Wild Iris Medical Education
COURSE PRICE: $40.00
CONTACT HOURS: 4
This course will expire or be updated on or before March 3, 2014.
ABOUT THIS COURSE
You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.
ACCREDITATION / APPROVAL
Wild Iris Medical Education, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Wild Iris Medical Education is an approved provider of continuing education by the American Occupational Therapy Association (AOTA), Provider #3313. Courses are accepted by the NBCOT Certificate Renewal program.
Wild Iris Medical Education is approved as a provider of nursing continuing education by the Florida Department of Health, Division of Quality Assurance, Board of Nursing. Florida Board of Nursing Accreditation #NCE3403.
Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. See our disclosures for more information.
This course meets the HIV/AIDS continuing education requirement for many Florida healthcare professionals.
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Copyright © 2011 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to provide a review of the causes and incidence of HIV/AIDS in Florida and the United States, managing possible co-infections of HIV, tests for HIV, modes of transmission for HIV, clinical management of HIV/AIDS, recognizing HIV/AIDS-associated psychosocial issues, and Florida law governing HIV/AIDS testing and disclosure.
Upon completion of this course, you will be able to:
HIV can’t be cured, and it’s dangerous. But it can be prevented, it can be treated, and the pandemic can be stopped. Provided we each stop instinctively judging those who live with it and instead start learning more about it.
—MYLES HELFAND (2010)
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).
DEFINING AIDS
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).
| Source: UNAIDS, 2009. | |
| 33.4 million people living with HIV/AIDS |
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| More than 30 million dead of AIDS |
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| During the year 2008 |
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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).
| 1.1 million people living with HIV/AIDS |
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| Nearly 600,000 dead of AIDS since 1981 |
|
| During the year 2008 |
|
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.
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 percent 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 percent of male infections but more than 50 percent of female infections (CDC, 2010a).
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, 2010b)
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:
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, 2010b).
The NAS includes major outcomes to be achieved by 2015, such as:
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.
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.
In the United States, HIV/AIDS has been largely an urban epidemic, although it is growing rapidly in rural areas, particularly in the rural South. Prevalence is highest in Miami and Jacksonville, Florida; New Orleans and Baton Rouge, Louisiana; Baltimore, Maryland; and Washington DC (CDC, 2010i).
Florida has the third highest incidence of HIV/AIDS in the United States, exceeded only by California and New York. The Florida Department of Health (2009a) estimates that approximately 125,000 persons in the state are living with HIV infection (including AIDS). In 2009, Florida reported 5,508 new HIV diagnoses, and 4,369 cases of AIDS. Although the HIV/AIDS epidemic is prevalent throughout Florida, the majority of cases (76%) were reported in nine counties: Broward, Duval, Hillsborough, Lee, Miami-Dade, Orange, Palm Beach, Pinellas, and Polk.
The economic downturn since 2008 has affected both federal and state budgets, creating a drug access crisis in many states. As of June 2010, the AIDS Drug Assistance Program (ADAP) in Florida reported that nearly 1,800 HIV patients were waiting for access to lifesaving drug treatment. In late summer, the program received a $6.9 million federal grant, enough for three weeks’ worth of medications (Tasker, 2010). Meanwhile, the cost of HIV drugs almost tripled between 1999 and 2009 (National ADAP Monitoring Project, 2010).
HIV/AIDS is more prevalent among women in Florida than in women nationally and also more prevalent among blacks. However, the prevalence among MSM in Florida is lower than among MSM nationally. The prevalence of AIDS among heterosexual populations in Florida is much higher than among heterosexuals nationally (38% vs. 24%) (Florida Department of Health, 2009a).
Blacks account for nearly half of Florida’s HIV-positive population and nearly half of the AIDS cases, even though they comprise only 14 percent of the state’s population. HIV is the leading cause of death for black women between the ages of 25 and 44 and the third leading cause of death for black men in this age group (Florida Department of Health, 2009b). HIV is the third leading cause of death among Hispanic women in this age group and the ninth leading cause of death among white women in this age group (Florida Department of Health, 2009c).
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 percent of new HIV infections in the United States:
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 account for more than half of all newly reported HIV infections, and young men are at highest risk. MSM account for just 4 percent 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, 2010h). They are the only risk group in the United States in which new HIV infections are increasing.
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, 2010h).
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.
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, 2010h).
When AIDS emerged as a mysterious, deadly “gay epidemic,” it deepened America’s longstanding prejudice toward homosexuals. Some religious groups saw the epidemic as divine retribution for “unacceptable” and “unnatural” behavior. Despite these obstacles, the gay community’s extraordinary advocacy focused attention and research funding on the disease, ultimately helping to extend the lives of people with HIV/AIDS.
Society’s prejudice against gays continues to exacerbate the pain of the HIV/AIDS experience, although attitudes are slowly changing. Some community groups fail to offer support to those living with HIV/AIDS or their families because of the stigma attached to homosexuality. The Balm in Gilead is one organization working to build the capacity of faith communities to offer AIDS education and support networks for all people living with and affected by the disease (see “Resources” at the end of the course).
