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Washington State: HIV/AIDS (4 Units)

Incorporating the KNOW Curriculum

Nancy Evans, BS

This course meets the Washington State requirements for the four-unit HIV/AIDS Prevention, Education and Training program set forth by the Washington State Department of Health HIV Prevention and Education Services.

Our courses fulfill continuing nursing education requirements in all 50 states. For more accreditation information, click here.

The material contained in this course is based on the KNOW Curriculum, 6th ed., the June 2007 Washington State Revised Regulations on HIV Testing, and current articles in the scientific literature, as well as on updates from the Centers for Disease Control and Prevention (CDC) and other government agencies.

Today, and every day, we must all commit to making a future without AIDS, something we will all live to see. Julie Gerberding, MD Director, CDC, 2005

In the twenty-five years since the first case of acquired immunodeficiency syndrome (AIDS) was diagnosed, AIDS has killed more than half a million Americans (CDC, 2006). The daunting human and economic costs of this disease in the United States are eclipsed only by its international impact. Since 1981 nearly 28 million people worldwide have died from AIDS and more than 39 million are infected with the virus.

DEFINING AIDS

• Acquired: This disease is not hereditary. It is not passed casually from one person to another. To infect someone, the Human Immunodeficiency Virus must enter the bloodstream.
• Immunodeficiency: The immune system is the body's defense against infection and disease. When the immune system becomes damaged in its ability to fight off infectious diseases, it is called deficient. Over time, a person with a deficient immune system may become vulnerable to infections by disease-causing organisms such as bacteria or viruses. These infections may cause life-threatening illnesses.
• Syndrome: HIV infection causes a combination of symptoms, diseases and infections. This combination of health effects is known as a syndrome.
• AIDS: This is a complex condition caused by the human immunodeficiency virus (HIV), which kills or impairs cells of the immune system and progressively destroys the body's ability to fight infection and disease. People with damaged immune systems are vulnerable to diseases that do not threaten people with healthy immune systems. The term AIDS applies to the most advanced stages of an HIV infection. Medical treatment can delay the onset of AIDS. (KNOW, 2007)

Almost all (95%) of the newly infected people live in the developing world, particularly southern Africa. The majority are young adults, many of whom do not know they are infected. This disease is the leading cause of death in southern Africa. Worldwide, AIDS is the leading cause of death and lost years of productive life for adults ages 15 to 59 years (UNAIDS, 2006).

In the United States, HIV/AIDS has forever altered the landscape of healthcare. Patient activism early in the epidemic spurred a massive research effort that led to greater understanding of AIDS and accelerated development of innovative drugs. More effective antiviral drugs have slowed the death rate from AIDS in wealthier countries since 1996 but, without a cure or a preventive vaccine, there is no end in sight to the epidemic (Table 1).

TABLE 1

HIV/AIDS, THE GLOBAL EPIDEMIC, 2006

39.5 million people living with HIV/AIDS	37.2 million adults (17.2 million women) 2.3 million children under 15 11,000 new infections daily
Nearly 28 million dead of AIDS	22.5 million adults 5.3 million children under 15 14 million children orphaned; by 2010, AIDS orphans expected to number 25 million
During the year 2006	4.3 million people newly infected with HIV, half between ages 15-24 2.9 million people died of AIDS-related illnesses 2.6 million were adults 380,000 were children under 15
Source: UNAIDS, 2006.

HIV/AIDS IN THE UNITED STATES

Although the CDC estimates that between 1,039,000 and 1,185,000 people in the United States are currently infected with HIV, at least one-fourth of them do not know they are infected, putting them at high risk for transmitting the virus to others. The development of antiretroviral drugs has reduced deaths from AIDS; yet the number of new infections has not changed since the late 1990s.

Each year another 40,000 people are infected with HIV—approximately 1 new infection every 12 minutes. Almost half of the HIV-positive population in the United States is not being treated, either because they lack access to care or because they have not been tested (CDC, 2005).

In the United States AIDS has been largely an urban epidemic, although it is growing rapidly in rural areas, particularly in the rural South. New York City has the largest number of reported cases, followed by Los Angeles, San Francisco, Miami, and Washington, D.C.

HIV/AIDS IN WASHINGTON STATE

AIDS and symptomatic HIV infections are reportable diseases—that is, physicians must confidentially report any cases among their patients to the Washington State Department of Health. The first case of AIDS in Washington State was reported in 1982. Reporting of new HIV diagnoses has been required in Washington State since September 1999.

Since the CDC began tracking AIDS cases, 16,514 cases of HIV/AIDS have been reported in Washington State. Fifty-three percent of them are known to have died. As of 2006, the annual incidence rate in Washington was 7.7 per 100,000 (compared to 13.7 per 100,000 nationally).

Through August 2006, a total of 5,123 persons were living with AIDS in Washington State. King County accounts for about two-thirds of the total AIDS cases reported in the state (CDC, 2007; Washington State Department of Health, 2007).

Efforts to screen pregnant women for HIV and to treat those women who test positive for the virus have markedly reduced the incidence of pediatric HIV/AIDS in Washington. In 2006 Washington State reported only 6 cases of pediatric HIV or AIDS (HIV/AIDS Epidemiology Unit, 2007).

Although AIDS deaths have decreased in Washington State since the early 2000s, the rate at which people are becoming infected with HIV has slowed only slightly. Thus education and prevention remain critical to public health.

RISK GROUPS

AIDS is a changing epidemic. Once a disease of gay white men, HIV/AIDS is now decimating young people of color, particularly among the African American population. According to the CDC, more than half of all new HIV infections occur among African Americans, even though this group represents only 13 percent of the U.S. population.

Black men are diagnosed with HIV at more than seven times the rate of white men, and black women at more than 20 times the rate of white women and more than 4 times the rate for Hispanic women. In the African American population, heterosexual transmission accounts for 11 percent of male infections, but more than 50 percent of female infections.

Men who have sex with men (MSM) account for nearly half of all newly reported HIV/AIDS diagnoses, and young men are at highest risk. A 2005 survey of MSM in several large U.S. cities (CDC, 2005) found that 1 in 4 of those surveyed was HIV-positive and nearly half of them were unaware of their HIV status. Prevalence of HIV/AIDS is higher among MSM from racial and ethnic minorities than among white MSM.

Asians and Pacific Islanders (API) represent only 1 percent of the total HIV-infected population in the United States. However, there is growing concern that certain subgroups in some metropolitan areas may be at high risk for the virus. A study of 503 API men who have sex with men (MSM) ages 18 to 29 years in San Francisco found that the prevalence of HIV infection was nearly 3 percent and the rates of other sexually transmitted infections were also high.

