HIV/AIDS for Florida Healthcare Professionals (2 CH)

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By Nancy Evans, BS

LEARNING OBJECTIVES

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

• Discuss the incidence of HIV/AIDS in Florida.
• Describe modes of transmission for HIV.
• Summarize the testing-related requirements of the Florida Omnibus AIDS Act.
• Outline the issues in HIV/AIDS prevention.
• Explain the clinical management of HIV/AIDS.

HIV/AIDS IN FLORIDA

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.

Populations with High Prevalence

HIV/AIDS is more prevalent among women in Florida than in women nationally and also more prevalent among blacks. However, the prevalence among men who have sex with men (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).

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

Risk Groups

Three primary risk groups account for three-fourths 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

Other important groups at risk for HIV include women and children, seniors, commercial sex workers, and incarcerated populations. Poverty, unemployment, lack of education, limited access to healthcare, and disrupted social networks further increase risk among each of these groups.

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. 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.

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 a 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.

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). 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.

Women now constitute more than a fourth of the HIV/AIDS-infected population nationwide and nearly three-fourths of new AIDS cases. Women are primarily infected through heterosexual intercourse, although injection drug use accounts for 25% of female cases (CDC, 2008). 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.

Stereotypes about aging and about HIV/AIDS put seniors at risk for transmission. 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. 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.

Because commercial sex workers have hundreds of partners each year, this population is a critical element in the spread of HIV throughout the wider community. 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).

TRANSMISSION OF HIV

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

Three conditions are necessary for HIV to be transmitted:

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

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

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.)

Injection Drug Use

Sharing injection needles, syringes, and other paraphernalia with an HIV-infected person can send HIV directly into the user’s bloodstream. 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.

Needlesticks

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. 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.)

Uncommon Modes 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. The majority of those cases were in people who received blood or blood products before1985.

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.

HIV TESTING

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).

Who Should Be Tested?

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.

In addition to the primary high-risk groups, Florida law provides for testing special populations.

PREGNANT WOMEN

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.

CORRECTIONAL POPULATIONS

Florida Statute 495.355 mandates that prisons test inmates for HIV within 60 days before they are released back into the community. (Unlike prisons, jails are not required to test inmates unless they have been convicted of a sex-related crime.) Those who test positive must be provided with transitional assistance, which includes:

• Education on preventing transmission of the virus to others and on the importance of follow-up care and treatment
• A written, individualized discharge plan that includes referrals to and contacts with the county health department and local HIV primary care services in the area where the inmate plans to reside
• A 30-day supply of all HIV-related medications that the inmate is taking prior to release under the protocols of the Department of Corrections and the treatment guidelines of the United States Department of Health and Human Services

Types of HIV Tests

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). All positive (reactive) rapid HIV tests require repeat testing for confirmation.

RAPID HIV TESTS

1. OraQuick ADVANCE Rapid HIV-1/HIV-2 Antibody Test detects HIV-antibodies in oral fluid as well as in blood.
2. Uni-Gold Recombigen HIV Test detects HIV-1 antibodies in whole blood, serum, and plasma; results take from 10 to 12 minutes.
3. Reveal G3 Rapid HIV-1 Antibody Test detects HIV antibodies in serum or plasma; although the test takes only 3 minutes to run, it is categorized as a moderately complex test and is usually done in a clinical laboratory.
4. Multispot HIV-1/HIV-2 Rapid Test uses fresh or frozen serum and plasma to detect HIV-1 and HIV-2 and distinguish one from the other; results are available in 20 minutes. Also a moderately complex test, it is usually done in a clinical laboratory (FDA, 2008).
5. Clearview HIV-1/HIV-2 STAT-PAK uses whole blood or serum and plasma; results are available in 15 minutes; requires no training to use.
6. Clearview HIV-1/HIV-2 Complete is a single-use, self-contained closed system for the collection, processing, and analysis of a whole blood, serum, or plasma sample; results are available in 15 minutes.

HOME TESTING KITS

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 1/4 of clients at public testing services would choose a home self-test.

HIV Antibody Test Results

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.

NEGATIVE TEST RESULTS

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.

POSITIVE TEST RESULTS

A positive test result shows the presence of HIV antibodies, which means that:

• The person is infected with HIV
• The person can transmit the virus to others through unsafe sexual practices, sharing contaminated injection equipment, and/or breastfeeding
• The person is infected for life

INDETERMINATE TEST RESULTS

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. 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.

Testing and Informed Consent in Florida

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. Florida legislation stipulates four reasons for deviation from traditional educational and testing methods:

• It is assumed that involuntary and nonconfidential testing may drive HIV-infected individuals underground.
• The government cannot constitutionally investigate or regulate much of the private behavior that permits the transmission of HIV.
• Because there is no effective cure for AIDS, there is less incentive to enforce mandatory testing and notification of individuals who have been exposed.
• “The excessively anxious and sometimes intensely hostile public reaction” to people with this illness requires the protection afforded by anonymity.

OBTAINING CONSENT

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):

• That an HIV test is a test to determine if an individual is infected with the virus that causes AIDS
• The potential uses and limitations of the test
• The procedures to be followed
• That HIV testing is voluntary and consent to be tested can be withdrawn at any time prior to testing
• That if the test results are positive, that is, if the results show that the person is infected with HIV, the provider is required to report the test subject’s name to the local county health department

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.”

Minors

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.

During Pregnancy

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.

