HIV

Discuss the function of CD4+ T cells and provide an example of how the CD4+ T-cell count guides the management HIV.

CC4+ T cells are WBC that send signals to other immune cells to destroy the invader. HIV attacks these cells and therefore greatly reduces the number present. The lower the number of CD4+ T cells the poorer management of the HIV infection

As a nurse who frequently works with HIV positive patients, you are concerned about patient confidentiality of this information versus protection of known persons at risk. How does the Code of Ethics inform the nurse's decision?

Confidentiality: the patient's rights, well-being, and safety of the individual patient should be the primary factors in arriving at any professional judgment concerning the disposition of confidential information. Duties of confidentiality are not absolute and may need to be modified in order to protect the patient, other innocent parties and in circumstances of mandatory disclosure for public health reasons.

Any loss, such as the loss of one's health, results in a grief response. Describe the stages of grief according to Kubler-Ross.

Denial: To deny something is the first action. The person tries to rationalize the situation. Shy away from the facts of the situation & block out words; temporary. Anger: Reality begins to emerge. Anger is aimed at many objects (inanimate, friends, family, etc). May even blame person who died or God, even though he/she knows the idea is irrational. Guilt coincides with anger. ("Why would God let this happen?; How can this happen to me?") Bargaining: Person feels a need to regain control. Say, "If only..." (sought medical attention sooner, 2nd opinion from another doctor, etc). Deal making with God or a higher power such as promising to change a lifestyle. Depression: Person begins to understand certainty of death. Objects lose meaning; person refuses to see others. The person appears to detach from love and affection. Feelings of sadness, regret, uncertainty, and fear are normal in this stage. ("I miss my loved one, why go on?") Acceptance: Individual comes to terms with his/her life & future or someone else's; this stage varies. Eventually has a calm and stable mind set. ("It's going to be okay")

What are the laboratory tests used to confirm the diagnosis of HIV infection in an adult?

ELISA (Enzyme Linked Immunosorbent Assay): if tested positive for the ELISA, a western blot test should be performed (may test negative if tested within a few weeks of infection; more sensitive to chronic infections) Viral Load Test: measures amount of HIV in blood; can be used to detect early infection or monitor treatment outcomes; 3 Type measure viral load in blood: polymerase chain reaction, branched DNA, and nucleic acid sequence-based amplification assay. Western Blot Test: Blood test used to confirm a positive ELISA test

Briefly discuss how HIV is transmitted and how it is not. How can Mr. Thomas prevent the transmission of HIV to his wife and others?

HIV is transmitted through bodily fluids (blood, semen, vaginal secretions, amniotic fluid, and breast milk), it is not transmitted through skin contact unless there is inflammation and breaks in the skin or mucosa which can result in the increased probability than HIV exposure will lead to infection. Mother to child transmission of HIV may occur in utero, at time of delivery or through breast feeding, but most perinatal infections are thought to occur after exposure during delivery. Mr. Thomas must use safe sex practices such as a condom to prevent transmission to his wife. He must be vigilant to wear bandages or cleaning up blood or other bodily fluids if spilled. Standard contact precautions are sufficient for HIV. He family must be educated on transmission of disease and how to prevent it. It must also be stressed that causal contact does not spread HIV, so the family can hug the father etc.

Discuss how the nurse should respond if Mr. Thomas's wife approaches him in the hall and asks, "Did the test results come back yet? Do you know what is wrong with my husband?

I would request that we go to a private room to discuss this matter further. I would do this in a room separate from her husband to avoid conflict and allow her to bring up any questions or concerns privately.

Following the nurse's teaching, Mr. Thomas states, "How stupid I was to have that affair. Not only could it ruin my marriage, but it gave me a death sentence." Share with Mr. Thomas what you know about long-term survivors, long-term nonprogressors, and Highly Active Antiretroviral Therapy (HAART).

