hey everyone it's sarah register nurse rn.com and in this video i'm going to be talking about hiv and aids and as always whenever you get done watching this youtube lecture you can access the free quiz that will test you on this content so let's get started hiv stands for human immunodeficiency virus while aids stands for acquired immunodeficiency syndrome now hiv is a virus that attacks the body's immune system and it specifically loves to attack cd4 positive cells and what this means is that it attacks cells that have a cd4 receptor on its surface and a cell that it really loves to attack is called the helper t cell because the helper t cell has a lot of these cd4 receptors on its surface so it can easily just attack it but it also attacks other cells with the cd4 receptors such as macrophages monocytes and dendritic cells now helper t cells are a type of white blood cell and these cells are very vital in helping us fight infection but what hiv does is that in a sense it hijacks this cell and it causes it to produce more hiv and then whenever it's done with it it kills it so over time hiv strategically kills large numbers of these helper t cells and whenever we drop the count of these cells what happens is that that person is at high risk for infections that normally wouldn't hurt someone with a healthy immune system with a high number of helper t cells so they start to develop what's called opportunistic infections or diseases now let's look at some quick facts about hiv aids so whenever a person becomes infected with this virus they have hiv and over time this virus can transition into what we call aids therefore hiv really occurs in stages so a person becomes infected they enter the acute stage followed by the chronic stage and then the last stage which is the aids stage and this is the stage that has the shortest life expectancy now today there's no cure for aids but however there are antiretroviral therapy art which is a combination of medications that patients with hiv can take and this can help improve their cancer cd4 count their helper t cell count which helps them keep infection off and helps improve their life and help them to live a lot longer but now let's look at some statistics about hiv slash aids how many people have been infected with this virus since we have identified it and how many people currently are living with it well according to the world health organization since the beginning of the epidemic about 79.3 million people have been infected with the hiv virus and 36.3 million people have died from hiv now currently the number of people who are living with the virus who estimates that globally at the end of 2020 37.7 million people were living with hiv so how is hiv transmitted and what increases your risk of becoming infected with this virus well it really depends on several different factors one factor is the viral load of that infected person how much of that virus is actually in their blood because the higher amount the more likely they can transmit it to others for instance during the acute stage of hiv the person has a high viral load so they have a lot of virus in the blood and they can easily transmit it but if they're taking antiretroviral therapy this can decrease their viral load and decrease the chances of them transmitting it to others another factor depends on the type of contact you've had with that person who has hiv because certain activities increase the risk of transmitting the virus for example having unprotected sexual intercourse with someone with hiv increases the risk of transmitting the virus compared to a needle stick and an interesting statistic by the cdc says that health care workers who are exposed to hiv infected blood via a needle stick have a 0.23 percent chance of becoming infected next is the immune system of the person who's becoming potentially infected because there is a small percentage of people who are actually immune to hiv now in order for the virus to actually be transmitted it has to be in a specific type of fluid because otherwise it will die so it needs to be in either blood semen vaginal fluid or breast milk and once in this fluid it can easily enter the bloodstream either directly or indirectly like via injury or a mucous membrane and some activities that can increase the risk of transmitting hiv include unprotected sexual contact drug use like needle sharing or a contaminated blood product transfusion a needle stick injury or a contaminated needle for a piercing or tattoos or even during pregnancy and this can be pregnancy itself the birthing process or breast milk so how is hiv not transmitted well as i just pointed out hiv is a weak virus without a host of fluids so it needs to be in that fluid so generally activities like hugging closed mouth kissing touching clothes or objects tears sweat or saliva without blood in it or insect bites household items touching those coughing sneezing are not going to transmit the virus so now let's talk about the pathophysiology of hiv what happens in the body when this virus gets in attacks the cells how does it replicate multiply and damage these cells which leads to the destruction of the immune system well to help us understand that let's talk about the key players of the patho first key player is hiv the virus itself along with its life cycle and the cd4 positive cells mainly i'm going to be concentrating on the helper t cell so first let's talk about the helper t cell so this cell is a white blood cell that helps us fight infection and it plays a huge role in our adaptive immune system which gives us the ability to respond and protect ourselves from foreign invaders therefore it gives us acquired immunity so like a memory bank