In immunology, the human immunodeficiency virus (HIV) is a huge topic. So, in this lecture, you can expect a couple of things:
- The definition of HIV
- What viral load is
- How HIV is different from AIDS
- How HIV progresses into AIDS
- The diagnostic tests for HIV
- The signs and symptoms
- How to educate clients with HIV
There are a lot of things to tackle so let’s begin.
Human immunodeficiency virus is considered one of the most interesting topics in nursing school and is also a favorite when it comes to major exams. Diagnosing HIV can be quite complicated, especially during the initial stages when the client has just been infected with the virus.
Keep in mind that HIV transmission is through blood and body fluids – mainly semen and vaginal secretions. But blood is the main component for contracting the virus. And HIV can be transmitted to other people through all of its stages. However, the transmission would depend on the viral load; the higher the viral load, the higher chances of having HIV.
The Viral Load
Having mentioned the viral load, what is it, exactly?
On the first day of getting HIV, the client will have a very high viral load. During this period, the virus is already attacking the body, but the body doesn’t have an idea on how to defend itself from such virus.
Naturally, the body develops antibodies from the B cells or plasma cells. These antibodies inform the body that there are viruses and bacteria that have entered the system and need to be attacked and destroyed by the white blood cells. Technically, antibodies are tags that prompt white blood cells to certain harmful elements inside the body.
With the viral load of HIV, it will take time for the system to communicate that the body is already positive for HIV and this is because of the high antibody tolerance to the virus. One can expect that the viral load is constantly high in the first two to four weeks since the virus was contracted.
By that time, the body will not have enough antibodies and a robust defense system to fight off the virus.
The Window Period
Another term that you will encounter when it comes to HIV is an acute retroviral syndrome or the window period.
So, for the first two to four weeks, the body does not know that it already has HIV. Even the ELISA test, the test to know if there is the presence of antibodies against HIV is also unsure if there’s HIV.
Therefore, the first two to four weeks is what is termed as the window period or the period wherein the acute retroviral syndrome kicks in. During this period, the client will come in with flu-like symptoms – night sweats, fever, and muscle aches.
The medical team would think that the client just has a viral infection because the ELISA test will come back negative for HIV because, during the window period, the antibodies that determine the presence of HIV are not detected. The problem is, the majority of HIV clients who show signs and symptoms, are already positive with the virus but there is just not enough antibodies to prove the diagnosis.
The result might be a negative HIV, but can be positive for viral meningitis or flu, and it’s all because of the ELISA test, a rapid test usually used by medical institutions, provided negative results.
Initial Signs and Symptoms
After a couple of months, the antibodies against HIV have already been produced and has gone up, at the same time, the viral load is staying steady. The moment the client gets sick for whatever reason, the viral load will jump up because the body’s immune system is now compromised, and that’s when the signs and symptoms of HIV kick in.
At this point, another ELISA test is done to check if the person has HIV. The test will now show that the antibodies against HIV are increased and that’s when it will yield a positive result. Once the ELISA test confirms HIV, the client will still be subjected to a couple of diagnostic tests, which we will go through in a bit.
So remember, during the window period (two to four weeks), there would be flu-like symptoms, but the ELISA test will show negative results for antibodies against HIV. It is only after a couple of months when the body becomes sick again that these antibodies are detected.
Three Essential Lab Tests for HIV
There are three different confirmatory tests for HIV – the ELISA test, the Western blot, and the viral load test. And these tests follow a sequence.
1. The ELISA test
So, the first test in your diagnostic sequence is the ELISA test.
The ELISA test does not determine if a client has the virus; which is why, even if the viral load is high in the beginning, the ELISA test will not show a positive result. What the ELISA test determines is how the body is responding to the antibodies that are created against HIV.
The antibodies will not show during the first two to four weeks after having the virus because the body is still figuring out how to deal with the virus. By the time that the body has figured out how and has created enough antibodies, the time has already passed.
