HIV/AIDS for Washington Healthcare Professionals (4 CH)

Part 1: Etiology and Epidemiology of HIV

EPIDEMIOLOGY

Since the first case of acquired immune deficiency syndrome (AIDS) was diagnosed in 1981, AIDS has killed nearly 600,000 Americans (CDC, 2010a). The daunting human and economic costs of this disease in the United States are eclipsed only by its international impact. Since 1981, 30 million people worldwide have died from AIDS and more than 33 million are infected with the virus. Although HIV infection rates are declining globally, another 2.7 million people were infected in 2008. At the end of 2008, an estimated 4 million people were receiving AIDS drugs and another 5 million needed treatment and were not receiving it (UNAIDS, 2009).

A Global Pandemic

Almost all (95%) of the newly infected people live in the developing world, particularly southern Africa. The majority are young adults, many of whom do not know they are infected. This disease is the leading cause of death in southern Africa. Worldwide, AIDS is the leading cause of death and lost years of productive life for adults ages 15 to 59 (UNAIDS, 2009).

HIV/AIDS: THE GLOBAL EPIDEMIC, 2008

Source: UNAIDS, 2009.
33.4 million people living with HIV/AIDS	31.3 million adults (15.7 million women) 2.1 million children under 15
More than 30 million dead of AIDS	24.2 million adults 5.6 million children under 15 14 million children orphaned in southern Africa alone
During the year 2008	2.7 million people newly infected with HIV, half between ages 15 and 24 2.0 million people died of AIDS-related illnesses 280,000 children under 15 died of AIDS-related illnesses

HIV/AIDS in the United States

The CDC estimates that 1.1 million people in the United States are currently infected with HIV. At least 1 in 5 of them does not know he or she is infected and is at high risk for transmitting the virus to others. While antiretroviral drugs have reduced deaths from AIDS, the number of new infections has not changed since the late 1990s. Each year another 56,000 people are infected with HIV, approximately 1 new infection every 9.5 minutes (Hall et al., 2008). And each year more than 18,000 people die of AIDS in the U.S. (CDC, 2010a).

HIV IN THE UNITED STATES, 2010

1.1 million people living with HIV/AIDS	297,000 of them women 3,992 children under 13
Nearly 600,000 dead of AIDS since 1981	576,000 adults 5,200 children
During the year 2008	56,000 people newly infected with HIV 182 of them children under 13 18,000 people died of AIDS-related illnesses

In the United States, HIV/AIDS has forever altered the landscape of healthcare. Patient activism early in the epidemic spurred a massive research effort that led to greater understanding of AIDS and accelerated the development of innovative drugs. These drugs have slowed the death rate from AIDS in the U.S. and other countries since 1996, but without a cure and/or increased emphasis on prevention, there is no end in sight to the epidemic.

Antiretroviral drugs have reduced not only morbidity and mortality from AIDS. They have also reduced the public’s level of concern about the deadly nature of this epidemic, creating widespread complacency about the disease. This complacency, coupled with our society’s belief in the power of pharmaceuticals, has undermined prevention efforts. By extending the lives of people with HIV infection, drug treatment has also increased the prevalence (or number of cases per 100,000 people) of the disease and increased the likelihood of transmission.

AREAS OF HIGH PREVALENCE

The American epidemic of HIV/AIDS is characterized by “low prevalence in the general population, high prevalence among the disenfranchised and socially marginalized, with a concentration in geographic hotspots. …HIV infection in some U.S. populations now rivals that in some sub-Saharan African countries. For example, more than 1 in 30 adults in Washington, D.C., are HIV-infected—a prevalence higher than that reported in Ethiopia, Nigeria, or Rwanda.” (El-Sadr et al., 2010).

Three fourths of new HIV infections occur in just three groups: men who have sex with men (MSM), injection drug users, and MSM who also use injection drugs. These are primarily young men with no memory of the early epidemic. During the early 1980s, there were no effective drugs, and diagnosis of AIDS meant swift and certain death. Unaware of their HIV status, and of the serious side effects and prohibitive cost of drug treatment, today’s young MSM unknowingly infect others in their social network.

Once a disease of gay white men, HIV is now decimating young people of color, particularly among the black/African American population. According to CDC, nearly half of all new HIV infections occur among black/African Americans, even though they represent only 12% of the U.S. population.

Black men are diagnosed with HIV at more than six times the rate of white men, and black women at more than 15 times the rate of white women and more than 4 times the rate for Hispanic women. In the black/African American population, heterosexual transmission accounts for 11% of male infections but more than 50% of female infections (CDC, 2010a).

NATIONAL AIDS STRATEGY

We have learned what we can do to stop the spread of the disease. We’ve learned what we can do to extend the lives of people living with it. And we’ve been reminded of our obligations to one another—obligations that, like the virus itself, transcend barriers of race or station or sexual orientation or faith or nationality. So the question is not whether we know what to do, but whether we will do it.
—PRESIDENT BARACK OBAMA (White House, 2010)

After nearly three decades, the United States is no longer “in the embarrassing situation of having no overarching AIDS strategy for the country” (Holtgrave, 2010). Launched at the White House in July 2010, the National AIDS Strategy (NAS) has three overarching goals:

• Reducing infection rates
• Increasing access to care for those infected
• Eliminating disparities in prevalence, diagnosis, and treatment

The NAS envisions a future in which “the United States will become a place where new HIV infections are rare and, when they do occur, every person, regardless of age, gender, race/ ethnicity, sexual orientation, gender identity, or socioeconomic circumstance, will have unfettered access to high-quality, life-extending care, free from stigma and discrimination” (White House, 2010).

The NAS includes major outcomes to be achieved by 2015, such as:

• Reducing the number of new annual infections by 25%
• Increasing to 90% the percentage of people with HIV who know they are infected
• Increasing the proportion of newly diagnosed patients linked to care within 3 months from 65% to 85%
• Increasing by 20% the proportion of HIV-positive MSM, blacks, and Hispanics with undetectable viral loads

If the NAS target outcomes are achieved, then approximately 76,000 infections will be prevented and an estimated 219,000 more people living with HIV will be in care by 2015. Achieving these outcomes would substantially alter the trajectory of the epidemic in the United States and could prevent a total of nearly 238,000 infections through 2020 (Holtgrave, 2010).

Implementing the NAS will be costly, but experts believe that continuing on the current path would be even more costly, both financially and in human terms. CDC (2010b) estimates that a rapid scale up of HIV prevention efforts could most effectively reduce the number of new HIV infections and save the U.S. healthcare system up to 25 times the amount that would need to be invested in prevention.

CHANGES IN HIV SURVEILLANCE

Through 2007, more than 1 million cases of HIV/AIDS have been reported since CDC began tracking cases, and more than 576,000 people have died of the disease (CDC, 2010c). The statistics do not reflect the true magnitude of the epidemic, however, since the CDC considers reporting of cases to be only about 85% complete.

As of April 2008, all 50 states had implemented confidential name-based HIV infection reporting, but until that time only 37 states and some dependent territories had been reporting. The HIV Surveillance Report for 2012 (issued in 2014) will be the first time the data from all 50 states will be included in the estimates.

CDC has also changed some of the terminology in reporting surveillance of HIV. For example, “HIV/AIDS” has been replaced with “HIV infection,” and the term high-risk was removed from the “high-risk heterosexual contact” transmission category label to clarify that heterosexual contact itself is the mode of transmission for HIV infection. All data are presented by the year of diagnosis rather than the year they were reported to CDC.

HIV/AIDS in Washington State

AIDS and symptomatic HIV infections are reportable diseases—that is, physicians must confidentially report any cases among their patients to the Washington State Department of Health. Reporting of new HIV diagnoses has been required in Washington State since September 1999.

Since the CDC began tracking AIDS cases, approximately 17,200 cases of HIV/AIDS have been reported in Washington State. More than 12,000 of those infected progressed to full blown AIDS, and more than 5,500 of them have died.

As of December 2008, more than 10,000 people in Washington were infected with HIV, and nearly 6,000 of them had been confirmed with AIDS. The annual incidence rate of HIV/AIDS in Washington is 9.3 per 100,000 (compared to 13.7 per 100,000 nationally) (Washington State DOH, 2009a).

King County accounts for about 2/3 of the total AIDS cases reported in the state (Washington State Department of Health, 2009c). Despite continued outreach and awareness programs, the number of HIV diagnoses among Seattle men who have sex with men (MSM) has increased 8% each year since 2001, even though incidence has held stable in other populations. Diagnoses of other sexually transmitted diseases (STDs), such as gonorrhea, chlamydia, and syphilis, have also increased among MSM to levels last seen in the early- to mid-1980s (Grygiel, 2009).

More than half of all new HIV diagnoses in Washington State during 2003–2007 occurred among adults ages 35 and older, predominantly among white males. However, the proportion of new cases diagnosed in those under age 25 also increased during the same time period.  Although black/African Americans account for only 4% of the state’s population, they comprise nearly 20% of new HIV infections.

The prevalence of HIV among Washington State women has increased by an average of 6% per year. At the end of December 2008, there were almost 1,400 women with HIV disease in Washington State, more than half of whom had AIDS (Washington State DOH, 2009b).

Efforts to screen pregnant women for HIV and to treat those women who test positive for the virus have markedly reduced the incidence of pediatric HIV/AIDS in Washington. Since 2001, there have been only three confirmed cases of perinatal (mother-to-child) HIV transmission in Washington State (Washington DOH, 2009a).

RISK GROUPS

HIV/AIDS takes a heavy toll on people of all ethnicities, genders, ages, and income levels. However, some populations have been uniquely affected by the epidemic. These populations include men who have sex with men, injecting-drug users, women, and people of color.

Three primary risk groups account for 75% of new HIV infections in the United States:

1. Men who have sex with men (MSM)
2. Injecting-drug users (IDUs)
3. MSM who also use injection drugs

Heterosexual transmission accounts for the remainder of new cases. Although HIV infection among IDUs has declined since the early 1980s, continued efforts to prevent transmission of HIV and other STDs are needed (Hall et al., 2008). Poverty, unemployment, lack of education, limited access to healthcare, incarceration, and disrupted social networks further increase risk among each of these groups.

Other important groups at risk for HIV include women and children, seniors, commercial sex workers, incarcerated populations, and transgender (TG) people. Each of these groups has unique needs for outreach and education on prevention and treatment of HIV infection.

Men Who Have Sex with Men (MSM)

Men who have sex with men account for more than half of all newly reported HIV infections, and young men are at highest risk. MSM account for just 4% of the U.S. male population aged 13 years and older; however, the rate of new HIV diagnoses among MSM is more than 44 times that of other men. Although new infections have declined among both heterosexuals and injection drug users, the annual number of new infections among MSM has increased steadily since the early 1990s (CDC, 2010d). They are the only risk group in the United States in which new HIV infections are increasing.

Nearly half of HIV-infected young MSM do not know they are infected. A survey of MSM in 21 U.S. cities found that 1 in 5 of those surveyed was HIV-positive and nearly half of them (44%) were unaware of their HIV status. The highest HIV prevalence and infection unawareness were among young and minority MSM (CDC, 2010d).

INFECTION BY RACE

The age of acquiring HIV infection among MSM varies by race. The majority of new infections among young black MSM occur between ages 13–29, while infections among young white men occur during their 20s and 30s. Among young Hispanic MSM, most new infections occur in the youngest cohort, although a substantial number occur during their 30s (CDC, 2010d).

