HIV/AIDS INFECTION

1. HIV/AIDs infection

2. Margret marquart nurses training college, kpando COURSE TITLE: HIV/AIDS INFECTION MEDICAL NURSING (CODE: RGN 204) Mr. Wadza bless

3. What is it? • It is a sexually transmitted disease that is characterized by prolonged fever, weight loss and prolonged diarrhea. • It is a blood borne virus typically transmitted via sexual intercourse, shared intravenous drug paraphernalia and vertical transmission during child birth process or via breast milk. • The disease is caused by HIV-1 OR HIV-2 retroviruses

4. Cause • Human immunodeficiency virus • HIV is transmitted through body fluids that contain free virions and infected CD4+ T cells. Mode of transmission • It is grouped into three: • Sexual intercourse/sex related – 75% • Parenteral means – IV drug users, blood transfusion ,use of infected equipment e.g. Needles etc. • Mother to infant transmission which occurs during pregnancy, labor and delivery

5. Signs and symptoms • The signs and symptoms are grouped into major and minor. • Major • Prolonged fever for more than 1 month • Prolonged and chronic diarrhea for more than 1 month • Weight loss greater than 10% of body weight over a short period of time • Minor • Persistent cough for more than 1 month ✓ generalized skin rash that is itchy/infection ✓ history of herpes zoster in the last 2 years.

6. Pathophysiology Because HIV infection is an infectious disease, it is important to understand how HIV-1 integrates itself into a person’s immune system and how immunity plays a role in the course of HIV disease. • In this first step, the gp120 and gp41 glycoproteins of HIV bind with the host’s uninfected cd4+ receptor and chemokine coreceptors, usually ccr5, which results in the fusion of HIV with the cd4+ t-cell membrane. • The contents of HIV's viral core are emptied into the cd4+ t cell.

7. DNA synthesis. HIV changes in genetic material from RNA to DNA through the action of reverse transcriptase, resulting in double-stranded DNA that carries instruction for viral replication. • New viral DNA enters the nucleus of the cd4+ t cell and through the action of integrase is blended with the DNA of the cd4+ t cell, resulting in permanent, lifelong infection. • When the cd4+ t cell is activated, the double-stranded DNA forms single-stranded messenger RNA, which builds new viruses. • The mRNA creates chains of new proteins and enzymes that contain the components needed in the construction of new viruses.

8. The HIV enzyme protease cuts the polyprotein chain into the individual proteins that make up the new virus. • New proteins and viral RNA migrate to the membrane of the infected cd4+ t cell, exits from the cell, and starts the process all over.

9. Classification • The stages of HIV disease is based on clinical history, physical examination, laboratory evidence of immune dysfunction, signs and symptoms, and infections and malignancies. • Primary infection (acute/recent HIV infection). The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection. • HIV asymptomatic (CDC category a). After the viral set point is reached, HIV-positive people enter into a chronic stage in which the immune system cannot eliminate the virus despite its best efforts. • HIV symptomatic (CDC category b). Category B consists of symptomatic conditions in HIV-infected patients that are not included in the conditions listed in category C. • Aids (CDC category c). When the CD4+ t-cell level drops below 200 cells/mm3 of blood, the person is said to have AIDS.

10. cont. • Oral thrush (candidiasis) • Recurrent shingles (“ananse”) • Enlargement of the lymph nodes • Aggressive skin cancer (kaposi sarcoma)

11. Diagnosis • ELISA test (enzyme – linked immunosorbent assay) • Western blot test or immunofluorescent antibody test • The presence of major and minor signs and symptoms • Physical examination • Clinical history of the patient • Treatment • No cure • Treatment of symptoms • Antiretroviral drugs; efavirenz (sustiva), nevirapine (viramune), delavirdine

12. Nursing care :Rest and comfort • Warm bed should be ensured • Hospitalization may be necessary at the terminal stage • Proper and well ventilated room should be provided to enhance rest and comfort Nutrition • Patient should be given highly nutritious diet high in protein and calories • Liberal fluids should be ensured

13. Observation • Monitor TPR and BP 4 hourly • Monitor intake and output • Observe for skin rashes • Weigh the patient daily to determine the weight loss Psychological support • The disease condition should be explained to the patient and to help allay fear and anxiety • Reassurance should be given to the patient and the family members

