Autoimmune Disorders and HIV/AIDS - Revision Notes
This chapter covers two critical ends of the immune-dysfunction spectrum that are high-yield topics in the Philippine Nursing Licensure Examination (NLE). Autoimmune disorders — including Systemic Lupus Erythematosus (SLE), Scleroderma, and Sjögren's Syndrome — occur when the immune system loses self-tolerance and attacks the body's own tissues. HIV/AIDS, by contrast, is a progressive destruction of the immune system by a retrovirus. In the Philippine context, HIV is one of the fastest-growing epidemics in the Asia-Pacific region, governed by Republic Act No. 11166 (Philippine HIV and AIDS Policy Act of 2018). Transplant immunosuppression is also covered because it shares core pharmacology and infection-risk principles with immune suppression therapy. Mastering these topics requires understanding pathophysiology, clinical manifestations, nursing diagnoses, pharmacological management, and the Philippine legal framework.
Autoimmune Disorders — Foundational Concepts
Exam tips
- When the exam asks about the PRIORITY nursing diagnosis for any autoimmune flare, think PHYSIOLOGICAL first (Maslow): pain, infection risk, organ dysfunction.
- Remember the key autoantibodies as mnemonics: 'SLAM' — SLE = ANA, Anti-dsDNA, Anti-Smith; Scleroderma = Anti-Scl-70 or Anti-centromere (CREST); Sjögren's = Anti-Ro (SSA), Anti-La (SSB).
- Relapsing-remitting pattern is a classic NLE distractor — remission does NOT mean discontinue medication.
Key points
- Autoimmunity = loss of SELF-TOLERANCE: the immune system fails to distinguish 'self' from 'non-self' and produces autoantibodies or self-reactive T cells that attack the body's own tissues.
- Autoimmune disorders are more common in WOMEN OF CHILDBEARING AGE and have a genetic predisposition.
- The course is typically RELAPSING-REMITTING: periods of flares (active disease) followed by remissions (quiet disease).
- Chronic inflammation from autoimmunity leads to progressive tissue and organ damage.
- Most autoimmune disorders share common triggers: infection, UV exposure, stress, hormonal changes, and certain drugs.
- Standard NANDA nursing diagnoses for autoimmune disorders include: Chronic Pain, Fatigue, Impaired Physical Mobility, Risk for Infection (due to immunosuppressant therapy), Disturbed Body Image, Deficient Knowledge, and Ineffective Health Management.
- Maslow prioritization: physiological needs (organ protection, pain, infection) always come before psychosocial needs (body image, self-esteem) in exam questions.
Definitions
Self-tolerance
The immune system's ability to recognize the body's own tissues as 'self' and not attack them. In autoimmunity, this mechanism breaks down.
Importance
Understanding self-tolerance failure explains why autoimmune disorders occur and why they require lifelong immunosuppression.
Autoantibodies
Antibodies produced by the immune system that mistakenly target the body's own proteins, cells, or tissues.
Importance
Specific autoantibodies (e.g., ANA, anti-dsDNA, anti-Sm, anti-Ro, anti-La) are used as diagnostic markers for specific autoimmune disorders.
Relapsing-Remitting Course
A pattern of disease where active periods (flares/exacerbations) alternate with quiet periods (remissions). Triggers can initiate a flare.
Importance
Critical for patient teaching — patients must know their triggers and how to minimize flare risk.
Common mistakes
- Confusing the type of immune reaction: SLE is a TYPE III (immune complex) hypersensitivity, NOT type II or IV.
- Forgetting that autoimmune disorders primarily affect women — exam questions often specify the demographic.
- Assuming remission means the patient is cured — lifelong medication and monitoring are still required.
Systemic Lupus Erythematosus (SLE)
Exam tips
- BUTTERFLY RASH + PHOTOSENSITIVITY + YOUNG WOMAN = SLE until proven otherwise in the NLE.
- Remember: Anti-dsDNA TRACKS disease activity. If the question says 'which lab test monitors SLE flare severity?' — Anti-dsDNA.
- Hydroxychloroquine keyword in an NLE question → your answer should include EYE EXAMINATION.
- Teaching priority for SLE: SUN PROTECTION (SPF 30+, protective clothing, hats) — this prevents both the rash and systemic flares.
- If a patient with SLE develops hypertension + proteinuria + edema → suspect LUPUS NEPHRITIS — priority is renal monitoring.
- Corticosteroid teaching: take with food, do not stop abruptly, monitor for signs of infection (fever may be masked).
Key points
- SLE is a chronic, MULTISYSTEM autoimmune disease caused by TYPE III (immune complex) hypersensitivity — antigen-antibody complexes deposit in tissues throughout the body.
- HALLMARK SIGN: Butterfly (malar) rash — a red/purple rash across both cheeks and bridge of the nose in a butterfly pattern, SPARING the nasolabial folds.
- PHOTOSENSITIVITY is a defining feature — UV light triggers both the rash and disease flares.
- SLE can affect nearly every organ system: skin, joints, kidneys, heart, lungs, blood, and CNS.
- LUPUS NEPHRITIS is a leading cause of morbidity and mortality — monitor urine output, proteinuria, hematuria, creatinine, edema, and blood pressure.
- Hematologic effects: anemia, leukopenia, thrombocytopenia — monitor CBC regularly.
- KEY DIAGNOSTIC ANTIBODIES: ANA (sensitive, not specific), Anti-dsDNA (specific, tracks disease activity/nephritis), Anti-Smith/Anti-Sm (highly specific).
- COMPLEMENT LEVELS (C3, C4) DECREASE during active disease — useful for monitoring flares.
- FLARE TRIGGERS (mnemonic SIPS-FDP): Sun/UV, Infection, Physical/emotional Stress, Fatigue, Drugs, Pregnancy.
- PRIORITY NURSING ACTIONS: protect from sun, prevent infection, monitor renal function, ensure medication adherence, family planning counseling.
- HYDROXYCHLOROQUINE is a mainstay drug — requires PERIODIC EYE EXAMINATIONS (retinal toxicity).