Estimated Number* of New HIV Infections in Men Who Have Sex with Men, by Race/Ethnicity and Age Group, United States, 2006.
* Incidence estimates are adjusted for reporting delays and reclassification of cases reported without a known risk factor for HIV but not for underreporting.
† Non-Hispanic whites and non-Hispanic blacks are referred to as white and black, respectively. Persons of Hispanic ethnicity might be of any race.
Note: The “I” bars denote the data range for each confidence interval.
Source: CDC, 2010h.

The prevalence of HIV among Asians and Pacific Islander (API) MSM is estimated at 3%, and API represent only 1% of the total HIV-infected population in the United States. However, prevalence varies widely by ethnicity, ranging from 0% for Vietnamese MSM to 13.6% for Thai MSM (CDC, 2008a). A survey of API MSM in Seattle indicated that 90% of them perceived themselves to be at some risk for HIV infection, yet fewer than half of those surveyed had been tested during the past year (Kahle et al., 2005).

FACTORS THAT INCREASE RISK AMONG MSM

According to CDC (2010c), several factors increase the risk of HIV/AIDS transmission among MSM. These include the following:

• High prevalence of HIV and multiple partners: The risk of exposure to infection increases with each sexual encounter.
• Lack of knowledge of HIV status: Those who know they are infected are more likely to take precautions to protect their partners. Those who don’t know they are infected may unknowingly transmit the virus to others.
• Complacency about risk: Young men who did not experience the early AIDS epidemic may believe that HIV drugs mean that AIDS is no longer a serious health risk. They fail to understand that HIV drug regimens are expensive, complex, and can have disabling, disfiguring side effects.
• Social discrimination and cultural issues: For some, ignorance, homophobia, stigma, and lack of access to healthcare may increase risky behaviors or act as a barrier to testing and other prevention services.
• Substance abuse: Some MSM use alcohol and other drugs, including methamphetamines, increasing risky behaviors while under the influence; this includes sharing needles or other injection equipment.

Injecting-Drug Users (IDUs)

Injecting-drug use is the third most frequently reported risk factor for HIV infection in the United States. During 2004–2007, approximately two thirds of newly infected IDUs were males, more than half were black/African Americans, and three fourths lived in urban areas. Many IDUs continue to engage in high-risk behaviors such as sharing syringes and/or having unprotected sex. The highest prevalence of having unprotected vaginal sex was among those 18–24 years (CDC, 2009).

Mainstream America disapproves of illegal drug use and those who become addicted. The methamphetamine epidemic has increased the risk of HIV transmission because the drug is so cheap and accessible. Successful efforts to prevent the spread of HIV/AIDS, HBV, and HCV among injection-drug users (e.g., syringe exchange programs) remain controversial because some people equate these programs with “approval” of drug use.

Injection-drug use (IDU) often coexists with poverty, low self-esteem, anxiety, depression, and mental illness. While drugs offer temporary relief from the realities of harsh living conditions, they create a tangled web of problems, including risk-taking behaviors like unprotected sex. Drug users who would like to stop using often lack access to inpatient treatment facilities. Waiting lists for drug treatment programs are long, and by the time a place is available, users may be lost to follow-up.

Those drug users who do seek treatment for HIV may find the cost of the drugs prohibitive or the complex multidrug regimens beyond their ability to manage. In addition, street drugs and drugs unapproved by FDA but available through online pharmacies may have dangerous interactions with AIDS medications.

Correctional Populations

Increasing access to HIV and STI [sexually transmitted infections] prevention and care services for incarcerated men and women has important public health benefits. It can help avert the spread of HIV infection and STIs among incarcerated persons and to their sexual partners and drug-using partners after their release.
—KACANEK ET AL. (2007)

Incarcerated individuals in the United States have 2.5 times the rate of confirmed AIDS cases than among the general population (Bureau of Justice Statistics, 2009). They also have higher rates of other STDs, hepatitis C, and tuberculosis.

Many prison inmates engage in high-risk behaviors before being incarcerated, including unprotected sexual intercourse and drug and alcohol abuse, behaviors that often continue inside prisons, even though sex and drugs are prohibited. Most U.S. prisons fail to follow recommendations from World Health Organization (WHO) that condoms be made available to prisoners, that prisoners have access to bleach for cleaning injection equipment, and that needle exchange programs be considered.

HIV testing is available to all correctional populations in the United States, but policies and specific procedures differ. In some cases, testing is mandatory. For example, Washington State law mandates HIV testing for anyone convicted of a sexual offense, prostitution or offenses relating to prostitution, or drug offenses associated with the use of hypodermic needles. In Mississippi, HIV testing is mandatory for all incarcerated individuals upon entry into prison. In Rhode Island, HIV testing is mandatory for all sentenced people.

Commercial Sex Workers

There is little research on HIV and other STDs among commercial sex workers in the United States. Yet the mathematical reality that sex workers have hundreds of partners each year makes this population a critical element in the spread of HIV throughout the wider community. One international meta-analysis showed that “it is the number of infected prostitutes in a country that is highly significant and robust in explaining HIV prevalence levels across countries” (Talbott, 2007).

The Center for AIDS Prevention Studies (2008) stated: “Male, female, and transgender sex workers who are most vulnerable to HIV are street-based workers, most of whom are poor or homeless and likely to have had a history of sexual or physical abuse.” The use of drugs, particularly injection drugs, among street-based sex workers heightens the HIV risk. One study of drug-using female sex workers in Miami found that more than 22% of the women were HIV positive (Inciardi et al., 2006). One-fourth of male sex workers in Houston were found to be HIV positive (Timpson et al., 2007).

When sex work occurs in brothels, massage parlors, private homes or through escort services, workers (and clients) are at lower risk of HIV transmission because workers have more control over their working conditions and are more likely to use condoms. However, both street workers and Internet-based escorts report inconsistent condom use, high rates of unprotected sex, and low rates of HIV status disclosure (Mimiaga et al., 2008).

Because sex work is illegal, sex workers often distrust both police and public health authorities. This makes it difficult to conduct prevention outreach, education, or research.

Women and Children

Women now constitute more than 25% of the HIV/AIDS-infected population nationwide and nearly 75% of new AIDS cases. Three-fourths of the women and girls living with AIDS in the United States are African American and Hispanic, even though these populations account for only one fourth of U.S. females. HIV/AIDS is the leading cause of death of black/African American women aged 25 to 34. Women are primarily infected through heterosexual intercourse, although injection drug use accounts for one fourth of female cases (CDC, 2008b).

In Washington State between 2003–2007, women accounted for 16% of new HIV diagnoses, significantly less than the national average. However, black/African American women in Washington State accounted for 38% of new HIV infections. More than half the new HIV diagnoses occur in women over 30 (Washington State DOH, 2009b), slightly less than the national average.

Ninety percent of children with AIDS are infected by their mothers. Although the incidence of mother-infant transmission has decreased greatly among whites, it remains a challenge in the African American community. Nationwide, two thirds of infected children younger than 5 years old are black.

Female adolescents and young women under the age of 25 are at higher risk for HIV/AIDS and other STDs than older women. Having sex with multiple partners, engaging in risky behaviors such as alcohol and drug use, and/or being unable to negotiate safer sex practices with partners all contribute to this heightened risk.

Seniors (Aged 50 and Older)

According to CDC (2008d), people over 50 in the United States account for:

• 15% of new HIV diagnoses
• Nearly 25% of persons living with HIV
• Nearly 20% of all AIDS diagnoses
• More than one third of all deaths of persons with AIDS

Seniors represent 27% of the HIV-infected population in the United States. Males account for three fourths of cases and females account for one fourth. Half of HIV-infected seniors are black, a third are white, and the remainder are Hispanic.

The recent increase in HIV among people over 50 is partly due to antiretroviral therapy, which has extended the lives of HIV-infected people, and partly due to newly diagnosed infections in older people.

In December 2009, the Centers for Medicare and Medicaid Services (CMS) announced its decision to cover HIV infection screening for Medicare and Medicaid beneficiaries who are at increased risk for the infection, including pregnant women and Medicare beneficiaries of any age who voluntarily request the service.

Stereotypes about aging and about HIV/AIDS put seniors at risk for transmission. Many seniors are sexually active well into their seventies and eighties, a fact sometimes overlooked by health professionals. Thus, physicians and other healthcare workers may fail to ask patients about unprotected sex or to offer voluntary HIV testing.

Health professionals also may fail to diagnose AIDS in seniors because symptoms can mimic those of normal aging, such as fatigue, weight loss, forgetfulness, and/or confusion. As a result, many seniors are diagnosed only in the late stages of the disease—or not at all.

Most sexually active older couples do not use condoms because they are unconcerned about pregnancy. Unless a couple is monogamous, however, unprotected sex increases the risk of infection with HIV or other sexually transmitted diseases from multiple sexual partners. Older women face a higher risk than older men because age-related vaginal thinning and dryness can cause tears in the vaginal area.

Perceived barriers to condom use among seniors include the following factors:

• Drug and/or alcohol use before or during sexual activity
• Belief that unprotected sexual activity is more exciting and that condoms reduce sexual pleasure
• Lack of knowledge about effective use of condoms
• HIV conspiracy beliefs
• Belief that known and/or trusted partners are “safe”

Since Viagra and other drugs for erectile dysfunction entered the marketplace in the late 1990s, rates of HIV/AIDS and gonorrhea increased more rapidly in middle-aged and older heterosexual adults than in people under age 40 (Jena et al., 2010).

Unprotected sexual activity is not the only risk factor among seniors. To control the rising costs of medications such as insulin, some seniors share needles for insulin and other prescription drugs.

The stigma of HIV/AIDS may be much more severe among seniors, leading them to hide their diagnosis from family and friends. Keeping their diagnosis a secret can limit or eliminate potential emotional and practical support.

Transgender (TG) People

According to the San Francisco AIDS Foundation (2009), transgender is an inclusive term for persons those whose gender identity, expression, or behavior differs from the norms expected from their birth sex. Gender identities within this category include transgender woman, transgender man, male-to-female (MTF), female-to-male (FTM), transsexual, transvestite, drag queen/king, and gender queer.

Transgender people face multiple challenges that increase their risk for HIV infection. Marginalized by society and institutions, sometimes rejected by their families, transgender people often suffer low self-esteem, job discrimination, precarious economic status, and lack of social support. Nearly two thirds of TG people ages 16–25 are unemployed (Garofalo, 2006), and some choose commercial sex work as a means of economic support and substance abuse as a coping mechanism.

According to CDC (2007b), there are no reliable data on the number of TG individuals in the United States. However, there is consensus that the HIV prevalence is high, based on several studies. Estimated infection rates range from 14% to 69% among specific TG populations. The highest rates may be among male-to-female (MTF) sex workers. A 2008 meta-analysis estimated national HIV prevalence at 27.7% among MTF (Herbst et al., 2008).

Seattle and King County Public Health (2009) reports that of the 6,283 HIV-infected persons in King County, 27 identify as transgender. Almost all were born male but consider their current gender to be female. One to three diagnoses of HIV among this population have been reported each year since 2004.

