Human Immunodeficiency Virus (HIV) is a type of retrovirus that causes immunosuppression. HIV progresses to Acquired Immunodeficiency Syndrome (AIDS) when the virus has severely damaged the immune system, and the body can no longer fight off infections. There currently is no cure for HIV, but medication can help patients live a healthy life with a normal life expectancy.
HIV can be transmitted through sexual intercourse with an infected partner, needle-sharing, and to an infant during pregnancy, childbirth, or breastfeeding. HIV cannot be transmitted casually through a handshake, sharing utensils, kissing, or hugging.
In this article:
- Stages of HIV Infection
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Imbalanced Nutrition: Less Than Body Requirements
- Ineffective Protection
- Ineffective Sexuality Pattern
- Risk for Infection
Stages of HIV Infection
HIV infection occurs in the following stages:
- Acute HIV Infection: 2-4 weeks after the initial infection, the patient may develop a flu-like illness as the body attempts to fight off the virus. Symptoms include inflamed lymph nodes, fever, sore throat, malaise, muscle pain, diarrhea, rash, and night sweats.
- Chronic HIV Infection: This phase can last 10-15 years from the initial HIV infection. During this time, patients with HIV are often asymptomatic. They may still infect others, especially if they continue high-risk behaviors without knowing they are infected. If taking antiretroviral therapy, the patient may remain in this stage for decades. If HIV is left untreated, it will advance to AIDS.
- AIDS: This is when the patient’s immune system becomes severely compromised and they cannot fight off opportunistic infections. Their viral load is very high, and they can easily transmit the virus to others. Patients in this stage will only survive a few years.
Nursing Process
Interprofessional management for patients with HIV infection focuses on monitoring the immune function and disease progression, prevention, detection, and treatment of opportunistic illnesses, management of symptoms of the infection, prevention of complications, and prevention of HIV transmission to other people. These goals can only be achieved through ongoing assessment, consistent patient interaction, and patient education and support. Nurses take part in all of these aspects of patient care.
Antiretroviral therapy (ART) are medications prescribed for HIV infection to decrease the viral load, maintain CD4 cell counts at acceptable levels, prevent HIV-related symptoms, delay the progression of the disease, and prevent transmission of the infection. Nurses are instrumental in educating patients about their medication regimen including side effects and strict adherence.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to HIV.
Review of Health History
1. Know the HIV stages and inquire about the patient’s general symptoms.
Symptoms depend on the stage of infection:
- Stage 1: primary infection (acute HIV) – 2-4 weeks after the initial infection, the patient may develop a flu-like illness as the body attempts to fight the virus. Symptoms include:
- Inflamed lymph nodes (most common initial sign of HIV infection)
- Fever
- Headache
- Sore throat
- Malaise
- Muscle aches
- Diarrhea
- Rash
- Night sweats
- Stage 2a: clinical latency – patients may be asymptomatic during this time
- Stage 2b: advanced HIV infection – the patient may develop mild infections or the following chronic signs and symptoms, including:
- Stage 4: progression to AIDS – a patient’s immune system becomes severely compromised and cannot fight off opportunistic infections. Patients may experience:
- Night sweats
- Fever and chills
- Chronic diarrhea
- Inflamed lymph nodes
- White spots or lesions on the tongue or mouth
- Generalized weakness
- Severe weight loss
- Skin rashes or sores
2. Elicit the patient’s possible exposures and histories.
It is essential to perform proper history-taking to uncover any possible HIV exposures. Risk factors include:
- Unprotected sexual contact (receptive anal intercourse has more risk for transmission)
- Multiple sexual partners
- Exposure to sexually transmitted diseases (STDs)
- Sharing of needles
- History of being a recipient of blood transfusion (rare)
- Needle-stick injuries
- HIV infection passed from the mother to the infant during childbirth
3. Advise on contact tracing.
HIV contact tracing (HIV partner notification) is identifying, locating, and notifying someone that a partner with whom they have engaged in sexual activity or drug use has been diagnosed with HIV. Patients must be willing to provide this information.
