Posted in Med Surg

HIV and AIDS Overview

Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) are two conditions along the same spectrum. HIV is the virus that destroys CD4+ cells, and AIDS is the condition that results when the immune system is severely impaired. So, while everyone who develops AIDS has HIV, not everyone who has HIV will progress into having AIDS.

In HIV, an RNA retrovirus destroys CD4+ cells, also known as “helper T cells.” These cells play a key role in adaptive immunity by activating the other immune cells:

  • B cells – these cells produce antigen-specific immunoglobulin (Ig), also known as antibodies
  • Cytotoxic T cells – also known as CD8+ cells, these killer cells fight viruses, bacteria and malignant cells
  • Macrophages – these cells detect and destroy bacteria and other pathogens via phagocytosis
  • NK cells – “natural killer” cells, mainly attack viral pathogens as well as cancer cells

Over time, HIV destroys CD4+ cells faster than they can be produced, leaving the individual highly susceptible to both infection and cancer. Common opportunistic infections in HIV are tuberculosis, candidiasis, pneumocystis pneumonia (PCP), and Kaposi’s sarcoma. Individuals can also develop cancers, including those that originate from lymph cell tissue such as lymphoma. 

Fortunately, advances in treatment have made complications from HIV less common and less severe. However, they can still occur due to individuals not knowing they are HIV positive, not receiving treatment, or in those for whom treatment is ineffective. 

When does HIV become AIDS?

The key complication of HIV is AIDS, which is present when the CD4+ count drops below 200 cells per cubic millimeter OR the patient has one or more opportunistic infections known as “AIDS-defining illnesses.” These include, but are not limited to: 

  • Invasive cervical cancer
  • Mycobacterium tuberculosis
  • HIV-related encephalopathy
  • Esophageal candidiasis
  • Histoplasmosis
  • Chronic intestinal cryptosporidiosis
  • Pneumocystis jirovecii pneumonia
  • Cytomegalovirus retinitis with loss of vision
  • Kaposi sarcoma
  • Wasting syndrome – weight loss greater than or equal to 10% of their body weight with concurrent diarrhea, weakness or fever for more than 30 days

The average onset of AIDS is about 10 years after infection with untreated HIV. However, early detection and lifelong treatment can greatly increase the length and quality of life for these individuals. 

Let’s go through HIV and AIDS using the Straight A Nursing LATTE method.

L: How does the patient LOOK? 

In this component of the LATTE method, we look at the patient’s signs and symptoms. It’s important to note that the progression of HIV and AIDS is unique from one person to the next and that many people live long and uncomplicated lives with proper HIV treatment. These individuals will likely have no symptoms whatsoever.

Untreated HIV will produce symptoms as the disease progresses. 

  • Within 2-4 weeks of infection, most individuals will have flu-like symptoms such as fever, swollen lymph nodes, sore throat, nausea, body aches, headache, fatigue and rash.
  • After the initial acute infection, HIV becomes a more chronic disease where people can go nearly ten years before untreated HIV progresses to AIDS.  
  • As the CD4+ counts drop and the viral load of HIV increases, the symptoms will get more severe and opportunistic infections will occur. Patients at this stage often complain of symptoms such as night sweats, chronic diarrhea, persistent fever, and severe fatigue. 
  • White patches on the tongue (oral hairy leukoplakia) are triggered by the Epstein-Barr virus. Oral thrush and mouth ulcers are also common.
  • Kaposi’s sarcoma is a common opportunistic infection that looks like purple-pink spots on the skin
  • The patient may complain of abdominal cramps and diarrhea, which is associated with parasitic infection (Cryptosporidium and Cystoisosporiasis).
  • Reduced visual acuity due to cytomegalovirus retinitis.
  • Encephalopathy and progressive multifocal leukoencephalopathy can cause alterations in LOC and abnormal neurological function such as confusion, paralysis, difficulty speaking, and blindness.
  • Fever blisters around the mouth, genitals or anus are due to herpes simplex virus, another opportunistic infection.
  • A patient with a respiratory infection will likely show signs of respiratory compromise.
  • Many patients with HIV will be of low body weight and possibly also complain of a lack of appetite.

A: How do you ASSESS the patient? 

  • Assessments for a patient with HIV will focus on watching for opportunistic infections. This can include: 
    • A full set of VS
    • A thorough skin assessment to identify conditions such as Kaposi’s sarcoma, candidiasis, and fever blisters
    • Weigh the patient, assessing for drastic and unexplained weight loss or lack of appetite
    • Listen to lungs
    • Asses bowel habits
    • Assess for dehydration secondary to diarrhea
  • You also want to assess the patient’s understanding of their medication regimen and practices for preventing the spread of HIV

T: What TESTS are likely to be ordered?

