AIDSMs. Minu Sharma

MSc Nursing 2nd Year

Himalayan College of Nursing

Objectives

• Define AIDS

• Enlist etiology and risk factors of AIDS

• Describe pathophysiology of AIDS

• Elaborate the clinical manifestation of AIDS

• Describe the diagnostic finding of AIDS

• Explain medical management of AIDS

• Explain nursing management of AIDS

• Understand the article related to AIDS

Acquired immunodeficiency syndrome (AIDS) is defined as the most severe form of a continuum of illnesses associated with human immunodeficiency virus (HIV) infection

HIV belongs to a group of viruses known as retroviruses. These viruses carry their genetic material in the form of ribonucleic acid (RNA) rather than deoxyribonucleic acid (DNA)..

Infection with HIV occurs when it enters the host CD4 (T) cell and causes this cell to replicate viral RNA and viral proteins, which in turn invade other CD4 cells

Four categories of infected states have been denoted:

• Primary infection (acute/recent HIV infection, acute HIV syndrome: dramatic drops in CD4 T-cell counts, which are normally between 500 and 1,500 cells/mm3)

• HIV asymptomatic (CDC Category A: more than 500 CD4 T lymphocytes/mm3)

• HIV symptomatic (CDC Category B: 200 to 499 CD4 T lymphocytes/mm3)

• AIDS (CDC Category C: fewer than 200 CD4 T lymphocytes/mm3)

CDC (central for disease control and prevention ) (January 1994): “Persons with CD4 cell count of under 200 (with or without symptoms of opportunistic infection) who are HIV-positive are diagnosed as having AIDS.”

Risk Factors

• Heterosexual intercourse with an HIV-infected partner

• Injection drug use

• Male homosexual relations.

• Transfusions of blood or blood products contaminated with HIV

• Children born to mothers with HIV infection

• Breast-fed infants of HIV-infected mothers• Health care workers exposed to needle-stick

injury associated with an infected patient

 

Etiology

Human immune deficiency virus (HIV)

Pathophysiology

Clinical Manifestations

ACUTE INFECTION

Flu like syndrome of fever

Swollen lymph glands

Sore throat

Muscle & joint pain

Diarrhea

Diffuse rash

 

CHRONIC HIV INFECTION (Asymptomatic disease):

- Early chronic infection:

CD4 cell count - >500 cells/µl

Fatigue

Head ache

Low grade fever

Night sweats

Persistent generalized lymphadenopathy

 

 

 

- Intermediate chronic infection:

CD4 cell count – 200-500 cells/µl

Persistent fever

Drenching night sweats

Chronic diarrhea

Recurrent headaches

Fatigue

Lymphadenopathy

Oro-pharyngeal candidiasis/thrush

Shingles

Bacterial infection

Kaposi’s sarcoma

Oral hairy leukoplakia

- Late chronic infection:

The ratio of CD4 to CD8 cells about 1:2

Increased viral load

Opportunistic diseases

Disability & death

WHO Clinical staging

WHO has developed a staging system in which 4 clinical staging of disease have been identified

•PRIMARY INFECTION•Proliferation of virus in blood and lymph node CD4 cell count decline

STAGE2ND

•EARLY IMUNE DEFICIENCY Immune system control the infection CD4 cell >500/m3,no symptoms

•INTERMEDIATE IMMUNE DEFICIENCY•Viral application is very highCD4 cell 200-500/m3,sign & symptoms begin to appers.

•ADVANCE IMMUNE DEFICIENCY•Viral proliferation through body, patient having opportunistic infection and malignancies.

Diagnostic Studies

• CBC: Anemia and idiopathic thrombocytopenia (anemia occurs in up to 85% of patients with AIDS and may be profound). Leukopenia may be present; differential shift to the left suggests infectious process (PCP), although shift to the right may be noted.

• PPD: Determines exposure and/or active TB disease. Of AIDS patients, 100% of those exposed to active Mycobacterium tuberculosis will develop the disease.

• Serologic: Serum antibody test: HIV screen by ELISA. A positive test result may be indicative of exposure to HIV but is not diagnostic because false-positives may occur.

• Western blot test: Confirms diagnosis of HIV in blood and urine.

Viral load test:

RI-PCR: The most widely used test currently can detect viral RNA levels as low as 50 copies/mL of plasma with an upper limit of 75,000 copies/mL.

 

 

• bDNA 3.0 assay: Has a wider range of 50–500,000 copies/mL. Therapy can be initiated, or changes made in treatment approaches, based on rise of viral load or maintenance of a low viral load. This is currently the leading indicator of effectiveness of therapy.

• T8+ CTL (cytopathic suppressor cells): Reversed ratio (2:1 or higher) of suppressor cells to helper cells (T8+ to T4+) indicates immune suppression.

• CD4+ lymphocyte count (immune system indicator that mediates several immune system processes and signals B cells to produce antibodies to foreign germs): Numbers less than 200 indicate severe immune deficiency response and diagnosis of AIDS.

 

• Polymerase chain reaction (PCR) test: Detects HIV-DNA; most helpful in testing newborns of HIV-infected mothers. Infants carry maternal HIV antibodies and therefore test positive by ELISA and Western blot, even though infant is not necessarily infected.