Nearly half of these men reported having had unprotected anal intercourse during the past six months (Choi et al., 2002). A survey of Asians and Pacific Islander MSM in Seattle indicated that 90 percent of them perceived themselves to be at some risk for HIV infection, yet less than half of those surveyed had been tested during the past year (Kahle et al., 2005).

Washington State is 1 of 10 states that account for three-fourths of all API populations (the other nine: CA, NY, HI, TX, IL, NJ, WA, VA, FL, MA). Asians and Pacific Islanders are a diverse population group that includes many nationalities—Chinese, Filipinos, Koreans, Hawaiians, Asian Indians, Japanese, Samoans, Vietnamese, and others—with more than one hundred languages, dialects, cultures, and histories. Such diversity poses special challenges to effective communication of public health messages.

More than 400,000 people in the United States are living with full-blown AIDS, about three-fourths of them males. Men who have sex with men still comprise a majority of male AIDS cases. Injection drug users account for nearly one-fourth of new male cases. Men infected by a female partner comprise 10 percent of all male cases.

Women now constitute the fastest growing HIV/AIDS population, accounting for more than one-fourth of the infected population and nearly three-fourths of new AIDS cases. Women are primarily infected through heterosexual intercourse with the exchange of semen and pre-ejaculate fluid, although injection drug use accounts for more than one-third of female cases (CDC, 2004).

Ninety percent of children with AIDS are infected by their mothers. However, routine screening of pregnant women, prenatal treatment of HIV-infected women with antiretroviral drugs, and avoidance of breastfeeding have greatly reduced the incidence of mother-infant transmission nationwide.

Mother–infant transmission remains a challenge in the African American community. Nationwide, two-thirds of infected children younger than 5 years old are black. Nearly two-thirds of HIV-positive women in the United States are African Americans.

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

Varying levels and concentrations of HIV have been found in most body fluids of infected persons: 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.

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), 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.

MODES OF TRANSMISSION

Contrary to flourishing 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

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 latex condom use carries the greatest risk.

Scientists believe that women and receptive partners are more easily infected with HIV, as compared to the insertive partner, probably because of the larger surface area of mucous membranes involved. Actually, receptive partners are at greater risk for transmission of any sexually transmitted disease, including HIV.

Scientists believe that women and receptive partners are more easily infected with HIV, as compared to the insertive partner, probably because of the larger surface area of mucous membranes involved. Actually, receptive partners are at greater risk for transmission of any sexually transmitted disease, including HIV.

According to the CDC, female-to-female transmission of HIV appears to be rare. However, case reports of female-to-female transmission of HIV, and the well-documented risk of female-to-male transmission of HIV, indicate that vaginal secretions and menstrual blood are potentially infectious and that exposure of mucous membrane (oral, vaginal, anal) to these secretions may lead to HIV infection (CDC, 2003). Therefore, women who have sex with women (WSW) should consider female sexual contact a possible means of transmission of HIV.

Health professionals need to remember that sexual identity and gender preference do not always predict behavior and that women who identify as lesbian may 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 bloodborne 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 percent of national 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 before 1985.

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.

Washington State law requires that pregnant women be counseled concerning risks about HIV and offered voluntary HIV testing.

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 percent. In addition, the infant is treated for the first six weeks of life (PHS Task Force, 2005).

The incidence of perinatally acquired AIDS peaked in 1992 and has decreased in recent years. Other contributing factors include the use of prophylactic cesarean delivery before the onset of labor or the rupture of membranes and the avoidance of breastfeeding by HIV-infected mothers. Advice about medications and C-section 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.

Factors Affecting Risk of HIV Transmission

CO-EXISTING INFECTIONS

People who are HIV-positive often have other sexually transmitted diseases (STDs) 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 herpes, genital warts and HPV infection, syphilis, scabies, and pubic lice.

Although syphilis rates declined steadily among African American women and newborns between 1999 and 2004, rates have escalated sharply among gay and bisexual men. Nearly two-thirds of all cases of syphilis reported in 2004 occurred in MSM (CDC, 2004). Research indicates that STDs increase the risk of HIV transmission, and the immune suppression caused by HIV facilitates infection with other STDs, creating a destructive synergy.

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 new HPV vaccine (Gardasil) has not been tested in HIV-positive women so no data is available on its safety or efficacy in this population.

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 CDC, most people 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. Treatment of HSV-2 with antiviral agents reduces but does not eliminate subclinical virus shedding.

Screening for STDs is critical since many of those infected do not have symptoms. For example, 80 percent of those with chlamydia and 70 percent of those with herpes are asymptomatic but can still spread the infections. It is essential that sexually active women get Pap tests and that both women and men disclose any history of STD during medical workups.

Prompt treatment should follow for any persons who test positive for any STDs. Treatments vary with each disease or syndrome. Because of developing resistance to medications for certain STDs, healthcare providers should check the latest STD treatment guidelines at http://www.cdc.gov/std.

ACUTE HIV INFECTION AND HIGH VIRAL LOAD

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, which 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, a new study indicates that those people in the asymptomatic stage of HIV who have medium levels of the virus have the greatest risk of infecting others. The asymptomatic stage lasts for years, rather than weeks, during which time the infected but untested population may continue to unknowingly spread the virus (Fraser et al., 2007).

MULTIPLE PARTNERS

The individual with multiple sex or injection drug–sharing partners is at very high risk for exposure to HIV/AIDS. Anyone having unprotected sex with multiple partners, which CDC defines as six or more partners in a year, is considered at high risk for HIV/AIDS infection. But even unprotected sex with one partner who is HIV-positive involves risk of 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 marijuana and poppers, and some also use cocaine, heroin, hallucinogens, and ketamine (Patterson et al., 2005). Certain substances have both physiologic and biologic effects on the body, such as masking pain and/or creating sores on the mouth and genitals, which creates 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.

PREVENTION AND RISK REDUCTION

High-risk drug use and high-risk sexual behaviors are often linked, further increasing risk of transmission.

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.

That's the good news. Because the virus is transmitted through behaviors that many people find pleasurable—sexual activity and injection drug use—prevention is difficult but not impossible. The bad news is that the annual number of new infections has held steady at 40,000 since the early 1990s.

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 $210,000. In 2006, CDC announced new prevention initiatives with the overarching goal to "reduce the number of new HIV infections in the United States from an estimated 40,000 to 20,000 per year, focusing particularly on eliminating racial and ethnic disparities in new HIV infections."

