hiv aids nursing case study

AIDS Case Study (45 min)

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Mr. Hernandez is a 33 year old male with a history of IV Drug Use, Hepatitis C, and HIV. He has previously been managed on HAART therapy, but has been having recurrent bouts of pneumonia in the last 6 months.  He presents to the Free Clinic today complaining of weakness and fatigue, shortness of breath, and a persistent cough. He reports a 10 lb weight loss over the last 3 weeks. He says “I think I have pneumonia again”. 

What further history questions and assessment data would you obtain at this time?

• Weight loss and a persistent cough should always spark “TB” in your mind – ask about fever,chills, night sweats as well
• Heart and lung sounds
• Assess skin condition and peripheral perfusion

What laboratory or diagnostic tests do you anticipate the provider ordering?

• Chest X-ray
• Complete Blood Count – with CD4 due to HIV history
• Liver Function Tests due to Hepatitis C history
• Chemistry Panel to evaluate for renal involvement or electrolyte abnormalities
• Blood and/or sputum cultures to determine source of infection

Upon further questioning, the patient reports fever, chills, and night sweats for the last few days. His coughing has been nonproductive. He has diffuse rhonchi through his right lung and scattered rhonchi on the left.  A Chest x-ray shows a nodular consolidation on the right side and diffuse infiltrates. The provider orders a CBC with Diff and a CD4 cell count.

Vital signs show the following:

Temp 101.6°F

What respiratory disease has Mr. Hernandez contracted?

• Tuberculosis

What should your first nursing action be?

• Isolate the patient. In this case, he is in a Free Clinic, so they may not have negative airflow rooms. In this case, close the door and prevent staff from entering without respirator masks. When the patient leaves the clinic, he must be wearing a surgical mask.
• He will need to be transported safely to the hospital to place him in proper isolation

The Complete Blood Count with Differential shows the following abnormal values:

H/H 8.1/24.3

Plt 104,000

CD4 <10 / mm 3  

What is going on physiologically with Mr. Hernandez? How do you know?

• He has developed AIDS. He is having recurrent infections (pneumonia), and now he has contracted Tuberculosis
• Combine that with his extremely low CD4 cell count and that confirms that he has officially progressed to full blown AIDS

Mr. Hernandez is sent straight to the hospital to be admitted. He is started on high-dose IV antibiotics and his HAART therapy dosages are increased.  He receives 2 units of Packed Red Blood Cells when his Hgb drops to 7.6 mg/dL. He continues to be weak and has fevers and night sweats, treated with PO Acetaminophen. He is flushed and his skin is warm. His vital signs in the morning are:

SpO 2 92% on 4 lpm nasal cannula

Temp 101.8°F

What condition is Mr. Hernandez developing because of his infection?

• Sepsis – this may even develop into septic shock if we start to see signs of end-organ damage due to low perfusion

What medications or treatments might he require to maintain his hemodynamics?

• IV fluid resuscitation
• He may require vasopressors – meaning he also needs a central line placed
• After 2 weeks of treatment and severe sepsis, Mr. Hernandez elects to stop all treatments. He decides to enter an inpatient hospice program to manage his pain and keep him comfortable. He passes away peacefully 5 days later.

Could anything have been done differently for Mr. Hernandez?

• As always, it’s hard to know for sure. It’s possible that he wasn’t taking his medications properly, or that his dosages could have been increased sooner
• Given the fact that he is being seen at a free clinic, there’s a chance that he didn’t have one specific doctor following his case – otherwise they would have noticed recurrent pneumonia and could have made medication adjustments earlier
• Unfortunately, there’s no cure for AIDS and it is a progressive disorder.

Reference :

Diagnostic Criteria for AIDS – https://www.ucsfhealth.org/conditions/aids/diagnosis.html

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Nursing Case Studies

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

Nursing Case Studies Introduction

Cardiac nursing case studies.

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GI/GU Nursing Case Studies

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Obstetrics Nursing Case Studies

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Pediatrics Nursing Case Studies

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Neuro Nursing Case Studies

Mental health nursing case studies.

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Metabolic/Endocrine Nursing Case Studies

Other nursing case studies.

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July/August 2024 - Volume 35 - Issue 4

• Editor-in-Chief: Michael V. Relf, PhD, RN, AACRN, ACNS-BC, CNE, ANEF, FAAN
• ISSN: 1055-3290
• Online ISSN: 1552-6917
• Frequency: Bimonthly
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HIV and AIDS Nursing NCLEX Review

This review will cover Human Immunodeficiency Virus (HIV) and AIDS (Acquired Immunodeficiency Syndrome) .

This review will cover:

• What is HIV and AIDS?
• Quick Facts
• Pathophysiology
• Stages of HIV (signs and symptoms, testing etc.)
• Nurse’s Role
• Antiretroviral treatment (ART)

When you’re done reviewing, don’t forget to take the HIV/AID NCLEX Questions Quiz and watch the HIV lecture.

HIV/AIDS NCLEX Nursing Review

HIV stands for “Human Immunodeficiency Virus” and AIDS stands for “Acquired Immunodeficiency Syndrome”.

Helper t cells are white blood cells that help the immune system fight infection. These cells are strategically attacked and killed overtime by HIV. When the number of helper t cells fall too low, the body loses its ability to fight infection.

Therefore, if a person becomes infected with HIV and is not treated with medical therapy, HIV will turn into AIDS. HIV occurs in stages, and a person can have HIV for several years before it transitions into AIDS.

There is no cure for HIV, as of today, but medical therapy has advanced (and continues to advance) so that people with HIV can now live longer healthier lives.

Quick Statistics about HIV/AIDS

How many have died for this infection and how many people are currently infected?

According to the World Health Organization (WHO):

“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 .

Current number of people who have HIV? WHO estimates that: “ globally at the end of 2020, 37.7 million  people were living with HIV.” (World Health Organization, 2021)

How is HIV Transmitted? What increases your risk of getting it?

Transmission from someone with HIV depends on:

• A high viral load can occur during the acute phase of HIV and if the person is not receiving medication therapy to help decrease the viral load.
• How much of the virus was actually transmitted (certain activities will transmit more of the virus)
• An interesting statistic about this…CDC says that: “ Healthcare workers who are exposed to HIV-infected blood via a needlestick have a 0.23% risk of becoming infected.” ( Occupational HIV Transmission and Prevention among Health Care Works , 2015)
• some people (a very small percentage) are actually resistant to HIV

In order to transmit the virus, the virus must be in a specific fluid like blood, semen, vaginal fluid, or breastmilk. This fluid must enter the blood stream directly or indirectly via injury or a mucous membrane (like the vagina, penis, rectum, or mouth).

Activities that could transmit HIV:

• Unprotected sexual contact
• Drug use (needle sharing)
• Blood product transfusion
• Needle stick injury or unclean needle from a piercing or tattoo
• During pregnancy (pregnancy itself, birthing process, or via breastmilk)

 HIV is NOT Transmitted

HIV is a weak virus without a host of fluid like blood, semen, vaginal fluid or breastmilk. It doesn’t survive without it. Therefore, activities that are not likely to transmit the virus include:

Hugging, closed mouth kissing, touching clothes or objects, tears, sweat, or saliva (without blood), insect bites mosquitoes, household items, coughing/sneezing

Pathophysiology of HIV

Key Players in the Patho:

• HIV (the virus) and its life cycle
• CD4+ receptors (mainly targeted is the helper t cells)

Helper t cells are a type of white blood cell used to help us fight infection. They play a huge role in the adaptive immune system, which is what our body uses to help us respond and be protected from a foreign invader exposure.

Therefore, this system plays a vital role with us developing acquired immunity, which gives our body the ability to build a foreign invader memory bank against foreign invaders. If you don’t have this handy memory bank we are at risk for developing opportunistic diseases or infections.

OIs (opportunistic infections) don’t tend to cause an issue in a person with a healthy immune system . However, when HIV is present in the body it wipes out the immune system cells (hence helper t cells) that help protect us from them. OIs can be cancerous, viral, bacterial or protozoal.

When a patient with HIV develops an opportunistic infection or disease it could lead to death. In fact, the presence of an opportunistic disease in a patient with HIV is one of the criteria use to diagnose AIDS.

These cytokines help activate another type of t cell called cytotoxic t cells to kill invaders, macrophages who will eat invaders, and b cells who will make antibodies to fight invaders.

Now, let’s look at HIV:

HIV is a retrovirus that cannot grow or multiply by itself, but must find something that will allow it to do this…hence a host cell. Therefore, it finds the helper t cell and other cells that have a CD4 receptor on its surface as the perfect host cell. HIV uses this receptor to gain access to the cell, which allows the virus to reproduce and destroy its host cell.

This leads me to the “Life Cycle of HIV”. The Life Cycle of HIV is how HIV strategically takes over the host cells, replicates, matures, and eventually kills the host cell. As the nurse, it is important to have a basic understanding on this life cycle because this is what Antiretroviral Therapy (ART) targets in the treatment of HIV.

It’s an enveloped virus that is surrounded by proteins called glycoproteins. A particular glycoprotein I want you to pay close attention to is glycoprotein 120 (GP120).  These proteins look like a knob that projects from the virus. These protein projections are key for attaching to the CD4 receptor on the helper t-cell or CD4 positive receptor for entry into the cell.

Packaged on the inside of the virus is it’s “suitcase”. HIV doesn’t plan on staying as itself but plans to take a trip inside the host cell and set up a new  temporary residence.

So, mainly on the inside of the virus is it’s RNA and three important enzymes that I want you to remember: Reverse transcriptase, Integrase, and Protease

Life Cycle of HIV

Attachment occurs when the GP120 protein projections make contact and bind with a CD4 receptor. In addition, there is also binding with certain co-receptors called CCR5 or CXCR4 to gain entry into the cell.

Fusion occurs when the virus becomes united with the cell and dumps its content into the cell, which is genetic material (RNA) and enzymes (unpacks it “suitcase”).

Reverse transcription: Now it’s time to set up shop with the goal of getting into the cell’s nucleus and becoming integrated with the cell! Therefore, the single strand of viral RNA needs to turn into viral DNA. The HIV virus brought along with it an enzyme called reverse transcriptase . This enzyme causes the viral RNA to turn into double stranded DNA. This viral DNA moves into the nucleus of the cell.

Integrate: Once inside the nucleus it needs to hijack the cell’s DNA (hence become part of it so it can take control, produce more HIV virus, and kill the cell). To do this, the HIV DNA strand releases another enzyme called integrase, which allows it to become part of the cell’s DNA. So, it’s now integrated into the cell’s DNA.

Replicate: Now that the HIV’s DNA is in control, it starts to use the parts of the hijacked cell to make long chains of the virus.

Assembly: These long chains and other viral material are being assembled and start to move toward the cell’s surface.

Budding: The assembled parts start to grow (hence bud) off the cell wall.

Once it has completely grown off the cell’s surface, it pops off.  Then protease (an enzyme that cuts the long chain of virus prepping it for maturity) completes its job of maturing the viral material and a new mature virus is born. The cell it hijacked dies and this new mature HIV virus has a mission of finding another cell victim with a CD4 receptor and start the whole process again.

HIV Stages, Sign/Symptoms & Testing

Acute Stage:

• Begins about a couple of weeks to a month after becoming infected
• Can spread to others
• Viral load very high in the blood (HIV rapidly killing CD4 cells and multiplying)
• Aches, joint pain, headache, fever, fatigue, sore throat, swollen lymph nodes, GI upset, rash
• No test available that can show immediate infection because there is a window period. The window period is the time when infected to when a test can deliver a positive result (hence detect antibodies against the virus which is known as seroconversion ).
• Window periods vary on the test (some are earlier than others).
• A person can have the virus in the body (get a negative test result) because not enough time has passed for the test to pick it up (still can transmit). If a person suspects they may have HIV they need to abstain for sex and drug usage until confirmation. There are tests available that can show infection a couple of weeks to months after infection, but not immediately.
• HIV antigen is p24 (shows HIV as early as 2 weeks)
• Antibody HIV test : some types can give rapid results and you can self-test with these types but can’t detect as early as the combination test (2 ½ weeks) and test for the antibody (not antigen)
• used for high risk exposure patients
• the test that can detect the earliest (around 10 days after exposure)
• not commonly used unless high risk and showing symptoms due to costs of the test
• Normal range: 500 to 1500 cells/mm3 (cells per millimeter)…in this stage it should be greater than 500 cells per millimeter
• <200 cells/mm3 AIDS and opportunistic infection
• Antiretroviral therapy (ART) should be started as soon as possible (lowers viral load , lowers chance of transmission of virus, lowers risk of OIs)

Chronic Stage (Asymptomatic Stage):

• May not have signs and symptoms
• This stage can last up to a decade or more for people who are NOT taking medications to treat and some who are taking ART may stay in this stage and may never progress to the last stage…AIDS.
• Lower viral load but the virus is still replicating and destroying the cells
• Can still transmit HIV to others (ART can help lower this chance)
• CD4 count is more than 200 to about 500 cell/mm3
• No opportunistic infections present at time
• Stage ends: viral count increasing, CD4 drops less than 200, signs/symptoms start to appear along with opportunistic infections

Acquired Immunodeficiency Syndrome (AIDS)

• CD4 count drops to less than 200 cells per millimeter or
• Opportunistic disease is present

Opportunistic Diseases or Infections:

This is a quick review over the main types of OIs a patient can experience with AIDS. The types of OIs include:

Cancerous, Viral, Bacterial, Fungal or Protozoal

Mycobacterium tuberculosis: It spreads easily in the air and affects the lungs and other parts of the body like the brain etc. Watch for s/s: night sweats, weight loss, trouble breathing, coughing

Salmonella septicemia: occurs from eating contaminated food or drinking contaminated water

MAC (Mycobacterium Avium Complex): These are various types of mycobacterium which is found in the environment that normally don’t harm people with healthy immune systems

Streptococcus Pneumoniae: causes pneumonia (educate about preventative vaccine Pneumovax)

Coccidioidomycosis: infected from inhaling spores which are found in the soil

Crytococcosis: can cause  pneumonia and affect the neuro system

Histoplasmosis : found in soil that has a lot of animal feces in it like from birds. It causes a lung infection that can affect the neuro system

Pneumocystis pneumonia (PCP): causes a lung infection

Protozoal: parasitic type infections

Toxoplasmosis: parasitic infection that can be inhaled (found in cat and bird feces) or from ingestion of pork and red meat. It infects the lungs and other structure of the body.