Physical Assessment
1. Check for the presence of infection.
There are no physical signs unique to HIV infection, and not all patients will display symptoms. Signs of risk factors or mild concomitant opportunistic infections, such as herpetic sores on the groin or extensive oral candidiasis, may indicate HIV infection.
2. Observe for swollen lymph nodes.
Generalized lymphadenopathy commonly occurs in patients with HIV. Swollen or abnormal lymph nodes in the cervical and axillary area are the most common.
3. Monitor for significant weight loss.
HIV weight loss (HIV wasting syndrome) is a sudden loss of more than 10% of body weight. Note if weight loss is accompanied by diarrhea, weakness, and a fever that lasts longer than 30 days. This is more common with advanced HIV/AIDS.
Diagnostic Procedures
1. Perform screening tests.
Since infected people may go years without showing symptoms while the infection worsens, it is crucial to screen for HIV infection. The CDC recommends screening for anyone between the age of 13-64. If participating in risky sexual or drug practices, screen more frequently. HIV screening is also recommended as part of routine prenatal screenings. Antigen/antibody immunoassay tests are the most commonly used screening test. HIV infection can be detected in as little as 18 days post-infection.
2. Assist the patient in ongoing diagnostic evaluation.
Patients diagnosed with HIV must receive routine testing to monitor their immune status, HIV progression, and medication effectiveness. These tests include:
- CD4 T-cell count indicates the current immune status and risk of acquiring an infection. CD4 counts are typically between 500-2000. A CD4 count below 200 is considered AIDS.
- Viral load measures the number of copies of HIV in the blood. Antiretroviral therapy keeps viral loads low, so patients are less likely to transmit the virus to others. An “undetectable” viral load is the goal of treatment.
3. Monitor the overall health status.
The patient will need to be monitored for other health conditions that may occur. These tests include:
- CBC – performed at least every 3-6 months
- Electrolytes, kidney function, liver function – performed at baseline and every 3-6 months
- Lipid profile – performed annually unless abnormal
- Viral hepatitis screening
- Chest X-ray as needed
- Pap smear
- Tuberculosis as needed
- STD testing – annually or with each new partner
4. Assess the patient’s mental health and coping status.
Depression screenings should be completed regularly to assess for emotional concerns.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with HIV.
Control the Virus
1. Administer antiretroviral therapy (ART).
Antiretroviral therapy (ART) is the most effective management of HIV. ART often involves two or more drugs from several pharmacological classes together, such as:
- Nucleoside reverse transcriptase inhibitors (NRTIs)
- Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
- Protease inhibitors (PIs)
- Fusion inhibitors
- CCR5 antagonists
- Integrase strand transfer inhibitors (INSTIs)
- Attachment inhibitors
- Post-attachment inhibitors
- Pharmacokinetic enhancers
- Combination of HIV medicines
2. Encourage treatment adherence.
Patients must strictly adhere to their medication regimen as prescribed. Patients who adhere to their treatment plan can maintain control of the virus and may never progress to AIDS. When ART is taken as prescribed, the medication provides the following benefits:
- Boosts the immune system
- Reduces the infection risk
- Lessens the likelihood of treatment-resistant HIV
- Decreases the risk of HIV transmission to others
3. Refer to an infectious disease specialist.
A specialist in infectious diseases should prescribe and monitor ART. The choice of an antiretroviral regimen is made specifically for each patient based on the following:
- Virologic effectiveness
- Toxicity
- Pill burden
- Dosage frequency
- Potential drug-drug interactions
- Findings from drug resistance testing
- Comorbid conditions
4. Advise to undergo genotyping for drug resistance.
Testing for drug resistance often entails genotyping or phenotyping the patient’s viral strains for signs of resistance. Before patients begin treatment, recommend genotypic testing to ensure the proper medication is selected. If the viral load increases, this testing can be completed before switching to another medication. When complicated drug resistance mutation patterns are present, phenotypic and genotypic testing are combined.
5. Ensure the patient’s optimal health.
HIV-positive patients should receive screenings for diabetes, osteoporosis, and colon cancer as needed. Monitoring and managing lipid levels and other cardiovascular risk factors is essential.
