HIV/AIDS

Course Objectives

1.  Identify the psychosocial and cultural considerations necessary when working with HIV positive patients.

2.  Describe the stigma associated with the HIV virus.

3.  Describe counseling techniques that can be used before and after HIV testing.

4.  Identify the treatment protocol most often used with HIV/AIDS patients.

 

HIV stands for Human Immunodeficiency Virus.

The immune system is responsible for fighting off viruses in the body.  White blood cells protect the body from the germs such as viruses, parasites, fungi and bacteria.  The HIV disease is a deterioration of the body’s immune function.

The term AIDS stands for Acquired Immune Deficiency Syndrome. 

A positive HIV test result means that the person has been infected with HIV (Human Immunodeficiency Virus), the vi type of whrus that causes AIDS (Acquired Immune Deficiency Syndrome). HIV disease progresses to AIDS when the CD4+ T cell count drops below 200 cells/mm, and/or you develop an AIDS-defining condition.  CD4+ T cells are aite blood cell that fights infections. When HIV enters a person’s CD4+ T cell, it uses the cell to make copies of itself. This process destroys the CD4+ T cells, weakening the immune system and making it harder for the body to fight infections.The AIDS Surveillance Case Definition of the U.S. Centers for Disease Control and Prevention

A diagnosis of AIDS is made whenever a person is HIV-positive and:

he or she has a CD4+ cell count below 200 cells per micro liter OR his or her CD4+ cells account for fewer than 14 percent of all lymphocytes OR that person has been diagnosed with one or more of the AIDS-defining illnesses listed below.

AIDS Infection   

AIDS is caused by infection with a virus called human immunodeficiency virus (HIV). This virus is passed from one person to another through blood-to-blood and sexual contact. In addition, infected pregnant women can pass HIV to their babies during pregnancy or delivery, as well as through breast feeding.

White blood cells of the immune system provide a first line of defense against viruses and cancers. White blood cells affected with the HIV virus resist treatment by disguising themselves as protease inhibitors. Other cells of the immune system that get infected with AIDS are CD4-possitive T-cells, which orchestrate the immune response, and monocyte macrophage cells, which collect infected cells.

 Body fluids that pass the Virus:   

  • blood
  • semen
  • vaginal fluid
  • breast milk
  • other body fluids containing blood

These are additional body fluids that may transmit the virus that health care workers may come into contact with:

  • cerebrospinal fluid surrounding the brain and the spinal cord
  • synovial fluid surrounding bone joints
  • amniotic fluid surrounding a fetus

HIV and Its Transmission    

Research has revealed a great deal of valuable medical, scientific, and public health information about the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). The ways in which HIV can be transmitted have been clearly identified.

 HIV is spread by sexual contact with an infected person, by sharing needles and/or syringes (primarily for drug injection) with someone who is infected through transfusions of infected blood or blood clotting factors. Babies born to HIV-infected women may become infected before or during birth or through breast-feeding after birth.

In the health care setting, workers have been infected with HIV after being stuck with needles containing HIV-infected blood or, less frequently, after infected blood gets into a worker’s open cut or a mucous membrane (for example, the eyes or inside of the nose).

 Kissing

 Casual contact through closed-mouth or "social" kissing is not a risk for transmission of HIV. Because of the potential for contact with blood during "French" or open-mouth kissing, the Center for Disease Control recommends against engaging in open mouth kissing with a person that has been infected with the virus. The risk of acquiring HIV during open-mouth kissing is believed to be very low.

 Saliva, Tears, and Sweat

 HIV has been found in saliva and tears in very low quantities from some AIDS patients. It is important to understand that finding a small amount of HIV in a body fluid does not necessarily mean that HIV can be transmitted by that body fluid. HIV has not been recovered from the sweat of HIV-infected persons. Contact with saliva, tears, or sweat has never been shown to result in transmission of HIV.

Needles

At the start of every intravenous injection, blood is introduced into needles and syringes. HIV can be found in the blood of a person infected with the virus. The reuse of a blood-contaminated needle or syringe by another drug carries a high risk of HIV transmission. Infected blood can be introduced into drug solutions by:

  • using blood-contaminated syringes to prepare drugs
  • reusing water
  • reusing bottle caps, spoons, or other containers ("spoons" and "cookers") used to dissolve drugs in water and to heat drug solutions
  • reusing small pieces of cotton or cigarette filters ("cottons") used to filter out particles that could block the needle

"Street sellers" of syringes may repackage used syringes and sell them as sterile syringes. For this reason, people who continue to inject drugs should obtain syringes from reliable sources of sterile syringes, such as pharmacies.