- CORTICOSTEROIDS: never stop abruptly — taper gradually; monitor blood glucose, blood pressure, and signs of infection.
- NANDA diagnoses: Impaired Skin Integrity (rash), Chronic Pain (arthritis), Risk for Impaired Kidney Function (nephritis), Risk for Infection (immunosuppression), Fatigue, Disturbed Body Image (alopecia, rash).
Definitions
Butterfly (Malar) Rash
A red or purple facial rash distributed across both cheeks and the bridge of the nose, resembling a butterfly. It SPARES the nasolabial folds. It is the hallmark sign of SLE.
Importance
The most recognizable and frequently tested manifestation of SLE in the NLE. If an exam question shows a facial rash sparing the nasolabial folds — think SLE.
Lupus Nephritis
Kidney inflammation caused by immune complex deposition in the glomeruli. Manifests as proteinuria, hematuria, hypertension, edema, and rising creatinine.
Importance
The leading cause of death in SLE. Nursing must monitor urinalysis, renal function tests, and blood pressure closely.
Anti-dsDNA Antibody
An antibody against double-stranded DNA — highly specific for SLE. Rising titers correlate with disease activity, particularly lupus nephritis.
Importance
Used both for diagnosis AND for monitoring disease activity. An NLE question asking 'which antibody is most specific for SLE' — answer is Anti-dsDNA or Anti-Smith.
Antinuclear Antibody (ANA)
An antibody against components of the cell nucleus. Positive in nearly all SLE patients (95%+) but NOT specific to SLE — also positive in other autoimmune diseases.
Importance
ANA is the SCREENING test for SLE — high sensitivity. But for specificity, Anti-dsDNA and Anti-Sm are the confirmatory antibodies.
Common mistakes
- Forgetting that hydroxychloroquine requires eye exams — retinal toxicity is a key nursing consideration.
- Stating corticosteroids can be stopped abruptly — NEVER. Always taper to prevent adrenal insufficiency and disease flare.
- Confusing ANA (sensitive, used for screening) with Anti-dsDNA/Anti-Sm (specific, used for confirmation).
- Missing that complement levels (C3, C4) DECREASE (are consumed) during active SLE — not increase.
- Overlooking pregnancy as a major flare trigger — family planning counseling is essential for women of childbearing age with SLE.
Scleroderma (Systemic Sclerosis)
Exam tips
- CREST mnemonic: Calcinosis, Raynaud, Esophageal dysmotility, Sclerodactyly, Telangiectasia — memorize this for NLE.
- Patient education priority for Raynaud: WARMTH (gloves, layered clothing, avoid cold drafts) and STOP SMOKING (nicotine causes vasospasm).
- Scleroderma + severe hypertension + rising creatinine = RENAL CRISIS → give ACE inhibitors.
- Scleroderma GERD teaching: small frequent meals, remain upright 2–3 hours after eating, elevate head of bed 30–45 degrees, avoid spicy/acidic foods.
Key points
- Scleroderma = excessive COLLAGEN DEPOSITION and FIBROSIS of the skin and internal organs, plus vascular injury (vasospasm).
- RAYNAUD PHENOMENON is often the EARLIEST sign: episodic vasospasm causing pallor (white) → cyanosis (blue) → redness (red) of the fingers triggered by cold or stress.
- SKIN: thickened, hardened, tight, shiny skin ('hide-bound') — starts in fingers, hands; tight, mask-like face with limited mouth opening (microstomia).
- GI: esophageal dysmotility causing DYSPHAGIA and severe GERD/reflux — most common GI complaint.
- PULMONARY HYPERTENSION and INTERSTITIAL FIBROSIS are the LEADING CAUSES OF DEATH in scleroderma.
- RENAL: scleroderma renal crisis — sudden severe hypertension and acute renal failure; treated with ACE inhibitors.
- LIMITED FORM (CREST syndrome): Calcinosis, Raynaud, Esophageal dysmotility, Sclerodactyly, Telangiectasia.
- NURSING MANAGEMENT: protect from cold, smoking cessation, small frequent meals + upright positioning for GERD, range-of-motion exercises, skin moisturizers, strict BP monitoring.
- NANDA diagnoses: Impaired Physical Mobility (skin tightness), Imbalanced Nutrition: Less Than Body Requirements (dysphagia), Chronic Pain, Risk for Impaired Skin Integrity.
Definitions
Raynaud Phenomenon
Episodic vasospasm of the digital arteries causing a classic color change: pallor (white/ischemia) → cyanosis (blue/deoxygenation) → redness (red/reperfusion). Triggered by cold or emotional stress.
Importance
The earliest and most common manifestation of scleroderma; also seen in SLE. Key nursing intervention: keep extremities warm, avoid cold, stop smoking.
CREST Syndrome
A limited form of scleroderma: Calcinosis (calcium deposits in skin), Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly (finger skin tightening), Telangiectasia (dilated blood vessels on skin).
Importance
Frequently tested as a memory device in NLE. Generally has a better prognosis than diffuse scleroderma but pulmonary hypertension remains a risk.
Scleroderma Renal Crisis
A sudden, severe hypertensive emergency with oliguria and acute renal failure in scleroderma patients. Treated with ACE inhibitors.
Importance
If the NLE question asks about sudden severe hypertension in a patient with tight skin and Raynaud's — think scleroderma renal crisis. Priority: BP monitoring and ACE inhibitors.
Common mistakes
- Forgetting that PULMONARY involvement (pulmonary hypertension and fibrosis) is the LEADING CAUSE OF DEATH in scleroderma — not renal or skin.
- Missing that Raynaud phenomenon can also occur in SLE — it is not exclusive to scleroderma.
- Overlooking the CREST acronym — each letter must be memorized for NLE.
- Failing to teach patients to remain UPRIGHT after meals — lying down worsens GERD in scleroderma.
Sjögren's Syndrome
Exam tips
- DRY EYES + DRY MOUTH + ARTHRITIS in a woman = Sjögren's Syndrome.
- Teaching priority: ORAL HYGIENE (fluoride toothpaste, dental visits) and artificial TEARS + artificial SALIVA.
