HIV/AIDS Transmission and Infection Control

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By Nancy Evans, BS

LEARNING OBJECTIVES

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

• Name the modes of transmission for HIV.
• Discuss HIV prevention efforts.
• Describe precautions and procedures for controlling HIV infection among healthcare workers in particular.

THE AIDS VIRUS

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

Strains of HIV

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

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

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

Disease Mechanism

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

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

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

TRANSMISSION OF HIV

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

Three conditions are necessary for HIV to be transmitted:

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

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

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

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

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

Sexual Contact

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

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

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

Injection Drug Use

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

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

Transfusions of Infected Blood or Blood Clotting Factors

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

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

Tattooing and Blood-Sharing Activities

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

Pregnancy and Breastfeeding

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

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

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

Biting

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

PROBABILITIES OF HIV INFECTION (per one exposure to HIV)

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

FACTORS AFFECTING RISK OF HIV TRANSMISSION

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

Other Sexually Transmitted Diseases (STDs)

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

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

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

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

Genital herpes (HSV-2) also appears to be a major risk factor for acquiring HIV infection, increasing the risk more than three-fold. According to the CDC, 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 et al., 2006). A rare and virulent strain of chlamydia appears to be spreading in the United States, Western Europe, and the United Kingdom, primarily among MSM. More common to Africa and Southeast Asia, the strain is called lymphogranuloma venereum chlamydia (LGV), and it can cause genital ulcers, swollen lymph glands in the groin, flu-like symptoms, and gastrointestinal distress. Rectal symptoms among MSM, including bleeding of the rectum and colon, likely result from unprotected anal intercourse. These lesions increase the risk of transmitting or contracting HIV or other bloodborne diseases (Stark et al., 2007).

Multiple Partners

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

Use of Noninjecting Drugs

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

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

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

Gender, Culture, and Equality Issues

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

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

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

PREVENTION AND RISK REDUCTION

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

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

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

Safer Sex

Safer sex practices include:

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

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

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

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

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

Injection Precautions

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

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

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

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

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

Preventing Transmission to Uninfected Partners

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

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

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

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

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

Prevention among People of Color

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

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

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

Male Circumcision

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

Challenges to Prevention

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

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

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

Prevention Research

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

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

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

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

INFECTION CONTROL

Risks for Occupational Exposure

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

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

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

NEEDLESTICK INJURIES

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

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

Needlestick injuries, also called percutaneous injuries (PIs), are a critical issue for nurses, according to a nationwide survey of more than 700 nurses. More than 2/3 of nurses surveyed said that PIs and bloodborne infections remain major concerns, and more than half believe their workplace safety climate threatens their personal safety. Reduced staffing, increased workloads, and workplace stress all affect workplace safety, increasing the potential for errors and shortcuts (ANA, 2008). Improving these working conditions could reduce needlestick injuries (Trinkoff et al., 2007).

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

IN CORRECTIONAL INSTITUTIONS

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

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

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

Defining Bloodborne Pathogens

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

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

Infection Control Systems

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

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

These precautions include:

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

USE OF BARRIERS

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

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

Gloves should be worn:

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

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

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

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

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

HANDWASHING

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

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

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

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

SHARPS DISPOSAL

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

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

Adhere to agency protocols for disposal of infectious waste.

HOUSEKEEPING AND WASTE DISPOSAL

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

Disinfectants

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

Laundry

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

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

Regulated Waste

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

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

Regulated waste is defined as any of the following:

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

PERSONAL ACTIVITIES

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

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

Protocols for Healthcare Workers Exposed to Blood

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

IMMEDIATE RESPONSE

Immediately after exposure to blood of a patient:

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

REPORTING THE INCIDENT

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

In some states, employers must make a confidential postexposure medical evaluation available to employees who report an exposure incident. Workers may also have a right to file a worker’s compensation claim for exposure to bloodborne pathogens.

POSTEXPOSURE PROPHYLAXSIS (PEP)

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

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

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

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

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

SOURCE TESTING

Some states may require the employer to arrange to test the “source individual”—the person whose blood or OPIM an employee was exposed to—for HIV, HBV, and HCV. Such testing may or may not require the consent of the source individual according to state laws.

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

FOLLOW-UP

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

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

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

Infection Control Procedures at Home

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

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

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

GLOVES AND HANDWASHING

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

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

CLEANING BLOOD/OPIM FROM SURFACES

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

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

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

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

CLOTHING AND OTHER LAUNDRY

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

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

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

TOILET AND BEDPAN SAFETY

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

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

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

THERMOMETERS

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

PERSONAL HYGIENE ITEMS

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

FOOD PREPARATION

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

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

SAFE AND LEGAL DISPOSAL OF SHARPS

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

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

Safe disposal of found syringes should follow these guidelines:

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

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

PET CARE

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

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

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

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

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

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

CONCLUSION

In the United States, HIV is most commonly transmitted through specific sexual behaviors (anal or vaginal sex) or sharing needles with an infected person. It is less common for HIV to be transmitted through oral sex or for an HIV-infected woman to pass the virus to her baby. It is also possible to acquire HIV through exposure to infected blood, transfusions of infected blood, blood products, or organ transplantation, though this risk is extremely remote due to rigorous testing of the U.S. blood supply and donated organs.

HIV/AIDS is preventable, 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.

The risk of healthcare workers being exposed to HIV on the job is very low, especially if they carefully follow universal precautions. It is important to remember that casual, everyday contact with an HIV-infected person does not expose healthcare workers or anyone else to HIV. For healthcare workers on the job, the main risk of HIV transmission is through accidental injuries from needles and other sharp instruments that may be contaminated with the virus; however, even this risk is small.

Although preventing exposures to blood and body fluids is the primary means of preventing occupationally acquired HIV infection, appropriate postexposure management is an important element of workplace safety.