in a sense against foreign invaders so whenever we see these foreign invaders we're like i've seen you before i can deal with you and you're not going to cause me harm but if hiv is present in the body and it's had enough time to damage these cells that help give us that memory bank against those foreign invaders we can easily be overtaken by those infections or diseases and develop what's called opportunistic infections or diseases and this can be forms of cancer it can be from bacteria virus or parasitic type organisms and the development of an opportunistic disease is actually one of the criteria used to diagnose aids now the reason we call these types of t cells the helper t cells is because they help the immune system fight infection and how they do this is that they release cytokines now cytokines are like chemical agents that send a message to the receptor site on a targeted cell to cause it to act in a certain way therefore these cytokines actually help activate other types of t cells known as the cytotoxic t cells and they help kill invaders it also helps activate macrophages which help eat invaders and then it helps activate b cells which help us produce antibodies in response to those invaders so as you can see this helper t cell plays a very important role in our immune system but now let's look at the hiv virus itself and how it affects this helper t cell here i have a basic hiv virus and beside of it is a helper t cell now the hiv virus is a retrovirus it cannot grow or multiply without a host cell and the hiv virus loves cells that have a cd4 receptor on its surface because the way it's designed it can easily access that receptor and once it access and attaches to that receptor it gets inside the cell then inside the nucleus where it takes over the cell's function and it causes that cell to produce more hiv so once it's done producing the amount of hiv it wants to produce it kills that cell and then all that fresh new hiv goes and just repeats this cycle so in order to do this it has to be designed in a certain way so let's look at the anatomy of the virus the virus is surrounded by proteins glycoproteins and here you will see those glycoproteins and the particular part i want you to pay attention to are these little knobs here these little protein projections this is known as gp120 glycoprotein 120 because this protein is essential in helping attach to this cd4 receptor once we've done that the hiv virus can attack and enter the cell then on the inside of the cell i like to think of it as its little suitcase because hiv knows it's not going to stay like this it's whole goal is to get in and fuse with this cell so it just needs to bring along the basic supplies and i want you to remember some things that it's going to bring along three enzymes these enzymes are very important in the life cycle of hiv first enzyme is called reverse transcriptase second is in tegrace and then the third one is protease also inside is a single strand of rna so now let's look at the life cycle of hiv and how it actually gets inside this cell it integrates itself it starts replication assembly budding and then we get new mature hiv so the first step is attachment what happens is that these glycoproteins specifically gp120 goes and attaches itself to the cd4 receptor on that cell surface here we have a helper t whenever that happens there's also binding of a co-receptor this could either be ccr5 or cxcr4 whenever that happens hiv has gained entry into the cell now what it's going to do the next step is fusion it's going to fuse itself with this helper t cell and whenever it does that it's going to take its hints suitcase as i called it earlier its contents and just dump it inside the cell because the whole goal of what it's got to do is it's got to set up shop and take over that cell so it has some things to do once this material is dumped in we have our enzymes and we have our rna it knows that this rna needs to turn into dna so it brought along an enzyme we're going to have reverse transcription that's the next step so reverse transcriptase is going to turn that rna into double-stranded dna this viral dna now needs to integrate itself inside the cell's nucleus so it moves to the nucleus it gets inside and now it releases another enzyme that it brought along called integrase so here it sees the cell's dna so integrase allows the viral dna that was created to integrate inside the cell's dna so now it's just taken over the cell and it can control the cell's function so now the next step is to replicate so we have replication we have the creation of these long protein chains rna they start to become assembled our next step and move up because it needs to get out of this cell so it moves up towards the cell surface it starts to grow outward and it's budding that's our next step and once budding is complete it pops off and whenever it pops off we have maturity and the new hiv material in there releases another enzyme called protease and what that does is it takes those long chains of proteins and cuts them makes them shorter and then that helps with maturity of the hiv virus once this process has been completed to the hiv satisfaction it will kill this cell and then new hiv is going to go around find new cells to infect and the cycle happens over and over now why do you want to be familiar with the life cycle of hiv well in order to understand how anti-retroviral therapy works for a patient who has hiv you have to really have a basic understanding of this whole life cycle because these medications a patient takes a combination of them will target certain parts of this life cycle like the attachment step or the fusion step or the assembly step and by