Human Immunodeficiency Disease and Acquired Immunodeficiency Syndrome
Human Immunodeficiency Disease and Acquired Immunodeficiency Syndrome
| DRG Category: | 975 |
| Mean LOS: | 6.2 days |
| Description: | MEDICAL: HIV With Major Related Conditions With CC |
| DRG Category: | 977 |
| Mean LOS: | 4.7 days |
| Description: | MEDICAL: HIV With or Without Other Related Condition |
Human immunodeficiency virus (HIV) is a blood-borne retrovirus transmitted primarily through sexual intercourse, blood transfusions, and mother-to-child transmission during pregnancy and/or breastfeeding. Acquired immunodeficiency syndrome (AIDS) is the final result of an infection with HIV. AIDS is a disease rather than a syndrome, which is a term used to refer to collections of symptoms that do not have an easily identifiable cause. This name was more appropriate in the early years of the AIDS epidemic, when healthcare providers were aware only of the late stages of the disease and did not fully understand its mechanisms. The more current name for the condition is HIV disease, which refers to the pathogen that causes AIDS and encompasses all the phases of the disease, from infection to the deterioration of the immune system. AIDS is still the name that most people use to refer to the immune deficiency caused by HIV.
The Centers for Disease Control and Prevention (CDC) first described AIDS in 1981, and since then, the disease has become one of the most widely publicized and feared diseases of our time. Experts suggest that more than 1 million Americans and 33 million people worldwide are infected with HIV. More than 95% of those people infected are in developing nations.
The early, acute phase in an immunocompetent person occurs with widespread viral production and seeding of lymph tissues. The symptoms are generally nonspecific, such as sore throat, myalgia, fever, weight loss, and fatigue; they occur 3 to 6 weeks after infection and resolve 2 to 4 weeks later. As the disease progresses, people may remain asymptomatic or may develop a persistent generalized lymphadenopathy. In either case, HIV replication occurs primarily in the lymphoid tissues. HIV infection of lymphocytes and other cells that bear specific protein markers leads to lymphopenia and impaired T-cell and B-cell function. When HIV infection becomes advanced, it often is referred to as AIDS, which generally occurs when the CD4 count is below 200/mL. AIDS is characterized by the appearance of opportunistic infections.
Both the CDC and the World Health Organization have classifications for the phases of HIV infection. Table 1 presents a combination of the stages and summary of the associated disorders.
| CLASSIFICATION/CLINICAL STATE | HIV-ASSOCIATED SYMPTOMS | ASSOCIATED DISORDERS AND HIV-ASSOCIATED IMMUNODEFICIENCY |
|---|---|---|
| 1 | Asymptomatic | No or little immunodeficiency: persistent generalized lymphadenopathy |
| 2 | Mild | Mild immunodeficiency: moderate unexplained weight loss, recurrent respiratory tract infections, herpes zoster infections or recurrent oral ulceration, skin eruptions, fungal infections |
| 3 | Advanced | Moderate immunodeficiency: unexplained severe weight loss, unexplained chronic diarrhea and persistent fever, persistent oral candidiasis, pulmonary tuberculosis, severe bacterial infections, acute necrotizing ulcerative stomatitis, gingivitis or periodontitis, unexplained anemia, chronic thrombocytopenia |
| 4 | Severe | Severe immunodeficiency: HIV wasting syndrome, pneumocystis pneumonia (also known as pneumocystosis pneumonia and formerly known as Pneumocystis carinii), recurrent severe bacterial pneumonia, chronic herpes simplex infection, oral candidiasis, extrapulmonary tuberculosis, Kaposi’s sarcoma, cytomegalovirus infection, central nervous system toxoplasmosis, HIV encephalopathy, progressive opportunistic infections, lymphoma, HIV-associated tumors, invasive cervical carcinoma, HIV-associated cardiomyopathy |
Causes
Two HIV strains have been identified: HIV-1 and HIV-2. HIV-1 is the prototype virus and is responsible for most cases of AIDS in the United States. HIV-2 is found chiefly in Africa, appears to be less easily transmitted, and has a longer incubation period. Susceptibility to infection is unclear. The presence of sexually transmitted infections (STIs) with open lesions, such as herpes and syphilis, may increase the patient’s susceptibility to viral entry. People with cytomegalovirus and Epstein-Barr virus infections may also be more susceptible because of an increased number of target cells. Routes of transmission are through sexual contact (male to male, male to female, female to male, and female to female); by blood to blood or transfusion contact (generally blood products given between 1977 and 1985); through the use of needles contaminated by an HIV-infected person; by blood or other HIV-infected fluids coming in contact with open lesions or mucous membranes; and by mother to child during the in utero period, during delivery, or by breastfeeding. The time from the onset of HIV transmission to the development of AIDS varies from a few months to years. The median incubation period is 10 years, but estimates vary with age. Infants and older adults seem to have shorter incubation periods. High-risk behaviors that are linked to HIV infection include unprotected anal and vaginal intercourse, having multiple sex partners, and using nonsterile drug injection equipment.
