Clinical Manifestations
Acute HIV Infection
- Acute HIV infection, occurring 2-4 weeks after exposure, presents with flu-like symptoms including fever, fatigue, pharyngitis, lymphadenopathy, myalgia, and maculopapular rash. These symptoms typically last 1-2 weeks and often go unrecognized as HIV infection.
- During this phase, viral replication is extensive with high viral loads, making individuals highly infectious despite negative antibody tests (window period).
Key Points
- Acute HIV symptoms are often mistaken for influenza or mononucleosis.
- The window period (time between infection and detectable antibodies) can last 3-12 weeks.
AIDS-Defining Conditions
- AIDS is diagnosed when a person with HIV develops one or more opportunistic infections or certain cancers, or when CD4 count drops below 200 cells/mm³. Common opportunistic infections include Pneumocystis jirovecii pneumonia (PJP), candidiasis, toxoplasmosis, and cryptococcal meningitis.
- AIDS-defining malignancies include Kaposi's sarcoma, non-Hodgkin lymphoma, and invasive cervical cancer. These conditions rarely occur in individuals with intact immune systems.
Key Points
- PJP is one of the most common opportunistic infections, presenting with nonproductive cough, fever, and dyspnea.
- Kaposi's sarcoma presents as purplish-brown lesions on the skin and mucous membranes.
- Wasting syndrome (involuntary weight loss >10% of baseline) is an AIDS-defining condition.
Clinical Scenario
A 32-year-old male presents with persistent fever, night sweats, unexplained weight loss (15 lbs in 2 months), and white patches in his mouth. Laboratory results show CD4 count of 175 cells/mm³. The white patches are diagnosed as oral candidiasis. This presentation is consistent with AIDS, and the patient should be started on antiretroviral therapy immediately along with prophylaxis for opportunistic infections.
Treatment
Antiretroviral Therapy (ART)
- Antiretroviral therapy is recommended for all individuals diagnosed with HIV, regardless of CD4 count or clinical stage. Current guidelines recommend combination therapy with at least three drugs from at least two different drug classes to prevent resistance.
- Common antiretroviral drug classes include nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), integrase strand transfer inhibitors (INSTIs), and entry inhibitors.
Key Points
- ART should be initiated as soon as possible after diagnosis to prevent disease progression and reduce transmission risk.
- Medication adherence of >95% is critical to prevent viral resistance.
- Single-tablet regimens improve adherence and are preferred when possible.
Common Antiretroviral Medications
| Drug Class |
Examples |
Mechanism |
Common Side Effects |
| NRTIs |
Tenofovir, Emtricitabine, Lamivudine |
Block reverse transcriptase enzyme |
Lactic acidosis, hepatomegaly, lipoatrophy |
| NNRTIs |
Efavirenz, Rilpivirine |
Bind to reverse transcriptase enzyme |
Rash, neuropsychiatric symptoms |
| PIs |
Darunavir, Atazanavir |
Block protease enzyme |
GI intolerance, lipid abnormalities |
| INSTIs |
Dolutegravir, Raltegravir |
Block integrase enzyme |
Insomnia, headache, weight gain |
| Entry Inhibitors |
Maraviroc, Enfuvirtide |
Block viral entry into cells |
Injection site reactions (enfuvirtide) |
Opportunistic Infection Prophylaxis
- Prophylactic medications are prescribed based on CD4 count to prevent common opportunistic infections. For CD4 counts <200 cells/mm³, trimethoprim-sulfamethoxazole (TMP-SMX) is recommended to prevent Pneumocystis pneumonia (PJP).
- Additional prophylaxis may be indicated for toxoplasmosis (CD4 <100 cells/mm³), Mycobacterium avium complex (CD4 <50 cells/mm³), and fungal infections depending on exposure risk and geographic location.
Key Points
- Prophylaxis can be discontinued when CD4 counts increase and remain above threshold levels for at least 3-6 months with viral suppression.
- TMP-SMX prophylaxis also provides protection against toxoplasmosis and some bacterial infections.
Important Alert
Patients taking antiretroviral medications often experience significant drug-drug interactions. Always check for interactions before starting any new medication, including over-the-counter drugs and herbal supplements. Protease inhibitors and NNRTIs have the highest potential for interactions as they affect cytochrome P450 enzymes.