- Anti-Ro (SSA) and Anti-La (SSB) = Sjögren's markers. 'SSA and SSB — the S stands for Sjögren's.'
- If an NLE question asks what test confirms tear production — answer: SCHIRMER TEST.
Key points
- Sjögren's = autoimmune infiltration and destruction of EXOCRINE (moisture-producing) GLANDS — primarily salivary and lacrimal glands.
- CLASSIC TRIAD: Dry eyes (keratoconjunctivitis sicca), Dry mouth (xerostomia), and Arthritis.
- Often occurs SECONDARY to another autoimmune disease (SLE, rheumatoid arthritis).
- DIAGNOSTIC ANTIBODIES: Anti-Ro (SSA) and Anti-La (SSB); Schirmer test measures tear production.
- HIGH DENTAL CARIES RISK — lack of saliva removes the protective antimicrobial and buffering effects.
- NURSING MANAGEMENT: artificial tears, saliva substitutes, frequent sips of water, sugar-free gum/candy, meticulous oral/dental hygiene, humidifiers, avoid dry/smoky/windy environments.
- NANDA diagnoses: Impaired Oral Mucous Membrane, Risk for Dry Eye, Risk for Impaired Dentition, Chronic Pain (arthritis).
Definitions
Keratoconjunctivitis Sicca
Clinical term for dry eyes caused by decreased tear production due to lacrimal gland destruction. Patients report burning, gritty sensation, photophobia, and blurred vision.
Importance
The eye symptom of Sjögren's triad. Management: preservative-free artificial tears, protective eyewear, avoid fans/air conditioning directed at the face.
Xerostomia
Dry mouth due to reduced saliva production from salivary gland destruction. Creates extreme discomfort in speaking, eating, and swallowing, and massively increases dental caries risk.
Importance
The oral symptom of Sjögren's triad. Management: saliva substitutes, sipping water, sugarless gum/hard candy, frequent dental visits.
Schirmer Test
A diagnostic test for dry eyes where a small strip of filter paper is placed inside the lower eyelid to measure tear production. Less than 5mm of wetting in 5 minutes is abnormal.
Importance
A key diagnostic test for Sjögren's syndrome mentioned in NLE questions about diagnosis.
Common mistakes
- Forgetting the dental caries risk — meticulous oral hygiene and regular dental visits are priority teaching for Sjögren's.
- Using SUGARY gum or candy — must be SUGAR-FREE to stimulate saliva without increasing caries risk.
- Confusing Sjögren's antibodies (Anti-Ro/SSA, Anti-La/SSB) with SLE-specific antibodies (Anti-dsDNA, Anti-Sm).
HIV and AIDS — Pathophysiology and Staging
Exam tips
- CD4 < 200 cells/mm³ = AIDS DIAGNOSIS. CD4 < 200 = also start CO-TRIMOXAZOLE prophylaxis for PCP.
- WINDOW PERIOD concept: patient tested negative but has recent high-risk exposure → advise RETEST at 3 months.
- HIV TRANSMISSION routes (4 Bs): Blood, Body fluids (semen, vaginal/rectal secretions), Breast milk, Birth (perinatal). NOT by casual contact.
- ART GOAL: UNDETECTABLE viral load. This also means UNTRANSMITTABLE (U=U concept).
Key points
- HIV (Human Immunodeficiency Virus) is a RETROVIRUS that specifically targets and destroys CD4+ T HELPER LYMPHOCYTES.
- MECHANISM: HIV uses REVERSE TRANSCRIPTASE to convert its RNA into DNA, which integrates into the host's genome. The virus then replicates and buds out, destroying the CD4 cell.
- As CD4 cells are depleted, CELL-MEDIATED IMMUNITY collapses, making the person vulnerable to opportunistic infections and cancers.
- NORMAL CD4 COUNT: approximately 500–1,600 cells/mm³.
- AIDS IS DEFINED BY: CD4 count BELOW 200 cells/mm³ OR presence of an AIDS-defining opportunistic infection or malignancy — regardless of CD4 count.
- VIRAL LOAD measures the amount of HIV RNA in the blood — high viral load = more infectious, faster progression, poorer prognosis.
- TREATMENT GOAL: UNDETECTABLE viral load (suppresses virus, restores CD4, prevents transmission, prevents progression).
- THREE STAGES OF HIV INFECTION: (1) Acute HIV infection — flu-like seroconversion illness 2–4 weeks after exposure; (2) Clinical latency/asymptomatic — virus replicates slowly, may last years; (3) AIDS — CD4 <200, opportunistic infections.
- WINDOW PERIOD: the gap between HIV infection and detectable antibodies (typically up to 3 months with antibody tests). Person is INFECTED AND INFECTIOUS but tests NEGATIVE — must RETEST after window period.
Definitions
CD4+ T Helper Lymphocyte
The primary target of HIV. These cells coordinate the entire immune response by activating other immune cells (B cells, cytotoxic T cells, macrophages). As HIV destroys these, the immune system loses its 'general commander.'
Importance
The CD4 count is the most important immune monitoring tool in HIV. Below 200/mm³ = AIDS. Below 200 = start PCP prophylaxis with co-trimoxazole.
Retrovirus
A type of RNA virus that uses the enzyme reverse transcriptase to convert its RNA genome into DNA, which is then inserted into the host cell's DNA. HIV is the most clinically important retrovirus.
Importance
Understanding the retroviral life cycle explains why NRTIs (which block reverse transcriptase) and integrase inhibitors (which block DNA integration) are core ART drugs.
Window Period
The time between HIV infection and the point when a test can reliably detect the infection. Antibody tests: up to ~3 months. 4th-generation antigen/antibody tests: 2–4 weeks. During this period, the person tests NEGATIVE but IS infectious.
Importance
A critically important concept in HIV counseling. Patients must be told to RETEST if tested during the window period. Negative result ≠ not infected if exposure was recent.
AIDS (Acquired Immunodeficiency Syndrome)
The most advanced stage of HIV infection, defined by CD4 count below 200 cells/mm³ OR the presence of an AIDS-defining opportunistic infection or malignancy.