6. Inform the patient about treatment side effects.
Treatment side effects depend on the medication and may include:
- CNS: cognitive and emotional alterations, sleep problems, headache
- GI: nausea, vomiting, diarrhea, liver damage
- Cardiovascular: heart disease
- Genitourinary: kidney injury
- Musculoskeletal: Weak bones or osteoporosis
- Laboratory: abnormal cholesterol levels, increased glucose
7. Collaborate with the HIV treatment team.
HIV patients may be supported by a team of healthcare professionals, including social workers, doctors, nurses specializing in rare diseases, and mental health specialists, throughout their treatment. Collaborating with a team ensures proper follow-up, and prevention and management of complications.
8. Educate on lab monitoring.
Patients should receive CD4 count and viral load testing before beginning ART treatment, 4 weeks after initiation, and every 3-6 months to monitor treatment effectiveness. If, after two years, the patient’s viral load remains suppressed, CD4 testing may decrease annually or as directed.
Prevent Transmission
1. Administer prophylactic antimicrobials for opportunistic infections (OI).
Patients may require antibiotics or antifungal treatment to prevent certain infections when coupled with low CD4 counts.
2. Encourage frequent handwashing.
Instruct patients on handwashing principles to prevent infection. Patients with HIV should also be instructed to wash their hands after touching animals, as a potential OI called toxoplasmosis is found in the feces of birds, rodents, and cats.
3. Encourage the patient to avoid crowded places.
Avoid contact with large crowds (such as events and social gatherings) to prevent exposure to different infections, especially if CD4 counts are suboptimal.
4. Promote safe sex practices.
Teach the patient the importance of using latex condoms to prevent transmission of HIV.
5. Educate on PrEP.
Pre-exposure prophylaxis is a medication taken to prevent getting HIV. People who form intimate relationships with someone with HIV can reduce their risk of getting the disease through sex by 99% on this medication.
6. Schedule the patient for vaccinations.
Patients should receive pneumococcal, influenza, varicella, hepatitis A, hepatitis B, HPV, and meningococcal vaccinations to boost their ability to fight infection.
7. Encourage the pregnant patient to get screened.
It is recommended that all pregnant women be screened for HIV.
8. Assist in meal planning.
Encourage the patient to eat nutritious foods. Recommend lean protein, whole grains, and fresh produce to enhance the immune system and keep their energy high. Discourage taking raw food (such as sushi or raw eggs) and unpasteurized dairy products as they may carry live microorganisms causing infection.
9. Promote good personal hygiene.
Teach the patient the importance of good personal hygiene. Maintaining a clean body reduces the risk of pathogens on the skin. Emphasize oral care due to the risk of oral fungal infection.
10. Monitor visitors and caregivers for infection symptoms.
The patient shouldn’t interact with family members or visitors who are unwell.
11. Promote a healthy lifestyle.
Encourage exercise as a method to boost the immune system. Abstain from smoking and drug use that can lead to cancer and other complications.
Infection Control Precautions for Healthcare Workers
1. Universal precautions.
When treating patients with HIV/AIDS, universal precautions are instituted. Don personal protective equipment (PPE) such as gloves, gowns/aprons, masks, and eye protection for direct contact with blood or bodily fluids from an HIV-positive person.
2. Instruct on needle-stick precautions.
Never recap needles. If an accidental needle-stick occurs, wash the area immediately with soap and water. Alert your manager and employee health department. Screening will begin for infection, and the employee may be required to start ART.
3. Dispose of contaminated items appropriately.
Linens and items contaminated with infected blood must be disposed of in red biohazard bags.
Psychosocial Support
1. Ask the patient to share their feelings and emotions.
Expression of feelings and thoughts lessens anxiety. Nurses can be nonjudgmental listeners and a source of support.
2. Encourage the patient to join support groups.
A support group allows members to open up and discuss their feelings, coping mechanisms, and lived experiences. People with HIV who attend support groups are less likely to experience feeling isolated or depressed. Because of this, those with support, whether from a group or family and friends, live longer, healthier lives.
