HIV Nursing Care Guide

HIV Pathophysiology

Virus Types

HIV-1: Global pandemic strain; more virulent and transmissible
HIV-2: Predominantly West Africa; lower virulence, slower progression, some ARVs less effective

Cellular Entry & Replication

HIV binds CD4 receptor on T-helper lymphocytes, macrophages, dendritic cells
CCR5 co-receptor: used by R5-tropic strains (transmission strains)
CXCR4 co-receptor: used by X4-tropic strains (late disease)
Maraviroc (CCR5 antagonist) blocks R5-tropic entry
Reverse transcriptase converts viral RNA → DNA (NRTIs/NNRTIs act here)
Integrase inserts viral DNA into host genome (INSTIs act here)
Protease cleaves viral polyproteins for assembly (PIs act here)

CD4+ T-Cell Depletion

Progressive destruction leads to immunodeficiency
Normal CD4: 500–1500 cells/μL
AIDS threshold: <200 cells/μL
Severe immunosuppression: <50 cells/μL

Transmission Modes

Sexual Transmission

Anal (receptive): highest risk per act (~1.4%) — rectal mucosa thin and vascular
Vaginal (receptive): ~0.08% per act
Oral sex: very low (<0.04%) — saliva inhibitory, intact mucosa protective
Co-existing STIs significantly increase transmission risk

Blood-Borne

Sharing needles/syringes: ~0.63% per episode
Infected blood transfusion: ~90% (near certain)
Needlestick injury (HCW): ~0.3%
Mucous membrane splash: ~0.09%

Mother-to-Child (MTCT / Vertical)

In utero, during labour/delivery, breastfeeding
Without ART: 15–45% MTCT risk
With ART + obstetric interventions: <1% risk

          HIV is NOT transmitted by casual contact: shaking hands, hugging, sharing food/water, coughing, sneezing, insect bites, or toilet seats.
        

Transmission Risk Per Exposure Type

Exposure Type	Risk per Act	Risk Level
Blood transfusion (infected blood)	~90%	Extreme
Receptive anal intercourse	~1.4%	High
Sharing needles/syringes (PWID)	~0.63%	Moderate
Needlestick injury (healthcare worker)	~0.3%	Moderate
Receptive vaginal sex	~0.08%	Low
Oral sex (receptive)	<0.04%	Very Low

Risk increases significantly with high viral load, STIs, genital ulcers. U=U: Undetectable Viral Load = Zero transmission risk.

HIV Disease Staging

Stage 1

Acute HIV Infection

2–4 weeks post-exposure
Flu-like: fever, rash, lymphadenopathy
High viral load; highly infectious
Window period — may test negative

Stage 2

Clinical Latency

Months to 10+ years
Asymptomatic (or mild)
CD4 slowly declining
Still transmissible

Stage 3

AIDS

CD4 <200 cells/μL
OR AIDS-defining illness
Opportunistic infections
Fatal without ART

AIDS-Defining Conditions

PCP — Pneumocystis jirovecii pneumonia (most common OI)
Toxoplasmosis — CNS lesions, seizures, ring-enhancing lesion on CT
CMV retinitis — "pizza pie" fundus; risk of blindness, CD4<50
MAC — Mycobacterium avium complex; disseminated; CD4<50

Cryptococcal meningitis — fungal, severe headache, photophobia
Kaposi's Sarcoma — HHV-8 associated; violaceous skin lesions
Non-Hodgkin Lymphoma — EBV-associated B-cell lymphoma
HIV wasting syndrome — >10% weight loss + diarrhoea or fever >30 days

GCC Epidemiology & Legal Context

        Mandatory HIV Testing: Required for employment visas in all 6 GCC countries (UAE, Saudi Arabia, Qatar, Kuwait, Oman, Bahrain). HIV-positive expats face deportation in most countries.
      

