HIV/AIDS

HIV stands for the human immunodeficiency virus. It is one of a group of viruses known as retroviruses. After getting into the body, the virus kills or damages cells of the body's immune system. The body tries to keep up by making new cells or trying to contain the virus, but eventually the HIV wins out and progressively destroys the body's ability to fight infections and certain cancers. AIDS stands for the acquired immunodeficiency syndrome. It is caused by HIV and occurs when the virus has destroyed so much of the body's defenses that immunecell counts fall to critical levels or certain life-threatening infections or cancers develop.

HIV/AIDS TRANSMISSION

HIV is transmitted when the virus enters the body, usually by injecting infected cells or semen. There are several possible ways in which the virus can enter.

Most commonly, HIV infection is spread by having sex with an infected partner. The virus can enter the body through the lining of the vagina, vulva, penis, rectum,

or mouth during sex. Although intercourse is the primary risk factor, oral sex transmission is also possible. HIV frequently spreads among injection-drug users who share needles or syringes that are contaminated with blood from an infected person. Women can transmit HIV to their babies during pregnancy or birth, when infected maternal cells enter the baby's circulation, or through breastfeeding. HIV can be spread in health-care settings through accidental needle sticks or contact with contaminated fluids. Very rarely, HIV spreads through transfusion of contaminated blood or blood components. All blood products are tested to minimize this risk. If tissues or organs from an infected person are transplanted, the recipient may acquire HIV. Donors are now tested for HIV to minimize this risk. HIV has been spread when organs from an infected person are transplanted into an uninfected recipient. Because donors are tested for HIV routinely in the United States, this does not usually happen. However, a recent incident in Taiwan occurred when the HIV test results for the donor were mistakenly thought to have been negative. People who already have a sexually transmitted infections, such as syphilis,genital herpes, chlamydial infection, human papillomavirus (HPV), gonorrhea, or bacterial vaginosis, are more likely to acquire HIV infection during sex with an infected partner. The virus does not spread through casual contact such as preparing food, sharing towels and bedding, or via swimming pools, telephones, or toilet seats. The virus is also unlikely to be spread by contact with saliva, unless it is contaminated with blood.

HIV/AIDS SIGNS and SYMPTOMS

Many people with HIV do not know they are infected.

Many people do not develop symptoms after they first get infected with HIV. Others have a history of a flu-like illness within several days to weeks after exposure to the virus. Early HIV symptoms also includefever, headache, tiredness, and enlarged lymph nodes in the neck. These symptoms usually disappear on their own within a few weeks. After that, the person feels normal and has no symptoms. This asymptomatic phase often lasts for years. The progression of disease varies widely among individuals. This state may last from a few months to more than 10 years. o During this period, the virus continues to multiply actively and infects and kills the cells of the immune system. o The virus destroys the cells that are the primary infection fighters, a type of white blood cell called CD4 cells. o Even though the person has no symptoms, he or she is contagious and can pass HIV to others through the routes listed above.

AIDS is the later stage of HIV infection, when the body begins losing its ability to fight infections. Once the CD4 cell count falls low enough, an infected person is said to have AIDS. Sometimes, the diagnosis of AIDS is made because the person has unusual infections or cancers that show how weak the immune system is.

The infections that happen with AIDS are called opportunistic infectionsbecause they take advantage of the opportunity to infect a weakened host. The infections include (but are not limited to) o pneumonia caused by Pneumocystis, which causes wheezing; o brain infection with toxoplasmosis which can cause trouble thinking or symptoms that mimic a stroke; o widespread infection with a bacteria called MAC (mycobacterium avium complex) which can cause fever and weight loss; o yeast infection of the swallowing tube (esophagus) which causes pain with swallowing; o widespread diseases with certain fungi like histoplasmosis, which can cause fever, cough, anemia, and other problems. A weakened immune system can also lead to other unusual conditions: o lymphoma in (a form of cancer of the lymphoid tissue) in the brain, which can cause fever and trouble thinking; o a cancer of the soft tissues called Kaposi's sarcoma, which causes brown, reddish, or purple spots that develop on the skin or in the mouth.