Bisexual men (who have sex with both men and women and may not self-identify as gay) are not the major target for HIV prevention messages. Bisexual men may not have the same access to social and community resources as men who have sex with men. Many hide their sexual activities with men (called sex on the down low) because of cultural homophobia and may unknowingly infect their female partner(s).
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 an opening 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.
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 U.S., but policies and specific procedures differ. In some cases, testing is mandatory. Florida Statute 495.355 mandates that prisons test inmates for HIV within 60 days before they are released back into the community. Those who test positive must be provided with transitional assistance, which includes:
Unlike prisons, jails are not required to test inmates unless they have been convicted of a sex-related crime.
Women now constitute more than a fourth of the HIV/AIDS-infected population nationwide and nearly three-fourths 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 a fourth of female cases (CDC, 2008b).
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.
In Florida, the Targeted Outreach for Pregnant Women Act (TOPWA), established in 1999 by Florida statute 381.0045, requires that healthcare providers counsel and offer HIV testing to all pregnant women on their initial prenatal visit and again at 28 to 32 weeks’ gestation. TOPWA outreach workers go into the community and seek out pregnant women in housing projects, laundromats, bars, or other public places.
The TOPWA program has increased poor women’s access to prenatal care, including HIV testing and antiviral therapy, reducing the number of babies born with HIV infection. Through July 2009, more than 32,000 pregnant high-risk or HIV-infected women have been enrolled in TOPWA, assessed to determine their level of risk, and linked to prenatal care and other needed services such as referrals for substance abuse testing and treatment, family planning services, and HIV prevention education and condoms.
According to CDC (2008d), people over 50 in the United States account for:
Seniors represent 27% of the HIV-infected population in Florida and in the United States. Males account for 75% of cases and females accounted for 25%. Half of HIV-infected seniors are black, a third are white, and the remainder are Hispanic. Nearly two-thirds of all Florida senior HIV/AIDS cases reported through April 2010 came from four counties: Miami-Dade, Broward, Palm Beach, and Orange. Of the nearly 2,500 HIV-related deaths in 2008, almost half were among people age 50 or older (Florida Department of Health, 2009d).
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:
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.
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 use of drugs, particularly injection drugs, among street 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).
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.
According to the San Francisco AIDS Foundation, 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 (2007), 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).
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:
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.
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.)
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.
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.
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.
An infected pregnant woman can transmit HIV to her fetus, and an infected mother can infect her breastfeeding infant. However, the incidence of perinatally acquired HIV peaked in 1992 and has decreased to 2% nationally in recent years. Implementation of Public Health Service guidelines for universal counseling and voluntary HIV testing of pregnant women, scheduled cesarean delivery, avoidance of breastfeeding, and the use of antiretroviral therapy by pregnant women and administered to newborn infants primarily account for the decline. (See additional discussion of treatment protocols for pregnant and nursing women under “Antiretroviral Treatment” below.)
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.
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.”
Other occupational groups with potential exposure to HIV (and HBV, 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.)
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 PEP (2005). Mental health issues can include sleep disruption, anxiety, panic attacks, and posttraumatic stress disorder (PTSD) (Shalo, 2007).
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. 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:
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.
Infections that are commonly found in HIV-positive patients include a number of other sexually transmitted diseases, TB, and hepatitis C. Coexisting infections may increase the risk of transmission of HIV and make its treatment more complex.
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.
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).
Florida ranks 25 among 50 states in chlamydial infections (389.1 per 100,000 people) and 17 among 50 states in gonorrheal infections (127.8 per 100,000 people). Rates of chlamydial infections were nearly 3 times greater among women than men and have increased sharply since 2005. Florida ranks 11 among 50 states, with 5.7 cases of primary and secondary syphilis per 100,000 people, and rates have increased sharply since 2005. The number of congenital syphilis cases decreased from 30 in 1999 to 17 in 2008. (CDC, 2010d)
Mycobacterium tuberculosis (M. tuberculosis, or TB) is the most common and most deadly coexisting infection for HIV-positive individuals. The CDC estimates that TB is the cause of death for a third of people with HIV worldwide. The spread of HIV/AIDS has helped fuel the TB epidemic. All people infected with HIV should be tested for TB and, if infected, begin complete therapy as soon as possible to prevent active TB disease.
In 2008, reported cases of TB in the United States fell to 12,904, the lowest rate (4.2 cases per 100,000) since 1953. However, the rate of decline in TB incidence has slowed, which experts see as cause for concern. Left untreated, active TB disease will develop in 5% to 10% of infected individuals.
Coinfection with TB and HIV also declined in 2008. However, coinfection rates were much higher among such subgroups as injection drug users, non-injection drug users, homeless persons, non-Hispanic blacks, and correctional facility inmates (CDC, 2009d).
Florida is one of 15 states with TB rates higher than the national average. In 2009, the Florida Department of Health reported 821 new cases of TB, a case rate of 4.4 per 100,000 population and a 13% decline since 2008. As the decline in TB rates has slowed, the number of multidrug-resistant TB (MDR TB) cases has increased, and disparities in TB rates between whites and racial/ethnic minorities have persisted. In Florida, non-Hispanic whites accounted for nearly half the cases of TB, followed by blacks, Hispanics, Asians, and Native Americans.
