The document discusses AIDS (acquired immunodeficiency syndrome), which is caused by HIV (human immunodeficiency virus) infection. It defines AIDS and describes the pathophysiology, risk factors, clinical manifestations, diagnostic tests, medical management including antiretroviral drugs, and nursing management of patients with AIDS. It also summarizes a research study on the use of first-line antiretroviral therapy from an ART program clinic in Pune, India.

1. AIDS
Ms. Minu Sharma
MSc Nursing 2nd Year
Himalayan College of Nursing

2. Objectives
• Define AIDS
• Enlist etiology and risk factors of AIDS
• Describe pathophysiology of AIDS
• Elaborate the clinical manifestation of AIDS
• Describe the diagnostic finding of AIDS
• Explain medical management of AIDS
• Explain nursing management of AIDS
• Understand the article related to AIDS

4. Acquired immunodeficiency syndrome (AIDS) is
defined as the most severe form of a continuum
of illnesses associated with human
immunodeficiency virus (HIV) infection

5. HIV belongs to a group of viruses known as
retroviruses. These viruses carry their genetic
material in the form of ribonucleic acid (RNA)
rather than deoxyribonucleic acid (DNA)..

6. Infection with HIV occurs when it enters the host
CD4 (T) cell and causes this cell to replicate viral
RNA and viral proteins, which in turn invade
other CD4 cells

7. Four categories of infected states have been denoted:
• Primary infection (acute/recent HIV infection,
acute HIV syndrome: dramatic drops in CD4 T-cell
counts, which are normally between 500 and 1,500
cells/mm3)
• HIV asymptomatic (CDC Category A: more than
500 CD4 T lymphocytes/mm3)

8. • HIV symptomatic (CDC Category B: 200 to 499
CD4 T lymphocytes/mm3)
• AIDS (CDC Category C: fewer than 200 CD4 T
lymphocytes/mm3)

9. CDC (central for disease control and prevention )
(January 1994): “Persons with CD4 cell count of
under 200 (with or without symptoms of
opportunistic infection) who are HIV-positive are
diagnosed as having AIDS.”

10. Risk Factors
• Heterosexual intercourse with an HIV-infected
partner
• Injection drug use
• Male homosexual relations.

11. • Transfusions of blood or blood products
contaminated with HIV
• Children born to mothers with HIV
infection
• Breast-fed infants of HIV-infected mothers
• Health care workers exposed to needle-stick
injury associated with an infected
patient

12. Etiology
Human immune deficiency virus (HIV)

13. Pathophysiology

16. Clinical Manifestations
ACUTE INFECTION
Flu like syndrome of fever
Swollen lymph glands
Sore throat
Muscle & joint pain
Diarrhea
Diffuse rash

17. CHRONIC HIV INFECTION (Asymptomatic disease):
- Early chronic infection:
CD4 cell count - >500 cells/μl
Fatigue
Head ache
Low grade fever
Night sweats
Persistent generalized lymphadenopathy

18. - Intermediate chronic infection:
CD4 cell count – 200-500 cells/μl
Persistent fever
Drenching night sweats
Chronic diarrhea
Recurrent headaches
Fatigue

19. Lymphadenopathy
Oro-pharyngeal candidiasis/thrush
Shingles
Bacterial infection
Kaposi’s sarcoma
Oral hairy leukoplakia

20. - Late chronic infection:
The ratio of CD4 to CD8 cells about 1:2
Increased viral load
Opportunistic diseases
Disability & death

21. WHO Clinical staging
WHO has developed a staging system in which 4
clinical staging of disease have been identified

22. STAGE
1ST
• PRIMARY INFECTION
• Proliferation of virus in blood and
lymph node CD4 cell count decline
STAGE
2ND
• EARLY IMUNE DEFICIENCY
Immune system control the
infection CD4 cell >500/m3,no
symptoms

23. STAGE
3RD
• INTERMEDIATE IMMUNE
DEFICIENCY
• Viral application is very highCD4 cell 200-
500/m3,sign & symptoms begin to appers.
STAGE
4th
• ADVANCE IMMUNE DEFICIENCY
• Viral proliferation through body, patient
having opportunistic infection and
malignancies.