Legal Landscape

UAE, Saudi, Qatar, Kuwait, Oman: deportation of HIV+ expatriate workers
Bahrain: changed policy in 2020 — HIV+ expats no longer automatically deported
GCC nationals: improving access to treatment; some centres offer anonymised treatment
MSM (men who have sex with men) is illegal in all 6 GCC countries — profoundly affects care-seeking behaviour

Nursing Implications

Stigma is a major barrier to testing, disclosure, and treatment adherence
Fear of deportation prevents many expat workers from seeking HIV testing
Non-judgmental, confidential care is ethically and legally essential
Never disclose HIV status without patient consent — professional misconduct
Cultural sensitivity: family-centred cultures may create disclosure dilemmas

HIV Testing Algorithm

Step 1 — Screening

          4th Generation Ag/Ab Combination Test

          Detects p24 antigen (appears earliest) + HIV-1 & HIV-2 antibodies

          Window period: 18–45 days post-exposure

          Recommended for routine screening

Step 2 — Confirmatory

HIV-1/2 Differentiation Assay — confirms and differentiates type
HIV-1 NAT (Nucleic Acid Test) — detects viral RNA; window period 10–33 days; used when early acute infection suspected or indeterminate result

Point-of-Care Rapid Test

OraQuick (oral fluid or blood) — result in 20 minutes
Useful in resource-limited or outreach settings
Reactive result MUST be confirmed with lab-based 4th gen test
Window period: 23–90 days (antibody-based)

Pre & Post-Test Counselling

Pre-Test Counselling

Obtain informed consent before testing (verbal or written per policy)
Explain purpose of test, procedure, and what results mean
Assess risk factors — non-judgmentally
Discuss window period and need for repeat testing if recent exposure
Ensure confidentiality — results shared only with patient
Assess support system; discuss potential emotional impact of positive result

Post-Test Counselling — Negative Result

Reinforce prevention: condoms, PrEP if high-risk, harm reduction
Discuss window period — repeat test if recent exposure

Post-Test Counselling — Positive Result

NEVER deliver positive result by phone — face-to-face only
Allow time for emotional response; have tissues, quiet private space
Explain that HIV is a manageable chronic condition with ART
Provide immediate linkage to HIV care
Discuss partner notification and confidentiality
Connect to psychosocial support services

Monitoring Parameters for People Living with HIV

CD4 Count — Immune Function Marker

Normal

≥500/μL

Healthy immune function

Concern

200–499/μL

Moderate immunosuppression

AIDS Threshold

<200/μL

OI prophylaxis required

Severe

<50/μL

CMV, MAC risk

Does not change rapidly; reflects immune trend over time
Guides need for OI prophylaxis (e.g. TMP-SMX for PCP if CD4<200)
Target: sustained CD4 >500/μL on ART

Viral Load (VL) — Treatment Efficacy Marker

Undetectable

<50 copies/mL

U=U — goal of ART

Suppressed

<200 copies/mL

Treatment success

Low-level

200–1000

Review adherence

Detectable

>1000

Risk of resistance

            U=U (Undetectable = Untransmittable): A person with an undetectable VL (<200 copies/mL) on stable ART has effectively zero risk of sexually transmitting HIV to partners.
          

Monitoring Schedule

Test	Baseline	3–6 months on ART	Stable on ART (annual)	Rationale
CD4 count	Yes	Yes	If CD4>500: optional	Immune function trend
Viral Load (HIV RNA)	Yes	Yes	Yes	ART efficacy; must remain <200
FBC (Full Blood Count)	Yes	Yes	Yes	Anaemia, cytopenias
LFTs (Liver Function)	Yes	Yes	Yes	Hepatotoxicity (NVP, boosted PIs)
Renal function / eGFR	Yes	Yes	Yes	TDF nephrotoxicity monitoring
Fasting lipids & glucose	Yes		Yes	Metabolic syndrome (PIs)
HBV / HCV serology	Yes		If risk	Co-infection management
STI screen	Yes		Yes (if sexually active)	Concurrent infections

When to Start ART

        WHO 2021 Recommendation: ALL people living with HIV should start antiretroviral therapy regardless of CD4 count, ideally on the same day as diagnosis ("Same-Day ART"). Earlier treatment improves outcomes and prevents transmission.
      