 HIV/AIDS and Stigma

 HIV-related stigma refers to all unfavorable attitudes, beliefs, and policies directed toward people perceived to have HIV/AIDS as well as toward their significant others and loved ones, close associates, social groups, and communities. Patterns of prejudice, which include devaluing, discounting, discrediting, and discriminating against these groups of people, play into and strengthen existing social inequalities—especially those of gender, sexuality, and race—that are at the root of HIV-related stigma.

Erving Goffman is widely credited for conceptualizing and creating a framework for the study of stigma. His work was seminal in creating an environment for ongoing academic research on the topic. In his landmark book Stigma: Notes on the Management of Spoiled Identity (1963), Goffman described stigma as “an attribute that is deeply discrediting within a particular social interaction” (p. 3). His explanation of stigma focuses on the public’s attitude toward a person who possesses an attribute that that falls short of societal expectations. The person with the attribute is “reduced in our minds from a whole and usual person to a tainted, discounted one” (p. 3). Goffman further explained that stigma falls into three categories:

1.   Abominations of the body—various physical deformities.

2.   Blemishes of individual character—weak will, domineering or unnatural passions, treacherous and rigid beliefs, or dishonesty. Blemishes of character are inferred from, for example, mental disorder, imprisonment, addiction, alcoholism, homosexuality, unemployment, suicidal attempts, or radical political behavior.

3.  Tribal stigma of race, nation, and religion—beliefs that are transmitted through lineages and equally contaminate all members of a family (Goffman, 1963).

The stigma concept has been applied to myriad circumstances (Link and Phelan, 2001). Goffman’s ideas are a common thread in much of the published research and provide the theoretical underpinnings for much of the literature on stigma and stereotyping.

According to Goffman and other researchers, diseases associated with the highest degree of stigma share common attributes:

  • The person with the disease is seen as responsible for having the illness
  • The disease is progressive and incurable
  • The disease is not well understood among the public
  • The symptoms cannot be concealed.

HIV infection fits the profile of a condition that carries a high level of stigmatization (Goffman, 1963; Herek, 1999; Jones et al., 1988). First, people infected with HIV are often blamed for their condition and many people believe HIV could be avoided if individuals made better moral decisions. Second, although HIV is treatable, it is nevertheless a progressive, incurable disease (Herek, 1999; Stoddard, 1994). Third, HIV transmission is poorly understood by some people in the general population, causing them to feel threatened by the mere presence of the disease. Finally, although asymptomatic HIV infection can often be concealed, the symptoms of HIV-related illness cannot. HIV-related symptoms may be considered repulsive, ugly, and disruptive to social interaction (Herek, 1999).

The discrimination and devaluation of identity associated with HIV-related stigma do not occur naturally. Rather, they are created by individuals and communities who, for the most part, generate the stigma as a response to their own fears. HIV-related stigma manifests itself in various ways. HIV-positive individuals, their loved ones, and even their caregivers are often subjected to rejection by their social circles and communities when they need support the most. They may be forced out of their homes, lose their jobs, or be subjected to violent assault. For these reasons, HIV-related stigma must be recognized and addressed as a life-altering phenomenon.

HIV-related stigma has been further divided into the following categories:

Instrumental HIV-related stigma—a reflection of the fear and apprehension that are likely to be associated with any deadly and transmissible illness (Herek, 1999)

Symbolic HIV-related stigma—the use of HIV/AIDS to express attitudes toward the social groups or “lifestyles” perceived to be associated with the disease (Herek, 1999)

Courtesy HIV-related stigma—stigmatization of people connected to the issue of HIV/AIDS or HIV- positive people (Snyder, 1999, based on Goffman, 1963).

Stigma and Access to Care

The literature devoted to stigma and access to care falls roughly into three categories. Most of the literature deals with barriers to care that HIV-positive individuals encounter across the continuum from HIV diagnosis to end of life. The next largest category of studies documents the reluctance of health care providers to treat individuals with HIV infection. Finally, a few studies cover the stigma experienced by providers of ancillary and support services to people living with HIV/AIDS.