Importance
The key diagnostic threshold. NLE questions frequently ask: 'At what CD4 count is AIDS diagnosed?' Answer: BELOW 200 cells/mm³.
Common mistakes
- Saying HIV is transmitted by casual contact (hugging, sharing utensils, insect bites, toilet seats) — HIV is NOT transmitted this way.
- Confusing viral load (amount of virus) with CD4 count (immune status). High viral load = bad. Low CD4 = bad. Undetectable viral load = treatment goal.
- Thinking a negative HIV antibody test during the window period means the person is HIV-negative — they must be RETESTED.
- Stating AIDS is diagnosed only by CD4 count — it can also be diagnosed by ANY AIDS-defining condition regardless of CD4 count.
HIV — Opportunistic Infections and AIDS-Defining Conditions
Exam tips
- PCP = CLASSIC AIDS-defining pneumonia. DRY COUGH + DYSPNEA + FEVER in HIV patient = suspect PCP → co-trimoxazole.
- In Philippine context: HIV + COUGH + WEIGHT LOSS = screen for TB first (TB is endemic and the most common OI in PH).
- CD4 < 200 → start CO-TRIMOXAZOLE prophylaxis. This is both for PCP AND toxoplasmosis prevention.
- Kaposi sarcoma = RED-PURPLE lesions = AIDS-defining cancer. Caused by HHV-8 (Human Herpesvirus 8).
Key points
- Opportunistic infections (OIs) occur because the immune system is too weak to fight normally harmless organisms — they 'take the opportunity' of a weakened host.
- Most OIs occur at CD4 < 200 cells/mm³.
- PNEUMOCYSTIS JIROVECII PNEUMONIA (PCP): the CLASSIC AIDS-DEFINING infection. Presents with DYSPNEA, DRY COUGH, and FEVER. Treatment: Co-trimoxazole (TMP-SMX). Prophylaxis: Co-trimoxazole when CD4 < 200.
- TUBERCULOSIS (TB): a MAJOR opportunistic infection in the Philippines — one of the leading causes of death in Filipino PLHIV. May present atypically (extrapulmonary TB). All HIV patients in PH should be screened for TB.
- ORAL CANDIDIASIS (Thrush): white plaques in mouth, may progress to esophageal candidiasis (dysphagia). Treated with fluconazole or nystatin.
- CRYPTOCOCCAL MENINGITIS: fungal meningitis; presents with headache, fever, stiff neck, altered mental status. Treated with amphotericin B.
- TOXOPLASMOSIS: CNS infection causing brain lesions, headache, focal neurological deficits, seizures.
- CMV RETINITIS: cytomegalovirus infection of the retina causing vision loss — a serious OI at very low CD4 counts.
- KAPOSI SARCOMA: AIDS-defining cancer; red-purple lesions on skin, mouth, and internal organs.
- NON-HODGKIN LYMPHOMA and INVASIVE CERVICAL CANCER: AIDS-defining malignancies.
- HIV WASTING SYNDROME: involuntary weight loss >10% body weight with diarrhea or weakness.
- HIV ENCEPHALOPATHY (AIDS DEMENTIA COMPLEX): cognitive decline, memory loss, behavioral changes due to HIV in the CNS.
- NURSING PRIORITY for OIs: Infection control, respiratory monitoring (PCP), neurological monitoring (toxoplasmosis, meningitis), nutritional support, adherence to prophylaxis.
Definitions
Pneumocystis jirovecii Pneumonia (PCP)
An AIDS-defining fungal pneumonia caused by Pneumocystis jirovecii (formerly P. carinii). Classic presentation: progressive dyspnea, dry non-productive cough, low-grade fever, hypoxia. Treated and prevented with co-trimoxazole (TMP-SMX).
Importance
The CLASSIC AIDS-defining infection — the most frequently tested opportunistic infection in NLE. Remember: co-trimoxazole is BOTH treatment AND prophylaxis.
AIDS-Defining Condition
A specific opportunistic infection or malignancy that, when diagnosed in an HIV-positive person, automatically classifies their disease as AIDS regardless of CD4 count. Examples: PCP, CMV retinitis, Kaposi sarcoma, cryptococcal meningitis, toxoplasmosis, MAC, invasive cervical cancer.
Importance
An NLE patient may be asked: 'What confirms the diagnosis of AIDS?' Any AIDS-defining condition OR CD4 < 200 cells/mm³.
Common mistakes
- Forgetting that TB is a major OI in the Philippines — in Filipino PLHIV, TB is one of the most common causes of death.
- Confusing oral candidiasis (mouth) with esophageal candidiasis (dysphagia) — both are OIs but esophageal candidiasis is AIDS-defining.
- Missing that Kaposi sarcoma lesions are RED-PURPLE and can occur on the skin, mouth, and internal organs.
HIV — Diagnostics, ART, and Adherence
Exam tips
- PEP = 72 HOURS. This is a classic NLE time-critical answer. After a needlestick: wash → report → PEP within 72 hours.
- ART ADHERENCE = LIFELONG. Even if the patient feels well. Even if viral load is undetectable. NEVER STOP ART without medical advice.
- U=U: If a patient asks 'Can I transmit HIV to my partner if my viral load is undetectable?' — Answer: With sustained undetectable VL, sexual transmission does NOT occur. But ART must be continued.
- Zidovudine (AZT) → monitor CBC (bone marrow suppression). Tenofovir → monitor kidneys (nephrotoxicity). Efavirenz → take at BEDTIME (CNS side effects).
Key points
- HIV SCREENING: 4th-generation antigen/antibody immunoassay (detects both HIV antibody AND p24 antigen — shortens window to ~2–4 weeks); also rapid HIV tests.
- HIV CONFIRMATION: supplemental antibody differentiation assay OR HIV RNA (nucleic acid) test (NAT).
- MONITORING: CD4 count (measures immune status — how damaged is the immune system?) and HIV VIRAL LOAD (measures disease activity and ART effectiveness).
- ART PRINCIPLE: Always use a COMBINATION of at least 3 drugs from 2 or more drug classes (HAART = Highly Active Antiretroviral Therapy) to suppress viral replication at multiple steps.