Cryptosporidiosis (Cryto): GI problems

Cystoisosporiasis: infected from contaminated food and water that causes GI problems

Education on How to Prevent OIs

Patients develop OIs because of a WEAKEN immune system.

• W ater consumed should be treated (not from untreated sources and avoid water in foreign countries)
• E at foods that are NOT raw or unpasteurized (avoid: raw meats, unpasteurized dairy products, or anything undercooked)…toxoplasmosis
• A void risky sexual activities (major risk for STIs) and drug activities
• K eep vaccines up-to-date (pneumonia major risk for death)
• E xposure to animal feces should be limited (birds, cats, rats).. toxoplasmosis
• N eed to take ART (antiretroviral) therapy as prescribed to help maintain a healthy immune system

Nurse’s Role and Treatments for HIV/AIDS

Our Goal: Screening patients for possible HIV infection, Educating (testing, transmission, preventing OIs, antiretroviral therapy), Monitoring labs, patient’s signs/symptoms for opportunistic diseases (progression of the disease)

Who’s at risk? Anyone who has or is participating in an activity that allows their blood system or mucous membranes to come into contact with body fluids that transmit HIV.

As the nurse ask your patient questions about the following topics to help guide you in screening patients for HIV:

• Sexual behavior (assess if sexually active, how often, ever had an STI, barrier devices used, and number of partners)
• Drug usage (type or using devices to use drugs)
• Blood transfusions especially before 1985 (didn’t screen very well for HIV or AIDS virus)

If at risk, needs to be tested with HIV antibody testing. It’s very important HIV is detected early so ART can be initiated, prevent transmission, etc.

CDC recommends that high risk patients have yearly testing .

And that everyone ages 13 to 64 should be tested for HIV regardless of risk factors at least once during a routine health visit. This is because some people have HIV, don’t know it, and unknowingly spread it to others. If the patient is positive, they will need a lot of support and education. (“HIV Testing CDC”, 2020)

Educate High Risk Patients:

PrEP : Pr e- E xposure P rophylaxis

• Prevents becoming infected with HIV BEFORE an encounter with HIV
• Must be HIV negative but engages in high risk activities that could transmit HIV
• Higher chance of prevention with sexual contact than with injecting drugs
• Truvada (emtricitabine/tenofovir disoproxil fumarate)
• Descovy (emtricitabine/tenofovir alafenamide)

PEP: ( P ost- E xposure P rophylaxis)

HIV medications taken AFTER an encounter with an HIV infected person to help prevent HIV.

• Has to be started within 72 hours of the exposure
• Not for routine use (if at high risk consider PrEP) but in emergencies (sexual assault, needle stick etc.)
• Taken for 28 days
• Truvada and Isentress (Raltegravir)
• not for pregnant women or could become pregnant due to birth defects

Preventing Transmission, if Positive

Limit or eliminate activities that transmit HIV

• Nurse needs to assess patient’s understanding of how to prevent transmitting sexually and with drug use. Educate based on the patient’s needs, the importance of getting partners or others tested if they have participated in these activities with them.

Pregnancy: HIV can be spread to the baby during pregnancy, birth, and in breastmilk.

• Needs to start ART therapy during pregnancy to help decrease the transmission to baby. Breastfeeding should be avoided because breastmilk contains the virus.
• According to HIV.gov: “if HIV medications are taken as prescribed during pregnancy and childbirth and given to the baby for 4- 6 weeks after birth there is a 1% or less chance the baby will develop HIV.” (Preventing Mother-to-Child Transmission of HIV, 2021)

So, with that said, identifying and educating the pregnant woman about this is crucial in protecting a baby from HIV.

Antiretroviral Treatment (ART):

Goal of ART : limit the virus’ ability to replicate by interfering with parts of the HIV life cycle:

• Result: decreases the amount of virus in the blood (viral load) within about 6 months (lower chances of transmission to others)
• helps prevent opportunistic infections/diseases…will have these levels checked regularly to monitor treatment and make sure medication resistance isn’t developing

6 Classes of ARTs

Attachment Inhibitors:

Post-attachment Inhibitors: binds with the CD4 receptors and inhibits the HIV’s glycoprotein (gp120 knob) from being able to activate and engage the co-receptors CXCR4 and CCR5

• Trogarzo (ibalizumab)
• Given IV every two weeks (not a pill)

Attachment Inhibitors : binds to the glycoprotein on HIV (gp120) and inhibits it from engaging with the CD4 receptor

• Rukobia (Fostemsavir) (pill)

Entry Inhibitors:

Chemokine Receptor Antagonists (CCR5 Antagonist): blocks the co-receptor CCR5 on the cell so HIV can’t engage the receptor and enter the cell

• Maravirco (Selzentry) (pill)

Fusion Inhibitors: stops HIV from entering the cell (the virus must fuse with the CD4 cell in order to enter and inject its viral material into the cell)

• Enfuvirtide (Fuzeon)
• Injection in subq fat

Inhibits Reverse Transcriptase : prevents the enzyme reverse transcriptase from turning viral RNA into viral DNA

Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs): stops the enzyme reverse transcription from working by BINDING to it

• Doravirine, Efavirenz, Etravirine, Nevirapine, Rilpivirine

Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs): modifies reverse transcriptase’s role when it tries to convert viral RNA into viral DNA. This will alter the development of the HIV’s DNA so the virus can’t recreate itself.

• Abacavir, Emtricitabine, Lamivudine, Zidovudine, Tenofovir disoproxil fumarate

Integrase Inhibitors : prevents the enzyme integrase from allowing HIV to insert its DNA into the cell’s DNA

• easy to remember “ tegra “…integrase
• Ral tegra vir (PEP), Dolu tegra vir, Cabo tegra vir

Protease Inhibitors: stops the enzyme protease from cutting the long chains of virus. This process is stopped so the immature virus can’t be assembled and mature.

• Ataza navir
• Fosampre navir

Education about ARTs:

• Even though viral load (the amount of the virus) that is in the blood is undetectable doesn’t mean the person is free from the virus (or cured)…they need to still take measures to prevent transmitting the virus others during risky activities (but risk of transmitting is low when medications are taken exactly as prescribed).
• These medications have to be taken exactly as prescribed (at the right time, frequency, dosage). The patient can’t skip dosage because the medication won’t work (viral load increases) and resistance can develop . Assess a patient’s ability to take the medications (financial, lifestyle etc.) The patient must be educated about this.
• Medications can interact with many over-the-counter medications (especially herbal)…know what other medications your patient is taking.

References:

Centers for Disease Control and Prevention. (2015). Occupational HIV Transmission and Prevention among Health Care Works [Ebook] (p. 1). Retrieved 3 December 2021, from https://www.cdc.gov/hiv/pdf/workplace/cdc-hiv-healthcareworkers.pdf.

FDA-Approved HIV Medicines | NIH . Hivinfo.nih.gov. (2021). Retrieved 8 December 2021, from https://hivinfo.nih.gov/understanding-hiv/fact-sheets/fda-approved-hiv-medicines.

HIV/AIDS. Who.int. (2021). Retrieved 3 December 2021, from https://www.who.int/data/gho/data/themes/hiv-aids.

HIV Testing | HIV/AIDS | CDC . Cdc.gov. (2020). Retrieved 8 December 2021, from https://www.cdc.gov/hiv/testing/index.html.

Preventing Mother-to-Child Transmission of HIV. HIV.gov. (2021). Retrieved 8 December 2021, from https://www.hiv.gov/hiv-basics/hiv-prevention/reducing-mother-to-child-risk/preventing-mother-to-child-transmission-of-hiv.

The HIV Life Cycle | NIH . Hivinfo.nih.gov. Retrieved 8 December 2021, from https://hivinfo.nih.gov/understanding-hiv/fact-sheets/hiv-life-cycle.

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HIV Nursing Diagnosis and Nursing Care Plan

Last updated on April 29th, 2023 at 11:27 pm

HIV Nursing Care Plans Diagnosis and Interventions

Acquired immunodeficiency syndrome (AIDS) is a chronic medical condition that involves damage on the immune system. AIDS is caused by human immunodeficiency virus (HIV), which is a sexually transmitted infection (STI).

Types of HIV AIDS

Signs and symptoms of hiv aids, causes and risk factors of hiv aids.

AIDS is caused by HIV infection. HIV is a virus that is able to destroy CD4 T-cells, which are immune cells that have a huge role in fighting disease. The virus can be spread through infected blood (such as when sharing contaminated needles or through blood transfusions ), sexual contact (semen or vaginal discharge), and from the mother to her child during her pregnancy, childbirth, and breastfeeding.

The risk factors of HIV/AIDS include:

Complications of HIV AIDS

Diagnosis of hiv aids, prevention of hiv aids, treatment for hiv aids, nursing diagnosis for hiv, nursing care plan for hiv 1.

Desired Outcome : The patient will be able to avoid the development of an infection.

Nursing Care Plan for HIV 2

Nursing Care Plan for HIV 3

Nursing Diagnosis: Fatigue related to body weakness secondary to HIV/AIDS infection as evidenced by overwhelming lack of energy, verbalization of tiredness, generalized weakness, lack of appetite, and shortness of breath upon exertion

Nursing Care Plan for HIV 4

  Desired Outcome: The patient will be able to achieve a weight within his/her normal BMI range, demonstrating healthy eating patterns and choices.

More HIV AIDS Nursing Diagnosis

Nursing references.

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020).  Medical-surgical nursing: Concepts for interprofessional collaborative care . St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

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• OJIN Homepage
• Table of Contents
• Volume 14 - 2009
• Number 1: January 2009
• Articles on Previously Published Topics
• Telehealth and HIV/AIDS Clients

Using Telehealth to Deliver Nursing Case Management Services to HIV/AIDS Clients

Jennifer Lillibridge received both her baccalaureate and master’s degrees from California State University, Chico, CA, and her doctoral degree in education from Monash University in Australia. Dr. Lillibridge has extensive experience in qualitative research methods. Over the past six years she has collaborated with nurses at Home Health Care Management Incorporated in Chico, California, in the research areas of fall prevention and telehealth.

Barbara Hanna received her Bachelor of Science degree from California State University, Chico, CA. Ms Hanna is the founder and president of Home Health Care Management Incorporated in Chico, California. The agency is a licensed and Medicare Certified Home Health Agency, with over 100 employees. Since 1992, she has been contracted with the California State Office of AIDS to provide home- and community-based services to HIV infected clients in a seven county region of Northern California.

The purpose of this qualitative, descriptive study was to explore the use of telehealth technology to assist case managers to effectively manage their caseloads of HIV/AIDs clients, increase responsiveness to their clients’ changing medical conditions, and serve as a partial solution to the ongoing nursing shortage. Telehealth monitors were placed and used in the homes of six HIV/AIDS clients for a period of four months. Clients were interviewed following the removal of the telehealth equipment from the home. Findings clustered around the three major themes of missing the nurse, being satisfied, and drawbacks. The findings suggest that the use of telehealth technology has the potential to effectively assist case management and home health agencies manage their caseloads, increase responsiveness to a client’s changing medical conditions, and address the ongoing nursing shortage.

Keywords : e-health, e-nursing, HIV/AIDS, homecare, telehealth, telemedicine, technology, telenursing, telecare, telehomecare

The year 2006 marked the 25 th year of the presence of Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) in the United States (US). Glynn and Rhodes ( 2005 ) predicted that by 2006, more than one million persons would be living with HIV/AIDS in the US, and an estimated 40,000 new HIV infections would occur during that year. Hall, Long, Phodes, and Prejean ( 2008 ) have now reported that the year 2006 actually saw 56,300 new cases of HIV infection. According to the Centers for Disease Control (CDC), the two fastest growing segments of the population at risk for contracting new infections are the men having sex with men (MSM) while using injectable drugs, and the heterosexual population ( CDC, 2006 ).

In the beginning of the HIV/AIDS epidemic, most persons became ill quickly and died within 18-24 months of initial diagnosis. However, with the advent of the protease inhibitors and other new medications, HIV/AIDS has become a medically complex, chronic disease ( Scandlyn, 2000 ). HIV/AIDS clients today continue to require assistance with housing, mental health services, medication adherence, managing side effects of the medications, transportation to and from medical providers, and food subsidies. Coordination of care amongst medical and social service providers has become essential for these chronically ill clients.

