Altered Immune Responses and Transplantation
Case Study
A.O. tells you he drinks at weekend parties and has smoked pot but "not recently." He reports no regular use of injection drugs, tobacco, or anabolic steroids but that sometimes he gets so drunk he doesn't remember. How would you rate his risk and why? A.O. is at high risk for contracting another STI and/or HIV because of his active sexual life with multiple partners, direct contact sex with same-sex partners, inability to recall possible exposure when under the influence, unprotected sex, and history of STI.
Consequences of Integrase
1. Newly formed double-stranded DNA is infected with HIV because all genetic material is replicated during cell division 2. Viral DNA in genome directs cell to make new HIV Protease, another enzyme involved in the replication process, cleaves the newly formed strands of HIV genetic material into smaller pieces. New HIV virions are then formed and released. The CD4+ T cell is then destroyed after the HIV virions are released.
Audience Response Question
A diagnosis of AIDS can be made for a patient with HIV with A. a CD4+ T-cell count <500/µL. B. a WBC count <3000/µL (3 × 109/L). C. development of oral candidiasis (thrush). D. onset of Pneumocystis jiroveci pneumonia. Answer: d Rationale: The Centers for Disease Control (CDC) has established criteria for a patient to be diagnosed with AIDS. AIDS is diagnosed when an HIV-positive individual develops at least one of several criteria: examples are CD4+ T-cell count less than 200 cells/µL and fungal infection such as Pneumocystis jiroveci pneumonia (PCP). Candidiasis infection must be of the bronchi, trachea, lungs, or esophagus (not only the mouth).
Case Study
A.O. informs you he has been sexually active since age 15 with both males and females. He states he is always "on top" (inserting partner). He has had intercourse with 3 people in the last month and doesn't use protection. What should you do next? If you haven't already recommended it, further testing for other STIs including HIV is in order. Inform him that testing is the only way to determine if he has contracted HIV. Negative results can relieve anxieties about past behaviors and provide opportunities for prevention teaching. Positive results can provide impetus to seek treatment and protect his sex partners. Talk with him about ways to protect himself and others from sexually transmitted diseases: Abstinence Noncontact sex Use of barriers
Case Study
A.O. is a 20-year old Hispanic male college student who comes to the student health center complaining of pain on urination. His urine test is positive for Neisseria gonorrhea. What should you do? Talk about treatment options for the gonorrhea. Obtain a complete health and social history including drug and sexual practices.
Case Study
A.O. returns to the clinic 3 months later after refusing HIV testing or teaching. He is now concerned as one of his "partners" was just diagnosed with HIV. He wants help. What should you tell him about HIV testing? It involves testing a sample of blood or oral fluid for HIV-specific antibodies. It is important you work together. Testing is the only way to determine if he has HIV. Early treatment and support is very important for his health. You will provide him with information and support to help him understand and deal with this concern. You would like to know more about his available support system. You need to know when the last risk of exposure occurred. Teaching is important to help prevent further STIs. Tests need to be repeated at intervals for up to 3 months after each possible exposure. Let him know if rapid testing is available at your clinic (staff is trained to perform the test and the clinic is qualified for a Clinical Laboratory Improvement Amendments [CLIA] waiver). Results are available in 20 minutes, but it is more expensive than standard testing and should be verified with standard testing. It is important to protect himself and his partners from further risky behaviors during the 3-month interval until final results are available.
Case Study
A.O. says he will not be abstinent but is willing to use a condom during contact sex. What are the main points you need to cover when teaching about barrier methods of protection? Use only condoms made of latex or polyurethane; store condoms in a cool, dry place, protect them from trauma, and do not use them past the expiration date; use only water-soluble lubricants with condoms; place the condom on the erect penis before any contact is made with the partner's mouth, vagina, or rectum; hold the condom at the base of the penis and remove the penis and condom from the partner's body immediately after ejaculation; dispose of the condom by removing it, wrapping in tissue, and discarding it; and never reuse condoms.
Case Study
A.O. tells you he "really cares" about one of his partners. What do you tell him about informing his previous sexual partners about his gonorrhea? What should he tell them about the HIV infection if he tests positive? A.O. should be encouraged to inform his sexual partners about his gonorrhea diagnosis. He should be told that gonorrhea is often asymptomatic in women, and his recent female sexual partners need to be tested and receive treatment, or they may develop infertility. His male partners also need to be diagnosed, treated, and counseled about transmitting the infection to others. Gonorrhea is a reportable disease, which means that the diagnosing clinician must report A.O.'s case to the health department. Personnel at the health department have been trained to trace the sexual contacts of people with sexually transmitted infections and to tell them of their risks for infection. A.O. will be encouraged to provide the names of his recent sexual partners to health department personnel. Health department personnel can make disclosures anonymously (i.e., A.O.'s name will not be used). HIV is also a reportable disease, and partner tracing and notification can be handled in a similar manner. If A.O. chooses to notify his partners himself, he should be provided with assistance and counseling on how to approach the discussion and how to prepare for his partner's reactions.
Antiretroviral Therapy
ART can significantly slow HIV progression, but it - Is complex - Has side effects - Does not work for everyone - Is expensive These factors can contribute to problems with adherence to treatment, a dangerous situation because of the high risk of developing drug resistance. Table 14-16 provides a guide to providing patient and caregiver teaching on HIV treatment and initial follow up. Interventions you may provide include teaching about (1) advantages and disadvantages of new treatments, (2) dangers of poor adherence to therapeutic regimens, (3) how and when to take each drug, (4) drug interactions to avoid, and (5) side effects that must be reported to the HCP. When to start therapy - Patient readiness is most important concern - To avoid burnout and non-adherence, treatment is recommended when immune suppression is great Clinical guidelines provide information on initial drug regimens. However, one of the most important considerations for initiating therapy is patient readiness for treatment. Guidelines on when and how to initiate ART are based on the degree of immune suppression. Issues to consider when selecting an initial drug regimen include the ability of the patient's HIV to resist specific drugs, potential medication side effects, existing co-morbidities, and dosing schedules. This is a critical decision, because the first treatment regimen is generally the patient's best chance for success. Adherence to drug regimens is critical to prevent - Disease progression - Opportunistic disease - Viral drug resistance An individualized approach is best Example: The difficulty of adhering consistently is probably clear to anyone who has tried to take a 10-day course of antibiotics. Patients in treatment for HIV infection must take at least 1 pill a day (but most take many more), and they must take those pills every day for the rest of their lives, even when uncomfortable side effects occur. Missing even a few doses can lead to drug resistance. See Table 14-17 for strategies to improve adherence to ART. Simplify regimens. Use reminders. Elicit support.