Individuals

HIV/AIDS-related stigma affects issues related to HIV testing including delays in testing, the effect of delay on further transmission of HIV, and individuals’ responses to testing positive (Chesney and Smith, 1999). Early detection of HIV infection is important. Knowledge of one’s HIV seropositivity can lead to earlier treatment and improved outcomes (Herek, 1990). Knowledge of seropositivity also can lead to changes in risk behaviors that can reduce or eliminate the risk of HIV transmission. A Kaiser Health Poll report (2000) suggested that fear of being stigmatized by HIV/AIDS has some relationship to people’s decisions about getting tested for HIV. One-third of survey respondents said that if they were tested for HIV, they would be “very” or “somewhat” concerned that people would think less of them if they discovered that they had been tested. In addition, 8 percent of people who had never been tested for HIV said that worries about confidentiality played a part in their decision not to have the test.

Studies provide evidence that stigma is associated with delays in HIV testing among individuals who are at high risk of being infected with HIV (Myers et al., 1993; Stall et al., 1996). In a study of gay and bisexual men who were unaware of their HIV status, two-thirds of the participants expressed a fear of discrimination against people with HIV and said it was a reason for not getting tested (Stall et al., 1996). Earlier in the epidemic, HIV stigmatization was shown to influence the way in which at-risk populations approached HIV testing. People at risk for HIV infection were more likely to seek testing that was offered anonymously (i.e., no names were recorded) than testing that was offered confidentially (i.e., names were kept in confidential files) (Fehrs et al., 1988; Johnson et al., 1988).

HIV/AIDS-related stigma also influences individuals’ responses to testing positive: It aggravates the psychological burden of receiving a positive HIV test (Chesney and Smith, 1999). Earlier in the epidemic, there were reports of severe psychological responses to notification, including denial, anxiety, depression, and suicidal ideation (Coates et al., 1987; Ostrow et al., 1989). Over time, studies have shown a decrease in severe reactions to being notified of positive test results; however, research continues to show that notification is associated with high distress. Distress is greatest immediately after notification and typically declines within 2 to 10 weeks (Ironson et al., 1990; Perry et al., 1990). Stigma also affects the care of HIV-positive individuals. After a person tests positive, he or she faces decisions that include how to enter and adhere to care and whether to disclose HIV seropositivity to partners, friends, family, colleagues, employers, and health care providers (Chesney and Smith, 1999). At each level, a decision to disclose seropositivity may either enhance access to support and care or expose the individual to stigmatization and potential discrimination.

HEALTH CARE PROVIDERS

Accessing health care can be a challenge for people who are HIV positive, because the health care system itself is often a source of stigma. Health care professionals, particularly those who infrequently encounter HIV-positive people, can be insensitive to their patients’ concerns about stigma. In addition, health care professionals are not always knowledgeable about appropriate procedures for maintaining patient confidentiality (Herek et al., 1998).

The literature on caregiving reveals that stigmatization is evident among health care providers. Fear of contagion and fear of death have clear negative effects on health care providers’ attitudes toward and treatment of HIV-positive patients (Gerbert et al., 1991; Weinberger et al., 1992).  Health care providers also may fear stigmatization themselves because of their work with HIV-positive patients (Durham, 1994). Caregivers, whether professionals or volunteers, risk what Goffman called “courtesy stigma,” in which they are stigmatized as a result of their association with HIV/AIDS and people living with HIV disease. That stigma may influence their willingness to work with people with HIV or may make their work more difficult (Snyder et al., 1999).

Statistics

United States:  Through December 2001, a total of 816,149 cases of AIDS had been reported to the CDC.

Worldwide: Based on estimates from the United Nations AIDS program (UNAIDS), approximately 65 million people have been infected with HIV since the start of the global epidemic. At the end of 2002, an estimated 42 million people were living with HIV infection or AIDS.

UNAIDS estimates 5.0 million new HIV infections occurred in 2002. This represents about 14,000 new cases per day. An estimated 3.1 million adults and children died of HIV/AIDS in 2002.

Men Who Have Sex with Men

In the United States, HIV-related illness and death historically have had a tremendous impact on men who have sex with men. Even with the increase among drug users, men having sex with men continues to account for the largest number of people reported with AIDS each year.

Impact of HIV Infection on African Americans

In the early 1980s, HIV/AIDS was primarily considered a gay white disease in the U.S. Today, however, the epidemic has expanded and the disease is also a major health problem in the African-American community.