• STD screening tests: Hepatitis B envelope and core antibodies, syphilis, and other common STDs may be positive.

 

• Cultures: Histologic, cytologic studies of urine, blood, stool, spinal fluid, lesions, sputum, and secretions may be done to identify the opportunistic infection. Some of the most commonly identified are the following:

Protozoal and helminthic infections: PCP, cryptosporidiosis, toxoplasmosis.

Fungal infections: Candida albicans (candidiasis), Cryptococcus neoformans (cryptococcosis), Histoplasma capsulatum (histoplasmosis).

Bacterial infections: Mycobacterium avium-intracellulare (occurs with CD4 counts less than 50), miliary mycobacterial TB, Shigella (shigellosis), Salmonella (salmonellosis).

Viral infections: CMV (occurs with CD4 counts less than 50), herpes simplex, herpes zoster.

Neurological studies

• Electroencephalogram (EEG)

• Magnetic resonance imaging (MRI)

• Computed tomography (CT) scans of the brain

• Electromyography (EMG)/nerve conduction

• Chest X-ray

• Pulmonary function tests

• Gallium scan

• Biopsies

• Bronchoscopy/tracheobronchial washings

• Barium swallow, endoscopy, colonoscopy

Medical Management

• Rest

• Proper nutritious diet

• Psychological support

Counseling

Counseling services are the backbone of the HIV program. Counseling is offered through the ICTC ( Integrated Counseling Treatment Centre ) programme for voluntary clients PICT ( Provider Initiative Counseling and Testing) for pregnant women

Types of counseling

1. Pre Test Counselling

2. Post Test Counselling

3. PPTCT Counselling

4. Family and Relationship Counselling

5. Adherence Counselling

6. Crisis Counselling

7. On-going Counselling

Drugs

• Nucleotide reverse transcriptase inhibitors

• Nucleoside reverse transcriptase inhibitors

• Non-nucleoside reverse transcriptase inhibitors

• Protease inhibitors

• Fusion inhibitors

Antiretroviral Therapy

Antiretroviral treatment for HIV infection consist of drugs which works against HIV infection itself by slowing down the replication of HIV in the body drugs are often referred to as :

ART – Anti Retroviral Therapy

ARVs - Anti Retro Virals

HAART- Highly Active Anti Retroviral Therapy

Antiretroviral Agents

Nucleoside reverse transcriptase inhibitors (NRTIs)

• HIV infects a cell, reverse transcriptase Copies the viral single stranded RNA genone into double stranded viral DNA. The viral DNA is than integrated into the host chromosomal DNA, which then allow host cellular processes, such as transcription and translation to reproduce virus.

• NRTIs block reverse transcriptase enzymatic function and prevent completion of synthesis of the double stranded viral DNA, thus preventing HIV from multiplying

Zidovudine Lamivudine Stavudine Didanosine Abacavir Tenofavir

Non-Nucleoside reverse transcriptase inhibitors (NNRTIs)

• NNRTIs are not incorporated into the viral DNA but instead inhibit the movement of protient domains of reverse transcriptase that are needed to carry out the process of DNA synthesis.

Efavirenz Nevirapine

Protease inhibitors

• Protease inhibitors blocks the Protease enzymes. When protease is blocked, HIV makes copies of itself that can’t infect new cells. Studies have shown that protease inhibitors can reduce the virus in the blood and increase CD4 cell counts.

Nelfinavir Lopinavir /retonavir Saquinavir Indinavir Ritonavir

 

Treatment of infection

• Antibacterial agents like trimethoprim-sulfamethoxazole for treating various infection

• Amphotericine B or Fluconazole to treat meningitis

• Antiviral agents such as ganciclovir and foscavir for cytomegalovirus retinitis

• Acyclovir can be used to treat infection caused by herpes simplex or herpes zoster

Antidiarrhreal therapy

• Therapy with octreotide acetate, a synthetic analogue of somatostanin, has been effective in managing chronic severe diarrhea. High concentration of somatostanin receptors have been found in the GI tract and other tissues.

Chemotherapy

• Kaposi’s Sarcoma is treated with alpha- interferone

• Lymphoma treatment is the combination of radiotherapy and chemotherapy

Antidepressant therapy

Depressive symptoms are severe and of longer duration, treatment with antidepressant such as imipramine, desipramine and fluoxetine. A psychostimulant such as methylphenidate may be used in low doses

Complementary therapies

• Yoga : Yoga is a set of exercise that people use to improve their fitness, reduce stress, and increase flexibility. Yoga can involve breathing exercise, certain stretches and poses and meditation

• Massage : An excellent way to deal with the stress and to deal with the stress and side effects that go along with having an illness, including HIV. A trained therapist moves and rub on muscles.

• Aromatherapy : It is based on the idea that certain smells can change the way the person feels. The smells used are from plant oil, and they can be inhaled or used in baths or massages

• Relaxation technique (meditation, imagery ) : Relaxation therapy such as meditation and guided imagination focus on how a person’s mind and imagination can promote overall health and well- being.

