This document provides information on the medical and nursing management of patients with HIV infection. It discusses the objectives of management which include early identification of HIV, continuous care of asymptomatic patients, early intervention, adequate medical care and therapy, and delaying progression to AIDS. The medical management is described in stages from asymptomatic to AIDS-related illnesses. Key aspects of management include risk assessment, establishing diagnosis, determining stage, laboratory tests, initiating antiretroviral therapy and PCP prophylaxis. Nursing management focuses on health education, universal precautions, and prevention. Alternative therapies discussed for treatment include physical therapies like yoga and massage, relaxation techniques, and herbal medicines.

1. MEDICAL AND NURSING MANAGEMENT OF PATIENTS WITH
HIV INFECTION
Antiretroviral Therapy
ALTERNATIVE THERAPIES

2. Introduction
Acquired Immunodeficiency Syndrome (AIDS) is caused by a retrovirus known as the
Human immunodeficiency Virus (HIV). To date there are two types of HIV; HIV-1 and HIV-
2. HIV-1 is known to cause AIDS, however HIV-2 may eventually lead to an
immunodeficiency state; however, perhaps the development of severe immunodeficiency
due to HIV-2 may require a longer latent period. It is thought that 80% of people infected
with HIV-1 will progress to clinical AIDS within 10 years. Management of HIV infection will
require a prolonged period of follow-up and monitoring of these HIV-infected individuals.
The chronic nature of the infection and the social stigma associated with AIDS makes
management of HIV infection more than just providing medical care to these patients. Not
only are we, the medical professionals, providing medical care to them, we may also have
to be their confidante, for seldom will they have anyone else to confide in regarding issues
related to the illness, their jobs, fears, anxieties, etc. Therefore, it is necessary to have a
multidisciplinary approach to the care of HIV-infected patients. In order to develop this, we
need dedicated people working in this area as care givers, and also to provide support to
our other colleagues working in this area

3. Objectives of the management
• To identify early HIV infection
• To provide continuous care to asymptomatic
• To provide early intervention
• To provide adequate medical care with therapy
when required
• To delay progression to full-blown AIDS

4. Medical management
Clinical management of HIV infection will depend on the stage at which the disease process has developed. This
can be broadly classified into 2 clinical stages:
1. Asymptomatic HIV infection
2. Advanced HIV disease.
3. AIDS-related Opportunistic Infections and Tumours.
4. Neuropsychiatric illness
In the process of assessing the possibility of HIV infection, the following steps are recommended.
1. Risk Assessment
2. Establish Diagnosis
3. Ascertain Stage
4. Useful laboratory tests
5. Initiate antiretroviral therapy
6. Initiate PCP prophylaxis
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Assessme
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Establish
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Ascertain
Stage
Useful
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Initiate
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Initiate
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5. Risk Assessment
In the initial evaluation of a patient, a full history including a detailed sexual and
drug history should be obtained.
Questions asked should be:
1. Open-ended Questions
2. Non-Judgemental
3. Not to stigmatise
A complete physical examination has to be done to look specifically for relevant
signs that might indicate the stage of the disease. Initial laboratory tests will include:
a. A Full Blood Count with differential count, particular attention to be given to
platelet and Lymphocyte counts
b. A Monteux Test with 1 Tuberculin unit intradermal
c. A Chest Radiograph

6. Establish Diagnosis
HIV antibody Testing:
ELISA and or Particle agglutination tests Confirmed by supplementary test These tests can be done on
a:
a. voluntary basis
b. anonymously
c. confidential basis
Pre-test Counselling should be given and consent obtained from the patient. Whether the test is
positive or negative, post-test counselling should follow. During the post-test counselling, discussion
on partner notification should be done by the physician or counsellor*. However if the patient is from
out of town and there is no way in getting the partner to be seen by the counsellor or physician, then
the medical officer of Health of that state should be notified and follow-up and counselling will be
done by the health department.
Patient confidentiality should be maintained at all times, however, where the possibility of a spouse or
regular sexual partner may be at risk of being infected, the physician/counsellor should discuss the
need for the patient to inform the partner and further counselling given.