Part 2: Transmission and Infection Control

THE AIDS VIRUS

AIDS is caused by the human immunodeficiency virus (HIV). DNA analysis has identified HIV-1 as originating in a substrain of chimpanzees in west equatorial Africa (Gao et al., 1999). Scientists theorize that HIV-1 moved from chimps to humans when hunters were exposed to infected blood while handling bush meat (the flesh of various primates, including chimps and gorillas). Once in the human population, HIV quickly became a global pandemic, driven by travel and migration patterns, sexual practices, drug use, war, and economics.

Strains of HIV

There are at least two types of HIV virus: HIV-1 is the cause of AIDS, and HIV-2 is a related group of viruses found in West African patients. Worldwide, the predominant virus is HIV-1. Most of the West Africans infected with HIV-2 show none of the symptoms of classical AIDS. A few cases of HIV-2 infections have been found in people in the United States. It is unclear at this time whether HIV-2 is a less serious infection or whether it simply has a longer latency preceding the onset of AIDS.

HIV mutates readily, leading to many different strains of HIV, even within the body of a single infected person. Based on genetic similarities, the numerous viral strains may be classified into types, groups, and subtypes.

Both HIV-1 and HIV-2 have several known subtypes, and more subtypes are certain to be discovered as the virus evolves and mutates. As of 2001, blood testing in the United States could detect both strains and all known subtypes of HIV.

Disease Mechanism

By attacking the immune system, HIV makes the body vulnerable to a number of opportunistic infections caused by viruses, bacteria, and yeasts that would pose no threat to a person with a normal immune system. With a weakened immune system, however, these infections are life-threatening.

Although the mechanisms of HIV and the way it affects the immune system are not fully understood, the primary event is the entrance of HIV into the body’s CD4+ cells (“T-Helper lymphocytes,” also called T4 cells), which are white blood cells essential to the function of the immune system in fighting infection.

Once inside a T4 cell, the virus replicates and signals other cells that produce antibodies. Producing antibodies is an essential immune system function. HIV infects and destroys the T4 cells and damages their ability to signal for antibody production. Thus, it steadily deactivates the immune system, leading to dysfunction of various organ systems, including the endocrine, gastrointestinal, and nervous systems.

TRANSMISSION OF HIV

Contrary to myths and misinformation, HIV is not transmitted by casual contact such as hugging, other nonsexual touching, and the shared handling of objects. Insects do not carry HIV, nor is the virus transmitted through air or water. HIV is a relatively fragile virus. Once outside the human body, HIV has a very short lifespan, which makes most medical procedures and caregiving activities safe if standard infection control procedures are followed.

Three conditions are necessary for HIV to be transmitted:

1. An HIV source
2. A sufficient dose (viral load) of virus
3. Access to the bloodstream of another person

Varying levels and concentrations of HIV have been found in most bodily fluids of infected persons, including blood, semen, saliva, tears, breast milk, and vaginal and cervical secretions. However, only blood, semen, breast milk, and vaginal and cervical secretions have been proven to transmit HIV infection.

The first week or two after infection with HIV constitute the acute or primary HIV infection stage. During this time, infected persons may be symptom-free and unaware of the infection but highly infectious because of the viral load (high levels of the virus) in the bloodstream. Once infected, the person remains infectious for life.

Some researchers use the term acute HIV infection to describe the 6- to 12-week interval between initial infection and production of antibodies that can be detected by an HIV test. This interval is also called the window period.

Although a high viral load is present during the acute stage of HIV, one study indicates that those in the asymptomatic stage of HIV with medium levels of the virus have the greatest risk of infecting others. The asymptomatic stage lasts for years, rather than weeks, during which time those infected but untested may continue to unknowingly spread the virus (Fraser et al., 2007).

Sexual Contact

Transmission of HIV occurs primarily through sexual contact with an infected person. This includes anal, oral, and vaginal contact. The risk of transmission depends on sexual practices. Receptive anal contact without a latex condom carries the greatest risk, probably because of the larger surface area of mucous membranes involved. (Receptive partners are at greater risk for transmission of any sexually transmitted disease, including HIV.)

Female-to-female transmission of HIV appears to be rare. However, some case reports of female-to-female transmission—and the well-documented risk of female-to-male transmission—suggest that women who have sex with women (WSW) should consider female sexual contact a possible means of transmission of HIV (CDC, 2006a).

Health professionals need to remember that sexual identity and gender preference do not always predict behavior, and that women who identify as lesbian may still be at risk for HIV through unprotected sex with men or with injection drug users.

Injection Drug Use

Sharing injection needles, syringes, and other paraphernalia with an HIV-infected person can send HIV directly into the user’s bloodstream (along with Hepatitis B and C viruses and other blood-borne diseases). Paraphernalia with the potential for transmission include the syringe, needle, “cooker,” cotton, and/or rinse water (sometimes called works).

Transmission also occurs through indirect sharing of contaminated paraphernalia and/or dividing a shared or jointly purchased drug while preparing and injecting it. “Indirect sharing” includes squirting the drug back from a dirty syringe into the drug cooker and/or someone else’s syringe, or sharing a common filter or rinse water.

Transfusions of Infected Blood or Blood Clotting Factors

Transmission of HIV through transfusion has been uncommon in the United States since 1985 and in other countries where blood is screened for HIV antibodies. In 1999, about 1% of U.S. AIDS cases were caused by transfusions or use of contaminated blood products. The majority of those cases were in people who received blood or blood products before1985.

Donor screening, blood testing, and other processing methods have reduced the risk of transfusion-caused HIV transmission to between 1 in 450,000 to 1 in 600,000 transfusions in the United States. Donating blood in the United States is always safe because sterile needles and other equipment are used.

Tattooing and Blood-Sharing Activities

HIV can be transmitted during tattooing or during blood-sharing activities such as “blood brothers” rituals or ceremonies where blood is exchanged or unsterilized equipment contaminated with blood is shared.

Pregnancy and Breastfeeding

A pregnant woman who is infected can transmit HIV to her fetus; after delivery an infected mother can transmit HIV to her infant while breastfeeding. Women newly or recently infected with HIV or those in the later stages of AIDS tend to have higher viral loads and may be more infectious.

When a woman’s healthcare is monitored closely and she receives a combination of antiretroviral therapies during the last two trimesters of pregnancy and during delivery, the risk of perinatal transmission to the newborn drops below 2%. Other measures to prevent perinatal transmission include the use of prophylactic cesarean delivery before onset of labor or rupture of membranes and avoidance of breastfeeding by HIV-infected mothers. In addition, the infant is treated for the first six weeks of life (Public Health Service Task Force, 2009).

Washington State law requires that pregnant women be counseled concerning risks about HIV and offered voluntary HIV testing. Advice about medications and cesarean delivery should be given on a case-by-case basis by a healthcare provider experienced in treating HIV-infected women.

Biting

Biting poses little risk of HIV transmission unless the person who is biting and the person who is bitten have an exchange of blood (such as through bleeding gums or open sores in the mouth). However, bites can transmit other infections and should be treated immediately by thorough washing of bitten skin with soap and warm water and disinfection with antibiotic skin ointment.

PROBABILITIES OF HIV INFECTION (per one exposure to HIV)

Type of Exposure	HIV Infection Risk*
Source: CDC, 2005.
Contaminated blood transfusion (prior to 1986)	95%
One intravenous syringe or needle exposure	0.67%
One percutaneous exposure (e.g., needlestick)	0.4%
One episode of receptive anal intercourse	0.1%–3%
One episode of receptive vaginal intercourse	0.1%–0.2%
One episode of insertive vaginal intercourse	0.03%–0.09%
* 1% risk means a likelihood of 1 in 100 for infection to occur; 0.1% means a likelihood of 1 in 1,000.

FACTORS AFFECTING RISK OF HIV TRANSMISSION

Additional factors affect the risk of HIV transmission. For instance, coexisting infections may increase the risk of transmission of HIV and make its treatment more complex.

[H2] Other Sexually Transmitted Diseases (STDs)

People who are HIV-positive often have other sexually transmitted diseases, such as syphilis, gonorrhea, genital warts, human papilloma virus (HPV), trichomoniasis, scabies, herpes, and chlamydia. Sores, lesions, or inflammation from STDs make the skin or mucous membrane more vulnerable to other infections. Skin-to-skin contact can transmit these infections, which increases the risk of HIV transmission. The immune suppression caused by HIV facilitates infection with other STDs, creating a destructive synergy.

Prevention of HIV/AIDS should be part of a general program of sexually transmitted disease (STD) prevention because other preventable STDs, most of which are curable, have also reached epidemic proportions, particularly among sexually active young people. For example, rates of primary and secondary syphilis (the stages when syphilis is most infectious) in males have increased each year between 2000 and 2006. Two-thirds of the cases diagnosed in 2006 were among MSM (CDC, 2007a).

Screening for STDs is also critical since many of those infected do not show symptoms. This includes Pap tests for sexually active women and a thorough history of STDs during medical workups for both women and men. Prompt treatment should follow for any persons who test positive for STDs. Treatments vary with each disease or syndrome. Because of the risk of developing resistance to medications for certain STDs, healthcare providers should check the latest STD treatment guidelines, available on the CDC website.

Human papilloma virus (HPV) is highly prevalent among HIV-infected women and men, increasing viral shedding and raising the risk of cervical and anal cancers. Multiple strains of this virus are often present in HIV-positive women. The HPV vaccine (Gardasil) has not been tested in HIV-positive women, so no data is available on its safety or efficacy in this population. However, Gardasil and Cervarix have been found safe for use in HIV-positive patients with high-grade anal intraepithelial neoplasia (AIN), a precancerous condition caused by infection with high-risk forms of HPV. In October 2009, the FDA approved Gardasil to prevent HPV in boys and men, ages 9 through 26 (FDA, 2009).

Genital herpes (HSV-2) also appears to be a major risk factor for acquiring HIV infection, increasing the risk more than three-fold. According to the CDC (2010j), 8 out of 10 of those infected with HSV-2 have not been diagnosed. Many of them have mild or unrecognized infections but shed virus intermittently in the genital tract. These are the individuals most likely to transmit the infection. Diagnosis of HSV-2 should be confirmed by type-specific laboratory testing, and anyone infected with HSV-2 should also be tested for HIV. Treatment of HSV-2 with antiviral agents reduces but does not eliminate subclinical virus shedding.

Both oral and anal sex can result in the transmission of gonorrhea and chlamydia as well as HIV (Johnson, Ghanem & Erbelding, 2006). A rare and virulent strain of chlamydia appears to be spreading in the United States, Western Europe, and the United Kingdom, primarily among MSM. More common to Africa and Southeast Asia, the strain is called lymphogranuloma venereum chlamydia (LGV), and it can cause genital ulcers, swollen lymph glands in the groin, flu-like symptoms, and gastrointestinal distress. Rectal symptoms among MSM, including bleeding of the rectum and colon, likely result from unprotected anal intercourse. These lesions increase the risk of transmitting or contracting HIV or other bloodborne diseases (Stark et al., 2007).

Multiple Partners

The individual with multiple sex or injection drug-sharing partners is at great risk for exposure to HIV/AIDS. Anyone having unprotected sex with multiple partners (defined by CDC as six or more partners in a year) is considered at high risk for HIV/AIDS infection. However, unprotected sex with even one infected partner risks transmission.

Use of Noninjecting Drugs

Use of any mood-altering substance, including alcohol or non-injectable street drugs such as methamphetamine, can increase risk of HIV transmission by impairing judgment, thereby leading to risky behaviors such as unprotected sex. Methamphetamine abuse is growing among MSM, especially younger MSM.

