Describing the HIV/AIDS
Human immunodeficiency virus (HIV) belongs to the group of retroviruses and carries ribonucleic acid (RNA) as genetic material. HIV infection occurs when the virus enters CD4+ T-cells of the host and causes the host cell to replicate viral RNA and proteins, which in turn invade the other host cells. HIV infection may be divided onto four stages depending on the clinical history, physical examination, status of immune dysfunction, signs and symptoms and infections/malignancies. The first stage or the primary infection is characterized by acute HIV syndrome with a dramatic drop in CH4+ T-cells (500 to 1500 cells/mm3). The second stage i.e. asymptomatic HIV has more than 500 cells/mm3. The cell count is between 200 to 499 cells/mm3 in the third HIV symptomatic stage. Acquired Immuno-deficiency Syndrome (AIDS) results from the fourth and the last stage of HIV infection characterized by fewer than 200 CD4+ T-cells/mm3. AIDS progressively reduces the effectiveness of the immune system and makes the individual susceptible to opportunistic infections.
HIV is transmitted through body fluids by high-risk behaviors including heterosexual intercourse with HIV-infected partner, male homosexual relations and drug use with same needle/injection. HIV can also be transferred by a) transfusion of blood and blood products contaminated with HIV, b) HIV-infected mothers to their fetus, c) HIV-infected mothers to their breast-fed infants, and d) healthcare workers exposed to needle injury from an HIV-infected patient. The symptoms of HIV are widespread and may affect multiple organ systems. Clinical manifestations range from mild abnormalities in immune response to life-threatening infections and malignancies. Shortness of breath, dyspnea, chest pain and fever are characteristic of opportunistic respiratory infections caused by Pneumocystis, Mycobacterium avium-intracellulare and Legionella species. HIV-associated tuberculosis is another common complication seen in HIV patients. Kaposi’s sarcoma is a common HIV-related malignancy involving lesions in the endothelial layer of blood and lymphatic vessels. B-cell lymphomas and invasive cervical cancer are the other oncologic complications associated with HIV infection.
The medical management of HIV includes treatment of opportunistic infections using Highly Active Anti-Retroviral Therapy (HAART). Trimethoprim-sulfamethoxazole is the treatment of choice for Pneumocystis pneumonia. Alternative therapeutic regimens for this infection include dapsone and trimethoprim. Azithromycin and clarithromycin are the prophylactic agents used for Mycobaterium avium infections in HIV-infected adults. Cryptococcal meningitis is treated with amphotericin B (i.v.) and flucytosine or fluconazole (oral). HIV-associated malignancies may require chemotherapy and radiation therapy (Smeltzer, 2010).
Demographics of interest
A total of 35.3 million people were living with HIV in 2012 globally. This number included 32.1 million adults and 3.2 million children. The newly infected cases of HIV in the year 2012 were 2.3 million, of which 2.0 million were adults and the rest were children. AIDS-related deaths in the same year were a total of 1.6 million globally. Overall, 6300 new HIV infections were noted in a day in the year 2012. About 95% of these infections were seen in low- and middle-income countries. The incidence of HIV/AIDS was observed to be highest in Sub-Saharan Africa followed by Middle -East and North Africa. Mortality in the HIV-infected people has decreased dramatically with the introduction of combination treatment and prevention of AIDS related events (Public Health Agency of Canada, 2009).
Determinants of health
The links between the determinants of health and the well-being of HIV-infected individuals are well-documented. Income, education and employment are significant determinants of health in the case of HIV-infected patients. Therefore, people with low income and people living in poverty are at higher risk of HIV infection and progression of HIV to AIDS. Inadequate nutrition, poor housing, stress, limited access to medication and lack of social support are the indirect implications of poverty that increase the risk of HIV infection.
Support from families friends and communities can improve the quality of life and the life expectancy of people infected with HIV or AIDS. Socially isolated individuals are often reluctant to disclose their HIV status and may compromise their health. Social environment for HIV/AIDS is characterized by discrimination by people, cultures and governments. The stigmatizing attitudes towards HIV-positive people results in denial of HIV and thereby increases its vulnerability.