- ART DOES NOT CURE HIV — it SUPPRESSES the virus, RESTORES CD4, PREVENTS progression, and REDUCES transmission.
- U=U: UNDETECTABLE = UNTRANSMITTABLE — a person with a sustained undetectable viral load does NOT sexually transmit HIV.
- STRICT LIFELONG ADHERENCE IS NON-NEGOTIABLE — missing doses allows viral replication and DRUG RESISTANCE, leading to TREATMENT FAILURE.
- POST-EXPOSURE PROPHYLAXIS (PEP): must be started within 72 HOURS of HIV exposure (ideally as early as possible), continued for 28 DAYS. Delay beyond 72 hours = PEP ineffective.
- PRE-EXPOSURE PROPHYLAXIS (PrEP): given to HIGH-RISK HIV-NEGATIVE individuals (available under DOH programs in the Philippines).
- PMTCT (Prevention of Mother-to-Child Transmission): ART throughout pregnancy, safe delivery, infant prophylaxis, and AVOID breastfeeding where safe formula is available.
- ART DRUG CLASSES: NRTIs (tenofovir, lamivudine, zidovudine, abacavir), NNRTIs (efavirenz, nevirapine), Integrase Inhibitors (dolutegravir — NOW PREFERRED FIRST LINE in many regimens), Protease Inhibitors (lopinavir/ritonavir), Entry/Fusion Inhibitors.
- KEY SIDE EFFECTS TO KNOW: Zidovudine = bone marrow suppression (anemia, neutropenia); Abacavir = hypersensitivity reaction (test HLA-B*5701 first); Efavirenz = CNS side effects (vivid dreams, dizziness — take at bedtime); Tenofovir = nephrotoxicity and bone loss; all PIs = metabolic syndrome/lipodystrophy.
Definitions
Post-Exposure Prophylaxis (PEP)
A 28-day course of ART (3-drug combination) started within 72 hours of potential HIV exposure (e.g., needlestick injury, unprotected sex) to prevent infection. The sooner it is started, the better — ideally within hours.
Importance
Critical nursing knowledge — if a healthcare worker has a needlestick injury from an HIV-positive patient: wash the site, report IMMEDIATELY, and INITIATE PEP EVALUATION WITHIN 72 HOURS.
Drug Resistance
When HIV mutates and becomes resistant to one or more ART drugs due to viral replication in the presence of subtherapeutic drug levels — caused by poor adherence (missed doses). Leads to treatment failure.
Importance
THE #1 reason for strict adherence. Explain to patients: 'Every missed dose gives the virus a chance to mutate and make the medicine stop working.'
Dolutegravir (Integrase Inhibitor)
A preferred first-line ART drug in many current guidelines (including DOH Philippines) that works by blocking the integrase enzyme, preventing HIV DNA from integrating into the host cell's genome.
Importance
NLE may ask about preferred first-line ART regimen — dolutegravir-based regimens are increasingly the standard of care.
Common mistakes
- Stating that PEP must be started within 24 hours — the correct window is 72 HOURS, but earlier is always better.
- Saying ART cures HIV — ART CONTROLS, NOT CURES HIV. Lifelong therapy is required.
- Recommending a single ART drug — COMBINATION THERAPY (3+ drugs from 2+ classes) is always required to prevent resistance.
- Forgetting to advise HIV-positive mothers to AVOID breastfeeding where safe alternative feeding is available (to prevent MTCT).
HIV Transmission, Standard Precautions, and Philippine Legal Framework
Exam tips
- RA 11166 KEY NUMBERS: Consent age for HIV testing = 15 YEARS OLD. PEP window = 72 HOURS. ART combination = 3+ drugs.
- CONFIDENTIALITY under RA 11166: A nurse who tells a patient's employer or family about their HIV status without consent is LEGALLY LIABLE.
- STANDARD PRECAUTIONS sequence for needlestick: WASH → REPORT → PEP within 72 hours.
- NLE scenario: nurse asked to disclose PLHIV's status to their employer → REFUSE. Uphold CONFIDENTIALITY under RA 11166.
- Remember: RA 9173 (Nursing Act) + RA 11166 (HIV Act) together define the nurse's legal and ethical duties in HIV care.
Key points
- HIV TRANSMISSION ROUTES (4 Bs): Blood (transfusions, needle sharing, needlestick), Body fluids (semen, vaginal and rectal secretions), Breast milk, Birth (perinatal/vertical transmission from mother to child).
- HIV IS NOT TRANSMITTED BY: hugging, kissing, handshaking, sharing food/utensils, insect bites, toilet seats, coughing, sneezing, or swimming pools.
- STANDARD (UNIVERSAL) PRECAUTIONS: Treat ALL blood and body fluids as potentially infectious for EVERY patient, regardless of HIV status or any other diagnosis.
- HAND HYGIENE = THE SINGLE MOST IMPORTANT INFECTION CONTROL MEASURE.
- Wear GLOVES for contact with blood/body fluids; add GOWN, MASK, EYE PROTECTION when splashing is likely.
- NEVER RECAP NEEDLES (one-handed scoop technique only if absolutely necessary). Dispose in PUNCTURE-PROOF (sharps) containers IMMEDIATELY after use.
- NEEDLESTICK INJURY PROTOCOL: (1) Wash the wound with soap and water, (2) Report IMMEDIATELY to supervisor/occupational health, (3) Seek PEP evaluation WITHIN 72 HOURS.
- RA 11166 (Philippine HIV and AIDS Policy Act of 2018) — KEY PROVISIONS: Strict CONFIDENTIALITY of HIV status; NON-DISCRIMINATION in employment, education, healthcare; Voluntary informed HIV COUNSELING AND TESTING; Consent for HIV testing at age 15 (minors under 15 may also access with conditions); Establishes Philippine National AIDS Council (PNAC); Universal access to ART.
- Nurses under RA 9173 (Philippine Nursing Act of 2002) are bound by their CODE OF ETHICS to provide NON-JUDGMENTAL, COMPASSIONATE care to all patients including PLHIV (People Living with HIV).