The HIV/AIDS epidemic continues to be a major health crisis facing the African-American community.  Although African Americans make up about 12 percent of the U.S. population, they accounted for half of the new HIV cases reported in the United States in 2001.  African-American women accounted for nearly 64 percent of HIV cases reported among women in 2001.

Overall, it is estimated that half of new HIV infections occur among teenagers and young adults aged 25 years and younger.

Hispanic Population and Aids

The Hispanic population accounts for 19% of the number of new U.S. AIDS cases reported each year. 81% of the Hispanic population infected with the AIDS virus is male.  In 1993, 18% of those estimated to be living with AIDS were Hispanic, while in 1999, 20% were Hispanic. In comparison, non-Hispanic whites represented 46% of people estimated to be living with AIDS in 1993, but only 38% in 1999. . Sixty percent of Hispanics reported with AIDS in 2000 were born in the U.S. 47% of the Hispanic AIDS cases are linked to heterosexual sex.

HIV Testing

The tests commonly used to detect HIV infection actually look for antibodies produced by the body to fight HIV. Most people will develop detectable antibodies within 3 months after infection, the average being 25 days. In rare cases, it can take up to 6 months.

Many places provide testing for HIV infection. Common testing locations include local health departments, offices of private doctors, hospitals, and sites specifically set up to provide HIV testing.  It is important to seek testing at a place that also provides counseling about HIV and AIDS. Counselors can answer any questions the person might have about risky behavior and ways they can protect themselves and others in the future. In addition, they can help you understand the meaning of the test results and describe what AIDS-related resources are available in the local area. Hiv Aids Online Continuing Education Course approved for all Nursing Professionals in Florida. CE Broker Reporting Provided.

Only the Home Access test is approved by the Food and Drug Administration. The Home Access test kit can be found at most local drug stores. The testing procedure involves pricking your finger with a special device, placing drops of blood on a specially treated card, and then mailing the card in to be tested at a licensed laboratory. Customers are given an identification number to use when phoning for the test results. Callers may speak to a counselor before taking the test, while waiting for the test result, and when getting the result.

A rapid test for detecting antibody to human immunodeficiency virus (HIV) is a screening test that produces very quick results, in 30 minutes or less. In comparison, results from the commonly used HIV antibody screening test, the enzyme immunoassay (EIA), are not available for 1-2 weeks.  OraQuick is a test that can detect antibodies to HIV in finger-stick whole-blood specimens and provide results in as little as 20 minutes.

The viral load is to be tested 2–8 weeks after the start of treatment. If the drugs are working, the viral load should decrease. It should continue to decrease as they continue to take the medication. Throughout HIV treatment, the viral load should be tested every 3–4 months to make sure the drugs are still working. If the viral load is still detectable within 4–6 months after starting treatment, they should talk to the doctor about possibly changing the HIV drugs.

Anonymous HIV testing should be available to increase options for individuals seeking to learn their HIV status. In this age of effective treatment, it is increasingly important for people to know their HIV status. Recent studies show that eliminating the availability of anonymous HIV testing services has a deterrent effect on some people's willingness to come forward for testing. People with legitimate concerns about discrimination or people who are unfamiliar with or distrust the public health system are able to gain access to the system through anonymous testing and subsequently receive referrals for needed treatment, care, or prevention services. Partner counseling also can be provided following anonymous testing, if requested.

Voluntary, confidential notification of potentially exposed partners is to be an essential component of a comprehensive HIV prevention program. Partner counseling is a primary prevention service with the following objectives:

  • To provide prevention information to people who are at very high risk of becoming HIV infected, but who may be unaware of or misunderstand their risks
  • To assist these individuals in obtaining HIV prevention counseling and voluntary testing, and referral
  • To provide access to partners who are already infected to prevention and treatment services that can improve their health and quality of life.

Effectiveness of Condoms

Condoms are classified as medical devices and are regulated by the Food and Drug Administration (FDA). Condom manufacturers in the United States test each latex condom for defects, including holes, before it is packaged. The proper and consistent use of latex or polyurethane (a type of plastic) condoms when engaging in sexual intercourse--vaginal, anal, or oral--can greatly reduce a person’s risk of acquiring or transmitting sexually transmitted diseases, including HIV infection.

