HIV: Stages, Progression, and Long-Term Non-Progressors

HIV

• HIV weakens the immune system by using docking proteins to "hijack" CD4 T-helper cells, forcing them to make copies of the virus.
• Disease progression to AIDS depends on how the virus was contracted, personal health factors, and medical treatment
• Without treatment, HIV advances to its final stage quicker
• Around 1% of people with HIV are long-term non-progressors (LTNPs), staying asymptomatic with normal CD4 count for over a decade, without severe immune system damage.

Stages of HIV

• HIV-1 (Acute seroconversion) includes symptoms like fever, swollen lymph nodes, and rash and appear within a few weeks of infection.
• HIV-2 (Chronic (asymptomatic Stage) occurs when the virus is present and diagnosable, but symptoms may be mild or absent for years with proper treatment. People in this stage are LTNP or PLWH
• HIV-3 (AIDS) occurs when the immune system is severely weakened (CD4 count below 200), making the body vulnerable to infections (opportunistic bacteria).

Risk Factors for HIV

• Risk factors include sexual practices, health history, drug use, blood transfusion, changes in immunity, and health status
• The virus is transmitted through body fluids of infected persons (semen, blood, breastmilk, vaginal secretions)
• It is transmitted through sexual, parenteral, and prenatal routes.
• Needle stick injuries are the leading cause of occupational-related HIV

Diagnosis

• EIA detects antibodies, resulting in positive results and marking the end of the window period from initial contraction.
• Western blot also detects antibodies and can be used to confirm EIA.
• Viral load measures HIV RNA in the plasma
• CD4/CD8 are markers found on lymphocytes; HIV kills CD4+ cells, which results in a significantly impaired the immune system.

HIV Treatment

• Combination Antiretroviral Agent (cART), also called Highly-active Antiretroviral Agent (HAART), inhibits but does not kill the cell
• Using multiple HIV medications from different drug classes prevents the virus from becoming resistant
• Should only one drug be used, the virus can quickly adapt and stop responding to treatment
• To prevent resistance, therapy should is administered with the 90% rule: 9 out of 10 doses should be taken correctly and on time

Nursing Interventions for HIV

• Promote checking HIV status to allow early prevention and treatment.
• PrEP prevents exposure in an uninfected person
• PEP is used for people exposed to infection within 36 hours
• Strict adherence to cART and HAART medication (90% rule)
• Teach ways to prevent transmission
• Report cognition, GI, respiratory and skin changes

Myasthenia Gravis (MG)

• Myasthenia gravis is a rare autoimmune disease that progresses over time.
• The body's immune system mistakenly attacks acetylcholine (Ach) postsynaptic receptors in the muscles which makes it harder for signals to reach the muscles, leading to muscle weakness that gets worse with use but improves with rest
• Muscles around the eyes, face, and throat are usually most affected
• The condition is treatable and can be well-managed with the correct medical care.

Risk Factors for MG

• History of ptosis (drooping eyelid), diplopia (double vision), dysphagia (difficulty chewing or swallowing)
• History of respiratory difficulty and thyroid disease
• Time of peak activity
• History of stress, infection, and weight loss

Causes of MG

• In most patients, this is idiopathic
• Drugs like anticholinergics, abx, beta blockers, lithium, magnesium
• Hyperthyroidism and other thymic disorders
• Exposure to heat, stress, infection, systemic illness

Signs and Symptoms of MG

• Ptosis "Droopy eyes”
• Diplopia "Double Vision"
• Dysphagia - difficulty swallowing
• Dyspnea - difficulty breathing
• Tiredness with slight exertion
• Indicate myasthenic crisis

Diagnostics for MG

• Imaging scans (like a CT or MRI) check for a tumor in the thymus (thymoma), which can be linked to MG.
• Repetitive Nerve Stimulation (RNS) tests how well nerves send signals to muscles and helps diagnose generalized MG.
• The Tensilon test (using edrophonium chloride) includes giving a quick-acting drug to see if muscle strength temporarily improves, which can confirm MG, but this is no longer used in the US

Treatment for MG

• Pyridostigmine is used for symptomatic treatment and maintenance, stimulates production of secretions. Mainstay of MG treatment.
• Neostigmine can be used if pyridostigmine is not available
• Corticosteroid (oral prednisone) is used as the lowest effective dose for a long-term basis to prevent swelling. (start with a low dose and gradual escalation to avoid the paradoxical steroid-induced weakness)
• IVIg is for severe, acute exacerbation

Nursing Interventions for MG

• Aim to prevent myasthenic crisis
• Monitor for respiratory compromise

Patient education for MG

• Teach factors that cause increased risk of exacerbation: Avoid 4 Ss (Stress, Sun, Sickness/Sepsis, Smoking)
• Promote medication compliance (take pyridostigmine before meals)
• Promote physical mobility and lifestyle alterations

Multiple Sclerosis (MS)

• Multiple sclerosis (MS) is a long-term disease that causes inflammation and damage to the protective covering of nerves (myelin sheath)

Risk Factors for MS

• Family history of MS or autoimmune disease
• History of bowel and bladder dysfunction
• History of vision, mobility, and sensory perception
• The causes are mostly idiopathic but may be associated with genetics and environmental factors

Signs and Symptoms of MS

• Stiffness of the extremities, especially the legs
• Fatigue
• Pain
• Ataxia
• Changes in cognition and speech indicate upper brain demyelination
• Bladder (urinary retention) and bowel dysfunctions indicate spinal cord demyelination

Diagnostics of MS

• A brain MRI showing the presence of plaques in the brain confirms the diagnosis

Treatment for MS

• Interferon interferes with the body attacking itself
• Fingolimod was the first oral medication approved for MS

Nursing Interventions for MS

• Prevention of Exacerbation
• Pain management
• Promote patient safety
• Promote independence

Nursing Considerations for MS

• Balance exercise with rest
• Avoid 4 S's (Stress, Sun (extreme heat), Sickness/Sepsis, Smoking)

Systemic Lupus Erythematosus (SLE)

• Lupus is a long-term autoimmune disease that causes inflammation throughout the body.
• The immune system mistakenly attacks healthy tissues, leading to swelling and damage in different organs, including the skin, joints, kidneys, and heart
• Lupus develops slowly and takes years to diagnose
• The disease can reduce blood flow to organs or directly damage them, which may lead to serious complications over time.

Risk Factors for SLE

• Personal or family history of autoimmune disease
• Previous and current medications
• Physical changes observed over the past five years
• Presence and quality of pain without Injury
• Causes include Idiopathic, Genetics, hormonal, and environmental factors

Signs and Symptoms of SLE

• Fever, painful swollen joints, and rash
• Butterfly rash on the face
• Fatigue

Diagnostics of SLE

• Decreased WBC
• Creatinine over 1.3

Treatment for SLE

• Anti-inflammatory and immunosuppressive agents, like hydroxychloroquine
• Corticosteroids, like prednisone

Nursing Interventions for SLE

• Manage symptoms and complications
• Prevent Exacerbations
• Manage drug adverse effects
• Avoid 4 S's (Sun, smoking, stress, sepsis)