targeting that we're going to limit how much hiv can be created hence in the blood so whenever a patient starts taking art they want to do it as soon as possible the earlier we can start the better and this leads me into the stages of hiv so let's take a look at those so with this we're going to talk about the signs and symptoms that you could see in each stage along with the testing so the first stage is the acute stage and this is acute infection and this begins about a couple of weeks to a month after becoming infected the person can spread it to others and their viral load is very high in the blood so there's a lot of virus in the blood now what signs and symptoms will they have during this stage they tend to have flu-like symptoms which could include gi upset headache aches in the body rash fever fatigue joint pain sore throat swollen lymph nodes and many times the patient or even the healthcare provider may not connect that this may be hiv and so they don't really order testing for the patient now with testing there is not a test that is available at this time to show immediate infection there must be a window period that passes and this is the time when the person is infected to when a test can deliver a positive result hence detects antibodies the body made against the virus and this is known as seroconversion so therefore a person can have the virus in the body get a negative test result because enough time hasn't passed for the test to come back positive so the person can still transmit the virus and if a person suspects they have hiv they still need to abstain from activities that could transmit it until they have confirmation so window periods can vary depending on the test so let's look at the different types of tests one test is the combination test and this tests for the antigen and antibodies of hiv the hiv antigen is p24 and it can show hiv as early as two weeks another type of test is the antibody hiv test and this detects antibodies of hiv and some types of these tests can give rapid results and a person can self-test with these now it doesn't detect as early as the test above the combination test instead it can show as early as two and a half weeks and then there's the nucleic acid test this test assesses for the virus hence its rna genetic material so it demonstrates the amount of virus in the blood hence that viral load now this test can give the earliest results for hiv it can detect hiv in some people as early as 10 days but this test is not routinely ordered compared to the other ones unless the patient is high risk and showing signs and symptoms associated with hiv because the costs are high next is a cd4 count now the cd4 count doesn't tell a person if they have hiv or not instead this is very helpful in monitoring a patient who does have hiv looking at the helper t cells because that is what this measures and seeing how they are doing on medication therapy so a normal count for this is about 500 to 1500 cells per millimeter and anything less than 200 is not good it shows that hiv is really progressing it's progressing to aids and there is a risk for the patient of developing opportunistic infections because remember these helper t cells are not there to help us fight infection their account is really low so we're at risk for this and during the acute stage whenever the patient is found out to have hiv they need to start antiretroviral therapy as soon as possible because what this is going to do is going to help lower that viral load lower the risk of transmitting it to others and lower the risk of the patient developing ois those opportunistic infections the next stage is the chronic infection stage and sometimes this is referred to as the asymptomatic stage with this signs and symptoms tend to disappear and the viral load is lower but the virus is still active it's still replicating and destroying cells during this stage the person can still transmit hiv to others but arts help lower this chance and the cd4 count is going to be greater than 200 but to about 500 and no opportunistic infections should be present during this time this stage ends and the patient progresses to the last stage whenever the viral load starts to increase there's the appearance of signs and symptoms and then the presence of opportunistic infections so the last stage is the aids stage and this is again acquired immunodeficiency syndrome and in this stage the immune system is destroyed by the virus and the viral load is very very high in these patients and they can easily transmit it and without medications during this time the survival time is only a few years so how is a patient diagnosed what are some criteria used to diagnose them with aids well you look at the cd4 count if that cd4 count is less than 200 that could indicate that or they have the presence of those opportunistic infections and this leads me to the opportunistic infections and diseases that a patient who is progressing into the latter stages of hiv may experience so i'm going to cover the main ones that you want to know for exams like the viral bacterial protozoal and cancerous so the first type is a cancerous type and here we're talking about capsid sarcoma so this is mainly seen in people who have a decreased immune system and causes the small blood vessels to grow abnormally so this is a form of cancer that can grow in various places like the lymph nodes organs mucous membranes and it tends to present as dark purplish brown lesions here you can see it in the mouth and this patient has aids and a cd4 count of less than 200 which again increases the risk of developing this also if you look closely you can see a white film on the lesion this is another opportunistic infection