 

• Reflexology : Reflexology is an ancient Chinese technique that uses pressure-point message usually on feet, but also on the hands and ears that relate to every organ and part of our body.

• Laughter therapy : Laughter therapy is the use of laughter for the relief of physical or emotional pain or stress. It improves the immunity

• Music therapy : It consist of systemic application of music by the music therapist to bring about the helpful changes in the physical and emotional health of the client.

• Hydrotherapy : It is the use of water (hot, cold, steam or ice) to relieve discomfort and promote well being.

Nursing Process

Assessment

• Nutritional Status

• Skin and Mucous Membranes

•  Respiratory Status

•  Neurologic Status

•  Level of Knowledge

•  Use of Alternative Therapies

 

Nursing Priorities

• Prevent/minimize development of new infections.

• Maintain homeostasis.

• Promote comfort.

• Support psychosocial adjustment.

• Provide information about disease process/prognosis and treatment needs.

Discharge Goals

• Infection prevented/resolved.

• Complications prevented/minimized.

• Pain/discomfort alleviated or controlled.

• Patient dealing with current situation realistically.

• Diagnosis, prognosis, and therapeutic regimen understood.

• Plan in place to meet needs after discharge.

Nursing diagnosis:-

Impaired thermoregulation related to chronic HIV infection, secondary opportunistic infection, malignancy, autoimmune disorders, diarrhea, dehydration, allergic response to medications, or infection at IV sites, catheter, drains and incisions.

Outcome :- Control fever and replace fluid loss

Intervention:-

• Nonpharmacologic intervention include keeping the patient in a warm room and applying a loose woven sheet or blanket

• Increase calorie and fluid intake by providing a plan of six feeding over 24 hours and high protein, high calorie nutrient supplements

• Provide dry cloths and bed linens

• Keep liquids at bedsides

• Antipyretic agents

Nursing diagnosis:-

Activity intolerance related to chronic HIV infection, secondary opportunistic infection, anemia, malnutrition, dehydration, prolonged immobility, and situational factor

Outcome :- Increase self awareness of fatigue and self care

Intervention:-

• Daily fatigue diary for at least 1 week

• Advise to avoid coffee, tobacco and alcohol which may increase fatigue

• Promote adequate sleep by increasing amount of sleep everyday

• Reduce sleep-cycle interruption

• Promote rest and activity by developing a 24 hour schedule

• Prepare exercise schedule and plan at peak energy time

• Progressive muscles relaxation, acupuncture, massage therapy, relaxation, therapeutic touch and social support

Nursing diagnosis:-

Imbalance nutrition: Less than body requirements related to increase nutrients requirements, decrease food intake secondary to side effects of medication and infection such as anorexia, nausea, vomiting, impaired swallowing or chewing, diarrhea, fatigue and impaired cognition

Outcome :- Increase food intake, preserve lean body mass and provide adequate level of all nutrients.

Intervention:-

• Minimise anorexia

• Prevent weight lossSmall and frequent mealsEating high calorie snacksIndulging in favourite foodsConsuming more nutrientsDrinking liquids 30 minutes before meals instead of eating with mealsEncourage to dine with friends or family

• Improve food intake Eat food at room temperature Choose mild food and drinks such as apple juice

instead of orange juice Eat dry grains Use a straw when drinkingtilt head forward or

backward for good swallowing

• Increase the availability of foods

• Teach nutritional requirements

Nursing diagnosis:-

Acute pain or chronic pain related to Arthralgia, Myalgia or neuropathy associated with HIV infection, mass lesion associated with opportunistic infection, malignancy, side effects of medication or intervention such as surgery

Outcome :- Enhance comfort and satisfaction

Intervention:-

• Provide comfort measures

• Provide physical therapyExercise to maintain physical activityApplication of heat or cold to reduce musculoskeletal

abnormalityTherapeutic massageTranscutaneous electrical nerve stimulation (TENS)

• Administer pain medication : opioids

• Encourage complementary therapy

Research study

Use of first line antiretroviral therapy from a free ART programme clinic in Pune, India - A preliminary report prepared on a study of antiretroviral therapy (ART) programme conducted in pune. Antiretroviral naive HIV infected patients attending the clinic between December 2005 and April 2008 and followed up till March 31, 2011 were included in the analysis.

The enrolment and follow up of these patients were done as per the national guidelines. Viral load estimations were done in a subset of patients. The study concluded that the first line treatment was effective in patients attending the programme clinic. The adherence level influenced immunological and virological outcomes of patients.

Reference

• Use of first line antiretroviral therapy from a free ART programme clinic in Pune, India v.137(5); May 2013 PMC3734687Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734687

• Black JM,Hawks JH medical surgical nursing 7th ed.elsevier ; Missouri, 2005 vol:2; 2375-99

• Suzzane ,Brenda Suddarth’s B ,textbook of medical surgical nursing 10th ed. Lippincot Williams and Wilkins; vol:1;2012; 1548-76

• National AIDS control organisation, HIV/AIDS and art training for nurses, nurse’s manual 2nd ed; INC,2011: p - 7-146