HIV/AIDS: A Comprehensive Review
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Nurse case managers in Washington State: Take the WA version of this course
HIV/AIDS: A Comprehensive Review
Copyright © 2014 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to prepare healthcare professionals to care for those with HIV/AIDS, based on a review of HIV etiology and epidemiology, transmission of HIV and infection control, clinical manifestations and treatment, legal and ethical issues, and psychosocial issues associated with this disease process.
Upon completion of this course, you will be able to:
- Discuss the etiology and epidemiology of HIV worldwide and in the United States.
- List the risk factors for transmission of HIV in general and among healthcare workers in particular.
- Identify preventive and control measures for HIV/AIDS
- Discuss accepted procedures and regulations for HIV testing and post-test counseling.
- Describe the clinical manifestations and treatment guidelines for HIV/AIDS.
- Explain legal and ethical issues related to HIV/AIDS.
- Summarize the psychosocial issues associated with HIV/AIDS.
TABLE OF CONTENTS
ETIOLOGY AND EPIDEMIOLOGY OF HIV/AIDS
Upon completion of this section, you will be able to discuss the etiology and epidemiology of HIV worldwide and in the United States.
Defining HIV and AIDS
The human immunodeficiency virus (HIV) is like most other viruses contracted by humans, but with one important difference—the body’s immune system can destroy most viruses and clear them from the body, but that is not true for HIV. The immune system cannot get rid of HIV because the virus attacks a key component of the system (the T-cells or CD4 cells), invades them, uses them to produce copies of itself, and then destroys them.
AIDS (acquired immunodeficiency syndrome) is a complex condition caused by 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 HIV infection. Medical treatment is available to delay the onset of AIDS.
AIDS is 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. The virus causes an immune deficiency, and the body cannot defend against infection and disease. Over time, a person with a deficient immune system may become vulnerable to infections by disease-causing organisms such as bacteria, viruses, parasites, or yeasts. These opportunistic infections may cause life-threatening illnesses. HIV infection causes a combination of symptoms, infections, and diseases. This combination of health effects is known as a syndrome.
Origin and Strains of HIV
DNA analysis has identified the HIV-1 virus 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.
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 that is less easily transmitted. Worldwide, the predominant virus is HIV-1. Most of the West Africans infected with HIV-2 show none of the symptoms of classical AIDS. Viral load tends to be lower in persons infected with HIV-2, which may explain this type’s lower transmission rates and nearly complete absence of perinatal transmission. Most persons infected with HIV-2 do not develop AIDS, although when they do, the symptoms are indistinguishable from HIV-1. A few cases of HIV-2 infections have been found in people in the United States.
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. HIV-1 comprises four distinct groups: M, N, O, and P. Group M was the first to be discovered and represents the pandemic form of HIV-1 (Sharp & Hahn, 2011).
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). These white blood cells are essential to the function of the immune system in fighting infection. Once inside a T4 cell, HIV replicates and signals other cells that produce antibodies, which are essential for immune system function. It is not known whether HIV replication directly kills the infected cells or the anti-HIV immune response destroys them, but HIV demolishes 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.
Acute HIV infection is the time period immediately following infection with the virus. HIV replication is very rapid in the 6–8 weeks after acquiring the HIV infection and results in a high amount of HIV in the blood (viral load). During this time, the infected person may be symptom-free and unaware of the infection, but the viral load is the highest it will ever be because the body’s defenses have not yet responded. It is at this time when the risk of contagion is much higher than that from patients with established infections (Cohen et al., 2011). 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. Others refer to this period as primary HIV infection, acute retroviral syndrome, or acute HIV syndrome. This interval is also called the window period. During this period the person can infect other people through unprotected anal or vaginal sex, oral sex, or sharing of needles. Following this period, the person can remain asymptomatic for many years before the start of symptomatic AIDS.
Impact of HIV/AIDS
A GLOBAL PANDEMIC
Since the first case of AIDS was diagnosed in 1981, AIDS has killed more than 630,000 Americans (CDC, 2013a). The daunting human and economic costs of this disease in the United States are eclipsed only by its international impact. Since 1981, 33.4 million people worldwide have died from AIDS, and an estimated 35.3 million people were living with HIV in 2012. Although HIV infection rates are declining globally, AIDS deaths totaled 1.6 million in 2012.
Almost all (95%) of the newly infected people live in the developing world, particularly southern Africa, where it is the leading cause of death. Sixty-nine percent of all people living with HIV are living in this region, and nearly 1 in every 20 adults is infected with HIV (amfAR, 2013). In 2012 more than 9.7 million people were receiving AIDS drugs in low- and middle-income countries, and the United Nations has set a target to raise that to 15 million by 2015 (WHO, 2013).
GLOBAL HIV/AIDS STATISTICS, 2012
- 35.4 million people living with HIV
- 32.1 million adults (17.7 million women)
- 3.3 million children under 15 years
- 2.3 million people newly infected with HIV
- 2.0 million adults
- 260,000 children under 15 years
- 0.8% prevalence among people 15–49 years
- 1.6 million AIDS deaths
- 1.4 million adults
- 210,000 children under 1
- 6,300 new HIV infections a day
- 95% in low- and middle-income countries
- 700 in children under 15 years
- 5,500 in adults 15 years and older
- 47% in women
- 39% in young people 15–24 years
Source: WHO, 2013.