I would tell him that the diagnosis is not necessarily a death sentence. Though relatively rare (about 1 in 300) long-term nonprogressors never have their HIV develop into aids and do not require medical intervention. These anomalies are due to genetic mutations that make them less vulnerable to the disease. There are a number of different types of long-term survivors, including nonprogressors and slow progressors, but with early treatment before the immune system is compromised, medication adherence and without other comorbidities, people with HIV can potentially match, or even exceed, the typical life expectancy. We can promote the health of someone with HAART or highly active anti-retroviral therapy. This regimen is usually several drugs that disrupt the virus during different phases in its replication, this greatly slowing or halting its progress.

Mr. Thomas expresses a readiness to learn more about HIV. Discuss the nurse's initial intervention when beginning client teaching, and then discuss the progression of the HIV disease, including an explanation of primary infection, categories (groups) A, B, and C, and four main types of opportunistic infections.

Initially the nurse should assess the clients knowledge about HIV, and his ability to learn about the disease. There are 3 stages of HIV; Acute infection, Clinical Latency, and AIDS. The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection, also known as stage 1. During this stage the virus is being replicated rapidly within the body that leads to a dractic drop on CD4+T cells; this may manifest itself as severe flu-like symptoms within 1-2 weeks after infection in most people. After the initial immune response a viral set point is reached-an equilibrium between HIV levels and the immune response. The laboratory evidence of this stage is the confirmation of HIV infection and a CD4+T lymphocyte count > 500 mcL or CD4+T lymphocyte percentage > 29. Stage 2, clinical latency the reproduction rate slows. Symptoms may be non existent and this stage can last for decades with proper medical treatment. Laboratory evidence of this stage includes confirmation of HIV infection and a CD4+T lymphocyte count 200-499 mcL or CD4+T lymphocyte percentage 14-28 The 3rd, and final stage is AIDS and occurs when CD4+T cells fall below 200 cells/mm3. A person is also considered in the AIDS stage if they have one or more opportunistic infections. With treatment the average lifespan at this stage is 3 years, and 1 without. The four main types of opportunistic infections are; Pneumocystis Pneumonia (PCP), Mycobacterium avium complex (MAC), Tuberculosis, and Candidiasis. PCP is caused by P. jiroveci. Symptoms start as nonspecific such as nonproductive cough, SOB, fever, chills, and chest pain. Eventually it causes significant pulmonary impairment and respiratory failure. Respiratory failure can occur as early as 2-3 days after infection. MAC is comprised of a group of acid fast bacilli. It usually causes respiratory infection, but can commonly be found in the GI tract, lymph nodes, and bone marrow. TB can develop in the lungs as well as extrapulmonary sites such as the CNS, bone, pericardium, stomach, peritoneum and scrotum. Candidiasis, commonly found in the oral cavity, is characterized by thrush. If untreated it can progress to the esophagus and stomach.

List five possible nursing Diagnoses appropriate to consider for Mr. Thomas

Knowledge deficit related to HIV as evidenced by verbalized misinformation about prognosis. Ineffective coping related to HIV as evidenced by verbalized panic over diagnosis Impaired gas exchange related to pneumonia as evidenced by shortness of breath Risk for infection Imbalanced nutrition: less than body requirements related to HIV as evidenced by weight loss

Discuss the ethical dilemmas inherent in this case.

Mr. Thomas does not want to tell his wife, who could possibly be infected with HIV. In most cases, sharing your HIV status is a personal choice—but it may also be a legal requirement. Many states have laws that require you to tell specific people about your HIV status.

Discuss which stage of grief Mr. Thomas is most likely experiencing. Provide examples of Mr. Thomas's behavior that support your decision.

Mr. Thomas is most likely experiencing the bargaining stage of grief as evidenced by his negotiations with himself on the extent of information he chooses to share with his wife. Mr. Thomas believes that by with holding the information from his wife he can prevent her from becoming upset and leaving him so he only tells half of the truth. He also promises to tell her the whole truth if she becomes ill.

Does Connecticut have statutes that allow other health care providers to disclose a client's HIV status?