...clients managing HIV/AIDS on a long-term basis, especially those in rural areas, have a difficult time obtaining healthcare and monitoring due to the shortage of nursing and other healthcare providers. Given the complexity of the disease process, HIV/AIDS clients often experience many co-morbidities. These co-morbidities may include changes in nutritional status leading to weight changes; fluctuations in blood pressure; and metabolic disorders, such as diabetes, due to co-existing treatment regimes. Opportunistic infections that need frequent intervention and monitoring also affect this group of individuals ( Miller, 2000 ). Unfortunately, clients managing HIV/AIDS on a long-term basis, especially those in rural areas, have a difficult time obtaining healthcare and monitoring due to the shortage of nursing and other healthcare providers. A recurrent theme at the California Department of Public Health/Office of AIDS Case Management Program and Medi-Cal Waiver Program Project Directors meetings has been the lack of registered nursing staff to fill the available nursing case management positions throughout the state due to limited resources of providers/agencies and flat funding and/or funding restrictions for the programs (B. Hanna, personal communication, October 16, 2006). This article will describe telehealth nursing, present a study that explored the use of telehealth technology, report and discuss the study findings, and conclude that the use of telehealth technology has the potential to effectively assist case management and home health agencies manage their HIV/AIDS client caseloads, increase responsiveness to their clients’ changing medical conditions, and address the ongoing nursing shortage

Telehealth Nursing

Use of the term ‘telemedicine’ has long been associated with providing medical services to distant or remote clients using some type of technology, such as the telephone, audio/video equipment, or the Internet. The American Nurses Association, in choosing to use the term ‘telehealth’ rather then ‘telemedicine,’ describes a broader use of telecommunications technologies in healthcare which include nursing roles and functions ( ANA, 1997 ). Interactive, home telehealth is the term used in the current study and is described by Kinsella as occurring when “[P]atients and health care providers use two-way interactive audio and/or video to collect and transmit clinical data. This service provides remote assessment, education and data collection” (2003, p. 26).

Audio/video systems, initially confined primarily to the collection of vital signs, now allow nurses to provide palliative care, rehabilitation, case management, and chronic disease management ( Kinsella, 2003 ). Advances in telehealth technology have contributed to the use of telehealth as a viable solution to both the shortage of nurses and limited healthcare resources by allowing nurse case managers and clients to establish and maintain direct and ongoing communication with their clients over geographical distances ( Kinsella ; Russo, 2001 ).

There is an abundance of literature describing perceived benefits and documented successes of combining telehealth technology and nursing. Geographic isolation and limited preventative services due to lack of medical specialists have been cited as the rationale for implementing telehealth services to underserved populations ( Reed, 2005 ). Peck has argued that telehealth can be used to “help save money and improve care through efficient and accurate patient tracking, and by retaining experienced and dedicated nurses” ( 2005 , p. 339). Positive outcomes associated with using telehealth technologies in various client populations have been well documented. Telehealth technologies have been used effectively for outpatient management of cancer patients with new ostomies ( Bohnenkamp, McDonald, Lopez, Krupinski, & Blackett, 2004 ), to decrease hospitalizations in congestive heart failure patients ( Kobb, Hoffman, & Lodge, 2003 ), to provide pre-operative education to rural patients having total joint replacement ( Thomas, Burton, Withrow, & Adkisson, 2004 ), to assist acutely ill patients transition from hospital to home ( Marineau, 2007 ), and to provide care to elders and their caregivers in rural communities ( Buckwalter, Davis, Wakefield, Kienzle, & Murray, 2002 ).

Despite the documented benefits of the general use of telehealth technologies, there is a paucity of data on the use of telehealth technology by nurses for HIV/AIDS clients. Becker ( 2002 ) did describe a federally funded telemedicine project involving a group of HIV/AIDS clients in New York City. The nurse in this project acknowledged her satisfaction with the streamlined visits and the convenience of monitoring clients from the office, thereby eliminating time previously spent driving and parking. She believed she truly made a difference in client outcomes, despite not being physically present in clients’ homes. Unfortunately research data for this telehealth project is not available. Additionally, a recent qualitative study ( Marineau, 2007 ) found that acutely ill patients transitioning from hospital to home were satisfied with telehealth and expressed an interest in having telehealth access in the future. This study used a qualitative method to study the use of this technology with HIV/AIDS clients.

In response to the lack of literature, and especially the lack of qualitative studies, describing nurses’ use of telehealth technology with HIV/AIDS clients, the qualitative, descriptive study reported below sought to explore the use of telehealth technology to assist case managers to effectively manage their caseloads of HIV/AIDs clients, increase responsiveness to their clients’ changing medical conditions, and serve as a partial solution to the ongoing nursing shortage.

This qualitative, descriptive study used face-to-face interviews with six participants to assess what the client experienced when a nurse used telehealth technology to conduct case management visits.

The target population was HIV/AIDS clients living in the study’s rural service area, which constituted seven counties in northern California. Volunteers were sought purposively using the following inclusion criteria: a medical diagnosis of HIV/AIDS, ability to manage the technology, the assurance of safety of the equipment in the home, and agreement to participate in the evaluation interview. Home Health Care Management, Incorporated, located in Chico, California, provides case management services to HIV/AIDS clients. This agency assisted in finding study participants. Based on inclusion criteria, potential participants were identified by the agency nursing case managers. Due to funding restrictions, the number of participants for the study was limited to six participants. Once potential participants were identified, case managers presented a brief, verbal summary of the study and asked if the principal investigator of the research team could contact the client to provide further information. Two females and four males volunteered to participate. Ages ranged from 34-58 years. Clients had varying levels of computer skills and experience, with two clients owning a home computer before the study started.

Ethical Considerations

Approval from the appropriate State of California Institutional Review Board, namely, The Committee for the Protection of Human Subjects, California Health and Human Services Agency, was obtained prior to the commencement of the study. Approval to conduct the study was also obtained from the Centers for Infectious Disease, California Department of Public Health, Office of AIDS. No unusual or sensitive ethical considerations were noted. An explanatory statement and photograph of the equipment was given in person to all clients. Written informed consent was obtained prior to the placement of equipment in the home and the collection of any data.

Data Collection/Interviews

This study utilized American TeleCare equipment, including both a provider station and a patient station. Peripheral equipment used by the nurse included a stethoscope, sphygmomanometer, scale, glucometer, camera, and floor lamp. Thermometers were provided to all participants. A video monitor in each home connected to a computer video monitor in the agency office. When a scheduled visit was due to begin, the client called the agency on a toll-free line to let the nurse know he/she was ready for the visit. The nurse then called the client back using the telehealth base-station equipment in the agency office that connected to the client’s home station. This equipment enabled the nurse and the client to see each other. Diagrams were provided to the clients showing them where to place the stethoscope in order to hear lung, heart, and bowel sounds. Using the peripheral equipment the nurse could collect the following data: blood pressure, temperature, heart rate, lung sounds, blood sugar levels, abdominal sounds, weight, nutritional status, skin condition, and opportunistic infections. Discussions included recent hospitalizations or emergency room visits, current medications, and general health status, including any problems the client may have encountered since the last nurse case management visit.

Diagrams were provided to the clients showing them where to place the stethoscope in order to hear lung, heart, and bowel sounds. Clients used the telehealth technology in their homes for a period of four months. Funding allowed for the purchase of three client monitors, therefore two data collection periods were used with three clients participating in each period, which extended data collection to a total of eight months.

Interviews were conducted after the four-month trial of the equipment and removal of the monitoring station. All interviews took place in the client’s home where privacy was maintained. Interviews were semi-structured using five basic, yet broad questions that allowed clients to share their individual experiences. Interview time averaged 20-30 minutes. Although an indefinite period of time was allowed for the interviews, all interviews were completed in 30 minutes or less. Questions were identified that would help assess client satisfaction with telehealth visits in-order-to determine whether this technology was a viable way to manage caseloads, including a client’s changing medical conditions, and also address the nursing shortage. Examples of questions included:

• What was it like to use the equipment for your nursing visits?
• What was the best part about using the equipment?
• What was the worst part about using the equipment?
• Was the visit different than having the nurse actually there, if yes how?
• Did you require additional help with the equipment?

Although the main focus of this study was on client perceptions, the nurse case manager was also interviewed.

Data Analysis

Data sorting and management was facilitated by the computer program NVivo ( Richards, 1999 ). Initially transcripts were read and reread for recurring patterns in the data. Beginning descriptive codes were then entered into NVivo. This initial process involved considering what words meant within the smaller context of specific questions as well as the broader context of the entire interview. This process enabled the researcher to reflect on the recurring patterns in the data. Pattern areas were then reviewed following the coding of all interviews. At this time discrepancies were noted and pattern areas renamed, collapsed, and clustered to accommodate more abstract themes. This process of thematic development, a process developed by Thomas and Pollio ( 2002 ), can also be used when analyzing phenomenological data. Thomas and Pollio define themes as “patterns of description that repetitively recur as important aspects of a participant’s description of his/her experience” (p. 37).

All interviews were tape recorded and transcribed verbatim. The computer program NVivo ( Richards, 1999 ) was used to enhance rigor so that identification codes and specific data could be linked to the complete original transcript. To decrease bias, a member of the research team not employed by the case management/home health agency was responsible for obtaining informed consent and conducting all interviews. An audit trail was kept to record all analysis decisions. Confirmability ( Streubert-Speziale & Carpenter, 2003 ) was demonstrated by having another member of the research team review the analysis process. Additionally, all analysis decisions were also reviewed by an outside expert in qualitative research.

Although all participants in the study had the same medical diagnosis, sample variation was evident in terms of age, computer-technology expertise, and gender. However, the experiences of these clients in using telehealth technology were similar as evidenced by the common themes expressed by the clients. Findings clustered around three major themes: (a) missing the nurse, (b) being satisfied, and (c) drawbacks, each of which will be described below.

Missing the Nurse

Participants consistently expressed a desire to have the nurse make actual face-to-face contact via home visits. Reasons given included a desire for an initial connection to develop trust, social interactions, and/or emotional support. The hallmark of home health agency services is client contact with healthcare professionals. When nursing case management services were delivered via computer technology, two clients responded with the following comments:

I probably miss not having somebody to come out every once  in a while and do their thing with me here…I didn’t really like it, but like I said, I wished I could have had her here instead of on the screen. But it was alright.

I really would prefer the nurse, because I’m more into contact with people, because I don’t get many visitors usually so when I do get them it’s good, because I don’t drive, I don’t go anywhere really.

All participants missed having the physical presence of the nurse during the case management assessment.

When asked what was different about not having the nurse come to her house, one client responded:

I’m a whine baby, I like sympathy. I couldn’t get a hug or you know and she wasn’t allowed to come see me personally while I had the machine here and I missed that personal touch.

For this participant the lack of physical touch and presence of the nurse was critical to her feelings of satisfaction with the visit.

Another client saw value in an initial visit with the nurse to set up and begin a relationship. This client suggested using the technology as support for some but not all visits:

A combination probably maybe even quarterly would be fine. But see, I set up in my relationship with them prior to the Telemed, but to start out… I guess it’s about getting to know the people and being able to be completely honest and frank, you know in your conversation.

This participant preferred to begin a nurse/client relationship using a face-to-face meeting rather than using only telehealth technologies.

One client commented on the shortness of the telehealth visit and the lack of social interaction:

Mainly talking because you know usually the telecom went 10 minutes or so, when a nurse comes she’s at least here for half hour or 45 minutes, social talking you know, it’s more personal than just doing it over teleconference.

...the use of technology did not provide the same level of social interaction as face-to-face visits would have provided. This comment demonstrates the importance of the social nature of a nursing visit and that the use of technology did not provide the same level of social interaction as face-to-face visits would have provided.

The theme of missing the nurse evolved for a variety of reasons, but the majority of clients in the study explained that in some way they missed the physical contact of the nurse in the home. For these clients the technical aspect of the visit was easily accomplished with the use of technology; however the human touch was missed.

Being Satisfied

Being satisfied encompassed several subthemes that identified how different ways of using the telehealth equipment was seen as beneficial by these clients. It is interesting to note that although clients missed the nurse, as noted in the previous theme, they all enthusiastically said they would be willing to have the equipment back in their house to use again on a short term or more permanent basis. The idea of being able to see the nurse and have the nurse on the monitor see them was in part what increased satisfaction, as clients felt this was an improvement over a regular telephone call if they had questions or became ill. Three sub-themes contributed to being satisfied: (a) mastering the technology, (b) convenience and (c) it gets the job done.

The idea of being able to see the nurse and have the nurse on the monitor see them was in part what increased satisfaction... Mastering the technology . Although initially mastering the technology was an area of potential concern for the home health agency, it proved to be of little consequence to the clients. There were considerably more skills for the agency and the nurse to master. These skills included the mechanical set up of the base station, developing a teaching plan for clients, determining privacy and security protocols, and troubleshooting the equipment. Only one client required additional help, beyond that given by the nurse, with the initial set up. This client asked a friend to be present during installation and initial training to provide support when she was on her own. All others were able to master the equipment easily and had no difficulty using it during the course of data collection. Typical comments included, “The fact that I was able to use it and not have any problems with it. Probably I guess is the best thing,” and “It’s small, doesn’t take up a lot of space, and it doesn’t take any education really to use it, it’s very simple.” One participant added:

…but as far as the patient goes all you do is follow what she asks you to do. The equipment is very simple to work. Very reliable. Every time we confirmed information that was showing on the LED read out on the machine, it jived with the information they were getting. So I knew the information she was getting was accurate and I just thought it was simple and safe. Those are my best things, for me in particular I think it was the best thing to have in my home.

Participants found the equipment easy to use and not intrusive in their homes.

Convenience. Convenience seemed to contribute to clients’ sense of satisfaction. Clients liked both the convenience of not having to fit in with a busy nurse’s schedule that included organizing driving time and visiting other clients. They appreciated the opportunity to quickly set up a telehealth visit. The time of day was also a factor that supported convenience, as noted by the two clients who commented on this convenience:

Sometimes she did them on days when I was off but she was able to do it even when I got off work. You know what I mean, it was still more convenient for her being in the office, it wasn’t where she had to be here in [town 30 minutes away] and see me like she was seeing her other clients. So it didn’t interfere with her so much and it didn’t interfere with my life style. I was able to continue to work, and keep my appointments with her.

Clients were pleased to have mastered the equipment. They found it easy to use and convenient.

It was very convenient. When they called, the nurse didn’t have to make a scheduled appointment or anything to come out. I could talk to her and see her on the computer, which was very nice.

Clients were pleased to have mastered the equipment. They found it easy to use and convenient. These factors were all important in determining whether they were satisfied with this technology in place of home visits on an ongoing basis.