According to CDC (2009d):
HIV-infected persons with either latent TB infection or active TB disease can be effectively treated. The first step is to ensure that HIV-infected persons are tested for TB. The second step is to help those infected with TB to get proper treatment and prevent rapid progression from latent TB infection to active TB disease.
TB TESTS
The blood assay for TB testing, QuantiFERON-TB Gold (QFT-G), can be used in any situation in which a tuberculin skin test (TST) is used. It offers quicker results, one-step testing, and dependable accuracy. Results are available 24 hours after blood collection. However, laboratory analysis must begin within 12 hours of blood collection, necessitating rapid transport of specimens. The CDC (2007a) cautions that there are limited data on the use of QFT-G in children under age 17 and in immunocompromised persons, such as people with HIV/AIDS.
A diagnosis of latent tuberculosis infection (LTBI) requires that TB disease be excluded by medical evaluation, which should include evaluating signs and symptoms associated with TB disease, a chest x-ray, and, when indicated, examination of sputum or other clinical samples for the presence of M. tuberculosis.
Treatment of HIV/TB coinfected patients involves a complex 6-month or 9-month multidrug regimen. All these drugs have significant side effects, which can lead to nonadherence and development of MDR TB, which is much more difficult to treat successfully. Coinfected individuals are at increased risk of developing active TB disease, and their anti-HIV medications must be carefully orchestrated to coincide with the TB regimen. Ideally, this complex care involves experts in the management of both tuberculosis and HIV disease (CDC, 2007a).
Healthcare workers should be screened and evaluated to identify those who are at risk for TB disease or exposure. In situations that pose a high risk of exposure to M. tuberculosis (such as rooms where cough-inducing or aerosol-generating procedures are performed), healthcare workers need to use respiratory protection equipment such as particulate filter respirators. Effectiveness of respiratory protection depends on how well the respirator fits the individual, the care in using the respirator, and the adequacy of the training and fit-testing program.
The CDC also recommends that visitors to airborne infection isolation (AII) rooms and other areas where there are patients who have suspected or confirmed infectious TB should be offered disposable respirators and should be instructed by a healthcare worker on use of the respirator before entering an AII room (CDC, 2005d).
Hepatitis is inflammation of the liver that may be caused by drugs and toxic agents or by one of several viruses, including hepatitis A, B, C, D, and others. People who are HIV-positive are at risk for hepatitis A, B, and C infection. Hepatitis A is transmitted by fecal/oral route, usually by contamination of water or food due to poor sanitation. Hepatitis B (HBV) and C (HCV) are transmitted by the blood and body fluids of an infected person.
HIV-infected people should be tested for both A and B viruses, and if they test negative, should receive vaccines against both. However, there is no vaccine for HCV.
Those who receive hepatitis B vaccine should be tested for antibodies to hepatitis B surface antigen (antiHBs) 1 to 2 months after completion of the primary series of hepatitis B vaccine. Those who fail to respond should be revaccinated with up to three additional doses.
Hepatitis B (HBV) can cause chronic liver disease or liver cancer, which makes vaccination essential to prevention. HBV vaccine is relatively inexpensive for infants and children and commonly administered to most infants before their first birthday. It is critical that infants whose mothers are HBV positive receive the vaccine; otherwise, they have a 90% chance of developing the disease. Adult doses of HBV vaccine cost about $150 per person, which may explain why most adults are not vaccinated against HBV.
Each year, an estimated 43,000 people in the United States are infected with HBV. Each year, more than 11,000 people will be hospitalized and about 4,000 to 5,000 people will die from chronic liver disease or liver cancer caused by HBV (CDC, 2009e). Florida reported that between 1999 and 2008, rates of acute HAV and acute HBV decreased by more than 50% (Florida Department of Health, 2009).
People with HBV should not donate blood, semen, or body organs.
Symptoms of HBV may vary. Some people may feel fine and look healthy; others may have only mild symptoms, such as loss of appetite, extreme fatigue, abdominal pain, jaundice (yellowing of the eyes and skin), joint pain, malaise, dark urine, nausea or vomiting, and skin rashes. Still others may experience more severe symptoms and may be incapacitated for weeks or months.
Risk factors for HBV include:
There are no medications available for recently acquired (acute) HBV infection. There are antiviral drugs available for the treatment of chronic HBV infection, but they are not always effective.
Hepatitis C (HCV) is the most common chronic bloodborne infection in the United States and a leading cause of chronic liver disease. HCV was discovered in the late 1980s, although it was probably being spread for decades prior to that. The CDC (2009e) estimates that 3.2 million Americans have been infected with HCV, many of them from blood transfusions, and half of them do not know they are HCV-positive. (Since 1992, all blood donations in the United States have been tested for HCV.) People infected with HCV may have no symptoms for decades. When symptoms do appear, they are similar to those of HBV (see above).