There are many different types and brands of condoms available--however, only latex or polyurethane condoms provide a highly effective mechanical barrier to HIV. In laboratories, viruses occasionally have been shown to pass through natural membrane ("skin" or lambskin) condoms, which may contain natural pores and are therefore not recommended for disease prevention (they are documented to be effective for contraception). Women may wish to consider using the female condom when a male condom cannot be used.

For condoms to provide maximum protection, they must be used consistently (every time) and correctly. Several studies of correct and consistent condom use clearly show that latex condom breakage rates in this country are less than 2 percent. Even when condoms do break, one study showed that more than half of such breaks occurred prior to ejaculation.

Treatment

Treatment of HIV Infection

When AIDS was first recognized in 1981, patients with the disease were unlikely to live longer than a year or two. Since then, scientists have developed an effective arsenal of drugs that can help many people infected with HIV (human immunodeficiency virus) live longer and healthier lives.

Drugs for Treating HIV 

As of 2003, antiretroviral drugs have been approved for treating HIV infection. They are called antiretroviral because they attack HIV, which is a retrovirus. Once inside the cell, HIV uses specific enzymes to survive. Antiretroviral drugs work by interfering with the virus' ability to use these enzymes.

Reverse transcriptase inhibitors interfere with an enzyme called reverse transcriptase or RT that HIV needs to make copies of itself. There are two main types of RT inhibitors and they each work differently

Nucleoside/nucleotide drugs provide faulty DNA building blocks, halting the DNA chain that the virus uses to make copies of itself.

Non-nucleoside RT inhibitors bind RT so the virus cannot carry out its copying function.

Protease inhibitors interfere with the protease enzyme that HIV uses to produce infectious viral particles.

In March 2003, the Food and Drug Administration (FDA) announced the accelerated approval of Fuzeon (enfuvirtide) for use in combination with other anti-HIV medications to treat advanced HIV-1 infection in adults and children ages 6 years and older.

FDA’s accelerated approval of Fuzeon makes it the first product in a new class of medications called fusion inhibitors to receive marketing approval anywhere in the world. Drugs in this class interfere with the entry of HIV-1 into cells by inhibiting the fusion of viral and cellular membranes. This inhibition blocks the virus’ ability to infect certain components of the immune system. The approved labeling for Fuzeon warns physicians to carefully monitor patients for signs and symptoms of pneumonia. Patients receiving Fuzeon are advised to seek medical evaluation immediately if they develop signs or symptoms suggestive of pneumonia such as cough with fever, rapid breathing and shortness of breath. In addition, Fuzeon can cause both serious systemic allergic reactions and local skin reactions at the site of injection.

Symptoms of a serious systemic allergic reaction with Fuzeon can include: trouble breathing, fever and skin rash, chills, vomiting and low blood pressure. Patients taking Fuzeon should contact their healthcare provider right away if they get any of these symptoms. People with HIV must take complicated treatment regimens, often taking several drugs on a daily basis. Patients may forget to take their medicine, find the food restrictions difficult to deal with, and may experience unpleasant side effects. Aside from the complicated dosing regimens, antiretroviral drugs themselves may cause serious medical problems. Metabolic changes are occurring in people with chronic HIV infection Researchers have found garlic supplements can cause a potentially harmful side effect when combined with a type of medication used to treat HIV/AIDS. Investigators from the National Institutes of Health (NIH) observed that garlic supplements sharply reduced blood levels of the anti-HIV drug saquinavir.

 The Pharmaceutical Research and Manufacturers Association list nearly two dozen new anti-HIV drugs now in development. They include new protease inhibitors and more potent, less toxic RT inhibitors, as well as drugs that interfere with entirely different steps in the virus' lifecycle. These new categories of drugs include:

  • Fusion inhibitors -- drugs that interfere with HIV's ability to enter a cell
  • Integrase inhibitors -- drugs that interfere with HIV's ability to insert its genes into a cell's normal DNA.  

HIV and Pregnancy

For those who are pregnant or want to become pregnant, they must consider the general risks and benefits of drug treatment to both themselves and the child. Some of the drugs (such as efavirenz and hydroxyurea) should be avoided, because they may cause birth defects if taken early in pregnancy.