Antibodies are created by the B cells. And these B cells or plasma cells shoot tags or spray paint the infecting organism for the white blood cells to attack at.
HIV Mechanism of Attack
Before going on to the next types of diagnostic tests, we’ll quickly go through how HIV attacks the body, primarily, the CD4 cells. The CD4 cells are types of white blood cells that HIV attaches to.
Once HIV has attached itself to the CD4 cell, it infuses its DNA inside the cell and is now in control of the army composed of the following:
- B cells
- Natural killer cells
The CD4 cell is considered as the general that commands the abovementioned elements to fight off harmful elements in the body. The moment HIV becomes in-charge of the CD4 cells, the army goes into limbo and will no longer become active.
ELISA Test: Labeling Antibodies
For antibodies to label HIV, it usually takes anywhere between three to 12 weeks. Sometimes, HIV labeling can take up to 36 weeks; that’s how long antibodies can build up. Normally, the ELISA test will pick up antibodies in the first two to four weeks. And in labeling antibodies, there are results like false negative and false positive. How do these results happen?
A false negative result for an HIV client means that the virus is there, but the client will have a low antibody screening result. This is called false negative because, it’s too early to tell if the client does or does not have HIV, especially if the ELISA test is done before the window period.
Low antibodies do not immediately rule out HIV infection. The body is just taking time adjusting to the presence of the virus and creating an antibody immune response to appropriately label the bad guys.
Therefore, checking for antibodies before the two to four-week marker will yield a false negative results.
On the other hand, a false positive means that there are increased antibodies but can be due to reasons like:
- The client has hepatitis.
- The client is a newborn mom.
- The client is an IV drugs user.
- The client has a history of malaria.
Due to the extensive causes of high antibodies, the ELISA test will yield a false positive result. This happens because the ELISA test does not specifically test on the type of virus that’s causing the increase in antibodies. That is why having a positive ELISA test is still considered false positive unless other diagnostic tests are done.
Why use the ELISA test?
The reason why the ELISA test is a popular method used to determine HIV is because it’s inexpensive and can be done rapidly.
If the ELISA test shows a positive result, the next step in the diagnostic sequence is the Western blot.
2. The Western Blot Test
The Western blot test is more accurate than the ELISA test because it specifically looks for the HIV antibody serum created by the plasma cells. The Western blot test usually detects around two to four antibodies to provide a positive result. Basically, this is the test to confirm the presence of HIV.
Aside from confirming the infection, the Western blot test also provides information on the status of the CD4 cells and how long has it been since the client has the virus in his or her system.
3. The Viral Load Test
The viral load test is the final diagnostic test in this sequence that is done during HIV treatment to determine if the viral load has gone down or is rebounding.
If the client has a negative result with the ELISA test, it is important to remind him or her to do a follow-up especially after the two to the four-week marker to verify further signs and symptoms.
How far long your client has HIV? How bad is it? What’s the progression status? To answer all of these questions, we have to concentrate on the CD4 cells and the viral load which are two different things.
As mentioned, the CD4 cells are the generals that instruct the white blood cells what to do and what to attack to efficiently defend the body from intruders. The normal CD4 cell count is usually more than 500. At this range, the body still has HIV and is defending itself from bacteria, viruses, and other elements that can affect the body’s health.
HIV to AIDS
If the body’s CD4 cells start to drop below 200, that’s when the major signs and symptoms of HIV comes out and is also the moment when the client is diagnosed with AIDS. Technically, everyone who have had AIDS are diagnosed with HIV. But not everyone with HIV has AIDS because there are clients who stay above the 200 CD4 cell count and they do not develop signs and symptoms.
Dropping below the Therapeutic Range
The moment the body’s CD4 cells drop to 200 and below, a cascading series of events happen, mainly:
Opportunistic infections are those infections that are already inside the system for a while and have seen the opportunity to attack the body because the CD4 cells have dropped below the therapeutic level. Because there are not enough soldiers or policemen patrolling and stopping crime, the body will now be overwhelmed with bad guys that cause sickness.