HIV/AIDS IN THE UNITED STATES
In 1984, the Centers for Disease Control and Prevention (CDC) began to develop a surveillance system in order to uniformly track the HIV/AIDS epidemic in the United States. Information is collected from state and local health departments and reported to the CDC for analysis to determine who is being affected and why. The main goal is to have in a place a nationwide system that combines information on AIDS cases, new HIV infections, and the behaviors and characteristics of people at high risk. As of 2013, all 50 states, the District of Columbia, and six U.S. dependent areas use a uniform HIV infection reporting system for collecting data on HIV infection (CDC, 2013b). The HIV Surveillance Report for 2012 (issued in 2014) will be the first time the data from all these areas will be included in the estimates.
The CDC estimates that more than 1.1 million people in the United States are currently infected with HIV. More than 200,000 of them do not know they are infected and are at high risk for transmitting the virus to others. While antiretroviral drugs have reduced deaths from AIDS, the number of new infections has not changed since the late 1990s. The estimated incidence of HIV has remained stable overall in recent years, at about 50,000 new HIV infections per year and 15,000 deaths from AIDS in the United States (CDC, 2013b).
HIV has been reported in all 50 states, the District of Columbia, and U.S. dependencies. It has not, however, been uniformly distributed. In 2011 ten states accounted for about 65% of HIV diagnoses, and the South accounted for about 48% of HIV diagnoses. The state with the highest number of cases diagnosed in 2011 was California, reporting 5,965 new infections; the District of Columbia had the highest number of HIV diagnoses per 100,000 population (177.9) (Henry J. Kaiser Family Foundation, 2013).
New HIV cases center primarily in large U.S. metropolitan areas (81%), with New York, Los Angeles, and Miami at the top of the list (CDC, 2013b). The epidemic’s scope varies across the country and continues to have a disproportionate impact on certain populations, in particular racial and ethnic minorities and gay and bisexual men.
HIV transmission patterns have shifted over time. New infections among men who have sex with men, who represent about 4% of the population, increased between 2008 and 2010 by 12%. Heterosexual sex has accounted for a growing share of transmissions over time, representing 25% of new infections in 2010. A 3% reduction in infections has occurred among men who have sex with men and also have a history of injection drug use. New infections related to injection drug use also have declined, accounting for 8% of new infections in 2010 (CDC, 2012a).
U.S. HIV/AIDS STATISTICS, 2011
- 1,148,200 persons 13 and older living with HIV infection
- 207,600 (18.1%) are unaware
- 510,000 blacks
- 280,000 women
- Deaths from AIDS
- 15,529 in 2011
- 636,000 since epidemic began
- New infections
- 49,273 people diagnosed with HIV
- 32,052 diagnosed with AIDS
- 217 children under 13 diagnosed with HIV
- 20% diagnosed with HIV are women
- 31% in adults 25–34 years
- 26% in young people 13–24 years
Source: CDC, 2013b.
In the United States, HIV/AIDS has forever altered the landscape of healthcare. Patient activism early in the epidemic spurred a massive research effort that led to greater understanding of AIDS and accelerated the development of innovative drugs. These drugs have slowed the death rate from AIDS in the United States and other countries since 1996, but without a cure and/or increased emphasis on prevention, there is no end in sight to the epidemic.
Antiretroviral drugs have reduced not only morbidity and mortality from AIDS. They have also reduced the public’s level of concern about the deadly nature of this epidemic, creating widespread complacency about the disease. This complacency, coupled with our society’s belief in the power of pharmaceuticals, has undermined prevention efforts. By extending the lives of people with HIV infection, drug treatment has also increased the prevalence (or number of cases per 100,000 people) of the disease and increased the likelihood of transmission. The CDC (2012a) reports that of Americans with HIV, only 28% are currently being treated effectively. Effective treatment reduces the level of virus in the body so transmission to others is less likely to occur.
NATIONAL HIV/AIDS STRATEGY
In 2010, the government outlined the National HIV/AIDS Strategy for the United States (NHAS), which has three overarching goals:
- Reducing infection rates
- Increasing access to care for those infected and optimizing health outcomes
- Eliminating disparities in prevalence, diagnosis, and treatment
The NHAS envisions a future in which “the United States will become a place where new HIV infections are rare and, when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socioeconomic circumstance, will have unfettered access to high-quality, life-extending care, free from stigma and discrimination” (White House, 2010).
The NHAS includes major outcomes to be achieved by 2015, such as:
- Reducing the number of new annual infections by 25%
- Increasing to 90% the percentage of people with HIV who know they are infected
- Reducing the HIV transmission rate in relation to the number of people living with HIV by 30%
- Increasing the proportion of newly diagnosed patients linked to care within 3 months from 65% to 85%
- Increasing by 20% the proportion of HIV-positive men who have sex with men (MSM), blacks, and Hispanics with undetectable viral loads
If the NHAS target outcomes are achieved, then approximately 76,000 infections will be prevented and an estimated 219,000 more people living with HIV will be in care by 2015. Achieving these outcomes would substantially alter the trajectory of the epidemic in the United States and could prevent a total of nearly 238,000 infections through 2020 (Holtgrave, 2010).
Since 2010, NHAS has become a significant factor in the progressive change occurring to improve the United States’ approach to ending the HIV epidemic here at home. There are successful, innovative programs being implemented across the country to get more people tested, treated, and engaged in care. In addition, the discovery that medical treatment for persons living with HIV can significantly reduce the rate of HIV transmission provides an additional reason for integrating prevention and care. The success so far bolsters the belief that we can achieve remarkable progress against the epidemic.