Most women with HIV/AIDS in the United States reside in the Northeast and the South. The highest numbers of cases were first observed in the Northeast, but the South has reported the greatest increases in recent years. African-American and Hispanic women are disproportionately affected by the epidemic and account for 80% of AIDS cases reported in U.S. women in 1999. Over time, the proportion of cases in women attributable to injection-drug use has declined, whereas the proportion of cases from heterosexual contact has increased, particularly among young women. Worldwide, approximately 600,000 infants each year become infected through mother-to-child transmission of the HIV virus. In the United States, widespread implementation of the PHS guidelines for universal counseling and testing and perinatal use of ZDV has sharply reduced transmission risk and the number of perinatally acquired HIV infections.

Despite the declines, cases of perinatal HIV transmission continue to occur, largely because of missed opportunities for prevention, particularly among women who lack prenatal care or who are not being offered voluntary HIV counseling and testing during pregnancy. The estimated 280–370 infants born with HIV infection each year represent populations in which prevention efforts are impeded by lack of timely HIV testing and treatment of pregnant women.

Dynamics of Perinatal HIV Transmission

 Perinatal transmission can occur during pregnancy (intrauterine), during labor and delivery (intrapartum), or after delivery through breast-feeding (postpartum). In the absence of breast-feeding, intrauterine transmission accounts for 25%–40% of infection, and 60%–75% of transmission occurs during labor and delivery. Among women who breast-feed, approximately 20%–25% of perinatal infections are believed to be associated with intrauterine transmission, 60%–70% with intrapartum transmission or very early breast-feeding, and 10%–15% with later postpartum transmission through breast-feeding. In a randomized trial of formula feeding versus breast-feeding, approximately 44% of HIV infection was attributed to breast-feeding. In breastfeeding populations, a shift toward an increasing proportion of transmission related to breast-feeding is likely to occur as a consequence of successful preventive interventions directed at late prenatal and intrapartum transmission.

Intrapartum transmission can occur during labor through maternal-fetal exchange of blood or during delivery by contact of the infant’s skin or mucous membranes with infected blood or other maternal secretions. Several studies have indicated that most infections transmitted through breast-feeding probably occurred during the first few weeks to months of life. Risk factors during breast-feeding include viral load in breast milk, subclinical or clinical mastitis, breast abscesses and maternal seroconversion during the lactation period. Hiv Aids Online Continuing Education Course approved for all Nursing Professionals in Florida. CE Broker Reporting Provided.

Several risk factors are associated with perinatal HIV transmission. Clinical factors that increase the likelihood of transmission include immunologically or clinically advanced HIV disease in the mother, high plasma viral load, maternal injection-drug use during pregnancy, preterm delivery, nonreceipt of the PACTG 076 regimen, and breastfeeding. No link has been established between perinatal HIV transmission and maternal age, race/ethnicity, or history of having a previously infected child.

Obstetric factors also influence HIV transmission risk. The risk for perinatal transmission increases per hour duration of membrane rupture after controlling for other risk factors. Delivery >4 hours after the rupture of the fetal membranes can double the risk for HIV transmission. Maternal infection with another sexually transmitted disease (STD) during pregnancy and certain obstetrical procedures can also increase risk. Chorioamnionitis (i.e., uterine infection) has been associated with an increased risk for HIV transmission.

Most of these risk factors were identified before the recommended use of ZDV to prevent perinatal HIV transmission. Their effects are unknown now that most pregnant women infected with HIV are receiving ZDV chemoprophylaxis to prevent mother-to child transmission, as well as combination therapy for their own health. Because of the sharp reductions in perinatal HIV transmission associated with effective antiretroviral interventions, factors that interfere with women or their infants receiving ZDV treatment (e.g., barriers to prenatal care, lack of HIV testing for some pregnant women) are increasingly important.

 Prevention of Perinatal Transmission

The birth of every perinatally HIV-infected infant is a sentinel health event signaling either a missed prevention opportunity or, more rarely, a failure of prophylaxis. An opportunity is missed whenever a woman of childbearing age is unaware of her HIV status or her risk for HIV or when an HIV-infected pregnant woman a) does not receive prenatal care, b) is not offered HIV testing, c) is unable to obtain HIV testing, d) is not offered chemoprophylaxis, e) is unable to obtain chemoprophylaxis, or f) does not complete the chemoprophylaxis regimen. Prophylaxis failures occur when an infant becomes infected despite chemoprophylaxis and other preventive interventions. Each of these missed opportunities or failures deserves attention from service providers and prevention programs.