Each year another 17,000 people are infected with HCV, and more than 8,000 people die from HCV-associated liver disease. Complications and costs associated with chronic HCV infection are expected to increase during 2010–2019 because the incidence of new infections peaked from the late 1960s to early 1980s (Klevens et al., 2009). About 4 of every 100 infants born to mothers with hepatitis C become infected with the virus. However, the risk increases if the mother is coinfected with both HIV and HCV.
An estimated 1 in 3 of HIV-positive people in the United States are also infected with HCV. Incidence is even higher among HIV-positive injection drug users (IDUs) (50%–90%). Coinfection with HIV and HCV is associated with higher titers of HCV, more rapid progression to HCV-related liver disease, and increased risk for cirrhosis of the liver.
Liver disease from chronic HCV is now one of the leading causes of death among people living with HIV. The U.S. Public Health Service/Infectious Disease Society of America guidelines recommend that all HIV-infected persons be screened for HCV infection.
The incidence of HCV in Florida is unclear because HCV was not a reportable disease until 1999 and cases have only been reported to CDC since 2002. However, national estimates suggest that approximately 300,000 people in Florida are chronically infected with HCV, and approximately 2,000 new infections occur each year. Prevalence is higher among people with multiple sexual partners (9% among those having 50 or more sexual partners during their lifetime) (Florida Department of Health, 2010).
People who should consider testing for HCV include:
Type 2 diabetes is a known complication of all liver disease, regardless of cause. However, research suggests a direct role of HCV in disrupting glucose metabolism. Type 2 diabetes appears to accelerate the progression of chronic HCV but also reduces the effectiveness of interferon-alpha-based therapy (Negro & Alaei, 2009).
Coinfected patients also need to consult their health professional before taking any new medications, including over-the-counter (OTC), alternative/complementary, or herbal medicines, because of their possible effects on the liver. Those receiving ART may also be at risk for drug-induced liver injury (DILI) and should be carefully monitored.
In coinfected patients with lower CD4 counts (<200 cell/mm3), it may be preferable to initiate antiretroviral therapy and delay HCV therapy until CD4 counts increase. Patients receiving or considering therapy with ribavirin should avoid didanosine, stavudine, and zidovudine. Antiretroviral agents with the greatest risk of DILI should be used with caution (Public Health Service Task Force, 2009).
CHRONIC HEPATITIS C: FACTORS IN PROGRESSION OR SEVERITY
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 practices include:
Both women and men may need instruction in the correct use of condoms:
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, 2006b). Precautionary measures include:
The CDC (2010c) has identified challenges to prevention of HIV transmission among MSM, particularly those aged 15–49 years old. They include:
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.
Injection-drug users who refuse treatment or who have no treatment programs available to them need instructions about precautions: Do not exchange 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.
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.
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:
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.
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:
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)
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:
OTHER POTENTIALLY INFECTIOUS MATERIALS (OPIM)
OPIM linked to transmission of HIV, HBV, and HCV are listed below. Standard precautions and universal precautions apply to all of the following:
Source: OSHA, 2004.
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 (2005c):
Immediately after exposure to blood of a patient:
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.
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, 2005c). 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, 2005c).
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.
Postexposure Prophylaxis (PEP)
Postexposure prophylaxis is not as simple as swallowing a single pill. The medications must be started as soon as possible and continued for 28 days. The antiviral drugs used in PEP are potentially toxic and should not be used for exposures that pose a negligible risk.
If the source individual cannot be identified or tested, decisions regarding follow-up should be based on the exposure risk and whether the source is likely to be infected with a blood-borne pathogen. Follow-up testing should be available to all personnel who are concerned about possible infection through occupational exposure.
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, 2005c).
Safety devices have been developed to help prevent needle-stick injuries. If used properly, these types of devices may reduce the risk of exposure to HIV. Many percutaneous injuries are related to sharps disposal. Strategies for safer disposal, including safer design of disposal containers and placement of containers, are being developed.
Most HIV infections are transmitted by people who do not know they are infected. Therefore, HIV testing is the first step in halting spread of the virus. Research shows that people who are unaware of their HIV infection have a transmission rate of almost 11 percent compared with a rate of less than 2 percent in those who know they are HIV-positive. When counseling services are available and effective, that rate falls to near zero (Holtgrave & Anderson, 2004).
The revised CDC recommendations (2006) for routine voluntary HIV screening of patients aged 13–64 in all healthcare settings include the following:
Testing is essential for anyone who has had a potential exposure to HIV. This includes anyone who has had unprotected anal, vaginal, or oral sex; who has shared needles or other injection drug preparation equipment; or who has had an occupational exposure. People with partners who have such risk factors should also consider testing.
Florida’s Omnibus AIDS Act of 1988 and its 1998 update are essential for doctors, nurses, and other healthcare providers to understand. This legislation corresponds closely with federal guidelines and accepted medical practice. Violations are heavily penalized, and good-faith efforts at compliance do not ensure anyone against legal difficulties.
The principal methods for dealing with the HIV/AIDS epidemic as stipulated in the Florida Omnibus Aids Act are education and testing that is informed, voluntary, and confidential.
