HIV Infection and AIDS

Darlene Louise A. Lim

3rd year, BS Occupational Therapy
Origins and Current Status of
HIV Infection
• An estimated 33.4 million people globally are infected with human
immunodeficiency virus (HIV) or have acquired immunodeficiency
syndrome (AIDS).
• Approximately 2 million people die annually of HIV/AIDS, and each
year an estimated 2.7 million new HIV infections occur.
• At least 25 million people have died of HIV/AIDS since the earliest
cases of HIV infection
• HIV appears to have originated in Africa; although the exact date of
origin is uncertain, the virus has been present were detected.
• HIV appears to have originated in Africa; although the exact date of origin is
uncertain, the virus has been present in Africa since at least 1959 and possibly
decades earlier.
• The virus is thought to have reached Haiti in approximately 1966.
• HIV probably migrated to the United States as early as 1969 and has since spread
globally.
• The earliest cases of what is now known as HIV infection were identified in the
United States in 1981.
• These initial cases of AIDS in the United States were concentrated in men having
sex with men, injection drug users, and persons receiving contaminated blood
supplies (from transfusions or clotting factor for persons with hemophilia).
• By 1983, HIV, the virus that causes AIDS, was identified.
• It soon became apparent that HIV is spread by contact with specific body fluids
(including blood products, semen, and vaginal fluids).
• The estimated annual number of new infections globally declined from 3
million in 2001 to 2.7 million in 2007.
• An estimated 2 million people died of AIDS in 2007, an increase from an
estimated 1.7 million in 2001.
• Half of all persons infected with HIV are women.
• Young persons (15 to 24 years of age) account for an estimated 45% of
new HIV infections globally.
• Sub-Saharan Africa is the region most affected by HIV and accounts for
67% of the global total of persons infected with HIV. It is difficult to
overstate the social, economic, and human costs that the HIV pandemic
has had in sub-Saharan Africa. For example, in Swaziland, the life
expectancy fell by half (to 37 years of age) between 1990 and 2007.
Swaziland has an estimated adult HIV prevalence of 26%. Overall, 1 in 20
adults in sub-Saharan Africa are estimated to be infected with HIV. The
number of children younger than 18 years orphaned by AIDS in sub-
Saharan Africa has increased from 2 million in 1995 to nearly 12 million
at present.
• In Asia, HIV epidemics in Indonesia, Vietnam, and Pakistan are
growing rapidly. The number of persons infected with HIV in Vietnam
doubled between 2000 and 2005. New infections are also increasing,
though at a lower rate, in Bangladesh and China.
• Infection rates in eastern Europe and central Asia have also increased.
The total number of persons with HIV infection in this region is
highest in the Russian Federation. HIV infection rates in the Ukraine
are increasing at a particularly rapid pace, with new annual infections
doubling between 2001 and 2007.
• Infection rates have been stable in the United States but have
increased in western Europe.
Infection Process
• HIV is the virus that causes AIDS and belongs to a class of viruses
known as retroviruses.
• Retroviruses share a unique process of replication characterized by
the viral genetic material being encoded by RNA rather than DNA.
• Retroviruses, including HIV, replicate as viral RNA is transcribed into
DNA in the host cell.
• The process begins as the virus binds to a cell surface receptor. During
the attachment phase, HIV binds with the surface proteins receptors on
the cell membrane.
• The receptors operate in a lock-and-key fashion, with CD4 being the
primary receptor for HIV (although other receptors and processes are
also critical in the process of HIV cellular infection).
• The initial binding with surface receptors is a necessary stage for
cellular infection.
• Once the initial binding to cell receptors is completed, the virus passes
through the cellular membrane and enters the cytoplasm. On entering
the cytoplasm, the retrovirus uses an enzyme called reverse
transcriptase to synthesize a proviral DNA copy from the viral RNA
template.
• During this process, the transcriptase reads the RNA material as it is
converted to DNA that can be integrated into the host cells’ genetic
material.
• As a result, not all copies of HIV DNA are identical.