Clinical Manifestations and Complications
Acute Infection 1. Flulike symptoms - Fever, swollen lymph nodes, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhea, or a diffuse rash - Occurs about 2 to 4 weeks after infection - Highly infectious Some people also develop neurologic complications, such as aseptic meningitis, peripheral neuropathy, facial palsy, or Guillain-Barré syndrome. During this time a high viral load (the amount of HIV circulating in the blood) is noted, and CD4+ T cell counts fall temporarily but quickly return to baseline or near-baseline levels (Fig. 14-3). Many people, including HCPs, mistake acute HIV symptoms for a bad case of the flu. Individuals are most infectious during the acute infection stage because of the high amounts of circulating HIV. Asymptomatic Infection - Left untreated, a diagnosis of AIDS is made about 10 years after initial HIV infection - Symptoms are generally absent or vague - High risk behaviors may continue Because most of the symptoms during early infection are vague and nonspecific for HIV, people may not be aware that they are infected. Risky behaviors become a public health problem because infected individuals can transmit HIV to others even though they have no symptoms. Personal health is also affected because people who do not know that they are infected have little reason to seek treatment and are less likely to make behavior changes that could improve the quality and length of their lives. Symptomatic Infection 1. CD4+ T cells decline closer to 200 cells/μL - Symptoms become worse - HIV advances to a more active stage As the viral load increases, symptoms such as persistent fever, frequent night sweats, chronic diarrhea, recurrent headaches, and severe fatigue may develop. Symptomatic Infection - Shingles - Persistent vaginal candidal infections - Herpes - Bacterial infections Other infections that can occur at this time include shingles (caused by the varicella-zoster virus), persistent vaginal candidal infections, outbreaks of oral or genital herpes, and bacterial infections.
Normal Immune Response Humoral Immunity
Antibody-mediated immunity Antibodies produced by plasma cells (differentiated B cells) Primary immune response is evident 4 to 8 days after initial exposure to antigen The term humoral comes from the Greek word humor, which means body fluid. Production of antibodies is an essential component in a humoral immune response. Five classes of immune globulins Each has specific characteristics IgG - Largest component of total immune globulins Found in plasma and interstitial fluid. Only Ig to cross placenta and provide newborn with passive acquired immunity lgA - Found in body secretions: saliva, tears, breast milk, colostrum Lines mucous membranes lgM - Largest of immune globulins is found in plasma; responsible for primary immune response; forms antibodies to ABO blood antigens lgD - Found in plasma; present on lymphocyte surface; assists in differentiation of B lymphocytes lgE - Found in plasma and interstitial fluids; causes symptoms of allergic reaction When an individual is exposed to an antigen for a second time, response is faster (1 to 3 days) and lasts longer - Main product of secondary response is IgG rather than IgM - Memory cells account for more rapid production of IgG IgG crosses the placental membrane and provides the newborn with passive-acquired immunity for at least 3 months. Infants may also get some passive immunity from IgA in breast milk and colostrum.
Normal Immune Response
Antigens - Substances the body recognizes as foreign that elicit an immune response - Most are composed of protein Antibodies - Immune globulins produced by lymphocytes in response to antigens Most antigens are composed of protein. However, other substances such as large-size polysaccharides, lipoproteins, and nucleic acids can act as antigens. All of the body's cells have antigens on their surface that are unique to that person and enable the body to recognize self. The immune system normally becomes "tolerant" to the body's own molecules and therefore is nonresponsive to "self" antigens.
Case Study
As you talk to A.O. about barrier methods of protection, he begins to look away and seems to lose interest. He finally says, "I don't know if I can do this." What are some cultural considerations that may be a factor here? Hispanic culture may influence an individual's acceptance of condoms. Condoms not only protect an individual from disease, they also prevent conception. Contraception is problematic for many Hispanic cultures, either because of religious prohibitions or the desire to have children. Hispanic men may also have been raised with the cultural concept of machismo, which supports the notion that men are in control. This may especially interfere with condom use in heterosexual encounters if condom use is seen as weak and not using condoms is seen as a way to control the female partner.
Perinatal Transmission
Can occur during pregnancy, delivery, or breastfeeding An average of 25% of infants born to women with untreated HIV will contract the infection Treatment can reduce rate of transmission to less than 2% Perinatal transmission can occur from an HIV-infected mother to her infant. Fortunately, the risk of transmission can be reduced to less than 2% in settings where pregnant women are routinely tested for HIV infection and, if found to be infected, treated with antiretroviral therapy (ART), a combination of medication used to control and suppress HIV replication.
Normal Immune Response Lymphoid Organs
Central (primary) lymphoid organs 1. Thymus gland - Thymus gland shrinks with age - Involved in the differentiation and maturation of T lymphocytes 2. Bone marrow - Produces RBCs, WBCs, and platelets Lymphocytes are produced in the bone marrow and eventually migrate to the peripheral organs. The thymus is involved in the differentiation and maturation of T lymphocytes and is therefore essential for a cell-mediated immune response. During childhood, the thymus is large. It shrinks with age, and in the older person, the thymus is a collection of lymphocytes and connective tissue. Peripheral lymphoid organs - Lymph nodes - Tonsils - Spleen - Lymphoid tissues associated with gut, genitals, bronchi, and skin When antigens are introduced into the body, they may be carried by the bloodstream or lymph channels to regional lymph nodes. The antigens interact with B and T lymphocytes and macrophages in the lymph nodes. The two important functions of lymph nodes are (1) filtration of foreign material brought to the site and (2) circulation of lymphocytes. The tonsils are an example of lymphoid tissue. The spleen, a peripheral lymph organ, is important as the primary site for filtering foreign antigens from the blood. Lymphoid tissue is found in the submucosa of the gastrointestinal (gut-associated), genitourinary (genital-associated), and respiratory (bronchial-associated) tracts. This tissue protects the body from external microorganisms. The skin-associated lymph tissue primarily consists of lymphocytes and Langerhans' cells (type of dendritic cell) found in the epidermis of skin. When Langerhans' cells are depleted, the skin cannot initiate an immune response. Therefore a delayed hypersensitivity reaction (as determined by skin testing with injected antigens) does not occur.