7. Ascertain Diagnosis
To ascertain the stage of the disease process, a complete history and physical
examination and the initial investigations are helpful; however certain other tests
may help with staging the disease. The most commonly used surrogate marker to
assess progression of the disease is by measuring the CD4+ T lymphocyte count and
percentage. Therefore, it is recommended that all HIV infected individuals should
have a baseline CD4+ count done at the initial follow-up, when he is found to be
HIV positive.
Infants born of HIV-infected mothers may be ELISA positive. If the infant is not
HIV infected, the ELISA titres will fall within 18 months after birth. Therefore, a
better indicator of HIV infection in an infant younger then 18 months will be the
measurement of p24 antigen, by doing a polymerase chain reaction (PCR) test, or
detection of the virus itself.

8. Antiretroviral Therapy

19. Initiate PCP prophylaxis
Pneumocystis carinii pneumonia (PCP) is a common opportunistic infection
occurring in HIV infected individuals. In 80% of cases it is the first indicator
of the development of AIDS. Usually these patients will have a CD4+ T
lymphocyte counts of less then 200/uL or a CD4+/CD8+ ratio of less then
20%. Early PCP may be asymptomatic, therefore a high index of suspicion
should be developed in physicians caring for HIV-infected individuals.
Symptoms of PCP may include dry cough of more then 5 days, fever and
difficulty in breathing. Physical examination may show minimal signs. More
advanced infection will include acute breathlessness, cyanosis and presence
of respiratory rates. The chest X-ray may be normal.

20. Management of mild PCP can be done on an outpatient basis, if the patient is
compliant, however in moderately severe infections it is advisable to admit the
patient to the hospital for more intensive management. 25 If the patient is not acutely
ill, oral cotrimoxazole, 4 tablets 6 hourly for 14 days is adequate. In severe PCP
infection, intravenous cotrimoxazole, 20 mg trimethoprim and 100 mg
sulphamethoxazole/kg/day (diluted 1:25 in 0.9% saline or 5% dextrose) should be
given for 14 days. In patients with severe PCP infection, a short course of steroids
can be used together with the cotrimoxazole. Prednisolone is used when the pA02 is
less then 70 mmhg. may lead When using high doses of cotrimoxazole, the side
effects may include: nausea, fever, rashes, which d to Steven-Johnson's syndrome,
raised liver enzymes, bone marrow suppression, and hypernatremia.

21. Follow –up Management
Regular out-patient follow-up of HIV-infected patients is the key in
providing good medical and health services. Follow-up
management requires dedicated health care professionals who will
provide continuity of care and link-up with other services that the
patient requires. The concept of "holistic medicine" and "total care"
should be provided to people with HIV and AIDS. Supportive
counselling and medical care will help detect problems earlier. In
the medical follow-up management of AIDS patients, it is useful to
monitor the following: Clinical Weight gain General well-being Free
from infections Laboratory Full Blood Count & ESR CD4+ cells A
Karnofsky score chart

22. Nursing Management
Health education – The healthcare worker must:
Know the patient
Avoid fear tactics
Avoid judgmental and moralistic messages
Be consistent and concise
Use positive statement
Give practical advice
Practice universal/standard precaution
There is a need for a thorough medical handwashing after every contact with patient and
after removing the gown and gloves, and before leaving the room of an AIDS suspect or
known AIDS patient.
Use of universal barrier or Personal Protective Equipment (PPE) e.g., cap, mask, gloves,
CD gown, face shield/goggles are very necessary.