Research shows that both meth and HIV infection cause significant changes in the brain, impairing cognitive function (Jernigan et al., 2005). Many MSM who use methamphetamine also use other drugs such as marijuana, “poppers,” cocaine, heroin, hallucinogens, and ketamine (Patterson et al., 2005).

Certain substances can mask pain and/or create oral and genital sores, which create additional entry points for HIV and other STDs.

Gender, Culture, and Equality Issues

The balance of power in an intimate relationship can affect an individual’s ability to insist on safer sex practices such as condom use. Women who are socially and economically dependent on men may be unable to negotiate condom use or to leave a relationship that puts them at risk.

Culturally imposed ignorance about their bodies, especially about sexuality and reproduction, can make women even more vulnerable to HIV-infection. Some cultures endorse the concept of multiple sexual partners for men but monogamous relationships for women.

A history of childhood sexual abuse and family violence is associated with HIV-related risk in adulthood. In one study, researchers found that a history of trauma was a general risk factor for HIV, regardless of race/ethnicity. Limited material resources, exposure to violence, and high-risk sexual behaviors were the best predictors of  HIV risk (Wyatt et al., 2002).

PREVENTION AND RISK REDUCTION

HIV/AIDS is preventable. For example, screening of blood and blood products for the HIV virus has reduced the risk of HIV transmission with transfusion to 1:1,000,000. Mother-to-baby transmission has dropped by two thirds (CDC, 2006a). Following universal precautions in healthcare has unquestionably prevented thousands, if not millions, of cases of HIV/AIDS in the United States. But, because the virus is transmitted through behaviors that many people find pleasurable—sexual activity and injection-drug use—prevention is difficult.

Prevention of HIV/AIDS saves money as well as lives. The CDC estimates that the average cost of lifetime treatment for one person with HIV infection is $618,900 (Schackman et al., 2006).

Prevention of HIV begins with education and counseling about sexual practices and injection-drug use. People unable to “just say no” need basic, practical, how-to information.

Safer Sex

Safer sex practices include:

• Abstinence from sexual contact
• Mutual monogamy
• Correct use of latex condoms for all sexual intercourse (anal, oral, and vaginal)

Both women and men may need instruction in the correct use of condoms:

• Use a new latex condom for each act of intercourse.
• Leave space at the tip of the condom as a receptacle for semen and to decrease the risk of condom breakage.
• Hold on to the base of the condom to prevent slippage when withdrawing the penis after ejaculation.
• Do not attempt intercourse with a condom if the penis is only partly erect.

Women who have sex with women (WSW) need to take precautions during oral sex, even though female-to-female transmission appears to be rare. According to the CDC, “vaginal secretions and menstrual blood are potentially infectious and mucous-membrane (e.g., oral, vaginal) exposure to these secretions have the potential to lead to HIV infection” (CDC, 2006a). Precautionary measures include:

• Using condoms consistently and correctly each and every time for sexual contact with men or when using sex toys; not sharing sex toys
• Using natural-rubber latex sheets, dental dams, cut-open condoms, or plastic wrap during oral sex; however, no barrier methods for use during oral sex have been shown to be effective by the FDA
• Knowing one’s own and one’s partner’s HIV status; this can help uninfected women reduce their risk of becoming infected and assist those who are infected to get early treatment and avoid transmitting the virus to others

Injection Precautions

Injection drug users who refuse treatment or who have no treatment programs available to them need instructions about precautions:

• Do not share needles or other paraphernalia.
• If sterile needles are not available, use bleach to clean needles.
• If you have sexual intercourse, use a latex condom to prevent infecting others.
• Anyone who knowingly exposes others to HIV/AIDS endangers the public health and may be taken into custody, tested for HIV without consent, hospitalized, and isolated.

These risk-reduction measures also apply to people who use needles to inject insulin, vitamins, steroids, or prescription or nonprescription drugs.

In December 2009, new U.S. legislation ended the 20-year ban on federal funding for needle exchange programs, making additional resources available to states and communities. HIV experts called this a crucial, lifesaving step forward for HIV prevention. “The science could not be more clear: Needle exchange programs are cost effective, save lives, and do not promote drug use. They connect hard-to-reach populations to primary care and to the addiction treatment they need” (Saag, 2009).

Syringe exchange or needle exchange programs also help prevent spread of hepatitis and other bloodborne pathogens. Many local health departments in Washington State operate syringe exchanges in their communities.

Preventing Transmission to Uninfected Partners

Optimal care of people with HIV/AIDS includes not only antiviral therapies, health maintenance, and referral to support services, but also an emphasis on prevention of transmission to uninfected partners. The CDC recommends that anyone with HIV/AIDS use prevention strategies even if his or her partner is also HIV infected.The partner may have a different strain of the virus that could behave differently in each individual or that could be resistant to different anti-HIV medications.

Implementing preventive strategies begins at the initial visit and continues throughout subsequent visits or periodically, at least once a year. Care providers should use a straightforward, nonjudgmental approach and open-ended questions to screen and assess patient behaviors associated with HIV transmission. Other strategies include self-administered questionnaires and computer-, audio-, or video-assisted questionnaires.

Initial and periodic screening for STDs should also be performed. At the initial visit, both men and women should have laboratory tests for syphilis. Women should also be screened for trichomoniasis, and women age 25 and younger should be screened for cervical chlamydia, the most common STD among women. Screening for STDs, particularly for chlamydia, should be repeated periodically if the patient is sexually active. Women younger than 19 are often reinfected with chlamydia, probably by male partners who have not been diagnosed and treated because the disease is asymptomatic.

HIV-positive women of childbearing age should be screened for pregnancy at initial and subsequent visits and asked about interest in future pregnancy and use of contraceptives. Counseling about reproductive healthcare or prenatal care, as appropriate, should be offered.

Intravenous drug users (IDUs) should be referred for substance abuse treatment. Those who refuse treatment should be counseled to use once-only sterile syringes and not to share needles with others.

Prevention among People of Color

African Americans and Hispanics of both sexes have disproportionately higher rates of HIV/AIDS in the United States. There are no biologic reasons for these disparities, and there is no single reason why these disparities exist. However, there are a number of contributing factors, including:

• Health disparities, linked to socioeconomic conditions
• Distrust of the healthcare system, based on historical abuses of people of color
• Difficulty communicating health education in culturally appropriate ways to diverse communities
• Denial about HIV risk due to stigma about the disease and its connection to homosexuality and drug use

Prevention messages need to be culturally appropriate and relevant and they must be delivered through channels appropriate to individual communities. These channels may include religious institutions or respected elders in the community.

Male Circumcision

Male circumcision is being discussed as a possible measure to reduce the risk of male-to-female HIV transmission. International observational studies and three clinical trials have found that male circumcision is associated with a lower risk for HIV infection as well as other STDs and urinary tract infections. CDC is reviewing recommendations related to neonatal circumcision of male newborns as well as post-neonatal male circumcision (CDC, 2008c).

Challenges to Prevention

The CDC (2010c) has identified challenges to prevention of HIV transmission among MSM, particularly those aged 15–49 years old. They include:

• Unprotected sex
• Use of alcohol and other drugs
• Lack of awareness of HIV infection
• Stigma and internalized homophobia
• Social isolation
• Racism, poverty, and lack of access to healthcare
• Complacency about HIV based on ignorance

Complacency about HIV among young MSM stems from two key factors. The first is their lack of experience with the severity of the early HIV epidemic. The second is their mistaken belief that advances in treatment and decreased mortality mean that HIV is no longer a serious threat. They also fail to recognize that antiretroviral drugs are very expensive and may have serious, even life-threatening side effects.

Prevention Research

In late 2010 researchers reported that daily use of the antiretroviral pill Truvada, currently used to treat HIV, can also be used for preexposure prophylaxis (PrEP) to prevent new infections. This large multinational trial showed that the drug reduced the risk of HIV transmission by 44% and reduced new infections by as much as 73% among those who used the drug most (Grant et al., 2010). (Because the trial enrolled only men and transgender women who have sex with men, the drug’s efficacy in women or intravenous drug users is unknown.)

While the FDA has not yet approved the drug for preventive use, the CDC has released interim guidelines for healthcare providers electing to provide PrEP to high-risk MSM (CDC, 2011). These state that PrEP has the potential to contribute to effective and safe HIV prevention under the following conditions:

• It is targeted to MSM at high risk for HIV acquisition
• It is delivered as part of a comprehensive set of prevention services, including risk-reduction and PrEP medication adherence counseling, ready access to condoms, and diagnosis and treatment of sexually transmitted infections
• It is accompanied by monitoring of HIV status, side effects, adherence, and risk behaviors at regular intervals

The cost of PrEP is a major concern for public health agencies and private insurers, since Truvada costs about $1,000 per month when used to treat HIV, which will prove prohibitive for the populations at highest risk of infection. However, “a generic version is available overseas that costs about 40 cents a day” (Allday, 2010).

INFECTION CONTROL

Risks for Occupational Exposure

Healthcare workers may be infected with HIV through needlesticks or direct contact with HIV-infected blood—for example, through a break in the skin or through the eyes or the mucosal lining of the nose. According to the CDC, of all adults reported with AIDS in the United States through December 2002, 5.1% of the AIDS cases reported to the CDC for whom occupational information was known had been employed in healthcare.

In 2007 the CDC reported that “57 healthcare personnel in the United States have been documented as having seroconverted to HIV following occupational exposures. In addition, 140 possible cases of HIV infection or AIDS have occurred among healthcare personnel…. More than 90% of healthcare personnel infected with HVI have nonoccupational risk factors for acquiring their infection.”

Healthcare providers who work in correctional institutions and in home care are at higher risk for occupational exposure to HIV and other bloodborne pathogens than those who work in other settings. Other occupational groups with potential exposure to HIV (as well as HBV and HCV) include, but are not limited to, law enforcement; fire, ambulance, and other emergency responders; and public service employees.

NEEDLESTICK INJURIES

The risk of developing HIV infection from a needlestick with infected blood is about 1:300 without prompt antiretroviral treatment, and the risk increases with deep punctures, hollow bore needles, visible blood on the needle, and high viral load in the source. (Comparatively, the risk after a mucous membrane exposure is about 1:9,000, and the risk of HIV transmission after nonintact skin exposure is estimated to be less than the risk for mucous membrane exposure.)

According to the CDC, the risk of infection varies on a case-by-case basis. Factors affecting the risk include: whether the exposure was from a hollow-bore needle or other sharp instrument; whether to nonintact skin or mucous membranes (such as eyes, nose, and/or mouth); the amount of blood involved; and the amount of virus present in the source’s blood.

Needlestick injuries, also called percutaneous injuries (PIs), are a critical issue for nurses, according to a nationwide survey of more than 700 nurses. More than two thirds of nurses surveyed said that PIs and bloodborne infections remain major concerns, and more than half believe their workplace safety climate threatens their personal safety. Reduced staffing, increased workloads, and workplace stress all affect workplace safety, increasing the potential for errors and shortcuts (ANA, 2008). Improving these working conditions could reduce needlestick injuries (Trinkoff et al., 2007).

Needlestick injuries and other occupational exposures to potentially life-threatening infections can have profound implications for mental as well as physical health. This aspect of post-exposure care is barely mentioned in the CDC counseling guidelines for postexposure prophylaxis (PEP) (2005). Mental health issues can include sleep disruption, anxiety, panic attacks, and posttraumatic stress disorder (PTSD) (Shalo, 2007).