Same-Day

ART initiation (where possible)

>95%

Adherence needed for viral suppression

<1%

MTCT risk with optimal ART

ART Drug Classes

Class	Abbreviation	Key Drugs	Mechanism	Key Nursing Considerations
Nucleoside/Nucleotide Reverse Transcriptase Inhibitors	NRTI	Tenofovir (TDF/TAF), Abacavir (ABC), Emtricitabine (FTC), Lamivudine (3TC)	Terminate viral DNA chain; block RT	TDF: monitor renal function & bone density. ABC: HLA-B*5701 screen before use (hypersensitivity). Backbone of all first-line regimens
Non-Nucleoside Reverse Transcriptase Inhibitors	NNRTI	Efavirenz (EFV), Rilpivirine (RPV), Doravirine (DOR), Nevirapine (NVP)	Non-competitively block RT	EFV: CNS side effects (vivid dreams, dizziness) — take at bedtime; teratogenic — avoid in pregnancy. RPV: must be taken with a full meal; avoid with PPIs. NVP: hepatotoxic — monitor LFTs
Integrase Strand Transfer Inhibitors	INSTI	Dolutegravir (DTG), Bictegravir (BIC), Raltegravir (RAL), Cabotegravir (CAB)	Block integration of viral DNA into host genome	Excellent tolerability; preferred first-line class. DTG: neural tube defect risk (first trimester) — counsel women of reproductive age. Take 2h before or 6h after antacids/iron
Protease Inhibitors	PI	Darunavir (DRV), Lopinavir (LPV), Atazanavir (ATV) — always boosted with ritonavir or cobicistat	Block viral protease; prevent maturation	Multiple CYP3A4 drug interactions. Monitor lipids, glucose (lipodystrophy, metabolic syndrome). GI side effects common. Boosting agents inhibit CYP450 — check all concomitant meds
Entry / Attachment Inhibitors	EI	Maraviroc (MVC) — CCR5 antagonist Enfuvirtide (T-20) — fusion inhibitor Fostemsavir — attachment inhibitor	Block HIV entry into CD4 cell	Maraviroc: requires tropism testing before use (only for CCR5-tropic virus). Enfuvirtide: subcutaneous injection twice daily — injection site reactions common
Long-Acting Injectables	LAI	Cabotegravir + Rilpivirine (CAB+RPV) injection	INSTI + NNRTI combination	Monthly or bi-monthly IM gluteal injection. Eliminates daily pill burden — improves adherence. Must achieve viral suppression on oral ART first. Refrigerate; warm to room temp before injection

WHO Recommended First-Line ART Regimen

        TDF + 3TC (or FTC) + DTG

        Tenofovir + Lamivudine/Emtricitabine + Dolutegravir

Why This Regimen?

High barrier to resistance (DTG)
Excellent tolerability and safety profile
Available as single tablet once daily (Triumeq / generic)
Effective across a broad range of baseline CD4 counts
Widely available and affordable in GCC national programmes

Adherence is Critical

>95% adherence required to maintain viral suppression
Missed doses → subtherapeutic levels → viral replication → drug resistance
Pill burden, side effects, stigma, work schedules are barriers in GCC
Strategies: pill reminders, counselling, simplified single-tablet regimens, long-acting injectables
Treat-and-tell: patients need to understand missing doses = resistance risk

ART Side Effect Monitoring Summary

Renal toxicity (TDF): monitor eGFR, urine protein; switch to TAF if renal impairment
Hepatotoxicity (NVP, boosted PIs): LFTs at baseline and 3 months; stop drug if >5×ULN
Lipid dyslipaemia (PIs): fasting lipid profile annually; manage with statins (check interactions)

Bone density loss (TDF): DEXA scan if risk factors; vitamin D/calcium supplementation
CNS effects (EFV): vivid dreams, dizziness, depression — usually improve after 2–4 weeks
Immune Reconstitution Syndrome (IRIS): paradoxical worsening after ART initiation — OI symptoms worsen as immune system recovers; manage supportively

Occupational Exposure Protocol — TIME CRITICAL

        PEP must start within 72 hours — every hour counts. Optimal start: within 2 hours.
      

