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This course will expire or be updated on or before March 3, 2014.
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You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.
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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.
This course is appropriate for EMTs, paramedics, and first responders.
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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COURSE OBJECTIVE: The purpose of this course is to provide a review of HIV/AIDS incidence in Florida, modes of transmission, types of HIV tests, prevention, clinical management of HIV/AIDS, and Florida law governing HIV/AIDS testing and disclosure.
Upon completion of this course, you will be able to:
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.
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).
Three primary risk groups account for three-fourths of new HIV infections in the United States:
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 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).
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. 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.
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.
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).
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.
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.
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:
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.
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. 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.
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:
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.
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.
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.)
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.
Any healthcare worker who receives a needlestick or other significant exposure to potential HIV, HSV, or HBV infection should follow the employer’s protocol, which is based on guidelines issued by the CDC (2005):
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, 2005). Animal studies indicate that cellular HIV infection occurs within 2 days of exposure to HIV. Virus in blood is detectable within 5 days. Therefore, prompt initiation of PEP is essential and should be continued for 28 days. PEP for HIV does not prevent other blood-borne diseases such as HBV or HCV.
For exposure to HIV-positive blood, recommendation is for a four-week course combining either two antiretroviral drugs for most HIV exposures, or three antiretroviral drugs for exposures that may pose a greater risk for transmitting HIV (e.g., those involving a larger volume of blood with a larger amount of HIV or a concern about drug-resistant HIV). The antiviral drugs used in PEP are potentially toxic and should not be used for exposures that pose a negligible risk. CDC recommends consultation with an infectious disease consultant or another physician experienced with antiretroviral drugs; however, consultation “should not delay timely initiation of PEP” (CDC, 2005).
Frequent advances in treatment make it impractical to list medications and dosages here. PEP can only be obtained from a licensed healthcare provider. The employing facility may have recommendations and procedures in place for staff members to obtain PEP. After evaluation, certain anti-HIV medications may be prescribed.
The National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline) offers treating clinicians up-to-the-minute advice on managing occupational exposures (i.e., needlesticks, splashes, etc.) to HIV, hepatitis, and other blood-borne pathogens. In rural areas, police, firefighters and other at-risk emergency responders should identify a 24-hour source for PEP.
Hepatitis B vaccine is available for HBV exposure. There is no vaccine for Hepatitis C and no treatment that will prevent infection. Immune globulin is not advised. Medical counseling is recommended regarding personal risk of infection or risk of infecting others.
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, 2005).
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.
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.
Screening for STDs is 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.
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 (2010b), 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).
Mycobacterium tuberculosis (M. tuberculosis, or TB) is the most common and most deadly coexisting infection for HIV-positive individuals. The CDC (2009b) estimates that TB is the cause of death for 1/3 of people with HIV worldwide, and Florida is one of 15 states with TB rates higher than the national average. The spread of HIV/AIDS has helped fuel the TB epidemic.
According to CDC:
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. 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 multi-drug resistant (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, 2007).
Healthcare workers should also 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. 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.
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. Liver disease from chronic HCV is now one of the leading causes of death among people living with HIV.
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 hepatitis, and if they test negative, should receive vaccines against types A and B; there is no vaccine for HCV.
Risk factors for HBV include:
Hepatitis C is the most common chronic bloodborne infection in the United States and a leading cause of chronic liver disease. An estimated one third 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%).
People infected with HCV may have no symptoms for decades; when symptoms do appear, they are similar to those of HBV (see above).
People who should consider testing for HCV include:
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.
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)||
|Definitive AIDS diagnoses (with laboratory evidence of HIV infection)||
|Presumptive AIDS diagnoses (with laboratory evidence of HIV infection)||
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):
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.
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.
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 (Panel on Antiretroviral Guidelines for Adults and Adolescents, 2009).
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.
Successful treatment not only requires the patient to have significant financial resources but also the ability to understand and comply with a complex regimen.
Unfortunately, many of the patients with the greatest need for treatment lack the necessary financial resources to make treatment a reality. However, patient demographics, such as race/ethnicity, sex, age, and socioeconomic status, do not predict who will adhere to a treatment regimen. Research in Africa among the poorest populations showed 90% adherence, as compared to 70% in the United States (McNeil, 2003).
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
* Pneumocystis jiroveci pneumonia
** antiretroviral therapy
Source: Hoberg et al., 2010.
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 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 practices include:
Both women and men may need instruction in the correct use of condoms:
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:
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.
The CDC (2010a) 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:
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.
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:
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.
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).
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.
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.
Act Against AIDS
AIDS Education Global Information System (AEGIS)
AIDSinfo (Comprehensive site of the USDHHS)
Black AIDS Institute
The Body (HIV/AIDS Resource)
Centers for Disease Control and Prevention (CDC)
CDC National STD and AIDS Hotlines
English: 800-342-2437 or 800-227-8922
Center of Excellence for Transgender HIV Prevention, University of California, San Francisco
HIV InSite, University of California San Francisco (HIV/AIDS Treatment, Prevention, Policy)
HIV Wisdom for Older Women
National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPLINE)
National Minority AIDS Council
National Perinatal HIV Consultation and Referral Hotline
The Well Project (Women with HIV)
Women Organized to Respond to Life-threatening Disease (WORLD)
Resources in Florida
Center for Multicultural Wellness and Prevention
Family Health Line
Florida Department of Health, Bureau of HIV/AIDS
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)
Jacksonville Area Sexual Minority Youth Network (JASMYN)
Sembrando Flores (HIV/AIDS Latino Ministry)
Shadowood II, Inc.
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