Inflammation , Immune Response, and HIV Infection (1)

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Jan 9, 2024

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NUFT 351- IMMUNE SYSTEM 1 Immune System Inflammation , Immune Response, and HIV Infection Normal Immune Response ● Immunity ○ Body’s ability to resist disease ○ Antigen and Antibody ○ Serves three functions ■ Defense ■ Homeostasis ■ Surveillance Immunity = body’s ability to resist disease Immune response Defense – prevents development of infection by attacking foreign antigens/pathogens Homeostasis – damaged cellular substances are removed Surveillance - foreign/mutated cells are recognized and destroyed Antigen Substance that elicits an immune response Most are protein All body cells have surface antigens that are unique and enable the body to recognize itself Inflammatory Response Clinical Manifestations ● Local manifestations ○ Redness ○ Heat ○ Pain ○ Swelling ○ Loss of function See Chapter 11, Inflammatory Response: Clinical Manifestations; Table 11-3, Local Manifestations of Inflammation; and Figure 11-3 (next slide). Warmth Increased metabolism at the inflammatory site Redness Hyperemia from vasodilation (increase of blood flow to different tissues in the body) Swelling Fluid shift to extracellular spaces, fluid exudate accumulation Pain Change in pH. Nerve stimulation from chemicals (histamine/prostaglandins). Pressure from fluid exudate. Decreased function Swelling and pain Inflammatory Response Clinical Manifestations Local Response

NUFT 351- IMMUNE SYSTEM 2 Occurs in response to tissue injury, invasion of organisms Usually accompanied by inflammation, but inflammation can occur without infection Inflammation does not always mean infection is present! Inflammatory Response Clinical Manifestations ● Systemic manifestations ○ Increased WBC count “shift to the left” ○ Malaise ○ Nausea and anorexia ○ Increased pulse and respiratory rate ○ Fever Infection ● Occurs in response to tissue injury, invasion of organisms ● Usually accompanied by inflammation, but inflammation can occur without infection ● Inflammation does not always mean infection is present! Inflammation – acute vs chronic Acute 2-3 weeks for healing without residual damage (neutrophils) Subacute – same features as acute, but lasts longer Chronic – weeks/months/years. Lymphocytes and macrophages. Types of Immunity ● Innate ○ Present at birth ○ First-line defense against pathogens ● Acquired ○ Developed immunity ○ Active ○ Passive

NUFT 351- IMMUNE SYSTEM 3 Acquiring Antibody-Mediated Immunity ● Adaptive immunity ● Active immunity ○ Natural active immunity ○ Artificial active immunity ● Passive immunity ● Natural passive immunity ● Artificial passive immunity Also called humoral immunity Adaptive = acquired Acquired Naturally acquired active immunity occurs when the person is exposed to a live pathogen, develops the disease, and becomes immune as a result of the primary immune response. Artificially acquired active immunity can be induced by a vaccine, a substance that contains the antigen.Result of invasion of body by microorganisms and development of antibodies and sensitized lymphocytes Arises from disease or immunization Takes time to develop, but is long lasting Passive the short-term immunity that results from the introduction of antibodies from another person or anima Artificially acquired passive immunity is a short-term immunization by the injection of antibodies, such as gamma globulin, that are not produced by the recipient's cells. Naturally acquired passive immunity occurs during pregnancy, in which certain antibodies are passed from the maternal into the fetal bloodstream.

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NUFT 351- IMMUNE SYSTEM 4 Chapter 14 HIV Infection Human Immunodeficiency Virus Infection ● Retrovirus that causes immunosuppression making persons more susceptible to infections. ● HIV can be transmitted through contact with certain body fluids ○ Blood, semen, vaginal secretions, and breast milk ● HIV is not spread through casual contact ○ hugging, dry kissing, shaking hands, sharing eating utensils, using toilet seats Greater than 1 million currently living with HIV About 36,500 new infections occur in United States each year Effective treatment has led to a dramatic drop in death rates Sexual Transmission ● Unprotected sex with an HIV-infected partner is most common mode of transmission ○ Greatest risk is for partner who receives semen ■ Prolonged contact with infected fluids ■ Women at higher risk ■ Trauma increases likelihood of transmission ○ Contact with blood: Sharing drug-using paraphernalia is highly risky ■ Routine screening of blood donors have improved blood supply safety ■ Puncture wounds are most common means of work-related HIV transmission Perinatal Transmission ● Can occur during pregnancy, delivery, or breastfeeding ● On average, 25% of infants born to women with untreated HIV will be born with the infection ● Treatment can reduce rate of transmission to less than 2% Pathophysiology of HIV ● HIV is a ribonucleic acid virus ○ Called retroviruses because they replicate in a “backward” manner going from RNA to DNA ○ CD4+T cell is the target cell for HIV ■ Type of lymphocyte ■ HIV binds to the cell through fusion ● Immune problems start when CD4+ T cell counts drop to less than 500 cells/μL ○ Severe problems develop when less than 200 CD4+ T cells/μL ○ Normal range is 800 to 1200 cells/μL ● Insufficient immune response allows for opportunistic diseases

