HIV/AIDS

• Human Immunodeficiency Virus 1983
• Retrovirus, genetic material contains RNA (replicates backwards)
• Infectious disease
• mutates rapidly- no vaccine bc of this
• to replicate, it must invade a living host
• target: t lymphocytes (T4, CD4)
• replicates backwards from RNA-DNA

• fastly growing in elders
• 1/5 don't know

• HIV gp knobs on virus bind CD4 sites on the cell
• bind and enter cell
• - viral RNA and three enzymes
• - reverse transcriptase
• - integrase
• - protease
• 90% of the meds work on all three enzymes

• 1. Reverse transcriptase: this is when RNA is transcribed into DNA
• 2. Integrase: integrates into host cell- once intergrates HIV is now permanant
• 3. protease- break off and pack and release
• - helps to push this viral DNA- goes to another cell to replicate for them

• new viral proteins leave cell by budding
• - protease
• - mature
• - process starts again and it replicates

• primary infection:
• - period between initial exposure to virus and appearance of HIV antibodies (window period- can transmit the virus)
• - test negative HIV antibody (antibodies are not dectected can take weeks)- 1m-3m 3w-12w
• - highly infectious (virus fast and furious)
• - elevated HIV viral load, decreased CD4 and increased CD8 cells (t suppressors cells)- immune system is working but not enough
• Viral set point (looking at this)- how much viral load do you have. incre in viral load means you will have a poor prognosis (in the early stages)
• tx early

the stages varies from person to person. someone could be asymptomatic for years whereas someone could show symptoms in weeks

• Acute Retroviral Syndrome (up to 90% get this flu, mono- nothing will let u know when u have HIV)
• - nonspecific symptoms, fever, fatigue, lympadenopathy, rash
• - fever, pharyngitis, myalgia (muscle weakens)
• - nausea, vomiting, diarrhea
• Usually appears within days/wks of exposure- last few days- months

• Acute retroviral syndrome- think HIV
• - fever 96%
• -lymphadenopathy (incr lymph)
• - pharyngitis- sore throat
• - rash- diffuse
• if you think mono, think HIV also
• if you think flu, think HIV too

• s/s of PHI (primary) resolve, viral load decreases
• asymptomatic patients feels well
• CD4 levels are high
• - CD4 above 500
• non specific symptoms once in awhile can last for months to years where u see no symptoms
• mostly they are not aware but can transfer disease
• depending on CD4 count- reg count CD4 800-1200

• CD4 200-499
• - develop symptomatic disease
• - oral candidiasis, pneumocystic pneumonia (PCP), shingles
• - many patients are dx at this stage
• initial symptoms of primary stages will start to present but will be way worst like incr fatigue, night sweats, high fever, consist headache

• Third Stage
• Need to meet criteria defined by CDC
• - CD4 level<200 or 14% of all lymphocytes
• - positive antibodies for HIV
• - dx with one or more AIDS defining illness, candiadiasis, PCP, HIV encephalopathy (chx in mental status), lymph, kaposi sacroma....
• wasting syndrome- specific to AIDS
• these opportunistic infections
• dec immune system
• once classified as AIDS it will always stay this way

• S/s widespread
• fatigue, malaise
• involuntary weightloss
• opportunistic infection- which can be fatal bc immune system is compromise, and cancers
• - virus, bacteria, fungi, protozoal
• can be fatal

• PCP
• MAC- myobacteriums Avium complex
• myobacterium TB
• - opportunistic infections
• Assessments:
• - change in LS
• - SOB
• - dec O2 stat

• TX w/antibiotic progress rapidly could be fatal
• becareful

• Thrush
• tx with Nystatin
• swish and spit but if in the esophagus then swallow
• significant and severe they will use diflucan

• involuntary weightloss > 10%
• rapid weightloss
• chronic diarrehea- > 30%
• chronic weakness with fever
• protein energy nutrition- no protein (breaking down proteins)
• Tx- megace:  oral progesteron incr appetitite, prompt weight gain, incr body weight and body fat stores, well tolerated
• Marinol- activates compotent of marijuanna, relieves N/V, incre wt gain
• Nx interventions
• incre protein- fish
• skin breakdown
• monitor BUN/Cr
• increa food intake- small intake
• incre calorie count, low fats
• monitor weight
• I&O
• oral care
• vitamin
• boost drinks
• soft foods - no energy
• TPN, PPN- last resort

• Most common HIV maligency involving endothelial layers of blood vessels, lymph nodes, viscera and mm
• course variable
• skin ulcer
• localized vascular cutaneous lesions
• - dark brown to deep violet in color
• - multiple organs
• Tx: palliative radiation0- even if u remove they come back
• initially painless as time progressive....
• bleed/obstruction

• peripheral neuropathy
• usually distal
• tx- gabapentin (neurotin)
• well tolerated

• progressive decline in cogintive behavioral and motor function
• HIV has a direct damage to the brain- lesser brain cells
• s/s fatigue, memory gaps, h/a, difficulty concertrating, apathy, poor coordination
• progresses: global cognitive deficits, delayed responses, hallucinations
• lead to coma
• ischemia to the brain

• herpes simplex
• opportunistic infection
• virus- painful vesicles
• shingles- CD4 cells

atopic dermatis- autoimmune

• psychosocial
• - depression
• - isolation
• cardiac disease hyperlipidemia- incr risk for MI
• liver disease- high rate HIV (if u have liver disease b4 for this it will inc risk more) and hep b virus, HCV
• renal disease- glomerulonephritis- drugs used can affect the organs

• rapid testing
• - orasure rapid HIV antibody test
• - results within 30 mins
• - high number of false positive
• - need confirmatory testing ***

• oraquick rapid HIV antibody test
• - results within 30 minutes
• - need confirmatory testing

saliva and blood

• home based testing
• - privacy
• - technique/contamination
• - # false positive/negative results
• - need confirmatory testing ***
•  confirmatory testing is essential!!!
• pre/post counseling
• pt ed is essential

• counseling, consent patient education and specific follow up plan
• if high risk negative confirmatory
• - plan to repeat in 4 weeks
• - reccommended testing q 3-6 months
• - does not mean 100% of the pt is negative, the body has not produced antibodies

• EIA (enzyme immunoassay)
• - defects presence of antibodies
• - gold standard
• - you need positive EIA, then u take another one it is has to be positive
• Western Blot Assay
• - detects antibodies
• - confirm EIA

• 2 EIA and a western blot assay- confirms HIV
• post test counseling, aware of reporting, privacy, partner notification

• Viral Load:
• - measure plasma HIV RNA
• - used track response to Tx
• - high viral load= active viral replication
• if this is undetectable- it does not mean there is no HIV it is at the lowest amt we can detect

• CD4 counts and T cells %
• - extent of HIV damage to immune system
• - < 200 high incidence of progression to AIDS

• CBC- WBC
• chem studies including LFT (BUN, cr, electrolytes)
• HIV drug resistancer testing- bc it mutates
• STD screening
• MRI/CT- damage complication
• complete detail PE, assess s/s opportunistic diseases
• psychosocial assessment- depression, isolation

• indentification- who are at risk
• testing
• treatment- right away
• pre exposure prophalytic- given to high risk people

• patient education and counseling is essential
• follow up care
• community resources and support systems
• nursing care
• - accurate assessments, education
• - assess and treat substance abuse
• - stay aware and active in HIV education/policy
• do the 30 mins test- to incre teaching

• lifelong
• compliance (30-50% of patients)
• to achieve viral suppression, combination therapy
• treatment decisions are based on patients s/s CD4 counts, viral load
• they are combining the drugs
• decre viral load and incr CD4- med changes depend on this