Human Immunodeficiency Virus/AIDS

By: Bryan Mae H. Degorio, MAN

Human Immunodeficiency Virus Infection

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Results from 1-2 similar retrovirus (HIV 1 and HIV 2) that destroy CD4 lymphocytes and
impaired cell-mediated immunity thus increasing the risk of infection and cancer.
AIDS (Acquired Immunodeficiency Syndrome)
Is syndrome characterized by immune abnormalities resulting from infection and
destruction of CD4 T-lymphocytes which immunologically compromised the infected
person
It is defined by serious opportunistic infection or cancer or a CD4 count of less than
200/ul.
All patients with HIV with CD4 count of less than 200/ul as well as HIV related conditions
and symptoms

Modes of Transmission
A. Factors Affecting the Transmission of HIV:
Duration and frequency of contact, volume of fluid, virulence and concentration of
organism and the host immune status
The viral load in the blood, semen, vaginal secretions or breast milk of the donor
B. Sexual transmission
Unprotected sexual intercourse with an HIV infected partner is the most common
mode of transmission
Sexual activity provide opportunity for contact with semen, vaginal secretions and
blood which all have lymphocytes that may contain HIV
Examples:
Heterosexual transmission is more prevalent and now the most common
C. Contact with Blood and Blood Products
Exposure to blood through drug using equipments contaminated with HIV
Transfusion of Infected blood and blood products
Puncture wounds:
Needle-stick exposure (0.3-0.4%)
Notes: The risk increases if the exposure involves blood from the patient,
deep puncture wound, needle with a hallow bore, device used for venous and
arterial access
Splash exposure of blood through open lesions but poses lower risk than puncture
wound
D. Perinatal Transmission
Is the most common route of infection to children (25 % of infants born to untreated
HIV-infected women will be born with HIV
It can occur during pregnancy, during delivery or during breastfeeding

Pathophysiology:
Human Immunodeficiency Virus
A RNA virus or known as retrovirus because they replicate in a backward manner (from
RNA to DNA)
It needs a living cell in order to replicate

Human Immunodeficiency Virus

- has gp120 knob that
attaches to the CD4 and
chemokine receptor of the
cell surface
Virus binds to the CD4 as the major receptor
and chemokine receptors (CXCR4 and CCR5)
as co-receptors
Viral RNA enters the Cell and transcribed to single
strand of viral DNA with the assistance of reverse
transcriptase that will later develop into double
strand
Viral DNA enters the
nucleus using enzyme
integrase thus
becoming a permanent
part of the genetic

As result:
a. All daughter cell will
be infected
b. DNA in the genome
will direct the cell to
produce new HIV

The viral RNA is

cut into strands
with the enzyme
protease during
the budding
sequence

HIV replication
occurs at a very
rapid rate

Note:
1. Replication process is prone to error thus associated to mutation making treatment difficult for
HIV
2. The amount of virus in the blood (viral load) is highest in the initial infection and followed by
prolong period wherein the virus in the blood remains low and it starts to elevate at the terminal
stage
3. The virus attack all cell containing CD4 receptor including lymphocytes, monocytes and
astrocytes with predominantly damage and destruction of the CD4 T-cells or known as T-helper
cells or CD4 T-Lymphocytes (because they have more CD4 cells)
4. Normally: the function of the CD4 T-Cells is for immune system to recognize and defend against
infection
5. Damage to this cell causes immune suppression leading to the development of Opportunistic
Diseases
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Stages and Classification of HIV

A. CDC classification of HIV Infection

Clinical Categories
CD4 Cell Categories

A
Asymptomatic, Acute HIV, or PGL

B
C
Symptomatic Conditions,#* not A or C AIDS-Indicator Conditions*

(1) 500 cells/L

A1

B1

C1

(2) 200-499 cells/L

A2

B2

C2

(3) <200 cells/L

A3

B3

C3

People with AIDS-indicator conditions (clinical

Clinical Category C

category C) and those in categories A3 or B3 are

Examples of conditions in adults and adolescents include
considered to have AIDS.
the following:
Clinical Category A