Strategies to reach that goal include:

• Make voluntary testing a routine part of medical care for all U.S. residents between the ages of 13 and 64.
• Implement new models for diagnosing HIV infection, such as rapid testing in high-prevalence areas, for example, correctional facilities.
• Prevent new infections by working with persons diagnosed with HIV, screening for risk behaviors, communicating prevention messages, discussing sexual and drug-use behaviors and offering positive reinforcement for changes to safer behaviors.
• Further decreasing perinatal HIV transmission, by promoting voluntary prenatal testing, rapid testing during labor, delivery and postpartum for women with unknown HIV status, and ensuring appropriate antiretroviral treatment and follow-up for HIV-positive women and their infants.

Prevention of HIV begins with education and counseling about sexual practices and injection drug use. For many people, just saying no isn't enough. Patients need basic, practical, how-to information.

SAFER SEX PRACTICES

• Abstinence from sexual contact
• Non-penetrative sex; no sharing of sex toys
• Mutual monogamy
• Correct use of latex (or polyurethane, if allergic to latex) condoms for all sexual intercourse (anal, oral, vaginal)
• Using only water-soluble lubricants with latex condoms; oil-based lubricants can cause condoms to break or tear.
• Avoiding natural membrane condoms, which do not protect against HIV, HBV and some other STDs
• Limiting the number of sexual and/or drug-injecting partners

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.
• When withdrawing the penis after ejaculation, hold on to the base of the condom to prevent slippage.
• Do not attempt intercourse with a condom if the penis is only partially erect.

INJECTION DRUG USERS

• 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.

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

Syringe exchange or needle exchange programs are public health measures that help prevent spread of HIV/AIDS and other bloodborne pathogens. These programs also offer referral sources for drug treatment. Many local health departments in Washington State operate syringe exchanges in their communities. For more information, contact your local health department/district's HIV/AIDS Program.

WOMEN WHO HAVE SEX WITH WOMEN

• Use condoms consistently and correctly each and every time for sexual contact with men or when using sex toys. Sex toys should not be shared.
• Use 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.
• Know yours and your partner's HIV status. If you are uninfected, this knowledge reduces your risk of becoming infected and assists those who are infected to get early treatment and avoid transmitting the virus to others.

The availability of more effective therapies for HIV/AIDS is no reason for complacency among healthcare providers or the public. Without aggressive widespread prevention efforts, the tragedy of AIDS will continue to spread.

Every healthcare professional has a role in identifying people at high risk, offering education and counseling, encouraging testing, and linking HIV-positive patients with treatment and social services. This is the most cost-effective and humane way to halt the devastation of this disease.

INFECTION CONTROL

Standards and Procedures

WASHINGTON ADMINISTRATIVE CODE REQUIREMENTS

The following requirements are mandated by Washington Administrative Code (WAC) 296-823, Occupational Exposure to Bloodborne Pathogens, to protect employees from exposure to blood or other potentially infectious materials (OPIM) that may contain bloodborne pathogens.

These requirements are enforced by the state's Department of Labor and Industries (L&I) Division of Occupational Safety and Health. Failure to comply with these requirements may result in citations or penalties.

This is a brief summary, and is not meant to provide direction on compliance with WAC 296-823. The federal Occupational Safety and Health Administration's compliance directive on occupational exposure to bloodborne pathogens, CPL 2-2.69, may be referenced for additional direction. For more information or assistance, contact an L&I consultant in your area. Check the blue government section of the phone book for the office nearest you, or call L&I's 24-hour toll-free line, 1-800-BE-SAFE. For Internet access, go to http://www.lni.wa.gov.

This material applies to employers who have employees with occupational exposure to blood or OPIM, even if no actual exposure incidents have occurred.

DEFINING EXPOSURE

• Occupational exposure means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or OPIM that may result from the performance of an employee's duties.
• Exposure incident means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties. Examples of non-intact skin include skin with dermatitis, hangnails, cuts, abrasions, chafing, or acne.

Occupational groups widely recognized as having potential exposure to HBV/HCV/HIV include, but are not limited to, healthcare employees, law enforcement, fire, ambulance, and other emergency response and public service employees.

Although HBV and HIV are specifically identified in the standard, "bloodborne pathogens" include any human pathogen present in human blood or OPIM. Bloodborne pathogens may also include 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.

BODY FLUIDS

Body fluids recognized as OPIM and linked to transmission of HIV, HBV and HCV, and to which Standard Precautions and Universal Precautions apply are:

• Blood and blood products
• Semen
• Vaginal secretions
• Cerebrospinal fluid
• Synovial (joint) fluid
• Pleural (lung) fluid
• Peritoneal (gut) fluid
• Pericardial (heart) fluid
• Amniotic fluid (fluid surrounding the fetus)
• Saliva in dental procedures
• Specimens with concentrated HIV, HBV and HCV viruses

Body fluids such as urine, feces, and vomitus are not considered OPIM unless visibly contaminated by blood.

Wastewater (sewage) has not been implicated in the transmission of HIV, HBV, and HCV and is not considered to be either OPIM or regulated waste. However, plumbers working in healthcare facilities or who are exposed to sewage originating directly from healthcare facilities carry a theoretical risk of occupational exposure to bloodborne pathogens. Employers should consider this risk when preparing their written "exposure determination."

Plumbers or wastewater workers working elsewhere are probably not at risk for exposure to bloodborne pathogens. Wastewater contains many other health hazards and workers should use appropriate personal protective equipment and maintain personal hygiene standards while working.

EXPOSURE CONTROL PLAN (ECP)

Each employer covered under WAC 296-823 must develop an exposure control plan (ECP). The ECP shall contain at least the following elements:

• A written "exposure determination" that includes those job classifications and positions in which employees have potential for occupational exposures. The exposure determination shall have been made without taking into consideration the use of personal protective clothing or equipment. It is important to include those employees who are required or expected to administer first aid.
• The procedure for evaluating the circumstances surrounding exposure incidents, including maintenance of a Sharps Injury Log.
• The infection control system used in your workplace.
• Documentation of consideration and implementation of appropriate, commercially available safer medical devices designed to eliminate or minimize occupational exposure.
• The ECP must be updated on at least an annual basis and whenever changes occur that effect occupational exposure.

Bloodborne pathogens training is mandated for all new employees or employees being transferred into jobs involving tasks or activities with potential exposure to blood and/or other potentially infectious material (OPIM). This training must take place at the time of initial assignment to tasks where occupational exposure may occur, and must include:

• Information on hazards associated with blood/OPIM.
• Protective measures to minimize risk of occupational exposure.
• Information on appropriate actions to take if exposure occurs.