HIV/AIDS LABORATORY/DIAGNOSIS

HIV nucleic acid testing (NAT) to detect HIV RNA or DNA, is recommended for establishing the diagnosis of infection in infants born to HIV-1-infected mothers. . Clinicians should use an HIV antibody test with confirmation by Western blot or indirect immunofluorescence assay to establish diagnosis of chronic HIV infection. HIV antibody screening tests include enzyme immunoassays (ELISA/EIA), chemiluminescent immunoassays (CIAs), and rapid tests.

Patients who test negative for HIV antibody at baseline should receive a follow-up HIV antibody test at 3 months. For individuals who test negative at 3 months but continue to engage in high-risk behavior, clinicians should discuss goal-oriented harm-reduction strategies, including referral for risk-reduction counseling services. Repeat testing at least every 3 months should be offered as long as high-risk behavior continues. Clinicians should evaluate the following populations for acute HIV infection, particularly when they present with a febrile, flu-, or mono-like illness that is not otherwise explained:

Those who present for HIV testing Those who report a recent sexual or parenteral exposure with a known HIVinfected partner or a partner of unknown HIV serostatus in the past 2 to 6 weeks Men who report having unsafe sexual practices with other men Those who report needle-sharing Those who present with a newly diagnosed sexually transmitted infection Those who present with aseptic meningitis Pregnant or breastfeeding patients When acute HIV infection is suspected: An HIV serologic screening test should be used in conjunction with a plasma HIV RNA assay; the plasma RNA test should be performed even if the serologic screening test is negative; a fourth-generation HIV antigen/antibody combination test is the preferred serologic screening test if available Detection of HIV RNA or antigen in the absence of HIV antibody should be considered a preliminary positive result; HIV RNA testing from a new specimen should be repeated immediately to confirm the presence of HIV RNA Both serologic and RNA testing should be repeated to exclude a false-positive result when low-level quantitative results (<5,000 copies/mL) from an HIV RNA assay are reported in the absence of serologic evidence of HIV infection

HIV serologic testing should be repeated 2 to 3 weeks after diagnosis by HIV RNA testing to confirm infection. However, clinicians should not wait for HIV serologic confirmatory test results to initiate ART (Antiretroviral therapy) when pregnant women are diagnosed with acute HIV infection by HIV RNA testing. Initiation of ART is strongly recommended for pregnant women Lab test important to HIV HIV PCR (Viral Load) Testing should be performed every three or four months when the patient is stable, except prior to changing medications or when viral activity is changing, it is suggested that the test be done twice as a confirmation that viral activity has in fact changed.

HIV Genotype/Phenotype This testing is extremely important in determining the correct course of treatment., before initial therapy and if there has been treatment failure, as it outlines any resistance to HIV drugs currently available. In 2005, 8 to 10% of newly diagnosed HIV patients were resistant to certain therapies before even beginning. It has been suggested that this testing become standard of care for treatment-nave HIV patients. Dehydroepiandrosterone (DHEA) and Dehydroepiandrosterone-S (DHEA-S) The levels of hormones are extremely important in the management of HIV. These hormone levels must be kept high in order to assist the immune system in fighting the virus. In fact, any T cell activity against HIV (TH1), CD4 requires DHEA for full activation. Since the virus, as noted above, changes frequently, so does the immune system working in fighting the virus. Therefore, these tests are needed in order to monitor the proper dosage of DHEA the patient is required to take and inferentially to determine the increased amount of work the immune system is performing to control viral activity. IGF-1 This test is used to monitor the levels of growth hormones. It is an early indication of wasting syndrome. Estrodial This test monitors the levels of estrogen. Low levels (even in males) may indicate poor immune response to drug therapy or early signs of wasting syndrome. Thyroxine, TSH, Triodothyronine, Thyroxine Free, and T3 Free A high percentage of HIV patients complain of fatigue. Hypothyroidism is a part of the differential diagnosis of fatigue as is anemia. In addition, thyroid abnormalities are found in 10-15% of all patients with HIV/AIDS. The testing utilized would indicate abnormalities and how to treat them. In addition, it becomes even more important as thyroid function is integrally limited to the function of the immune system in fighting the HIV virus. Testosterone This test monitors the levels of testosterone. Low levels may indicate poor immune response to drug therapy and/or early signs of wasting. HHV-6 IT has been well shown that his virus acts as a co-factor for HIV (Ablashi, DNA, 1995). As such any change in activity of HHV-6 has been shown in numerous publications to presage a change in HIV activity. In addition, Conant (10th Int. Aids Congress, 1994) has shown that suppressing Herpes virus activity, when present, reduces the incidence of death in AIDS patients. Sedimentation Rate This test is required to identify other infections frequently occurring with HIV/AIIDS, such as MAC. This test also monitors inflammatory or malignant disease in HIV/AIDS patients and aids in the detection and diagnosis of occult diseases.

