NCP The HIV Positive Patient

The individual identified as HIV-seropositive is one who is asymptomatic and does not meet the Centers for Disease Control and Prevention (CDC) definition for AIDS. Studies reveal that persons with HIV-positive status may remain asymptomatic for 10 or more years. During the period of asymptomatic infection, the individual has HIV in the blood and is contagious to others. Patients may live longer without symptoms if receiving highly active antiretroviral therapy (HAART) to reduce the viral load. After approximately a decade, especially in the undertreated individual, the immune system begins to decline and he or she develops symptoms of immune deficiency, a phase termed “symptomatic HIV infection.” The individual might then develop AIDS-defining diseases. With the inception of multiple drug regimens (using combinations of nucleoside reverse transcriptase inhibitors [NRTIs], protease inhibitors [PIs], or nonnucleoside
reverse transcriptase inhibitors [NNRTIs]), the CD8+ CTL (cytotoxic T-lymphocyte) and the CD4 count can be maintained at higher levels longer and the viral load minimized.Controlling replication of HIV and lowering the viral load are the current focus of early intervention. Although imminent death is not a realistic concern, the patient needs to make major behavioral and lifestyle changes to prolong life expectancy and may have significant problems that require
information and assistance. The person who is well supported medically may lead a productive life for an extended period. At present the rate of new infections is rapidly increasing among people of color, women in general (with the most common mode of transmission being heterosexual activity), and resurgence among young homosexual men who did not experience the losses of their predecessors and have a misconception regarding the efficacy of medications and therefore are engaging in unsafe sexual practices.

CARE SETTING

Community setting, although development of opportunistic infections may require occasional inpatient acute medical
care.

RELATED FACTORS

AIDS
Extended care
Fluid and electrolyte imbalances
Pneumonia: microbial
Psychosocial aspects of care
Sepsis/septicemia

Patient Assessment Database

Although patient may be asymptomatic, refer to CP: AIDS for potential signs/symptoms.

Refer to section at end of plan for ongoing considerations.

DIAGNOSTIC STUDIES
Enzyme-linked immunosorbent assay (ELISA): A positive test result may be indicative of exposure to HIV but is not diagnostic. Sensitivity varies, with the incidence of false-positive results being approximately 10%.
(Seroconversion can occur between 4 wk to 6 mo after exposure.)
Western blot test (blood/urine): Confirms diagnosis of HIV-1 in individuals with positive ELISA screening.
Viral load tests:
RI-PCR: Detects viral RNA levels as low as 50 copies/mL of plasma.
bDNA 3.0 assay: Has a wider range: 50–500,000 copies/mL. (The RI-PCR range is 50–75,000/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 effectivenss of therapy.
CD8+ CTL (cytopathic suppressor cells): Current quantitative assays allow for rapid evaluation of levels. CD8+ (CTL) have been strongly implicated in the control of HIV-1 replications. At late stage of infection, CD8+ (CTL) numbers are reduced.
CD4+ lymphocyte count (previously T4 helper cells): Reduced. Patients with counts below 500 benefit from antiretroviral therapy; counts equal to/or below 200 define progression to AIDS. Levels are measured immediately before and again 4–8 wk after initiation of antiretroviral therapy. Thus, it is used to diagnose HIV infection and progression and to monitor effects of drug therapy. The role of CD4+ T-cells is unclear. CD4+ cells are a target for HIV infection and destruction. Some researchers postulate CD4+ cells are eliminated early. They may not contribute to host defense substantially in the late stages of disease.
Screening tests: Purified protein derivative (PPD): Used to screen for TB exposure. A positive result reflects current or prior exposure to TB. The criterion for positive PPD when immunodeficiency is present is 5-mm induration.
Serologies: Rapid plasma reagin (RPR)/VDRL: Determines current/past exposure to syphilis and need for more specific testing. Toxoplasma and hepatitis B and C serologies may be done.
Pap smear: Higher incidence (40%) of abnormal cells occurs in HIV-infected women. The critical role of Pap smear screening relates to its ability to detect precursor lesions that can precede the diagnosis of invasive carcinoma by several years.
Pelvic/genital examination: Identifies presence of lesions from sexually transmitted diseases (STDs), cervical and vaginal abnormalities.
Chemistries: Glucose levels elevated as a result of insulin resistance, and lipids rise as HIV infection progresses.
Albumin/prealbumin and transferrin levels are decreased secondary to malabsorption/malnutrition that is usually progressive.
CBC: Hemoglobin, RBC counts are decreased and abnormalities in iron metabolism can result in anemia, which occurs in 17% of asymptomatic patients and up to 85% of patients with advanced disease.
Chest x-ray: Abnormalities suggest presence of TB in PPD-positive, anergic, and/or symptomatic individuals.
Diagnosis is then verified by sputum cultures or other tests, such as gallium scan.

NURSING PRIORITIES

1. Promote acceptance of reality of diagnosis/condition.
2. Support incorporation of behavioral/lifestyle changes to enhance well-being.
3. Provide information about disease process/prognosis and treatment needs.
4. Assist in developing plan and strategies to meet long-term medical, behavioral, and financial needs.

GOALS

1. Dealing with current situation realistically.
2. Participating in and appropriately managing therapeutic regimen.
3. Diagnosis, prognosis, and therapeutic regimen understood.
4. Plan in place to meet medical, behavioral change, and financial needs.