See also “National HIV/AIDS Strategy” under “Resources” at the end of this course.
Nationally, HIV/AIDS takes a heavy toll on people of all ethnicities, genders, ages, and income levels. However, three primary risk groups account for nearly three quarters (73%) of new HIV infections in the United States:
- Men who have sex with men (MSM) (63%)
- Injecting drug users (6%)
- MSM who also use injection drugs (4%)
Heterosexual transmission accounts for the remainder (27%) of new cases.
Other important groups at risk for HIV include blacks, women and children, seniors, incarcerated populations, commercial sex workers, and transgender (TG) people. Each of these groups has unique needs for outreach and education on prevention and treatment of HIV infection.
MEN WHO HAVE SEX WITH MEN
Although MSM are only a small percentage of the population, they account for more than half of all estimated new HIV infections. It is estimated that about 1 in 5 MSM is living with HIV. In 2010 MSM accounted for 63% of estimated new HIV infections in the United States and 78% of infections among all newly infected men (CDC, 2013c).
Among MSM, whites account for the highest number of new infections. In 2011 MSM HIV prevalence was highest among older age groups, blacks, and men with lower education and income. Black MSM had the highest HIV prevalence but the lowest awareness among racial/ethnic groups. HIV-positive MSM overall are increasingly aware of their infections (Wejnert et al., 2013).
The age of acquiring HIV infection among MSM varies by race. The majority of new infections among young African American MSM occur between ages 13–24; the largest number of new infections in Hispanic/Latino MSM (39%) occur between ages 25–34; and the most infections among young white MSM occur during their 20s and 30s (CDC, 2013d).
HIV INFECTION AMONG U.S. MSM BY RACE, 2011
- 38% African Americans
- 34% whites
- 24% Hispanics/Latinos
- 2% Asians
- 2% multiracial
- <1% American Indians/Alaska Natives
- <1% Native Hawaiians/other Pacific Islanders
Source: CDC, 2013e.
According to the CDC (2013d), several factors increase the risk of HIV transmission among MSM. These include the following:
- High prevalence of HIV and multiple partners: The risk of exposure to infection increases with each sexual encounter.
- Lack of knowledge of HIV status: Those who know they are infected are more likely to take precautions to protect their partners. Those who don’t know they are infected may unknowingly transmit the virus to others.
- Complacency about risk: Young men who did not experience the early AIDS epidemic may believe that HIV drugs mean AIDS is no longer a serious health risk. They fail to understand that HIV drug regimens are expensive, complex, and can have disabling or disfiguring side effects.
- Social discrimination and cultural issues: For some, ignorance, homophobia, stigma, and lack of access to healthcare may increase risky behaviors or act as a barrier to testing and other prevention services.
- Substance abuse: Some MSM use alcohol and other drugs, including methamphetamines, increasing risky behaviors while under the influence; this includes sharing needles or other injection equipment.
INJECTING DRUG USERS
In 2011 injecting drug users accounted for 6% of new HIV diagnoses in the United States and its six dependent areas, and MSM and injecting drug users accounted for 4%. Of all newly diagnosed HIV infections among injecting drug users, 47% occurred in African Americans, 25% in Hispanic/Latino(a), and 24.5% in whites. All other races accounted for 3.4% (CDC, 2013f).
Mainstream America disapproves of illegal drug use and those who become addicted. The methamphetamine epidemic has increased the risk of HIV transmission because the drug is so cheap and accessible. Successful efforts to prevent the spread of HIV/AIDS, HBV, and HCV among injection drug users (e.g., syringe exchange programs) remain controversial because some people equate these programs with “approval” of drug use.
Injection drug use often coexists with poverty, low self-esteem, anxiety, depression, and mental illness. While drugs offer temporary relief from the realities of harsh living conditions, they create a tangled web of problems, including risk-taking behaviors like unprotected sex. Drug users who would like to stop using often lack access to inpatient treatment facilities. Waiting lists for drug treatment programs are long, and by the time a place is available, users may be lost to follow-up.
Those drug users who do seek treatment for HIV may find the cost of the drugs prohibitive or the complex multidrug regimens beyond their ability to manage. In addition, street drugs and drugs unapproved by FDA, but available through online pharmacies, may have dangerous interactions with AIDS medications.
Among races/ethnicities, African Americans continue to be disproportionately affected. The estimated rate of new HIV infection for U.S. black men is seven times higher than that of white men, two times higher than Latino men, and almost three times higher than black women. Black gay, bisexual, and other MSM account for an estimated 72% of new infections among all black men (CDC, 2013c). Black women represent 29% of estimated new HIV infections among all adult and adolescent blacks. This is twenty times higher than for white women and nearly five times as high as for Latinas.
It is estimated that 1 in 16 black men and 1 in 32 black women will be diagnosed with HIV infection. In 2010, blacks accounted for about half (48%) of deaths among those diagnosed with HIV. It is the fourth leading cause of death for black men and women ages 25–44 (CDC, 2013c).
WOMEN AND CHILDREN
At the end of 2011, 1 in 4 people living with HIV infection in the United States was female, and women accounted for 20% of the estimated new HIV infections. In 2010, HIV was among the top-10 leading causes of death for black/African American women ages 15–64 and Hispanic/Latino women ages 25–44 (CDC, 2013i).