23. Prevention
Care should be taken to avoid accidental pricks from sharp instruments contaminated with potentially
infectious materials form AIDS patient.
Gloves should be worn when handling blood specimens and other body secretions as well as surfaces,
materials and objects exposed to them.
Blood and other specimens should be labelled with special warning “AIDS Precaution”.
Blood spills should be cleaned immediately using common household disinfectants, like “chlorox”.
Needles should not be bent after use, but should be disposed into a puncture-resistant container.
Personal articles like razor or razor blades, toothbrush should not be shared with other members of the
family. Razor blades may be disposed in the same manner as needles are disposed.
Patients with active AIDS should be isolated.
The Four Cs in the Management of HIV/AIDS
Compliance – giving of information and counselling the client which results to the client’s successful
treatment, prevention and recommendation.
Counselling/education
Giving instruction about the treatment
Disseminating information about the disease
Providing guidance on how to avoid contracting STD again
Sharing facts about HIV and AIDS
Contact tracing
Tracing out and providing treatment or partners
Condoms
Promoting the use of condom, giving instructions about its use, and giving away available condoms

24. Alternative Therapies in treatment of
patients with HIV
Many people use alternative (sometimes known as complementary) health treatments in addition to
the medical care they get from their provider.
These therapies are sometimes called "alternative" because they don't fit into the more mainstream,
Western ways of looking at medicine and health care.
They are called "complementary" therapies because usually they are used alongside the more standard
medical care you receive (such as your VA provider visits and the anti-HIV drugs you might be
taking).
Some common complementary therapies include:
Physical (body) therapies, such as yoga, massage, and acupuncture
Relaxation techniques, such as meditation and visualization
Herbal medicines (from plants)
With most complementary therapies, your health is looked at from a holistic (or "whole picture") point
of view. Think of your body as working as one big system. From a holistic viewpoint, everything you
do--from what you eat to what you drink to how stressed you are--affects your health and well-being.

25. Physical (body) therapies
of these types of therapies.
Yoga
Yoga is a set of Physical, or body, therapies include such activities as yoga, massage, and
aromatherapy. These types of therapies focus on using a person's body and senses to promote
healing and well-being. Here you can learn about examples exercises that people use to improve
their fitness, reduce stress, and increase flexibility.
Yoga can involve breathing exercises, stretching and strengthening poses, and meditation
Many people, including people with HIV, use yoga to reduce stress and to become more relaxed.
Some people think that yoga helps make them healthier in general, because it can make a person's
body stronger.
There are many different types of yoga and various classes you can take.
Before you begin any kind of exercise program, always talk with your health care provider.
Massage
Many people believe that massage therapy is an excellent way to deal with the stress and side
effects that go along with having an illness, including HIV.
During massage therapy, a trained therapist moves and rubs your body tissues (such as your
muscles). There are many kinds of massage therapy.
You can try massage therapy for reducing muscle and back pain, headaches, and soreness.
Massages also can improve your blood flow (circulation) and reduce tension.

26. Acupuncture
Acupuncture is part of a whole healing system known as traditional Chinese medicine. During
acupuncture treatment, tiny needles (about as wide as a hair) are inserted into certain areas of a
person's body. Most people say that they don't feel any pain from the needles.
Many people with HIV use acupuncture. Some people think that acupuncture can help treat symptoms
of HIV and side effects from the medicine, like fatigue and nausea.
Some people say that acupuncture can be used to help with neuropathy (body pain caused by nerve
damage from HIV or the medicines used to treat HIV).
Others report that acupuncture gives them more energy.
If you are interested in trying it out, ask your VA provider to recommend an expert. At the end of this
guide are links to websites where you can read more about the history of acupuncture and how it
works.
Aromatherapy
Aromatherapy is based on the idea that certain smells can change the way you feel. The smells used
in aromatherapy come from plant oils, and they can be inhaled (breathed in) or used in baths or
massages.
People use aromatherapy to help them deal with stress or to help with fatigue. For example, some
people report that lavender oil calms them down and helps them sleep better.
At the end of this guide are links to websites where you can learn more about aromatherapy.
Please remember! The oils used in aromatherapy can be very strong and even harmful. Always talk
with an expert before using these oils yourself.