24. Diagnostic Studies
• CBC: Anemia and idiopathic thrombocytopenia (anemia
occurs in up to 85% of patients with AIDS and may be
profound). Leukopenia may be present; differential shift
to the left suggests infectious process (PCP), although
shift to the right may be noted.
• PPD: Determines exposure and/or active TB disease. Of
AIDS patients, 100% of those exposed to active
Mycobacterium tuberculosis will develop the disease.

25. • Serologic: Serum antibody test: HIV screen by
ELISA. A positive test result may be indicative
of exposure to HIV but is not diagnostic because
false-positives may occur.
• Western blot test: Confirms diagnosis of HIV in
blood and urine.

27. Viral load test:
RI-PCR: The most widely used test currently can
detect viral RNA levels as low as 50 copies/mL of
plasma with an upper limit of 75,000 copies/mL.

28. • bDNA 3.0 assay: Has a wider range of 50–500,000
copies/mL. Therapy can be initiated, or changes made in
treatment approaches, based on rise of viral load or
maintenance of a low viral load. This is currently the
leading indicator of effectiveness of therapy.
• T8+ CTL (cytopathic suppressor cells): Reversed ratio
(2:1 or higher) of suppressor cells to helper cells (T8+ to
T4+) indicates immune suppression.

29. • CD4+ lymphocyte count (immune system indicator that
mediates several immune system processes and signals
B cells to produce antibodies to foreign germs):
Numbers less than 200 indicate severe immune
deficiency response and diagnosis of AIDS.

30. • Polymerase chain reaction (PCR) test: Detects
HIV-DNA; most helpful in testing newborns of
HIV-infected mothers. Infants carry maternal
HIV antibodies and therefore test positive by
ELISA and Western blot, even though infant is
not necessarily infected.

31. • STD screening tests: Hepatitis B envelope and
core antibodies, syphilis, and other common
STDs may be positive.

32. • Cultures: Histologic, cytologic studies of urine, blood,
stool, spinal fluid, lesions, sputum, and secretions may
be done to identify the opportunistic infection. Some of
the most commonly identified are the following:
 Protozoal and helminthic infections: PCP,
cryptosporidiosis, toxoplasmosis.
 Fungal infections: Candida albicans (candidiasis),
Cryptococcus neoformans (cryptococcosis),
Histoplasma capsulatum (histoplasmosis).

33.  Bacterial infections: Mycobacterium avium-intracellulare
(occurs with CD4 counts less than 50),
miliary mycobacterial TB, Shigella (shigellosis),
Salmonella (salmonellosis).
 Viral infections: CMV (occurs with CD4 counts less
than 50), herpes simplex, herpes zoster.

34. Neurological studies
• Electroencephalogram (EEG)
• Magnetic resonance imaging (MRI)
• Computed tomography (CT) scans of the brain
• Electromyography (EMG)/nerve conduction

35. • Chest X-ray
• Pulmonary function tests
• Gallium scan
• Biopsies
• Bronchoscopy/tracheobronchial washings
• Barium swallow, endoscopy, colonoscopy

36. Medical Management
• Rest
• Proper nutritious diet
• Psychological support

37. Counseling
Counseling services are the backbone of the HIV
program. Counseling is offered through the ICTC
( Integrated Counseling Treatment Centre )
programme for voluntary clients PICT ( Provider
Initiative Counseling and Testing) for pregnant
women

38. Types of counseling
1. Pre Test Counselling
2. Post Test Counselling
3. PPTCT Counselling
4. Family and Relationship Counselling
5. Adherence Counselling
6. Crisis Counselling
7. On-going Counselling

39. Drugs
• Nucleotide reverse transcriptase inhibitors
• Nucleoside reverse transcriptase inhibitors
• Non-nucleoside reverse transcriptase inhibitors
• Protease inhibitors
• Fusion inhibitors

40. Antiretroviral Therapy
Antiretroviral treatment for HIV infection consist of
drugs which works against HIV infection itself by
slowing down the replication of HIV in the body drugs
are often referred to as :
ART – Anti Retroviral Therapy
ARVs - Anti Retro Virals
HAART- Highly Active Anti Retroviral Therapy

41. Antiretroviral Agents

42. Nucleoside reverse transcriptase inhibitors (NRTIs)
• HIV infects a cell, reverse transcriptase Copies the viral
single stranded RNA genone into double stranded viral
DNA. The viral DNA is than integrated into the host
chromosomal DNA, which then allow host cellular
processes, such as transcription and translation to
reproduce virus.