Disease and Drug Side Effects
Common physical problems - Anxiety, fear, depression - Diarrhea - Peripheral neuropathy - Pain - Nausea/vomiting - Fatigue Physical problems related to HIV and/or its treatment can interrupt the patient's ability to maintain a desired lifestyle. Nursing interventions are similar to those for patients who do not have HIV.
Normal Immune Response
Comparison of Humoral and Cell-Mediated Immunity Humoral - b cells - antibodies - memory cells Protection of: - Bacteria - viruses (extracellular) - respiratory pathogens - GI pathogens Cellular - T cells - macrophages - sensitized T cells - cytokines - memory cells Protection of: - fungus - viruses (intracellular) - chronic infections - tumor cells Humoral immunity consists of antibody-mediated immunity. In contrast, immune responses that are initiated through specific antigen recognition by T cells are termed cell-mediated immunity. Humans need both humoral and cell-mediated immunity to remain healthy.
Nursing Management Assessment
Do not make assumptions about who may be at risk Candid conversation is important for effective management of HIV Since HIV infection can be prevented, nursing care for individuals not known to be infected with HIV should focus on preventing disease transmission. The first step is to assess the patient's individual risk behaviors, knowledge, and skills. Do not make assumptions about people or their behavior. Assess for risky behaviors on a regular basis - things can change. Ask at-risk patients - Received blood transfusion or clotting factors before 1985? - Shared needles with another person? - Had a sexual experience with your penis, vagina, rectum, or mouth in contact with these areas of another person? - Had a sexually transmitted infection? Ask if they have ever had sexual contact with someone known to have HIV. These questions provide the minimum information needed to initiate a risk assessment. Follow-up a positive response to any of these questions by an in-depth exploration of issues related to the identified risk. Based on the assessment, nursing interventions can then encourage the patient to adopt safer, healthier, and less risky behaviors, particularly in regard to sexual intercourse, drug use, perinatal transmission, and work issues. Assess diagnosed patients thoroughly - Past health history - Medications - Functional health patterns - Presence of symptoms using a systems review Specific assessments are needed for an individual who has been diagnosed with HIV infection. Subjective and objective data should be obtained (see Table 14-14). Early recognition and treatment can slow the progression of HIV infection and prevent new infections. A complete history and thorough systems review can help identify and address problems in a timely manner.
Safety Alert
Drug interactions 1. Herbal therapies - St. John's wort 2. Commonly used drugs 3. OTC drugs - Antacids, proton pump inhibitors, supplements Many ART drugs have dangerous and potentially lethal interactions. Be sure to ask patients about prescribed and OTC drugs as well as herbal products and supplements.
Acute Intervention
Early intervention promotes health and delays disability Reactions to positive HIV test 1. Similar to any life-threatening, chronic illness - Panic, anxiety, fear, guilt, depression, denial, anger, hopelessness The nursing assessment in HIV disease should focus on early detection of symptoms, opportunistic diseases, and psychosocial problems. They will be confronted with complex treatment decisions; feelings of loss, anger, powerlessness, depression, and grief; social isolation; altered concepts of the physical, social, emotional, and creative self; the possibility of death; and/or thoughts of suicide. Patients and their family members, friends, and caregivers must also deal with associated social stigma and discrimination.
End-of-Life Care
Focus of nursing intervention - Patient comfort - Promoting acceptance of finite nature of life - Helping significant others deal with loss - Maintaining safe environment Despite new developments in the treatment of HIV infection, many patients eventually experience disease progression, disability, and death. Sometimes treatments do not work for the patient. Sometimes the patient's HIV becomes resistant to all available drug therapies. In other cases, a patient may make a decision to forego further treatment, allowing the disease to progress toward death. (End-of-life care is discussed in Chapter 9.)
Nursing Management Planning
Goals for care are aimed at - Compliance with drug regimens - Adopting a healthy lifestyle - Beneficial relationships - Spiritual well-being in regard to life and death - Coping with the disease and its treatment Nursing interventions can help the patient to (1) adhere to drug regimens (2) promote a healthy lifestyle that includes avoiding exposure to other sexually transmitted and blood-borne diseases (3) protect others from HIV (4) maintain or develop healthy and supportive relationships (5) maintain activities and productivity (6) explore spiritual issues (7) come to terms with issues related to disease, disability, and death (8) cope with symptoms caused by HIV and its treatments.
Transmission of HIV
HIV can be transmitted through contact with certain body fluids - Blood, semen, vaginal secretions, and breast milk HIV is not spread through casual contact HIV transmission occurs through sexual intercourse with an infected partner; exposure to HIV-infected blood or blood products; and perinatal transmission during pregnancy, at delivery, or through breastfeeding. The virus cannot be transmitted through hugging, dry kissing, shaking hands, sharing eating utensils, using toilet seats, or casual encounters in any setting. It is not spread by tears, saliva, urine, emesis, sputum, feces, sweat, respiratory droplets, or enteric routes.
Viral Load in Blood and CD4+ T-Cell Counts
HIV destroys about 1 billion CD4+ T cells every day. For many years the body can produce new CD4+ T cells to replace the destroyed cells. However, over time the ability of HIV to destroy CD4+ T cells exceeds the body's ability to replace the cells. The decline in the CD4+ T cell count impairs immune function.
Acute Exacerbations
HIV infection - Has no cure - Continues for life - Causes physical disability - Impairs social, emotional, economic, and spiritual wellbeing - Ultimately leads to death Chronic diseases are characterized by acute exacerbations. Nursing care becomes more complex as the patient's immune system deteriorates and new problems arise to compound existing difficulties. The best way to prevent opportunistic disease is to assure that the patient is adhering to an effective ART regimen and taking prophylactic medications for opportunistic infections. Providing supportive care specific to the opportunistic disease, should it occur, is important nursing care.
