HIV/ AIDS IV.

ETIOLOGY

Etiologic agent: HIV

Subfamily: Lentivirus
GENERAL MEDICAL BACKGROUND
Family: human retrovirus
I. DEFINITION
Retrovirus- it depends upon unique enqyme called
AIDS (acquired immunodeficiency Syndrome) Reverse Transcriptase (RNA directed DNA
is a recently recognized condition polymerase) to replicate with the host
characterized by a defect in natural immunity
against diseases. There are 4 recognized Human retroviruses
Acquired refers to the fact that the disease is a. Human T lymphotropic virus
not inherited or genetic but develops as result HTLV-I = which is associated with lymphoma.
of a virus. HTVL-II= provirus in circulating cells of the
Immuno refers to the bodys immune system monocyte/macrophage
and deficiency indicates that the immune
system is under functioning resulting in a group
of signs and symptoms that occur together b. Human immunodeficiency viruses
called syndrome. HIV-I= classic AIDS virus
= much more closely related to
II. CLASSIFICATION phylogenetically to the simian
immunodeficiency virus (SIV) found
Classification of HIV =most common type
HIV-II= has 40% nucleotide sequence
CD4 Cell Group A: Group B: Group C:
Asymptomatic, Symptomati Indicator
homology with HIV-I
Count
Acute HIV, or c, not A or C Conditions
Genralized Present -MODE OF TRANSMISSION-
Lymphadenop
athy Horizontal
1. Sexual contact
3
>500/mm A1 B1 C1* 2. Exposure to infected blood or other blood
products
200- A2 B2 C2* 3. Intravenous drug users/needle sharing
3
499/mm
A3* B3* C3* Vertical
3
<200/mm 1. Peri-natally from the mother to the neonate

HIV has been isolated from blood, semen,

* Indicates the presence of AIDS vaginal secretions, saliva, tears, breast milk,
cerebrospinal fluid, amniotic fluid & urine & is
Group A patients are seropositive but likely to be isolated from other body fluids,
eventually symptom free. secretions & excretions. However,
Group B patients have early symptoms of epidemiologic evidence has implicated only
immune deficiency in the absence of an AIDS- blood, semen, vaginal secretions & possibly
indicator condition breast milk in transmission.
Group C patients have one or more AIDS-
indicator illnesses. There is no evidence of transmission by
Patients falling into either group C or category causal contact through the use of shared
3 are classified as having AIDS. food, towel, cups, razors, toothbrush or even
kissing.
III. EPIDEMIOLOGY
The WHO estimated that 2.5 million and 1
million children has AIDS and about 22 million
people were affected with HIV worldwide. AIDS
was the leading cause of death among
American 25 44 years old.
The ratio of men to women who are infected is
estimated to be 6:1, but the number of infected
women is growing faster than the number of
infected men.
Asia has the lowest number of cases 3,561.
American has the highest 371,086 and in USA
alone 47,051 are affected.

RISK GROUPS:
Homosexuals
Intravenous drug users
Bisexuals
Blood transfusion
Organ transplantation
Dialysis recipients
Hemophiliacs - blood disease which the body
lacks a chemical that thickens & stops flow of
blood when a vessel is injured
People with heterosexual contact with partner
who are infected with AIDS
Transmission from mother to baby
Health care professionals & laboratory workers
 1. General
Fever
Pharyngitis
Lymphadenopathy
Headache
Retro-orbital pain
Arthralgias / myalgias
Lethargy/malaise
Weight loss/anorexia
Nausea/vomiting/diarrhea
2. Neuropathic
Meningitis
Encephalitis- inflammation of brain
Peripheral neuropathy- disease in
peripheral nerves causing weakness &
numbness
Myelopathy
3. Dermatologic
Erythematous maculopapular rash
Mucocutaneous ulceration

B. Asymptomatic stage- Clinical Latency

- The initial symptoms may be associated with
the first manifestation an opportunistic
disease.
- Experiences varying degrees of intermittent
sypmtoms such as malaise, lethargy,
weakness, anorexia, and persistent
generalized lymphadenopathy
- High risk opportunistic & clinically apparent
disease

C. Early symptomatic disease ( ARC or AIDS

Related Complex)