43. • NRTIs block reverse transcriptase enzymatic function
and prevent completion of synthesis of the double
stranded viral DNA, thus preventing HIV from
multiplying
 Zidovudine
 Lamivudine
 Stavudine
 Didanosine
 Abacavir
 Tenofavir

44. Non-Nucleoside reverse transcriptase inhibitors
(NNRTIs)
• NNRTIs are not incorporated into the viral DNA but
instead inhibit the movement of protient domains of
reverse transcriptase that are needed to carry out the
process of DNA synthesis.
 Efavirenz
 Nevirapine

45. Protease inhibitors
• Protease inhibitors blocks the Protease enzymes. When
protease is blocked, HIV makes copies of itself that
can’t infect new cells. Studies have shown that protease
inhibitors can reduce the virus in the blood and increase
CD4 cell counts.
 Nelfinavir
 Lopinavir /retonavir
 Saquinavir
 Indinavir
 Ritonavir

48. Treatment of infection
• Antibacterial agents like trimethoprim-sulfamethoxazole
for treating various infection
• Amphotericine B or Fluconazole to treat meningitis
• Antiviral agents such as ganciclovir and foscavir for
cytomegalovirus retinitis
• Acyclovir can be used to treat infection caused by
herpes simplex or herpes zoster

49. Antidiarrhreal therapy
• Therapy with octreotide acetate, a synthetic analogue of
somatostanin, has been effective in managing chronic
severe diarrhea. High concentration of somatostanin
receptors have been found in the GI tract and other
tissues.

50. Chemotherapy
• Kaposi’s Sarcoma is treated with alpha- interferone
• Lymphoma treatment is the combination of radiotherapy
and chemotherapy

51. Antidepressant therapy
Depressive symptoms are severe and of longer
duration, treatment with antidepressant such as
imipramine, desipramine and fluoxetine. A
psychostimulant such as methylphenidate may be used
in low doses

52. Complementary therapies
• Yoga : Yoga is a set of exercise that people use to
improve their fitness, reduce stress, and increase
flexibility. Yoga can involve breathing exercise, certain
stretches and poses and meditation
• Massage : An excellent way to deal with the stress and
to deal with the stress and side effects that go along with
having an illness, including HIV. A trained therapist
moves and rub on muscles.

53. • Aromatherapy : It is based on the idea that certain smells
can change the way the person feels. The smells used
are from plant oil, and they can be inhaled or used in
baths or massages
• Relaxation technique (meditation, imagery ) :
Relaxation therapy such as meditation and guided
imagination focus on how a person’s mind and
imagination can promote overall health and well- being.

54. • Reflexology : Reflexology is an ancient Chinese
technique that uses pressure-point message usually on
feet, but also on the hands and ears that relate to every
organ and part of our body.
• Laughter therapy : Laughter therapy is the use of
laughter for the relief of physical or emotional pain or
stress. It improves the immunity

55. • Music therapy : It consist of systemic application of
music by the music therapist to bring about the helpful
changes in the physical and emotional health of the
client.
• Hydrotherapy : It is the use of water (hot, cold, steam or
ice) to relieve discomfort and promote well being.

57. Nursing Process
Assessment
• Nutritional Status
• Skin and Mucous Membranes
• Respiratory Status
• Neurologic Status
• Level of Knowledge
• Use of Alternative Therapies

58. Nursing Priorities
• Prevent/minimize development of new infections.
• Maintain homeostasis.
• Promote comfort.
• Support psychosocial adjustment.
• Provide information about disease process/prognosis
and treatment needs.