1

Immediate First Aid (at scene):
Needlestick / cut wound: wash thoroughly with soap and water for at least 5 minutes. Do NOT squeeze or suck blood from the wound (may increase mucosal absorption).
Mucous membrane splash (eye, nose, mouth): flush immediately with copious clean water or saline for 5–10 minutes. Remove contact lenses first if applicable.
2

Report Immediately (within 30 minutes):
Notify line manager / charge nurse. Report to Occupational Health or Emergency Department if out of hours. Complete incident report form — document exact time, nature of exposure, PPE worn, source patient details.
3

Risk Assessment by Designated Doctor:
Assess exposure type and volume (hollow-bore needle > solid needle). Determine source patient HIV status, viral load if known. Assess HBV and HCV status of source. Higher risk: source HIV+ with detectable VL, deep puncture wound, blood visible on device.
4

PEP Decision:
Start PEP if: source is HIV+ with detectable VL, source HIV status unknown, high-risk exposure (blood transfusion, large volume splash). PEP not required if: source confirmed HIV-undetectable, or exposure is negligible (intact skin contact). Document decision rationale.
5

PEP Regimen — Start within 2 hours (max 72 hours):
TDF + FTC + Dolutegravir × 28 days
Tenofovir Disoproxil Fumarate 300mg + Emtricitabine 200mg + Dolutegravir 50mg — once daily for 28 days. Complete the full 28-day course even if source tests negative (initial test may be in window period). Support adherence — side effects include nausea, headache.
6
Follow-up Testing Schedule:
- Baseline (Day 0): HIV Ag/Ab (4th gen), HBV sAg, HCV Ab, FBC, renal function, LFTs, pregnancy test (if applicable)
- 6 weeks: HIV Ag/Ab test, FBC, renal/hepatic function
- 12 weeks: HIV Ag/Ab test
- 3–6 months: Final HIV test; HCV RNA if source HCV+

Post-Exposure Prophylaxis (PEP)

Key Facts

Indicated after potential HIV exposure (occupational or sexual)
Must start within 72 hours — sooner is better; ideal <2 hours
After 72 hours: PEP is NOT effective — do not start
Duration: 28 days full course (do not stop early)
Not a substitute for ongoing prevention
Approximately 80% effective when taken correctly and promptly

PEP Regimen (WHO 2021)

          TDF 300mg + FTC 200mg + DTG 50mg

          Once daily × 28 days

          Available as combination tablet (Triumeq or generic)

Common Side Effects

Nausea, headache, fatigue (usually mild; manage with food)
Insomnia, diarrhoea
Monitor renal function (TDF)

Pre-Exposure Prophylaxis (PrEP)

What is PrEP?

Daily oral medication for HIV-negative individuals at high risk of HIV
Reduces HIV acquisition risk by >99% when taken consistently
Regimen: TDF 300mg + FTC 200mg (Truvada / generic) — once daily
Alternative: Cabotegravir long-acting injection every 2 months

Who Should Consider PrEP?

Serodiscordant couples (one partner HIV+)
High-risk sexual exposure (multiple partners, inconsistent condom use)
People who inject drugs (PWID) sharing needles
Sex workers

PrEP in GCC Context

Growing availability in UAE and Qatar private sector
Limited public sector access in most GCC countries
Legal barriers (criminalisation of MSM) limit uptake
Nurses can counsel without judgement; encourage STI testing every 3 months

PrEP Monitoring

HIV test every 3 months (must confirm HIV-negative)
Renal function every 6 months (TDF nephrotoxicity)
STI screen every 3 months

Universal Precautions — Non-Negotiable

        Treat ALL blood and body fluids as potentially infectious — regardless of known or suspected HIV status.
      

Standard Precautions

Hand hygiene before and after patient contact
Appropriate PPE: gloves (all blood/fluid contact), mask, eye protection for splash risk, gown
Safe sharps handling: never recap needles by hand (use one-hand technique or safety device)
Use safety-engineered devices (retractable needles, needleless IV systems)
Dispose sharps immediately into puncture-resistant sharps container — never overfill (>3/4 full)

GCC Healthcare Worker Protections

All GCC countries have mandatory occupational health protocols for blood exposure
Mandatory incident reporting for needlestick injuries
Employers required to provide PEP at no cost to exposed healthcare worker
HAAD / DHA / MOH guidelines for occupational exposure management
HCWs with HIV: ethical guidance — disclosure not mandated if VL undetectable and exposure-prone procedures avoided; local policy applies