Clinical characteristic are the ffL

1. Generalized lymphadenopathy (>1cm)

Extra-inguinal sites; >3mos.; idiopathic
Earliest symptoms ff. Acute syndrome

2. Oral lesions
a. Thrush
White, cheesy exudate- erythematous
V. PATHOPHYSIOLOGY mucosa
HIV type 1 infection results in the destruction of Soft palate are most affected
CD4 positive lymphocytes, leading to a b. Oral hairy leukoplakia
decline in their numbers. Filamentous white lesion (lateral
In acute primary infection, HIV-1 replicates borders of the tongue)
c. Aphthous ulcers of the posterior
briskly and vital titer rises rapidly.
oropharynx
As more CD4 cells are killed, the immune Painful, interference swolloing
system weakens.
5 7
Within 1 week of onset, 10 to 10 infectious 3. Reactivation herpes zoster or shingles
particles per microliter of plasma can be (10%-20%)
st
measured. 1 clinical indication of immunodeficiency
5 years following primary infection
Within a few weeks to months, scroconversion
occurs and HIV-1 anibodies can be measured 4. Thrombocytopenia (3%; platelet 150,000) -
by ELISA and western blood tests. platelet in blood
Within 6-12 month of seroconversion, a steady Bleeding gums
state of plama HIV RNA level is established extremity petechiae

6
Levels of 10 HIV-1 RNA copies or greater per easy bruisabilty
microliter of blood correlate with rapid
D. AIDS (Full Blown)
progression over a few years.
Opportunistic infection disease would set in
Hallmark of HIV Disease: like pneumocystis carinii (causes pneumonia
Profound Immunodeficiency (quantitative and in immunosuppressed pts, usually ff
qualitative decrease of CD4+ T-lymphocyte; intensive chemotherapy), Pneumonia, TB,
normal is 700 1400/mL). Kaposis sarcoma (a malignant tumor arising
from BV in the skin & appearing as purple to
VI. CLINICAL MANIFESTATIONS dark brown plaques or nodules) & the like
A. Acute HIV syndrome (approx. 50%-70%)
- Symptoms usually persist for 1-2 wks. &
gradually subside as immune response to
HIV.
- Opportunistic infections have been reported
during this stage of infection, presumably as a
result of the transient immunosuppression.

Typical clinical findings VII. COMPLICATIONS

 b. p24 Antigen Capture Assay- Simplest
The complications of HIV-related infections test
and neoplasm affect virtually every organ. The c. Plasma HIV RNA AssayMost
general approach to HIV-infected persons with sensitive and reliable measurement of
symptoms is to evaluate the organ system plasma viral load.
involved, aiming to diagnose treatable
conditions rapidly. Certain infections may occur J. DIFFERENTIAL DIAGNOSIS
at any CD4+ count, while others rarely occur
unless the CD4+ lymphocyte count has Many individuals with HIV/AIDS may remain
dropped below a certain level. Abnormal asymptomatic for years, with a mean time of 10
findings range from completely non-specific to years between exposure and development.
highly specific for HIV infection. Virtually, all the findings in the initial onset of AIDS
may be found/mimic other diseases such as:
A. Gynecologic complications Fever
Vaginal candidiasis Headaches
Cervical dysplasia- abN devt of skin, bone Night sweats
or other tissues. Fatigue
Neoplasia- formation of abN cells Hypertension
Pelvic inflammatory disease Back pain
Pulmonary complications ex. cough and SOA
B. HIV-related malignancies: GI complaints (change in bowel habits and
Kaposis Sarcoma function)
Non-hodgkins carcinoma
Cutaneous complaints (dry skin, new rashes,
nail bed changes)
C. Endocrinologic complications:
Adrenal gland is the most commonly
Poor wound healing
afflicted Thrush
Easy Bruising
D. Skin complications: Weight loss
Viral dermatitis Herpes Simplex virus
Bacterial dermatitis Cytomegalovirus
Fungal dermatitis Lymphoma
Neoplastic dermatitis
Nonspecific dermatitis All of these signs/symptoms may be associated
with other diseases,
E. Gastrointestinal complications: *A combination of complaints is more suggestive of
Candidal esophagitis HIV infection than any one symptom alone.
Hepatic diseases
Enterocolitis IX. PROGNOSIS
Other disorder From the time of seroconversion, 10%-20% of
Gastropathy HIV-infected individuals will progress to AIDS
Malabsorption in 3-6 years.
Once the patient has constitutional symptoms,
F. CNS complicationsl herpes zoster, thrush or lower CD4+
Toxoplasmosis lymphocyte count, chances are >40% of
CNS lymphoma progressing to AIDS after 3 years of follow-up
AIDS dementia complex and >50% after 5 years.
Cryptococcal meningitis -Prognosis can be modified by antiretroviral
therapy and general medical support.
G. Sinupulmonary complications:
Pneumonia & other infectious pulmonary
diseases GENERAL HEALTHCARE MANAGEMENT
Noninfectious pulmonary diseases
Sinusitis I. Medical, surgical, & pharmacologic