Health Promotion
HIV infection is preventable - Avoid risky behaviors - Modify risky behaviors - Candid, culturally sensitive, language- appropriate, age-specific information and behavior change counseling The goal is to develop safer, healthier, and less risky behaviors. These techniques can be divided into safe activities (those that eliminate risk) and risk-reducing activities (those that decrease, but do not eliminate, risk). You need to be prepared to discuss sensitive topics including sexuality and drug use. Suggest a wide variety of activities to reduce the risk of HIV infection so individuals can choose methods that best fit their needs and circumstances and individual life patterns. Prevention of HIV 1. Decreasing risks: Sexual intercourse - Abstinence - Noncontact safe sex - Use of barriers Safe sexual activities eliminate the risk of exposure to HIV in semen and vaginal secretions. Abstinence is the most effective strategy. There are safe options for those who cannot or do not wish to abstain. Safe sexual activities include masturbation, mutual masturbation ("hand job"), and other activities that meet the "no contact" requirements. Insertive sex between partners who are not infected with HIV and are not at risk of becoming infected with HIV is also considered to be safe. Risk-reducing sexual activities decrease the risk of contact with HIV through the use of barriers. Barriers should be used when engaging in insertive sexual activity (oral, vaginal, or anal) with a partner whose HIV status is not known or who is known to have HIV. The most commonly used barrier is the male condom, which can be used for protection during anal, vaginal, and oral intercourse. Female condoms provide an alternative to male condoms. Squares of latex (known as dental dams) can be used as a barrier during oral sexual activity. Prevention of HIV 1. Decreasing risks: Drug use - Do not use drugs - Do not share equipment - Do not have sexual intercourse under the influence of any impairing substance - Refer for help with substance use Drug use, including alcohol and tobacco can cause immunosuppression, poor nutrition, and a host of psychosocial problems. However, drug use does not cause HIV infection. The major risk for HIV related to using drugs involves sharing equipment or having unsafe sexual experiences while under the influence of drugs. Injecting equipment ("works") includes needles, syringes, cookers (spoons or bottle caps used to mix the drug), cotton, and rinse water. Equipment used to snort (straws) or smoke (pipes) drugs can also be contaminated with blood and should not be shared. Some communities have needle and syringe exchange programs (NSEPs) that provide sterile equipment in exchange for used equipment. Studies show drug use does not increase, rates of HIV and other blood-borne infections are controlled, and an overall cost benefit results in these communities. Cleaning equipment before use can also reduce risk by decreasing the chance of blood contact. Providing support for patients with substance use and referring individuals to professionals who can assist patients manage the psychologic aspects of substance use is important. Other self-help programs (e.g., Narcotics Anonymous, Alcoholics Anonymous) may also be beneficial. Prevention of HIV 1. Decreasing risks: Perinatal transmission - Family planning - Prevent HIV in women - Appropriately medicate HIV-infected pregnant women Women need to have information about family planning methods, HIV, HIV-antibody testing, and ART if infected. Pregnant HIV-infected women need information about abortion, how to maintain the pregnancy, and using ART to decrease the risk of transmission. If HIV-infected pregnant women are appropriately treated during pregnancy, the rate of perinatal transmission can be decreased from 25% to less than 2%. ART has significantly decreased the risk for infants born to HIV-infected women, and more of these women are now becoming mothers. Prevention of HIV 1. Decreasing risk: Work - Adhere to precautions and safety measures to avoid exposure - Report all exposures for timely treatment and counseling - Post-exposure prophylaxis with combination ART can significantly decrease risk of infection The risk of infection from occupational exposure to HIV is small but real. Should the nurse be exposed to HIV-infected fluids, post-exposure prophylaxis with combination ART can significantly decrease the risk of infection. See Table 14-8 on OSHA guidelines.
Pathophysiology of HIV
HIV is a ribonucleic acid virus 1. Called retroviruses because they replicate in a "backward" manner going from RNA to DNA 2. CD4+T cell is the target cell for HIV - Type of lymphocyte - HIV binds to the cell through fusion
Components of HIV
HIV is surrounded by an envelope made up of proteins, including gp120. HIV virus contains a core of viral RNA and proteins. Like all viruses, HIV cannot replicate unless it is inside a living cell.
Laboratory Studies
HIV progression is monitored by 1. CD4+ T-cell counts - CD4+ T-cell count provides a marker of immune function 2. Viral load - The lower the viral load the less active the disease As the disease progresses, the number of CD4+ T cells usually decreases (Fig. 14-3). The normal range for CD4+ T cells is 800 to 1200 cells/µL. Viral loads are reported as real numbers (e.g., 1260 copies/µL). The goal of treatment is to suppress the viral load to the lowest level possible, which is below the level of detection on a commercial assay. This is often referred to as "undetectable." "Undetectable" does not mean that the virus has been eliminated from the body or that the individual can no longer transmit HIV to others. Rather, it refers to the fact that the amount of circulating HIV in the blood is below the level of detection of the test.
Pathophysiology of HIV
Immune problems start when CD4+ T cell counts drop to < 500 cells/μL - Severe problems develop when < 200 CD4+ T cells/μL - Normal range is 800 to 1200 cells/μL Insufficient immune response allows for opportunistic diseases A point is eventually reached where so many CD4+ T cells have been destroyed that not enough are left to regulate immune responses (Fig. 14-3). This allows opportunistic diseases (infections and cancers that occur in immunosuppressed patients) to develop. Opportunistic diseases are the main cause of disease, disability, and death in patients with HIV infection.
Normal Immune Response Cell-Mediated Immunity
Immune responses initiated through specific antigen recognition by T cells Several cell types involved in cell-mediated immunity - T cells - Macrophages - NK cells Important roles - Immunity against pathogens that survive inside cells (viruses, some bacteria) - Fungal infections - Rejection of transplanted tissues - Contact hypersensitivity reactions - Tumor immunity
Normal Immune Response
Immunity - Body's ability to resist disease - Serves three functions 1. Defense 2. Homeostasis 3. Surveillance Immunity is a state of responsiveness to foreign substances such as microorganisms and tumor proteins. It serves three functions: Defense: The body protects against invasion by microorganisms and prevents the development of infection by attacking foreign antigens and pathogens. Homeostasis: Damaged cellular substances are digested and removed. Through this mechanism, the body's different cell types remain uniform and unchanged. Surveillance: Mutations continually arise in the body but are normally recognized as foreign cells and destroyed.
