HIV/AIDS

I. Classification
a. Stage 1
i. Confirmed HIV infection
ii. CD4 and T cell count of greater than 500 or > than 29%
iii. No AIDS-defining illness
b. Stage 2
i. Confirmed HIV infection
ii. CD4 and T cell count between 200-499 or between 15-28%
iii. No AIDS-defining illness
c. Stage 3
i. Confirmed HIV infection
ii. CD4 and T cell count of < less 500 or < than 14%
iii. AIDS or defining illness (person with higher CD4 and T-cell counts still meets the criteria)
d. Stage 4
i. Confirmed HIV infection
ii. No information regarding CD4 and T-cell counts
iii. AIDS or defining illness
II. HIV has been found in
a. Blood
b. Semen
c. Vaginal secretions
d. Breast milk
e. Amniotic fluid
f. Urine
g. Feces
h. Saliva
i. Tears
j. CSF
k. Lymph nodes
l. Cervical cells
m. Corneal tissue
n. Brain tissue
 Not transmitted by casual contact, sharing household utensils, towels and linens, toilet facilities, or by insects.
III. Modes of Transmission
a. Sexual
i. More easily transmitted from infected male to uninfected female
ii. Anal sex has the highest risk
iii. The higher a persons viral load the greater the risk for sexual and perinatal transmission
iv. Risk for transmission still exists for people receiving HAART
v. Prevention
1. Use latex or polyurethane condoms rather than natural membrane condoms
2. Store condoms in a cool, dry place
3. Do not use condoms that were in damaged packages, or that show signs of age such as,
brittle, sticky or discolored
4. Put a condom on before making in genital contact
5. Hold the tip of the condom and unroll it onto the erect penis making sure that no air is
trapped. Leave space in the tip to collect semen
6. Use adequate lubrication. Use water based lubricants only. Oil based lubricants can
damage condoms
7. Replace a broken condom immediately. If ejaculation occurs after the condom breaks
there may be some protection in the immediate use of a spermicide
8. After ejaculation, the condom must remain on until the penis is withdrawn
9. Never reuse condoms
b. Parenteral
i. Prevention
1. Clean previously used needles
a. Fill and flush them with clear water
b. Fill with bleach
c. Shake 30-60 sec
2. Carry a small container with this solution
3. Refer to needle Exchange programs
c. Perinatal
i. Prevention
1. Continue or begin antiretroviral therapy asap
IV. Clinical Manifestations
a. Immunologic
i. Low WBC counts
1. CD4/CD8 ratio <2
2. CD4 count < 200
 ii. Hypergammagloulinemia
iii. Opportunistic infections
iv. Lymphadenopathy
v. Fatigue
b. Endocrine
i. Gonadal Dysfunction
1. Low testosterone in men
2. Menstrual irregularities in women
3. Change in libido
4. Decrease in energy and increase in fatigue
ii. Body shape changes
1. Buffalo humps (cervical fat development)
2. Large abdominal fat accumulations
3. Face, arm, legs, have a wasted appearance and show prominent vein patterns from loss of
subcut fat
iii. Adrenal dysfunction
1. Fatigue
2. Weight loss
3. N/V
4. Low BP
5. Electrolyte disturbances
6. Can be life threatening
iv. Type 1 Diabetes
v. Elevated cholesterol and triglycerides
c. Integumentary
i. Dry skin
ii. Poor wound healing
iii. Skin lesions
iv. Night sweats
d. Respiratory
i. Cough
ii. ShOB
e. Gastrointestinal
i. Diarrhea
ii. Weight loss
iii. N/V
f. CNS
i. Confusion
ii. Dementia
iii. Headache
iv. Fever
v. Visual changes
vi. Memory loss
vii. Personality changes
viii. Pain
ix. Seizures
g. Opportunistic infection
i. Protozoal
1. Pneumocystitis jiroveci pneumonia (PCP)
a. Assessment
i. Dyspnea on exertion
ii. Crackles
iii. Tachypnea
iv. Persistent dry cough
v. Fever
vi. Fatigue
vii. Weight loss
b. Interventions
i. Drugs
1. Trimethoprim/sulfamethoxazole
a. Side effects
i. N/V
ii. Hyponatremia
iii. Rashes
iv. Fever
v. Leukopenia
vi. Thrombocytopenia
vii. Hepatitis
2. Pentamidineisethionate
3. Bronchodilators
 4. Dapsone
5. Atovaquone
6. Steroids
2. Toxoplasmosis
a. Assessment
i. Changes in mental status
ii. Neurologic difficulties
iii. Headaches
iv. Fever
v. Difficulties
1. Speech
2. Gait
3. Vision
vi. Seizures
vii. Lethargy
viii. Confusion
b. Interventions
i. Perform comprehensive baseline mental examination
ii.