Between 2008–2012 women accounted for an average of 81 per 100,000 population new HIV diagnoses each year. However, non-Hispanic African American women accounted for 31.8 new HIV cases per 100,000 population, which was more than 20 times higher than for white non-Hispanic women. The median age among new female cases was 36, and about 40% were over the age of forty. Approximately 10% were infants or children (WA DOH, 2013c).
Women may be unaware of their partner’s risk factors, and women who have experienced sexual abuse are more likely to engage in high-risk sexual behaviors. Unprotected vaginal sex is a much higher risk for HIV for women than for men, and unprotected anal sex is riskier for women than unprotected vaginal sex. Injection drug and other substance use either directly or indirectly increase the risk. Some women may not insist on a condom due to fear of the loss of their partners or even physical abuse by them (CDC, 2013i).
Female adolescents and young women under the age of 25 are at higher risk for HIV/AIDS and other sexually transmitted diseases (STDs) than older women. Having sex with multiple partners, engaging in risky behaviors such as alcohol and drug use, and/or being unable to negotiate safer sex practices with partners all contribute to this heightened risk (CDC, 2013j).
The most common route of HIV infection in children is perinatal, either during pregnancy, labor and delivery, or breastfeeding. Although the incidence of mother-infant transmission has decreased greatly among whites, it remains a challenge in the African American community.
According to CDC (2013k), between 2010 and 2011, people aged 50 and older in the United States accounted for:
- 5% of new HIV diagnoses
- Nearly 19% of persons living with HIV
- Nearly 24% of all AIDS diagnoses
- 53% of deaths among persons living with HIV
Of new infections during this time period:
- 36% were in white men and 4% were in white women
- 24% were in black men and 15% were in black women
- 12% were in Hispanic/Latino men and 4% were in Hispanic/Latina women
- 44% of the new infections among people aged 50 and older were among gay, bisexual, or other MSM
- Among MSM 67% were in white MSM, 16% in Hispanic/Latino MSM, and 15% in black MSM
Health professionals also may fail to diagnose AIDS in seniors because symptoms can mimic those of normal aging, such as fatigue, weight loss, forgetfulness, and/or confusion. As a result, many seniors are diagnosed only in the late stages of the disease—or not at all.
Stereotypes about aging and about HIV/AIDS put seniors at risk for transmission. Many seniors are sexually active well into their seventies and eighties, a fact sometimes overlooked by health professionals. Thus, physicians and other healthcare workers may fail to ask patients about unprotected sex or to offer voluntary HIV testing.
OLDER ADULTS AND CONDOM USE
Most sexually active older couples do not use condoms because they are unconcerned about pregnancy. Unless a couple is monogamous, however, unprotected sex increases the risk of infection with HIV or other sexually transmitted diseases from multiple sexual partners. Older women face a higher risk than older men because age-related vaginal thinning and dryness can cause tears in the vaginal area.
Perceived barriers to condom use among seniors include the following factors:
- Drug and/or alcohol use before or during sexual activity
- Belief that unprotected sexual activity is more exciting and that condoms reduce sexual pleasure
- Lack of knowledge about effective use of condoms
- HIV conspiracy beliefs that HIV/AIDS is a man-made virus that the government created to kill and wipe out black people (Bogart et al., 2011)
- Belief that known and/or trusted partners are “safe”
Studies indicate these beliefs exist in all races and ethnic groups.
Since Viagra and other drugs for erectile dysfunction entered the marketplace in the late 1990s, rates of HIV/AIDS and gonorrhea increased more rapidly in middle-aged and older heterosexual adults than in those under age 40 (Jena et al., 2010).
Unprotected sexual activity is not the only risk factor among seniors. To control the rising costs of medications such as insulin, some seniors share needles for insulin and other prescription drugs.
The stigma of HIV/AIDS may be much more severe among seniors, leading them to hide their diagnosis from family and friends. Keeping their diagnosis a secret can limit or eliminate potential emotional and practical support.
More than 2 million people are incarcerated in the United States, and these people are at increased risk for acquiring and transmitting HIV. Each year, 1 in 7 persons living with HIV pass through a correctional facility. Most acquired HIV in the community (CDC, 2013g).
Many prison inmates engage in high-risk behaviors before being incarcerated, including unprotected sexual intercourse and drug and alcohol abuse, behaviors that often continue inside prisons, even though sex and drugs are prohibited. Most U.S. prisons fail to follow recommendations from the World Health Organization (WHO) that condoms be made available to prisoners, that prisoners have access to bleach for cleaning injection equipment, and that needle exchange programs be considered.
HIV testing is available to all correctional populations in the United States, but policies and specific procedures differ. In some cases, testing is mandatory. For example, Washington State law mandates HIV testing for anyone convicted of a sexual offense, prostitution or offenses relating to prostitution, or drug offenses associated with the use of hypodermic needles. Since March 2010, the Washington State Department of Corrections has notified all inmates that HIV screening will be performed during the prison intake medical evaluation unless they decline (CDC, 2011a).
Currently, eleven states mandate HIV testing upon intake as part of a comprehensive medical assessment and diagnostic screening. These states are Colorado, Georgia, Indiana, Michigan, Missouri, Nebraska, Nevada, Ohio, Rhode Island, Tennessee, and Utah. Other states have mandatory testing upon release, and include Florida, Idaho, Mississippi, Missouri, Nebraska, Oregon, Rhode Island, and Texas. The states of Missouri, Nebraska, and Rhode Island require mandatory testing both on intake and release (Dwyer et al., 2011).