HIV/AIDS infection not only carries the stigma of a sexually transmitted disease but also the association with homosexuality and 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 one Florida family’s home was burned after a young family member developed AIDS.
Thus, Florida legislation stipulates four reasons for deviation from traditional educational and testing methods:
Before anyone can be tested for HIV in Florida, they must explicitly consent to be tested. Testing without informed consent 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.
A general consent to draw a patient’s blood and run unspecified tests does not meet the Florida criteria of informed consent for HIV testing. The healthcare provider must explain the HIV test in a manner appropriate to the age, mental capacity, and language skill of the subject. The explanation should include the following information (Department of Health Rule 64D-2.004, F.A.C):
A separate statute, designed to eliminate “unnecessary diagnostic testing,” may make an HIV test illegal even when informed consent is granted. The law forbids diagnostic tests “which are not reasonably calculated to assist the healthcare provider in arriving at a diagnosis and treatment of a patient’s condition.” It is also forbidden to test for evidence of HIV infection “solely for the purpose of protecting healthcare workers.”
Children under 18 are considered adults for the purpose of consenting to, or refusing, an HIV test. Parental permission is not required for a child judged by the healthcare provider to be sufficiently mature to consent or refuse an HIV test. Florida law forbids informing parents of a minor’s HIV test results either directly or indirectly (such as sending a bill for testing or treatment without the minor’s consent). It is up to the healthcare provider to decide whether the minor is capable of understanding the risks and benefits of the test or treatment.
A 1998 amendment to the Florida Omnibus AIDS Act requires the physician or midwife attending a woman for a condition related to pregnancy to offer HIV testing in conjunction with her required blood tests at the initial prenatal care visit and again at 28 to 32 weeks’ gestation, regardless of risk behaviors.
In 2005, the statute was amended to establish the current system of opt-out testing for all pregnant women. Under this system, all pregnant women are advised that their healthcare provider will conduct an HIV test but that they have the right to refuse testing. Any pregnant woman who refuses testing must do so in writing, and her refusal must be placed in her medical record (§384.31, F.S.).
Any pregnant woman who has positive test results should be referred to medical and support services related to HIV/AIDS as well as the Healthy Start Care Coordination System. Any pregnant woman who presents at delivery without a record of a blood test for HIV during pregnancy must be counseled and offered an HIV test.
HIV testing without informed consent may occur in the following circumstances:
Anonymous and confidential HIV tests are available at Florida county health departments and other registered testing sites. County health departments and registered testing sites are required to provide private pre-test and post-test counseling for all persons tested. Confidential HIV tests are also increasingly available in private-sector doctors’ offices and hospitals.
The legal requirements for counseling and testing are different for public- and private-sector facilities. County health departments must obtain written informed consent from the test subject. Registered testing sites and private-sector facilities are not required to obtain written consent, provided that the medical record includes documentation that the test was explained and consent was obtained. Written consent is preferable, nonetheless, because it provides practical advantages to the testing agency or facility and the healthcare worker in the event of litigation.
Medical records are, by law, confidential. The Florida Omnibus Aids Act designates information about HIV testing as superconfidential if the tests can be traced to an identifiable individual. All test results, positive or negative, are superconfidential, which means that the information is only made available to healthcare personnel on a need-to-know basis. Providers, in turn, must sign a legal document not to divulge this information except on a need-to-know basis.
However, the law uses a narrow definition of “HIV test result.” The superconfidentiality standard applies only to the part of a person’s medical record that documents an HIV test and the results, negative or positive, of that test. If the documented HIV status was based on a health department anonymous test or a home testing kit, that does not constitute “HIV test results” and is not covered by the superconfidentiality standard.
Providers’ clinical assessments of any medical conditions associated with AIDS are also exempt from the superconfidentiality standard because they do not constitute “HIV test results” unless they include laboratory reports or medical-record notes of an HIV test. For example, a patient’s chart documenting symptoms of AIDS and including the word AIDS throughout the chart, but without an HIV test result or report, is not considered superconfidential.
Disclosure of HIV test results is limited to the following:
The 1998 amendment to Florida’s Omnibus AIDS Act increased the penalty for breaches of confidentiality. Anyone who maliciously, or for monetary gain, breaches the confidentiality of sexually transmitted disease information commits a third-degree felony.
The healthcare provider ordering an HIV test must make all reasonable efforts to notify the person tested of the results. If the HIV-negative person fails to obtain the results, either by missing a scheduled visit or not calling in, the provider has met the “all reasonable efforts” standard.
However, if the test results show the person to be HIV-positive, the provider must exhaust all available means to contact the patient. If all efforts fail, the responsibility for notification can be transferred to the county health department through HIV infection–reporting requirements.
If test results are HIV-negative, notification should include appropriate information on preventing transmission of HIV. Information for high-risk test subjects may not be appropriate for low-risk test subjects and vice versa.
If test results are HIV-positive, counseling the test subject must include information on the following:
Counseling someone who has just learned of his or her HIV-positive status requires not only that the healthcare provider be familiar with local HIV health and social services but also that the provider have the ability to communicate with clarity, sensitivity, and compassion.