Another important determinant of health in the case of HIV is physical environment. Homeless people living on streets are at greater risk of exposure to contaminants that are harmful for their health. Risk of HIV/AIDS is also linked to employment and working conditions. The physical environment associated with incarceration also increases the likelihood of HIV infection. Similarly, personal health practices and risk-taking behaviors such as sex without condoms, choosing not to be tested for HIV, choosing non-disclosure of HIV status to sexual partners, drug use and involvement into sex work for earning money increase a person’s vulnerability to HIV/AIDS. Inappropriate social health services, institutional discrimination and lack of culturally-sensitive healthcare staff are the other factors that pose greater risk of HIV infection in certain communities (Public Health Agency of Canada, 2009).
The epidemiologic triangle has three vertices viz. microbe that causes the disease (Agent), organism harboring the disease (host) and external factors allowing the transmission of the disease (environment). In the case of HIV/AIDS, the causative agent is HIV subtypes and the hosts are humans of any age. The cervical zone in female and seminal cells & seminal plasma in males are the genital reservoirs of HIV. Infectiousness of the hosts increases in the case of late stage HIV infection, menstruation, lack of anti-retrovirals and STDs. The environmental factors include social, cultural and political aspects including sexual practices, patterns of partnering, commercial sex, gender relations, choice of contraceptive, substance abuse, education and economic resources (Royce, Sena, Cates & Cohen, 1997).
The role of community health nurse
While working in HIV care, the community health nurses have distinct roles in patient-oriented themes as well as health systems-oriented themes. The patient-oriented themes include counseling, home-based care, adherence support and education. These nurses target the vulnerable populations and educate the patients, enhance their drug readiness, and thereby step towards infection control in the community. They also undertake counseling of the patients so as to increase uptake of HIV testing, improved disclosure of HIV status and motivation to be tested for HIV. They support nutritional screening and screening for opportunistic infections as well as provide personal and palliative care. Community nurses enhance the reach, uptake and quality of HIV services to the patients. Their presence in clinics has been reported to reduce waiting times and streamline patient flow. They play a significant role in patient retention in care through defaulter tracing, mobile reminders, counseling and collecting drugs from clinics.
Community nurses play a significant role in the service organization and delivery. They act as mediators between patients, healthcare workers and health services. They improve patient-provider communication through translation and mobilization of communities to undertake the health services. Community nurses also participate in filling and maintenance of register, data collection, surveillance and reporting of HIV. They fill medical records using standardized forms or collect the patient data using mobile technology tools. Depending upon the healthcare setting, these nurses may provide community outreach and engage in active case finding in the marginalized populations. They monitor and record vital signs of the patients, monitor the side effects of HAART and HIV disease progression. Overall, they enhance the dignity and quality of life of people with HIV and improve the filling and keeping of medical records (Mwai, Mburu, Torpey, Frost, Ford & Seeley, 2013).
A number of national and international organizations are working to reduce the impact of HIV/AIDS by providing access to prevention, treatment and care options to the infected and at-risk people. The World Health Organization and Centers of Disease Prevention and Control are the primary agencies working in this field. California STD/HIV prevention training center (CA PTC) provides capacity building, training and technical assistance to healthcare professionals. The mission of this center is to strengthen the capacity of health professionals and other organizations to reduce the spread of HIV infection and STDs. They provide online courses for clinicians as well as non-clinicians with an aim to improve health outcomes and well-being of HIV infected persons. They design, deliver and develop training courses in HIV/STD management, evidence-based intervention and strategies, stigma and cultural sensitivity (California HIV/STD Prevention Training Center).
California HIV/STD Prevention Training Center, University of California, San Francisco. Retrieved from: https://www.stdhivtraining.org/
Mwai, G. W., Mburu, G., Torpey, K., Frost, P., Ford, N. & Seeley, J. (2013). Role and outcomes of community health workers in HIV care in sub-Saharan Africa: A systematic review. Journal of the International AIDS Society, 16(1), 18586.
Public Health Agency of Canada. (2009). Population-specific HIV/AIDS status report: People from countries where HIV is endemic - Black people of African and Caribbean descent living in Canada. Retrieved from http://www.phac-aspc.gc.ca/aids-sida/publication/ps-pd/africacaribbe/index-eng.php
Royce, R. A., Sena, A., Cates, W. & Cohen, M. S. (1997). Sexual transmission of HIV. The New England Journal of Medicine, 336(15), 1072-1078.
Smeltzer, S. C. (2010). Handbook for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. Philadelphia: Wolters Kluwer Health / Lippincott Williams & Wilkins.