Genetic considerations
Susceptibility to HIV infection and progression to full-blown AIDS varies among people. Investigators are finding genetic variants that increase or mitigate susceptibility to HIV infection. CCL3L1 is a protein that interacts with the CCR5 coreceptor that is used by HIV to infect cells. Persons with more copies of the gene that codes for CCL3L1 are less likely to contract HIV infection than others of the same ethnicity with fewer copies. Polymorphisms in CCR5 itself also affect viral entry, with one particular deletion in CCR5 preventing viral infection and disease progression. Genetic variants for other coreceptors or coreceptor ligands, such as CCR2, CCL5, CXCL12, CX3CR1, CXCR1, and certain HLA alleles, also affect viral entry and/or progression to AIDS.
Gender, ethnic/racial, and life span considerations
The patterns of HIV-related deaths have changed during the past 10 years. In the late 1990s, HIV was the second-leading cause of death in the United States in men ages 25 to 44 and the third-leading cause of death in women of the same age range. Recent statistics show that in the United States, approximately 15,000 people die from HIV/AIDS a year, with the highest number of deaths occurring in people ages 35 to 54. Blacks/African Americans bear a disproportionate burden of HIV disease compared with other populations. In addition, 64% of women with newly diagnosed HIV disease are black/African American, and many of those women live in the southern parts of the United States.
Individuals can contract HIV at any time during their life span, including infancy. The average time between exposure and diagnosis in adults is from 8 to 10 years, although the incubation period varies among people. In children, the incubation period is approximately 18 months. Children are likely to have a history of repeated bacterial infections, such as middle ear infections and pneumonia. Most of the AIDS cases in children are the result of maternal-child transmission.
The progression of HIV and HIV-related symptoms and response to seropositive status vary in men and women in several ways. Women seek healthcare interventions later than men and are at risk for gynecological complications, such as pelvic inflammatory disease and cervical dysplasia. Approximately 86% of new HIV infections among women in the United States occur through heterosexual contact and 14% through use of injected drugs. Among women in the United States living with AIDS, 60% were infected through heterosexual contact and 40% through use of injected drugs. Of men living with AIDS in the United States, 60% were exposed through male-to-male sexual contact, 20% through the use of injected drugs, 8% through both behaviors, and 8% through heterosexual contact. A pattern is emerging for HIV-infected men who have sex with men (MSM) that suggests that risky sexual behaviors are on the rise in this population. Due to the availability of highly active antiretroviral therapy (HAART), there are several metropolitan areas reporting an increase in the prevalence of seropositive conversion and risky sexual behaviors in men due to confidence in HAART as a management strategy. A second reason suggested for the change is that seropositive MSM are living into older adulthood due to HAART therapy and therefore have an increased number of partners throughout their life span. Efforts to support safe sex behaviors throughout the life span are important in both men and women.