Candidiasis of bronchi, trachea, or lungs;

Includes one or more of the following in an adult or
esophagus
adolescent with

Cervical cancer, invasive

confirmed HIV infection and without conditions in

Coccidioidomycosis, disseminated or
clinical categories
extrapulmonary
B and C:

Cryptococcosis, extrapulmonary

Asymptomatic HIV infection

Cryptosporidiosis, chronic intestinal (exceeding 1

Persistent generalized lymphadenopathy (PGL)

months duration)
Acute (primary) HIV infection with

Cytomegalovirus disease (other than liver, spleen,

accompanying illness or history of acute HIV
or lymph nodes)
infection

Cytomegalovirus retinitis (with loss of vision)

Clinical Category B

Encephalopathy, HIV-related
Examples of conditions in clinical category B include,

Herpes simplex: chronic ulcer(s) (exceeding 1

but are not
months duration); or bronchitis, pneumonitis, or
limited to, the following:
esophagitis

Bacillary angiomatosis

Histoplasmosis, disseminated or extrapulmonary

Candidiasis, oropharyngeal (thrush) or

Isosporiasis, chronic intestinal (exceeding 1

vulvovaginal (persistent, frequent, or poorly
months duration)
responsive to therapy)

Kaposis sarcoma

Cervical dysplasia (moderate or

Lymphoma, Burkitts (or equivalent term);

severe)/cervical carcinoma in situ
immunoblastic (or equivalent term); primary, of

Constitutional symptoms, such as fever

brain
(38.5C) or diarrhea exceeding 1 month in

Mycobacterium avium complex or M. kansasii,

duration
disseminated or extrapulmonary

Hairy leukoplakia, oral

Mycobacterium tuberculosis, any site (pulmonary

Herpes zoster (shingles), involving at least two

or extrapulmonary)
distinct episodes or more than one dermatome

Mycobacterium, other species or unidentified

Idiopathic thrombocytopenic purpura

species, disseminated or extrapulmonary

Listeriosis

Pneumocystis carinii pneumonia

Pelvic inflammatory disease, particularly if

Pneumonia, recurrent
complicated by tuboovarian abscess

Progressive multifocal leukoencephalopathy

Peripheral neuropathy

Salmonella septicemia, recurrent

Toxoplasmosis of brain

Wasting syndrome due to HIV

B. WHO Clinical Staging of HIV/AIDS

Primary HIV Infection
Asymptomatic
Acute retroviral syndrome

Clinical Stage 1
Asymptomatic
Persistent generalized lymphadenopathy

Clinical Stage 2
Moderate unexplained weight loss (<10% of presumed or measured body weight)
Recurrent respiratory infections (sinusitis, tonsillitis, otitis media, and pharyngitis)
Herpes zoster
Angular cheilitis
Recurrent oral ulceration
Papular pruritic eruptions
Seborrheic dermatitis
Fungal nail infections

Clinical Stage 3
Unexplained severe weight loss (>10% of presumed or measured body weight)
Unexplained chronic diarrhea for >1 month
Unexplained persistent fever for >1 month (>37.6C, intermittent or constant)
Persistent oral candidiasis (thrush)
Oral hairy leukoplakia
Pulmonary tuberculosis (current)
Severe presumed bacterial infections (eg, pneumonia, empyema, pyomyositis, bone or joint infection,
meningitis, bacteremia)
Acute necrotizing ulcerative stomatitis, gingivitis, or periodontitis
Unexplained anemia (hemoglobin <8 g/dL)
Neutropenia (neutrophils <500 cells/L)

Chronic thrombocytopenia (platelets <50,000 cells/L)

Clinical Stage 4
HIV wasting syndrome
Pneumocystis pneumonia
Recurrent severe bacterial pneumonia
Chronic herpes simplex infection (orolabial,
genital, or anorectal site for >1 month or
visceral herpes at any site)
Esophageal candidiasis (or candidiasis of
trachea, bronchi, or lungs)
Extrapulmonary tuberculosis
Kaposi sarcoma
Cytomegalovirus infection (retinitis or infection
of other organs)
Central nervous system toxoplasmosis
HIV encephalopathy
Cryptococcosis, extrapulmonary (including
meningitis)
Disseminated
nontuberculosis Mycobacteria infection