• The modifications or mutations during this process contribute to the
resistance of the virus to the body’s immune system and to certain
antiviral treatments.
• The completed HIV virions (containing HIV RNA and HIV proteins or
enzymes) are released from the host cell membrane in a process
referred to as budding.
Transmission
• HIV is transmitted through exchange of body fluids via unprotected
sex with an infected person, exposure to contaminated blood
products (as in transfusions, needle sticks, or injection drug use), or
transfer from an infected mother to a child before, during, or after
birth.
• Body fluids with high concentrations of HIV that are known to be
capable of transmitting the virus include blood, semen, vaginal fluids,
breast milk, and exudates from wounds. HIV is not transmitted
through casual (nonsexual) contact with persons
Diagnosis
• HIV infection can be categorized along a continuum ranging from
asymptomatic persons with high CD4+ counts to persons with clinical
AIDS (representing the most advanced and serious stage of HIV
infection).
• In 1993, the CDC revised the categories that determineone’s HIV or
AIDS status.7 They include the following:
Category 1 (C1): counts of 500 or more CD4+ cells per microliter of
blood.
Category 2 (C2): counts from 200 to 499 CD4+ cells
Category 3 (C3): counts below 200 CD4+ cells
• The second set of categories relates to expression of HIV from a
clinical perspective:
Category A: individuals who have been asymptomatic except for
persistent, generalized lymphadenopathy seroconversion syndrome.
This includes the initial acute onset of HIV exposure.
Category B: individuals who have never had an AIDS-defining illness
but have had some symptoms of HIV infection, such as candidiasis,
fever, persistent diarrhea, oral hairy leukoplakia, herpes zoster,
idiopathic thrombocytopenic purpura, peripheral neuropathy, cervical
dysplasia, or pelvic inflammatory disease.
Category C: individuals who have or have had one or more of the
AIDS-defining illnesses.
Pharmacology
Aging and HIV Infection
• A few issues related to aging in persons infected with HIV are important
and require the attention of the OT practitioner.
• As HAART prolongs the life of persons with HIV, the presence of HIV
with other age-related conditions is becoming more common.
• Recent research has indicated that both hospitalizations and deaths
from HIV-related causes have declined in recent years.
• The reduction in opportunistic infections and clinical AIDS has resulted
in alternative causes of mortality in aging persons infected with HIV.
• Elderly persons with HIV are more likely to have additional medical
comorbid conditions.
Neurologic Sequelae of
HIV/AIDS
• Neuropathies: Peripheral neuropathies are the most common
neurologic complication of HIV. They can occur both as a primary
effect of the virus and as a side effect of antiviral medications used to
treat HIV. It is often difficult to distinguish clinically between the two
causes of neuropathy.
• Dementia: ADC is also referred to as AIDS-related dementia, HIV
associated dementia, AIDS encephalopathy, or HIV encephalitis and is
a common neurologic condition associated with HIV infection.
Dementia associated with HIV infection has been identified since the
earliest years of the HIV/AIDS pandemic and has been characterized
by the cardinal features of progressive dementia with motor and
behavioral deficits.
Early Stages of AIDS-Dementia
Complex
• During the early phases of the disorder, it is possible for the deficits to
be overlooked or be attributed to other causes.
• The early stages are consistent with subcortical dementia and are
characterized by difficulty concentrating and attending to task and
delayed processing of information, which may require extended time
for completion of ADLs; minor forgetfulness and difficulty with
executive functioning tasks are not unusual.
Later Stages of AIDS-Dementia
Complex
• By the late stages, ADC is a condition characterized by global
deterioration involving cognition, motor skills, behavioral
deficits, and limited insight into the client’s condition and
deficits.
• As ADC progresses, the person will probably exhibit
significant cognitive deficits, disorientation, general
confusion, and impaired speech and language ability.