COMMERCIAL SEX WORKERS
The mathematical reality that sex workers have hundreds of partners each year makes this population a critical element in the spread of HIV throughout the wider community. However, there is little research on HIV and other STDs among commercial sex workers in the United States.
The CDC reported in 2013 that many socioeconomic factors are involved in sex work, including mental health issues, incarceration, prior physical/emotional/sexual abuse, drug use, and selling of sex for survival. Among this population, there is high-risk drug and alcohol use. Many sex workers are unaware of services such as HIV testing and do not know their HIV status. Use of condoms among sex workers is not consistent and may be the result of economics, type of partner, power dynamics, and the fact that many sex workers may receive more money for unprotected vaginal and anal sex.
Because sex work is illegal, sex workers often distrust both police and public health authorities. (In the United States, prostitution is legal and regulated only in the state of Nevada.) This contributes to a lack of data regarding sex work and a significant barrier to HIV prevention efforts and other services (CDC, 2013h).
Many police practices increase the risk for HIV among sex workers. Human Rights Watch (2012) reported that New York, Los Angeles, Washington, DC, and San Francisco were confiscating condoms from sex workers and transgender women as evidence of prostitution. Such policies can defeat HIV prevention programs in which free condoms are made available to sex workers. In one study, 52% of sex workers said there had been times when they chose not to carry condoms because they were afraid it would mean problems with the police (Open Society Foundations, 2012).
Transgender is an inclusive term for persons whose gender identity, expression, or behavior differs from the norms expected from their birth sex. The American Psychological Association (2014) writes, “The ways that transgender people are talked about in popular culture, academia, and science are constantly changing … and the meaning of gender nonconformity may vary from culture to culture.” Currently, gender identities within this category include transgender woman, transgender man, male-to-female (MTF), female-to-male (FTM), transsexual, transvestite, drag queen/king, and genderqueer. The exact definitions of these terms vary from person to person.
In 2011, a National Gay and Lesbian Task Force and the National Center for Transgender Equality survey found that transgender people had over four times the national average of HIV infection than the general population, with rates higher among transgender people of color (Grant et al., 2011). Similarly, the results of a meta-analysis of studies from 15 countries “were surprising in terms of the magnitude of the increased odds—nearly 50 times—of transgender women having HIV compared to other adults of reproductive age” (Baral, 2013).
The CDC (2013l) reported that in 2010 the highest percentage of newly identified HIV-positive test results was among transgender people. Behaviors and factors contributing to this high risk of HIV infection included “higher rates of drug and alcohol abuse, sex work, incarceration, homelessness, attempted suicide, unemployment, lack of familial support, violence, stigma and discrimination, limited healthcare access, and negative healthcare encounters.”
Additionally, some transgender people (and others) gather at “pump parties” for body modification in which a non-professional injects industrial silicone mixed with other substances into their breasts, cheeks, hips, and/or buttocks. Others use injectable hormones for body modification. In these street settings, it is not unusual for syringes and needles to be shared, placing the persons at high risk for HIV and other infectious diseases (USDHHS, 2012a).
TRANSMISSION AND INFECTION CONTROL
Upon completion of this section, you will be able to list the risk factors for transmission of HIV in general and among healthcare workers in particular, and identify preventive and control measures for HIV/AIDS.
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.
In terms of the classic “chain of infection,” three links are necessary for the transmission of HIV:
- An HIV source
- A sufficient dose (viral load) of virus
- Access to the bloodstream of another person
Varying levels and concentrations of HIV have been found in most body 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. Healthcare workers, however, may be exposed to some other body fluids with high concentrations of HIV, including amniotic, cerebrospinal, pericardial, pleural, and synovial fluids.
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.
Since last reported in 2006, there have been no confirmed cases of female-to-female transmission of HIV, but female sexual contact should be considered 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 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 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.
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 before 1985.
Donor screening, blood testing, and other processing methods have reduced the risk of transfusion-caused HIV transmission. All donated blood is tested for HIV. Also, other measures are used to screen possible donors. For example, donors are questioned about whether they have any signs and symptoms of HIV or HIV risk factors. Only about 1 in 2 million donations might carry HIV and transmit HIV if given to a patient (NIH, 2012).
TATTOOING AND BLOOD-SHARING ACTIVITIES
HIV can be transmitted during tattooing or during blood-sharing activities such as “blood brothers/sisters” rituals or ceremonies where blood is exchanged or unsterilized equipment contaminated with blood is shared. The CDC reported no cases of HIV transmission documented from tattooing or body piercing, but these activities do present a risk if new needles, ink, and other supplies are not used and the person doing the procedure is not properly trained and licensed.
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 therapy, the risk of perinatal transmission to the newborn drops below 1%. 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 (CDC, 2013j). Alternatively, a simple method of flash-heating pumped breast milk has been shown to inactivate the HIV virus (Israel-Ballard et al., 2007). In addition, the infant is treated for the first six weeks of life (NIH, 2013a).
Some states require that pregnant women be counseled concerning risks about HIV and offered voluntary HIV testing. A healthcare practitioner experienced in treating HIV-infected women should give advice about medications and cesarean delivery on a case-by-case basis.