IgE In HIV, a patient becomes susceptible to allergies causing T helper cells to become TH2 instead of TH1. TH1 are required to fight the virus and as a result of the patients already overworked immune system, the onset of this change in condition needs to be identified as soon as possible. Once identified, medication can be rendered to cope with the allergies and prevent the increased immune activity associated with allergies. No test is perfect. Tests may be falsely positive or falsely negative. For example, it can take some time for the immune system to produce enough antibodies for the antibody test to turn positive. This time period is commonly referred to as the "testing window period" and may last six weeks to three months following infection. Therefore, if the initial antibody test is negative, a repeat test should be performed three months later. Early testing is crucial, because early treatment for HIV helps people avoid or minimize complications. Furthermore, high-risk behaviors can be avoided, thus preventing the spread of the virus to others.

HIV/AIDS TREATMENT/MEDICATION

Over the past years, several drugs have become available to fight both the HIV infection and its associated infections and cancers. These drugs are called highly active antiretroviral therapy (HAART) and have substantially reduced HIV-related complications and deaths. However, medications do not cure HIV/AIDS. In one case, a patient treated for cancer apparently was cured of HIV through use of a stem cell transplant, but this "stem cell cure" is not recommended for HIV due to the high risk of mortality and uncertain chance of success. Therapy is initiated and individualized under the supervision of a physician who is an expert in the care of HIV-infected patients. A combination of at least three drugs is recommended to suppress the virus from replicating and boost the immune system. The following are the different classes of medications used in treatment.

Reverse transcriptase inhibitors: These drugs inhibit the ability of the virus to make copies of itself. The following are examples: o Nucleoside or nucleotide reverse transcriptase inhibitors (NRTIs). These include medications such as zidovudine(AZT/Retrovir), didanosine (ddI/Videx),zalcitabine (ddC/Hivid), st avudine(d4T/Zerit), lamivudine (3TC/Epivir),abacavir (ABC/Ziagen), emtricitabi ne (FTC/Emtriva), and tenofovir(Viread). o Non-nucleoside reverse transcriptase inhibitors (NNRTIS) are commonly used in combination with NRTIs to help keep the virus from multiplying. Examples of NNRTIs are efavirenz (Sustiva), nevirapine (Viramune),delavirdine (Rescriptor), and etravirine (Intelence). Rilpivirine (Edurant), the newest member of this class of drugs, was approved by the U.S. FDA in May of 2011. o Two complete HIV treatment regimens that combine two NRTIs and one NNRTI in one pill taken once a day are available for convenience. Atripla: a combination of efavirenz, emtricitabine, and tenofovir. Atripla was approved for use by the FDA in 2006. Complera: a combination of rilpivirine, emtricitabine, and tenofovir. This combination pill was approved in August 2011 by the FDA as another firstline treatment for HIV infection in patients who need to start therapy. Protease inhibitors (PIs): These medications interrupt virus replication at a later step in its life cycle, preventing cells from producing new viruses. These include ritonavir (Norvir), a lopinavir and ritonavir combination (Kaletra),saquinavir (Invirase), indinavir sulphate (Crixivan), amprenavir (Agenerase),fosamprenavir (Lexiva), darunavir (Prezista), atazanavir (Reyataz), tipranavir(Aptivus), and nelfinavir (Viracept). Using PIs with NRTIs reduces the chances that the virus will become resistant to medications. Fusion and entry inhibitors are newer agents that keep HIV from entering human cells. Enfuvirtide (Fuzeon/T20) was the first drug in this group. It is given in injectable form like insulin. Another drug called maraviroc (Selzentry) binds to a protein on the surface of the human cell and can be given by mouth. Both drugs are used in combination with other anti-HIV drugs. Integrase inhibitors stop HIV genes from becoming incorporated into the human cell's DNA. This is a newer class of drugs recently approved to help treat those who have developed resistance to the other medications.Raltegravir (Isentress) was the first drug in this class approved by the FDA in 2007. Antiretroviral viral drugs stop viral replication and delay the development of AIDS. However, they also have side effects that can be severe. They include decreased levels of red or white blood cells, inflammation of the pancreas, liver toxicity, rash, gastrointestinal problems, elevated cholesterol level, diabetes, abnormal body-fat distribution, and painful nerve damage. An expert in infectious diseases should be consulted if the patient needs concomitant treatment for diseases such as cancer or hepatitis C.

