later stage in the HIV replication process by preventing the protease enzyme from cutting HIV viral proteins into the viral particles that infect new CD4 T4 cells. As a result, new copies of HIV are defective and unable to infect new host cells (Gracia Jones, 2001). Possible adverse reactions include hemolytic anemia, paresthesia, kidney stones, asymptomatic hyperbilirubinemia, dyspepsia, numbness (of lips, hands, or feet), altered taste, drowsiness, mood alterations (Gracia Jones, 2001); in patients with hemophilia, there are possible increased bleeding episodes (Panel on Clinical Practices, 2000, 2001).

e. Entry InhibitorPrevents the binding of HIV cells thus preventing the entry of HIV cells, thus preventing entry of HIV cells into cells where replication would occur.

Note: For specific examples of drugs please read Medical Surgical Nursing by Lewis pp. 258.

5. Vaccination Despite several efforts, vaccines for HIV is still elusive

HIV mutation may all not respond to simple vaccine. Notes:

All HIV patient should be screened for tuberculosis every year with PPD (purified protein derivatives. An induration of 5 mm is considered positivePneumococcal pneumonia all patients should receive Pneumovax and it should be repeated every 5 to 6 years.Influenza patients with a CD4+ greater than 100 should receive a flu vaccine each fall.Tetanus booster patients with a CD4+ count greater than 200/mm3 should receive routine booster every 10 years.

Note: a. Post and Pre-test Counseling Associated with HIV-Antibody Testing (pp. 264)b. Standard Precaution as applied to HIV prevention (any source is acceptable)c. HIV manifestation by system (available in the library)