- UNAUTHORIZED DISCLOSURE of a patient's HIV status is PENALIZED under RA 11166 — nursing duty is to PROTECT CONFIDENTIALITY.
Definitions
Standard (Universal) Precautions
An infection control approach that treats ALL blood and body fluids from EVERY patient as potentially infectious, regardless of diagnosis. Includes hand hygiene, PPE (gloves, gowns, masks, eye protection), safe sharps handling, and proper waste disposal.
Importance
The foundation of nurse protection from HIV and all bloodborne pathogens in the Philippine clinical setting. All nurses are required to practice standard precautions at ALL times.
RA 11166 — Philippine HIV and AIDS Policy Act of 2018
The primary Philippine law governing HIV/AIDS prevention, treatment, and rights. Key features: HIV testing confidentiality, non-discrimination protections, voluntary counseling and testing, lowered consent age to 15, establishment of PNAC, and expanded ART access.
Importance
NLE frequently tests knowledge of Philippine nursing law. Know the key provisions: confidentiality, non-discrimination, consent age for testing (15 years old), and voluntary testing.
PNAC (Philippine National AIDS Council)
The inter-agency government body established by law to coordinate, monitor, and evaluate the Philippine HIV/AIDS prevention and control program.
Importance
May appear in NLE questions about Philippine healthcare delivery structure and HIV governance.
Common mistakes
- Recapping needles after use — this is the most common cause of needlestick injury. NEVER two-handed recap.
- Breaching HIV confidentiality — nurses must never disclose a patient's HIV status to unauthorized individuals, including family members, without the patient's explicit consent.
- Thinking standard precautions only apply to known HIV-positive patients — they apply to ALL patients ALWAYS.
- Confusing the consent age for HIV testing: RA 11166 lowered it to 15 years old (not 18).
Transplant Immunosuppression
Exam tips
- GRAPEFRUIT JUICE + CALCINEURIN INHIBITORS = CONTRAINDICATED. This is a classic NLE drug-interaction question.
- LIVE VACCINES = CONTRAINDICATED in transplant patients. Only inactivated vaccines are allowed.
- Signs of ACUTE REJECTION: fever (may be masked), decreased organ function, graft tenderness → REPORT IMMEDIATELY.
- Cyclosporine UNIQUE side effects: GUM HYPERPLASIA + HIRSUTISM. If NLE question asks 'which side effect is unique to cyclosporine vs. other immunosuppressants?' — answer: gum hyperplasia or hirsutism.
Key points
- Organ transplant patients require LIFELONG IMMUNOSUPPRESSION to prevent REJECTION — the immune system recognizing the transplanted organ as 'foreign' and attacking it.
- ACUTE REJECTION is a TYPE IV (cell-mediated/delayed hypersensitivity) reaction — T cells attack the graft.
- TYPES OF REJECTION: Hyperacute (minutes to hours — preformed antibodies; usually irreversible), Acute (days to months — most common, often REVERSIBLE with treatment), Chronic (months to years — progressive, irreversible).
- CENTRAL NURSING TENSION: balancing ADEQUATE immunosuppression (to protect the graft) against the resulting INFECTION RISK (from over-suppression).
- CALCINEURIN INHIBITORS (Cyclosporine, Tacrolimus): MONITOR BLOOD DRUG LEVELS (narrow therapeutic window). Side effects: NEPHROTOXICITY, hypertension, tremor. Cyclosporine also causes gum hyperplasia (gingival overgrowth) and hirsutism.
- ANTIPROLIFERATIVES (Mycophenolate, Azathioprine): MONITOR CBC — risk of BONE MARROW SUPPRESSION (anemia, neutropenia, thrombocytopenia).
- CORTICOSTEROIDS (Prednisone): MONITOR blood glucose, blood pressure, bone density. Risk of INFECTION (and fever may be masked).
- mTOR INHIBITORS (Sirolimus): used for maintenance; monitor lipids and wound healing.
- GRAPEFRUIT JUICE: AVOID — raises blood levels of calcineurin inhibitors by inhibiting CYP3A4.
- LIVE VACCINES: ABSOLUTELY CONTRAINDICATED in immunosuppressed transplant patients (e.g., live measles-mumps-rubella, live varicella, oral polio, BCG). Only INACTIVATED vaccines are safe.
- NURSING PRIORITIES: strict infection prevention and monitoring (fever may be blunted by steroids — use other signs), medication adherence, drug-level monitoring, graft function monitoring, long-term cancer risk monitoring (immunosuppression increases risk of skin cancers and lymphoma).
Definitions
Acute Rejection
A type IV (cell-mediated) immune response in which recipient T cells recognize and attack the transplanted organ, usually occurring days to months post-transplant. Often reversible with intensified immunosuppression.
Importance
The most commonly tested type of rejection in NLE. Presenting signs: fever (may be masked by steroids), decreased graft function (e.g., rising creatinine in kidney transplant), tenderness over the graft.
Calcineurin Inhibitors
A class of immunosuppressant drugs (cyclosporine, tacrolimus) that inhibit T-cell activation by blocking calcineurin. They have a narrow therapeutic window and require regular therapeutic drug monitoring.
Importance
Key pharmacology for transplant nursing. Always MONITOR DRUG LEVELS (trough levels). Nephrotoxicity is the major side effect of both. Cyclosporine-specific: gum hyperplasia, hirsutism.
Therapeutic Drug Monitoring (TDM)
Regular measurement of drug blood levels to ensure they remain within the therapeutic range — high enough to prevent rejection but low enough to avoid toxicity.
Importance
Critical nursing role for calcineurin inhibitors. If drug level is too LOW → rejection risk. If too HIGH → nephrotoxicity, neurotoxicity.
Common mistakes
- Giving live vaccines to immunosuppressed transplant patients — this is CONTRAINDICATED and can cause serious infection.
- Forgetting that fever in a transplant patient on steroids may be ABSENT or BLUNTED — other signs of infection (changes in WBC, graft function, warmth) must be monitored.
- Allowing patients to drink grapefruit juice while on calcineurin inhibitors — grapefruit raises drug levels and can cause toxicity.