called candidiasis next is viral type and this can be caused by the cytomegalovirus and this is a virus that when you actually put it under magnification it will have what's called an owl eye appearance like in this picture here and this virus can cause multiple problems in the body affect the lungs brain gi system and eyes for example cmv can cause retinitis in patients with aids and it can lead to blindness so they need to make sure that they're getting their eyes checked and here is an illustration of a lesion caused by cmv on the eye next is the epstein-barr virus and this can cause oral hairy leukoplakia and this presents as white patches with hair like projections on the side of the tongue as you can see here and this is actually a hallmark finding in a patient in this stage of hiv because it's signaling that the immune system is being taken over and that this disease is progressing the patient is also at risk for herpes simplex virus this causes cold sores and genital herpes and it really depends on if they have type 1 or type 2. but it doesn't tend to cause severe problems in people with a healthy immune system like yes they have some signs and symptoms but not as severe as what can happen in aids and it can actually lead to deadly infections and complications next is bacterial type so some infections patients with advanced hiv are at risk for is like the mycobacterium tuberculosis so tv and this is spread in the air and affects the lungs and other parts of the body like the brain so you want to be watching out for signs and symptoms of night sweats weight loss trouble breathing coughing they can also be affected by salmonella septicemia and you get this from eating contaminated food or drinking water that has this bacteria in it they won't be able to fight this off and then there's also the mycobacterium avm complex and this is various types of mycobacterium and they are found in the environment that normally don't harm people with healthy immune systems but it's at risk for a person who has a low cd4 count and lastly streptococcus pneumoniae this can cause a serious form of pneumonia so as a nurse you want to educate the patient that they should get the pneuma vax because this can actually help prevent them from getting it next type is fungal such as candidiasis and this actually happens in people who don't have aids but whenever a person does have aids it can be severe and be really hard to treat and this can be found in various places such as the mouth the vagina and lungs next is coccidial mycosis and these are fungal spores that are found in dry soils like in the southwest of the u.s along with cryptococcosis which can cause pneumonia and affect the neurosystem and histoplasmosis which is a lung infection that can also affect the nervous system and it's found in like bird and bat feces and lastly pneumocystis pneumonia pcp and this can cause a serious lung infection and lastly protozoal infections and these are parasitic and type one type is toxoplasmosis and this is a parasitic infection that can be inhaled it comes from either cat or bird feces or it can be ingested from pork and red meat it causes serious lung infections and can affect other structures of the body next is cryptosportiosis and this can cause serious gi problems and then lastly cysto isosporiasis which comes from eating contaminated food or drinking contaminated water and this causes serious gi problems now what are some preventative measures that your patient can take to prevent these opportunistic infections when they're at risk well we know that they have a weakened immune system so let's remember the word weaken w is for water consumed should be from treated sources they don't want to drink water from an untreated source let's say they're outdoors hiking they don't want to drink water from a river or a lake or if they're traveling abroad they don't want to drink water from foreign sources e is for eat foods that are not raw or unpasteurized so they want to make sure that they're consuming foods that have been fully cooked to prevent those gi illnesses a is for avoid risky activities such as sexual activities that could cause sexually transmitted infections or drug activities k is for keep vaccinations up to date like the with the pneumovax which will help prevent pneumonia e is for exposure to animal feces should be very limited especially if they own birds or cats where they have to change out that feces so they want to limit this or get someone else to do that for them because that puts them at risk for that toxoplasmosis and then n is for they need to take their arts their anti-retroviral therapy because this is going to help keep their immune system strong now let's talk about the nurses role and treatment for hiv so as a nurse we play a huge role with screening patients identifying who is at risk for hiv because if we can help the patient identify if they are at risk we can get them treatment sooner with arts which can help improve their life and we can help prevent transmission so all we have to do is ask specific questions and that can help tip us off if this patient needs a test or not plus we can help with educating educating them about the disease how to prevent transmission about antiretroviral therapy etc and monitoring the patient monitoring their labs knowing what tests have to be ordered what's normal what's not the progression of the disease opportunistic infections etc so with screening we want to know who's at risk so who is at risk for hiv well anyone who engages in activities that's going to put their bloodstream or mucous membranes into contact with the fluids that can transmit hiv so you want to ask them questions that can help identify