No. The AIDS Law Project believes that any general laws related to "duty to warn"55 do not pertain to HIV disclosure, because Connecticut law specifically protects the confidentiality of HIV-related information and makes no exceptions for mental health providers, such as psychologists and social workers.

Discuss HIV/AIDS from a global perspective, and identify cultural/economic or other barriers to worldwide prevention

Spread varies in different places. Some has spread of HIV/AIDS to most of the population and others places it has effect the high risk populations (i.e. sex workers and customers, injection drug users, men who have sex with men. Africa is the most effected by HIV/AIDS; it has the lowest level access to care and low economic stability. Most transmissions are heterosexual; transmissions from blood transfusions and mother to child also contribute to high infection rates. Breast feeding is still encourage with HIV/AIDS infected mothers due to water contamination and improper use of bottle feeds causing malnutrition.

What is recommended for "partner notification" of a patient who refuses to tell a partner?

The following are specific recommendations for implementing partner-notification procedures: HIV-infected patients should be encouraged to notify their partners and to refer them for counseling and testing. If requested by the patient, health-care providers should assist in this process, either directly or by referral to health department partner-notification programs. If patients are unwilling to notify their partners or if they cannot ensure that their partners will seek counseling, physicians or health department personnel should use confidential partner notification procedures. Partners who have been reached and were exposed to genital secretions and/or blood of an HIV-infected partner through sex or injection-drug use within the preceding 72 hours should be offered postexposure prophylaxis with combination antiretrovirals

Briefly explain the purpose of viral load blood tests in monitoring the progression of HIV.

Viral load is the amount of HIV that is found in your blood stream, and typically a person's viral load and CD4+ T have an inverse relationship and therefore are more prone to opportunistic infections.Typically, when a person is first infected with HIV their viral load is very high, initially the body responds and brings the viral load down to a "set point", here the viral load will gernerally remain low in the early part of the disease but viral load eventually increases. Therefore amount of viral load can be a good predictor of the progression of HIV.

Mr. Thomas stated, "What will people think of me if they know I have AIDS?" How can the nurse explain the difference between being HIV positive and having AIDS?

When a person is infected with the human immunodeficiency virus (HIV) we say that he or she is "HIV positive," or "has HIV." A person who has HIV is classified as having AIDS if one of two things happens: the CD4 count has dropped below 200/cc, or an HIV-related infection or HIV-related cancer develops. A CD4 count below 200 cells/cc is called AIDS by definition. A patient may have 200 CD4 cells or less and feel very healthy, but he or she still has AIDS by definition. The reason 200 was chosen as the cut-off for AIDS is that most HIV-related infections and cancers occur in patients with less than 200 CD4 cells. AIDS is the final stage of HIV infection, and not everyone who has HIV advances to this stage. People at this stage of HIV disease have badly damaged immune systems, which put them at risk for opportunistic infections (OIs). You are considered to have progressed to AIDS if you have one or more specific OIs, certain cancers, or a very low number of CD4 cells. If you have AIDS, you will need medical intervention and treatment to prevent death.

Does Connecticut have an HIV-specific duty to warn statute that pertains to physicians and public health officers?

Yes, Connecticut law permits both public health officers and physicians, under certain circumstances, to inform or warn partners that they may have been exposed to HIV The requirements for such a disclosure by a public health officer are that: There is a reasonable belief of a significant risk of transmissionto the partner; The public health officer has counseled the individual regarding the need to notify a partner and reasonably believes that the individual will not disclose to the partner; and The public health officer has informed the protected individual of his or her intent to make the disclosure.

Does the health care provider have a legal obligation to tell anyone other than Mr. Thomas that he is HIV positive? If so, discuss.

Yes, the health care provider has a legal obligation to notify the state health department about Mr. Thomas's HIV status so that public health officials can keep track of the HIV epidemic. Also, if the state has a partner-notification law then he or his health care provider may be legally obligated to tell his spouse.