NUFT 351- IMMUNE SYSTEM 5 Clinical Manifestations ● Acute infection ○ Mononucleosis-like symptoms ■ Fever, swollen lymph nodes, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhea, and/or a diffuse rash ■ Occurs about 2 to 4 weeks after infection ■ Highly infectious. ● Asymptomatic infection ● Left untreated, a diagnosis of AIDS is made about 10 years after initial HIV infection ● People are typically asymptomatic or have limited signs of infection ● High-risk behaviors may continue Clinical Manifestations ● Symptomatic infection ○ CD4+ T cells decline closer to 200 cells/μL ■ HIV advances to a more active stage ■ Symptoms become worse ● persistent fever, frequent night sweats, chronic diarrhea, recurrent headaches, severe fatigue ● Symptomatic infection ○ Shingles ○ Persistent vaginal candida infections ○ Oral or genital herpes ○ Bacterial infections Oral Thrush Shown is Fig. 14-5 from the textbook: Oral thrush involving hard and soft palate. (From Emond R, Welsby P, Rowland H: Colour atlas of infectious diseases, ed 4, Edinburgh, 2003, Mosby.)

NUFT 351- IMMUNE SYSTEM 6 Kaposi Sarcoma •Shown is Fig. 14-6 from the textbook: Kaposi sarcoma (KS). KS lesions can appear anywhere on the skin surface or on internal organs. Lesions vary in size from pinpoint to large and may appear in a variety of shades. (From Friedman-Kien AE: Color atlas of AIDS, Philadelphia, 1989, Saunders.) Oral Hairy Leukoplakia Shown is Fig. 14-7 from the textbook: Oral hairy leukoplakia on the lateral aspect of the tongue. (Set of slides published in 1992 by Jon Fuller, MD, and Howard Libman, MD, at Boston University School of Medicine, Boston.) Clinical Manifestations and Complications ● Acquired immunodeficiency syndrome (AIDS) ○ Diagnostic criteria is established by CDC ○ Immune system severely compromised ■ Infections ■ Malignancies ■ Wasting ■ HIV-related cognitive changes

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NUFT 351- IMMUNE SYSTEM 7 Pneumocystis jiroveci Pneumonia Shown is Fig. 14-8 from the textbook: Chest x-ray showing interstitial infiltrates as the result of Pneumocystis jiroveci pneumonia. (From the Centers for Disease Control and Prevention. Courtesy Jonathan W.M. Gold, MD, New York.) Diagnostic Studies ● Most useful screening tests detect HIV-specific antibodies and/or antigens ○ May take several weeks to detect antibodies (window period) ○ Done using blood or saliva ○ Combination antigen-antibody tests can detect HIV earlier ○ ELISA, Western Blot Laboratory Studies ● HIV progression is monitored by 1. CD4 cell count ■ CD4 cell count provides a marker of immune function 2. Viral load ■ The lower the viral load the less active the disease ● Diagnostic Studies ● Abnormal blood tests are common ○ Caused by HIV, opportunistic diseases, or complications of therapy ■ Decreased WBC counts, especially ● Lymphopenia ● Neutropenia ■ Low platelet counts (thrombocytopenia) ■ Anemia is associated with ART ■ Altered liver function

NUFT 351- IMMUNE SYSTEM 8 Interprofessional Care, Management ● Monitor disease progression, immune function, and manage symptoms ● Initiate and monitor ART ● Prevent, detect and/or treat opportunistic infections ● Manage symptoms ● Prevent or decrease complications of therapies ● Prevent further transmission of HIV Interprofessional Care ● First patient visit ○ Gather baseline data ○ Begin to establish rapport and use patient input to develop a plan of care ○ Complete history and physical exam ○ Initiate teaching about spectrum of HIV, treatment, preventing transmission, improving health, and family planning Preventing Transmission of HIV ● Preexposure prophylaxis (PrEP) ○ Comprehensive strategy to reduce chances of acquiring HIV infection in persons at risk ○ Currently involves taking part of an HIV antiretroviral regimen on a daily ○ Used in conjunction with other proven prevention interventions Nursing Management Assessment ● Ask at-risk patients ● Assess diagnosed patients thoroughly ○ Past health history ○ Medications ○ Functional health patterns ○ Presence of symptoms using a systems review See Nursing Assessment under Nursing Management: HIV Infection. Received blood transfusion or clotting factors before 1985? Shared drug-using equipment? Had a sexual experience with your penis, vagina, rectum, or mouth in contact with these areas of another person? Had a sexually transmitted infection? Nursing Management Implementation ● Primary prevention and health promotion are the most effective strategies for diseases of a chronic nature including HIV ○ When prevention fails ■ Disease results ■ Early intervention is facilitated by health promotion practices

