AIDS

INTRODUCTION

 

          Acquired Immuno Deficiency Syndrome (AIDS) was first identified in USA in 1981.  The first case of HIV in India was diagnosed in commercial sex workers in Chennai. Tamil Nadu in 1986.  AIDS is the clinical end stage of Human Immuno Deficiency Virus (HIV) infection, which results in severe irreversible immune suppression.  The population at risk of acquiring HIV has increased as a result of demographic, sociologic and behavioral changes that have occurred over the past 20 years.

         

Definition:

 

          Acquired Immunodeficiency Syndrome is caused   by Human Immunodeficiency virus [ HIV], which is a group of retro virus, HIV-I and HIV-II.  HIV causes an incurable infection that leads ultimately to a terminal disease called acquired Immuno Deficiency Syndrome [AIDS].

 

INCIDENCE:

          Incidence is difficult to work out but the fact remains that the disease is alarmingly increasing both in the developed and in developing countries.

          World wide 25-30% of infected patients are women and 905 of them are 20 to 49 years of age.

 

THE VIRUS

          HIV viruses (HIV-1 and HIV-2) are RND retroviruses having the enzyme reverse transcriptase, which permits genomic RND to be transcribed into double stranded DNA.  The virus attaches to T lymphocytes known as CD₄⁺ cells whose action in the immune system is to combact  viruses, bacteria and certain malignancies.  Once the virus is into the genome of the host, it produces multiple copies of itself, which will eventually cause host cell damage.  There is gradual depletion of CD₄⁺ cells.  There is also failure of B lymphocytes to produces anti bodies to HIV.  These events leads to progressive loss of host immune defence and development of AIDS.

 

INCUBATION PERIOD:

          HIV positive person can develop  AIDS within 10 years usually.  Median incubation period 5-8 years in adults while in infants and children 2-5 years.

 

MODE OF TRANSMISSION

1.      Sexual contact (homosexual or heterosexual)

2.      Transplacental transmission (perinatal)

3.      Exposure to infected blood or tissue fluids.

4.      Breast Feeding

5.      Intraveneous drug abuses.

6.      Use of contaminated, needles, needle stick injuries.

7.      Perinatal transmission

 

IMMUNO PATHOGENESIS

          Profound cell mediated immuno deficiency is the basic pathology as the HIV leads to slow but progressive destruction  of T cells.  After a peak viral load, there is a set point which is a state of balance between the virus’s ability to replicate and this hosts ability to protect itself by neutralization and removal of virus.

 

When the set point viral load is high

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More destruction of host CD₄⁺ cells

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Progressive immuno-suppression

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Opportunistic infections and cancer

 

CLINICAL FEATURES

Initial presentation of an infected patient are

Ø     Fever

Ø     Malaise

Ø     Headache

Ø     Sorethroat

Ø     Lymphadenopathy

Ø     Maculopapular rash

Ø     Primary illness may be followed by an asymptomatic period.

Ø     Progression of the disease may lead to multiple opportunistic infection

Examples:

o       Candida

o       Liberculosis

o       Pneumocystis

Ø     Autoimmune thrombocytopenia

Ø     Cervical Carcinoma

Ø     Lymphomas

Ø     Kaposi’s Sarcoma

Ø     Constitutional symptoms like

o       Weight loss

o       Lymph adenopathy

o       Protected diarrhea

 

DIAGNOSSIS

1.     History  of the mother

a.     Any past history of accident, blood transfusion or surgery.

b.    Socio economic status

c.     Age

d.    Extra marital relationship

2.     Physical Examination

3.     CD₄⁺ count L200 cells / mm³

4.     Serum test for HIV

a.     ELISA test [Enzyme-Linked Immunosorbent Assay].

b.    Western blot or immunoflurescence assay.

c.     Polymerase chain reaction technique of amplifying viral DNA.

 

MANAGEMENT

PRENATAL CARE

Ø     All clients should be offered voluntary serologic testing for HIV infection.

Ø     In Sero-poistive cases, additional investigations should be done to test for other STDs.  Husbands should be offered serologic testing for HIV.

Ø     Counselling about the risk of HIV transmission to the fetus and neonates should be made and termination of pregnancy offered.