Progressive multifocal leukoencephalopathy

Candida of the trachea, bronchi, or lungs
Chronic cryptosporidiosis (with diarrhea)
Chronic isosporiasis
Disseminated mycosis (eg, histoplasmosis,
coccidioidomycosis, penicilliosis)
Recurrent nontyphoidal Salmonella bacteremia
Lymphoma (cerebral or B-cell non-Hodgkin)
Invasive cervical carcinoma
Atypical disseminated leishmaniasis
Symptomatic HIV-associated nephropathy
Symptomatic HIV-associated cardiomyopathy
Reactivation of American trypanosomiasis
(meningoencephalitis or myocarditis)

Clinical Manifestations:

A. Acute infection
Primary HIV infection may be asymptomatic
Seroconversion period- development of HIV-Specific antibodies (HIV antibody test becomes
positive after 3 weeks- 3 months)
Acute retroviral syndrome
Transient non-specific manifestations
Usually begins 1-4 weeks after the infection and usually lasts for 3-14 days
Fever. malaise, rash, arthralgia, generalized lymphadenopathy and sometimes
aseptic meningitis, diarrhea
B. Specific Manifestations
Pulmonary manifestations
Persistent cough with and without sputum production, shortness of breath, chest
pain, fever
From Pneumocystis carinii pneumonia (PCP) (most common), bacterial pneumonia
(community-acquired pneumonia), Mycobacterium tuberculosis, disseminated
Mycobacterium avium complex, cytomegalovirus (CMV), Histoplasma, Kaposi's
sarcoma, Cryptococcus, Legionella, and other pathogens
GI manifestations
Diarrhea, weight loss, anorexia, abdominal cramping, rectal urgency (tenesmus)
From enteric pathogens including Salmonella, Shigella, Campylobacter, Entamoeba
histolytica, C. difficile, CMV, M. avium complex, herpes simplex, Strongyloides,
Giardia, Cryptosporidium, Isospora belli, Chlamydia, and others
Oral manifestations
Appearance of oral lesions, white plaques on oral mucosa, particularly in the posterior
pharynx and angular cheilitis from Candida albicans of mouth and esophagus
Vesicles with ulceration from herpes simplex virus
White, thickened lesions on lateral margins of tongue from hairy leukoplakia
Oral warts due to human papillomavirus and associated gingivitis
Periodontitis progressing to gingival necrosis
Aphthous ulcers of unclear etiology, painful, solitary lesions with raised margins
Central nervous system (CNS) manifestations
Cognitive, motor, and behavioral symptoms (AIDS dementia complex/HIV
encephalopathy)
Demonstrated by mental slowing, impaired memory and concentration, loss of
balance, lower extremity weakness, ataxia, apathy, and social withdrawal
May be caused by CNS toxoplasmosis, cryptococcal meningitis, herpesvirus
infections, CMV encephalitis, progressive multifocal leukoencephalopathy, and CNS
lymphoma.
May also have sensory symptoms (distal symmetric polyneuropathy)demonstrated by
numbness, tingling, and neuropathic pain.
Ocular manifestations
Retinopathy due to CMV retinitis
Visual impairment that progresses to blindness, if untreated

Malignancies
Kaposi's sarcoma (aggressive tumor involving skin, lymph nodes, GI tract, and lungs)
Non-Hodgkin's lymphoma and lymphomas
Cervical carcinoma

Diagnostic Evaluations:
1. HIV Antibody Test
a. Enzyme Immunoassay Test or Enzyme Linked Immunoabsorbent Assay

A serological test used in detecting antibodies for HIV

But it rarely produced a false positive result and therefore should be confirmed
with Western Blot