Effects of Aging on Immune System
Immunosenescence - ↑ Incidences of tumors - Greater susceptibility to infection - ↑ Autoantibodies - ↓ Cell-mediated immunity - Thymic involution - ↓ Delayed hypersensitivity reaction - ↓ IL-1 and IL-2 synthesis - ↓ Expression of IL-2 receptors - ↓ Proliferation response of T and B cells - ↓ Primary and secondary antibody responses There is a decline in function of the immune response with advancing age. This decline in the immune system is termed immunosenescence. The primary clinical evidence of immunosenescence is the high incidence of malignancies in older adults. A greater susceptibility also occurs to infections (e.g., influenza, pneumonia) from pathogens that an older person had been relatively immunocompetent against earlier in life. Bacterial pneumonia is the leading cause of death from infections in older adults. The antibody response to immunizations (e.g., flu vaccine) in older adults is considerably lower than in younger adults. The bone marrow remains relatively unaffected by increasing age. Immunoglobulin levels decrease with age and therefore lead to a suppressed humoral immune response in older adults. Thymic involution (shrinking) occurs with aging, along with decreased numbers of T cells. These changes in the thymus gland are a primary cause of immunosenescence. Delayed hypersensitivity response, as determined by skin testing with injected antigens, is frequently decreased or absent in older adults. This altered response reflects anergy (immune deficient condition characterized by lack of or diminished reaction to an antigen or a group of antigens).
Gerontologic Considerations
Increasing rates of HIV disease among older adults - Death rate from opportunistic infections reduced - People 60 and older are increasingly being infected The number of persons over age 60 living with HIV is anticipated to grow. As a nurse, you need to be aware of the special health concerns of the HIV-infected older adult. They are susceptible to the same diseases (heart, cancer, diabetes, bone disease, arthritis, HTN, kidney disease, cognitive impairment) as non-HIV-infected older people but may experience them at an earlier age may be at higher risk of co-morbidities due to the effects of the medications used to treat HIV. Polypharmacy (taking multiple medications to treat a variety of conditions) is a concern because the multiple medications older adults may have to take could have interactions or be potentiated by HIV medications. It may be difficult for the older adult to get appropriate health care and support if they are ashamed and hesitate to tell anyone they have HIV. As a nurse, you need to recognize that HIV is a chronic disease that will affect an increasing number of older adults and be prepared to help the older person who is living with HIV infection.
Types of Immunity
Innate - Present at birth - First-line defense against pathogens Acquired - Developed immunity 1. Active 2. Passive Innate immunity involves a nonspecific response, and neutrophils and monocytes are the primary white blood cells (WBCs) involved. Innate immunity is not antigen-specific so it can respond within minutes to an invading microorganism without prior exposure to that organism. Active acquired immunity results from the invasion of the body by foreign substances such as microorganisms and subsequent development of antibodies and sensitized lymphocytes. With each reinvasion of the microorganisms, the body responds more rapidly and vigorously to fight off the invader. Active acquired immunity may result naturally from a disease or artificially through immunization. Because antibodies are synthesized, immunity takes time to develop but is long-lasting. Passive acquired immunity implies that the host receives antibodies to an antigen rather than synthesizing them. This may take place naturally through the transfer of immunoglobulins across the placental membrane from mother to fetus. Artificial passive acquired immunity occurs through injection with gamma globulin (serum antibodies). The benefit of this immunity is its immediate effect. Unfortunately, passive immunity is short-lived, because the person did not synthesize the antibodies and consequently does not retain memory cells for the antigen.
Pneumocystis jiroveci Pneumonia
Opportunistic diseases generally do not occur in the presence of a functioning immune system. Pneumocystis jiroveci is a type of pneumonia that can appear as an opportunistic disease associated with HIV infection.
Metabolic Disorders
Lipodystrophy Hyperlipidemia Insulin resistance Hyperglycemia Bone disease Lactic acidosis Renal disease Cardiovascular disease Some HIV-infected patients, especially those who have been infected and on ART for a long time, may develop a set of metabolic disorders. Hyperlipidemia includes elevated triglycerides, elevated low-density lipoproteins, and decreased high-density lipoproteins. Lipid abnormalities are generally treated with lipid-lowering drugs, dietary changes, and exercise. Insulin resistance is treated with hypoglycemic drugs and weight loss. Bone disease involves osteoporosis, osteopenia, avascular necrosis. Bone disease may be improved with exercise, dietary changes, and calcium and vitamin D supplements. It's not clear why these disorders develop, but it is probably from a combination of factors including: Long-term infection with HIV Side effects of ART Genetic predisposition Chronic stress.
Lipodystrophy
Lipodystrophy is changes in body shape caused by a redistribution of fat in the abdomen, upper back, and breasts along with fat loss in the arms, legs, and face. Management of these metabolic disorders focuses on early detection, symptom management, and helping patients cope with emerging problems and changing treatment regimens, especially to avoid potentially fatal complications. A frequent first intervention is to change ART medications because some drugs are more often associated with these disorders.
Drug Therapy
Main goals - Decrease viral load - Maintain/increase CD4+T counts - Prevent HIV-related symptoms and opportunistic diseases - Delay disease progression - Prevent HIV transmission Recommendations for starting therapy in the chronically infected patient are summarized in Table 14-13. HIV cannot be cured, but ART can delay disease progression by decreasing viral replication. When taken consistently and correctly, ART can reduce viral loads by 90% to 99%, which makes adherence to treatment regimens extremely important. The major advantage of using drugs from different classes is that combination therapy can inhibit viral replication in several different ways, making it more difficult for the virus to recover and decreasing the likelihood of drug resistance. A major problem with most drugs used in ART is that resistance develops rapidly when they are used alone or taken in inadequate doses. Thus, combinations of three or more should be used. Opportunistic diseases complicate management of HIV infection - Prevention is key - Onset can be delayed with adequate measures - Effective management has significantly increased life expectancy Management of HIV is complicated by the many opportunistic diseases that can develop as the immune system deteriorates. Prevention is the preferred approach to opportunistic diseases. A number of opportunistic diseases associated with HIV can be delayed or prevented with adequate ART, vaccines (including hepatitis B, influenza, and pneumococcal), and disease-specific prevention measures. Although it is usually not possible to eradicate opportunistic diseases once they occur, prophylactic medications can significantly decrease morbidity and mortality rates. Advances in the prevention, diagnosis, and treatment of opportunistic diseases have contributed significantly to increased life expectancy.