Retraining is required annually, or when changes in procedures or tasks affecting occupational exposure occur.

Employees must be provided access to a qualified trainer during the training session to ask and have answered questions as questions arise.

All employees whose jobs involve participation in tasks or activities with exposure to blood/OPIM must be offered the first of the hepatitis B vaccination series within 10 working days of employment and/or new assignment. The vaccination will be provided free of charge. Serologic testing after vaccination (to ensure that the vaccination was effective) is recommended for all persons with ongoing exposure to sharp medical devices.

The provision of employer-supplied hepatitis B vaccination may be delayed until after probable exposure for employees whose sole exposure risk is the provision of first aid (see WAC 296-823-130).

Infection Control Systems

Universal Precautions, as defined by CDC, is a system designed to prevent transmission of bloodborne pathogens in healthcare and other settings. Under Universal Precautions, healthcare personnel are to assume that the blood and other body fluids from all patients are potentially infectious, and therefore they should always follow infection-control precautions in all settings.

Standard Precautions is a newer system that hospitals and other agencies are moving toward. It includes all recommendations for Universal Precautions plus body substance isolation (BSI) when OPIM are present.

Meticulous adherence to Universal Precautions is recommended by CDC for the care of all patients and mandated by OSHA.

Universal and Standard Precautions involve the use of protective barriers, defined below in the Personal Protective Equipment section, to reduce the risk of exposure of the employee's skin or mucous membranes to OPIM. It is also recommended that all healthcare workers take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices.

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, or processing of any bodily fluid specimen, and postmortem (after death) procedures.

Universal Precautions include wearing the following personal protective equipment:

GLOVES

• 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 you have cuts, scratches or other breaks in the skin

Change gloves after each client.

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.

MASKS, GOGGLES, FACE SHIELDS, AND GOWNS

• During all invasive procedures and any procedure in which blood or body fluids may spatter or become airborne.
• During procedures where heavy bleeding or other extensive fluid (such as peritoneal fluid) loss 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.

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

Soap-and-water handwashing must be performed whenever hands are visibly contaminated or there is a reasonable likelihood of contamination. Proper soap-and-water handwashing technique involves the following:

• Using soap, warm (almost hot) water, and good friction, scrub the top, back, and all sides of the fingers.
• Lather well and rinse for at least 10 seconds. When rinsing, begin at the fingertips, so that the dirty water runs down and off the hands from the wrists. It is preferable to use a pump-type of liquid soap rather than bar soap.
• Dry hands on paper towels. Use the dry paper towels to turn off the faucets. Don't touch the faucets with clean hands.

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, 2002.

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.

Bar caregivers with weeping dermatitis (such as poison ivy or poison oak) or exudative lesions from all patient care and/or handling of patient care equipment or supplies. Adhere to agency protocols for disposal of infectious waste

HOUSEKEEPING

The work area of the facility is to be maintained in a clean and sanitary condition. The employer is required to determine and implement a written schedule for cleaning and disinfection, based on the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed. All equipment and all environmental and working surfaces must be properly cleaned and disinfected after contact with blood or OPIM.

Potentially contaminated broken glassware must be removed using mechanical means, like a brush and dustpan or vacuum cleaner. Specimens of blood or OPIM must be placed in a closeable, labeled or color-coded leakproof container prior to being stored or transported.

DISINFECTANTS

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) as required by WISHA.

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.

WASTE DISPOSAL

All regulated waste must be placed in closeable, leakproof containers or bags that are color-coded (red-bagged) or labeled as required by WISHA to prevent leakage during handling, storage, and transport.

TAGS AND LABELS

Tags or labels must be used as a means to protect employees from exposure to potentially hazardous biological agents in accordance with the requirements contained in WAC 296-823-14025, 296-823-14050, and 296-800-11045.

All required tags must meet the following specifications:

• Tags must contain a signal word or symbol and a major message.
• The signal word shall be "BIOHAZARD," or the biological hazard symbol (below).
  
• The signal word must be readable at a minimum of five feet or such greater distance as warranted by the hazard.
• The tag's major message must be presented in either pictographs, written text, or both.
• The signal word and the major message must be understandable to all employees who may be exposed to the identified hazard.
• All employees will be informed as to the meaning of the various tags used throughout the workplace and what special precautions are necessary.

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.

POST-EXPOSURE MANAGEMENT

Risks for Transmission to Healthcare Workers

In 2003, CDC reported that "57 healthcare personnel in the United States have been documented as having seroconverted to HIV following occupational exposures. Twenty-six have developed AIDS. In addition, 139 other cases of HIV infection or AIDS have occurred among healthcare personnel who have not reported other risk factors for HIV infection and who report a history of occupational exposure to blood, body fluids, or HIV-infected laboratory material, but for whom seroconversion after exposure was not documented"(CDC, 2003).

According to 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; to non-intact skin or mucous membranes (such as eyes, nose and/or mouth); amount of blood involved and the amount of virus present in the source's blood.

The risk of developing HIV infection from a needle stick 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 virus load in the source. The risk after a mucous membrane exposure is about 1:1000. The risk of HIV transmission after nonintact skin exposure is estimated to be less than the risk for mucous membrane exposure.

The CDC recommends that postexposure prophylaxis (PEP) begin as soon as possible, 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 bloodborne diseases such as HBV or HCV.

The risk of HBV infection from a needlestick is 22 to 31 percent if the source person tests positive for hepatitis B surface antigen (SBsAg) and hepatitis Be antigen (HBeAg). If the source person is HBsAg positive and HBeAg negative, there is a 1 to 6 percent risk of getting HBV unless the person exposed has been vaccinated.

The risk of HCV infection from a needlestick is 1.8 percent. The risk of getting HBV or HCV from a blood splash to the eyes, nose, or mouth is possible but believed to be very small. As of 1999, about 800 healthcare workers a year are reported to be infected with HBV following occupational exposure. There are no exact estimates of how many healthcare workers contract HCV from occupational exposure, but the risk is considered to be low.

Good places to start PEP include the emergency department of your local hospital. In Seattle and Western Washington, there are clinics that specifically treat HIV-positive people. Information about these clinics can be found at Public Health Seattle-King County's website: http://www.metrokc.gov/health/news.

PEP 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 uses 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."

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 for HCV exposure. Medical counseling is recommended regarding personal risk of infection or risk of infecting others.