3. Cryptosporidiosis
a. Assessment
i. Mild diarrhea-Severe wasting with electrolyte imbalance
ii. Unplanned weight loss of > 5lbs
b. Interventions
4. Isosporiasis
5. Microsporidiosis
6. Strongyloidiassi
7. Giardiasis
ii. Fungal
1. Candidiasis
a. Stomatitis
i. Assessment
1. Reports of food tasting “funny”
2. Mouth pain
3. Difficulty swallowing
4. Cottage cheese, yellowish white plaque
5. Inflammation
ii. Diagnosis
1. Endoscopic biopsy and culture
iii. Intervention
1. Drug therapy
a. Ketoconozole (Nizoral)
b. Fluconozoel (Diflucan)
c. Amphotericin B (Fungizone IV)
2. Mouth Care
a. Rinse with sodium bicarbonate with sterile
water or normal saline q.2h
b. Use soft toothbrush
3. Complementary Therapies
a. Lemon Juice
b. Lemongrass infusions
b. Vaginal
i. Assessment
1. Severe pruritus
2. Perineal irritation
3. Thick, white vaginal discharge
2. Cryptococcosis (Debilitating Meningitis)
a. Assessment
i. Fever
ii. Headache
iii. Blurred vision
iv. N/V
v. Nuchal rigidity
vi. Mild confusion
vii. Mental status changes
viii. Seizure
ix. Malaise
3. Histoplasmosis
a. Assessment
i. Dyspnea
 ii. Fever
iii. Weight loss
iv. Enlargement of lymph nodes, spleen, liver
4. Coccidioidomycosis
iii. Bacterial
1. Mycobacterium avium complex infection (MAC)
a. Assessment
i. Fever
ii. Debility
iii. Weight loss
iv. Malaise
v. Swollen lymph nodes
vi. Organ disease
b. Diagnosis
i. Cultures obtained form lymph nodes, bone marrow, and blood
c. Interventions
2. TB
a. Assessment
i. Cough
ii. Dyspnea
iii. Chest pain
iv. Fever
v. Chills
vi. Night sweat
vii. Weight loss
viii. Anorexia
b. Diagnosis
i. PPD
1. Patients with CD4 and T-cell count below 200may not
have a positive TB skin test because of an inability to
mount an immune response to the antigen
ii. Quantiferon-TB Gold
1. Most sensitive
2. Results are ready
iii. Chest X-ray
iv. Acid Fast sputum smear
v. Sputum Culture
c. Interventions
3. Pneumonia
a. Assessment
i. Chest pain
ii. Dyspnea
iii. Productive cough
iv. Fever
4. Nococardiosis
iv. Viral
1. Cytomegalovirus
a. Assessment
i. Fever
ii. Malaise
iii. Weight loss
iv. Fatigue
v. Swollen lymph nodes
vi. Vision impairment
vii. Diarrhea
viii. Bloating
ix. Discomfort
b. Interventions
2. HSV
a. Assessment
i. Numbness or tingling at the site of infection up to 24 hours before
blisters form
ii. Painful lesions
iii. Chronic open areas after blisters rupture
iv. Fever
v. Pain
vi. Bleeding
vii. Lymph node enlargement
viii. Headache
ix. Myalgia
 x. Malaise
b. Interventions
i. Nursing
1. Keep area dry and clean
2. Clean abscess once per shift with normal saline and
allow them to air dry
3. Frequent changes in position (pain)
ii. Drug therapy
1. Analgesics
a. Pain
2. Acyclovir (Zovirax)
3. Valcyclovir (Valtrex)
iii. Comfort
1. Burrow’s solution soaks promotes healing
3. Varicella zoster virus
a. Assessment
i. Pain and burning sensation along sensory nerve tracts
ii. Examine skin for fluid fill blisters
iii. Headaches
iv. Low grade fever
b. Interventions
h. Malignancies
i. Kaposi’s sarcoma
1. Assessment
a. Small, purplish brown raised lesions that are usually not painful or itchy