Kaposi Sarcoma
Malignant vascular lesions such as Kaposi sarcoma lesions can appear anywhere on the skin surface or on internal organs. Kaposi sarcoma is caused by human herpesvirus 8. Lesions vary in size from pinpoint to very large and may appear in a variety of shades.
Oral Hairy Leukoplakia
Oral hairy leukoplakia, an Epstein-Barr virus infection that causes painless, white, raised lesions on the lateral aspect of the tongue, can occur at this phase of the infection and is another indicator of disease progression.
Interprofessional Care
Monitor disease progression, immune function, and manage symptoms Initiate and monitor ART Prevent, detect and/or treat opportunistic infections Interprofessional care of the HIV-infected patient focuses on (1) monitoring HIV disease progression and immune function (2) initiating and monitoring antiretroviral therapy (ART) (3) preventing the development of opportunistic diseases (4) detecting and treating opportunistic diseases (5) managing symptoms (6) preventing or decreasing complications of treatment (7) preventing further transmission of HIV. To accomplish these goals, ongoing assessment, clinician-patient interactions, and patient teaching and support are required. Prevent or decrease complications of therapies Prevent further transmission of HIV Interprofessional care of the HIV-infected patient focuses on (1) monitoring HIV disease progression and immune function (2) initiating and monitoring antiretroviral therapy (ART) (3) preventing the development of opportunistic diseases (4) detecting and treating opportunistic diseases (5) managing symptoms (6) preventing or decreasing complications of treatment (7) preventing further transmission of HIV. To accomplish these objectives, ongoing assessment, clinician-patient interactions, and patient teaching and support are required. Initial patient visit - Gather baseline data - Begin to establish rapport and use patient input to develop a plan of care - Initiate teaching about spectrum of HIV, treatment, preventing transmission, improving health, and family planning Perform complete history and physical examination. These findings will determine the patient's needs. This is also a good time to ensure that case reports required by the state health department have been completed. Determine the need for referrals. Remember that a newly diagnosed patient may not be able to retain or understand information. Be prepared to repeat and clarify information over the course of several months.
Diagnostic Studies
Most useful screening tests detect HIV-specific antibodies and/or antigens - May take several weeks to detect antibodies (window period) - Performed using blood or saliva - Combination (4th generation) tests can detect HIV earlier Combination antibody and antigen tests decrease the window period to within 3 weeks following infection Abnormal blood tests are common 1. Caused by HIV, opportunistic diseases, or complications of therapy - Decreased WBC counts - Low platelet counts - Anemia is associated with ART - Altered liver function Decreased white blood cell (WBC) counts, especially below-normal numbers of lymphocytes (lymphopenia) and neutrophils (neutropenia), are often seen. Low platelet counts (thrombocytopenia) may be caused by HIV, antiplatelet antibodies, or drug therapy. Anemia is associated with the chronic disease process and with adverse effects of ART. Altered liver function, caused by HIV infection, drug therapy, or co-infection with a hepatitis virus, is common. Early identification of co-infection with hepatitis B virus (HBV) or hepatitis C virus (HCV) is extremely important because these infections have a more serious course in patients with HIV, may ultimately limit options for ART, and can cause liver-related morbidity and mortality. Resistance tests can help determine if a patient is resistant to ART Assays help HCPs know which medications may be effective - Genotype assay - Phenotype assay Resistance tests can determine if a patient's HIV is resistant to drugs used for ART. Genotype and phenotype assays are similar to culture and sensitivity testing used for antibiotic selection.
Types of Acquired Specific Immunity
Natural 1. Active Natural contact with antigen through actual infection (e.g., chickenpox, measles, mumps) 2. Passive Transplacental and colostrum transfer from mother to child (e.g., maternal immunoglobulins passed to baby) Artificial 1. Active Immunization with antigen (e.g., vaccines for chickenpox, measles, mumps) 2. Passive Injection of serum with antibodies from one person (e.g., injection of hepatitis B immune globulin) to another person who does not have antibodies
HIV Proteins Bind to Cell
Once HIV is attached and fused with specific protein receptors on the outside of the CD4+ T cell, HIV RNA enters the cell. This triggers the release of reverse transcriptase, an enzyme that transforms HIV RNA into a single strand of DNA. This strand copies itself, becoming double-stranded viral DNA. Another enzyme, called integrase, allows the newly formed double-stranded DNA to integrate itself into the host's genetic structure.
Oral Thrush
One of the more common infections associated with symptomatic infection is oropharyngeal candidiasis (thrush). Candida organisms rarely cause problems in healthy adults, but are more common in HIV-infected people. AIDS 1. Diagnostic criteria is established by CDC 2. Immune system severely compromised - Infections - Malignancies - Wasting - HIV-related cognitive changes Organisms that do not cause severe disease in people with functioning immune systems can cause debilitating, disseminated, and life-threatening infections during this stage. Several opportunistic diseases may occur at the same time, compounding the difficulties of diagnosis and treatment. Advances in HIV treatment have decreased the occurrence of opportunistic diseases.