Washington State workers have a right to file a worker's compensation claim for exposure to bloodborne pathogens. Industrial insurance covers the cost of postexposure prophylaxis (PEP) and followup care for the injured worker.

Infection Control Procedures at Home

Healthcare providers and other caregivers who care for patients at home or in home-like settings 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

Gloves (latex or vinyl—or nitrile, in the case of latex allergy) should be worn in the following situations:

• When you anticipate contact with any body substance (blood/OPIM)
• When you anticipate contact with any nonintact skin

At the end of a procedure, gloves should be carefully pulled off, inside-out, one at a time, so the contaminated surfaces are inside, preventing any contact with any potentially infectious material.

Gloves are not necessary for general care, or during casual contact (serving food, bathing intact skin). Gloves should be changed and hands washed as soon as possible after care of each patient. Never rub the eyes, mouth, or face while wearing gloves. Latex and other disposable gloves should never be washed and reused.

HANDWASHING

Correct handwashing is critically important. Good handwashing technique includes these elements:

• Use soap, warm (almost hot) water, and friction, scrubbing the top, back, and all sides of the fingers.
• Lather well and rinsing for at least 10 seconds. When rinsing, begin at the fingertips so the dirty water runs down and off the hands from the wrists. A pump-type liquid soap is preferable to bar soap.
• Dry hands on paper towels. Use a dry paper towel to turn off the faucets (don't touch the faucets with clean hands).
• Waterless handwashing product should be made available for immediate use if a suitable sink is not readily available. This does not replace proper handwashing with soap and water.

People who have been exposed to body fluids should wash their hands before as well as after using the toilet. The paper towel used to dry the hands may also be used to open the bathroom door, if necessary, before disposing of the towel.

PERSONAL HYGIENE ITEMS

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

CLEANING BLOOD/OPIM FROM SKIN 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.

CLEANING BODY FLUID SPILLS ON VINYL FLOORS

Broken glass should be swept up using a broom and dustpan (never bare hands!). Empty dustpans into a well-marked plastic bag or heavy-duty container. Pretreat the body fluid spill with full-strength liquid disinfectant or detergent and then wipe it up with either a mop and hot soapy water or appropriate gloves and paper towels. Dispose of paper towels in the plastic bag.

Use a disinfectant such as household bleach 5.25 percent mixed fresh with water (1 part bleach to 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 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.

CLEANING BODY FLUID SPILLS ON CARPETING

Pour dry kitty litter or other absorbent material on the spill to absorb the body fluid. Then pour full-strength liquid detergent on the carpet to help disinfect the area. Any broken glass should be swept up with the kitty litter, using a broom and dustpan.

Carefully pour carpet-safe liquid disinfectant on 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.

Any debris, paper towels, or soiled kitty litter should be disposed of in a sealed plastic bag that has been placed inside another plastic garbage bag. Twist and seal the top of the second bag as well.

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 the next 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 dry cleaned to remove and disinfect the stain.

DIAPER CHANGES

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.

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 and 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.

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 percent ethyl alcohol for 30 minutes then rinsed under a stream of warm water between each use.

Glass thermometers pose an additional hazard because they contain mercury, which is a potent neurotoxin. Broken thermometers and their contents should be treated as hazardous waste and disposed of appropriately. Never touch mercury with bare hands.

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 nonintact 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. Avoid wooden cutting boards if possible.
• 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.

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. These items 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.

Pets can spread disease by licking their person's face or open wounds. Wash hands after stroking or other contact with pets. 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.

CONFIDENTIALITY

Confidentiality is a paramount concern for people with HIV/AIDS. This infection not only carries the stigma of a sexually transmitted disease but also the association with homosexuality and/or injection drug use. Workplace, housing, and insurance discrimination have been (and, in some areas, continue to be) barriers to disclosure of HIV status and seeking treatment. Children with AIDS have sometimes been barred from attending classes and, in at least one instance, a family's home was burned after a family member developed AIDS.

All medical records are confidential and must be maintained in a manner that protects that confidentiality. Special requirements for HIV and AIDS are found in WAC 246-100 and RCW 70.24.105.

Confidentiality of medical information means that any information that can be related to a specific patient may not be disclosed to anyone except under specific circumstances. This usually means that the individual signs a release-of-information form, but there are exceptions. The most common circumstances permitting disclosure of confidential patient information are:

• Existence of a separate, signed release-of-information form
• Release to another healthcare provider for related ongoing medical care
• A life or death emergency
• Release to a third party payer (insurance provider)
• Reporting notifiable conditions to the local health jurisdiction or the department of health

Anyone who violates the confidentiality laws may be found guilty of a gross misdemeanor and be subject to action for reckless or intentional disclosure, up to a fine of $10,000 for each infraction, or actual damages, whichever is greater (RCW 70.24.080, RCW 9A.20.021, RCW 70.24.084). (Washington State Department of Health, 2005).

The county health officer has the responsibility to investigate potential breaches of confidentiality of HIV identifying information and report those to the department of health.

Informed Consent

Before HIV testing is performed, patients must be explicitly told that HIV testing is recommended and the patient must agree to the HIV testing.

HIV testing without informed consent, except in legally mandated situations described below, can result in disciplinary action by a healthcare provider's licensing board, fines, suspension or revocation of license, and civil liability for negligence and invasion of privacy (Washington State Department of Health, 2005).

SPOUSE/PARTNER NOTIFICATION

Both federal and state laws require that a good faith attempt be made to notify the spouse of an HIV-infected individual. Spouse is defined as the person(s) who is or has been in a marriage relationship with the infected person up to 10 years prior to the HIV test. Procedures and guidance for partner notification can be found in WAC 246-200-072.

Notification means that spousal information will be discussed with individuals prior to their HIV test. If the test result is positive, the individual will be given the choice to notify his/her spouse(s), to allow the healthcare provider to notify the spouse(s), or refer to the local health jurisdiction for assistance in notifying the spouse(s).

Partner notification also includes sex and/or injection equipment–sharing partners. It is a voluntary, confidential service that uses a variety of strategies to make sure exposed partners are notified of their exposure to HIV and receive appropriate counseling in a way that respects the confidentiality of the source patient.

MINORS

Washington law (RCW 70.24.110) specifies that children 14 years of age or older who may have come in contact with any sexually transmitted disease or suspected sexually transmitted disease may give consent to the furnishing of hospital, medical, and surgical care related to the diagnosis or treatment of such disease.

Parental or legal guardian consent is not necessary, and parent(s) or legal guardians are not liable for payment for any care rendered. Washington state law forbids informing the subject's parents of the test, or of the results, without the subject's permission.