TESTING WITHOUT INFORMED CONSENT

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

• Bona fide medical emergencies in which treatment is indicated by HIV status
• When there has been significant exposure by medical personnel to a person’s blood, the source will not voluntarily submit to HIV testing, and a blood sample is not available (court order required)
• In the event of a significant exposure to medical or nonmedical personnel providing help in an emergency and the victim has expired during treatment for the emergency
• When a person is charged with sexual offenses (court order required)
• When donating blood, sperm, or tissue to specialty banks
• For infants whose parents cannot be located after reasonable attempts (court order required, and attempts to locate the parents documented)
• Of prison inmates before they are released into the community
• When performing HIV testing to monitor the clinical progress of a patient previously diagnosed as HIV-positive or repeated HIV testing conducted to monitor possible conversion from a significant exposure
• Certain medical examiner cases, including court-ordered autopsies
• When a child is deemed too young to make an informed decision (however, parental consent is required; the law does not specify what age is too young to make an informed decision)
• Established epidemiologic research methods that ensure test subject anonymity
• Of convicted prostitutes

CONFIDENTIALITY

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.

Superconfidentiality

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

Disclosure of HIV test results is limited to the following:

• The test subject and his or her representative
• Healthcare providers consulting among themselves regarding diagnosis and treatment of AIDS
• The Department of Health
• Healthcare providers exposed to the subject’s body fluids
• Authorized medical or epidemiologic researchers; repeated tests may be given to monitor clinical progress without seeking renewed consent
• Hospital staff, administrators, and healthcare workers who provide aid and care to the subject, on a need-to-know basis; this is especially important in cases of significant exposure to body fluids by healthcare workers
• Appropriate authorities in the course of reporting child abuse
• Adults responsible for a child who is placed in foster care or for adoption
• An exposed healthcare worker who exercised the right to subpoena the medical records of the patient and demand that HIV status be determined

Breaches of Confidentiality

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.

NOTIFICATION RESPONSIBILITIES

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.

POST-TEST COUNSELING

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:

• Availability of appropriate medical and support services
• Importance of notifying partners who may have been exposed
• Prevention of the transmission of HIV

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.

INFECTION CONTROL PROCEDURES

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

Protocols for Healthcare Workers Exposed to Blood

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

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

REPORTING THE INCIDENT

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

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, 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.

FOLLOW-UP

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).

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

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.

CLINICAL MANAGEMENT

Antiretroviral therapy (ART) has become the gold standard for treatment of HIV/AIDS. Antiretroviral drugs are administered in “cocktails” of three or more. The primary goal of ART is to reduce HIV-associated morbidity and mortality by suppressing the individual’s viral load to below detectable levels. People with HIV may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia.

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.

Stages of HIV/AIDS

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:

1. Viral transmission: the initial infection with HIV, also called acute HIV infection. Persons may become infectious to others within days of transmission and before any symptoms appear. Once infected, a person is always infectious to others. During acute HIV infection, high levels of virus circulate in the bloodstream. Symptoms are nonspecific and may include fever, swollen lymph glands, rash, fatigue, and sore throat. This is sometimes called seroconversion syndrome or seroconversion sickness. Initial symptoms resolve in a few weeks but the person remains infectious for life.
2. Seroconversion: the time period from infection to the production of antibodies detectable on an HIV test, usually within 3 to 6 months of transmission.
3. Asymptomatic HIV infection: a variable time period, sometimes 10 years or longer, during which an HIV-infected person has no noticeable signs or symptoms and appears healthy, but can transmit the virus to others. Unless tested for HIV, the person will not be aware of being infected.
4. Symptomatic HIV infection: the stage during which noticeable physical symptoms of HIV are present. The most common symptoms include:
   • Persistent low-grade fever
   • Pronounced weight loss not due to dieting
   • Persistent headaches
   • Diarrhea lasting more than 1 month
   • Difficulty recovering from colds and flu
   • More acute illness than normal
   • Recurrent vaginal yeast infections in women
   • Oral thrush (candidiasis) coating the mouth or tongue
5. AIDS: diagnosis can be made only by a licensed healthcare provider. The diagnosis is based on the result of HIV-specific blood tests and the person’s physical condition. Once diagnosed with AIDS, a person is always considered to have AIDS, even if their health seems to improve. Over time, people with AIDS frequently have a reduced white-blood-cell count and deteriorating health. They also may have a significant amount of virus present in their blood, measured as viral load.

Initiating ART

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):

• Antiretroviral therapy should be initiated in all patients with history of an AIDS-defining illness or with a CD4+ T cell count <350 cells/mm.
• Antiretroviral therapy should also be initiated in the following groups of patients regardless of CD4 T-cell count:
  • Pregnant women
  • Patients with HIV-associated nephropathy
  • Patients coinfected with HBV when treatment is indicated
• Antiretroviral therapy may be considered in all patients with CD4 T-cell counts between >350 and 500 cells/mm. (See detailed guidelines on the AIDSinfo website listed under “Resources” at the end of the course.)
• Patients initiating ART should be willing and able to commit to lifelong treatment and should understand the benefits and risks of therapy and the importance of adherence. Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy based on clinical and/or psychosocial factors.

ART Complications

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.

Drug Access Crisis

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).

PREVENTION AND RISK REDUCTION

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

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

Safer Sex

Safer sex practices include:

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

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

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

Women who have sex with women (WSW) also 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:

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

Injection Precautions

Injection-drug users who refuse treatment or who have no treatment programs available to them need instructions about precautions: Do not 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.

Prevention among MSM

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

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

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

Prevention among Seniors

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.

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

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

Preventing Transmission to Uninfected Partners

Optimal care of people with HIV/AIDS includes 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.

Prevention Research

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

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

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

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

CONCLUSION

Thousands of people are living with HIV/AIDS in Florida, which 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. 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, testing, and educating patients, families, and communities. Health professionals can also teach by example, through offering nonjudgmental, compassionate care to those affected by this deadly virus.