HIV/AIDS for Washington Healthcare Workers (2 CH)

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By Nancy Evans, BS

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• Trace the etiology and epidemiology of HIV in Washington State and the United States.
• Name the factors affecting risk for transmission of HIV in general and among healthcare workers in particular.
• List confidentiality and legal reporting requirements in Washington State for HIV/AIDS.
• Summarize the psychosocial issues associated with HIV/AIDS.

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).

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).

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.

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 two thirds of the total AIDS cases reported in the state (Washington State Department of Health, 2009). 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, injection-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, 2010b). 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, 2010b).

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, 2009a).

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.

Other High-Risk Populations

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.

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. 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).

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 a 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 25% of female cases (CDC, 2008).

Seniors represent 27% of the HIV-infected population in the United States. Males account for three fourths of cases and females account for a 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.

TRANSMISSION OF HIV

AIDS is caused by the human immunodeficiency virus (HIV). 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.

Means of Transmission

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.

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, 2006).

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.

LESS COMMON MEANS OF TRANSMISSION

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, and 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.

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.

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. However, 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%.

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.

Additional Risk Factors

People who become 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 then facilitates infection with other STDs, creating a destructive synergy.

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 any mood-altering substances, 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.) Certain substances can also mask pain and/or create oral and genital sores, which create additional entry points for HIV and other STDs.

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. 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.

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.)

The high prevalence of HIV infections in correctional institutions increases the risk of exposure, as does the environment itself. CDC (2009b) 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. 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.

Each employer covered under WAC 296-823 must develop an Exposure Control Plan (ECP). This plan requires the employer to identify those tasks and procedures in which occupational exposure may occur. It also requires the employer to identify the individuals who will receive the training, protective equipment, vaccination, and other benefits of the standard.

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. Employees must be provided access to a qualified trainer during the training session to ask and have answered questions as they arise. This training must take place prior to assignment to tasks where occupational exposure may occur.

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

PERSONAL PROTECTIVE EQUIPMENT

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.

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

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

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. 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.

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.

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.

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.

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. 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.

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. 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. 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.

POSTEXPOSURE MANAGEMENT

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 (2005b).

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.

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. 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, 2005b).

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, 2005b).

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.

LEGAL ISSUES

Reporting Requirements

AIDS and HIV infection are reportable conditions in Washington State (WAC 246-101). 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.

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 (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).

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. 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.

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.

Disability and Discrimination

Washington law prohibits discrimination based on HIV status. It is also illegal to discriminate against someone “believed” to have HIV/AIDS, even though that person is not infected. (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.) 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.

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. An employee with a disability must self-identify and request a reasonable accommodation. The employer must engage in an interactive process with the requestor.

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 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

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.

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.

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
• Mental acuity (confusion/dementia)
• Income and savings
• Health insurance
• Employment
• Housing and personal possessions (including pets)
• Emotional support from family, friends, colleagues, and religious and social institutions
• Self-sufficiency and privacy
• Social contacts/roles
• 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.

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 two thirds 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.