It gets the job done . The positive aspects of this technology as identified by clients was supported by the nurse who took part in the study, especially in terms of the convenience of decreased driving for routine visits of stable clients. Telehealth visits increased the client’s personal privacy during a visit. Also, there was an added ‘security’ in that the equipment was there if they needed to make additional contact with the nurse and schedule a telehealth visit as opposed to just a telephone call. An additional benefit was the health safety issue, in that  telehealth visits resulted in one less person coming into the home of these clients when they might be vulnerable to infection, such as at a time when they were experiencing a low T-cell count making them more susceptible to colds and flu. Two typical comments included:

Well sometimes the [home] visits were a little more personal; let me put it that way. With the Telemed it seemed a little bit more professional, right to the point. There was not extra talking.

This way when we know it’s over, she’s done, I’m done, we say our goodbyes until the next month. I cover the machine up and it’s basically invisible until the next time I need to use it.

Getting the job done highlighted the professional nature of technology. Telehealth visits, although somewhat more impersonal than having the nurse come to the client’s home, streamlined the nature of the visit and included no ‘fluff’ for either the nurse or the client in the time spent.

Drawbacks were mentioned as clients talked about the equipment. It is interesting to note that clients did not talk about missing the nurse when asked about drawbacks or negative aspects of using the equipment. Rather missing-the-nurse comments were raised when asked what it was like to not have the nurse come to their house. The minimal drawbacks noted related to the equipment as seen in the following three quotes:

Well, there was really no bad thing about it. Other than the fact that every once in a while it wouldn’t go through and we’d have to do it all over again. But no.

Nothing at all really. Taking an extra plug in the wall because I’ve got so much electronic stuff in my bedroom. But other than that, nothing.

I think it took up a little bit of room from my mother, that’s about it. Otherwise you could barely tell it was there. Because it was covered.

One client identified privacy as an issue as the equipment was in a living area that could be seen by visitors. Another client didn’t offer a lot of explanation but mentioned that it just wasn’t the same, saying, “It felt different.”

Drawbacks focused mainly on simple equipment issues, most of which were fixable or were not substantial enough to cause concern for the client. Other types of drawbacks were revealed under more substantive themes, such as missing the nurse and visits being less social, as discussed above. Although participants did not complain about any difficulty in seeing the nurse via the equipment, the nurse, who interacted with clients and who was also interviewed, noted she had some difficulty with the lighting in clients’ homes in terms of clear and accurate visuals. This lighting problem might need further attention in terms of continued use of telehealth equipment, as appropriate lighting is necessary to allow the nurse to clearly see the client. Poor lighting has ramifications in areas such as visualizing wounds, rashes, or bruising.

Very few studies have evaluated the use of telehealth technologies with HIV/AIDS clients, and only one of these studies was found to utilize a qualitative method. Hence this qualitative study sought to explore the use of telehealth technology to assist case managers to effectively manage their caseloads of HIV/AIDs clients, increase responsiveness to their clients’ changing medical conditions, and serve as a partial solution to the ongoing nursing shortage. This section will discuss the clients’ reports of missing the nurse and their perceptions of satisfaction and drawbacks associated with the telehealth technologies.

Agrell, Dahlberg and Jerant ( 2000 ), conducted a pilot study with 15 participants to elicit views about home telecare. Their 34 item survey also allowed for open-ended responses to clarify choices for a select number of forced-choice responses. These authors also reported that participants found that telehealth visits are streamlined and lack social support for isolated, lonely clients. Our study supports this finding, as participants consistently expressed a desire to have the nurse come to the home to make actual face-to-face visits so they could develop trust, socialize and/or receive emotional support. Recognition of the importance of developing trust and providing social support for a client impacts the development of telehealth protocols with HIV/AIDS populations. Clients might benefit if protocols would include a time period during which the nurse could develop rapport with the client prior to the initiation of telehealth visits. An agency may also want to consider policies that allow for some face-to-face visits with clients, along with the telehealth visits. Some face-to-face visits may well benefit these HIV/AIDs patients.  

Satisfaction and Drawbacks

Some clients felt using the telehealth equipment was far superior to having the nurse come to their home, as using the equipment allowed for health protection and easier scheduling. It is important to note that in this study, concerns about missing the nurse’s in-home presence during the visit did not influence client satisfaction with the equipment as all clients who used the telehealth technology indicated they would have the equipment back again if given the opportunity. Our findings, that clients overall were satisfied with telehealth visits, support the conclusions reached by Agrell et al., ( 2000 ).

The use of telehealth technology can help provide nursing case management services in a cost-effective manner. Ease of mastering the technology clearly assisted clients’ acceptance of the telehealth equipment. All clients indicated they required no further assistance beyond the initial set up directions. Ease of mastering the technology was also found by Kobb, Hoffman, and Lange ( 2003 ), but is in contrast to Agrell, et al., ( 2000 ), who found some clients or caregivers struggled with the technology.

The lack or shortage of nursing staff, increases in travel costs associated with rising gasoline prices, and flat funding and/or reduction in reimbursement for HIV/AIDS services, have prompted agencies to explore alternative methods of providing care to their clients, such as using technology to save money. Nurse productivity can be increased by using telehealth technologies and thereby increase the number of clients a nurse case manager can see in a day. In rural areas, especially, nurses may need to spend an hour or more driving both to and from the client’s home. Limiting driving can save nurses’ time and decrease reimbursable mileage expenses. The continual flat funding and possible eroding of funding from the federal and state agencies that administer the Ryan White Care Act Program monies, constitute a significant impetus for agencies to find ways to decrease costs and avoid adding additional staff. The use of telehealth technology can help provide nursing case management services in a cost-effective manner.

The efficiency of the telehealth visits was articulated by all participants. Clients in this study felt that the visits using the telehealth technology were more ‘professional’ and had less of a social nature. However, the following questions were also raised by this research:

Does nursing want to move in the direction of being perceived as more ‘professional’ by the client using telehealth visits which are streamlined and faster?

Are these telehealth visits performed at the expense of a client’s need for a more holistic and personal interaction, such as might occur with a face-to-face in-home nursing visit?

The streamlined nature of the telehealth visits may be related to the lack of the nurse’s physical presence in the home. Yet HIV/AIDS clients are vulnerable for many reasons; it may be that the convenience of technology does not outweigh the benefit of human contact.

Previous research has not looked at client perceptions of providing nursing case management via telehealth technologies for an HIV/AIDS population. In this study, the ease at which the equipment could be used by the client was demonstrated and the clients’ expressed satisfaction with the nursing services provided. This study, however, also raised new questions regarding whether it was appropriate to use only telehealth technology for all levels of visits. Clients suggested that there might be value in structuring the initial assessment visit, and possibly other visits as face-to-face visits so as to strengthen the client-provider relationship and provide support to the clients.

Limitations and Additional Research Needed

Future research is needed to clarify the relative value of the social interaction and emotional support provided by in-home visits. Additional research related to the feasibility of using telehealth technologies with the HIV/AIDS client population using larger samples, longer data collection periods, and the use of a combination of in-home and telehealth visits is needed. Future research is also needed to examine the relative value of the social interaction and emotional support these clients reported missing when the nurse did not come to their home. Additional research could provide information to guide the formation of policies and procedures that would sustain telehealth as a successful adjunct for delivering nursing case management to HIV/AIDS clients.

In summary, the use of telehealth technology can be an effective tool for case management and home health agencies to use to effectively manage their caseloads, improve on responsiveness to clients’ changing medical conditions, and serve as a partial solution to the ongoing nursing shortage. The return on investment of the technology can be seen as reducing the costs associated with nurse and client face-to-face visits. Future research is needed to clarify the relative value of the social interaction and emotional support provided by in-home visits.

Acknowledgements

The authors acknowledge the California Consumer Protection Foundation for funding this study. The authors also acknowledge the Centers for Infectious Disease, California Department of Public Health, Office of AIDS, for its guidance in the IRB review process at the state level. Please note that the authors/investigators are solely responsible for the research and statements made in this document and that the Califronia State Office of AIDS is not responsible for this research or for the findings. The authors thank the clients who gave of their time to participate in telehealth visits and post-visit interviews.

Jennifer Lillibridge , RN, PhD E-mail: [email protected]

Barbara Hanna , RN, BSN, CCM E-mail: [email protected]

© 2008 OJIN: The Online Journal of Issues in Nursing Article Published November 26, 2008

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November 26, 2008

DOI : 10.3912/OJIN.Vol14No1PPT02

https://doi.org/10.3912/OJIN.Vol14No1PPT02

Citation: Lillibridge, J., Hanna, B. (November 26, 2008) "Using Telehealth to Deliver Nursing Case Management Services to HIV/AIDS Clients" OJIN: The Online Journal of Issues in Nursing Vol. 14 No.1

• Article September 30, 2001 Health Information Privacy Protection: Crisis or Common Sense? Joanne K. Kumekawa, BA, MBA
• Article September 30, 2001 Legal Considerations for Nurses Practicing in a Telehealth Setting Carolyn M. Hutcherson, MS, RN
• Article September 30, 2001 Window of Opportunity for Home Care Nurses: Telehealth Technologies Holly Russo, MSN, RN
• Article April 05, 2023 Put PEP into Telehealth: An Etiquette Framework for Successful Encounters Kelli Garber, DNP, APRN, PPCNP-BC; Tina Gustin, DNP, CNS, RN; Carolyn Rutledge, PhD, FNP-BC
• Article September 30, 2001 Telehealth: Promise or Peril? References
• Article November 14, 2003 Accessible Online Health Promotion Information for Persons with Disabilities Suzanne C. Smeltzer, EdD, RN, FAAN ; Vanessa Zimmerman, MSN, RN ; Marita Frain, EdM, RN ; Lynore DeSilets, EdD, RN,BC ; Janice Duffin, MSN, RN, CCM, CDMS
• Article May 31, 2017 Nurses Advancing Telehealth Services in the Era of Healthcare Reform Joelle T. Fathi, DNP, MN, BSN, RN, ANP-BC; Hannah E. Modin, MHA, B.A.; John D. Scott, MD, MSc, FIDSA
• Article August 31, 2004 Receptiveness, Use and Acceptance of Telehealth by Caregivers of Stroke Patients in the Home Kathleen M. Buckley, PhD, RN ; Binh Q. Tran, PhD ; Cheryl M. Prandoni, MSN, RN
• Article March 25, 2024 A Nurse-Led Employee Health Telehealth Clinic During the COVID-19 Pandemic Scott R Ziehm, DNP, RN, NEA-BC; Michael Schweikert II, MPH, CBIC, ASCP; Ruby Takahashi, MS APRN-Rx, NP-C; Robert Sussman, MD; Brooke Nakamura, OTD, OTR/L; Matthew Mitschele, MD
• Article September 30, 2001 Telemedicine: Follow the Money Dena S. Puskin, Sc.D.

11 AIDS (HIV Positive) Nursing Care Plans

Use this nursing care plan and management guide to help care for patients with HIV / AIDS . Enhance your understanding of nursing assessment , interventions, goals, and nursing diagnosis , all specifically tailored to address the unique needs of individuals facing HIV/AIDS . This guide equips you with the necessary information to provide effective and specialized care to patients dealing with HIV/AIDS .

Table of Contents

What is hiv and aids, nursing problem priorities, nursing assessment, nursing diagnosis, nursing goals, 1. promoting adequate nutrition and hydration, 2. managing fatigue and weakness, 3. promoting skin integrity, 4. managing acute and chronic pain, 5. maintaining oral mucous membrane integrity, 6. improving mental status and thought process, 7. managing anxiety and providing emotional support, 8. promoting safety and preventing injury, 9. preventing infection, 10. initiating patient education and health teachings, 11. administer medications and provide pharmacologic support, recommended resources.

Acquired immunodeficiency syndrome ( AIDS ) is a serious secondary immunodeficiency disorder caused by the retrovirus, the human immunodeficiency virus ( HIV ). Both diseases are characterized by the progressive destruction of cell-mediated (T-cell) immunity with subsequent effects on humoral (B-cell) immunity because of the pivotal role of the CD4+helper T cells in immune reactions. Immunodeficiency makes the patient susceptible to opportunistic infections, unusual cancers, and other abnormalities.

AIDS results from the infection of HIV which has two forms: HIV-1 and HIV-2. Both forms have the same model of transmission and similar opportunistic infections associated with AIDS, but studies indicate that HIV-2 develops more slowly and presents with milder symptoms than HIV-1. Transmission occurs through contact with infected blood or body fluids and is associated with identifiable high-risk behaviors.

Persons with HIV/AIDS have been found to fall into five general categories: (1) homosexual or bisexual men, (2) injection drug users, (3) recipients of infected blood or blood products, (4) heterosexual partners of a person with HIV infection, and (5) children born to an infected mother. The rate of infection is most rapidly increasing among minority women and is increasingly a disease of persons of color.

There is no cure yet for either HIV or AIDS. However, significant advances have been made to help patients control signs and symptoms and delay disease progression.

Nursing Care Plans and Management

The nursing care planning goals for a patient with HIV/AIDS may include preventing the progression of the disease, managing symptoms, decreasing the risk of complications and infections, promoting compliance with medication and treatment regimens, and providing emotional and social support. The goals may also focus on educating the patient and the family members about HIV/AIDS, its transmission, and prevention, as well as addressing any stigma or discrimination that the patient may experience.

The following are the nursing priorities for patients with HIV/AIDS:

• Initiate antiretroviral therapy (ART).
• Monitor and manage opportunistic infections.
• Provide comprehensive HIV care and support.
• Promote prevention and safe behavior.
• Address coexisting health conditions.
• Offer psychosocial support.
• Promote preventive care and screenings.
• Support treatment adherence and retention in care.
• Provide education on risk reduction for HIV transmission.
• Promote a healthy lifestyle.