HIV/AIDS Pathologies—Client
Factors
• Factors experienced by people with HIV and AIDS include, but are not
limited to the following:
• Fatigue and shortness of breath
• Impairment of the CNS
• Impairment of the peripheral nervous system
• Visual deficits
• Sensory deficits (including painful neuropathies)
• Cardiac problems
 • Muscle atrophy
• Altered ability to cope with and adapt to changes that the
illness creates
• Depression
• Anxiety
• Guilt
• Anger
• Preoccupation with illness versus wellness
Positive Prevention
• Prevention and health promotion can be a primary area of
intervention in OT.
• In primary prevention, the practitioner may develop and implement
health education and risk reduction strategies to help individuals and
communities understand the impact of reducing risk on occupational
participation.
• Secondary prevention, wherein OT services are provided for people
who are already infected with the virus, would include activities that
create and promote healthy lifestyles and thereby prevent future
opportunistic infections and promote balance and well-being.
Assessment
• One of the first assessments in OT specifically designe as a client-
centered and subjective health promotion tool is the Pizzi Holistic
Wellness Assessment (PHWA). An occupational history format is
used.
• PAPL is a holistic assessment for therapists to gather data on the
physical, psychosocial, emotional, and spiritual aspects of the client’s
life. The resultant data are synthesized via the practitioner’s clinical
reasoning skills to produce a collaborative intervention that is client
centered. All areas of occupational performance are addressed.
OT Intervention
• The OT intervention process involves both the therapeutic use of self
by the practitioner and the therapeutic use of occupations and
activities.
• OT practitioners engage and facilitate engagement in meaningful and
productive daily life occupations through a variety of techniques,
strategies, and inventive programming.
• Promotion of healthy lifestyles while living with the disease is crucial
for all clients infected with HIV.
• Interventions are individually tailored to meet the many physical,
psychosocial, and contextual issues of peoplewith HIV and AIDS.
Prevention of Disability
• Occupational therapists can play a significant role in primary prevention
by participating in occupation-based education for various community
groups to reduce the risk for infection and by promoting health.
• Secondary prevention can be addressed by occupational therapists
through various health promotion strategies to enhance occupational
engagement and performance with an emphasis on maintaining
performance patterns, including significant habits, routines, rituals, and
roles.
• OT intervention addressing tertiary prevention can focus on health
promotion and rehabilitation to enhance occupational performance.
Education and Health Promotion
• Occupational therapists can provide educational
opportunities for clients to address multiple concerns,
including energy conservation strategies to address fatigue,
generalized weakness, and deconditioning, which are
primary physical manifestations of HIV.
• Energy conservation, work simplification, and occupational
adaptations are used to enhance productivity and
participation.
Maintaining and Restoring
Performance
• Considerations for OT interventions include the following:
1. Control and choices of daily living options must be provided as much as
possible.
2. Most clients with symptomatic HIV and AIDS have an altered worker role.
3. Habit training and adaptation of the routine of daily living are essential
interventions and include performance of favored occupations with respect to
physical and cognitive status; the level at which the person feels comfortable
adapting routines; and times of day, contexts, and with whom the person
chooses to perform the occupations.
4. Short- and long-term goals must be readily adapted and changed as
needed.
Modifications, Adaptations, and
Compensatory
Approaches to Intervention
1. Adaptive equipment and positioning can be used to assist clients in
returning to independent performance of ADLs, work, and leisure
occupations.
2. Changes can be made in the physical environment or performance
patterns to help the client continue important roles despite medical
changes, including fatigue.
3. A variety of strategies can be used to compensate for cognitive
changes that may have an impact on occupational performance,
including activities that involve executive function (medication
management, work responsibilities, financial management) and
motor performance.
Advocacy and Psychosocial
Considerations
Occupational therapists can be involved in both advocating for
clients with HIV/AIDS and helping support client efforts for personal
advocacy. More unique psychosocial aspects of HIV rehabilitation are
present than in most other physical or psychosocial cases.
Many people with HIV have lost numerous friends to the same
disease for which they are receiving therapy; have undergone loss of
work and family as a result of discrimination, rejection, or physical
inabilities; and may have lost life partners to the same disease.