TESTING WITHOUT INFORMED CONSENT

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

• When the person is incompetent to give consent (RCW 7.70.065)
• In seroprevalence studies, where neither the persons whose blood is being tested know the test results nor the persons conducting the tests know who is undergoing testing
• If the Department Of Labor And Industries determines that it is relevant, in which case payments made under Title 51 RCW may be conditioned on the taking of an HIV antibody test.

Under Washington state law (WAC 246-100-205), someone who has experienced a substantial exposure to another person's bodily fluids in a manner that creates a possible risk of HIV transmission, and that exposure occurred while on the job in certain categories of employment deemed at substantial risk for HIV exposure, may ask a state or local health officer to order pretest counseling, HIV testing, and post-test counseling of the source person, in accordance with RCW 70.24.340.

Source persons include those convicted of a sexual offense (9A.44 RCW), prostitution (9A.88 RCW), or drug offenses involving hypodermic needles (69.50 RCW). This law does not apply to the department of corrections or to inmates in its custody or subject to its jurisdiction.

Substantial exposure that presents a possible risk of transmission is limited to:

• Physical assault upon the exposed person involving blood or semen;
• Intentional, unauthorized, nonconsensual use of needles or sharp implements to inject or mutilate the exposed person; or
• An accidental parenteral or mucous membrane or non-intact skin exposure to blood, semen, or vaginal fluids.

Categories of employment at substantial risk for HIV exposure:

• Healthcare provider
• Staff of healthcare facilities
• Law enforcement officer
• Firefighter
• Funeral director
• Embalmer

If the health officer refuses to order counseling and testing, the exposed person may petition the superior court for a hearing to determine whether an order shall be issued.

LEGAL REPORTING REQUIREMENTS

It is imperative that physicians, nurses, and other healthcare providers to understand Washington laws concerning HIV/AIDS (RCW 70.24 and WAC 246-101-010). AIDS and HIV infection are reportable conditions in Washington State. Medically diagnosed AIDS has been a reportable condition since 1984. Symptomatic HIV was designated as a reportable condition in 1993, and in 1999 asymptomatic HIV infection also became reportable.

Providers who diagnose an individual with AIDS must submit a confidential case report to the local health jurisdiction within 3 days. Providers who receive notice of an individual's positive HIV test must report this information, including the individual's name, to the local health jurisdiction within 3 days. In some local health jurisdictions, the state department of health fulfills this function for local authorities.

Positive HIV results obtained through anonymous testing are not reportable until the patient seeks medical care for conditions related to HIV or AIDS. At that time, the provider is required to report the case to the local health department.

Disability and Discrimination

People with HIV/AIDS are protected by federal law under the Americans with Disability Act (1990) and Section 504 of the Federal Rehabilitation Act of 1973, as amended. The Washington Law Against Discrimination (WLAD-RCW 49.60.174) regulates "disabled" status. These laws make it illegal to discriminate against someone with AIDS or who has HIV or Hepatitis C infection. It is also illegal to discriminate against someone "believed" to have HIV/AIDS, even though that person is not infected. The areas encompassed in the laws include:

• Employment (see below for details)
• Rental, purchase or sale of apartment, house, or other real estate
• Public places (restaurants, theaters)
• Healthcare, legal services, home repairs, and other personal services available to the general public
• Applying for a loan or credit card, or other credit transaction
• Certain insurance transactions

Note: Federal and state jurisdictions differ.

EMPLOYMENT ISSUES

The laws also protect people diagnosed with HIV/AIDS from employment discrimination, including

• Employment
• Recruitment
• Hiring
• Transfers
• Layoffs
• Termination
• Salary
• Job assignments
• Leaves of absence, sick leave, any other leave or fringe benefits available by virtue of employment

Employers are responsible for providing reasonable worksite accommodations that will enable a qualified, disabled employee or job applicant to perform the essential tasks of a particular job. Reasonable accommodation means relatively inexpensive and minimal modifications in the context of the entire employer's operation, such as:

• Providing special equipment
• Altering the work environment
• Allowing flex-time
• Providing frequent rest breaks
• Allowing the person to work at home (telecommute)
• Restructuring the job

An employee with a disability must self-identify and request a reasonable accommodation. The employer must engage in an interactive process with the requestor. The reasonable accommodation grant may not be exactly the same one as requested by the employee, but can be equally effective. The employer does not have to change the essential nature of its work, or engage in undue hardship or heavy administrative burdens. The essential functions of the job must be accomplished, with or without reasonable accommodations.

Employers do not have the right to have potentially prejudicial information about an employee or an applicant. This means that the employer should use the following best practices:

• Not ask an applicant or an employee questions directed at the perception or presence of HIV/AIDS, unless based on a bona fide occupational qualification (BFOQ), which can be obtained from the Washington State Human Rights Commission. RCW 49.60.172 and WAC 246.100.204).
• Not require a blood test to determine HIV infection, unless HIV status limits the ability to perform the work, ie, overseas assignment in a country that requires HIV status certification.
• Not require a physical exam directed to identify HIV infection, except for exams necessary to evaluate the need for, or nature of, reasonable accommodation or specific job-related conditions.
• Not ask questions about lifestyle, living arrangements, or sexual orientation.

Note: Chapter 49.60 RCW, the Washington Law Against Discrimination, prohibits discrimination based on age, creed, religion, race, color, national origin, sex, sexual orientation and gender identity, HIV and hepatitis C status, whistleblower retaliation, marital status (housing and employment), families with children (housing), or the presence of any sensory, mental, or physical disability or the use of a trained dog guide or service.

Exceptions to this law are applicants for the U.S. Military, the Peace Corps, the Job Corps, and persons applying for U.S. citizenship, under federal law, which supersedes state law.

Behaviors Endangering Public Health

Washington State law (RCW 70.24) and rules (WAC 246-100 and 246-101) give state and local health officers the authority and responsibility to carry out certain measures to protect public health from the spread of sexually transmitted disease (STD), including HIV/AIDS.

The local health officer is the physician who directs the operations of the local county's health department or health district. The responsibilities of the health officer include the authority to:

• Interview persons infected with an STD
• Notify sexual or needle-sharing partners of exposure to disease
• Order persons suspected of being infected to receive examination, testing, counseling, or treatment
• Issue orders to cease and desist from specific conduct that endangers the health of others

Court enforcement may be necessary. State law specifies the standards that must be met before the health officer may take action.

Washington law also permits the detention of an HIV-infected person who continues to endanger the health of others. After all less-restrictive measures have been exhausted, a person may be detained for periods up to 90 days after appropriate hearings and rulings by a court. The detention must include counseling.