Case Study
One year later A.O. returns to the clinic with complaints of night sweats and a productive cough for 1 week. His CD4+ lymphocyte count is 76 cells/µL. He has lost 13 pounds in the last month. His record shows a history of a positive PPD. What do you think is happening? He has an opportunistic infection and is likely HIV+. Indications are it is: Mycobacterium tuberculosis. Collectively, the night sweats, productive cough, weight loss, and history of positive tuberculin skin test result indicate this diagnosis
MAJOR COMPLICATION
Organ Rejection: - Hyperacute: within 48 hours after surgery - Acute: 1week - 2 years after surgery - Chronic: Gradually over months to years NURSING ACTIONS: Monitor for and report manifestations of rejection immediately. Hyperacute: Occurs within 48 hr after surgery ETIOLOGY: An antibody-mediated response causing small blood clots to form in the transplanted kidney that occlude vessels and result in massive cellular destruction. The process is not reversible. FINDINGS: Fever, hypertension, pain at the transplant site TREATMENT: Immediate removal of the donor kidney Acute: Occurs 1 week to 2 years after surgery ETIOLOGY: An antibody mediated response causing vasculitis in the donor kidney, and cellular destruction starts with inflammation that causes lysis of the donor kidney FINDINGS: Oliguria, anuria, low-grade fever, hypertension, tenderness over the transplanted kidney, lethargy, azotemia, and fluid retention TREATMENT: Involves increased doses of immunosuppressive medications Chronic: Occurs gradually over months to years ETIOLOGY: Blood vessel injury from overgrowth of the smooth muscles of the blood vessels causing fibrotic tissue to replace normal tissue resulting in a nonfunctioning donor kidney FINDINGS: Gradual return of azotemia, fluid retention, electrolyte imbalance, and fatigue TREATMENT: Conservative (monitor kidney status, continue immunosuppressive therapy) until dialysis is required CLIENT EDUCATION: Teach the client to monitor for manifestations of rejection and to contact the provider immediately. Instruct the client that rejection is diagnosed through a kidney scan and kidney biopsies. Instruct the client to adhere to the pharmacological regimen.
Audience Response Question
The nurse is caring for a patient who is receiving antiretroviral therapy (ART) for treatment of AIDS. Which assessment best indicates that the patient's condition is improving? A. Decreased viral load B. Increased drug resistance C .Decreased CD4+ T-cell count D. Increased aminotransferase levels Answer: a Rationale: Goals of antiretroviral therapy (ART) in the treatment of a patient with HIV are to decrease the viral load and maintain or increase CD4+ T-cell counts. Combination drugs are prescribed to prevent or decrease drug resistance. Some of these drugs may impair liver function; increased aminotransferase levels indicate impaired liver function.
Preventing Transmission of HIV
Pre-exposure prophylaxis (PrEP) - Comprehensive strategy to reduce risk of sexually-acquired infection in adults at high risk - Used in conjunction with proven prevention interventions PrEP should be used in conjunction with other proven prevention interventions such as condoms, risk reduction counseling, and regular HIV testing. Tenofovir in combination with emtricitabine, also known as Truvada, is used to reduce the risk of HIV infection in uninfected individuals who are at significant risk of acquiring HIV. Tenofovir/emtricitabine is also currently used in combination with other antiretroviral agents for the treatment of HIV-infected people.
Nursing Management Implementation
Primary prevention and health promotion are the most effective strategies for diseases of a chronic nature including HIV 1. When prevention fails - Disease results - Early intervention is facilitated by health promotion practices The complexity of HIV disease is related to its chronic nature. As with most chronic and infectious diseases, primary prevention and health promotion are the most effective health care strategies. Even with recent successes in HIV treatment, prevention remains a critical component to control the epidemic. Health promotion encourages early detection of the disease so that, if primary prevention has failed, early interventions can be initiated. Table 14-15 presents a summary of nursing goals, assessments, and interventions throughout the course of HIV infection. Nursing interventions are based on and tailored to patient needs at every stage of HIV disease and can be instrumental in improving the quality and quantity of the patient's life. Care plans are individualized and change as new treatment protocols are developed and/or as HIV disease progresses.
Human Immunodeficiency Virus Infection
Retrovirus that causes immunosuppression making persons more susceptible to infections - > 1 million currently living with HIV - About 50,000 new infections occur in United States each year - Effective treatment has led to a significant drop in death rates The viral infection causes the person to be susceptible to infections that would normally be controlled through immune responses. The term HIV disease is used interchangeably with HIV infection. In North America HIV has been is most prevalent among men who have sex with men (MSM). Increasing numbers of new HIV infections are occurring in women, people of color, people who live in poverty, and young adults.
Contact With Blood
Sharing drug-using paraphernalia is highly risky Screening measures have improved blood supply safety Puncture wounds are most common means of work-related HIV transmission Needles, syringes, straws, and other equipment may be contaminated with HIV or other blood-borne organisms, and sharing this equipment can result in disease transmission. Routine screening of blood donors to identify at-risk individuals and testing donated blood for the presence of HIV have improved the safety of the blood supply. The risk of infection after a needle-stick exposure to HIV-infected blood is 0.3% to 0.4% (or 3 to 4 out of 1000). The risk is higher if the exposure involves blood from a patient with a high level of circulating HIV, a deep puncture wound, a needle with a hollow bore and visible blood, or a device used for venous or arterial access. Splash exposures of blood on skin with an open lesion present some risk, but it is much lower than from a puncture wound. Health care workers have a low risk of acquiring HIV at work, even after a needle-stick injury.
Ambulatory Care
Stigma can lead to discrimination and result in social isolation, dependence, frustration, low self-image, loss of control, and economic pressures This, in turn, could lead to further involvement in risky behaviors Although HIV-infected patients share problems experienced by all individuals with chronic diseases, these problems are exacerbated by negative social attitudes and beliefs surrounding HIV. Behaviors may be viewed as immoral, illegal, or reflect a lack of personal control. Even though illegal according to the ADA, fear surrounding the transmittable nature of the disease can lead to pervasive stigma and discrimination.
Delaying Disease Progression
Supporting a healthy immune system - Adequate nutrition - Current vaccinations - Health habits - Avoiding risky behaviors - Supportive relationships Supporting a healthy immune system can help delay HIV disease progression whether or not the patient chooses to take ART or not. Interventions include (1) nutritional support to maintain lean body mass and ensure appropriate levels of vitamins and micronutrients (2) moderation or elimination of alcohol, tobacco, and drug use (3) keeping up to date with recommended vaccines (4) getting adequate rest and exercise (5) reducing stress (6) avoiding exposure to new infectious agents (7) accessing counseling (8) getting involved in support groups and community activities (9) developing a consistent relationship with HCPs, including attendance at regular appointments. Teach patients to recognize symptoms that may indicate disease progression and/or drug side effects so that prompt medical care can be initiated. See Table 14-18 for symptoms that patients should report.