- Stopping immunosuppressants if the patient feels well — abrupt discontinuation causes rejection. Lifelong adherence is mandatory.
Connections
- SLE and Scleroderma both feature Raynaud phenomenon as a vascular manifestation — connecting the pathophysiology of immune-complex deposition (SLE) and vascular fibrosis (scleroderma) to the same vasospastic symptom.
- Sjögren's syndrome frequently co-occurs with SLE and Rheumatoid Arthritis — establishing the concept of 'overlap syndromes' and the need to screen for multiple autoimmune conditions simultaneously.
- All autoimmune disorders (SLE, scleroderma, Sjögren's) share the nursing principle of INFECTION RISK when treated with immunosuppressants — connecting the pharmacology sections across all three diseases.
- HIV/AIDS and transplant immunosuppression share the same core nursing concern: OPPORTUNISTIC INFECTIONS as a consequence of impaired immunity — whether from viral destruction (HIV) or drug-induced suppression (transplant).
- CD4+ T helper cells are central to all immune discussions in this chapter: their destruction in HIV creates susceptibility identical to the over-suppressed transplant patient.
- Co-trimoxazole (TMP-SMX) serves dual roles: prophylaxis for PCP in HIV patients (CD4 < 200) AND as a treatment — connecting pharmacology across the HIV section.
- RA 11166 (HIV confidentiality) and RA 9173 (Philippine Nursing Act) together define the ethical and legal framework for ALL nursing care of PLHIV, connecting Philippine law to clinical practice.
- Type III hypersensitivity (SLE) connects to the immunology hypersensitivity chapter — immune complexes deposit in kidneys (lupus nephritis), joints, and blood vessels, causing type III-mediated damage.
- Acute transplant rejection is a Type IV (cell-mediated) hypersensitivity — connecting transplant immunology to the broader hypersensitivity framework where T cells, not antibodies, mediate the damage.
- Adherence counseling is a COMMON NURSING ROLE in both ART (HIV) and immunosuppressant therapy (transplant) — non-adherence leads to viral resistance (HIV) or organ rejection (transplant) — two different but equally serious consequences of missed doses.
- The window period concept in HIV testing connects to public health nursing and the Philippine HIV epidemic control strategy — nurses in DOH-accredited HIV treatment hubs must counsel patients about retesting after the window period.
Quick review questions
A 28-year-old Filipino woman presents with a red facial rash across both cheeks and the bridge of the nose, joint pain, and fatigue. Her ANA is positive and her C3/C4 complement levels are low. What is the most likely diagnosis and what is the PRIORITY nursing teaching for this patient?
Answer
Systemic Lupus Erythematosus (SLE). Priority teaching: strict sun protection (SPF 30+ sunscreen, protective clothing, and hats) to prevent flares.
The butterfly (malar) rash sparing the nasolabial folds, polyarthritis, fatigue, positive ANA, and low complement levels (C3/C4 consumed during active disease) are classic for SLE. SLE is a Type III immune-complex disease most common in young women. Photosensitivity is a hallmark — UV exposure triggers both the rash and systemic flares. Sun protection is therefore the PRIORITY patient teaching intervention.
A patient with SLE is prescribed hydroxychloroquine. What specific nursing consideration is MOST important to include in teaching?
Answer
Hydroxychloroquine requires periodic eye examinations because it can cause retinal toxicity (retinopathy) — a baseline eye exam before starting and regular follow-up exams are required.
Hydroxychloroquine is an antimalarial drug that is a cornerstone of SLE management for skin and joint disease. However, it deposits in the retina over time and can cause irreversible retinal toxicity and vision loss. Nurses must teach patients: baseline ophthalmology exam before starting the drug, and regular (annual or per ophthalmologist recommendation) eye exams thereafter.
A patient with scleroderma complains of difficulty swallowing and persistent heartburn. What are the appropriate nursing interventions?
Answer
Provide small frequent meals; instruct the patient to remain upright for 2–3 hours after eating; elevate the head of the bed 30–45 degrees; avoid spicy, acidic, and irritating foods; and administer proton pump inhibitors as prescribed.
Esophageal dysmotility is a hallmark GI manifestation of scleroderma, causing dysphagia (difficulty swallowing) and GERD (gastroesophageal reflux disease). This results from collagen fibrosis replacing the smooth muscle of the esophagus, reducing peristalsis. Gravity helps prevent reflux — upright positioning after meals and head-of-bed elevation are key nursing interventions.
A person living with HIV (PLHIV) has a CD4 count of 150 cells/mm³ and presents with progressive dyspnea, dry cough, and fever. What is the most likely diagnosis and what is the first-line treatment/prophylaxis drug?
Answer
Pneumocystis jirovecii Pneumonia (PCP) — the classic AIDS-defining infection. First-line treatment and prophylaxis: Co-trimoxazole (Trimethoprim-Sulfamethoxazole, TMP-SMX).
A CD4 count of 150/mm³ is below the AIDS threshold of 200/mm³. PCP is the classic AIDS-defining pneumonia that presents with progressive dyspnea, a DRY (non-productive) cough, and fever. It is the most high-yield opportunistic infection in NLE. Co-trimoxazole (TMP-SMX) is used both for treatment of active PCP AND for prophylaxis when CD4 falls below 200/mm³.
A healthcare worker sustains a needlestick injury while caring for an HIV-positive patient. List the CORRECT sequence of priority actions.
Answer
(1) Immediately wash the site with soap and water; (2) Report the incident IMMEDIATELY to the supervisor/occupational health; (3) Seek PEP evaluation WITHIN 72 HOURS (ideally as soon as possible); (4) Complete the full 28-day PEP course if indicated.
Post-exposure prophylaxis (PEP) is a time-critical emergency. The 72-hour window is non-negotiable — PEP after 72 hours is considered ineffective. This is a high-yield NLE scenario. The nurse also needs to be counseled about window period retesting. Under RA 11166 and standard precautions, all needlestick injuries must be reported.
Under RA 11166, a patient's employer calls the hospital and demands to know if their employee is HIV-positive. What is the CORRECT nursing action?