if they are engaging in high risk activities for example ask about their sexual behavior are they sexually active if so how often how many partners do they have what barrier methods do they use and if they've ever had a sexually transmitted infection because that increases the risk of developing hiv you also want to ask about if they use drugs if they do use drugs what type of drugs do they use and do they use devices that they share with others to take the drugs because that increases the risk as well especially if they're injecting drugs and sharing the needles and you want to ask them if they've ever had a blood transfusion because if they had before 1985 the screening of blood products for hiv is very low so there's a chance that they could have it now let's say you do identify a patient who's at risk for hiv well you want to let the physician know who will order hiv testing and we will test the patient for hiv you'll want to explain to the patient about the test about the whole window period etc now the cdc recommends patients who are at high risk have yearly testing for hiv now for patients who let's say aren't necessarily at risk but they're the ages between 13 to 64 regardless of their risk factors the cdc recommends that they at least be tested once during a routine health visit for hiv because some people may have hiv and not know it and unknowingly spread it to others now let's say that you do have a patient who is high risk for hiv and they get tested they're negative for hiv well you want to provide them with some education on prep prep is pre-exposure prophylaxis and this prevents from becoming infected with hiv and to use this they must be hiv negative and engage in high risk activities and some medications that are used for this are like truvata and descovie so patients who do take this they can have protection from getting hiv if they engage in sexual contact or injecting drugs it can provide protection but there is a higher percentage of prevention with sexual contact then injecting drugs with this next is pep and pep stands for post-exposure prophylaxis and this is taken after a potential exposure of hiv so prep was taken before a potential exposure this is taken after and it has to be started within 72 hours of that exposure and it's not for routine use but emergencies so it's used like in cases of sexual assault needle sticks etc and it's a medication regimen that is taken for 28 days and these medications include truvada and isentrose which is raw tega revere or truvada and doluteg revere which is tim vacay now tiffa k is not for pregnant women or for women who could become pregnant because it could cause birth defects now what education can you provide to a patient who does have hiv on how to prevent transmitting the virus to others well remember the virus is only spread in those certain body fluids we discussed earlier so one thing you can educate them about is limiting activities that actually transmit the virus itself so you really want to assess your patients understanding and knowledge of how this is transmitted and ask them questions because that's going to give you clues on where you should go with the education and talk about preventative measures on if they are engaging in these activities on how to prevent the spread and letting their partners know and their partners becoming tested as well and then there's pregnancy so if your patient has hiv and they do become pregnant there is a chance that they can transmit that virus to their baby and this could happen during the pregnancy during the birthing process or during the postpartum period in the breast milk so they shouldn't breastfeed because they could transmit it in their breast milk and they want to start antiretroviral therapy as soon as possible because this will help decrease the transmission of the virus to the baby an interestingly according to hiv.gov if hiv medications are taken as prescribed during pregnancy and childbirth and given to the baby for four to six weeks after birth there is a one percent chance or less the baby will develop hiv so with that said as a nurse we play a vital role in helping educate pregnant patients who are hiv positive and how to possibly prevent the transmission of the virus to their baby with these medications so let's take a look at the antiretroviral therapy so antiretroviral therapy or treatment has a goal of limiting the ability of the virus to replicate by interfering with the parts of the hiv life cycle remember we went over that in depth so we're targeting specific parts of that life cycle so whenever we do that we're going to decrease the amount of virus in the blood the viral load and this happens usually within about six months and it's going to help increase cd4 levels we want it greater than 500 because this is going to help prevent those opportunistic infections so while patients are receiving these treatments they will have these cd4 numbers checked regularly to monitor treatment and to make sure that medication resistance isn't developing whenever a patient does start this treatment they will take a combination of medications they'll start out taking three meds from at least two drug classes now there's a total of about six drug classes and they include attachment inhibitors entry inhibitors non-nucleoside reverse transcriptase inhibitors nucleoside slash nucleotide reverse transcriptase inhibitors integrase inhibitors and protease inhibitors and if you notice those words in those drug classes are very similar to the steps of the hiv life cycle so first let's talk about the attachment inhibitors and just as their name says they are going to inhibit the attachment step in the life cycle of hiv so hiv