The Florida Department of Health has developed “Model Protocols on Counseling and Testing” that may be obtained through the website at http://www.floridaaids.org.
HIV testing is a two-step process that includes a screening test and, when the screening test is reactive (positive), a confirmatory test.
Until 2002, testing for HIV antibodies relied on an enzyme-linked immunosorbent assay (ELISA) of blood. Since then, six rapid HIV tests have been approved by the FDA, all of which are interpreted visually. Four of the tests have been approved for use outside of a clinical laboratory. The FDA and the Centers for Medicare and Medicaid Services have also issued guidelines for a rapid HIV test quality-assurance program (Greenwald et al., 2006).
Until these rapid tests became available, many people being tested in public clinics did not return to get their test results. Making results available during the testing appointment means that people can take immediate precautions to prevent transmission to their sexual partners. In addition, the oral fluid test offers another option for those people who may fear a blood test.
All positive (reactive) rapid HIV tests require repeat testing for confirmation. The CDC described protocols for confirming reactive rapid HIV tests based on a consultation convened in January 2003 with expert laboratory scientists, the FDA, and the Centers for Medicare and Medicaid Services. These protocols recommend: (1) confirmation of all reactive rapid HIV test results with either Western blot (WB) or immunofluorescent assay (IFA), even if an enzyme immunoassay (EIA) screening test is negative; and (2) follow-up testing for persons with negative or indeterminate confirmatory test results, with a blood specimen collected 4 weeks after the initial reactive rapid test result (CDC, 2004).
Tests are now available for self-testing of HIV serostatus. Home Access Express HIV-1 Test System is the only FDA-approved home test kit currently on the market, but several unapproved kits are marketed on the Internet. This Home Access Express product is really an in-home sample collection system rather than a test with readily visible results. The person who wants to test at home pricks a finger and collects blood spots on special paper. The paper is mailed to a certified clinical laboratory with a confidential and anonymous personal identification number (PIN) and then tested using a standard ELISA process.
If the initial test result is positive, the results are confirmed by a Western blot test. The person tested obtains the results by calling a toll-free telephone and using the assigned PIN. Post-test counseling is available by telephone for everyone tested, whether the results are positive or negative.
Home testing is a controversial issue, primarily because of the need for counseling. The FDA has expressed concern that people who have not been appropriately counseled by experienced staff in a culturally competent way before they receive the news that they are HIV-positive may commit suicide. Counseling needs to help reduce anxiety and risk-taking behavior as well as link individuals to services. However, at least one survey showed that nearly 25% of clients at public testing services would choose a home self-test.
HIV test results can be one of three types: negative, positive, or indeterminate. A person may test negative for HIV antibodies even though recently infected. As stated earlier, newly infected persons may have high levels of the virus in their blood, making them highly infectious even though test results are negative.
If the test result is negative, it means either (1) the person is not infected with the virus, or (2) the person became infected recently and antibodies have not yet appeared. A person who tests negative for HIV but remains concerned about a possible recent infection should test again in 3 to 6 months and practice safer behaviors in the meantime. If risky behavior continues, infection may still occur.
A positive test result shows the presence of HIV antibodies, which means that:
Occasionally a rapid test or an enzyme immunoassay test will show an “indeterminate” or “inconclusive” test result. This may mean that the person is recently infected and is developing antibodies, a process called seroconversion. Indeterminate test results can also be caused by other factors, including but not limited to pregnancy, autoimmune diseases, blood transfusions, recent influenza vaccinations, or organ transplants.
People receiving indeterminate HIV test results should retest using a blood specimen collected 4 weeks after the initial test. Retesting is recommended even if HIV infection is extremely unlikely. Research has shown that only about 20% of people with indeterminate test results go on to become positive. Only rarely do people remain indeterminate throughout their lives.
The trajectory between infection with HIV and the development of full-blown AIDS can be steep or gradual and may take as long as a decade or more. If the infection is untreated, the average time from HIV infection to death is 10 to 12 years. However, early detection and appropriate medical treatment may result in longer lives for those infected and reduced rates of HIV transmission.
Antiretroviral therapy (ART) has become the gold standard for treatment of HIV/AIDS. People with HIV may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia.
Some conditions, called co-factors, can affect the course of disease progression, including age, genetic factors, drug use, smoking, nutrition, and co-infection with hepatitis C virus (HCV) and/or tuberculosis (TB). Although the slope of the disease trajectory varies with each individual, HIV/AIDS progresses through five stages:
| Source: Zolopa & Katz, 2010. | |
| Definitive AIDS diagnoses (with or without laboratory evidence of HIV infection) |
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| Definitive AIDS diagnoses (with laboratory evidence of HIV infection) |
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| Presumptive AIDS diagnoses (with laboratory evidence of HIV infection) |
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The advent of more effective antiretroviral drugs for treating HIV has decreased the number of people with infection, malignancy, or a low enough CD4 count to classify them as having AIDS. (Thus, the Social Security Administration and most social service agencies determine eligibility for AIDS benefits based on functional assessment of the individual.)