Global health considerations
Approximately 1% of the adult population around the world is infected with HIV, with the large majority of infected people in sub-Saharan Africa. Some areas have shown sharp increases since 2004, including central Asia, Eastern Europe, and South Africa, where in young adult women, HIV infection increased by 500% in less than 10 years. Co-infections with opportunistic organisms are a serious problem in many developing countries. For example, co-infection with HIV and tuberculosis is common because of the immunosuppression that is part of HIV infection.
Assessment
History
Common symptoms include night sweats, lymphadenopathy, fever, weight loss, fatigue, and rash. Gastrointestinal (GI) disturbances such as nausea, vomiting, diarrhea, and anorexia are common. The patient may describe neurological manifestations, including headache, lightheadedness, memory loss, word-finding difficulty, inability to concentrate, and mood swings. Patients may notice gait disturbance; a “stiff” neck and pain; and burning, numbness, and tingling in the extremities. A history of infections such as tuberculosis, herpes, hepatitis B, fungal infections, or STIs is common in the HIV and AIDS population.
Physical examination
Patients with HIV and AIDS are at risk for opportunistic infections that affect all systems and diseases common to their age group (Box 1). Wasting syndrome is common to AIDS patients. Fever may or may not be present. The patient’s skin may have a generalized rash or lesions from herpes or Kaposi’s sarcoma (a metastasizing skin cancer). Ask the patient to walk during the examination to examine the patient’s gait. Note ataxia, motor weakness, gait disturbance, and hemiparesis. Palpate the patient’s lymph nodes to determine if lymphadenopathy is present, particularly in two or more extra-inguinal sites.
Symptoms in Patients with AIDS Requiring Medical Attention- New cough
- Shortness of breath or dyspnea on exertion
- Increased fatigue or malaise
- Fever
- Night sweats
- Headache or stiff neck
- Visual changes: Floaters, blurring, photophobia, changes in visual fields
- Mental status alteration: Change in level of consciousness, loss of memory, forgetfulness, loss of concentration, depression, mood swings
- New onset of diarrhea
- Sudden weight loss
- Increased size of or pain in lymph nodes
- Skin lesions
- Pain
Psychosocial
Diagnosis of HIV is a crisis, and the crisis may exacerbate any underlying psychiatric disorders. A person may be in a state of denial or have anxiety, psychological numbness, depression, or suicidal ideation. Remember that, in this state, people cannot focus and do not hear what healthcare professionals tell them. The patient undergoes a fear of the loss of sex life, contaminating others, rejection, and stigma. Fears about loss of employment, financial independence, and insurance are realities. As the disease progresses, grief over losses, hopelessness, suicidal ideation, and emotional exhaustion may occur. The patient deals with stress over the demands of treatment, embarrassment because of physical symptoms, and loneliness.
Diagnostic highlights
| Test | Normal Result | Abnormality With Condition | Explanation |
|---|---|---|---|
| Enzyme-linked immunosorbent assay (ELISA) and Western blot | Negative for HIV antibodies | Positive for HIV antibodies; 50% of people are positive within 22 days and 95% within 6 wk after HIV transmission | Positive ELISA test is confirmed by a Western blot |
| T-lymphocyte and B-lymphocyte subsets; CD4 counts, CD4 percentages | B cells: 65–4,785/mL; CD4 T cells: 450–1,400/mL; CD4 to CD8 T-cell ratio: 1:2.5 | B-cell and T-cell values decreased. CD4 counts less than 500/mL are generally associated with symptoms; CD4 counts less than 200/mL are associated with severe immune suppression. Any HIV-infected person with a CD4 level less than 200/mL is considered to have AIDS; CD4:CD8 ratio inverts to less than 1:1 (CD4 count may decrease and CD8 count may increase) | HIV infects cells with the CD4 protein marker |
| HIV viral load: polymerase chain reaction | Negative | Detects number of copies/mL; test depending on sensitivity has a lower limit of 20 copies/mL but levels in AIDS can reach 30,000 copies/mL and higher; test correlates with disease progression and response to therapy | Quantitative assay that measures amount of HIV-1 RNA in plasma |
Other Tests: Tests include complete blood count; HIV p24 antigen, viral culture, and indirect fluorescent antibody. The HIV rapid antibody test is a screening test that can be performed with limited training. Results must be confirmed by ELISA and Western blot.