FLASH-HEATING BREAST MILK
- Collect breast milk into a clean glass jar.
- Cover the jar immediately.
- Place the covered jar into a cooking pan.
- Put enough water into the pan to cover the jar halfway up.
- Bring the water to a boil.
- Protecting hands, immediately remove the jar from the water.
- Allow milk to cool before feeding to the infant.
Source: Israel-Ballard et al., 2007.
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.
|Type of Exposure||HIV Infection Risk*|
|Source: CDC, 2013m.|
|HIV-infected blood transfusion||90%|
|Needle-sharing during injection drug use||0.67%|
|Receptive anal intercourse||0.5%|
|Receptive penile-vaginal intercourse||0.1%|
|Insertive anal intercourse||0.07%|
|Insertive penile-vaginal intercourse||0.05%|
|Receptive oral intercourse||Low|
|Insertive oral intercourse||Low|
|Throwing body fluids (including semen or saliva)||Negligible|
|Sharing sex toys, razors, toothbrushes||Negligible|
|*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 Transmission Risk
Many other factors, alone or in combination, affect the risk of HIV transmission.
OTHER SEXUALLY TRANSMITTED DISEASES (STDs)
Infectious organisms transmitted during sexual activity—and the clinical manifestations arising from them—cause sexually transmitted diseases. Bacteria, parasites, and viruses cause STDs. There are more than 20 types of STDs, including:
- Bacterial: chlamydia, gonorrhea, syphilis
- Fungal: candidiasis (yeast infection)
- Viral: hepatitis B, Herpes simplex, HIV, HPV
- Parasites: crab louse, scabies
- Protozoal: trichomoniasis
Sexually transmitted diseases increase the risk of acquiring HIV infection because they can cause lesions that make it easier for HIV to enter the body. They can also cause inflammation triggered by the immune system. Because HIV prefers to infect immune cells, any disease causing an increase in these cells will make it easier for a person to become infected with HIV. HIV-positive individuals with STDs are also more infectious and are 3 to 5 times more likely to transmit HIV during sexual activities (CDC, 2010a).
Prevention of HIV/AIDS should be part of a general program of 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 2000–2011. Seventy-two percent of all primary and secondary syphilis cases were among MSM (CDC, 2013n).
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 diagnostic studies 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
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. Pre-existing HPV infection in women is associated with a two-fold increase in the risk of HIV acquisition. HPV infection of the penis among heterosexual men almost doubles the risk of contracting HIV, and anal HPV infection among gay/bisexual men more than triples the risk of contracting HIV (Houlihan et al., 2012).
A study completed in 2012 supports recommendations to vaccinate young HIV-positive women with Gardasil and to target vaccination to 11- and 12-year-olds, who are less likely to have acquired HIV behaviorally (Mascolini, 2012). 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 9–26; and in 2010 the CDC recommended vaccination of boys and men ages 9–26 to reduce their likelihood of acquiring genital warts (CDC, 2010b).
Genital herpes (HSV-1 and -2) also appear to be a major risk factor for acquiring HIV infection, increasing the risk more than two-fold. The CDC (2011b) estimates that 776,000 people in the United States get new herpes infections every year. One out of 6 people aged 14–49 are estimated to have genital HSV-2 nationwide. Genital HSV-2 infection is more common in women than in men. Most have not been diagnosed. Many of them have mild or unrecognized infections but shed virus intermittently in the genital tract. These individuals are more likely to transmit the infection.
Two large, randomized controlled trials found that, for people with HSV-2 infection, taking daily treatment to suppress herpes infection did not lower the chances of getting HIV infection. Thus, testing for genital herpes and treatment with herpes medications will not diminish the potential risk of HIV acquisition due to HSV-2 infection (CDC, 2011b).
Chlamydia and Gonorrhea
In 2012 chlamydia was the most frequently reported bacterial sexually transmitted infection in the United States. Untreated chlamydia may increase a person’s chances of acquiring or transmitting HIV (CDC, 2014). It is estimated that 1 in 15 sexually active females aged 14–19 has chlamydia, which is transmitted through anal, vaginal, or oral sex and can be passed from an infected woman to her baby during childbirth. Gonorrhea often occurs along with chlamydia. It is spread by contact with infected body fluid and can be passed from a woman to her newborn during childbirth. It is estimated that less than half of all new cases are reported to the CDC, as gonorrhea may be asymptomatic. Sexually active teenagers have one of the highest rates of reported infections.
The individual with multiple sex or injection drug–sharing partners is at great risk for exposure to HIV. 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 prescribed medications, alcohol, or noninjectable 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.
Certain substances can mask pain and/or create oral and genital sores. For example, methamphetamine dries mucous membranes and increases the risk of abrasions (Hussain et al., 2012).
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
HIV infection 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 to a rate of less than 1% and less than 1 transmission per 100,000 live births (CDC, 2013j). Following Standard 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 varies from $253,000 to $402,000 (Farnham et al., 2013).
Prevention of HIV begins with education and counseling about sexual practices and injection drug use. People unable to “just say no” need basic, practical, how-to information.
Safer sex practices include:
- Abstinence from sexual contact
- Mutual monogamy
- Correct use of latex condoms for all sexual intercourse (anal, oral, and vaginal), even between two HIV-positive partners
- Getting tested and knowing the HIV status of one’s partner
Latex condoms are highly effective against HIV. If a partner is allergic to latex, polyurethane or polyisoprene condoms can be used. “Skins,” or natural-membrane condoms, used for birth control, however, will not protect against the virus.