Pregnant women who are HIV-positive should seek care immediately because HAART therapy reduces the risk of transmitting the virus to the fetus. There are certain drugs, however, that are harmful to the baby. Therefore, seeing a physician to discuss anti-HIV medications is crucial.

NURSING MANAGEMENT
Process of Care 1. Retention of care (seen at least twice annually at least 60 days apart) 2. CD4 cell count measurement (measured at least twice annually) Screening 3. Gonorrhea/chlamydia screening (at least once) 4. Syphilis screening (annually) 5. Injection drug use screening (annually) 6. 7. 8. 9. High-risk sexual behavior screening (annually) Tuberculosis screening (at least once) Hepatitis B screening (at least once) Hepatitis C screening (at least once)

Immunization 10. Influenza immunization (annually) 11. Pneumococcal immunization (at least once) 12. Hepatitis B vaccination first dose received (if appropriate) 13. Hepatitis B vaccination series completed (if appropriate) Prophylactic Therapy 14. PCP* prophylaxis if CD4 cell count <200 cells/l 15. Appropriately prescribed ART** 16. Achieving maximal viral control if prescribed ART 17. Achieving maximal viral control if prescribed ART or treatment plan documentation if maximal viral control not achieved

HIV PREVENTION
Despite significant efforts, there is no effective vaccine against HIV. The only way to prevent infection by the virus is to avoid behaviors that put you at risk, such as sharing needles or having unprotected sex. In this context, unprotected sex means sex without a barrier such as a condom. Because condoms break, even they are not perfect protection. Many people infected with HIV don't have any symptoms. There is no way to know with certainty whether a sexual partner is infected. Here are some prevention strategies:

Abstain from sex. This obviously has limited appeal, but it absolutely protects against HIV transmission by this route. Have sex with a single partner who is uninfected. Mutual monogamy between uninfected partners eliminates the risk of sexual transmission of HIV. Use a condom in other situations. Condoms offer some protection if used properly and consistently. Occasionally, they may break or leak. Only condoms made of latex should be used. Only water-based lubricants should be used with latex condoms. Do not share needles or inject illicit drugs. If you work in a health-care field, follow recommended guidelines for protecting yourself against needle sticks and exposure to contaminated fluids. If you have engaged in risky behaviors, get tested to see if you have HIV. The risk of HIV transmission from a pregnant woman to her baby is significantly reduced if the mother takes medications during pregnancy, labor, and delivery and her baby takes medications for the first six weeks of life. Even shorter courses of treatment are effective, though not as optimal. The key is to get tested for HIV as early as possible in pregnancy. In consultation with their physician, many women opt to avoid breastfeeding to minimize the risk of transmission after the baby is born.

HIV/AIDS PROGNOSIS
There is no cure for HIV infection. Before we had any treatment for the virus, people with AIDS lived only for a couple of years. Fortunately, medications have substantially improved the outlook and survival rates. Prevention efforts have sharply reduced HIV infection in young children and have the potential to sharply limit new infections in other populations.

Medications have extended the average life expectancy, and many people with HIV can expect to live for decades with proper treatment. An increasing number have a normal life expectancy if they adhere carefully to medication regimens. Medications help the immune system recover and fight infections and prevent cancers from occurring. Eventually, the virus may become resistant to the available drugs, and the manifestations of AIDS may develop.

Drugs used to treat HIV and AIDS do not eliminate the infection. It is important for the person to remember that he or she is still contagious even when receiving effective treatment. Intensive research efforts are being focused on developing new and better treatments. Although currently there is no promising vaccine, work continues on this front.

SUBMITTED BY: LEVITA, MA. ROSARIO B. OLIVAREZ COLLEGE GROUP 4