Assess for the following subjective and objective data :

• Persistent or recurrent fever
• Profound and unexplained fatigue and weakness
• Rapid weight loss and loss of appetite
• Chronic diarrhea or gastrointestinal problems
• Night sweats and chills
• Swollen lymph nodes in the armpits, groin, or neck
• Persistent cough, shortness of breath , and respiratory symptoms
• Recurrent infections, such as pneumonia , tuberculosis , or fungal infections
• Skin rashes, sores, or lesions
• Neurological symptoms, including memory loss, confusion , or difficulty concentrating
• Recurrent or severe vaginal yeast infections
• Recurrent oral thrush (white coating on the tongue and mouth)
• Persistent and unexplained pain , such as headaches or abdominal pain
• Visual changes or eye problems

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with AIDS based on the nurse ’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.

Goals and expected outcomes may include:

• The patient will maintain weight or display weight gain toward the desired goal.
• The patient will demonstrate positive nitrogen balance, be free of signs of malnutrition , and display improved energy levels.
• The patient will report an improved sense of energy.
• The patient will perform ADLs, with assistance as necessary.
• The patient will participate in desired activities at the level of ability.
• The patient will report relief/control of pain .
• The patient will be free of/display improvement in wound/lesion healing.
• The patient will demonstrate behaviors/techniques to prevent skin breakdown/promote healing.
• The patient will display intact mucous membranes, which are pink, moist, and free of inflammation/ulcerations.
• The patient will demonstrate techniques to restore/maintain the integrity of oral mucosa.
• The patient will maintain the usual reality orientation and optimal cognitive functioning.
• The patient will verbalize awareness of feelings and healthy ways to deal with them.
• The patient will display an appropriate range of feelings and lessened fear / anxiety .
• The patient will use resources for assistance.
• The patient will participate in activities/programs at the level of ability/desire.
• The patient will acknowledge feelings and have healthy ways to deal with them.
• The patient will verbalize some sense of control over the present situation.
• The patient will make choices related to the care and be involved in self-care .
• The patient will display homeostasis as evidenced by the absence of  bleeding .
• The patient will maintain hydration as evidenced by moist mucous membranes, good skin turgor , stable vital signs, and individually adequate urinary output.
• The patient will maintain hydration as evidenced by moist mucous membranes, good skin turgor, stable vital signs, and individually adequate urinary output.
• The patient will achieve timely healing of wounds/lesions.
• The patient will be afebrile and free of purulent drainage/secretions and other signs of infectious conditions.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with AIDS may include:

The nutritional and hydration status of a patient with AIDS can be compromised due to various factors. HIV infection can affect the body’s ability to absorb and utilize nutrients, leading to malnutrition and weight loss. Opportunistic infections, diarrhea, and gastrointestinal issues commonly seen in AIDS can further contribute to poor nutrition and fluid imbalance . It is crucial to assess and manage the nutritional needs of patients with AIDS through appropriate dietary interventions, oral supplements, and intravenous fluids when necessary.

Assess the patient’s ability to chew, taste , and swallow. Lesions of the mouth, throat, and esophagus (often caused by candidiasis, herpes simplex, hairy leukoplakia, Kaposi’s sarcoma other cancers) and metallic or other taste changes caused by medications may cause dysphagia , limiting the patient’s ability to ingest food and reducing the desire to eat.

Auscultate bowel sounds. Hypermotility of the intestinal tract is common and is associated with vomiting and diarrhea, which may affect the choice of diet/route. Lactose intolerance and malabsorption (with CMV, MAC, and cryptosporidiosis) contribute to diarrhea and may necessitate a change in diet or supplemental formula.

Weigh as indicated. Evaluate weight in terms of premorbid weight. Compare serial weights and anthropometric measurements. Indicator of nutritional adequacy of intake. Because of depressed immunity, some blood tests normally used for testing nutritional status are not useful.

Note drug side effects. Medications used can have side effects affecting nutrition. ZDV can cause altered taste, nausea , and vomiting ; Bactrim can cause anorexia , glucose intolerance, and glossitis; Pentam can cause altered taste and smell ; Protease inhibitors can cause elevated lipids, and blood sugar increase due to insulin resistance.

Record ongoing caloric intake. Identifies the need for supplements or alternative feeding methods.

Plan diet with the patient and include SO, suggesting foods from home if appropriate. Provide small, frequent meals and snacks of nutritionally dense foods and non-acidic foods and beverages, with a choice of foods palatable to the patient. Encourage high-calorie and nutritious foods, some of which may be considered appetite stimulants. Note the time of day when appetite is best, and try to serve a larger meal at that time. Including patients in planning gives a sense of control of the environment and may enhance intake. Fulfilling cravings for noninstitutional food may also improve intake. In this population, foods with a higher fat content may be recommended as tolerated to enhance taste and oral intake.

Limit food(s) that induce nausea and vomiting or are poorly tolerated by the patient because of mouth sores or dysphagia . Avoid serving very hot liquids and foods. Serve foods that are easy to swallow like eggs, ice cream, and cooked vegetables. Pain in the mouth or fear of irritating oral lesions may cause the patient to be reluctant to eat. These measures may be helpful in increasing food intake.

Schedule medications between meals (if tolerated) and limit fluid intake with meals, unless fluid has nutritional value. Gastric fullness diminishes appetite and food intake.

Encourage as much physical activity as possible. May improve appetite and general feelings of well-being.

Provide frequent mouth care, observing secretion precautions. Avoid alcohol-containing mouthwashes. Reduces discomfort associated with nausea and vomiting , oral lesions, mucosal dryness, and halitosis. A clean mouth may enhance appetite and provide comfort .

Provide a rest period before meals. Avoid stressful procedures close to mealtime. Minimizes fatigue ; increases the energy available for work of eating and reduces chances of nausea or vomiting food.

Remove existing noxious environmental stimuli or conditions that aggravate the gag reflex . Reduces stimulus of the vomiting center in the medulla.

Encourage the patient to sit up for meals Facilitates swallowing and reduces the risk of aspiration .

Maintain NPO status when appropriate. May be needed to reduce nausea and vomiting.

Insert or maintain a nasogastric (NG) tube as indicated. May be needed to reduce vomiting or to administer tube feedings. Esophageal irritation from existing infection (Candida, herpes, or KS) may provide site for secondary infections and trauma ; therefore, NG tube should be used with caution.

Administer medications (vitamins, antiemetics, appetite stimulants, antidiarrheals, TNF-alpha inhibitors, and sucralfate suspension as indicated. See Pharmacologic Management

Monitor vital signs, including CVP if available. Note hypotension, including postural changes. Indicators of circulating fluid volume.

Note temperature elevation and duration of the febrile episode. Administer tepid sponge baths as indicated. Keep clothing and linens dry. Maintain comfortable environmental temperature. Around 97%, fever is one of the most frequent symptoms experienced by patients with HIV infections. Increased metabolic demands and associated excessive diaphoresis result in increased insensible fluid losses and dehydration .

Assess skin turgor, mucous membranes, and thirst. Indirect indicators of fluid status.

Measure urinary output and specific gravity. Measure and estimate the amount of diarrheal loss. Note insensible losses. Increased specific gravity and decreasing urinary output reflect altered renal perfusion and circulating volume. Monitoring fluid balance is difficult in the presence of excessive GI and insensible losses.

Weigh as indicated. Although weight loss may reflect muscle wasting, sudden fluctuations reflect the state of hydration. Fluid losses associated with diarrhea can quickly create a crisis and become life-threatening.

Monitor oral intake and encourage fluids of at least 2500 mL/day. Maintains fluid balance, reduces thirst, and keeps mucous membranes moist.

Monitor laboratory studies as indicated: Serum or urine electrolytes ; BUN/Cr; Stool specimen collection . Alerts to possible electrolyte disturbances and determines replacement needs.Evaluates renal perfusion and function. Bowel flora changes can occur with multiple or single antibiotic therapy.

Make fluids easily accessible to the patient; use fluids that are tolerable to the patient and that replace needed electrolytes Enhances intake. Certain fluids may be too painful to consume (acidic juices) because of mouth lesions.

Eliminate foods potentiating diarrhea May help reduce diarrhea. The use of lactose-free products helps control diarrhea in lactose-intolerant patients.

Encourage the use of live culture yogurt or OTC Lactobacillus acidophilus (Lactaid). Antibiotic therapies disrupt normal bowel flora balance, leading to diarrhea. Must be taken 2 hr before or after antibiotic to prevent inactivation of live culture.

Maintain a hypothermia blanket if used. May be necessary when other measures fail to reduce excessive fever/insensible fluid losses.

Administer fluids and electrolytes via feeding tube and IV, as appropriate. May be necessary to support or augment circulating volume, especially if oral intake is inadequate, and nausea and vomiting persist.

Fatigue is a common symptom experienced by patients with HIV/AIDS, and can be caused by a variety of factors, including the disease process itself, side effects of medications, anemia , depression , anxiety, and poor sleep quality. HIV/AIDS can also cause chronic inflammation and immune activation, which can contribute to feelings of fatigue and malaise.

Assess sleep patterns and note changes in thought processes and behavior. Multiple factors can aggravate fatigue, including sleep deprivation , emotional distress, side effects of drugs and chemotherapies, and developing CNS disease.

Monitor physiological response to activity: changes in BP , respiratory rate, or heart rate. Tolerance varies greatly, depending on the stage of the disease process, nutrition state, fluid balance, and the number or type of opportunistic diseases that the patient has been subject to.

Recommend scheduling activities for periods when the patient has the most energy. Plan care to allow for rest periods. Involve patient and SO in schedule planning. Planning allows patients to be active during times when their energy level is higher, which may restore a feeling of well-being and a sense of control. Frequent rest periods are needed to restore or conserve energy.

Establish realistic activity goals with the patient. Provides a sense of control and feelings of accomplishment. Prevents discouragement from the fatigue of overactivity .

Encourage the patient to do whatever is possible: self-care, sitting in a chair, and short walks. Increase activity level as indicated. May conserve strength, increase stamina, and enable the patient to become more active without undue fatigue and discouragement.

Identify energy conservation techniques: sitting, breaking ADLs into manageable segments. Keep travel ways clear of furniture. Provide or assist with ambulation and self-care needs as appropriate. Weakness may make ADLs almost impossible for patients to complete. Protects patient from injury during activities.

Encourage nutritional intake. Adequate intake or utilization of nutrients is necessary to meet increased energy needs for activity. Continuous stimulation of the immune system by HIV infection contributes to a hypermetabolic state.

Provide supplemental O 2 as indicated. The presence of anemia or hypoxemia reduces oxygen available for cellular uptake and contributes to fatigue.

Refer to physical and/or occupational therapy. Programmed daily exercises and activities help patients maintain and increase strength and muscle tone, and enhance a sense of well-being.

Refer to community resources Provides assistance in areas of individual need as the ability to care for self becomes more difficult.

Patients with AIDS may experience compromised skin integrity due to several factors. The immunodeficiency associated with AIDS can increase the risk of skin infections, slow wound healing , and make individuals more susceptible to dermatological conditions such as fungal infections and skin rashes. Proper skincare, infection prevention measures, and timely management of skin-related issues are essential in maintaining skin integrity and preventing complications in patients with AIDS.

Assess skin daily. Note color, turgor, circulation, and sensation. Describe and measure lesions and observe changes. Take photographs if necessary. Establishes comparative baseline providing an opportunity for timely intervention.

Obtain cultures of open skin lesions. Identifies pathogens and appropriate treatment choices.

Maintain and instruct in good skin hygiene :  wash thoroughly, pat dry carefully, and gently massage with lotion or appropriate cream. Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces the risk of dermal trauma to dry and fragile skin. Massaging increases circulation to the skin and promotes comfort . Isolation precautions are required when extensive or open cutaneous lesions are present.

Reposition frequently. Use the turn sheet as needed. Encourage periodic weight shifts. Protect bony prominences with pillows, heel and elbow pads, and sheepskin. Reduces stress on pressure points, improves blood flow to tissues, and promotes healing.

Maintain clean, dry, wrinkle-free linen, preferably soft cotton fabric. Skin friction caused by wet or wrinkled or rough sheets leads to irritation of fragile skin and increases the risk of infection.

Encourage ambulation as tolerated. Decreases pressure on the skin from prolonged bed rest .

Cleanse the perianal area by removing stool with water and mineral oil or commercial product. Avoid the use of toilet paper if vesicles are present. Apply protective creams: zinc oxide, and A & D ointment. Prevents maceration caused by diarrhea and keeps perianal lesions dry. The use of toilet paper may abrade lesions.

File nails regularly. Long and rough nails increase the risk of dermal damage.

Cover open pressure ulcers with sterile dressings or protective barrier: Tegaderm, DuoDerm, as indicated. May reduce bacterial contamination, and promote healing.

Provide foam, flotation, and alternate pressure mattress or bed. Reduces pressure on skin, tissue, and lesions, decreasing tissue ischemia .

Apply and administer medications as indicated. Used in the treatment of skin lesions. The use of agents such as Prederm spray can stimulate circulation, enhancing the healing process. When multidose ointments are used, care must be taken to avoid cross-contamination.

Cover ulcerated KS lesions with wet-to-wet dressings or antibiotic ointment and nonstick dressing , as indicated. Protects ulcerated areas from contamination and promotes healing

Refer to physical therapy for regular exercise and activity programs. Promotes improved muscle tone and skin health.

HIV/AIDS can cause chronic pain due to various reasons, including the direct effects of the virus on the nervous system , HIV-related infections and inflammation, and the side effects of antiretroviral medications. HIV/AIDS can also lead to acute pain episodes, such as painful neuropathy and other types of infections that cause pain.

Assess pain reports, noting location, intensity (0–10 scale), frequency, and time of onset. Note nonverbal cues like restlessness, tachycardia, and grimacing. Indicates the need for or effectiveness of interventions and may signal the development or resolution of complications. Chronic pain does not produce autonomic changes; however, acute and chronic pain can coexist.