 Early Prenatal Care

Maximum reduction of perinatal transmission depends on preventing HIV infection in women or identifying HIV infection before pregnancy or as early as possible during pregnancy. Diagnosis allows a woman to receive effective antiretroviral therapies for her own health and preventive drugs (e.g., ZDV) to improve the chances that her infant will be born free of infection. Early knowledge of maternal HIV status is also important for decisions regarding obstetrical management. Achieving these goals requires increased access to and use of prenatal care.

HIV Treatment Adherence

 Adherence is a major issue in HIV treatment for two reasons.

  • First, adherence affects how well the HIV drugs decrease viral load. When patients skip medication doses even once, the virus has the opportunity to make copies of itself more rapidly. This makes it difficult for the drugs to be effective. Other factors that may affect treatment effectiveness include the baseline viral load and CD4+ T cell count, whether they have any AIDS-related illnesses, and whether you they used HIV drugs before.
  • Second, adherence to HIV treatment is very important to prevent drug resistance. Studies have shown that when the patient skips doses, they may develop strains of HIV that are drug-resistant. This may leave them with fewer treatment options if the viral load does not decrease. Because drug-resistant strains can be transmitted to others, it has serious consequences for anyone with whom they engage in risky behavior.
  • There are several reasons why many patients have difficulty adhering to an HIV treatment plan.
  • One reason is that HIV treatment plans are very complicated. Studies have shown that many people may have difficulty adhering to even simple treatment plans. Yet HIV treatment may involve taking 25 or more pills each day. In addition, some HIV drugs must be taken on an empty stomach, while others must be taken with meals. This can be difficult for many people, especially those who are sick or experiencing HIV symptoms. Also, HIV-infected patients may need to continue their treatment regimens for a long time, perhaps for their entire lives.
  • HIV-infected patients have reported other reasons for poor adherence, including unpleasant side effects (like nausea), sleeping through doses, traveling away from home, being too busy, feeling sick or depressed, or simply forgetting to take their medications.

 AIDS Wasting

 AIDS wasting is the involuntary loss of more than 10% of body weight, plus more than 30 days of either diarrhea, or weakness and fever. Wasting is linked to disease progression and death. Losing just 5% of body weight can have the same negative effects.  Wasting is still a problem for people with AIDS.

Part of the weight lost during wasting is fat. More important is the loss of muscle mass. This is also called "lean body mass," or "body cell mass." Lean body mass can be measured by bioelectrical impedance analysis (BIA). This is a simple, painless office procedure.

AIDS wasting and lipodystrophy both can cause some body shape changes. Wasting is the loss of muscle. Lipodystrophy is a loss of fat. They are not the same thing. However, wasting in women can start with a loss of fat.

Several factors contribute to AIDS wasting:

Low food intake: Low appetite is common with HIV. Also, some AIDS drugs have to be taken with an empty stomach, or with a meal. It can be difficult for some people with AIDS to eat when they're hungry. Drug side effects such as nausea, changes in the sense of taste, or tingling around the mouth also decrease appetite. Opportunistic infections in the mouth or throat can make it painful to eat. Infections in the gut can make people feel full after eating just a little food. Finally, lack of money or energy may make it difficult to shop for food or prepare meals.

Poor nutrient absorption: Healthy people absorb nutrients through the small intestine. In HIV disease, several infections (including parasites) can interfere with this process. HIV may directly affect the intestinal lining and reduce nutrient absorption. Diarrhea causes loss of calories and nutrients.

Altered metabolism: Food processing and protein building are affected by HIV disease. Even before any symptoms show up, you need more energy. This might be caused by the increased activity of the immune system. People with HIV need more calories just to maintain their body weight.

Hormone levels can affect the metabolism. HIV seems to change some hormone levels. Also, cytokines play a role in wasting. Cytokines are proteins that produce inflammation to help the body fight infections. People with HIV have very high levels of cytokines. This makes the body produce more fats and sugars, but less protein.

Unfortunately, these factors can work together to create a "downward spiral." For example, infections may increase the body's energy requirements. At the same time, they can interfere with nutrient absorption and cause fatigue. This can reduce appetite and make people less able to shop for or cook their meals. They eat less, which accelerates the process.