14. Establishment of good interpersonal relationship with patient and family members should also be ensured • Medications • Serve all prescribed drugs and monitor their side effects and desired effects. • Personal hygiene • Bed bath, mouth care, treatment of pressure areas and all other hygienic practices should be ensured

15. Prevention/health education • Educate the patient and the family on the following: • Proper screening of blood donors should be ensured • Drug abusers should be educated to stop that habit • Health workers should abide by the universal precaution guidelines for infection control • Patient should be educated on the mode of transmission of the disease. • Relative of infected clients should be educated on handle body fluids of the patient.

16. Cont. • Sex partners. Avoid sexual contact with multiple partners or people who are known to be HIV positive or IV/injection drug users. • Blood and blood components. People who are HIV positive or who use injection drugs should be instructed not to donate blood or share drug equipment with others. • Safe sex. Other than abstinence, consistent and correct use of condoms is the only effective method to decrease the risk of sexual transmission of HIV infection.

17. Complications • Pneumonia • Candidiasis • Tuberculosis • Kaposi sarcoma • Herpes simplex • Wasting syndrome occurs

18. VOLUNTARY COUNSELLING AND TESTING This is the process by which an individual undergoes counselling to enable him/her make an informed choice about being tested for HIV.

19. Conceptualizing VCT as an entry point for HIV prevention and care:

20. Cont. • Adapted from “voluntary counselling and testing for HIV infection in antenatal care: • Practical consideration for implementation.” World health organization, September, 1999

21. Objectives of VCT • The objectives of VCT include to: • Reduce further spread of infection in the country as a whole • Reduce the impact of HIV/AIDS status on the individual, family and the community • Adequately manage AIDS and STI cases • To prevent mother – to – child HIV transmission (PMTCT)

22. Goals of VCT • Prevention of HIV transmission • VCT would help prevent the transmission of HIV from positively tested people to untested or negative partners. Individuals who know their status will exhibit behavioral changes and therefore, would not transmit the HIV to their negative or untested partners. Again, it will inform untested partners to know their status.

23. Cont. 2. Prevention of HIV acquisition • VCT will help prevent negative tested people from positive or untested partners by way of having behavioral change. 3. Early and appropriate uptake of service • Positively tested individuals would have access to proper medical care in the form of ARV therapy, treatment of opportunistic infections, prevention of opportunistic infections, and HIV associated

24. Infections and screening for HIV – associated infections and tumors. It would also help in the family planning services especially counselling about choices. Through an early and appropriate uptake of services, emotional care including individual, couple and family support would be provided. Also the following services can be provided under early and appropriate uptake of service; • Social support • Improved coping and planning for the future • Counselling for positive living (nutrition, ongoing counselling, disclosure issues and identification of safety network) • Legal advice

25. Cont. 4. Societal benefits • Through VCT, the following benefits can be achieved socially; • Normalization of HIV • Challenging stigma • Promoting awareness • Supporting human rights

26. Cont.’ 5. Counselling for adherence This will help enforce the behavioral change. Also it helps in achieving adherence in the use of protection during sexual intercourse.

27. Guiding principles of VCT • WHO recommends that the following guiding principles be observed in the provision of all HIV testing and counselling services; • Testing and counselling must now be scaled up • Offering HIV testing and counselling should become standard practice wherever they are likely to enhance the health and well – being of the individual.

28. Cont. The objective is to enable the greatest possible number of people to benefit from the ever – improving treatment, care and prevention options and realize their right to the highest attainable standard of health care.

29. 2. HIV testing should be voluntary • Mandatory HIV testing is neither effective for public health purposes nor ethical, because it denies individuals choice and violates principles such as the right to health, including the right to privacy and the ethical duties to obtain informed consent and maintain confidentiality. Although the process of obtaining informed consent will vary according to different settings,

30. Cont. all those offered the test should receive sufficient information and should be helped to have an adequate understanding of the testing process and possible consequences of being tested. The three crucial elements in obtaining truly informed consent in HIV testing are; • Providing the purpose for the testing and on the treatment and support available once the results is known • Ensuring understanding • Respecting the individual’s right to decide if they want to be trusted.