Instruct and encourage the patient to report pain as it develops rather than waiting until the level is severe. The efficacy of comfort measures and medications is improved with timely intervention.

Encourage verbalization of feelings. Can reduce anxiety and fear and thereby reduce the perception of the intensity of pain.

Provide diversional activities: provide reading materials, light exercising, visiting, etc. Refocuses attention; may enhance coping abilities.

Perform palliative measures: repositioning, massage , and ROM of affected joints. Promotes relaxation and decreases muscle tension .

Instruct and encourage the use of visualization, guided imagery, progressive relaxation , deep-breathing techniques, meditation, and mindfulness. Promotes relaxation and a feeling of well-being. May decrease the need for narcotic analgesics (CNS depressants) when a neuro/motor degenerative process is already involved. May not be successful in presence of dementia , even when dementia is minor. Mindfulness is the skill of staying in the here and now.

Provide oral care . Oral ulcerations and lesions may cause severe discomfort.

Apply warm or moist packs to pentamidine injection and IV sites for 20 min after administration. These injections are known to cause pain and sterile abscesses

Administer analgesics and/or antipyretics, narcotic analgesics. Use patient-controlled analgesia (PCA) or provide around-the-clock analgesia with rescue doses PRN. Provides relief of pain and discomfort; reduces fever. PCA or around-the-clock medication keeps the blood level of analgesia stable, preventing cyclic under medication or overmedication. Drugs such as Ativan may be used to potentiate the effects of analgesics.

Patients with AIDS may experience compromised oral mucous membranes as a result of immune suppression and increased susceptibility to infections. Conditions such as oral thrush (Candida infection), oral ulcers, and viral lesions like herpes simplex virus (HSV) can manifest, requiring proper oral hygiene , antifungal or antiviral treatment, and regular dental care to preserve oral health and prevent complications.

Assess mucous membranes and document all oral lesions. Note reports of pain, swelling, and difficulty with chewing and swallowing. Edema, open lesions, and crusting on oral mucous membranes and throat may cause pain and difficulty with chewing and swallowing.

Obtain culture specimens of lesions. Reveals causative agents and identifies appropriate therapies.

Provide oral care daily and after food intake, using a soft toothbrush, non-abrasive toothpaste, non-alcohol mouthwash, floss, and lip moisturizer. Alleviates discomfort, prevents acid formation associated with retained food particles, and promotes a feeling of well-being.

Rinse oral mucosal lesions with saline and dilute hydrogen peroxide or baking soda solutions. Reduces the spread of lesions and encrustations from candidiasis and promotes comfort.

Suggest the use of sugarless gum and candy. Stimulates the flow of saliva to neutralize acids and protect mucous membranes.

Plan a diet to avoid salty, spicy, abrasive, and acidic foods or beverages. Check for temperature tolerance of foods. Offer cool or cold smooth foods. Abrasive foods may open healing lesions. Open lesions are painful and aggravated by salt, spice, acidic foods, or beverages. Extreme cold or heat can cause pain to sensitive mucous membranes.

Encourage oral intake of at least 2500 mL/day. Maintains hydration and prevents drying of the oral cavity.

Encourage the patient to refrain from smoking. Smoke is drying and irritates mucous membranes.

Administer medications such as ( nystatin (Mycostatin), ketoconazole (Nizoral), and TNF-alpha inhibitor, e.g., thalidomide as indicated:

Refer for dental consultation, if appropriate. May require additional therapy to prevent dental losses.

Patients with AIDS may experience changes in mental status and thought processes due to the impact of the disease on the central nervous system, as well as the emotional and psychological challenges associated with the diagnosis. This can include cognitive impairment , memory difficulties, depression, anxiety, and changes in overall mental well-being, requiring comprehensive mental health support and interventions.

Assess mental and neurological status using appropriate tools. Establishes functional level at the time of admission and provides a baseline for future comparison.

Consider the effects of emotional distress. Assess for anxiety, grief , and anger. This may contribute to reduced alertness, confusion , withdrawal , and hypoactivity, requiring further evaluation and intervention.

Monitor medication regimen and usage. Actions and interactions of various medications, prolonged drug half-life, and/or altered excretion rates result in cumulative effects, potentiating the risk of toxic reactions. Some drugs may have adverse side effects: haloperidol ( Haldol ) can seriously impair motor function in patients with AIDS dementia complex.

Investigate changes in personality, response to stimuli, orientation, and level of consciousness; or development of headache, nuchal rigidity, vomiting, fever, and seizure activity. Changes may occur for numerous reasons, including the development or exacerbation of opportunistic diseases or CNS infections. Early detection and treatment of CNS infection may limit permanent impairment of cognitive ability.

Maintain a pleasant environment with appropriate auditory, visual, and cognitive stimuli. Providing normal environmental stimuli can help in maintaining some sense of reality orientation.

Provide cues for reorientation. Put radio, television, calendars, clocks, room with an outside view if necessary. Use the patient’s name. Identify yourself. Maintain consistent personnel and structured schedules as appropriate. Frequent reorientation to place and time may be necessary, especially during fever and/or acute CNS involvement. A sense of continuity may reduce the associated anxiety.

Discuss the use of datebooks, lists, and other devices to keep track of activities. These techniques help patients manage problems of forgetfulness.

Encourage family and SO to socialize and provide reorientation with current news, and family events. Familiar contacts are often helpful in maintaining reality orientation, especially if the patient is hallucinating.

Encourage the patient to do as much as possible: dress and groom daily, see friends, and so forth. Can help maintain mental abilities for a longer period.

Provide support for the significant other (SO). Encourage discussion of concerns and fears . Bizarre behavior and/or deterioration of abilities may be very frightening for SO and makes management of care or dealing with situation difficult. The significant other may feel a loss of control as stress, anxiety, burnout , and anticipatory grieving impair coping abilities.

Provide information about care on an ongoing basis. Answer questions simply and honestly. Repeat explanations as needed. Can reduce anxiety and fear of the unknown. Can enhance patient’s understanding and involvement and cooperation in treatment when possible.

Reduce provocative and noxious stimuli. Maintain bed rest in a quiet, darkened room if indicated. If the patient is prone to agitation, violent behavior, or seizures, reducing external stimuli may be helpful.

Decrease noise, especially at night. Promotes sleep , reducing cognitive symptoms and effects of sleep deprivation .

Maintain a safe environment: excess furniture out of the way, call bell within patient’s reach, bed in low position and rails up; restriction of smoking (unless monitored by caregiver /SO), seizure precautions, soft restraints if indicated. Provides a sense of security and stability in an otherwise confusing situation.

Discuss causes or future expectations and treatment if dementia is diagnosed. Use concrete terms. Obtaining information that ZDV has been shown to improve cognition can provide hope and control for losses.

Administer antiretroviral, anti-anxiety, and antipsychotic medications as indicated . See Pharmacologic Management

Refer to counseling as indicated. May help the patient gain control in presence of thought disturbances or psychotic symptomatology.

Patients with AIDS may experience heightened anxiety and social isolation due to the stigma associated with the disease, fear of discrimination, and the emotional burden of managing a chronic illness. Supportive interventions focusing on education, counseling, and community engagement are essential to address anxiety and combat social isolation , promoting a sense of belonging, understanding, and empowerment for individuals living with AIDS.

Be alert to signs of withdrawal, anger, or inappropriate remarks as these can be signs of denial or depression. Determine the presence of suicidal ideation and assess potential on a scale of 1–10. The patient may use the defense mechanism of denial and continue to hope that the diagnosis is inaccurate. Feelings of guilt and spiritual distress may cause the patient to become withdrawn and believe that suicide is a viable alternative. Although the patient may be too “sick” to have enough energy to implement thoughts, ideation must be taken seriously and appropriate intervention initiated.

Assure the patient of confidentiality within the limits of the situation. Provides reassurance and opportunity for patients to problem-solve solutions to anticipated situations.

Maintain frequent contact with patients. Talk with and touch the patient. Limit the use of isolation clothing and masks. Provides assurance that patient is not alone or rejected; conveys respect for and acceptance of the person, fostering trust.

Provide accurate, consistent information regarding prognosis. Avoid arguing about the patient’s perceptions of the situation. Can reduce anxiety and enable patients to make decisions and choices based on realities.

Provide an open environment in which the patient feels safe to discuss feelings or refrain from talking. Helps patients feel accepted in their present condition without feeling judged, and promotes a sense of dignity and control.

Allow expressions of anger, fear, and despair without confrontation. Give information that feelings are normal and are to be appropriately expressed. Acceptance of feelings allows the patient to begin to deal with the situation.

Recognize and support the stage patient and/or family is at in the grieving process. Choice of interventions as dictated by the stage of grief, coping behaviors

Explain procedures, providing opportunities for questions and honest answers. Arrange for someone to stay with the patient during anxiety-producing procedures and consultations. Accurate information allows patients to deal more effectively with the reality of the situation, thereby reducing anxiety and fear of the known.

Identify and encourage patient interaction with support systems. Encourage verbalization and interaction with family/SO. Reduces feelings of isolation. If family support systems are not available, outside sources may be needed immediately

Provide reliable and consistent information and support for SO. Allows for better interpersonal interaction and reduction of anxiety and fear.

Include SO as indicated when major decisions are to be made. Ensures a support system for the patient, and allows SO the chance to participate in the patient’s life. If the patient, family, and SO are in conflict, separate care consultations and visiting times may be needed.

Discuss Advance Directives, end-of-life desires, or needs. Review specific wishes and explain various options clearly. May assist the patient or SO to plan realistically for terminal stages and death. Many individuals do not understand medical terminology or options,

Refer to psychiatric counseling (psychiatric clinical nurse specialist, psychiatrist, social worker). May require further assistance in dealing with diagnosis or prognosis, especially when suicidal thoughts are present.

Provide contact with other resources as indicated: Spiritual advisor or hospice staff Provides an opportunity for addressing spiritual concerns. May help relieve anxiety regarding end-of-life care and support for the patient/SO.

Ascertain the patient’s perception of the situation. Isolation may be partly self-imposed because the patient fears rejection/reaction of others.

Be alert to verbal or nonverbal cues: withdrawal, statements of despair, sense of aloneness. Ask the patient if thoughts of suicide are being entertained. Indicators of despair and suicidal ideation are often present; when these cues are acknowledged by the caregiver, the patient is usually willing to talk about thoughts of suicide and a sense of isolation and hopelessness .

Spend time talking with patients during and between care activities. Be supportive, allowing for verbalization. Treat with dignity and regard for the patient’s feelings. The patient may experience physical isolation as a result of the current medical status and some degree of social isolation secondary to the diagnosis of AIDS.

Limit or avoid the use of masks, gowns, and gloves when possible and when talking to patients. Reduces the patient’s sense of physical isolation and provides positive social contact, which may enhance self- esteem and decrease negative behaviors.

Identify support systems available to the patient, including the presence of and/or relationship with immediate and extended family. When the patient has assistance from SO, feelings of loneliness and rejection are diminished. The patient may not receive the usual or needed support for coping with a life-threatening illness and associated grief because of fear and lack of understanding (AIDS hysteria).

Explain isolation precautions and procedures to the patient and SO. Gloves, gowns, and masks are not routinely required with a diagnosis of AIDS except when contact with secretions or excretions is expected. Misuse of these barriers enhances feelings of emotional and physical isolation. When precautions are necessary, explanations help patients understand the reasons for procedures and provide a feeling of inclusion in what is happening.

Encourage open visitation (as able), telephone contacts, and social activities within a tolerated level. Participation with others can foster a feeling of belonging.

Encourage active role of contact with SO. Helps reestablish a feeling of participation in a social relationship. May lessen the likelihood of suicide attempts.

Develop a plan of action with the patient: Look at available resources; support healthy behaviors. Help patients problem-solve solutions to short-term or imposed isolation. Having a plan promotes a sense of control over own life and gives the patient something to look forward to and actions to accomplish.

Identify factors that contribute to the patient’s feelings of powerlessness : diagnosis of a terminal illness, lack of support systems, and lack of knowledge about the present situation. Patients with AIDS are usually aware of the current literature and prognosis unless newly diagnosed. Powerlessness is most prevalent in a patient newly diagnosed with HIV and when dying of AIDS. Fear of AIDS (by the general population and the patient’s family/SO) is the most profound cause of the patient’s isolation. For some homosexual patients, this may be the first time that the family has been made aware that the patient lives an alternative lifestyle.

Assess the degree of feelings of helplessness: verbal or nonverbal expressions indicating lack of control, flat affect, and lack of communication . Determines the status of the individual patient and allows for appropriate intervention when the patient is immobilized by depressed feelings.

Encourage active role in planning activities, establishing realistic and attainable daily goals. Encourage patient control and responsibility as much as possible. Identify things that the patient can and cannot control. May enhance feelings of control and self-worth and a sense of personal responsibility.

Encourage Living Will and durable medical power of attorney documents, with specific and precise instructions regarding acceptable and unacceptable procedures to prolong life. Many factors associated with the treatments used in this debilitating and often fatal disease process place patients at the mercy of medical personnel and other unknown people who may be making decisions for and about patients without regard for patients’ wishes, increasing loss of independence.

Discuss desires and assist with planning for the funeral as appropriate. The individual can gain a sense of completion and value to his or her life when he or she decides to be involved in planning this final ceremony. This provides an opportunity to include things that are of importance to the person.

Safety and injury prevention are paramount for patients with AIDS to reduce the risk of infections and complications. This involves implementing measures such as practicing safe sex, avoiding sharing needles or other injection equipment, ensuring proper hygiene practices, and taking precautions to prevent accidental injuries, all aimed at minimizing the transmission of HIV and maintaining well-being.