Although there have been no confirmed cases of female-to-female transmission of HIV, women who have sex with women (WSW) should take precautions, as vaginal secretions and menstrual blood are potentially infectious. Precautionary measures include:
- Using female condoms consistently and correctly each and every time for sexual contact 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
CORRECT USE OF MALE CONDOMS
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.
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.
- Be aware that 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 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. But in 2011, only two years after a landmark decision to allow federal funding for syringe exchange programs, the ban was renewed as part of a political compromise on a general spending bill. The reinstatement of the ban fails to take into account countless studies on the efficacy of such programs as HIV-prevention strategies.
Syringe exchange or needle exchange programs also help prevent spread of hepatitis and other bloodborne pathogens. Currently, 29 states have syringe or needle exchange programs, including many local health departments.
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.
Healthcare practitioners should implement preventive strategies with their patients beginning with the initial visit and continuing throughout subsequent visits or periodically, at least once a year. A straightforward, nonjudgmental approach and open-ended questions should be used 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.
Injection drug users 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 MINORITY POPULATIONS
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.
Research has documented that male circumcision significantly reduces the risk of contracting HIV through penile-vaginal sex. Studies have shown circumcised men had a 58% lower incidence of HIV infection compared with uncircumcised men. Male circumcision also lowers the risk for other STDs (CDC, 2013o).
In July 2012, the U.S. Food and Drug Administration (FDA) approved the combination medication tenofovir disoproxil fumerate plus emtricitabine (TDF/FTC), a combination pill known as Truvada, for use as preexposure prophylaxis (PrEP) to prevent new infections. In addition, in 2013 the CDC reported that daily medication with tenofovir disoproxil fumerate has now been proven to reduce the risk of acquiring HIV among all groups at high risk, including people who inject drugs, by 49% (CDC, 2013p).
The cost of PrEP is a major concern for public health agencies and private insurers, since Truvada costs about $1,200 per month. In addition, possible side effects include diarrhea, kidney, and bone damage. It is warned that this drug should not replace safer sex that includes using condoms and preventing impaired judgment.
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.
In 2013 the CDC reported that 57 healthcare personnel in the United States have been documented as having seroconverted to HIV following occupational exposures. In addition, 143 possible cases of HIV infection or AIDS have occurred among healthcare personnel. However, there have been no confirmed cases of occupational HIV transmission to healthcare workers reported since 1999. Healthcare workers exposed to HIV-infected blood at work have a 0.3% risk of becoming infected (CDC, 2013q).
Healthcare professionals 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
- Morticians and embalmers
- Ancillary medical facility personnel such as housekeeping, waste management, laundry staff
The risk of developing HIV infection from a needlestick with infected blood is about 1 in 300 without prompt antiretroviral treatment, and the risk increases with:
- Deep punctures
- Hollow-bore needles
- Visible blood on the needle
- High viral load in the source
(Comparatively, the risk after a mucous membrane exposure is about 1 in 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 it involved exposure to nonintact skin or to mucous membranes (such as eyes, nose, and/or mouth)
- The amount of blood involved
- The amount of virus present in the source’s blood
In Correctional Institutions
The high prevalence of HIV infections in correctional institutions increases the risk of exposure, as does the environment itself. The CDC 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.
The federal Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard (29 CFR 1910.1030) prescribes safeguards to protect workers against health hazards related to bloodborne pathogens. It includes regulations dealing with exposure control plans, engineering and work practice controls, hepatitis B vaccination, hazard communication and training, and recordkeeping. The standard imposes requirements on employers of workers who may be exposed to blood or other potentially infectious materials (OPIM) such as certain tissues and body fluids.
Most states have adopted standards that are identical to Federal OSHA. Twenty-five states, Puerto Rico, and the Virgin Islands have OSHA-approved state plans, which are required to be at least as effective as Federal OSHA.
In general, the standard requires employers to:
- Establish a written exposure control plan to eliminate or minimize occupational exposures and to update the plan annually
- Implement the use of Standard Precautions (treating all human blood and OPIM as if known to be infectious for bloodborne pathogens)
- Identify and use engineering controls (devices that isolate or remove bloodborne pathogens hazards from the workplace)
- Identify and ensure the use of work practice controls
- Provide personal protective equipment (PPE) and clean, repair, and replace this equipment as needed
- Make available hepatitis B vaccinations to all workers with occupational exposure
- Make available postexposure evaluation and follow-up to any occupationally exposed worker who experiences an exposure incident
- Use labels and signs to communicate hazards
- Provide information and training to workers on occupational exposures
- Maintain worker medical and training records
OTHER POTENTIALLY INFECTIOUS MATERIALS
OPIM linked to transmission of HIV, HBV, and HCV are listed here. Standard Precautions apply to all of the following:
- Blood and blood products
- Vaginal secretions
- Cerebrospinal fluid
- Synovial fluid
- Pleural fluid
- Peritoneal fluid
- Pericardial fluid
- Amniotic fluid
- Saliva in dental procedures
- Any body fluid or substance visibly contaminated with blood
- All body fluids in situations where it is difficult or impossible to differentiate between body fluids
- Any unfixed tissue or organ (other than intact skin) from a human (living or dead)
- HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV
Body fluids such as urine, feces, and vomit are not considered OPIM unless visibly contaminated by blood. Similarly, wastewater (sewage) has not been implicated in the transmission of HIV, HBV, or HCV and is not considered to be either OPIM or regulated waste.