31. Cont. • Only when these elements are in place will individuals be able to make fully informed decision on whether or not to be tested in light of their own circumstances and values. Once this is assured, the actual process of obtaining informed consent can be adapted to suit the different settings under which expanded HIV testing and counselling services will be implemented.

32. 3. Confidentiality must be protected • All medical records, whether or not they involve HIV – related information, should be managed in accordance with appropriate standards of confidentiality. Only health – care professionals with direct role in the management of patients or clients should have access to such records or the information they contain, and only on a “need to know” basis. In rare circumstances, confidentiality may be breached where there is a clear indication that a third party may be harmed by the actions of the patient. Steps that apply to such a process include;

33. Cont. • The HIV positive person (source client) has been thoroughly counselled on the need for partner notification/counselling. • The counselling has failed to achieve the appropriate behavioral changes, including the practicing of safer sex. • The source client has refused to notify or consent to the counselling of his/her partner. • There is real risk of HIV transmission to the identifiable partner • The health worker gives the source client reasonable advance notice of the intention to counsel.

34. Cont. • The identity of the source client is concealed from the partner if this is possible in practice. • Follow up is provided to ensure support to those involved as necessary and prevent violence, family disruption etc.

35. VCT Sites • These are areas or places where VCT services are provided. VCT is being carried out in various settings in developing and industrialized countries, depending on demands and resources. • Free standing VCT sites • Hospital services • NGOs within the hospitals • Integrated into general medical outpatient services in public hospitals

36. As part of specialist medical care e.g. STI clinic, dermatology clinic, chest clinic, antenatal and family planning services • VCT as entry into continuum of care/home based care (including palliative care services) • Health center – urban or rural • Private sector (clinics and hospitals) • Workplace clinics • Referral sites for legal requirements, pre – employment, pre – travel, premarital etc. • Youth health services and school health services

37. Cont. • Health services for vulnerable groups • Sex workers • Prison population • Men who have sex with men (MSM) • Children, orphan and street kids

38. Examples of best practices in the provision of counselling and VCT services include the following: • The location and opening hours of the services should reflect the needs of particular community. Voluntary counselling and testing is usually carried out in STD clinics, hospitals outpatient departments, and hospital wards, but can also occur in centers dedicated to this specific purpose (such as the anonymous clinics of the Thai red cross). VCT services as well as condom supplies for sex workers are sometimes offered in the vicinity of night clubs, and operate at night.

39. Cont. • VCT needs to be well planned so that informed consent is always sought and counselling offered before a client takes an HIV test. • Counselling should be integrated into other services, including std, antenatal and family planning clinics. In particular community – based counselling services can be initiated and expanded quickly, and at little expense.

40. Cont. • A referral system for provision of comprehensive HIV/AIDS prevention, care and support should be developed in consultation with NGOs, community – based organizations, hospital directors and other service managers, as well as with networks of people living with HIV and AIDS. Regular meetings should be held among service providers to review and improve the referral system.

41. Counselling services, with or without testing, can and should be tailored to the needs of particular client groups, some of which have very different needs. These groups include: • Women (regardless of their HIV status) who are or who want to become pregnant. • Couples who agree to attend sessions together before and after testing. • Children, including those living with HIV/aids, or who are part of a family in which one or both of the parents are either infected with the virus or have died of AIDS.

42. Cont. • Young people, both in and out of school. • Injecting drug users (including those who are young people) • Sex workers (including those who are young people) • Other socially marginalized or vulnerable groups such as gay, lesbians or transgender individuals, and migrants and refugees. • Adherence to ARVS and preventive therapies • Coping with adverse effects

43. Benefits of VCT services • VCT has many benefits of which some include: • It promotes and sustains behavior change • Help and prepare the client to accept the HIV test results • Care and support services including access to antiretroviral therapy (ART) ✓ Improves the quality of life and assist in reduction and discrimination.

44. Cont. • Links with other interventions such as prevention of STIs, treatment of opportunistic infections, facilitates early referral to comprehensive clinical and community based and prevention of mother – to – child transmission of HIV.