Observe for or report epistaxis, hemoptysis, hematuria , non-menstrual vaginal bleeding , or oozing from lesions or body orifices and/or IV insertion sites. Spontaneous bleeding may indicate the development of DIC or immune thrombocytopenia, necessitating further evaluation and prompt intervention.

Monitor for changes in vital signs and skin color: BP , pulse, respirations, skin pallor, and discoloration. The presence of bleeding and hemorrhage may lead to circulatory failure and shock.

Evaluate change in the level of consciousness. May reflect cerebral bleeding.

Hematest body fluids: urine, stool , vomitus, for occult blood. Prompt detection of bleeding or initiation of therapy may prevent critical hemorrhage.

Review laboratory studies: PT, aPTT, clotting time, platelets , Hb/Hct. Detects alterations in clotting capability; identifies therapy needs. Many individuals (up to 80%) display platelet count below 50,000 and may be asymptomatic, necessitating regular monitoring.

Avoid injections, rectal temperatures, and rectal tubes. Administer rectal suppositories with caution. Protects patient from procedure-related causes of bleeding: insertion of thermometers and rectal tubes can damage or tear rectal mucosa. Some medications need to be given via suppository, so caution is advised.

Maintain a safe environment. Keep all necessary objects and call bell within the patient’s reach and place the bed in a low position. Reduces accidental injury, which could result in bleeding.

Maintain bed rest or chair rest when platelets are below 10,000 or as individually appropriate. Assess medication regimen. Reduces the possibility of injury, although activity needs to be maintained. May need to discontinue or reduce the dosage of a drug. The patient can have a surprisingly low platelet count without bleeding.

Avoid the use of aspirin products and NSAIDs , especially in presence of gastric lesions. These medications reduce platelet aggregation, impairing and prolonging the coagulation process, and may cause further gastric irritation, and increased risk of bleeding.

Administer blood products as indicated. Transfusions may be required in the event of persistent or massive spontaneous bleeding.

Patients with HIV/AIDS are at an increased risk of infection due to their compromised immune system, which is unable to effectively fight off opportunistic infections. Certain treatments for HIV/AIDS, such as chemotherapy or immunosuppressive medications, can also further increase the risk of infection. To mitigate this risk, patients with HIV/AIDS require close monitoring, appropriate prophylactic treatments, and management of co-occurring infections or conditions.

Assess patient knowledge and ability to maintain opportunistic infection prophylactic regimen. Multiple medication regimens are difficult to maintain over a long period of time. Patients may adjust the medication regimen based on side effects experienced, contributing to inadequate prophylaxis, active disease, and resistance.

Assess respiratory rate and depth; note dry spasmodic cough on deep inspiration, changes in characteristics of sputum, and presence of wheezes or rhonchi. Initiate respiratory isolation when the etiology of productive cough is unknown. Respiratory congestion or distress may indicate developing PCP; however, TB is on the rise and other fungal, viral, and bacterial infections may occur that compromise the respiratory system . CMV and PCP can reside together in the lungs and, if treatment is not effective for PCP, the addition of CMV therapy may be effective.

Investigate reports of headache, stiff neck, and altered vision. Note changes in mentation and behavior. Monitor for nuchal rigidity and seizure activity. Neurological abnormalities are common and may be related to HIV or secondary infections. Symptoms may vary from subtle changes in mood and sensorium (personality changes or depression) to hallucinations , memory loss, severe dementias, seizures, and loss of vision. CNS infections ( encephalitis is the most common) may be caused by protozoal and helminthic organisms or fungi .

Examine skin and oral mucous membranes for white patches or lesions. Oral candidiasis, KS, herpes, CMV, and cryptococcosis are common opportunistic diseases affecting the cutaneous membranes.

Monitor vital signs, including temperature. Provides information for baseline data; frequent temperature elevations and the onset of new fever indicate that the body is responding to a new infectious process or that medications are not effectively controlling incurable infections.

Monitor reports of heartburn, dysphagia , retrosternal pain on swallowing, increased abdominal cramping, and profuse diarrhea. Esophagitis may occur secondary to oral candidiasis, CMV, or herpes. Cryptosporidiosis is a parasitic infection responsible for watery diarrhea (often more than 15L/day).

Inspect wounds and the site of invasive devices, noting signs of local inflammation and infection. Early identification and treatment of secondary infection may prevent sepsis .

Wash hands before and after all care contacts. Instruct patient and SO to wash hands as indicated. Reduces risk of cross-contamination.

Provide a clean, well-ventilated environment. Screen visitors and staff for signs of infection and maintain isolation precautions as indicated. Reduces the number of pathogens presented to the immune system and reduces the possibility of a patient contracting a nosocomial infection.

Discuss the extent and rationale for isolation precautions and maintenance of personal hygiene. Promotes cooperation with the regimen and may lessen feelings of isolation.

Clean the patient’s nails frequently. File, rather than cut, and avoid trimming cuticles. Reduces the risk of transmission of pathogens through breaks in the skin. Fungal infections along the nail plate are common.

Wear gloves and gowns during direct contact with secretions and excretions or any time there is a break in the skin of the caregiver’s hands. Wear a mask and protective eyewear to protect the nose, mouth, and eyes from secretions during procedures (suctioning) or when a splattering of blood may occur. The use of masks, gowns, and gloves is required for direct contact with body fluids, e.g., sputum, blood/blood products, semen, and vaginal secretions.

Dispose of needles and sharps in rigid, puncture-resistant containers. Prevents accidental inoculation of caregivers . The use of needle cutters and recapping is not to be practiced. Accidental needlesticks should be reported immediately, with follow-up evaluations done per protocol.

Label blood bags, body fluid containers, soiled dressings, and linens, and package them appropriately for disposal per isolation protocol. Prevents cross-contamination and alerts appropriate personnel and departments to exercise specific hazardous materials procedures.

Clean up spills of body fluids and/or blood with a bleach solution (1:10); add bleach to laundry. Kills HIV and controls other microorganisms on surfaces.

Patients with HIV/AIDS may have a lack of knowledge about their disease, its transmission, treatment options, and available resources. This can lead to poor medication adherence, increased risk of opportunistic infections, and other negative health outcomes.

Review disease process and future expectations. Provides a knowledge base from which patients can make informed choices.

Determine the level of independence or dependence and physical condition. Note the extent of care and support available from family and SO and the need for other caregivers. Helps plan the amount of care and symptom management required and the need for additional resources.

Review modes of transmission of disease, especially if newly diagnosed. Corrects myths and misconceptions; promotes safety for patients and others. Accurate epidemiological data are important in targeting prevention interventions.

Identify signs and symptoms requiring medical evaluation : persistent fever and night sweats, swollen glands, continued weight loss, diarrhea, skin blotches and lesions, headache, chest pain , and dyspnea . Early recognition of developing complications and timely interventions may prevent progression to life-threatening situations.

Instruct patient and caregivers concerning infection control , using good handwashing techniques for everyone (patient, family, caregivers); using gloves when handling bedpans, dressings, or soiled linens; wearing a mask if the patient has a productive cough; placing soiled or wet linens in a plastic bag and separating from family laundry, washing with detergent and hot water; cleaning surfaces with bleach and water solution of 1:10 ratio, disinfecting toilet bowl and bedpan with full-strength bleach; preparing patient’s food in clean area; washing dishes and utensils in hot soapy water (can be washed with the family dishes). Reduces risk of transmission of diseases; promotes wellness in presence of reduced ability of the immune system to control the level of flora.

Stress the necessity of daily skin care , including inspecting skin folds, pressure points, and perineum, and providing adequate cleansing and protective measures: ointments, and padding. Healthy skin provides a barrier to infection. Measures to prevent skin disruption and associated complications are critical.

Ascertain that the patient or SO can perform necessary oral and dental care. Review procedures as indicated. Encourage regular dental care. The oral mucosa can quickly exhibit severe, progressive complications. Studies indicate that 65% of AIDS patients have some oral symptoms. Therefore, prevention and early intervention are critical.

Review dietary needs (high-protein and high-calorie) and ways to improve intake when anorexia, diarrhea, weakness , and depression interfere with intake. Promotes adequate nutrition necessary for healing and support of the immune system; enhances the feeling of well-being.

Discuss medication regimen, interactions, and side effects Enhances cooperation with or increases the probability of success with the therapeutic regimen.

Provide information about symptom management that complements the medical regimen; with intermittent diarrhea, take diphenoxylate (Lomotil) before going to a social event. Provides patients with an increased sense of control, reduces the risk of embarrassment and promotes comfort.

Stress the importance of adequate rest. Helps manage fatigue; enhances coping abilities and energy level.

Encourage activity and exercise at a level that the patient can tolerate. Stimulates the release of endorphins in the brain, enhancing a sense of well-being.

Stress the necessity of continued healthcare and follow-up. Provides an opportunity for altering regimens to meet individual and changing needs.

Recommend cessation of smoking. Smoking increases the risk of respiratory infections and can further impair the immune system.

Identify community resources: hospice and residential care centers, visiting nurses, home care services, Meals on Wheels, and peer group support. Facilitates transfer from acute care setting for recovery/independence or end-of-life care.

In addition to antiretroviral therapy, patients with AIDS may require medications to manage specific symptoms or complications associated with the disease. These medications may include prophylactic antibiotics to prevent opportunistic infections, antifungal medications to treat fungal infections, antiviral drugs to manage viral co-infections, and other medications to address specific complications such as vomiting, anemia, pain, or mental health disorders.

Antiemetics: prochlorperazine (Compazine), promethazine (Phenergan), and trimethobenzamide (Tigan) Reduces the incidence of nausea and vomiting, possibly enhancing oral intake.

Sucralfate (Carafate) suspension; a mixture of Maalox, diphenhydramine (Benadryl), and lidocaine (Xylocaine) Given with meals (swish and hold in mouth) to relieve mouth pain, and enhance intake. The mixture may be swallowed for the presence of pharyngeal or esophageal lesions.

Vitamin supplements Corrects vitamin deficiencies resulting from decreased food intake and/or disorders of digestion and absorption in the GI system. Avoid megadoses and the suggested supplemental level is two times the recommended daily allowance (RDA).

Appetite stimulants: dronabinol (Marinol),   megestrol (Megace), oxandrolone (Oxandrin) Marinol (an antiemetic) and Megace (an antineoplastic ) act as appetite stimulants in the presence of AIDS. Oxandrin is currently being studied in clinical trials to boost appetite and improve muscle mass and strength.

TNF-alpha inhibitors: thalidomide Reduces elevated levels of tumor necrosis factor (TNF) present in chronic illness contributing to wasting or cachexia. Studies reveal a mean weight gain of 10% over 28 wk of therapy. Effective in the treatment of oral lesions due to recurrent stomatitis.

Antidiarrheals:  diphenoxylate (Lomotil), loperamide (Imodium), octreotide (Sandostatin) Inhibit GI motility subsequently decreasing diarrhea. Imodium or Sandostatin are effective treatments for secretory diarrhea (secretion of water and electrolytes by intestinal epithelium).

Antibiotic therapy: ketoconazole (Nizoral), fluconazole (Diflucan) May be given to treat and prevent infections involving the GI tract.

Nystatin (Mycostatin), ketoconazole (Nizoral) Specific drug choice depends on particular infecting organism(s) like Candida.

ZDV (Retrovir) and other antiretrovirals alone or in combination Shown to improve neurological and mental functioning for an undetermined period of time.

Antipsychotics: haloperidol (Haldol), and/or antianxiety agents: lorazepam (Ativan) Cautious use may help with problems of sleeplessness, emotional lability, hallucinations, suspiciousness, and agitation.

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care  Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health   Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ! Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

Other care plans related to communicable and infectious diseases:

• Acquired Immunodeficiency Syndrome (AIDS) (HIV Positive) | 13 Care Plans
• Acute Rheumatic Fever | 4 Care Plans
• Dengue Hemorrhagic Fever | 2 Care Plans
• Herpes Zoster (Shingles) | 4 Care Plans
• Influenza (Flu) | 5 Care Plans
• Pulmonary Tuberculosis | 5 Care Plans

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• v.55(6); Nov-Dec 2013

Language: English | Portuguese

CASE STUDY OF A PATIENT WITH HIV-AIDS AND VISCERAL LEISHMANIASIS CO-INFECTION IN MULTIPLE EPISODES

Estudo de caso de paciente com múltiplos episódios da coinfecção hiv-aids e leishmaniose visceral, elis dionísio da silva.

1 Postgraduate Course of Biology applied to Health, Federal University of Pernambuco, PE, Brazil. E-mail: [email protected] , [email protected]

2 Graduate Course on Biological Sciences, Institute of Biological Sciences, University of Pernambuco, PE, Brazil

3 Parasitology Department, Aggeu Magalhães Research Center, Oswaldo Cruz Foundation, PE, Brazil. E-mails: rb.zurcoif.maqpc@said , rb.zurcoif.maqpc@eciremla , rb.zurcoif.maqpc@said , rb.zurcoif.maqpc@eciremla

Luiz Dias de Andrade

Paulo sérgio ramos de araújo.

4 Tropical Medicine Department, Clinical Hospital, Federal University of Pernambuco, PE, Brazil. E-mails: rb.zurcoif.maqpc@oigresp , rb.moc.lou@seahlagamev , rb.zurcoif.maqpc@oigresp , rb.moc.lou@seahlagamev

Vera Magalhães Silveira

Carlos eduardo padilha.

5 Service of Infectious and Parasitic Diseases, Clinical Hospital, Federal University of Pernambuco, Brazil. E-mail: moc.liamg@ahlidapgec , moc.liamg@ahlidapgec

Maria Almerice Lopes da Silva

Zulma maria de medeiros.