Primary nursing diagnosis
Diagnosis
Risk for infection related to immune deficiencyOutcomes
Immune status; Respiratory status: Gas exchange; Respiratory status: Ventilation; ThermoregulationInterventions
Infection control; Infection protection; Respiratory monitoring; Temperature regulationPlanning and implementation
Collaborative
Much of the collaborative management is based on pharmacologic therapy (see next page). Supportive management consists of treatment of malignancies with chemotherapy and irradiation, treatment of infections as they develop, and the management of discomfort with analgesia. Surgical management may be needed to excise lesions from Kaposi’s sarcoma or to drain abscesses. If the patient becomes short of breath, oxygen is often prescribed to improve gas exchange. Dietary support is important in the treatment of HIV infection and AIDS throughout the progression of the illness.
Pharmacologic highlights
Antiretroviral therapies are grouped into four categories and should always be used in combination. Introduction of HAART is capable of maximally suppressing viral replication. The clinical benefits of HAART are significant and durable. Drugs have important interactions with other medication. Interactions need to be reviewed carefully.
| Medication or Drug Class | Dosage | Description | Rationale |
|---|---|---|---|
| Antiretroviral therapy classifications: Nucleoside analog reverse transcriptase inhibitors | Varies by drug | Nucleoside analog | Decreases HIV replication by incorporation into the strand of DNA, leading to chain termination |
| Antiretroviral therapy classification: Nucleotide reverse transcriptase inhibitors: tenofovir | 300 mg PO daily | Nucleotide analog | Decreases HIV replication by incorporation into the strand of DNA, leading to chain termination; may be effective when virus is resistant to nucleoside reverse transcriptase inhibitors |
| Antiretroviral therapy classification: protease inhibitors | Varies by drug | Protease inhibitor | Blocks the action of the viral protease required for protein processing near the end of the viral cycle |
| Antiretroviral therapy: nonnucleoside reverse transcriptase inhibitors | Varies by drug | Nonnucleoside reverse transcriptase inhibitors | Inhibits HIV by binding noncompetitively to reverse transcriptase |
| Antiretroviral therapy: HIV entry inhibitors (fusion inhibitor) | Varies by drug | New class of antiretroviral agents | Targets different stages of the HIV entry process |
| Antiretroviral therapy: Integrase inhibitor: raltegravir | 400 mg PO daily | New class of antiretroviral agents | Slows HIV replication by blocking the HIV integrase enzyme needed for viral multiplication |
Note: The monthly cost of antiretroviral agents ranges from $400 to $3200 for each medication.
Independent
Nursing interventions are complex because of the many physical, psychological, and social effects that occur from HIV infection and AIDS. During the more acute and severe stages of the illness, focus on maximizing the patient’s health and promoting comfort. Educate the patient and significant others regarding self-care by keeping any lesions and the skin clean and dry. Diarrhea can limit activities and also cause pain, both abdominal and perianal, if any lesions are present. Keep the perianal area clean and assist the patient with cleaning himself or herself immediately. Instruct the patient about the food substances that are GI irritants. Explain that diarrhea can cause dehydration, electrolyte disturbances, and malabsorption; provide the patient with ways to maintain fluid and electrolyte balance. All patients need to be instructed to perform frequent and thorough oral care. Teach patients to avoid toothbrushes. Tell them to clean the teeth, gums, and membranes with a soft gauze pad; to use mouthwashes without alcohol; to lubricate the lips; and to avoid foods that are spicy, acidic, thermally hot, and hard to chew. Also explain the need to seek treatment for Candida and herpes and to use lidocaine (Xylocaine) for discomfort.