cannot go down and attach to the cd4 receptor and engage those co-receptors so we can't really have hiv getting access to that cell and that's what that picture right there is representing so here we're talking about the post attachment inhibitors they bind with the cd4 receptors and inhibit the glycoprotein gp120 from being able to activate itself and engage those co-receptors which could either be cxcr4 or ccr5 and there's currently one medication like this and it's called trogarzo and this is not a pill it's given iv form and the patient will receive it every two weeks then we have the attachment inhibitors so it works a little bit different but overall it's going to stop that attachment of the hiv virus to those receptors it's going to bind to the glycoprotein on hiv which again was what gp120 and it's going to inhibit it from engaging itself with the cd4 receptor and a medication that does this is called reucovia and it comes in pill form next are entry inhibitors and they are going to block hiv from being able to enter the cell either by messing with co-receptor or blocking fusion so chemokine receptor antagonist ccr5 antagonist is a group of drugs that block the co-receptor ccr5 on the cell so hiv can't engage the receptor and enter the cell and a medication that does that is called maravaroc and it is given in pill form then we have fusion inhibitors and they stop hiv from entering the cell because remember the virus must fuse with the cd4 cell in order to enter and then it dumps its viral material into the cell so we're going to stop that fusion and this includes infuvertide which brand name is fusion so to help you remember if this is a fusion inhibitor remember fusion it's f-u-s-i-o-n and fusion has f-u-z-e that sort of looks like fuse and in fuvertide has fu so it's a fusion inhibitor maybe that'll help you keep it straight and these medications are injected in the sub-q fat so it's not a pill then we have the non-nucleoside reverse transcriptase inhibitors now just as the name says it is going to inhibit that enzyme reverse transcriptase from working and remember what did that enzyme do it was an enzyme that helped turn that viral rna into viral dna which eventually is going to go into that nucleus of that cell and take over so it stops the enzyme reverse transcriptase from working by binding to it and an example of this medication is like dravarine then we have nucleoside or nucleotide reverse transcriptase inhibitors and these are a little bit similar to the last ones we talked about but they modify reverse transcriptase's role when it tries to convert viral rna into viral dna and because of this it will alter the development of how that viral dna develops so the virus really can't recreate itself an example of this type of medication is a baccavir then we have the class of integrase inhibitors and just as their name says they're going to inhibit the enzyme integrase from doing its role and remember what did integrase do it allowed the viral dna to integrate itself with the cell's dna so it could take over that cell so we're going to prevent that from happening and it won't be able to insert itself now to help you remember this class of drugs remember the t t-e-g-r-a in integrase and their medication names have that in the middle of it and one example you've heard of before is raw tegravir and then lastly we have the protease inhibitors and just as their name says once again it's going to inhibit protease from being able to cut those long chains of virus so we're really not going to be able to allow that virus to mature it can't really be assembled so it can't go on and wreak havoc on the body an example of these medications is like ataxana fear and notice these medications all end in navir so maybe that can help you keep that straight now whenever you have a patient who is receiving this type of therapy you want to educate them on some things number one even though they have an undetectable viral load because that's what these medications are supposed to do they're supposed to decrease that viral load it doesn't mean that they're cured from hiv or their blood's free from it just means that it's very low where we can't detect it so they still want to take measures to prevent transmission the risk of transmitting hiv when they have a really low undetectable viral load is slim but they still want to take measures and the medications in order for them to work as they're prescribed they have to take these medications exactly as prescribed that means they can't skip doses they have to take them at the same time every day why is this because if they don't do this hiv smart it'll start a workaround of these medications so we want to take them as exactly as prescribed because it helps keep the viral level low and it prevents drug resistance from developing because if these medications aren't taken as prescribed again the hiv virus will get smart and they won't work anymore so assess your patients ability to take the medications will they have access to go get their medications do they have the money to afford these medications and so forth and then lastly many of these medications interact with other medications so as the nurse you want to look at the patient's medication history see what else they're taking because a lot of patients they take over the counter otc medications such as herbal medications to help them one medication that a patient may take that's herbal is saint john's war this is used for depression and this interferes with these medications so as a nurse we play a vital role with identifying that okay so that wraps up this review over hiv and aids and don't forget to take the free quiz that will test you on this content