b. Can be anywhere on the body
c. Assess number, size, location, and whether they are intact
d. Monitor progression
2. Diagnosis
a. Biopsy
b. Histological examination
3. Interventions
a. Nursing
i. Keep open, weeping lesions clean and dressed to reduce the risk of
secondary infection
b. Drug therapies
i. HAART
ii. Interferon-alpha
iii. Zidovudine
iv. Analgesics
1. Pain
c. Procedures
i. Radiation
ii. Chemotherapy
iii. Cryotherapy
iv. Topical retinoids
d. Teaching
i. Make-up, long sleeve shirts, and hats can help maintain a normal
appearance
ii. Non-hodgkins lymphoma
1. Assessment
a. Swollen lymph nodes
b. Weight loss
c. Fever
d. Night sweats
iii. Invasive cervical carcinoma
V. Diagnostic Testing
a. Lymphocyte Counts
i. WBC
ii. CD4
iii. T-cells
b. Antibody Tests
i. ELISA
1. Inexpensive and accurate
2. Procedure
a. Patients serum is mixed with HIV grown in culture
b. If the patient has antibodies to HIV, they bind to the HIV antigens and can be
detected (positive test)
3. False positive
 a. Test can be negative if the test is performed before antibodies are made in
sufficient amounts
b. May occur in pregnant women, women who have children, patients with
malaria, lymphomas and with other conditions
ii. Western Blot
1. Positive results is based on the presence of at least two of the major HIV antigens
iii. Oral testing
1. Same accuracy and provides results quickly
2. Procedure
a. Device is placed against the gum and cheek for 2 min.
b. Fluid is drawn into an absorbable pad
c. Pad is placed into a solution
iv. Home test kits
1. Procedure
a. A drop of blood is placed on a test card with a special code number.
b. The card is mailed to a lab where blood is tested for HIV antibodies.
c. A special telephone number is called and the code is entered
d. Test results are given
c. Viral load testing
i. Quanitative RNA Assay
VI. Analysis
a. Potential for infection
i. Prevention
1. Avoid crowds and other large gatherings of people who might be ill
2. Do not share personal toilet articles
3. If possible bathe daily
4. Clean tooth brush at least weekly
5. Wash hands before eating or drinking, after touching a pet, after shaking hands with
anyone, as soon you come home from an outing, and after using the toilet
6. Avoid eating salads, raw fruits and vegetables, undercooked meat, fish and eggs, and
pepper and paprika
7. Wash dishes between the use with hot, sudsy water, or use a dish washer
8. Do not drink water, milk, juice or other cold liquids that have been standing for longer
than an hour
9. Do not reuse cups and glasses without washing
10. Do not change litter boxes
11. Avoid having turtles and reptiles as pets
12. Do not feed pets raw or uncooked foods
13. Take your temperature at least once a day and whenever you do not feel well
14. Report any of the following signs and symptoms to your physician immediately
a. Temp. Greater than 100F
b. Persistent cough
c. Pus or foul smelling drainage from any open skin areas or normal body
openings
d. Presence of a boil or abscess
e. Take all prescribed medications
f. Do not dig in the garden or work with house plants
g. Wear a condom.