IN CORRECTIONAL INSTITUTIONS

The high prevalence of HIV infections in correctional institutions increases the risk of exposure, as does the environment itself. CDC (2009d) and the National Institute for Occupational Safety and Health (NIOSH) cite these challenges:

• Jails and prisons can be unpredictable work settings.
• Security issues are often a higher concern than infection control.
• Inmates may have a higher rate of bloodborne diseases.

Correctional healthcare workers can be bitten or stabbed during an inmate assault, punctured with a used needle, or splashed in the face with blood. Exposure to bloodborne pathogens can happen in any of these situations.

Workplace Standards

Standards have been developed to protect workers from bloodborne pathogens such as HIV.

DEFINING BLOODBORNE PATHOGENS

Bloodborne pathogens include any human pathogen present in human blood or other potentially infectious materials (OPIM). Other bloodborne pathogens include HBV, HCV, hepatitis D, malaria, syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections, relapsing fever, Creutzfeldt-Jakob disease, adult T-cell leukemia/lymphoma (caused by HTLV-I), HTLV-I-associated myelopathy, diseases associated with HTLV-II, and viral hemorrhagic fever.

EXPOSURE CONTROL PLAN (ECP)

Each employer covered under WAC 296-823 must develop an Exposure Control Plan (ECP). The ECP shall contain at least the following elements:

• A written “exposure determination” that includes those job classifications and positions in which employees have potential for occupational exposures. The exposure determination shall have been made without taking into consideration the use of personal protective clothing or equipment. It is important to include those employees who are required or expected to administer first aid.
• The procedure for evaluating the circumstances surrounding exposure incidents, including maintenance of a “Sharps Injury Log.” The Sharps Injury Log must contain, at a minimum: the type and brand of device involved in the incident; 2) the department or work area where the exposure incident occurred; and an explanation of how the incident occurred.
• The infection control system used in the workplace.
• Documentation of consideration and implementation of appropriate, commercially available safer medical devices designed to eliminate or minimize occupational exposure.
• An update at least annually and whenever changes occur that effect occupational exposure.

EMPLOYEE TRAINING

Bloodborne pathogens training is mandated for all new employees or employees being transferred into jobs involving tasks or activities with potential exposure to blood and/or OPIM. This training must take place prior to assignment to tasks where occupational exposure may occur, and must include:

• Information on hazards associated with blood/OPIM
• Protective measures to minimize risk of occupational exposure
• Information on appropriate actions to take if exposure occurs

Retraining is required annually or when changes in procedures or tasks affecting occupational exposure occur.

Employees must be provided access to a qualified trainer during the training session to ask and have answered questions as they arise.

Infection Control Systems

To prevent HIV transmission in healthcare settings, CDC instituted universal precautions (blood and body fluid precautions). Under universal precautions, healthcare personnel should assume that the blood and other body fluids from all patients are potentially infectious and therefore follow infection-control precautions at all times and in all settings.

Standard precautions is a newer term that hospitals and other agencies are moving toward. It includes all recommendations for universal precautions plus body substance isolation (BSI) when other potentially infectious materials (OPIM) are present.

These precautions include:

• Routine use of barriers (such as gloves and/or goggles) when anticipating contact with blood or body fluids
• Washing hands and other skin surfaces immediately after contact with blood or body fluids, and
• Careful handling and disposing of sharp instruments during and after use

USE OF BARRIERS

Gloves, masks, protective eyewear, and chin-length plastic face shields are examples of personal protective equipment (PPE). PPE shall be provided and worn by employees in all instances where they will or may come into contact with blood or OPIM. This includes, but is not limited to, dentistry, phlebotomy, processing of any bodily fluid specimen, and postmortem (after death) procedures.

Latex gloves are recommended when dealing with blood or OPIM. However, people with allergies to latex must be provided with nitrile, vinyl, or other glove alternatives that meet the definition of “appropriate” gloves. Gloves must be changed after each client.

Gloves should be worn:

• When working with blood, blood products, semen, vaginal secretions, and any other potentially contaminated body fluids, such as cerebrospinal fluid, amniotic fluid, and saliva, as well as any items or surfaces in contact with the aforementioned fluids
• When touching mucous membranes or breaks in the skin
• When performing or assisting with any invasive procedures, such as venipuncture, surgery, or repair of traumatic injury
• When working in situations where hand contamination may occur, such as with an uncooperative or aggressive patient
• When the healthcare provider has cuts, scratches, or other breaks in their own skin

Caregivers with weeping dermatitis (such as poison ivy or poison oak) or exudative lesions must be prohibited from all patient care and/or handling of patient care equipment or supplies.

Masks, goggles, face shields, and gowns should be worn:

• During all invasive procedures and any procedure in which blood or body fluids may spatter or become airborne
• During procedures in which heavy bleeding or other extensive fluid loss (such as peritoneal fluid) may occur; a disposable plastic apron or gown and boots are also recommended

Reusable PPE must be cleaned and decontaminated or laundered by the employer. Lab coats and scrubs are generally considered to be worn as uniforms or personal clothing. When contamination is reasonably likely, protective gowns should be worn. If lab coats or scrubs are worn as PPE, they must be removed as soon as practical and laundered by the employer.

HANDWASHING

Soap-and-water handwashing must be performed whenever hands are visibly contaminated or there is a reasonable likelihood of contamination. Universal precautions also include frequent handwashing with warm water and soap (or a waterless, alcohol-based hand rub):

• Between clients
• Immediately after gloves are removed, even if they appear to be intact
• Immediately, if contaminated with blood or other body fluids to which Universal Precautions apply
• Upon leaving the work area
• Before and after using restroom facilities

It is advisable to keep fingernails short and wear as little jewelry as possible.

Additional information on hand hygiene can be found in the CDC “Guideline for Hand Hygiene in Healthcare Settings” (2002).

SHARPS DISPOSAL

Needles are not to be recapped, purposely bent or broken, removed, or otherwise manipulated by hand. After they are used, disposable syringes, needles, and scalpel blades are to be immediately placed in puncture-resistant, labeled containers for disposal.

Phlebotomy needles must not be removed from holders unless required by a medical procedure. The intact phlebotomy needle/holder must be placed directly into an appropriate sharps container.

Adhere to agency protocols for disposal of infectious waste.

HOUSEKEEPING AND WASTE DISPOSAL

The work area of the facility is to be maintained in a clean and sanitary condition. The employer is required to determine and implement a written schedule for cleaning and disinfection, based on the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed.

Disinfectants

All equipment and all environmental and working surfaces must be properly cleaned and disinfected after contact with blood or OPIM. Chemical germicides and disinfectants in recommended dilutions must be used to decontaminate spills of blood and other body fluids. Consult the Environmental Protection Agency (EPA) for lists of registered sterilants, tuberculocidal disinfectants, and antimicrobials with HIV/HBV efficacy claims to verify that the product used is appropriate. Lists are available from EPA at http://www.epa.gov/oppad001/chemregindex.htm.

Laundry

Laundry that is or may be soiled with blood/OPIM and/or may contain contaminated sharps must be treated as contaminated. Contaminated laundry must be bagged at the location where it was used and shall not be sorted or rinsed in patient-care areas. It must be placed and transported in bags that are labeled or color-coded (red-bagged).

Laundry workers must wear protective gloves and other appropriate personal protective clothing when handling potentially contaminated laundry. All contaminated laundry must be cleaned or laundered so that any infectious agents are destroyed.

Regulated Waste

Potentially contaminated broken glassware must be removed using mechanical means, such as a brush and dustpan or vacuum cleaner.

All regulated waste must be placed in closeable, leak-proof containers or bags that are color-coded (red-bagged) or labeled as required by law to prevent leakage during handling, storage, and transport. Disposal of waste shall be in accordance with federal, state, and local regulations.

Regulated waste is defined as any of the following:

• Liquid or semiliquid blood or other potentially infectious materials (OPIM)
• Contaminated items that would release blood or OPIM in a liquid or semiliquid state, if compressed
• Items that are caked with dried blood or OPIM and are capable of releasing these materials during handling
• Contaminated sharps
• Pathological and microbiological wastes containing blood or OPIM

PERSONAL ACTIVITIES

Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas that carry the potential for occupational exposure.

Food and drink must not be stored in refrigerators, freezers, or cabinets where blood or OPIM are stored or in other areas of possible contamination.

Protocols for Healthcare Workers Exposed to Blood

Any healthcare worker who receives a needlestick or other significant exposure to potential HIV, HSV, or HBV infection should follow the employer’s protocol, which is based on guidelines issued by the CDC (2005):

IMMEDIATE RESPONSE

Immediately after exposure to blood of a patient:

• Wash the affected area(s) with soap and water. Application of antiseptics should not substitute for washing.
• Flush splashes to the nose, mouth, or skin with water.
• Irrigate eyes with clean water, saline, or sterile irrigants.
• Remove any potentially contaminated clothing should as soon as possible.
• In the event of a sharps injury, wash the exposed area with soap and water. Do not “milk” or squeeze the wound. There is no evidence that antiseptics such as hydrogen peroxide will reduce the risk of transmission; however, use of antiseptics is not contraindicated. Seek emergency treatment if the wound needs suturing.
• For bites or scratch wounds, wash with soap and water and cover with a sterile dressing. All bite wounds should be evaluated by a healthcare professional.
• Exposure to urine, feces, vomitus, or sputum is not considered a blood-borne pathogens exposure unless the fluid is visibly contaminated with blood. Follow your employer’s procedures for cleaning these fluids.

REPORTING THE INCIDENT

Immediately report the incident to the department (e.g., occupational health, infection control) within your agency responsible for managing exposures. Prompt reporting is essential because in some cases postexposure prophylaxis (PEP) may be recommended and started as soon as possible. Discuss with a healthcare professional the extent of the exposure, treatment, follow-up care, personal prevention measures, the need for a tetanus shot, and other care. You should have already received the hepatitis B vaccine, which is extremely safe and effective in preventing HBV infection.

In Washington, employers must make a confidential postexposure medical evaluation available to employees who report an exposure incident. This evaluation must be:

• Made immediately available
• Kept confidential
• Provided at no cost to the employee
• Provided according to current U.S. Public Health Service recommendations

In addition, the following information must be provided to the evaluating healthcare professional:

• A copy of WAC 296-823-160
• A description of the job duties the exposed employee was performing when exposed
• Documentation of the routes of exposure and circumstances under which exposure occurred
• Results of the source person’s blood testing, if available
• All medical records, including vaccination status, relevant to the appropriate treatment of the employee

(Note: HIV and hepatitis infection are notifiable conditions under WAC 246-101.)

Workers have a right to file a worker’s compensation claim for exposure to bloodborne pathogens. Industrial insurance covers the cost of postexposure prophylaxis and follow-up care for the injured worker.

POSTEXPOSURE PROPHYLAXSIS (PEP)

The CDC recommends that postexposure prophylaxis (PEP) begin as soon as possible, ideally within 24 hours after the exposure and no later than 7 days (CDC, 2005). Animal studies indicate that cellular HIV infection occurs within 2 days of exposure to HIV. Virus in blood is detectable within 5 days. Therefore, prompt initiation of PEP is essential and should be continued for 28 days. PEP for HIV does not prevent other blood-borne diseases such as HBV or HCV.