Ø     Tuberculin test is to be done.  If it is positive, a chest X-ray should be performed.  Even if the chest X-ray is negative chemoprophylaxis with isoniazid (INH) 300mg orally darty should be administered.

Ø     The woman should have T-lymphycyte count in each trimester.  If the count falls to less than 200 cells / mm³, the woman should be treated with zidovudine, the woman should receive prohylaxis aganst pneumocystis carimi infection with trimethoprim 160mg and sulphamethaxazole 800mg orally thrice weekly.  Nevirapine is found to reduce the viral transmission to breast fed infants.

Ø     The progression  of the disease is assessed by CD-4 lymphycytes count presence of P24 core antigen and decrease of tiles of P24 antibody.

Ø     Anti retroviral therapy to HIV-1 positive women is highly effective in reducing the viral (HIV, RNA) load.  Triple chemotherapy is preferred as a first line defence and to be started any time between 14 and 34 weeks and then continued throughout pregnancy, labour and post partum period.

Ø     Anti-HIV-1 drugs are grouped into

Group A     -        Neucleoside analogs

                   -        Zidovudine

                   -        Zalcitabline

                   -        Lamivudine

                   -        Stavudine

Group B     -        Protease inhibitors

                   -        Indinavir

                   -        Sqauinavir

                   -        Ritonavir

Ø     Group C     -        Nonnucleoside analogs

-        Nevirapine

-        Delivirdine

Ø     Group D    -        Integrase inhibitor

-        Elvitegravis

Ø     Group E     -        Entry inhibitor

-        Vicriviroc

 

Treatment regimen:

          Two from group A plus one from either group B or groupC.

Example: Zindovudine 100mg given five times daily it can reduce perinatal transmission.

 

INTRAPARTUM CARE

Ø     Zidovudine is given Iv infusion starting at the onset of labour in vaginal delivery or 4 hours before caesarean section.

Ø     Elective caesarean delivery reduces the risk of vertical transmission by about 50%.

Ø     Cord should be clamped as early as possible.

Ø     Baby should be bathed immediately.

Ø     A maternal sample for plasma viral load should be taken at delivery.

Ø     To avoid procedures that might result in break in the skin or mucous membrane of the infants.

Ø     Amniotomy, Attachment of scalp electrode and determination of scalp blood pH should best be avoid.

Ø     Caps, masks, gowns and double  gloves should be worn.  Protective eye wear should be used by physician and midwives.

Ø     Mechanical suctioning devices should be used to remove secretions from the neonates airways.

Ø     Blunt tipped needles should be used to avoid needle stick injury and washing of any blood contaimination off the skin immediately.

Ø     Health care workers should be protected from contact with potentially infected body fluids.

Ø     Post exposure prohylaxis with triple therapy for 4 weeks, reduces the risk of seroconversion by more than 80% [Zudovudine 200mg tid + lamivudin 150mg bd + indinavir 800 mg tid].

Ø     Disposable syringes and needles are used and they are deposited in the puncture proof containers.

 

POSTPARTUM CARE

Ø     Mothers must be counseled about the risk and benefits of breast feeding and hlped to make an informed choice.

Ø     Zidovudine syrip 2 mg / kg is given to the neonates 4 times daily for first 6 weeks.

Ø     Mother should be encouraged to manage the baby’s care herself with the support of the midwife.

Ø     Gloves must be worn for examining the perineum lochia or cesarian wound.

Ø     Disposal of sanitary napkins and disinfection and cleaning of any 8 pilled blood must be done correctly.

 

CARE OF BABY SOON AFTER BIRTH

1.     Suction any secretion from the oral cavity first and then from the nose to prevent the baby from swalloing any secretion.

2.     Do not milk the umbilical cord.

3.     Cut the cord as soon as pulsation are not felt.

4.     Wipe the baby’s body with a warm clean towel to remove any blood stained secretion.

5.     Administer single dose of syp neviapine to the child within 72 hours after birth.

 

REDUCING THE RISK OF INFECTION THROUGH BREAST FEEDING

Ø     Ensure good nutrition during pregnancy and post natal period.