Antiretroviral drugs are administered in “cocktails” of three or more, a treatment referred to as antiretroviral therapy. The primary goal of ART is to reduce HIV-associated morbidity and mortality by suppressing the individual’s viral load to below detectable levels.
Antiretroviral treatment of people with HIV continues to prove complex, controversial, dynamic, and expensive. These drugs do not constitute a “cure” for HIV/AIDS. If therapy is discontinued, viral load will increase. Even during treatment, the virus is replicating and the person remains infectious to others.
HIV/AIDS DRUGS
Five major classes of drugs are used to treat HIV/AIDS:
*CCR5 stands for chemokine (C-C motif) receptor 5, one of the two known points of entry used by the HIV virus to penetrate the CD4 T-cells. CCR5 antagonists are designed to block this receptor. The first of these drugs was approved by the FDA in August 2007 for use in treatment-experienced patients who have detectable HIV RNA and multidrug resistance to antiretrovirals.
**The first of these newest drugs, raltegravir (Isentress), was approved by the FDA on October 12, 2007. This class of drugs is designed to slow the progression of HIV by blocking the HIV integrase enzyme that the virus needs in order to multiply.
In 1996, tests to measure an individual’s viral load became available, providing objective criteria for treatment decisions. Following are treatment recommendations by the Panel on Antiretroviral Guidelines for Adults and Adolescents (2009):
Discontinuing or interrupting ART may become necessary due to factors such as serious drug toxicity, intervening illness, surgery, or unavailability of medications. Although unplanned short-term interruption of therapy may be unavoidable, planned interruption is no longer recommended. Interrupting therapy increases the risk of AIDS-related complications, declining CD4 counts, and other non–AIDS-related complications such as heart attack and liver failure.
While extending and improving lives of people with HIV, long-term use of some of these drugs increases the risk of liver problems, high cholesterol, stroke, heart disease, osteoporosis, diabetes, pancreatitis, neuropathy, and skin rashes. Some of the skin rashes can be life-threatening, such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), which are two different forms of the same kind of skin rash. TEN may involve as much as 30% of the total body skin area. Both these severe rashes must be treated by a physician.
Antiretroviral drugs may also interact with other drugs used to treat opportunistic infections. For example, researchers reported that using oral erythromycin while taking protease inhibitors increased the risk of sudden death from cardiac causes (Ray et al., 2004). As patients live longer with HIV/AIDS, many develop drug-resistant strains of the virus, which further complicates treatment.
The May 2010 Public Health Service guidelines emphasize that combination drug regimens—rather than zidovudine (ZDV) alone—are considered the standard of care both for treatment of maternal HIV infection and for prevention of perinatal HIV transmission. Clinical trial results indicate that antiretroviral prophylaxis to prevent perinatal transmission of HIV should be offered to all HIV-infected women, regardless of CD4 cell count (Panel on Treatment of HIV-Infected Pregnant Women, 2010).
Therapy should be individualized for each woman based on her history of HIV antiretroviral therapy (past or current use or never used) as well as possible co-infection with HBV and/or HCV. Choice of therapy regimen also should consider not only the effectiveness of drug treatment for maternal disease but also possible teratogenic effects of the drugs on the infant. For example, efavirenz (EFV) should be avoided during the first trimester of pregnancy, and no pregnant woman should be offered regimens containing nelfinavir (NFV).
Specific detailed guidelines for the antepartum, intrapartum, and postpartum treatment of HIV-infected women of childbearing age and treatment of their infants evolve rapidly. Practitioners are advised to consult the most recent information on the CDC’s AIDSinfo website (Panel on Treatment of HIV-Infected Pregnant Women, 2010).
Use of multi-drug ART by many people over time has allowed drug-resistant strains of the virus to develop. These drug resistant strains have been found in those receiving ART as well as in patients who have never received ART, which limits their treatment options at the outset.
Experts predict that drug-resistant infections are about to spike in developed countries. One recent study suggests that drug resistance will increase by about 30% in the next three to five years in San Francisco (Smith et al., 2010). Treating drug-resistant HIV requires a constantly changing cocktail of expensive new drugs, and adherence to such a complex regimen can be difficult for many patients. If drug resistance increases in developing countries, treatment would be unsustainable.
Experts recommend that pretreatment drug-resistance testing be done in persons with acute or chronic HIV infection and when changing antiretroviral regimens after drugs cease to be effective (treatment failure). Resistance testing helps clinicians better predict viral response to newly initiated therapy.
HIV drug resistance testing also should be performed:
In cases of virologic failure, drug resistance testing should be performed while the patient is taking his or her drugs or within 4 weeks of discontinuing therapy.
Two types of resistance assays are used: genotypic and phenotypic assays. Genotypic assays detect drug resistance mutations in the viral genes, while phenotypic assays measure a virus’s ability to grow in different concentrations of antiretroviral drugs. Genotypic assays take 1 to 2 weeks and phenotypic assays, 2 to 3 weeks. A genotypic assay is generally recommended for patients who have never had antiretroviral therapy. Genotypic resistance testing also is recommended for all pregnant women prior to initiation of therapy and for those entering pregnancy with detectable HIV RNA levels while on therapy.