For exposure to HIV-positive blood, recommendation is for a four-week course combining either two antiretroviral drugs for most HIV exposures, or three antiretroviral drugs for exposures that may pose a greater risk for transmitting HIV (e.g., those involving a larger volume of blood with a larger amount of HIV or a concern about drug-resistant HIV). The antiviral drugs used in PEP are potentially toxic and should not be used for exposures that pose a negligible risk. CDC recommends consultation with an infectious disease consultant or another physician experienced with antiretroviral drugs; however, consultation “should not delay timely initiation of PEP” (CDC, 2005).

Frequent advances in treatment make it impractical to list medications and dosages here. PEP can only be obtained from a licensed healthcare provider. The employing facility may have recommendations and procedures in place for staff members to obtain PEP. After evaluation, certain anti-HIV medications may be prescribed.

The National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline) offers treating clinicians up-to-the-minute advice on managing occupational exposures (i.e., needlesticks, splashes, etc.) to HIV, hepatitis, and other blood-borne pathogens. In rural areas, police, firefighters and other at-risk emergency responders should identify a 24-hour source for PEP.

Hepatitis B vaccine is available for HBV exposure. There is no vaccine for Hepatitis C and no treatment that will prevent infection. Immune globulin is not advised. Medical counseling is recommended regarding personal risk of infection or risk of infecting others.

SOURCE TESTING

WAC 296-823-160 requires the employer to arrange to test the “source individual”—the person whose blood or OPIM an employee was exposed to—for HIV, HBV, and HCV as soon as feasible after obtaining their consent. If the employer does not get consent, the employer must document such and inform the employee. The employer may request assistance from the local health officer.

Because of an increased risk for HIV exposure, the Revised Code of Washington 70.24.340 provides for HIV antibody testing of a “source individual” when a member of the following groups experiences an occupational exposure:

• Healthcare provider
• Staff of healthcare facilities
• Law enforcement officer
• Firefighter
• Funeral director
• Embalmer

These individuals can request HIV testing of the source through their employer or local health officer.

Before issuing a health order for HIV testing of the source individual, the officer will first determine whether a substantial exposure occurred and if the exposure occurred on the job. Depending on the type of exposure and risks involved, the health officer may determine that source testing is unnecessary.

Source testing does not eliminate the need for baseline testing of the exposed individual for HIV, HBV, HCV, and liver enzymes. Initiating PEP should also not be contingent upon the results of a source’s test. Current recommendations are to provide immediate PEP in certain circumstances, with possible discontinuation of treatment based on the source’s test results.

(See also “Testing Without Informed Consent” below.)

FOLLOW-UP

CDC recommends that “healthcare personnel with occupational exposure to HIV receive follow-up counseling, postexposure testing, and medical evaluation regardless of whether they receive PEP. HIV-antibody testing by enzyme immunoassay should be used to monitor healthcare personnel for seroconversion for >6 months after occupational exposure” (CDC, 2005).

After baseline testing at the time of exposure, follow-up testing is recommended to be performed at 6 weeks, 12 weeks, and 6 months after exposure. Extended HIV follow-up (e.g., for 12 months) is recommended for those who become infected with HCV after exposure to a source coinfected with HIV. Extended follow-up in other circumstances (such as those persons with impaired immunity) may also be considered.

• Healthcare personnel undergoing PEP should be monitored for drug toxicity by testing at baseline and again 2 weeks after starting PEP.
• It is important to complete the full 4 weeks of PEP, despite side effects, which can include nausea, malaise, and fatigue. Many healthcare personnel, perhaps as many as 47%, do not complete the full course of therapy because of an inability to tolerate the drugs.

Infection Control Procedures at Home

Healthcare providers and other caregivers who care for HIV patients at home or in home-like settings are also at risk of exposure to HIV and other bloodborne pathogens. Nurses, nurses’ aides, and personal care assistants (PCAs) experience PIs and other exposures to blood and body fluids during home care. However, more than half of these exposures go unreported (Gershon et al., 2009; Scharf et al., 2009).

Medical procedures contributing to PIs in home care include injecting medications, performing fingersticks and heelsticks, and drawing blood. Other contributing factors include sharps disposal, contact with waste, and patient handling. PCAs appear to be at increased risk when performing procedures for which they are inexperienced and/or lack training (Lipscomb et al., 2009). One study found that sharps with safety features often were not used, possibly due to their expense (Quinn et al., 2009).

Healthcare providers and other caregivers who care for HIV patients should practice good hygiene techniques in preparing food, handling body fluids, and using medical equipment. Cuts, accidents, or other circumstances can result in spills of blood/OPIM on carpeting, vinyl flooring, clothing, skin, or other surfaces. Everyone, even young children, needs to have a basic understanding that they should not put their bare hands in or on another person’s blood.

GLOVES AND HANDWASHING

Gloves (latex, vinyl, or nitrile in the case of latex allergy) should be worn whenever a caregiver anticipates contact with any body substance (blood/OPIM) or non-intact skin. Gloves are not necessary for general care or during casual contact (serving food, bathing intact skin). Never rub the eyes, mouth, or face while wearing gloves.

Gloves should be properly removed and disposed of and hands washed as soon as possible after care of each patient. Disposable gloves should never be washed and reused. Correct handwashing is critically important.

CLEANING BLOOD/OPIM FROM SURFACES

Wear appropriate gloves when cleaning blood from skin surfaces. Use sterile gauze or other bandages and follow normal first-aid techniques to stop the bleeding. After applying the bandage, remove the gloves slowly so fluid particles do not splatter or become aerosolized. Hands should be washed using proper technique as soon as possible.

On bare floors, pretreat body fluid spills with full-strength liquid disinfectant or detergent; then wipe up with either a mop and hot soapy water or appropriate gloves and paper towels. Dispose of paper towels into a well-marked plastic bag or heavy-duty container. Broken glass should be swept up using a broom and dustpan (never bare hands).

Use a disinfectant (such as 1 part 5.25% household bleach freshly mixed with 10 parts water) to disinfect the area where the spill occurred. If a mop was used for cleaning, soak it in a bucket of hot water and disinfectant it for the recommended time. Empty mop water in the toilet, not the sink. Sponges and mops used to clean up body fluid spills should not be rinsed in the kitchen sink or in a location where food is prepared.

On carpeting, pour dry kitty litter or another absorbent material onto the spill to absorb the body fluid. Carefully pour carpet-safe liquid disinfectant onto the contaminated carpeting and leave it there for the amount of time indicated in manufacturer’s instructions. Using sturdy rubber gloves, blot the spill with paper towels until it is absorbed. Vacuum normally afterward.

CLOTHING AND OTHER LAUNDRY

Clothes, washable uniforms, towels, or other laundry stained with blood/OPIM should be washed and disinfected before further use. If possible, have the patient remove the clothing or use appropriate gloves to assist with removing the clothes.

If the washing machine is not close by, transport the soiled items in a sturdy plastic bag. Then place the items in the washing machine and soak or wash them in cold, soapy water to remove any blood from the fabric.

Hot water will permanently set blood stains. Use hot water for a second washing cycle and include detergent, which will act as a disinfectant. Dry the items in a clothes dryer. Wool clothing or uniforms may be rinsed with cold soapy water, then drycleaned to remove and disinfect the stain.

TOILET AND BEDPAN SAFETY

It is safe to share toilets/toilet seats without special cleaning, unless the surface becomes contaminated with blood/OPIM. If this occurs, spray the surface with a solution of 1 part bleach to 10 parts water. Wearing gloves, wipe the seat dry with disposable paper towels.

Persons with open sores on their legs, thighs, or genitals should disinfect the toilet seat after each use. Urinals and bedpans should not be shared between family members unless these items are thoroughly disinfected after each person’s use.

Use a new pair of gloves to change diapers. Discard disposable diapers in an appropriate plastic bag or receptacle, along with gloves. Wash hands immediately after changing the diaper. Disinfect the diapering surface. Wash cloth diapers in very hot water with detergent and a cup of bleach, and dry them in a hot clothes dryer.

THERMOMETERS

Electronic thermometers with disposable covers do not need to be cleaned between users unless visibly soiled. Wipe the surface with a disinfectant if necessary. Glass thermometers should be washed with soap and warm water before and after each use. If the thermometer will be shared among family members, it should be soaked in 70% to 90% ethyl alcohol for 30 minutes, then rinsed under a stream of warm water after each use.

PERSONAL HYGIENE ITEMS

People should not share razors, toothbrushes, personal towels or washcloths, dental hygiene tools, vibrators, enema equipment, or other personal care items.

FOOD PREPARATION

Kitchens can harbor bacteria that may prove life-threatening to a person with HIV/AIDS. Use the following precautions during food preparation and clean-up:

• Wash hands thoroughly before preparing food.
• Use a clean spoon to taste food, and wash the spoon after each taste.
• Avoid unpasteurized milk, raw eggs or products that contain raw eggs, cracked or non-intact eggs, and raw fish. Cook all meat, eggs, and fish thoroughly to kill any organisms that may be present. Wash fruits and vegetables thoroughly.
• Disinfect countertops, stoves, sinks, refrigerators, door handles, and floors regularly. Use window screens to keep out insects.
• Discard food that has expired or is past a safe storage date, shows signs of mold, or smells bad.
• Use separate cutting boards for meat and for fruits and vegetables. Disinfect cutting boards.
• Keep kitchen garbage in a leak-proof washable receptacle that is lined with a plastic bag. Seal the garbage liner bags and change bags frequently.

SAFE AND LEGAL DISPOSAL OF SHARPS

Syringes, needles, and lancets are called “sharps,” and their disposal is regulated. Sharps can carry hepatitis, HIV, and other bacteria and viruses that cause disease. Throwing them in the trash or flushing them down the toilet can pose health risks for others—such as sanitation (garbage) workers, other utility workers, and the public—from needlesticks and illness. Rules and disposal options vary according to circumstance, so it is essential to check with your local health department to see which option applies to your situation.

Parents and caregivers should make sure that children understand never to touch a found needle or syringe, but to immediately ask a responsible adult for help.

Safe disposal of found syringes should follow these guidelines:

• Do not pick up a found syringe or needle with bare hands. Use gloves and tongs, shovel, or a broom and dustpan to pick it up. Hold the needle away from your body.
• Do not break the needle off from the syringe.
• Place used sharps and syringes in a safe container with at least a 1-inch opening and a lid that will seal tightly, such as an empty plastic laundry detergent container or glass bottle or jar. If a glass jar is used, place it in a larger plastic bucket or container that has a tight-fitting lid. Soda cans are not good containers to use because people often try to recycle discarded cans. Do not flush needles or syringes down the toilet.
• Tape the container shut for added safety and label it with the warning: “SHARPS, DO NOT RECYCLE!” Place it well out of reach of children.
• Call the local health department to determine what disposal sites are available.

Anyone with an accidental needlestick requires a prompt assessment by a medical professional. Testing for HIV, HCV, and HBV may be recommended. If someone finds and handles a syringe, but no needlestick occurs, testing for HIV is not necessary.

PET CARE

Certain animals can pose hazards for people with compromised immune systems. These animals include turtles, reptiles, birds, puppies and kittens under the age of eight months, wild animals, and pets without current immunizations or with illnesses of unknown origin.

Pet cages and cat litter boxes can harbor infectious organisms that may become aerosolized. Pets can also spread disease by licking a person’s face or open wounds. Wash hands after stroking or other contact with pets.