Wasting Treatment

The best prevention for AIDS Wasting is a baseline nutrition assessment by a Registered Dietitian, with general healthy eating nutrition counseling at diagnosis of HIV.  As weight loss occurs, or with the development of symptomatology that interfere with maintaining an adequate intake, follow-up visits to the Dietitian can allow an evaluation with a detailed individualized plan of treatment.   Once weight is lost, it is difficult to return to pre-illness weight with similar body composition.

Nutrition Guidelines for People with HIV

 Good nutrition means getting enough macronutrients and micronutrients. Macronutrients contain calories (energy): proteins, carbohydrates, and fats. They help maintain body weight. Micronutrients include vitamins and minerals. They keep cells working properly, but will not prevent weight loss. Good nutrition can be a problem for many people with HIV. When the body fights any infection, it uses more energy and the patient needs to eat more than normal. But when one feels sick, they eat less than normal.

Some medications can upset the stomach, and some opportunistic infections can affect the mouth or throat. This makes it difficult to eat. Also, some medications and infections cause diarrhea. With diarrhea, the body actually uses less of what you eat.  With weight lose, they might be losing fat, or they might be losing lean body weight like muscle. If they lose too much lean weight, the body chemistry changes. This condition is called wasting syndrome or cachexia. Wasting can kill. If the patient loses more than 5% of their body weight, it could be a sign of wasting.

A moderate exercise program will help the body turn food into muscle. Take it easy, and work exercise into daily activities. Drinking enough liquids is very important when the person has HIV. Extra water can reduce the side effects of medications. It can help avoid a dry mouth and constipation. Be aware that drinking tea, coffee, colas, chocolate, or alcohol can actually make you lose body liquid.

Important Nutrients
There has not been a lot of research on specific nutrients and HIV disease. Also, many nutrients interact with each other. Most nutritionists believe in designing an overall program of supplements.

  • People with HIV may benefit from taking supplements of the following vitamins and minerals:
  •  B Vitamins: Vitamin B-1 (Thiamine), Vitamin B2 (Riboflavin), Vitamin B6 (Pyridoxine), Vitamin B12 (Cobalamin), and Folate (Folic Acid).
  • Antioxidants, including beta-carotene (the body breaks down beta-carotene to make Vitamin A), selenium, Vitamin E (Tocopherol), and Vitamin C.
  • Magnesium and Zinc

 HIV counseling seeks to reduce HIV acquisition and transmission through the following:

• Information. Clients should receive information regarding HIV transmission and prevention and the meaning of HIV test results. Provision of information is different from informed consent.

• HIV prevention counseling. Clients should receive help to identify the specific behaviors putting them at risk for acquiring or transmitting HIV and commit to steps to reduce this risk. Prevention counseling can involve >1 sessions. Inform all clients who are recommended or who request HIV testing should receive the following information, even if the test is declined:

• Information regarding the HIV test and its benefits and consequences.

• Risks for transmission and how HIV can be prevented.

• The importance of obtaining test results and explicit procedures for doing so.

• The meaning of the test results in explicit, understandable language.*

• Where to obtain further information or, if applicable, HIV prevention counseling.

• Where to obtain other services (see Typical Referral Needs).

* For example, “A negative test means no HIV was found. But if you were exposed to HIV

   recently — in the last 1–2 months — this test may not be able to pick that up.” See Negative

HIV Test Results

In certain settings where HIV testing is offered, other useful information includes

a) descriptions or demonstrations of how to use condoms correctly

b) information regarding risk-free and safer sex options 

c) information regarding other sexually transmitted and bloodborne diseases

d) descriptions regarding the effectiveness of using clean needles, syringes, cotton, water, and other drug paraphernalia

e) information regarding drug treatment; and f) information regarding the possible effect of HIV vaccines on test results for persons participating in HIV vaccine trials (see Additional Counseling Considerations for Special Situations and Positive HIV Test Results).

For efficiency, information can be provided in a pamphlet, brochure, or video rather than a face-to-face encounter with a counselor. This approach allows the provider to focus face-to-face interactions on prevention counseling approaches proven effective with persons at increased risk for HIV infection. Information should be provided in a manner appropriate to the client’s culture, language, sex, sexual orientation, age, and developmental level. Certain informational videos and large-group presentations that provide explicit information regarding correct use of condoms have proven effective in reducing new STDs and could be effective in reducing HIV.

 

References: Nursing CEUs

Department of Health and Human Services, Center for Disease Control and Preventions

 

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