Explain the mechanisms for HIV transmission and teach the patient and significant others the precautions regarding transmission by both casual and sexual routes. Discuss safe sex behaviors. Explore mechanisms to assist with the large financial cost of retroviral therapy. Explain that if the patient has spills of blood or secretion, they should be cleaned up with a 1:10 solution of bleach and water to limit the risk of infection to others. Use universal precautions whenever you are exposed to blood, body fluids, or secretions, and teach the patient’s significant others to do the same.
Note that the best outcomes result from early intervention. Many times, the patient’s family members are unaware of her or his bisexual or homosexual orientation, or spouses may be unaware that their partner had high-risk behavior that exposed them to HIV infection. The diagnosis of AIDS may increase the distance between friends and family members. Social isolation often occurs because others avoid the patient out of the fear of being infected. Allow the patient to talk about the diagnosis and isolation.
If the patient has severe immunodeficiency at the end of life, use touch and encourage others to touch, hug, hold hands, and give back rubs to the patient to help fulfill the patient’s need for touch. Encourage the patient’s participation in support groups and use of volunteer “friends.” The patient may experience anger, denial, anxiety, hopelessness, and depression. Ensure that the needed support services are available for home healthcare; make sure the patient has support for meals, financial assistance, and hygienic care.
Evidence-Based Practice and Health Policy
Al-Dakkak, I., Patel, S., McCann, E., Gadkari, A., Prajapati, G., & Maiese, E. M. (2013). The impact of specific HIV treatment-related adverse events on adherence to antiretroviral therapy: A systematic review and meta-analysis. AIDS Care, 25(4), 400–414.
- Adherence to antiretroviral therapies (ARTs) is essential to viral load suppression and prevention of HIV progression and AIDS complications.
- A meta-analysis of 19 studies revealed that patients are less likely to adhere to treatment regimens if they experience treatment-related adverse events, such as gastrointestinal, sensory, and mental health disturbances. In this analysis, investigators found that adverse events in general decreased the odds of adherence by 38% (p = 0.001).
- Fatigue and anxiety were both associated with a 37% decreased odds of adherence (p = 0.016 and p = 0.028, respectively), and taste disturbances, loss of appetite, and nausea were associated with a 51% (p = 0.003), 46% (p = 0.027), and 43% (p < 0.001) decreased odds of adherence, respectively.
Documentation guidelines
- Physical changes: Weight, mental status, vital signs, skin integrity, bowel habits
- Tolerance to activity, fatigue, ability to sleep, ability to manage self-care
- Understanding of safe sex behaviors
- Emotional response, coping, signs of ineffective coping, support from family and friends
- Presence of opportunistic infections, complications of infections, medications, resistance, recurrence
- Requests for management of living with a chronic disease, living with a critical disease, and pertinent information about the patient’s wishes regarding the final stages of life
Discharge and home healthcare guidelines
prevention.
Teach the patient or caregiver universal precautions at home; adequate nutritional strategies; the names and telephone numbers for support organizations; self-assessments daily for temperature elevations; signs of thrush (Candida), herpes, and other opportunistic infections; symptoms of complications such as cough, lesions, and fever; and strategies to limit situations with high infection potential (crowds, people with colds or flu).transmission.
Teach the patient strategies to practice safe sex. Inform the patient that the disease can be transmitted during high-risk sexual practices that expose partners to body fluids. These practices include vaginal and anal intercourse without a condom and/or oral sex without protection. Encourage the patient to use safe sex practices such as hugging, petting, mutual masturbation, and protected anal and vaginal sex. Explore the patient’s knowledge about male and female condom use.Encourage the patient to notify any sexual partners and healthcare providers that she or he has an HIV infection. Explain that the patient should not donate blood, blood products, or organs, tissues, or sperm. If the patient continues to use intravenous drugs, make sure the patient knows never to share needles.
Explain to women of childbearing age that any pregnancy may result in an infant with HIV infection. Explain that HIV may also infect an infant during delivery or during breastfeeding. Encourage the woman to notify her physician as soon as pregnancy occurs to allow preventive treatment to limit the risk to the fetus.