Pets should be cared for by someone who is not immunocompromised. If this is not possible, a mask with a sealable nose clip and disposable latex gloves should be worn each time pet care is done.

All pet care should be followed by thorough handwashing. Cats’ and dogs’ nails should be kept trimmed. Wear latex or nitrile gloves to clean up any pet urine, feces, vomit, or OPIM. Clean the soiled area with a fresh solution of 1:10 bleach.

Pet food and water bowls should be washed regularly in warm soapy water and rinsed clean. Cat litter boxes should be emptied and washed regularly. Fish tanks should be kept clean. Heavy latex “calf-birthing” gloves can be purchased from a veterinarian for immunocompromised individuals to wear to clean the fish tank.

Do not let pets drink from the toilet or eat other animal feces, any type of dead animal, or garbage. Restrict cats indoors. Dogs should be kept indoors or on a leash. Many communities have volunteer groups and veterinarians who will assist people with HIV/AIDS in taking care of their pets if needed. Questions can be directed to a local veterinarian.

Part 3: Legal and Ethical Issues

LEGAL REPORTING REQUIREMENTS

AIDS and HIV infection are reportable conditions in Washington State (WAC 246-101). Medically diagnosed AIDS has been a reportable condition since 1984. Symptomatic HIV was designated as a reportable condition in 1993, and in 1999 asymptomatic HIV infection also became reportable.

Reporting of HIV and AIDS cases assists local and state health officials in tracking the epidemic. The statistics also allow for more effective planning and intervention services to prevent further transmission of HIV and reduce the burden of this disease.

Providers who diagnose an individual with AIDS must submit a confidential case report to the local health jurisdiction within 3 days. Providers who receive notice of an individual’s positive HIV test must report this information, including the individual’s name, to the local health jurisdiction within 3 days. In some local health jurisdictions, the state department of health fulfills this function for local authorities.

Positive HIV results obtained through anonymous testing are not reportable until the patient seeks medical care for conditions related to HIV or AIDS. At that time, the provider is required to report the case to the local health department.

CONFIDENTIALITY

Confidentiality is a paramount concern for people with HIV/AIDS. This infection not only carries the stigma of a sexually transmitted disease but also the association with homosexuality and/or injection drug use. Workplace, housing, and insurance discrimination have been (and, in some areas, continue to be) barriers to disclosure of HIV status and seeking treatment. Children with AIDS have sometimes been barred from attending classes and, in at least one instance, a family home was burned after one member of the family developed AIDS.

All medical records are confidential and must be maintained in a manner that protects that confidentiality, using an approach consistent with Washington law (RCW 70.02 and RCW 70.24) and, if applicable, the Privacy and Security Requirements promulgated by the federal government in the Health Insurance Portability and Accountability Act (HIPAA). Client information must be kept strictly confidential, and records should be managed and stored in a secure manner. Special requirements for HIV and AIDS are found in WAC 246-100 and RCW 70.24.105.

Confidential information includes any material, whether oral or recorded in any form or medium that identifies (or can readily be associated with the identity of) a person and is directly related to their health and care. All information related to an individual’s HIV/AIDS status is protected under medical confidentiality guidelines and legal regulations. Recognizing the sensitive nature of these conditions, medical record protection for HIV and AIDS, like those for substance abuse and mental health, are protected more rigorously than other medical information.

Confidentiality of medical information means that any information that can be related to a specific patient may not be disclosed to anyone except under specific circumstances. This usually means that the individual signs a release-of-information form, but there are exceptions. The most common circumstances permitting disclosure of confidential patient information are:

• Existence of a separate, signed release-of-information form
• Release to another healthcare provider for related ongoing medical care
• A life-or-death emergency
• Release to a third-party payer (insurance provider)
• Reporting notifiable conditions to the local health jurisdiction or the department of health

Anyone who violates the confidentiality laws may be found guilty of a misdemeanor and be subject to civil liability actions for reckless or intentional disclosure, up to a fine of $10,000 for each infraction, or actual damages, whichever is greater (RCW 70.24.080, RCW 9A.20.021, RCW 70.24.084) (Washington State Department of Health, 2005).

The county health officer has the responsibility to investigate potential breaches of confidentiality of HIV identifying information and report those breaches to the department of health.

INFORMED CONSENT

Before HIV testing is performed, patients must be explicitly told that HIV testing is recommended and the patient must agree to the HIV testing.

HIV testing without informed consent, except in legally mandated situations described below, can result in disciplinary action by a healthcare provider’s licensing board, fines, suspension or revocation of license, and civil liability for negligence and invasion of privacy (Washington State Department of Health, 2005).

Minors

Washington law (RCW 70.24.110) specifies that children 14 years of age or older who may have come in contact with any sexually transmitted disease or suspected sexually transmitted disease may give consent to the furnishing of hospital, medical, and surgical care related to the diagnosis or treatment of such disease.

Parental or legal guardian consent is not necessary, and parent(s) or legal guardians are not liable for payment for any care rendered. Washington State law forbids informing the subject’s parents of the test, or of the results, without the subject’s permission.

Testing Without Informed Consent

HIV testing without informed consent may occur in the following circumstances:

• When the person is incompetent to give consent (RCW 7.70.065)
• In seroprevalence studies, where neither the persons whose blood is being tested know the test results nor the persons conducting the tests know who is undergoing testing
• If the Department of Labor and Industries determines that it is relevant, in which case payments made under Title 51 RCW may be conditioned on the taking of an HIV antibody test.

Under Washington State law (WAC 246-100-205), someone who has experienced a substantial exposure to another person’s bodily fluids in a manner that creates a possible risk of HIV transmission, and that exposure occurred while on the job in certain categories of employment deemed at substantial risk for HIV exposure, may ask a state or local health officer to order pretest counseling, HIV testing, and post-test counseling of the source person, in accordance with RCW 70.24.340.

Source persons who may be tested for HIV without informed consent include those convicted of a sexual offense (9A.44 RCW), prostitution (9A.88 RCW), or drug offenses involving hypodermic needles (69.50 RCW). This law does not apply to the department of corrections or to inmates in its custody or subject to its jurisdiction.

Substantial exposure that presents a possible risk of transmission is limited to:

• Physical assault upon the exposed person involving blood or semen
• Intentional, unauthorized, nonconsensual use of needles or sharp implements to inject or mutilate the exposed person
• An accidental parenteral or mucous membrane or non-intact skin exposure to blood, semen, or vaginal fluids

Categories of employment at substantial risk for HIV exposure include:

• Healthcare provider
• Staff of healthcare facilities
• Law enforcement officer
• Firefighter
• Funeral director
• Embalmer

If the health officer refuses to order counseling and testing, the exposed person may petition the superior court for a hearing to determine whether an order shall be issued.

CIVIL RIGHTS

Chapter 49.60 RCW, the Washington Law Against Discrimination, prohibits discrimination based on age, creed, religion, race, color, national origin, sex, sexual orientation and gender identity, HIV and hepatitis C status, whistleblower retaliation, marital status (housing and employment), families with children (housing), or the presence of any sensory, mental, or physical disability or the use of a trained dog guide or service.

Exceptions to this law are applicants for the U.S. Military, the Peace Corps, and the Job Corps, under federal law, which supersedes state law.

Effective January 4, 2010, foreign visitors with HIV/AIDS can legally enter the United States without their infection being considered, and testing is no longer required for immigration. CDC removed HIV/AIDS from the inadmissible diseases list in 2009.

Disability and Discrimination

People with HIV/AIDS are protected by federal law under the Americans with Disability Act (1990) and Section 504 of the Federal Rehabilitation Act of 1973, as amended. The Washington Law Against Discrimination (WLAD-RCW 49.60.174) regulates “disabled” status. These laws make it illegal to discriminate against someone with AIDS or who has HIV or Hepatitis C infection. It is also illegal to discriminate against someone “believed” to have HIV/AIDS, even though that person is not infected. The areas encompassed in the laws include:

• Employment (see below for details)
• Rental, purchase, or sale of apartment, house, or other real estate
• Public places (restaurants, theaters)
• Healthcare, legal services, home repairs, and other personal services available to the general public
• Applying for a loan or credit card, or other credit transaction
• Certain insurance transactions

(Note: Federal and state jurisdictions differ.)

Employment Issues

Laws protect people diagnosed with HIV/AIDS from employment discrimination, including:

• Employment
• Recruitment
• Hiring
• Transfers
• Layoffs
• Termination
• Salary
• Job assignments
• Leaves of absence, sick leave, any other leave or fringe benefits available by virtue of employment

WORK ENVIRONMENT

Employers are required to provide and maintain a working environment free of discrimination. They must ensure that no harassment, intimidation, or personnel distinction is made in terms and conditions of employment. If a worksite situation poses the threat of discrimination, the employer is required to educate and supervise employees to end the harassment and any use of slurs and/or intimidation. An employer should promptly investigate allegations of discrimination, take appropriate action, and not retaliate against the person who complained.

Employers are responsible for providing reasonable worksite accommodations that will enable a qualified employee or job applicant with a disability to perform the essential tasks of a particular job. Reasonable accommodation means relatively inexpensive and minimal modifications in the context of the entire employer’s operation, such as:

• Providing special equipment
• Altering the work environment
• Allowing flex-time
• Providing frequent rest breaks
• Allowing the person to work at home (telecommute)
• Restructuring the job

An employee with a disability must self-identify and request a reasonable accommodation. The employer must engage in an interactive process with the requestor. The reasonable accommodation grant may not be exactly the same one as requested by the employee but can be equally effective. The employer does not have to change the essential nature of its work, or engage in undue hardship or heavy administrative burdens. The essential functions of the job must be accomplished, with or without reasonable accommodations.

EMPLOYEE GRIEVANCES

Employees who feel they are being discriminated against should first document the discrimination, speak with their supervisor, and follow the entity’s internal process to file a discrimination charge. However, it is not necessary to file an internal grievance process. If these remedies do not work, the employee should contact the federal Office for Civil Rights, U.S. Department of Health and Human Services, or the Washington State Human Rights Commission. An aggrieved person can also file directly in state court. A complaint must be filed within 180 days of the alleged discriminatory incident.

PROTECTING PUBLIC HEALTH

Washington State law (RCW 70.24) and rules (WAC 246-100 and 246-101) give state and local health officers the authority and responsibility to carry out certain measures to protect public health from the spread of sexually transmitted disease (STD), including HIV/AIDS.

The local health officer is the physician who directs the operations of the local county’s health department or health district. The responsibilities of the health officer include the authority to:

• Interview persons infected with an STD
• Notify sexual or needle-sharing partners of exposure to disease
• Order persons suspected of being infected to receive examination, testing, counseling, or treatment
• Issue orders to cease and desist from specific conduct that endangers the health of others

Court enforcement may be necessary. State law specifies the standards that must be met before the health officer may take action.

Washington law permits the detention of an HIV-infected person who continues to endanger the health of others. After all less-restrictive measures have been exhausted, a person may be detained for periods up to 90 days after appropriate hearings and rulings by a court. The detention must include counseling.

Knowingly transmitting HIV/AIDS is a Class A felony in Washington State (RCW 9A.36.011(1)(b).

Washington law requires that healthcare providers offer instruction on infection-control measures to any patient diagnosed with a communicable disease. Providers are also required to report to the local health officer any impediments or refusal to comply with prescribed infection-control measures.