3. Refer the patient to a social worker.
Patients with HIV can receive a variety of services and assistance through social workers and case managers. They can assist patients in navigating government programs, legal aid, and financial concerns while enabling them to make well-informed health choices.
4. Treat the patient the same as others.
Interact with the patient as you would with any other. The patient can tell if a healthcare professional is judgmental or prejudiced. HIV patients should receive the same treatment and communication as other patients. Assess oneself to recognize feelings of assumption or bias. Contact with a patient who has HIV does not require anything more than routine safeguards.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for HIV, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for HIV.
Disturbed Body Image
Patients diagnosed with HIV infection often develop anxiety disorders, depression, and low self-esteem. Disturbed body image is often associated with poor self-care behaviors, poor ART adherence, and risky behaviors.
Nursing Diagnosis: Disturbed Body Image
Related to:
- Altered body function
- Altered self-perception
- Distrust of body function
- Fear of disease progression
- Low self-efficacy
- Low self-esteem
- Cultural or religious beliefs
As evidenced by:
- Altered social involvement
- Loss of interest in activities
- Expresses concerns about sexuality
- Expresses fear of rejection by others
- Preoccupation with past strengths and functions
- Preoccupation with changes/loss
- Perceptions that reflect an altered view of appearance
- Nonadherence to treatment
Expected outcomes:
- Patient will demonstrate acceptance of body changes by adhering to their medication and treatment plan.
- Patient will verbalize acceptance of their progressive disease.
Assessment:
1. Assess factors that contribute to perceptions of disturbed body image.
Meticulous assessment of factors and psychological issues can help identify patients who are at risk for developing disturbed body image due to a permanent condition.
2. Observe the patient’s description of self.
Listen to the patient talk about their body and self and observe for positive and negative comments and how they believe others perceive them.
Interventions:
1. Allow the patient to express emotions and feelings.
Expression of feelings and emotions relieves anxiety and reduces depressive behavior. It also helps nurses better understand what the patient is going through.
2. Provide education and support.
Patients with HIV infection often feel rejected or stigmatized by society. Provide support to the patient about their disease and educate them that patients can live normal lives with treatment.
3. Interact as you would with any other patient.
Patients can sense if a healthcare provider is judgmental or stereotyping them. Patients with HIV deserve the same care and interaction as all patients. Contact with a patient with HIV does not require anything beyond standard precautions and the nurse must educate themselves if they recognize feelings of assumption or prejudice.
4. Encourage support groups.
Social support is important in learning to live with HIV. Encourage the patient to interact with others who are HIV positive by joining online groups and community programs to gain confidence and recognize their diagnosis does not define them.
Imbalanced Nutrition: Less Than Body Requirements
HIV infection affects the body’s ability to effectively absorb nutrients due to various infections. Malabsorption, altered metabolism, and weight loss caused by loss of appetite and mouth ulcers are common in patients with HIV infection.
Nursing Diagnosis: Imbalanced Nutrition
Related to:
- Altered taste perception
- Depressive symptoms
- Difficulty swallowing
- Food aversion
- Inability to absorb nutrients
- Inability to digest food
- Insufficient dietary intake
As evidenced by:
- Body weight below ideal weight range for age and gender
- Constipation
- Mouth sores/ulcers
- Diarrhea
- Food intake less than recommended daily allowance (RDA)
- Lethargy
- Muscle hypotonia
- Poor dentition
Expected outcomes:
- Patient will consume an ideal amount of calories for height/weight and activity level.
- Patient will report increased appetite and interest in food.
Assessment:
1. Assess the patient’s potential barriers to eating.
HIV patients often develop lesions in the mouth and throat caused by infections like candidiasis, limiting the patient’s ability to chew, swallow and ingest food.
2. Determine previous weight before HIV diagnosis.
Early wasting in patients with HIV cannot be determined by normal weight-to-height charts. It is vital to determine the pre-diagnosis weight and current weight to determine muscle wasting and assess nutritional needs.
Interventions:
1. Educate the patient about the side effects of the current medication regimen.
Drug therapy for HIV often causes altered taste, anorexia, nausea, and vomiting.