Washington law requires that healthcare providers offer instruction on infection-control measures to any patient diagnosed with a communicable disease. Providers are also required to report to the local health officer any impediments or refusal to comply with prescribed infection-control measures.

For example, if a healthcare provider knows that a specific patient is failing to comply with infection-control measures (failing to disclose HIV status to sexual or needle-sharing partners or selling HIV-infected blood), the provider should contact the local health officer to discuss the case and determine if the name of the person should be reported for investigation and follow-up. If credible evidence exists that an HIV-infected person is engaging in conduct that endangers public health, the health officer or other authorized representative will investigate the case.

There are other laws and regulations concerning endangering the public health and occupational exposures that may be specific to certain professions and to the jurisdictions of public health officers. The Washington State Hotline, 1-800-272-2437, can provide additional information.

Civil Rights

People with HIV/AIDS who believe they are being discriminated against on the basis of their disease may file a complaint with the Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services (DHHS, http://www.hhs.gov/ocr/hiv.html) or the Washington State Human Rights Commission. The OCR will investigate anonymous reports.

As people with HIV/AIDS live longer, their needs for healthcare services change. 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.

Case Management

Case managers in Washington State HIV/AIDS programs are the primary contact people for services, including medical care, insurance programs, volunteer groups, home care, hospice, and other types of care that may be needed during the course of a person's or family's living with HIV/AIDS. The HIV/AIDS program in a county health department or district can help patients find a case manager, as can the Washington State Department of Health Client Services toll-free line (1-877-376-9316).

Children with HIV may also benefit from the "Children with Special Healthcare Needs" program. Care coordinators for this program are located in every county health department or district. Local community-based organizations like the Northwest Family Center in Seattle, and specialty hospitals like Children's Medical Center in Seattle and Mary Bridge Children's Hospital in Tacoma, may provide additional support to children and families.

Personal Impact of HIV/AIDS

People with HIV/AIDS, and their families and friends, confront many painful realities: continuing uncertainty; loss; grief; costly, complex, sometimes disfiguring treatments; deteriorating health; and premature death. Those who are fortunate have families and friends who serve as a support system through this experience. Those without a support system face an even more difficult challenge.

Although antiretroviral drugs are helping extend lives, people with AIDS still die prematurely. Ninety percent of all adults with AIDS are in the prime of life and are ill-prepared to deal with the knowledge that they have a fatal disease. Fear, anxiety, and depression often result.

DEPRESSION

Depression in particular can interfere with a person's ability to comply with a drug regimen, which can lead to drug resistance and poor management of the diseases. Symptoms of depression include:

• Feeling sad, anxious, or "empty" most of the day, almost every day
• Decreased interest or pleasure in almost all activities, including sex
• Decreased or increased appetite and/or weight changes
• Decreased or increased sleep
• Physical slowing or agitation
• Feelings of worthlessness or excessive guilt
• Poor concentration or indecisiveness
• Recurrent thoughts of death or suicide, or suicide attempts

Depression is treatable, both with antidepressant medications and/or psychotherapy. Recognizing the symptoms in people with HIV/AIDS and referring them for appropriate treatment can greatly improve their quality of life.

HIV-infected individuals can live ten years or more without developing symptoms. Those who are aware of their HIV status may face a decade or more of uncertainty, which can be unsettling and even overwhelming.

REJECTION

Men who have sex with men (MSM), and injection drug users, may already be stigmatized and subjected to social and job-related discrimination. A diagnosis of HIV/AIDS will likely increase the societal pressure and level of stress. Rejection by family, friends, and coworkers may occur along with guilt about the disease, about past behaviors, or about the possibility of having infected someone else. The need to practice "safer sex" can also affect self-esteem.

ALTERED BODY IMAGE

Over time, HIV/AIDS can dramatically change a person's appearance. The disease itself can cause 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, sometimes described as "buffalo hump."

ANGER

People with HIV/AIDS may feel as though their normal lives have ended because of detailed medication schedules, medical appointments and the high cost of HIV/AIDS medications. Anger is common—anger at the virus, the side effects of the medications or the failure of medications, at the prospect of illness or death, and at the discrimination experienced. Some people with HIV consider or attempt suicide; some attempts are successful. Help in dealing with anger and other painful emotions is available from local crisis lines listed in the phone book or from the National Suicide Hotline: 1-800-784-2433 or 1-800-273-8255.

LOSS AND GRIEF

HIV/AIDS can involve many losses and grieving those losses:

• Loss of physical strength and abilities
• Loss of mental abilities(confusion/dementia)
• Loss of income and savings
• Loss of health insurance
• Loss of employment
• Loss of housing, personal possessions, including pets
• Loss of emotional support from family, friends, colleagues, religious and social institutions
• Loss of self-sufficiency and privacy
• Loss of social contacts/roles
• Loss of self-esteem

Experiencing multiple losses often leaves insufficient time to grieve those losses and creates feelings such as:

• Guilt
• Helplessness
• Hopelessness
• Withdrawal
• Isolation
• Rage
• Emotional "numbness"

Physical weakness and/or pain can also diminish the ability to cope with psychological stresses.

Grief is universal, individual and unpredictable. Although Elizabeth Kübler-Ross and others have described stages of grief, people do not move through these stages in a straight line or at a predictable speed. Instead, each person progresses at his or her own pace, and may recycle through one or more of the stages, which include:

• Shock and numbing
• Yearning and searching
• Disorganization and despair
• Some degree of reorganization

The time it takes to move among these stages is determined by the individual, his or her values and cultural norms, and circumstances. In uncomplicated grief, an individual is able to move through the stages and emerge from the grieving process.

Complicated grief (also called chronic grief) is an exaggeration of the normal process of grieving, often resulting from multiple losses and making it difficult for an individual to reorganize and move on. Many people living or working with HIV/AIDS over several years experience chronic grief as the result of a seemingly endless repetition of deaths and funerals and lost friends.

Chronic grief is similar to the emotions of Holocaust survivors, survivors of earthquakes, tornadoes or other natural disasters, and military veterans. Some individuals experience feelings of disbelief, numbness, and an inability to face facts. Fearing the unknown, the onset of infections, swollen lymph nodes, or loss of weight may be accompanied by fear of developing AIDS and of becoming sicker.

Issues for Care Providers and Families

The psychological suffering and grief experienced by people with HIV/AIDS is also shared by family members, friends, caregivers, and partners. These feelings may manifest as physical symptoms, clinical depression, hypochondria, anxiety, insomnia, and the inability to derive pleasure from normal daily activities. Coping with these issues may lead to self-destructive behaviors such as alcohol or drug abuse.