For example, if a healthcare provider knows that a specific patient is failing to comply with infection-control measures (failing to disclose HIV status to sexual or needle-sharing partners or selling HIV-infected blood), the provider should contact the local health officer to discuss the case and determine if the name of the person should be reported for investigation and follow-up.

If credible evidence exists that an HIV-infected person is engaging in conduct that endangers public health, the health officer or other authorized representative will investigate the case.

There are other laws and regulations concerning endangering the public health and occupational exposures that may be specific to certain professions and to the jurisdictions of public health officers. The Washington State Hotline, 1-800-272-2437, can provide additional information.

Part 4: Psychosocial Issues

For 30 years, HIV/AIDS has proved to be a moving target, spreading beyond gay white men in cities to women, children, and seniors in small towns and rural areas. As people with HIV live longer, needs for healthcare services are changing. Depending on their personal support system and other resources, some people may require the assistance of a case manager to link them with various care services.

PERSONAL IMPACT OF HIV/AIDS

People with HIV/AIDS face a host of personal challenges: unpredictable cycles of illness and wellness; feelings of loss, grief, anger, and depression; expensive, complicated, sometimes disfiguring treatments; and, finally, deteriorating health and premature death. The fortunate ones have families and friends who share the experience and offer support as needed. For those without a support system, the challenges can seem insurmountable.

HIV-infected individuals may live for 10 or more years before symptoms develop. For those who know they are infected, a decade of uncertainty can be unsettling, even overwhelming. Despite more effective treatment, most people with HIV still die prematurely. Many are in the prime of life, which makes it more difficult to deal with the diagnosis of a fatal disease.

Depression

Depression can be immobilizing and interfere with adherence to the treatment regimen, leading indirectly to drug resistance and poor management of the disease. Symptoms of depression include:

• Feeling sad, anxious, or “empty” most of the day, almost every day
• Lack of interest or pleasure in almost all activities, including sex
• Changes in appetite and/or weight
• Altered sleep patterns
• Changes in physical activity—ranging from slowing down to agitation or hyperactivity
• Feelings of worthlessness or excessive guilt
• Inability to concentrate or make decisions
• Recurrent thoughts of death or suicide, or suicide attempts

Depression can and should be treated, both with antidepressant medications and psychotherapy. Recognizing the symptoms of depression and referring patients for appropriate treatment may greatly improve their quality of life.

Rejection

In many areas of the United States, homosexuality and use of illegal drugs carry an indelible stigma and lead to social and employment discrimination. A diagnosis of HIV/AIDS adds another layer of social pressure and stress for MSM and injection-drug users. Failure of family, friends, or coworkers to accept and support the person with HIV/AIDS can evoke painful guilt about the disease, about past behaviors, or about possibly having infected someone else. The need to practice safer sex can also affect self-esteem and self-image.

Altered Body Image

HIV/AIDS causes dramatic changes in a person’s appearance, including severe weight loss and a wasted appearance. Concurrent infections and malignancies, as well as some of the treatments, can cause major alterations in body image. For example, antiretroviral drugs can lead to lipodystrophy, the redistribution of body fat. There are two types of lipodystrophy: fat wasting and fat accumulation. A person with fat wasting (also called lipoatrophy) loses fat from particular areas of the body, especially the arms, legs, face, and buttocks. Someone with fat accumulation (also called hyperadiposity) experiences fat build-up, especially in the belly, breasts, and back of the neck.

Anger

People with HIV/AIDS may feel angry with themselves for contracting the disease, as well as anger at the person who transmitted it. Their once-normal lives are now organized around medication schedules, medical appointments, and dealing with side effects such as intractable diarrhea and nausea. Expensive medications can create financial hardship, even for those with health insurance.

Loss and Grief

Living with HIV/AIDS involves loss of many kinds, including:

• Loss of physical strength and abilities, sometimes even loss of vision
• Loss of mental acuity (confusion/dementia)
• Loss of income and savings
• Loss of health insurance
• Loss of employment
• Loss of housing and personal possessions (including pets)
• Loss of emotional support from family, friends, colleagues, and religious and social institutions
• Loss of self-sufficiency and privacy
• Loss of social contacts/roles
• Loss of self-esteem

Grief—the normal response to loss—is universal, individual, and unpredictable. Although Elizabeth Kübler-Ross and others have described stages of grief, each person experiences these stages in a different order and at a different pace, depending on their values, cultural norms, and circumstances.

In uncomplicated grief, an individual is able to move through the stages and emerge from the process ready to move on with life. In complicated grief (also called chronic grief), the normal process of grieving is prolonged. Complicated grief often results from multiple losses that leave too little time and emotional energy to reintegrate and move on, and can lead to feelings of guilt, helplessness, hopelessness, withdrawal, isolation, rage, and emotional numbness.

People who live or work with the HIV/AIDS community for several years may themselves experience chronic grief from the seemingly endless repetition of deaths, funerals, and lost friends.

ISSUES FOR CARE PROVIDERS AND FAMILIES

The psychological suffering and grief experienced by people with HIV/AIDS is also shared by family members, friends, caregivers, and partners. These feelings may manifest as physical symptoms, clinical depression, hypochondria, anxiety, insomnia, and the inability to derive pleasure from normal daily activities. Coping with these issues may lead to self-destructive behaviors such as alcohol or drug abuse.

Caregivers often mirror the feelings of their patient, such as a sense of vulnerability, helplessness, or isolation. Access to a support system, including a qualified counselor, can be as important for the caregiver as for the patient. Support from coworkers is also especially important.

DO’S AND DON’T’S FOR CAREGIVER SUPPORT

DO	DON’T
Do meet with a support person, group, or counselor on a regular basis to discuss your experiences and feelings.	Don’t isolate yourself.
Do set limits in caregiving time and responsibility and stick to those limits.	Don’t try to be all things to all people.
Do allow yourself to have questions. Let “not knowing” be OK.	Don’t expect to have all the answers.
Do get the information and support you deserve and need.	Don’t deny your own fears about AIDS or dying.
Do discuss with your employer some strategies for performing your job in ways that reduce stress and burnout.	Don’t continue to work in an area where you “can’t cope.”
Do remember that Universal and Standard Precautions are for the patient’s health and welfare as well as your own.	Don’t dismiss Universal and Standard Precautions because you “know” the patient.

SPECIAL POPULATIONS

HIV/AIDS takes a heavy toll on all ethnicities, genders, ages, and income levels. However, some populations have been uniquely affected by the epidemic. Some of these populations include men who have sex with men, injection drug users, people with hemophilia, women, and people of color.

Men Who Have Sex with Men (MSM)

America’s HIV/AIDS epidemic deepened the nation’s longstanding prejudice toward homosexuality. Some religious groups see the epidemic as divine retribution for “unacceptable” and “unnatural” behavior. Many men with HIV/AIDS report lack of support from their church families because of the stigma attached to homosexuality.

Societal attitudes toward MSM have made it more difficult to live and die with HIV/AIDS. Self-esteem and other psychological issues related to HIV infections complicate the lives of MSM. Grief and loss are not always validated when relationships are judged “unacceptable.”

Injection Drug Users

Injection drug users (IDUs) often are seen as “deserving” their infection, rather than deserving treatment for their addiction. Successful efforts to prevent the spread of HIV/AIDS, HBV, and HCV among IDUs, such as syringe exchange programs, can now receive federal funding even though some equate these programs with “approval” of drug use.

Many IDUs would like to stop using but do not have access to inpatient treatment facilities. Waiting lists for treatment programs are long, and by the time a space is available, the individual may be lost to follow-up. IDUs who do seek treatment for HIV may find the regimens too complex and financially prohibitive.

People with Hemophilia

During the 1980s, 90% of people with severe hemophilia were infected by HIV and/or HCV through use of clotting factor concentrates, which are made from pooled, donated blood. This created understandable anger among the affected community because evidence indicated that the companies manufacturing the concentrates knew the dangers of contamination but continued to distribute them anyhow.

Although considered by some to be innocent victims of HIV/AIDS, people with hemophilia have not escaped discrimination. The Ryan White Care Act, which funds HIV/AIDS services, and the Ricky Ray Act, which provides compensation to hemophiliacs infected with HIV, were named for HIV-positive boys with hemophilia who suffered serious discrimination (arson, refusal of admittance to grade school) before they died of AIDS.

Women

Women of color, particularly black/African American women, are disproportionately affected by HIV/AIDS. They represent the majority of new HIV infections and AIDS cases among women. Many women with HIV are low-income, and most have children under the age of 18. 

According to the CDC, young women (ages 13–39) represent nearly 2/3 of new HIV infections among women. Having sex with multiple partners, engaging in risky behaviors such as alcohol and drug use, and/or being unable to negotiate safer sex practices with partners all contribute to this heightened risk of contracting HIV/AIDS.

Taking care of others’ needs—children or other family members—often prevents women with HIV/AIDS from taking care of themselves. Postponing medications or missing medical appointments may also be due to financial or transportation problems. Infection with HIV/AIDS may not seem to be a woman’s most serious problem. Income, housing, access to healthcare, possible abusive relationships, and concerns about her children seem more urgent and important, especially when HIV/AIDS symptoms are mild and manageable. Single mothers are especially vulnerable because they lack adequate financial and emotional support.

Older women with HIV/AIDS face complex challenges in addition to the common chronic health problems of this group—osteoporosis, high cholesterol, high blood pressure, obesity, and heart disease. Many of the antiretroviral drugs can exacerbate these conditions.

People of Color

As stated earlier, African Americans and Hispanics have disproportionately higher rates of HIV/AIDS in the United States. There are no biologic reasons for these disparities in incidence and no single reason why these disparities exist. However, there are a number of contributing factors, including:

• Health disparities linked to socioeconomic conditions
• Distrust of the healthcare system based on historical abuses of people of color
• Difficulty communicating health information in culturally appropriate ways to diverse communities
• Denial about HIV risk due to stigma about the disease and its connection to homosexuality and drug use

Prevention messages need to be culturally appropriate and relevant and they must be delivered through channels appropriate to individual communities. These channels may include religious institutions and respected elders in the community. Ironically, some of these same institutions or elders may have contributed to the misinformation and stigma associated with HIV/AIDS.

CONCLUSION

The AIDS epidemic has claimed the lives of more than 30 million people across the globe, more than 600,000 of them in the United States. More than a million people are living with HIV/AIDS in the United States, and every year another 56,000 Americans are infected with HIV.

Despite this ongoing tragedy, the public no longer has a sense of urgency or importance about AIDS. An editorial in the New England Journal of Medicine best describes the situation—“AIDS in America: Forgotten but Not Gone” (El-Sadr et al., 2010). Research has produced drugs that slow but do not stop the carnage, and the cost of these drugs has tripled during the past 10 years. No vaccine has proved effective in preventing HIV. So the epidemic continues to spread, primarily among disadvantaged and marginalized populations: the poor, people of color, people in prison, injection drug users, and men who have sex with men. Many do not realize they are infected and unknowingly transmit the virus to others.

Ignorance, prejudice, and lack of access to healthcare are fueling the epidemic. Therefore, health professionals have a critical role in screening and in educating patients, families and communities about prevention. Only by making prevention a priority will we achieve the goals of the National AIDS Strategy:

• Reducing infection rates
• Increasing access to care for those infected
• Eliminating disparities in prevalence, diagnosis, and treatment

Health professionals can also teach by example, through offering nonjudgmental, compassionate care to those affected by this deadly virus.