Nursing Care of Patients with HIV and AIDS PDF

Nursing Care of Patients with HIV and AIDS Chapter 20 History of HIV Epidemic was first reported in June 1981 The first antiretroviral drug (ARV) for HIV was introduced in 1987 Highly active antiretroviral therapy (HAART) was introduced in 1996 AKA Antiretroviral therap...

Nursing Care of Patients with HIV and AIDS Chapter 20 History of HIV Epidemic was first reported in June 1981 The first antiretroviral drug (ARV) for HIV was introduced in 1987 Highly active antiretroviral therapy (HAART) was introduced in 1996 AKA Antiretroviral therapy (ART) Combination of at least two ARV medications with different mechanisms of action At the end of 2018, there were 1.2 million people infected and 39,968 new cases reported that year HIV Human immunodeficiency virus Two strains HIV-1 – most common, global HIV-2 – found in small areas in West Africa Retrovirus (RNA makeup) attracted to CD4 receptors on lymphocytes and macrophages and destroys them CD4 T lymphocytes coordinate all immune functions, so destruction leads to progressive destruction of the immune response 7 Steps of the HIV Life Cycle 1. BINDING - Binding (attachment) to the CD4 receptor of the host cell 2. FUSION - Fusion of the HIV envelope/membrane and host cell membrane 3. REVERSE TRANSCRIPTION - HIV capsid (encloses genetic material) is released into host cell, and reverse transcriptase converts RNA to HIV DNA, which enters the host cell’s nucleus 4. INTEGRATION - HIV releases integrase which incorporates HIV DNA into host cell DNA 5. REPLICATION - HIV uses the host cell and replicates long chains of HIV proteins to build more HIV 6. ASSEMBLY - HIV RNA and HIV proteins are packaged in a viral envelope 7. BUDDING - Immature noninfectious HIV buds from the host cell and releases protease to cut chains into shorter functional forms, forming mature infectious HIV Pathophysiology (continued) HIV can persist in a latent or inactive state for many years Can lie dormant in small cells called viral reservoirs No cure, but controlled with lifelong antiviral treatment Ongoing research for cure, possible vaccine Antiretroviral medications Stop HIV in different life cycle stages 1. Binding – cellular chemokine receptor type 5 (CCR5) antagonists drugs block HIV attachment 2. Fusion – fusion inhibitor drugs 3. Reverse Transcription – nonnucleoside reverse transcriptase inhibitors (NNRTIs) and nucleoside reverse transcriptase inhibitors (NRTIs) 4. Integration – integrase inhibitors 7. Budding – Protease inhibitors Progression of HIV Infection Initial infection is usually followed by relatively symptom- free period called the clinical latency stage, while replication occurs CD4 counts begin to drop Symptomatic stage begins Period from infection to symptomatic stage varies, average 8-12 years Early symptoms relate to weakened immune system When CD4 counts drop below 200, certain opportunistic infections or cancers develop, a diagnosis of AIDs is given Box 20.1, p 298 AIDS Acquired immunodeficiency syndrome The final stage of an HIV infection Can happen at any point during an HIV infection Most people with HIV who are diagnosed early and receive treatment do NOT develop AIDS HIV positive ≠ AIDS Transmission Person to person through certain body fluids Blood, semen, preseminal fluid, vaginal secretions, rectal fluids, breast milk Can be transmitted within 2-4 weeks of initial infection and then throughout all stages of HIV and AIDs if untreated Chain of infection – portal of entry Tear in mucous membrane, nonintact skin, injection into bloodstream via needle, sexual contact NOT through hugging, closed-mouth kissing, shaking hands, sharing things like towels or bathroom fixtures (household transmission is very rare) NOT by air, water, food, or insects Cannot live long outside of the body Prevention Education about mode of transmission Pre-exposure prophylaxis (PrEP) with an ARV For those at high risk of contracting 99% effective Daily pill Routine testing – know your status Ages 15-65, pregnant women, sexual assault victims Post test counseling for positive patients for education and treatment Undetectable tests > 6 months = cannot transmit to others Education about safe sex Abstinence, limiting sexual partners, condoms Law requires individuals to inform