Having an opportunistic infection is one huge indication that CD4 cells have dropped drastically and has progressed into AIDS.
Viral Infection (Herpes)
Herpes doesn’t always mean genital; it can also mean oral if they contract type 2 herpes. Having herpes is another indication that the CD4 cells are below the therapeutic range.
Kaposi’s sarcoma is a condition where blotches that look like pepperoni can be seen all over the body.
It would take more than ten years for the CD4 cells to drop below 200 and proceed to the AIDS category. The progression is slow and can become slower if the client is given an antiviral medication called HAART.
Arriving at an AIDS Diagnosis
For a person to be diagnosed with AIDS, the following has to happen first:
- Positive HIV result through one of these tests – ELISA, Western blot, viral load.
- CD4 cells that are less than the 200 therapeutic mark.
- Having an opportunistic or viral infection.
The Two Most Important Nursing Interventions with HIV
In any type of diagnosis, the most important nursing interventions involve education and pharmacology.
Educating HIV Clients
Under education, there are three things that you have to keep in mind:
The most important part of client education is prevention. As a nurse, you want to prevent the spread of HIV to other people because clients can get infected at any stage, and there’s no cure for HIV. The only thing that medical providers can do with HIV clients is to slow down the progression of the infection to not reach the AIDS category.
Prevention through ABCs
So, how can you prevent the spread and transmission of HIV?
According to the AIDS Council, there are three ways to prevent HIV from getting transmitted:
- A – Abstinence
- B – Be faithful
- C – Condoms
Body Fluids Transmission
Educate your clients that body fluids transmission is the primary cause of getting HIV. There are two types of risk for transmission – highest and lowest.
- Highest risk – through semen and blood
- Lowest risk – vaginal secretions, breast milk, amniotic fluid, and saliva
For instance, your pregnant client is infected with HIV. The chances of the baby getting infected with the virus are slim. With saliva, it is said that a person needs to drink around two gallons of saliva to get infected with HIV.
Modes of Transmission
As said, the highest and most potent way to get HIV is through semen and blood. How are they transmitted?
- Having sex – either male to female or anal sex
- Parenteral route – for IV drug users who are used to sharing needles
- Perinatal – through the womb with a probability risk of around 8% to 25%; not as high as with a sexual or parenteral route
When educating, remind clients to:
- Abstain, be faithful, and use condoms.
- Don’t share needles.
- Be careful when using needles.
HIV Pharmacology – The HAART
Since HIV is incurable, the only thing that one can do is to prevent its progression to AIDS, and this can be done through HAART.
The HAART is an expensive but effective medication regimen that stands for High Active Anti-Retroviral therapy. What the HAART does is that it breaks up the virus to prevent it from attacking the body; like dismantling an empire by going against the virus and stopping it from progressing.
The HAART tells the virus to stop attacking the CD4 cells through replication and pirating. You have to remember that HAART does not kill the virus but only stops it from doing what it does to the CD4 cells.
Caution with HAART
Drug resistance is the biggest caution that you have to remember when dealing with HAART. If the client does not adhere to the regimen, drug resistance will occur. Therefore, you have to advise your client not to miss a dose or not to take less than the recommended prescription.
What are the important things that you have to remember regarding HIV?
- HIV can progress into AIDS if the CD4 cells go below 200.
- Blood and semen are the main culprits for contracting HIV.
- When a client has a high viral load with low antibodies, they are usually within the window period having the anti-retroviral
- The anti-retroviral syndrome is that moment when clients will develop flu-like symptoms but will not show signs of HIV antibodies during an ELISA test.
For those who are interested in an extensive immunology lecture, we have a video and an article on that. We highly recommend that you drop by our website and YouTube channel to get a hold of that comprehensive discussion.