Ø     Preparation of Breast in the antenatal period

                                                             i.      Examine her breast  for any bifid nipples and flat nipples.

                                                           ii.      Prepare the nipple for suckling by massaging them with oil every day.

Ø     Adopting proper position for breast feeding for herself and the baby.  Baby in facing mother and is close to her, babys tummy flat against moter tummy.

 

CORRECT ATTACHMENT

Ø     Baby’s chin is touching the breast.

Ø     Baby’s mouth covers all the areola.

Ø     Baby’s lower lip is curled outward.

TREATMENT

          Therapy of HIV is complicated by the fact that the HIV Genome is incorporated into the host cell genoma and can remain there in a dormant state for prolonged periods until it is reactivated.  Effective therapy must be directed against both free virus and virus – infected cells.  Although a number of substances with in vitro anti – HIV activity has been described, only a few drugs exhibit  anti HIV activity in vivo at tolerable toxicities.  The main group of substances described are:-

1.    Nucleoside analogues reverse transcriptase inhibitors.  AZT, DDC, DDI and lamu vidine.

2.    Non-Nucleoside analogue reverse transcriptase inhibitors eg., Nevirapine

3.    HIV protease inhibitors eg., Ritonair, Indivavir.  They are the most potent inhibitors of HIV replication to date. 

PREVENTION

Ø     Use of condoms or diaphragms can prevent sexual transmission of the disease.  Hormonal contraceptives and IUCD do not protect from the risk of infection.

Ø     Screening of blood donors should be mandatory.

Ø     Frozen semen in artificial donor insemination should be prechecked.

Ø     Screening of all high risk cases in the population.

Ø     Cessation of smoking.

Ø     Additionally, patients with CD45 count less than 200 or those with symptoms should receive trimethoprim and sulphamethoxazole or aerosol pentamidine.

 

DURING PREGNANCY

          Zidovudine reduces viral load, and 100mg three times a day may be given after 14^th week of pregnancy.

Ø     The neonate with positive HIV antigen should receive zidovudine.

Ø     ABC approach to AIDS prevention is widely accepted as a model to approach adolescent and young adults where HIV infection has been spreading most rapidly.

A – Abstain

B – Be faithful to one partner

C – Use condoms

Ø     Another new approach for prevention of AIDS is

SCAAB – P way

S       -        Safe Sex

C       -        Condom Promotion

A       -        Avoid substances abuse

A       -        Adopt traditional customs safely

B       -        Blood management and haling of body fluids safely

P       -        Prevention of mother to child transmission

 

COUNSELING

        Pre-pregnancy and early pregnancy counseling for HIV infected patient is essential.  The women suffering from AIDS should be advised against pregnancy and if pregnant, termination of pregnancy should be offered.  The counselor must provide uptodate knowledge which enables the patient to make an informed consent.

 

INDIA HIV AND AIDS STATISTICS

          India has a population of one billion, around half of whom are doubts in the sexually active age group.  The first AIDS case in India was detected in 1986.

          The highest HIV prevalence rates are found in Maharashtra, Andhra Pradesh and Karnataka in the South, and Manipur, Mizoram and Nagaland in the north – east.

 

Estimated number of people living with HIV / AIDS 2009

          People living with HIv / AIDS – 2.7 million adult (15 years or above) HIV prevalence 0.4%.

          The percentage of adults living with HIV globally has remained stable since 2000.  use of antiretroviral therapy has increased.

          In the end of 2007 only 335 of HIV infected women had received anti retroviral drugs to reduce the risk of mother to child transmission.

 

HIV STATISTICS 2008-2009

          The National Family Health Survey conducted between 2008 and 2009 measured HIV prevalence among the general adult population of India, as presented in the table below.  The survey found the rate among men to be considerably higher than that among women.

CONCLUSION

 

          AIDS is the emergency of the “Third Generation” of sexually transmitted diseases.  Prevalence rate in India at present in 4/1000, and amongst pregnant women it is 1 to 5/1000.  the incidence is expected to rise further by the turn of the century. So nurses should play an important role in informing and counseling the people with whom they come in contact including their patients about HIV and its prevention.