When the result is negative, the test is reported as negative

If recent risk is found, encourage retesting 3 weeks, 6 weeks and 3 months

b. Western Blot or Immunoflourescent Assay
Used to confirm positive result of the ELISA
c. Nursing Care:
patients who test positive may need ongoing counseling as well as referrals for
social, financial, medical, and psychological support services.
Patients whose test results are seronegative may develop a false sense of
security, possibly resulting in continued high-risk behaviors or feelings that they
are immune to the virus.
They may need ongoing counseling to help them modify high-risk behaviors and
to return for repeated testing. Other patients may experience anxiety regarding
the uncertainty of their status.
2. CD4 Count
It provides marker for immune functioning
As the disease progresses, CD4 count is usually decreasing
Normal: 750 250/l.
3. Viral Loads
Is use the measure the amount of HIV in the blood using the plasma HIV RNA level
High viral loads are usually found in the acute seroconversion and late disease
and also among patients who have infection
Viral result is presented in actual number (ex: 1260 copies/l) or as undetectable
(below 50 copies/l)
Undetectable doesnt mean that the patient is negative HIV

Management of HIV
1. Preventive Education and Reproductive Health Education
Safer sexual practice to prevent the transmission of HIV
Condom should be used during vaginal and anal intercourse
Condoms should be used for oral contact with the penis and dental dam
should be used for oral contact with vagina and rectum
Avoiding sexual practices that might cut or tear the lining of the rectum, penis, or
vagina and avoiding sexual contact with multiple partners or people who are known
to be HIV positive or injection drug users.
Women considering pregnancy need to have adequate information about the risks of
transmitting HIV infection to themselves, their partner, and their future children and
about the benefits of antiretroviral agents in reducing perinatal HIV transmission
Other than abstinence, the condom has been the only method that has proved to
decrease the risk of sexual transmission of HIV infection
female condom is also effective in preventing the transmission of HIV infection and
sexually transmitted diseases (STDs)
Notes:
a. Estrogen in oral contraceptives may increase a womens risk for HIV
infection
b. The intrauterine contraceptive device (IUD) may also increase the risk for
HIV transmission because the devices string may serve as a means to
transmit HIV infection.
2. Post-Exposure Prophylaxis

Is the response to exposure of health care personnel to blood or other body fluids has
been proven to reduce the risk for HIV infection (Worthington, 2001).
The CDC (1998) recommends that all health care providers who have sustained a
significant exposure to HIV be counseled and offered anti-HIV post exposure
prophylaxis, if appropriate.
Ideally, prophylaxis needs to start immediately after exposure; therapy started more
than 72 hours after exposure is thought to offer no benefit.
The recommended course of therapy involves taking the prescribed medications for 4
weeks.
Guidelines:
a. Wash the area with soap and water.
b. Alert your supervisor and initiate the injury-reporting system used in
the setting.
c. Identify the source patient, who may need to be tested for HIV,
hepatitis B, and hepatitis C. (State laws will determine if written
informed consent must be obtained from the source patient prior to his
or her testing.)
d. Report to the employee health services, the emergency department, or
other designated treatment facility.
e. Give consent for baseline testing for HIV, hepatitis B, and hepatitis C.
f. Get post exposure prophylaxis for HIV in accordance with CDC
guidelines. Start the prophylaxis medications within 2 hours after
exposure. Make sure that you are being monitored for symptoms of
toxicity. Practice safer sex until follow-up testing is complete.
g. Follow up with post exposure testing at 6 weeks, 3 months, and 6
months and perhaps 1 year.
h. Document the exposure in detail for your own records as well as for the
employer.
3. Standard Precautions
4. Retroviral Therapy (ART)
They act to prevent HIV replication at four different points along the replication
process.
The standard for ART is to take a minimum of three different drugs from at least two
different drug classifications.
Guidelines for ART:
a. Women should receive optimal ART regardless of pregnancy status
b. Treatment decision should be individualized by the risk of disease progression
indicated by higher viral loads and lower CD4 T-cells count and the patients
desires for therapy
c. Combination ART suppresses HIV replication and limit the potential for retroviral
resistance which is the major factor limiting treatment effect
d. HIV infected person even when viral loads are below detectable level and those
on effective ART should be considered infectious and should avoid behavior
associated with transmission of HIV
Goals of Antiretroviral Therapy
a. Prolong life and improve quality of life.
b. Reduce viral load to as low as possible for as long as possible.
c. Increase the CD4+ count to allow immune reconstitution.
d. Maintain options for future treatment by preventing the development of
treatment-resistant virus.
e. Avoid drug toxicities.
Specific Drug Therapy:
a. Nonnucleoside reverse transcriptase inhibitor
Act by attaching to the reverse transcriptase enzyme, which prevents it
from converting HIV RNA into HIV DNA (Gracia Jones, 2001).
Possible adverse reactions for this group of agents include abnormal
liver function test results, hepatitis, stomatitis, numbness, muscle pain,
drowsiness, changes in dreams, trouble concentrating, severe
psychiatric symptoms in rare cases (severe depression, suicidal
thoughts, angry behavior) (Gracia Jones, 2001). Rare cases of StevensJohnson syndrome have been reported with the use of this class of
medications (Panel on Clinical Practices, 2000, 2001).
Drug resistance develops very easily, which makes adherence
essential.
b. Nucleoside reverse transcriptase inhibitor