NUFT 351- IMMUNE SYSTEM 9 Health Promotion ● HIV infection is preventable ○ Prevention is a critical component ○ Encourage early detection and early intervention ● Prevention of HIV ○ Avoiding or modifying risky behaviors ○ Provide culturally sensitive, language-appropriate, and age-specific teaching, and behavior change counseling ○ Become comfortable talking about sensitive topics such as sexuality and drug use Health Promotion ● Prevention of HIV ○ Increase safer sexual practices ■ Abstinence ■ Use barriers such as condoms ■ Educate and counsel about preexposure prophylaxis (PrEP) ■ Do not use drugs ■ Do not share equipment ■ Do not have sexual intercourse under the influence of any impairing substance ■ Refer for help with substance use Health Promotion ● Prevention of HIV ○ Decreasing risks: Perinatal transmission ■ Prevent HIV in women ■ Family planning ■ Appropriately medicate HIV-infected pregnant women ○ Decreasing risk: Work ● Adhere to precautions and safety measures to avoid exposure ● Report all exposures for timely treatment and counseling ● Post exposure prophylaxis (PEP) with combination ART can significantly decrease risk of infection HIV Testing and Counseling ● Testing is the only sure method of determining HIV infection ○ CDC recommends universal, voluntary testing as part of routine medical care ○ An estimated 14% of people living with HIV are not aware they are infected Acute Intervention ● Early intervention can promote health and limit disability ● Reactions to positive HIV test ○ Similar to any life-threatening, chronic illness ■ Panic, anxiety, fear, guilt, depression, denial, anger, hopelessness ■ ART Regimen

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NUFT 351- IMMUNE SYSTEM 10 Delaying Disease Progression ● Promoting a healthy immune system ○ Nutritional support ○ Moderating or eliminating alcohol, tobacco, and drug use ○ Keeping up to date with vaccinations ○ Getting adequate rest and exercise ○ avoiding exposure to infectious agents ○ counseling and support groups Ambulatory Care ● Negative social beliefs and attitudes surrounding HIV ● Stigma can lead to discrimination and result in social isolation, dependence, frustration, low self-image, loss of control, and economic pressures ● ART side effects and compliance ● Audience Response A diagnosis of AIDS can be made for a patient with HIV with A. a WBC count less than 3000/µL. B. a CD4+ T-cell count less than 500/µL. C. development of oral candidiasis (thrush). D. onset of Pneumocystis jiroveci pneumonia. Audience Response Question The nurse is teaching a newly diagnosed 34-year-old male about his HIV infection. Which statement by the patient would indicate the patient needs additional education? A. “I will need to take my HIV medication daily for the rest of my life.” B. “Although I only take one pill, it has multiple medications combined into a single tablet.” C. “I should notify my HIV provider if I get fevers that do not go away with Tylenol or aspirin.” D. “Once my viral load is undetectable I don’t have to worry about taking my medication every day.” Audience Response Question The nurse is caring for a patient who is receiving antiretroviral therapy (ART) for treatment of HIV infection. Which assessment best indicates that the patient’s condition is improving? A. Decreased viral load B. Increased drug resistance C. Decreased CD4+ T-cell count D. Increased aminotransferase levels Persons with undetectable virus are still infected with HIV and need to take their HIV medications on a daily basis to keep the virus suppressed .

NUFT 351- IMMUNE SYSTEM 11 Audience Response Question The nurse informs the patient with a bacterial pneumonia that the most important factor in antibiotic treatment is: A. antibiotics should have been used to prevent pneumonia. B. all of the supplied antibiotics should be taken even when symptoms have resolved. C. enough antibiotics for 2 days’ treatment should be reserved in case symptoms recur. D. patients should get antibiotics for any infection to prevent development of streptococcal-related diseases. Goals of antiretroviral therapy (ART) in the treatment of a patient with HIV are to decrease the viral load and maintain or increase CD4+ T-cell counts. Combination drugs are prescribed to prevent or decrease drug resistance. Some of these drugs may impair liver function; increased aminotransferase levels indicate impaired liver function.

Inflammation , Immune Response, and HIV Infection (1)

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