HIV tests –  The CDC recommends at least one HIV screening for everyone age 13-64, as well as all pregnant women. Those that are considered higher risk should be screened more often, ranging from yearly to every three to six months. The test utilizes blood or saliva and can detect HIV at varying times after exposure. For example, an antigen/antibody test utilizing venous blood can usually detect the virus 18 to 45 days after exposure, while other tests take 23 to 90 days to detect the virus after an exposure. Testing too soon after the exposure to HIV can lead to a false negative result.

Monitoring a confirmed infection – Once the patient has been diagnosed with HIV infection, it is important their CD4+ levels and viral load be closely monitored. A normal CD4+ level is approximately  500 to 1500 cells per cubic millimeter, and recall the criteria for AIDS is less than 200 cells per cubic millimeter (mm3).

The viral load measures how much HIV is in the system. The patient will get a test done at diagnosis to determine the baseline, and then future tests are compared against this baseline measurement. The goal in HIV treatment is reduction in viral load, and in some cases, medication can get it down to undetectable levels. 

Other lab tests – These include CBC to monitor for anemia and infection. LFTs will be done to assess the medication’s impact on liver function. Specific tests, such as sputum cultures, may be conducted based on the presence or suspicion of an opportunistic infection.

Resistance testing – If an individual develops resistance to HIV medications, the virus will be able to replicate and can lead to progression of disease. A drug resistance test called TrueGeneTM can be used to determine if the individual with HIV has a mutated form of the virus that is not responsive to antiretroviral therapy (ART). 

Chest x-rays – If the patient is suspected to have respiratory involvement, the MD will likely order a chest x-ray or possibly a chest CT.

Biopsies – Some patients with untreated or poorly controlled HIV develop cancer, so biopsies may be ordered to determine type and stage of cancer. 

T: What TREATMENTS will be provided?

  • Prophylactic medication – PrEP (pre-exposure prophylaxis) is for those individuals who are HIV negative and high risk. Truvada and Descovy are both taken once per day and can reduce the risk of getting HIV from sex by approximately 99%, and reduce the risk of getting HIV from injection drug use by approximately 74%.
  • Post-exposure prophylaxis – For individuals who have been exposed to HIV, post-exposure prophylaxis (PEP) is utilized to reduce the chance of that individual becoming HIV positive. PEP is only effective when taken within 72 hours of exposure and consists of a combination of 2-3 medications taken for a period of 28 days. Note that it is not 100% effective.
  • Antiretroviral therapy (ART) – ART is a combination drug regimen utilized to suppress the virus, maintain CD4+ levels, and prevent opportunistic infections. In some patients, these regimens can even get the virus down to undetectable levels. The specific regimen utilized will vary from person to person but will generally consist of three medications from at least two different drug classes. Click here for a list of FDA-Approved HIV medications.
  • A case management consult can help the patient access low cost or free medication, as these therapies can be quite expensive.

E: How do you EDUCATE the patient with HIV or AIDS?

  • Teach patients how HIV is transmitted (through blood and bodily fluids) and help them identify high-risk behaviors that can lead to transmission. 
  • If the individual takes ART and maintains an undetectable viral load, teach them they have essentially no risk of transmitting HIV to others. They should continue to have their viral load assessed to ensure the safest possible practices. 
  • If the individual uses injection drugs, teach them about the importance of using clean needles and about any available needle exchange programs in your area. 
  • Ensure the patient understands how to take PrEP, PEP or ART medications.
  • Teach the patient the signs of infection to watch for and to report significant weight loss.
  • Teach the patient the importance of maintaining healthy lifestyle habits such as avoiding smoking and alcohol, exercising, and eating a well-balanced diet. 
  • Teach patients with AIDS (with or without opportunistic infection) the importance of infection prevention. In the clinical setting, these patients will be in “reverse isolation” where PPE is utilized to prevent visitors and healthcare workers from spreading infection to the immunocompromised patient. The patient should also receive education on key infection prevention measures such as avoiding raw fruits and vegetables, eating only cooked foods, drinking only bottled water, and practicing good hand hygiene. You should also explain to the patient why fresh flowers are not allowed in the room, as they are a ripe environment for bacteria.

I hope this general overview of HIV and AIDS helps you understand how to care for these patients in clinicals and on your exams. As always, defer to your facility and school’s protocols and procedures. 

To get this information in audio format, click here or subscribe to the Straight A Nursing podcast and look for Episode 204.

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