GCC HIV Legal & Immigration Context

Country	Visa HIV Test	Deportation if HIV+	Notes
🇦🇪 UAE	Required	Yes	DHA runs HIV programme at Latifa Hospital
🇸🇦 Saudi Arabia	Required	Yes	MOHAP HIV treatment available for nationals
🇶🇦 Qatar	Required	Yes	Qatar HIV programme for nationals
🇰🇼 Kuwait	Required	Yes	National HIV centre at Amiri Hospital
🇴🇲 Oman	Required	Yes	Royal Hospital HIV services
🇧🇭 Bahrain	Required	Changed 2020	Bahrain reversed automatic deportation policy in 2020 — HIV+ expats may remain

HIV in Pregnancy — Key Points

Offer HIV testing to ALL pregnant women at first antenatal visit
ART dramatically reduces MTCT from 15–45% to <1%
Preferred regimen: TDF + 3TC + DTG (note: DTG first-trimester neural tube risk — counsel and weigh benefits)
Elective Caesarean section recommended if VL >400 copies/mL near delivery
Avoid breastfeeding if safe formula alternative available (formula recommended in GCC settings)
Neonatal PEP: infant receives AZT +/- NVP for 4–6 weeks post-birth
Infant PCR testing at 6 weeks, 3 months, 6 months
HIV-positive mother does NOT mean HIV-positive infant — with interventions, most infants are HIV-negative

Nursing Care Principles for HIV Patients

Core Values

Non-judgmental care: HIV is not a moral failing; avoid language that implies blame
Confidentiality: HIV status is highly sensitive; disclosure without consent = professional misconduct and possible legal liability in GCC
Universal precautions: same care regardless of HIV status — prevents stigma-based over- or under-protection
Culturally sensitive: family dynamics, religious beliefs, and immigration status affect disclosure decisions and care acceptance

Holistic Support — GCC Context

Many patients fear deportation, job loss, family rejection — these fears are legitimate in GCC
Acknowledge barriers openly; build therapeutic trust before discussing disclosure
Social worker referral for expats facing immigration consequences
Mental health support: depression, anxiety common following diagnosis
Peer support: limited in GCC due to criminalisation and stigma — online/anonymous forums
Language barriers: ensure interpreter services; avoid using family as interpreters for sensitive diagnosis

GCC HIV Resources

UAE

DHA HIV Services

Latifa Hospital, Dubai — confidential HIV care, ART, counselling

UAE (Federal)

MOHAP HIV Programme

Ministry of Health and Prevention — national ART programme

Qatar

Qatar HIV Programme

Communicable Disease Centre (CDC), Hamad Medical Corporation

Quick Reference — Key Thresholds & Regimens

CD4 Normal

≥500/μL

No OI prophylaxis

CD4 — AIDS

<200/μL

Start PCP prophylaxis (TMP-SMX)

CD4 — Severe

<50/μL

MAC, CMV risk — prophylaxis

VL Target

<50 copies/mL

U=U — zero sexual transmission

PEP Window

<72 hours

Ideal: <2 hours

PEP Duration

28 days

TDF + FTC + DTG

1st-Line ART

TDF+3TC+DTG

WHO 2021 preferred

Window Period

18–45 days

4th gen Ag/Ab test

MTCT with ART

<1%

Without ART: 15–45%

Knowledge Check — 10 MCQ Quiz

Click an answer to check. Complete all 10 questions to see your score.

1. Which exposure type carries the HIGHEST risk of HIV transmission per act?

2. What CD4 count threshold defines the diagnosis of AIDS?

3. What does U=U mean in HIV care?

4. What is the WHO-recommended first-line ART regimen (2021)?

5. After a needlestick injury, what is the MAXIMUM time to start PEP for it to be effective?

6. Which drug class does Dolutegravir belong to?

7. When delivering a positive HIV test result, which of the following is essential?

8. A nurse sustains a needlestick injury. What is the FIRST immediate action?

9. Which GCC country changed its policy on deportation of HIV-positive expatriates in 2020?

10. Which antiretroviral drug requires monitoring of renal function due to nephrotoxicity risk?

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