Act by becoming part of HIVs DNA and derail its building process. As a
result, the damaged viral DNA cannot take control of the host cells
DNA (Gracia Jones, 2001).
Possible adverse reactions associated with medications that act
through this mechanism include peripheral neuropathy, pancreatitis,
lactic acidosis, bone marrow suppression, neutropenia, anemia,
arthralgia, myopathy, kidney dysfunction, hepatomegaly, liver failure,
vision changes, neuropathy, hypersensitivity reaction, abdominal pain,
fever, chills, sore throat, oral ulcers, dry mouth, muscle and joint pain,
irritability, anxiety, nervousness (Gracia Jones, 2001).
Lactic acidosis with hepatic steatosis (fatty degeneration of the liver) is
a rare but potentially life-threatening toxicity with this classification of
medications (Panel on Clinical Practices, 2000, 2001).
c. Nucleotide reverse transcriptase inhibitor
Inhibit the action of reverse trancriptase
d. Protease inhibitor
Work at a later stage in the HIV replication process by preventing the
protease enzyme from cutting HIV viral proteins into the viral particles
that infect new CD4 T4 cells. As a result, new copies of HIV are
defective and unable to infect new host cells (Gracia Jones, 2001).
Possible adverse reactions include hemolytic anemia, paresthesia,
kidney stones, asymptomatic hyperbilirubinemia, dyspepsia, numbness
(of lips, hands, or feet), altered taste, drowsiness, mood alterations
(Gracia Jones, 2001); in patients with hemophilia, there are possible
increased bleeding episodes (Panel on Clinical Practices, 2000, 2001).
e. Entry Inhibitor
Prevents the binding of HIV cells thus preventing the entry of HIV cells,
thus preventing entry of HIV cells into cells where replication would
occur.
Note:
For specific examples of drugs please read Medical Surgical Nursing
by Lewis pp. 258.
5. Vaccination
Despite several efforts, vaccines for HIV is still elusive
HIV mutation may all not respond to simple vaccine.
Notes:
All HIV patient should be screened for tuberculosis every year with PPD
(purified protein derivatives. An induration of 5 mm is considered positive
Pneumococcal pneumonia all patients should receive Pneumovax and it should
be repeated every 5 to 6 years.
Influenza patients with a CD4+ greater than 100 should receive a flu vaccine
each fall.
Tetanus booster patients with a CD4+ count greater than 200/mm3 should
receive routine booster every 10 years.

Note:
a. Post and Pre-test Counseling Associated with HIV-Antibody Testing (pp. 264)
b. Standard Precaution as applied to HIV prevention (any source is acceptable)
c. HIV manifestation by system (available in the library)