H. Oral lesions, retinitis, myopathy, and Medical Management

rheumatologic manifestations - Management is usually supportive because
there is no known cure for AIDS.
I. Others systemic complaints - Recent medical advantages have been made
that have allowed AIDS to become a chronic
VIII. DIAGNOSIS and manageable condition.
Licensed tests for diagnosing HIV infection - Currently researchers are working on the
If one cannot afford WBA, confirm results by development of a vaccine
repeating ELISA after 4-12 wks (3 mos.) for until a vaccine is developed the primary
secroonversion to occur. If still (+) then goal of intervention will be focused on
indicative of (+) HIV infection. stopping HIV from replicating, to increase
the number of CD4 cells, and to slow the
A. Enzyme-Linked Immunosorbent Assay (ELISA) progression of the disease.
Standard screening test
Extremely sensitive test Pharmacological Management
Disadvantage: Low specificity - The corner stone of pharmacological
management of HIV infection is
B. Western Blot Assay ( WBA) ANTIRTROVIRAL therapy.
Most common confirmatory test
Tests for assessing disease progression 1. Nucleoside analog reverse transcriptase
inhibitory (NARTI):
CD4+ T-cells count & plasma HIV RNA
Zidovudine (AZT)
assay are the most accurate assessment
Zalcitabine (ddC)
for disease progression & time death
Lamivudine (3TC)
Didanosine (ddl)
Stavudine (d4T)
Emtricitabine (FTC)
a. CD4+ T-cell count Abacavir
 PHYSICAL THERAPY PROGNOSIS, PLAN OF
2. Protease inhibitors CARE & INTERVENTIONS
Saquinavir
Ritonavir I. Plan of Care & Intervention
Indinavir To improve function:
Nelfinavir Gait and functional retraining
Amprenavir Prevention of effects of deconditioning
Fos-amprenavir
Lopinavir Use of adaptive equipment and strategies
Atazanavir For impaired mobility, difficulty with self-care,
Tipranavir impaired cognition and uncontrolled pain:
Darunavir Therapeutic exercises
Gait aids
3. Non-nucleoside Reverse Transcriptase Bathroom and safety equipment
inhibitor: Orthosis
Acvirapine
For acute exposure to the infected Pain management
products of an HIV-infected person, Whirlpool treatment
prophylaxis may be given. One may take Assistance especially in areas of stair
these drugs simultaneously climbing, ambulation, bowel management
AZT (Zidovudine) at 200mg 3x/day and LE dressing
La,ivudine 150mg 2x/day
For cancer pain and pain in patients with HIV:
Indivar 800mg 3x/day
Heat modalities
- These must be taken within 24 hours upon CAUTION: may increase circulation to
exposure preferably within the first 2-4 hrs. the involved area, possibly increasing the
Then take CBC count and use CD4+ as a potential for metastatic spread
baseline and repeat the test every 2 wks. US over malignant tissues in
- Efavirenz
contraindicated
- Nevirapine
- Delavurdine Therapeutic heat and cold are used in
- Etravirine non-cancer patients
TENS for reducing the dependence on
IMMUNE STIMULANTS opioid medication, particularly in phantom
a. Cytokines pain, radiculopathy and incisional pain;
CD4 Cells
conventional high frequency setting is
b. Interleukin-2
CD4 Cells; virus protection most effective

PT MANAGEMENT
Surgical Management
When surgery is planned, preparations for Most important aspect of rehabilitation is to keep
postoperative rehab can be made in advance. the patient as mobile as possible to prevent the
Orthotic and prosthetic appliances also can complications often associated with prolonged bed
be planned in advance and prosthetic fitting rest
can even take place in the operating room.
The need for pretreatment interventions in the A. To improve function:
patient undergoing radiation therapy are - Gait and functional retraining
equally important. - Prevention of effects of deconditioning
The institution of a vigorous stretching - Use of adaptive equipment and strategies
program can help to prevent contractures and
deformity that otherwise would occur as a B. For impaired mobility, difficulty with self-
result of radiation fibrosis. care, impaired cognition, and uncontrolled pain:
Training in skin care and the proper use of - Therapeutic exercises
moisturizing creams can help to prevent - Gait aids
breakdown or infection. - Bathroom and safety equipment
- Orthosis
PHYSICAL THERAPY EXAMINATION, - Pain management
EVALUATION, & DIAGNOSIS - Whirlpool treatment
- Assistance especially in areas of stair climbing,
I. Points of emphasis on examination ambulation, bowel management, and LE
Pulmonary test dressing
UE and LE
Instability test C. For cancer pain and pain in patients with HIV:
ROM Heat modalities
MMT
Motor and sensory tests Caution: may increase circulation to the involved
area, possibly increasing the potential for
Check for deconditioning problems: metastatic spread.
Contracture - US over malignant tissues is contraindicated
Adhesions - Therapeutic heat and cold are used on non-
Atrophy cancer patients
LOM - TENS for reducing the dependence on opioid
Weakness medications particularly in phantom pain,
Instabilities radiculopathy and incisional pain
Edema/swelling
Conventional high frequency setting is
II. Problem list most effective
Impaired mobility
Difficulty with self-care
Impaired cognition
Uncontrolled pain