2. Provide an environment conducive to eating.
Ensure uninterrupted mealtimes, provide small frequent meals and snacks, and remove noxious odors to help improve appetite and promote nutritional intake.
3. Encourage oral hygiene.
Patients with HIV infection often develop mouth sores, disrupting the patient’s ability to eat. Good oral hygiene can enhance appetite and promote a desire to eat.
4. Administer medications as indicated.
Antiemetics administered before meals can help reduce nausea and vomiting and promote appetite. Appetite stimulants may also be prescribed to enhance appetite.
5. Consult with a dietitian.
Collaborating with a dietitian ensures the formulation of a nutritionally balanced diet that prevents nutrient deficiencies in patients with HIV.
Ineffective Protection
The decreased number of CD4 cells depresses immune function, causing the patient to be at higher risk of acquiring infection.
Nursing Diagnosis: Ineffective Protection
Related to:
- HIV infection
- Impaired immunity
- Inadequate nutrition
- Engagement in risky behaviors (i.e., unprotected sex, sharing of needles)
- Insufficient knowledge about HIV and its management
As evidenced by:
- Detectable HIV viral load
- Decreased CD4 count (CD4 count <200 cells/mm3)
- Fever
- Chills
- Fatigue
- Weakness
- Weight loss
- Coughing
Expected outcomes:
- Patient will not acquire opportunistic infections.
- Patient will maintain a CD4 count of > 500 cells/mm3.
- Patient will demonstrate precautions preventing AIDs and HIV transmission.
Assessment:
1. Monitor CD4 level and viral load.
Regular monitoring of CD4 levels and viral load provides information about the status of the patient’s immunity and HIV progression. Lower CD4 counts and a higher viral load indicate a more significant risk of acquiring opportunistic infections.
2. Monitor for signs and symptoms of infection.
Impaired immunity decreases the ability of people living with HIV (PLHIV) to protect themselves from infection. PLHIV must monitor themselves for signs of infection such as fever, chills, new or productive coughs, rashes, mouth sores, and weight loss.
3. Assess risky behaviors.
HIV is commonly transmitted through unprotected anal or vaginal sex or sharing of contaminated needles, syringes, or other drug injection equipment. PLHIV who continue to engage in these behaviors place themselves and others at risk for infection.
4. Assess socioeconomic barriers.
The stigma and discrimination attached to having a positive HIV status are associated with unemployment, homelessness, and poverty. Nurse case managers can assess for barriers that limit the patient’s access to medical care, proper nutrition, and medication adherence.
Interventions:
1. Observe standard precautions.
Healthcare-associated infections are commonly due to the transmission of harmful microorganisms through the hands of health workers. Handwashing is the first step to reducing this risk. When starting IVs or performing invasive procedures, adhere to aseptic or sterile techniques to prevent the transmission of pathogens.
2. Provide meal planning with high-calorie and high-protein foods.
PLHIV experience wasting syndrome, especially with the progression to AIDS. Once muscle and fat are lost, it’s difficult to regain. Providing high-calorie and high-protein foods will help replace lost fat, muscle, and nutrients.
3. Administer antimicrobials and antifungals.
Patients may require prophylactic antibiotics and antifungals against opportunistic infections when CD4 counts become suboptimal.
4. Administer immunizations.
PLHIV have decreased protection against opportunistic infections. The CDC recommends that PLHIV be vaccinated against hepatitis B, human papillomavirus (HPV), influenza, meningitis, pneumonia, tetanus, diphtheria, and pertussis.
5. Referrals to community resources.
HIV’s devastating effects on the socioeconomic status of the patient can be addressed by linking them to social services, free health clinics, financial services, food banks, and more.
6. Encourage proper hygiene.
Bathing and oral hygiene are essential to prevent the development of oral thrush and skin rashes and sores that can occur with HIV and AIDS.
Ineffective Sexuality Pattern
The patient may experience concerns or dysfunction surrounding their sexuality following the diagnosis of HIV.