6 Pathology Department, Institute of Biological Sciences, University of Pernambuco, PE, Brazil. E-mail: rb.zurcoif.maqpc@soriedem , rb.zurcoif.maqpc@soriedem

Report of a 45-year-old male farmer, a resident in the forest zone of Pernambuco, who was diagnosed with human immunodeficiency virus (HIV) in 1999 and treated using antiretroviral (ARV) drugs. In 2005, the first episode of visceral leishmaniasis (VL), as assessed by parasitological diagnosis of bone marrow aspirate, was recorded. When admitted to the hospital, the patient presented fever, hepatosplenomegaly, weight loss, and diarrhea. Since then, six additional episodes of VL occurred, with a frequency rate of one per year (2005-2012, except in 2008). In 2011, the patient presented a disseminated skin lesion caused by the amastigotes of Leishmania , as identified by histopathological assessment of skin biopsy samples. In 2005, he was treated with N-methyl-glucamine-antimony and amphotericin B deoxycholate. However, since 2006 because of a reported toxicity, the drug of choice was liposomal amphotericin B. As recommended by the Ministry of Health, this report emphasizes the need for HIV patients living in VL endemic areas to include this parasitosis in their follow-up protocol, particularly after the first infection of VL.

Relato de caso de paciente masculino de 45 anos, agricultor, residente na zona da mata do Estado de Pernambuco, diagnosticado com HIV em 1999 e em uso de ARV. Em 2005 foi registrada a primeira ocorrência de LV através do diagnóstico parasitológico a partir do aspirado da medula óssea. À admissão no hospital apresentava-se com febre, hepatoesplenomegalia, perda de peso e diarréia. Desde então houve a ocorrência de mais sete episódios de LV, tendo ocorrido em media, um evento a cada ano (2005-2012 exceto em 2008). O paciente apresentou, em 2011, um quadro cutâneo disseminado, sendo realizada biopsia de pele que evidenciou formas amastigotas de Leishmania no exame histopatológico. Em 2005, o tratamento foi realizado com antimoniato de N-metil-glucamina e anfotericina B desoxicolato, mas desde 2006, devido à toxicidade, o medicamento de escolha foi a anfotericina B lipossomal. Como recomendado pelo Ministério da Saúde, esse relato reforça a necessidade de que os casos de HIV residentes em área endêmica de LV deverão ter inserido em seu protocolo de acompanhamento essa parasitose, principalmente após o primeiro episódio.

INTRODUCTION

Cases of visceral leishmaniasis (VL) co-infection with human immunodeficiency virus (HIV) and acquired immune deficiency syndrome AIDS (VL/HIV-AIDS) have been registered in 35 countries, mainly in southwestern Europe. VL/HIV-AIDS co-infections increase in areas where these two diseases coexist, as observed in Asian, African, and Latin American countries. In the latter group, Brazil has the highest number of cases 1 .

In 2011, in Brazil, VL appeared in 22 of the 27 Brazilian states, covering urban and suburban areas. Between 1998 and 2009, the annual average was 3,349 cases 7 . From 1980 to 2011 in Brazil, 608,230 cases of AIDS were reported. This epidemic tends to spread to poorly inhabited macro-regions as well as to medium and small cities 8 . When AIDS and VL databases were correlated, 176 cases of VL/HIV-AIDS co-infection were detected among the Federal States 7 .

Several episodes of VL are frequent in cases of VL/HIV-AIDS co-infection. According to BOURGEOIS et al. , 2010, these patients present a novel nosological entity called ‘active chronic visceral leishmaniasis’. This condition may be termed ‘chronic’ because of the presence of relapses over a period of several years and ‘active’ because of the continuous blood circulation of the parasite. On the other hand, it's impossible to know if repeated episodes are relapses or reinfections by using conventional parasitological and immunological methods 15 . Some studies show that individuals with HIV/AIDS and infected with VL often present atypical clinical manifestations and high incidence of relapse 5 22 24 25 . Molecular methods confirm that more than 90% of these cases are relapses, rather than reinfections 27 . The discrimination between relapses and reinfection can be made by molecular techniques based on restriction fragment length polymorphism (RFLP) analysis. The use of this technology may provide the physician with more information to determine Leishmania infections in patients who do not respond to treatment 20 .

Professionals, who treat patients with HIV/AIDS, report that this co-infection was not prioritized because of the variety of diseases related to immunosuppression, in addition to not being included among the AIDS-defining conditions 11 . To alert healthcare professionals about this association, we describe the case of a patient presenting multiple VL/HIV-AIDS co-infections during the seven years of evolution of this disease.

CASE REPORT

In 1999, a 31-year-old male farmer, who was a resident in the forest zone of Pernambuco, was admitted to the Clinics Hospital of the Federal University of Pernambuco. At the time of admission, he presented with asthenia and headache, and had diarrhea for at least 30 days. He was diagnosed with HIV, and began receiving antiretroviral therapy (ART) with stavudine, lamivudine, and efavirenz. Meanwhile, his 25-year-old partner and 9-month-old daughter were diagnosed with HIV infection.

Five years after initiating ART, the patient presented virological failure; after genotyping, his treatment was changed to tenofovir, lamivudine, and lopinavir/ritonavir. In 2005, he was diagnosed with VL as assessed by directly testing Leishmania in the bone marrow aspirate and initially treated with N-methyl-glucamine-antimony. However, because of pancreatitis, the patient began receiving amphotericin B, which was then replaced by a liposomal formulation because of the onset of renal failure.

In 2011, the patient presented disseminated cutaneous lesions caused by Leishmania , as assessed by histopathological analysis of skin biopsy samples. In July 2012, the patient was readmitted for presenting febrile disease with splenomegaly and pancytopenia, in addition to showing positive results for laboratory tests for leishmaniasis ( Table 1 ). After administration of liposomal amphotericin B deoxycholate, the patient's condition improved, and he was discharged upon recommendation of a secondary prophylaxis by administering liposomal amphotericin B twice a week. Between 2005 and 2012, seven VL infections occurred, as shown in the Table 1 .

HIV, human immunodeficiency virus; N.A., not available; N.D., not done; B.M. aspirate, bone marrow aspirate; d4T, stavudine; 3TC, lamivudine; EFV, efavirenz; TDF, tenofovir; LPVr, lopinavir/ritonavir; DAT, direct agglutination test; PCR, polymerase chain reaction.

This case describes some of the many clinical, diagnostic, and epidemiologic aspects of VL/HIV-AIDS co-infection. Immunosuppression caused by HIV might lead to the development of symptomatic VL 14 . In turn, VL might promote the clinical progression of HIV and of AIDS-defining conditions, thus, reducing the possibility of recovery after treatment and increasing the incidence of relapse 11 . This report showed that individuals with HIV/AIDS and living in endemic areas of VL should include VL assessment in their follow-up protocol. After the first co-infection, by means of clinical and laboratory support, a follow-up protocol of the patient should be created for early detection of relapse and re-infection.

One of the common features of co-infection is the increased tendency of relapse, observed in 37-80% of the patients 22 . Additionally, in some cases a chronic course with multiple occurrences might take place. This can be attributed not only to immunodeficiency but also to re-infection, host deficiencies correlating with ART, secondary prophylaxis, and CD4+ lymphocyte count 16 18 . CD4+ lymphocyte count is one of the most significant prognostic factors for survival 11 22 . VL usually appears as an opportunistic disease in HIV patients when CD4+ cell count is less than 200 cells/mm 3(1,6,12,13,17,25) . During the seven years of follow-up, the patient presented a CD4+ cell count ≤ 170 cells/mm 3 . This represents an important predictor of relapse. Relapses of VL are suggested to occur mainly in individuals with poor responses to antiretroviral treatment who have no improvement in CD4+ counts with a few exceptions 3 9 .

Based on clinical and biological [polymerase chain reaction (PCR)-based] follow-up, an ‘active chronic visceral leishmaniasis’ 5 has been proposed by BOURGEOIS et al. (2010). In our case, only the 6 th and 7 th episodes were able to have the peripheral blood (PB) analyzed by PCR, which showed positive results for Leishmania spp. As PCR-RFLP was only found in the 7 th sample episode, the etiological agent is Leishmania chagasi , according to the pattern of bands defined by SCHONIAN et al. (2003) 26 . Due to the absence of PB samples in previous episodes, the analysis by PCR-RFLP was not made. Therefore, it wasn't possible to distinguish between relapse and reinfection or characterize the case as ‘chronic visceral leishmaniasis’. Despite the medical importance of a clinical and laboratory monitoring of coinfected patients, this practice is still little used 12 19 20 .

ART plays an important role in reducing the effect of opportunistic diseases and in recent studies has shown a reduction in the incidence of VL. Studies in individuals with HIV/AIDS treated using ARV drugs showed a similar incidence of VL relapse when compared to studies of the pre-highly active antiretroviral therapy (HAART) era 11 14 . The increased survival resulting from ART might partially explain the high incidence of relapse observed in this population 18 . In the present study, during the eight years of follow-up, we observed seven VL infections, despite the patient receiving ART before the first infection.

VL manifestations associated with HIV infection might appear in a classical form, particularly in patients from VL-endemic areas, as well as with relatively aggressive symptoms that are sometimes non-specific and difficult to clinically diagnose 11 . In individuals with HIV/AIDS and presenting symptoms such as asthenia, anorexia, and weight loss, VL might be responsible for 7-23% of instances of fever of unknown origin 11 . This patient presented classic clinical manifestations during the study period, although in 2011, we observed the formation of skin lesions because of the parasite, as assessed by histopathological analysis.

Among the previously treated VL cases, several patients present a skin condition characterized by macular, popular, or nodular lesions, called Post-kala-azar dermal Leishmaniasis (PKDL) caused by the amastigotes of Leishmania donovani on the Indian subcontinent (India, Nepal, Bangladesh) and east Africa (Sudan, Ethiopia, Kenya) and caused by Leishmania chagasi in South America where it is rarely reported, as well as its presence in HIV positives 2 4 23 28 . It is worth noticing that exclusive involvement of the skin is an unusual condition, because the simultaneous appearance of skin lesions along with other VL manifestations was more frequently observed 21 . In this case, the skin lesion suggests a clinical PKDL, which developed five years after the first VL episodes, administration of multiple therapeutic regimens, and treatments of discontinuous secondary prophylaxis. Although it has been viewed amastigotes in biopsy specimens obtained from skin lesions, the hypothesis of PKDL can be suggested but not stated categorically because there was no characterization of Leishmania species involved in the cutaneous lesions, and may have been an infection of some sort cutaneous Leshmania endemic to the region as L. braziliensis .

Several studies on co-infected individuals show that they present a decrease in anti- Leishmania antibody levels in the peripheral blood 11 ; that is, in only 40-50% of VL/HIV-AIDS cases, specific antibodies are detected 1 . Conversely, assessment of Leishmania antigen in urine by latex agglutination test showed a sensitivity of 85-100% 1 . Polymerase chain reaction (PCR) in peripheral blood and bone marrow is a useful tool to diagnose, for follow-up, and detect relapses 22 . Although the literature shows that serological analyses are not the most convenient in patients presenting co-infection 1 6 , two serological tests (direct agglutination test and rK39-based rapid immunochromatographic test) performed enabled the diagnosis of such cases in 2011 and 2012. In the same years, latex agglutination test and PCR test showed positive results, thus, confirming the data in the literature. Similar to the finding in our study, CAVALCANTI et al. (2012), described a series of case studies of co-infection in the main hospitals of Recife, Brazil 10 .

There is currently sufficient evidence suggesting that secondary prophylaxis provides some protective effect but does not completely prevent the occurrence of relapse 11 . A meta-analysis study described that the average incidence of relapse in patients who did not receive secondary prophylaxis was 67%, whereas in those who received it was 31% 16 . Current recommendations from the Ministry of Health of Brazil 2 for the diagnosis, treatment, and follow-up of patients presenting co-infection state that the “efficacy of the secondary prophylaxis after the first successfully treated VL infection, was not completely established.” The suggested secondary prophylaxis ( Table 1 ) was poorly adopted, thus, compromising the clinical follow-up. Based on this case study and literature review, it is evident that co-infection presents typical clinical, diagnostic, and therapeutic features, and can be observed in the prognosis of the disease. Therefore, prospective studies are required to clarify gaps such as the efficacy of secondary prophylaxis and need for clinical and laboratory monitoring tools for the early assessment of relapse or re-infection.

Acknowledgments

This study was supported by the FACEPE/MS/CNPq Programme for Research and priority development to unified health system - SUS/ PCT Saúde II (project 03/2004) and CNPq/PIBIC/Fiocruz (process 139172/2012-2).

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HIV/AIDS in older adults: a case study and discussion

Affiliation.

• 1 University of Rochester School of Nursing, 601 Elmwood Avenue, Box SON, Rochester, NY 14642-8404, USA. [email protected]
• PMID: 11852723
• DOI: 10.1097/00044067-200202000-00003

Infection associated with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) in older adults is an increasing problem in clinical care. Often regarded as a disease of the young, more than 10% of HIV infection actually is found in people 50 years of age and older. In addition, individuals with HIV and AIDS are living longer. Approximately 71% of them currently are in their 30s and 40s. Given the current therapies available, it is conceivable that these patients will live well into their 60s and beyond. A case study describing the acute care experience of a 77-year-old African American man is reported. Pitfalls of diagnosis and management are discussed in relation to the care of an older person with HIV disease. The epidemiology of HIV in this population and a review of some recent literature and research on HIV and older adults are presented.

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• Nursing care management of older adults with HIV/AIDS and chronic depression. Petrovic K. Petrovic K. Care Manag J. 2006 Fall;7(3):115-20. doi: 10.1891/cmj-v7i3a002. Care Manag J. 2006. PMID: 17214244
• Clinical and behavioral characteristics of adults receiving medical care for HIV infection --- Medical Monitoring Project, United States, 2007. Blair JM, McNaghten AD, Frazier EL, Skarbinski J, Huang P, Heffelfinger JD. Blair JM, et al. MMWR Surveill Summ. 2011 Sep 2;60(11):1-20. MMWR Surveill Summ. 2011. PMID: 21881551
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