HIV Testing and Counseling
Testing is the only sure method of determining HIV infection - CDC recommends universal, voluntary testing as part of routine medical care - An estimated 14% of people living with HIV are not aware they are infected The goal is to normalize the test, decrease the stigma related to HIV testing, find hidden cases, get infected individuals into care, and prevent new cases of infection.
Immune Response to Virus
The immune response to a virus. A, A virus invades the body through a break in the skin or another portal of entry. The virus must make its way inside a cell to replicate itself. B, A macrophage recognizes the antigens on the surface of the virus. The macrophage digests the virus and displays pieces of the virus (antigens) on its surface. C, T helper cell recognizes the antigen displayed and binds to the macrophage. This binding stimulates the production of cytokines (interleukin-1 [IL-1] and tumor necrosis factor [TNF]) by the macrophage and interleukin-2 (IL-2) and γ-interferon (γ-IFN) by the T cell. These cytokines are intracellular messengers that provide communication among the cells. D, IL-2 instructs other T helper cells and T cytotoxic cells to proliferate (multiply). T helper cells release cytokines, causing B cells to multiply and produce antibodies. E, T cytotoxic cells and natural killer cells destroy infected body cells. F, The antibodies bind to the virus and mark it for macrophage destruction. G, Memory B and T cells remain behind to respond quickly if the same virus attacks again. A, A virus invades the body through a break in the skin or another portal of entry. The virus must make its way inside a cell to replicate itself. B, A macrophage recognizes the antigens on the surface of the virus. The macrophage digests the virus and displays pieces of the virus (antigens) on its surface. C, A T helper cell recognizes the antigen displayed and binds to the macrophage. This binding stimulates the production of cytokines (interleukin-1 [IL-1] and tumor necrosis factor [TNF]) by the macrophage and interleukin-2 (IL-2) and γ-interferon (γ -IFN) by the T cell. These cytokines are intracellular messengers that provide communication among the cells. D, IL-2 instructs other T helper cells and T cytotoxic cells to proliferate (multiply). T helper cells release cytokines, causing B cells to multiply and produce antibodies. E, T cytotoxic cells and natural killer cells destroy infected body cells. F, The antibodies bind to the virus and mark it for macrophage destruction. G, Memory B and T cells remain behind to respond quickly if the same virus attacks again
Primary and Secondary Immune Response
The introduction of antigen induces a response dominated by two classes of immune globulins—IgM and IgG. IgM predominates in the primary response, with some IgG appearing later. After the host's immune system is primed, another challenge with the same antigen induces the secondary response, in which some IgM and large amounts of IgG are produced.
Organs of Immune System
The lymphoid system is composed of central (or primary) and peripheral lymphoid organs. The central lymphoid organs are the thymus gland and bone marrow. The peripheral lymphoid organs are the lymph nodes; tonsils; spleen; and gut-, genital-, bronchial-, and skin-associated lymphoid tissues.
Audience Response Question
The nurse informs the patient with a bacterial pneumonia that the most important factor in antibiotic treatment is A. antibiotics should have been used to prevent pneumonia. B> all of the supplied antibiotics should be taken even when symptoms have resolved. C. enough antibiotics for 2 days' treatment should be reserved in case symptoms recur. D. patients should request antibiotics for upper respiratory infections to prevent development of streptococcal-related diseases. Answer: b Rationale: To prevent the emergence of antibiotic-resistant organisms, patients need to take the entire prescription even if symptoms have resolved. Antibiotics should not be used routinely to prevent bacterial pneumonia.
Audience Response Question
The nurse is teaching a newly diagnosed 34-year-old male about his HIV infection. Which statement by the patient would indicate the patient needs additional education? A. "I will need to take my HIV medication daily for the rest of my life." B. "Although I only take one pill, it has multiple medications combined into a single tablet." C. "I should notify my HIV provider if I get fevers that do not go away with Tylenol or aspirin." D. "Once my viral load is undetectable I don't have to worry about taking my medication every day." Answer: d Rationale: Persons with undetectable virus are still infected with HIV and need to take their HIV medications on a daily basis to keep the virus suppressed.
Timeline for Untreated HIV Infection
This displays the typical course of untreated HIV infection. It is important to remember that (1) disease progression is highly individualized, (2) treatment can significantly alter this pattern, and (3) an individual's prognosis is unpredictable. The information depicted in this figure represents data from large groups of people and should not be used to predict an individual's prognosis.
Normal Immune Response Cytokines
Tumor necrosis factor (TNF) 1. Activates macrophages and granulocytes 2. Promotes immune and inflammatory responses 3. Kills tumor cells 4. Responsible for extensive weight loss - Associated with chronic inflammation and cancer Clinical uses for soluble TNF receptor (Enbrel) - Rheumatoid arthritis Colony-stimulating factors (CSFs) - Granulocyte colony-stimulating factor (G-CSF) - Granulocyte-macrophage colony-stimulating factor (GM-CSF) - Macrophage colony-stimulating factor (M-CSF) G-CSF Stimulates proliferation and differentiation of neutrophils Enhances functional activity of mature PMN GM-CSF Stimulates proliferation and differentiation of PMNs and monocytes M-CSF Promotes proliferation, differentiation, and activation of monocytes and macrophages Clinical uses for G-CSF (Neupogen, Neulasta) Chemotherapy-induced neutropenia Clinical uses for GM-CSF (Leukine) Neutropenia, myeloid recovery after bone marrow transplantation
Sexual Transmission
Unprotected sex with an HIV-infected partner is most common mode of transmission 1. Greatest risk is for partner who receives semen - Prolonged contact with infected fluids - Women at higher risk - Trauma increases likelihood of transmission Sexual activity involves contact with semen, vaginal secretions, and/or blood, all of which have lymphocytes that may contain HIV. During any form of sexual intercourse (anal, vaginal, or oral), the risk of infection is greater for the partner who receives the semen, although infection can also be transmitted to the inserting partner. Sexual activities that cause trauma to local tissues can increase the risk of transmission. Genital lesions from other sexually transmitted infections (e.g., herpes, syphilis) significantly increase the likelihood of transmission.
Mechanism of Action of Interferon
When a virus attacks a cell, the cell begins to synthesize viral DNA and interferon. Interferon serves as an intercellular messenger. Interferon induces the production of antiviral proteins. Then the virus is not able to replicate in the cell.