Related to:
- Conflict about sexual orientation or variant preferences
- Fear of pregnancy with HIV
- Impaired relationship with partner
- Insufficient knowledge about alternative sexual practices
As evidenced by:
- Reported changes in sexual activities or behaviors
- Changes to intimate relationship
- Engaging in unsafe sexual practices
- Difficulty engaging in sexual practices
Expected outcomes:
- Patient will describe acceptable alternative sexual practices.
- Patient will partake in safe sex practices.
- Patient will state acceptance of sexual orientation.
Assessment:
1. Assess fear or anxiety surrounding sexual practices.
The patient with HIV may feel unsure of how to navigate current or future intimate relationships. HIV can cause feelings of low self-esteem, unworthiness, and shame that affect their sexuality.
2. Obtain a sexual history and behavioral risk assessment.
A comprehensive sexual history provides an understanding of the patient’s sexual patterns. Note the patient’s sexual orientation and their number of sexual partners. Assess the patient’s risk of STIs and pregnancy through their use of condoms and contraceptives.
Interventions:
1. Create a relaxed and accepting manner in discussing sexual issues.
Sexuality is a sensitive issue and private matter. Patients are often hesitant and uncomfortable reporting such concerns. The nurse must first build a rapport with the patient so both are comfortable discussing sexual topics.
2. Discuss thoughts on pregnancy.
Women with HIV can still become pregnant and deliver a baby without transmitting the virus. If a patient expresses interest in pregnancy, offer education on how ART can reduce the risk of transmitting the virus to the fetus to less than 1%.
3. Encourage the patient to share feelings and concerns with their partner.
Sexual concerns, if not communicated, can lead to stress and deterioration in the relationship.
4. Educate the patient about safe sex practices and pre-exposure prophylaxis (PrEP) intake.
Educating the patient about safe sex practices helps change behavior geared toward HIV prevention. Patients without HIV who wish to have an intimate relationship with an HIV-positive partner can protect themselves through pre-exposure prophylaxis (PrEP), a medication regimen that reduces the risk of getting HIV.
Risk for Infection
HIV infection causes immunosuppression, placing patients at risk for illness. Opportunistic infections such as pneumonia can be life-threatening in patients with HIV/AIDS.
Nursing Diagnosis: Risk for Infection
Related to:
- Chronic illness
- Immunosuppression
- Disease process
- Insufficient knowledge to avoid exposure to pathogens
- Nonadherence to ART
- Low CD4 count
- High viral load
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will remain free of symptoms of infection and demonstrate appropriate behaviors that reduce the risk of infection.
- Patient will maintain a CD4 count above 500 cells/mm3 and an undetectable viral load.
Assessment:
1. Assess for signs of infection.
Signs of infection with HIV include fever, rashes, swollen lymph nodes, weight loss, and fatigue.
2. Monitor viral load and CD4 count.
The viral load measures the amount of HIV cells in the blood. Over 200 copies/mL is a high viral load and signals HIV progression. CD4 cells are a type of white blood cell. Levels above 500 cells/mm3 are normal. A CD4 count below 200 cells/mm3 is a diagnosis of AIDS.
Interventions:
1. Perform hand washing before and after care of the patient.
Handwashing reduces the risk of introducing bacteria to the patient. Instruct the patient and family members to wash their hands as indicated.
2. Screen visitors and primary caregivers for signs of infection.
This helps reduce the possibility of nosocomial infection. Family members who are sick should not interact with the patient.
3. Administer medications as indicated.
Adhering to antiretroviral drug therapy can help reduce the risk of infection in patients diagnosed with HIV. Educate patients about the importance of adhering to their treatment regimen. Some over-the-counter drugs and herbal remedies have significant interactions with ART drugs and should be taken with caution.
4. Educate about routine testing
Patients with HIV require viral load testing with medication changes. Once they reach an undetectable viral load, testing will be less frequent.
5. Maintain a relationship with the HIV treatment team.
It is very important patients adhere to routine infectious disease appointments. Patients with HIV may have a team of providers including chronic disease nurses, physicians, social workers, and mental health professionals that help them navigate their disease.
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