sexual partners of HIV infection Prevention (continued) Parenteral transmission via injection Avoid injecting drugs or use clean supplies and safe technique Never share or reuse needles Pharmacies participate in syringe exchange programs Parenteral transmission via transfusion Blood products are tested and screened, very low chance that donated blood is infected but has not et had time to develop antibodies that can be detected with testing Autologous transfusions Perinatal transmission Routine testing of pregnant women and again in 3 rd trimester if high risk Prevention – Health Care Workers Occupational transmission is rare Standard precautions Hand hygiene Safety devices on needles, never recap needles If exposed, wash with soap and water and seek emergency care Prophylactic treatment with ARVs HIV signs and symptoms May be asymptomatic initially Stage 1 - Acute retroviral syndrome - Fatigue, headache, fever, enlarged lymph nodes, diarrhea, sore throat Stage 2 - Chronic HIV infection – asymptomatic if treated shortness of breath, fever, weight loss, fatigue, night sweats, diarrhea, peripheral neuropathy, seizures, dementia Stage 3 - AIDS – opportunistic infections or cancers Advanced stage - Increased weakness, pain, weight loss and wasting among other symptoms Complications Fewer complications are seen than in the past thanks to ART AIDS Wasting Syndrome Involuntary loss of more than 10% of baseline body weight plus chronic weakness, fever, or diarrhea for more than 30 days Malnourished Encourage protein, supplemental vitamins HIV-associated Neurocognitive Disorder Infection in brain or CNS Memory impairment, personality changes, hallucinations, leg weakness, loss of balance, slower responses Complications (continued) Cancer Mutated cells are not being destroyed by immune system Opportunistic infections Take advantage of weakened immune system (“opportunity”) Fungal Candida albicans Pneumocystis pneumonia Viral Cytomegalovirus (CMV) Bacterial Mycobacterium avium complex (MAC) Tuberculosis (TB) Diagnosis Finger stick Oral swab Serum Urine (rare) In health care facility or at home test kits Antigen can be detected within 2 weeks of exposure Antibodies form within 3 weeks to 3 months Lab testing Antigen and antibody testing CBC (WBC, Hgb, Plt) CD4 T lymphocyte counts 332-1642 cells/mm3 is normal Will drop with HIV infection ART causes increase Viral load testing, Quantitative RNA Assay Amount of HIV RNA in plasma Risk of progression and response to ART Goal of ART is to obtain undetectable viral load Genotyping Resistance to available ARV medications Screen for concurrent STIs, Hepatitis Enzyme immunoassay testing (EIA) to determine presence of HIV for initial diagnosis Western blot assay confirms diagnosis/seropositivity when the EIA is positive Treatment All patients, regardless of CD4 count, should be treated with ART Prophylactic treatment for certain opportunistic infections is also recommended if available Antiretroviral medications (ARV) inhibit the reproduction of HIV but do not kill it Classes act on different parts of the HIV pathophysiology When used in combination, it is referred to as Antiretroviral Therapy (ART) At least 3 medications in at least 2 different phases of the life cycle Most achieve undetectable viral load within 6 months Undetectable for > 6 months prevents transmission “undetectable = untransmissible” Medication adherence Medication resistance can occur if not taken as directed Resistant strains of HIV can be transmitted Promoting adherence is important – educate patients! If ART is not taken correctly, HIV can reemerge and multiply and become detectable again Encourage patients to report side effects – regimen can be changed to increase adherence Nursing implications Nonjudgmental approach, empathy, and psychosocial support Maintain confidentiality /HIPAA Infection prevention Table 20.5 Education about transmission, prevention, safety, and treatments Maintain nutrition and weight Patient Education Wash dishes in hot soapy water to destroy bacteria Soak sponges used for cleaning in bleach Clean up spills with bleach solution Avoid things that carry risk of toxoplasmosis (ex. Changing litter boxes) Wash with antimicrobial cleansers twice daily Monitor temperature daily to detect early signs of fever/infections