Answer
REFUSE to disclose any information. Under RA 11166, HIV status is STRICTLY CONFIDENTIAL and unauthorized disclosure to any party — including employers — without the patient's explicit informed consent is PROHIBITED and penalized.
RA 11166 (Philippine HIV and AIDS Policy Act of 2018) has strong confidentiality provisions to protect people living with HIV from discrimination. The nurse's legal and ethical duty is to protect the patient's HIV status as absolutely confidential. Disclosure without consent violates RA 11166 and the nurse's professional ethics under RA 9173. Nurses who breach this confidentiality face criminal and administrative liability.
A kidney transplant patient on tacrolimus and prednisone asks if they can receive the MMR (measles-mumps-rubella) vaccine to protect themselves from measles outbreaks in their community. What is the correct response?
Answer
Advise the patient NOT to receive the MMR vaccine. MMR is a LIVE attenuated vaccine and is ABSOLUTELY CONTRAINDICATED in immunosuppressed transplant patients. Only inactivated (killed) vaccines are safe. Consult the transplant team for an appropriate vaccination plan.
Live vaccines (MMR, varicella, BCG, oral typhoid, live attenuated influenza) can cause active infection in immunosuppressed patients because their immune system cannot mount an effective defense against even weakened vaccine strains. Only inactivated vaccines (injectable influenza, hepatitis A and B, pneumococcal, inactivated polio) are safe. This is a high-yield safety question in transplant nursing.
A patient with HIV asks: 'I've been on ART for 2 years and my viral load is undetectable. Do I still need to take my medications? And can I still transmit HIV to my partner?' What is the CORRECT nursing response?
Answer
Yes, the patient must CONTINUE ART LIFELONG — stopping ART allows viral rebound. Regarding transmission: under the U=U principle (Undetectable = Untransmittable), a person with a SUSTAINED undetectable viral load does NOT sexually transmit HIV — but ART must be maintained consistently for this to hold.
ART does not cure HIV — the virus remains in reservoirs in the body. Stopping ART even when viral load is undetectable causes viral rebound within weeks. The U=U (Undetectable = Untransmittable) principle is now recognized by the WHO and DOH Philippines — it is one of the most important messages in HIV counseling and helps reduce stigma. However, it is contingent on sustained, consistent ART adherence.
Diagrams
Chapter Overview: Autoimmune Disorders and HIV/AIDS
A comprehensive mind map showing the three major topic areas of the chapter: Autoimmune Disorders (SLE, Scleroderma, Sjögren's), HIV/AIDS (pathophysiology, OIs, ART, Philippine law), and Transplant Immunosuppression. Use this map to orient yourself at the beginning of review and to see connections between topics.
HIV Disease Progression and CD4-Based Clinical Decision Points
Flowchart showing HIV disease progression from initial exposure through acute infection, clinical latency, and AIDS. Key CD4 decision points are highlighted: CD4 < 200 triggers AIDS diagnosis and co-trimoxazole prophylaxis. The goal of ART is an undetectable viral load (U=U). Use this chart to understand the clinical timeline and when specific interventions are triggered.
Needlestick Injury Management Protocol — Standard Precautions
Step-by-step flowchart of the correct response to a needlestick injury in the clinical setting. The critical decision point is whether PEP can be started within 72 hours. This diagram aligns with standard precautions guidelines and RA 11166 documentation requirements. Essential for NLE scenario questions about occupational HIV exposure.
SLE Flare Triggers, Manifestations, and Priority Nursing Interventions
Flowchart illustrating SLE flare triggers, the major organ manifestations of an active flare, and priority nursing interventions. Lupus nephritis is highlighted as the priority concern. Use this to systematically organize SLE clinical decision-making for NLE scenario questions.
Transplant Rejection Types — State Transitions and Clinical Significance
State diagram showing the three types of transplant rejection and their clinical outcomes. Hyperacute rejection is rapid and irreversible. Acute rejection (days to months) is the most common and often reversible with treatment — making medication adherence critical. Chronic rejection is slow and irreversible. This diagram reinforces why lifelong adherence to immunosuppressants is non-negotiable.
Philippine HIV/AIDS Legal and Policy Milestones
Timeline of key Philippine HIV policy milestones from 1992 to present. Highlights the transition from RA 8504 to RA 11166, the expansion of ART access, and the lowering of the consent age for HIV testing to 15 years. Use this for NLE questions about Philippine nursing law and public health context.
Exam strategy
For the NLE, approach this chapter using a systematic PATTERN RECOGNITION strategy. First, master the HALLMARK SIGNS: butterfly rash (SLE), tight skin + Raynaud (scleroderma), dry eyes + dry mouth (Sjögren's), and PCP dyspnea + dry cough (AIDS). Second, memorize the CRITICAL NUMBERS: CD4 < 200 = AIDS and start co-trimoxazole; normal CD4 = 500–1,600; PEP within 72 hours; HIV consent age under RA 11166 = 15 years; HIV antibody window = up to 3 months. Third, for pharmacology questions, associate each drug with its UNIQUE CONCERN: hydroxychloroquine → eye exam; calcineurin inhibitors → drug levels + nephrotoxicity + no grapefruit; zidovudine → CBC (bone marrow suppression); corticosteroids → never stop abruptly + infection risk + hyperglycemia. Fourth, apply Maslow's hierarchy to prioritize nursing diagnoses: physiological threats (infection, organ failure, airway) ALWAYS come before psychosocial concerns (body image, anxiety). Fifth, for scenario-type NLE questions involving PLHIV, apply RA 11166 first — confidentiality and non-discrimination are the default correct answer in legal/ethical dilemmas. Sixth, memorize the mnemonics: CREST (scleroderma limited form), SIPS-FDP (SLE flare triggers: Sun, Infection, Physical/emotional Stress, Fatigue, Drugs, Pregnancy), and U=U (Undetectable = Untransmittable for HIV adherence counseling). Finally, for PMTCT and PEP questions, always prioritize the TIME-CRITICAL action (PEP within 72 hours, PrEP for high-risk individuals) — these are frequently tested as priority action questions.