Learning Outcome

• Describe the clinical picture, laboratory findings, and management of HIV disease.
• Outline the importance of enhancing care coordination among the multidisciplinary team to ensure proper evaluation and management of HIV disease.

Introduction

The human immunodeficiency virus (HIV) is an enveloped retrovirus that contains 2 copies of a single-stranded RNA genome. It causes the acquired immunodeficiency syndrome (AIDS) that is the last stage of HIV disease. Two to four weeks after HIV enters the body, the patient may complain of symptoms of primary infection.[1] After that, a long chronic HIV infection occurs, which can last for decades.[2] AIDS is mainly characterized by opportunistic infections and tumors, which are usually fatal without treatment.[3][4]

Nursing Diagnosis

• Anxiety-related to diagnosis and fear
• Deficient knowledge about the HIV disease
• Imbalanced nutrition less than body requirements
• The risk for Deficient fluid volume related to decreased fluid intakeand diarrhea
• The risk for infection related to altered immune protection

Causes

The cause of this infectious disease is the human immunodeficiency virus (HIV) which can be classified into HIV-1 and HIV-2. HIV-1 is more globally expanded and virulent. It originated in Central Africa. HIV-2 is much less virulent and comes from West Africa. Both viruses are related antigenically to immunodeficiency viruses found primarily in primates.

Risk Factors

The estimated number of people living with HIV/AIDS is 36.7 million worldwide as of 2016. In the United States, a critical risk factor for HIV propagation among young people is the use of drugs before having sex including marijuana, alkyl nitrites ("poppers"), cocaine, and Ecstasy.[3] Other risk factors associated with a risk of acquiring HIV infection include men who have sex with men, unsafe sexual practices, the use of intravenous drugs, and unsafe blood transfusions or blood products.

Assessment

Primary infection occurs 4 to 10 weeks after unprotected sexual practice with an HIV-infected person. The primary HIV infection is characterized by the following symptoms:

• Fever
• Joint pain
• Skin rash
• Sore throat
• Swollen lymph nodes[1]

Chronic HIV infection is characterized by the following signs and symptoms and can last for decades:

• Fever
• Fatigue
• Diarrhea
• Weight loss
• Oral thrush
• Shingles
• Persistent generalized lymphadenopathy[2]

Evaluation

HIV infection can remain undetected for years. However, they are several tests to diagnose it:[5][6]

• Fourth-generation assay: Detect specific antibodies and P24 HIV antigens
• Rapid test: Use blood or saliva to detect an HIV infection within hours
• Polymerase-chain-reaction: Can be a diagnostic or a confirmative test for HIV infection and can provide information about the viral load

When there is a possibility of acute or early HIV infection, the most sensitive screening immunoassay available (ideally, a combination antigen/antibody immunoassay) in addition to an HIV virologic (viral load) test is performed. RT-PCR based viral load test is favored. A positive HIV virologic test generally indicates HIV infection.

Detectable viremia does not develop until approximately 10 to 15 days after infection, and even the most sensitive immunoassays do not give a positive result until five days after that. Therefore, initial negative immunoassay and virologic tests can be misleading, and if the clinical suspicion for recent HIV exposure is high, repeat testing is done one to two weeks later.

Medical Management

Medical management focuses on the elimination of opportunistic infections and relieving pain:

• Treatment and prevention of opportunistic infections: Inform the health practitioner about health status, significant lab reports, and prescribe antibiotics as prescribed by the doctor.
• Antidiarrheal therapy: Therapy with octreotide acetate, a synthetic analog of somatostatin, for the management of severe chronic diarrhea.
• Antidepressant therapy: Monitor patients' sleep/wake cycle, any changes in appetite or concentrations and get help from psychiatrists if needed.
• Nutrition therapy: For all patients with unexplained weight loss, calorie counts should be obtained, and oral supplements and appetite stimulants should be discussed with the primary physician.
• Pain therapy: Administer NSAIDS or opioids as needed by the patient, in recommended dosages.

Nursing Management

• Promote skin integrity: Avoid scratching, use nonabrasive non-drying soaps, and apply moisturizers
• Promote regular oral care
• Promote regular bowel patterns
• Prevent infection: Monitor for signs of infection and laboratory test results that indicate infection.
• Improve activity: Assist in planning daily routines that maintain activity
• Maintain thought processes: Encourage ongoing family and friend interaction
• Maintain airway clearance: Deep breathing, coughing, postural drainage, percussion, and vibration every 2 hours
• Relieve pain: Use soft cushions and foam pads; administer pain medications as prescribed
• Maintain nutritional status: Eat foods that are easy to swallow while avoiding rough, sticky, and spicy foods

When To Seek Help

• High fever
• Signs of dehydration or malnutrition
• Unstable or changing vital signs
• Concerns over failure to take medications prescribed
• Increasing depression

Outcome Identification

Outcome goals for a patient with HIV/AIDS may include:

• Avoid infection
• Maintenance of skin integrity
• Regular bowel pattern
• Increase comfort
• Improve activity
• Improve thought processes
• Provide information about the disease process
• Maintain airway clearance
• Maintain nutritional status
• Maintain socialization
• Maintain homeostasis
• Promote comfort
• Support psychosocial adjustment

Monitoring

Monitor for side effects of medication. The most common side effects include nausea, vomiting, diarrhea, fever, loss of appetite, hair loss, cough, headache, stomach pains, tiredness, runny nose, insomnia (difficulty sleeping), joint pain, rash, dizziness, muscle pain, and hypersensitivity reaction. Liver toxicity is common to all treatment regimes and should be monitored by regular bloodwork including AST/ALT levels.

Coordination of Care

The management of an HIV-positive patient is complex, and it should be carried out by an interprofessional, health care team that includes nurses, a social worker, a family doctor, an internal medicine specialist, and an infectious disease specialist. If an opportunistic infection or a mass develops, the patient should be evaluated by an oncologist and/or surgeon. Psychological support must be provided once the diagnosis of HIV is made.

Health Teaching and Health Promotion

Principal facts for HIV prevention are patient education which includes the following:

• Inform all sexual partners if the individual is HIV positive.
• Use a clean needle to inject drugs and dispose of it. It is imperative that one should do not share it with anybody.
• Male circumcision reduces the likelihood of HIV infection. Discuss it with the primary care provider.  
• Use a clean condom at all times when having sexual intercourse. Preferably use a condom that contains a water-based lubricant, which is more protective.
• The HIV-positive female must be treated during pregnancy.
• Use emtricitabine/tenofovir disoproxil to reduce the risk of a sexually transmitted HIV infection. It must be taken every day, and the individual can still be involved in safe sex practices. It does not prevent other sexually transmitted diseases like syphilis.

Discharge Planning

Discharge planning includes written instructions on medication regime and adverse reactions to report. Patients who are not independent in activities of daily living may be referred to home care services for assistance with care. Physical Therapy and Occupational Therapy can be effective to increase strength and endurance. Patients often experience weakness and fatigue, requiring monitoring for safety. Including family and support, members to assist the patient's transition home is crucial to maintaining compliance with care. The patient should also be referred to as a social worker to ensure resources in the home are adequate for care. Community resources may also be considered for assistance with financial support to ensure the patient can pay for medications. It is important to remember that the person is "Living with HIV", and that the plan of care should include resuming activities of daily living. Patient teaching during the discharge process will include methods for healthy living, prevention of complications, and avoidance of transmission.