59. Discharge Goals
• Infection prevented/resolved.
• Complications prevented/minimized.
• Pain/discomfort alleviated or controlled.
• Patient dealing with current situation realistically.
• Diagnosis, prognosis, and therapeutic regimen
understood.
• Plan in place to meet needs after discharge.

60. Nursing diagnosis:-
Impaired thermoregulation related to chronic HIV
infection, secondary opportunistic infection,
malignancy, autoimmune disorders, diarrhea,
dehydration, allergic response to medications, or
infection at IV sites, catheter, drains and incisions.
Outcome :- Control fever and replace fluid loss

61. Intervention:-
• Nonpharmacologic intervention include keeping the
patient in a warm room and applying a loose woven
sheet or blanket
• Increase calorie and fluid intake by providing a plan of
six feeding over 24 hours and high protein, high calorie
nutrient supplements
• Provide dry cloths and bed linens
• Keep liquids at bedsides
• Antipyretic agents

62. Nursing diagnosis:-
Activity intolerance related to chronic HIV infection,
secondary opportunistic infection, anemia, malnutrition,
dehydration, prolonged immobility, and situational
factor
Outcome :- Increase self awareness of fatigue and self
care

63. Intervention:-
• Daily fatigue diary for at least 1 week
• Advise to avoid coffee, tobacco and alcohol which may
increase fatigue
• Promote adequate sleep by increasing amount of sleep
everyday
• Reduce sleep-cycle interruption

64. • Promote rest and activity by developing a 24 hour
schedule
• Prepare exercise schedule and plan at peak energy time
• Progressive muscles relaxation, acupuncture, massage
therapy, relaxation, therapeutic touch and social support

65. Nursing diagnosis:-
Imbalance nutrition: Less than body requirements
related to increase nutrients requirements, decrease food
intake secondary to side effects of medication and
infection such as anorexia, nausea, vomiting, impaired
swallowing or chewing, diarrhea, fatigue and impaired
cognition
Outcome :- Increase food intake, preserve lean body mass
and provide adequate level of all nutrients.

66. Intervention:-
• Minimise anorexia
• Prevent weight loss
Small and frequent meals
Eating high calorie snacks
Indulging in favourite foods
Consuming more nutrients
Drinking liquids 30 minutes before meals instead of
eating with meals
Encourage to dine with friends or family

67. • Improve food intake
 Eat food at room temperature
 Choose mild food and drinks such as apple juice
instead of orange juice
 Eat dry grains
 Use a straw when drinkingtilt head forward or
backward for good swallowing
• Increase the availability of foods
• Teach nutritional requirements

68. Nursing diagnosis:-
Acute pain or chronic pain related to Arthralgia, Myalgia
or neuropathy associated with HIV infection, mass
lesion associated with opportunistic infection,
malignancy, side effects of medication or intervention
such as surgery
Outcome :- Enhance comfort and satisfaction

69. Intervention:-
• Provide comfort measures
• Provide physical therapy
Exercise to maintain physical activity
Application of heat or cold to reduce musculoskeletal
abnormality
Therapeutic massage
Transcutaneous electrical nerve stimulation (TENS)
• Administer pain medication : opioids
• Encourage complementary therapy

70. Research study
Use of first line antiretroviral therapy from a free
ART programme clinic in Pune, India - A preliminary
report prepared on a study of antiretroviral therapy
(ART) programme conducted in pune. Antiretroviral
naive HIV infected patients attending the clinic between
December 2005 and April 2008 and followed up till
March 31, 2011 were included in the analysis.

71. The enrolment and follow up of these patients were
done as per the national guidelines. Viral load
estimations were done in a subset of patients. The study
concluded that the first line treatment was effective in
patients attending the programme clinic. The adherence
level influenced immunological and virological
outcomes of patients.

72. Reference
• Use of first line antiretroviral therapy from a free ART
programme clinic in Pune, India v.137(5); May 2013
PMC3734687Available at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734687
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