HIV affects women and men differently. Women are more likely to be diagnosed at more advanced stages of the disease. Although they tend to have lower viral loads than men at diagnosis, they generally have faster disease progression and lower CD4 cell counts than men with equivalent viral loads. Women are also more likely than men to develop bacterial pneumonia and have higher rates of herpes infections and thrush (yeast infection) than men (The Body, 2010).
Smoking cessation is important for women smokers receiving ART because it interferes with the therapy’s effectiveness. A study of more than 900 women over an 8-year period showed that those who smoked were more likely than nonsmokers to die during the study period. Smokers also had higher viral loads and lower CD4 counts. In addition, they were more likely to be diagnosed with an AIDS-related illness such as wasting syndrome or non-Hodgkin’s lymphoma (Feldman et al., 2006).
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.
U.S. women with HIV receive fewer healthcare services and HIV medications compared to men with HIV, not only because of lack of health insurance but also because of lack of awareness and testing. Women with HIV may suffer discrimination by prescribing physicians. A study of HIV-infected patients in 10 U.S. cities showed that women were less likely than men to receive prescriptions for the most effective treatments for HIV infection (McNaghten et al., 2003). Postponing medications or missing medical appointments may also be due to financial or transportation problems.
Taking care of others’ needs often prevents women with HIV/AIDS from taking care of themselves. Income, housing, access to healthcare, possible abusive relationships, and concerns about children seem more urgent and important, especially when HIV/AIDS symptoms are mild and manageable.
Women may fear disclosure of their HIV status due to concerns about employment, housing, or other discrimination issues. Single mothers are especially vulnerable because they lack adequate financial and emotional support.
The clinical management of HIV/AIDS is complex, comprising several major concerns. In 2010, a national multiagency collaboration consisting of the National Committee for Quality Assurance (NQA), American Medical Association (AMA), Health Resources and Services Administration (HRSA), Infectious Diseases Society of America (IDSA), and HIV Medicine Association (HIVMA) endorsed 17 measures for quality of HIV care (see below). All healthcare practitioners can use these benchmarks to assess the management of patients with HIV.
HIV CARE QUALITY MEASURES
Process of Care
Screening
Immunization
Prophylactic Therapy
* Pneumocystis jiroveci pneumonia
** antiretroviral therapy
Source: Hoberg et al., 2010.
Because of the stigmatizing attributes of the epidemic and the additional associations with death and contagion, AIDS is a disease of denial at the individual, group, and national level.
—STALL AND MILLS (2006)
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.
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 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:
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.
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.
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.
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.
Living with HIV/AIDS involves loss of many kinds, including:
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.
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. Florida has the third highest prevalence of HIV/AIDS in the country.
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., 2009). 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:
Health professionals can also teach by example, through offering nonjudgmental, compassionate care to those affected by this deadly virus.
Act Against AIDS
http://www.nineandahalfminutes.org
http://www.cdc.gov/hiv/aaa
AIDS Education Global Information System (AEGIS)
http://www.aegis.org
AIDS.gov
http://www.aids.gov
AIDSinfo (Comprehensive site of the USDHHS)
http://www.aidsinfo.nih.gov
Black AIDS Institute
http://www.blackaids.org
The Body (HIV/AIDS Resource)
http://www.thebody.com
Centers for Disease Control and Prevention (CDC)
http://www.cdc.gov/hiv/
CDC National STD and AIDS Hotlines
English: 800-342-2437 or 800-227-8922
Spanish: 800-344-7432
Center of Excellence for Transgender HIV Prevention, University of California, San Francisco
http://www.transhealth.ucsf.edu
HIV InSite, University of California San Francisco (HIV/AIDS Treatment, Prevention, Policy)
http://hivinsite.ucsf.edu/InSite
HIV Wisdom for Older Women
http://www.hivwisdom.org
Mothers’ Voices
http://www.mothersvoices.org
National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPLINE)
1-888-448-4911
National Minority AIDS Council
http://www.nmac.org
National Perinatal HIV Consultation and Referral Hotline
1-888-448-8765
Project Inform
http://www.projinf.org
The Well Project (Women with HIV)
http://www.thewellproject.org
Women Organized to Respond to Life-threatening Disease (WORLD)
http://www.womenhiv.org
Resources in Florida
Center for Multicultural Wellness and Prevention
http://www.cmwp.org
Family Health Line
http://www.211bigbend.org/hotlines/familyhealth
800-451-2229
Florida Department of Health, Bureau of HIV/AIDS
http://www.floridaaids.org/
Florida HIV/AIDS Hotlines
English: 800-FLA-AIDS (800-352-2437)
Spanish: 800-545-SIDA (800-545-7432)
Creole: 800-AUDS, 101 (800-243-7101)
TDD/TTY: 888-503-7118
Francis House
http://www.francishouse.org
Jacksonville Area Sexual Minority Youth Network (JASMYN)
http://www.jasmyn.org
Sembrando Flores (HIV/AIDS Latino Ministry)
http://www.sembrandoflores.org/
Shadowood II, Inc.
http://www.shadowoodii.org
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