Caregivers often mirror the feelings of their patient, such as a sense of vulnerability and helplessness, or of isolation. Access to a support system, including a qualified counselor, can be equally important for the caregiver as for the patient. Support from coworkers is especially important. Strategies for caregiver support are summarized in Box 2.

Special Populations

HIV/AIDS takes a heavy toll on all ethnicities, genders, ages, and income levels. However, some populations have been uniquely affected by the epidemic. These populations include men who have sex with men, injection drug users, people with hemophilia, women, and people of color.

MEN WHO HAVE SEX WITH MEN (MSM)

America's HIV/AIDS epidemic deepened the nation's longstanding prejudice toward homosexuality. Conservative religious groups saw the epidemic as divine retribution for "unacceptable" and "unnatural" behavior. Many men with HIV/AIDS report lack of support of their church families because of the stigma attached to homosexuality.

Societal attitudes toward MSM have made it more difficult to live and die with HIV/AIDS. Self-esteem and other psychological issues related to HIV infections complicate the lives of MSM. Grief and loss are not always validated when relationships are judged "unacceptable."

Societal attitudes toward MSM have made it more difficult to live and die with HIV/AIDS. Self-esteem and other psychological issues related to HIV infections complicate the lives of MSM. Grief and loss are not always validated when relationships are judged "unacceptable." Many church congregations fail to offer support to those living with HIV/AIDS and to their families because of the stigma attached to homosexuality.

HIV-negative MSM may resent the barrage of safer sex messages, and the attention, resources, and services devoted to HIV-positive MSM. Research has shown that some HIV-negative MSM feel HIV infection is inevitable and continue to engage in unprotected sex with multiple partners.

Bisexual men (who have sex with both men and women, and may not self-identify as "gay") are not the major target for HIV-prevention messages. Although they are also at high risk of HIV-infection, bisexual men may not have the same access to social and community resources as MSM.

INJECTION DRUG USERS

Mainstream America does not look kindly on illegal drug users, nor on the poor and the homeless. People in these circumstances often are seen as "deserving" their infection, rather than deserving treatment for their addiction or a hand up out of poverty. Successful efforts to prevent the spread of HIV/AIDS, HBV, and HCV among injection drug users, such as syringe exchange programs, are gaining public support but still remain controversial because some people equate these programs with "approval" of drug use.

Injection drug use often goes hand in hand with poverty, low self-esteem, anxiety, depression, and diagnosed mental illness, creating a tangled web of difficult problems, including risk-taking behaviors that can lead to HIV-infection. Many drug users would like to stop using but do not have access to inpatient treatment facilities.

Waiting lists for drug treatment programs are long and, by the time a place is available, the individual may be lost to follow-up. Even if injection drug users seek treatment for HIV, management of the complex regimens may be impossible and financially prohibitive. In addition, street drugs may have dangerous interactions with AIDS medications.

PEOPLE WITH HEMOPHILIA

Hemophilia is an inherited disease that prevents blood from clotting. Before injectable clotting factor concentrates were developed, people with hemophilia could bleed to death from a minor cut or bruise. However, clotting factor concentrates are made from pooled, donated blood, and prior to the advent of blood testing for HIV, some contaminated blood found its way into these products.

During the 1980s, 90 percent of people with severe hemophilia were infected by HIV and/or HCV through use of clotting factor concentrates. Understandably, this created anger among the affected community because of the evidence indicating that the companies manufacturing the concentrates knew the dangers of contamination but continued to distribute them anyhow.

Although considered by some to be innocent victims of HIV/AIDS, people with hemophilia have not escaped discrimination. The Ryan White Care Act, which funds HIV/AIDS services, and the Ricky Ray Act, which provides compensation to hemophiliacs infected with HIV, were named for HIV-positive boys with hemophilia who suffered serious discrimination (arson, refusal of admittance to grade school) in their home towns.

WOMEN

Women are the fastest growing segment of the HIV-infected population in the United States and worldwide. Three-fourths of the women and girls living with HIV/AIDS in the United States are African American and Hispanic, even though these populations account for only one-fourth of the females in this country.

Most women are infected through heterosexual contact with an infected male partner (often their only partner), or through injection drug use. But women are also at risk because they are often economically, culturally, and physically less powerful than men.

According to the CDC, female adolescents and young women under the age of 25 are at higher risk for HIV/AIDS and other STDs than older women. This increased risk is likely due to their tendency to have multiple sex partners, engage in risky behaviors, and/or to be unable to negotiate safer sex practices with partners.

Taking care of others' needs—children or other family members—often prevents women with HIV/AIDS from taking care of themselves. Postponing medications or missing medical appointments may also be due to financial or transportation problems. Infection with HIV/AIDS may not seem to a woman to be her most serious problem. Income, housing, access to healthcare, possible abusive relationships, and concerns about her children seem more urgent and important, especially when HIV/AIDS symptoms are mild and manageable.

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.

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.

CHILDREN

Infants and children with HIV infection or AIDS need the same things as other children—lots of love and affection. Small children need to be held, played with, kissed, hugged, fed, and rocked to sleep. As they grow, they need to play, have friends, and go to school, just like other kids. Children with HIV are still kids and they need to be treated like any other kids in the family.

PEOPLE OF COLOR.

As stated earlier, African Americans and Hispanics have disproportionately higher rates of HIV/AIDS in the United States. There are no biological reasons for these disparities in incidence 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 information in culturally appropriate ways to diverse communities
• Denial about HIV risk due to stigma about the disease and its connection to homosexuality and drug use

Prevention messages need to be culturally appropriate and relevant and they must be delivered through channels appropriate to individual communities. These channels may include religious institutions and respected elders in the community. Ironically, some of these same institutions or elders may have contributed to the misinformation and stigma associated with HIV/AIDS. The Balm in Gilead (see Resources) is one organization working to change these attitudes.

In October 2007, black pastors and the National Black Leadership Commission on AIDS called on the federal government to declare HIV/AIDS among blacks a public health emergency and proposed legislation to address the disease in their community. Ministers pledged to work with the Congressional Black Caucus on legislation they expected to introduce in January 2008.

The Office of Minority Health Resource Center is a national resource and referral center on HIV/AIDS and other health topics. Its website (http://www.omhrc.gov) includes access to publications, databases, events, conferences, and funding resources.

Posted March 31, 2008

Expires March 1, 2010

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