Nursing Care
Assessment Priorities
- Comprehensive nursing assessment for patients with HIV includes monitoring for signs of opportunistic infections, medication side effects, and treatment adherence. Key assessments include vital signs, weight, skin integrity, oral cavity examination, respiratory status, and neurological function.
- Psychosocial assessment is crucial, including evaluation of support systems, mental health status, substance use, and ability to perform activities of daily living.
Key Points
- Regular assessment of skin and mucous membranes for lesions, rashes, or infections.
- Monitor for signs of medication toxicity including hepatotoxicity, nephrotoxicity, and metabolic abnormalities.
- Assess for depression and anxiety, which are common in HIV patients.
Nursing Interventions
- Provide medication education, emphasizing the importance of strict adherence to prevent resistance.
- Teach patients to recognize and report signs of opportunistic infections promptly.
- Implement appropriate infection control measures, including standard precautions.
- Promote adequate nutrition and hydration to support immune function.
- Facilitate access to support services, including case management, mental health services, and support groups.
- Provide education about transmission prevention, including safer sex practices and harm reduction for substance users.
Key Points
- Use teach-back method to confirm patient understanding of complex medication regimens.
- Develop individualized adherence strategies based on patient's lifestyle and barriers.
Memory Aid: HAART Regimen Components
Remember the main antiretroviral drug classes with "PIN-E":
- Protease Inhibitors
- Integrase Inhibitors
- Nucleosides/Nucleotides (NRTIs) and Non-nucleosides (NNRTIs)
- Entry Inhibitors
Study Tips
Memory Aid: AIDS-Defining Conditions
Remember common AIDS-defining conditions with "CAPTIVATE":
- Candidiasis (esophageal, bronchial, or pulmonary)
- AIDS dementia complex
- Pneumocystis pneumonia
- Toxoplasmosis of the brain
- Invasive cervical cancer
- Viral infections (CMV, HSV)
- Atypical mycobacteria (M. avium complex)
- Tuberculosis (extrapulmonary)
- Extreme wasting (>10% body weight)
Memory Aid: CD4 Count Thresholds
Remember prophylaxis thresholds with "200-100-50":
- 200 cells/mm³: PJP prophylaxis (TMP-SMX)
- 100 cells/mm³: Toxoplasmosis prophylaxis (TMP-SMX)
- 50 cells/mm³: MAC prophylaxis (Azithromycin)
NCLEX Strategy for HIV/AIDS Questions
- For medication questions, focus on understanding drug classes rather than memorizing individual medications. Know the major side effects and contraindications for each class.
- For patient education questions, prioritize safety information, adherence strategies, and transmission prevention.
- For assessment questions, remember that opportunistic infections present atypically and may be more severe in immunocompromised patients.
- Apply the nursing process (assessment, diagnosis, planning, implementation, evaluation) to organize your approach to complex HIV/AIDS scenarios.
Quick Check
1. What CD4 count defines AIDS?
2. Name three antiretroviral drug classes.
3. What prophylactic medication is used to prevent PJP?
4. What is the window period in HIV testing?
5. What does U=U mean in HIV care?
Summary of Key Points
- HIV is a retrovirus that targets CD4+ T cells, leading to progressive immune system deterioration. AIDS is diagnosed when CD4 count falls below 200 cells/mm³ or when opportunistic infections develop.
- Transmission occurs through direct contact with infected body fluids, primarily through sexual contact, sharing needles, and mother-to-child transmission.
- Antiretroviral therapy (ART) is recommended for all HIV-positive individuals regardless of CD4 count, using a combination of medications from different drug classes.
- Strict medication adherence (>95%) is essential to prevent viral resistance and maintain viral suppression.
- Prophylactic medications are prescribed based on CD4 count thresholds to prevent opportunistic infections.
- Regular monitoring includes CD4 count, viral load, and screening for medication side effects and opportunistic infections.
- Nursing care focuses on medication management, symptom monitoring, infection prevention, and psychosocial support.
- Prevention strategies include PrEP, PEP, safer sex practices, and harm reduction for injection drug users.
- Treatment as prevention (U=U) emphasizes that individuals with undetectable viral loads cannot sexually transmit HIV.
Self-Assessment Checklist