h. Avoid travel to areas of the world with poor sanitation or less-than-adequate
health care facilities
ii. Drug therapy
1. Nucleoside Analog Reverse transcriptase Inhibitors
a. Action
i. Supresses viral DNA synthesis and replication
b. Drugs
i. Zidovudine
ii. Didanosine
iii. Lamivudine
iv. Stavudine
v. Tenofovir
vi. Emtricitadine
vii. Abacavir
2. Non- Nucleoside Analog Reverse transcriptase Inhibitors
a. Action
i. Inhibits reverse transcriptase
b. Drugs
i. Nevirapine
ii. Delavirdine
iii. Efavirenz
iv. Etravirine
 c. Nursing Considerations
i. Many interactions with other drugs
ii. Hypersensitivity reaction
3. Protease inhibitors
a. Action
i. Blocks HIV protease which leaves viral proteins dysfunctional and
viral particles cannot leave the cell to infect other cells
b. Drugs
i. Ritonavir
ii. Indinavir
iii. Saquinavir
iv. Nelfinavir
v. Lopinavir/ritonavir
vi. Atazanavir/ritonavir
vii. Fosamprenavir
viii. Darunavir/ritonavir
ix. Tipranavir
c. Side effects
i. Diarrhea
4. Fusion Inhibitors
a. Action
i. Blocks ability of gp41 to fuse with host cel’s CD4 receptor
b. Drugs
i. Enfuvirtide
c. Nursing Considerations
i. Administered as subcut injection
5. Entry Inhibitors
a. Action
i. Blocks CCR5 receptor on the CD4 T-cells
b. Drugs
i. Maraviroc
6. Integrase Inhibitors
a. Drugs
i. Raltegravir
iii. Immune Enhancements
1. Stem cell transplantations
2. Lymphocyte transfusion
3. Infusion of lymphokienes
iv. Complementary and Alternative therapies
1. Vitamins
2. Shark cartilage
3. Botanical products
b. Inadequate oxygenation
1. Respiratory support
a. Assessment q.8h
2. Comfort
a. Plan care to conserve energy
c. Pain
i. Comfort measures
1. Pressure relieving mattress pads
2. Warm baths
3. Applying cold or heat
4. Use lift sheets
ii. Drug therapy
1. NSAIDS
a. Arthralgia
b. Reduces inflammation without causing drowsiness
2. Pregabalin (lyrica)
a. Relief from muscle and joint pain
3. Tricyclic Antidepressants
a. Amitriptyline (Elavil)
4. Anticonvulsant drugs
a. Gabapentin (neurotnin)
b. Phenytoin (Dilantin)
c. Carbamazepine (Tegretol)
 Often interact with antiretrovirals
 May take several days to weeks before a full effect is seen
5. Opioids
a. Weaker (Mild-moderate)
i. Oxycodone
 ii. Codeine
b. Stronger (moderate-severe)
i. Morphine
ii. Hydromorphone
iii. Fentanyl transdermal
iii. Complementary therapies
1. Guided imagery
2. Progressive relaxation
3. Body talk
4. Biofeedback
d. Inadequate nutrition
i. Nutrition therapy
1. Monitor weight, I/O, and calorie count
2. High calorie and high protein diet
3. Avoid dietary fat
a. Fat intolerance occurs as a result of the disease
4. Small frequent meals
5. Supplemental vitamins
6. Fluids
e. Diarrhea
i. Drug therapy
1. Diphenoxylate hydrochloride (Lomotil)
2. Loperamide (Imodium)
ii. Dietary
1. Less roughage
2. Less fatty, spicy, sweet foods
3. No alcohol or caffeine
4. Eliminate dairy products
5. Smaller more frequent meals
6. Drink fluids
iii. Nursing interventions
1. Assess perineal skin q.8-12h
2. Bedside commode/Bed pan
3. Instruct UAP to report any skin changes
a. Redness
b. Rash
c. Blisters
d. Open areas
f. Reduced skin integrity
i. Caused by
1. KS
2. HSV
VZV
g. Confusion
i. Interventions
1. Assess baseline neurologic status
2. Assess for manifestations of increased intracranial pressure
3. Evaluate for subtle changes in memory, ability to concentrate, affect, and behavior
4. Reorient the confused patient
5. Safety measures
a. Institute seizure precautions
i. Keep side rail up
ii. Have oxygen and suctioning equipment available
ii. Drug therapy
1. Psychotropic drugs
a. Treat ongoing behavioral problems or emotional disorders
2. Antidepressants and anxiolytics
3. Anticonvulsants
h. Reduced self esteem
i. Help express feelings
ii. Identify positive aspects of themselves
iii. Allow for privacy but do not avoid or isolate the patient
iv. Encourage self care, independence, control and decision making by helping them set attainable short
term goals and offering praise when goal is achieved
i. Potential loss of social contact
i. Promote patient interaction
ii. Teach about HIV transmission