INFECTION CONTROL SYSTEMS
To prevent HIV transmission in healthcare settings, the CDC instituted “Universal Precautions” (blood and body fluid precautions) in the 1980s. Under Universal Precautions, healthcare personnel assumed that the blood and other body fluids from all patients were potentially infectious and therefore followed infection-control precautions at all times and in all settings.
In 1996, this practice was replaced. Standard Precautions is the current terminology, and it includes:
- Precautions to be used with all patients at all times and in all settings
- Transmission-based precautions to be used when specific modes of transmission are present (e.g., Contact Precautions or Droplet Precautions)
The emphasis has shifted to a more pragmatic focus on what healthcare professionals need to do with specific patients with specific modes of transmission associated with their diagnosis.
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
- 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 body 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 practitioner has cuts, scratches, or other breaks in their own skin
Clinicians 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.
Soap-and-water handwashing must be performed whenever hands are visibly contaminated or there is a reasonable likelihood of contamination. Standard Precautions also include frequent handwashing with warm water and soap:
- Before seeing each patient
- Immediately after gloves are removed, even if they appear to be intact
- Immediately, if contaminated with blood or other body fluids to which Standard Precautions apply
- Upon leaving and returning to 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” (CDC, 2002) (see “References” at the end of this course).
CAUTIONS REGARDING ALCOHOL-BASED HAND SANITIZERS
The use of an alcohol-based hand rub is appropriate in many, but not all, situations.
- Alcohol-based hand sanitizers are not effective against all pathogens, notably the spores of C. difficile and anthrax, and have limited effectiveness against norovirus (winter vomiting virus).
- The presence of protein material on the skin prevents the active ingredient from contacting the skin. Soap-and-water handwashing is recommended after known or suspected contact with blood or other body fluids and after eating to remove any protein from the skin.
Sharps containers should be placed as close to the point of use as possible to enhance compliance with correct disposal policies.
Needles are not to be recapped, purposely bent or broken, removed, or otherwise manipulated by hand. After they are used, disposable syringes, needles, scalpel handle-blade units, and removable scalpel blades are to be immediately placed in puncture-resistant, labeled containers for disposal.
Phlebotomy or injection needles must not be removed from holders or syringes unless required by a medical procedure. The intact phlebotomy or injection needle and holder or syringe 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 the EPA at epa.gov/oppad001/chemregindex.htm.
Laundry. Laundry that is or may be soiled with blood/OPIM 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 or sharp items 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
TAGS AND LABELS
Tags or labels must be used as a means to protect employees from exposure to potentially hazardous biological agents.
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 must be informed as to the meaning of the various tags used throughout the workplace and what special precautions are necessary.
Personnel handling laundry and waste are to be aware that these items may contain sharps despite the most stringent policies and the best efforts of healthcare workers. They should be trained in immediate first aid for a needlestick or other break in skin integrity. They should immediately report any potential exposure to a supervisor with the knowledge and authority to implement the exposure control plan.
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 EXPOSURE TO BLOOD OR OPIM
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 U.S. Public Health Service (Kuhar, 2013).
Immediately after exposure to blood or OPIM of a patient:
- Wash the affected area(s) with soap and water. Application of antiseptics should not substitute for washing.
- Flush splashes to the nose, mouth, or skin with water.
- Irrigate eyes with clean water, saline, or sterile irrigants.
- Remove any potentially contaminated clothing as soon as possible.
- In the event of a sharps injury, wash the exposed area with soap and water.
- Do not “milk” or squeeze the wound.
- There is no evidence that antiseptics such as hydrogen peroxide will reduce the risk of transmission; however, use of antiseptics is not contraindicated.
- Seek emergency treatment if the wound needs suturing.
- For bites or scratch wounds, wash with soap and water and cover with a sterile dressing. All bite wounds should be evaluated by a healthcare professional.
- Exposure to urine, feces, vomitus, or sputum is not considered a bloodborne pathogens exposure unless the fluid is visibly contaminated with blood. Follow the employer’s procedures for cleaning these fluids.
Reporting the Incident
Immediately report the incident to a supervisor and to the department (e.g., occupational health, infection control) within the 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.
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 prophylaxis is recommended when occupational exposure to HIV occurs. The U.S. Public Health Service (USPHS) recommends the following guidelines:
- Determine, if possible, the HIV status of the exposure source patient to guide the need for HIV PEP.
- Start PEP medication regimens as soon as possible after exposure (24 hours) and continue for a 4-week duration.
- PEP medication regimens should contain three or more antiretroviral drugs for all occupational exposures to HIV.
- Expert consultation is recommended for any occupational exposure to HIV situation as defined by the USPHS.
- Close follow-up should be provided, including counseling, baseline and follow-up HIV testing, and monitoring for drug toxicity beginning 72 hours after exposure.
- If a fourth-generation combination of HIV p24 antigen-HIV antibody test is used for follow-up HIV testing, testing may be ended four months following exposure. If a new testing platform is not available, follow-up HIV testing is to be concluded six months after exposure.
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.
Round-the-clock information regarding the most current PEP regimen is available from the Post-Exposure Prophylaxis Hotline (PEPline): 1-888-448-4911.
The PEPline offers treating clinicians up-to-the-minute advice on managing occupational exposures (i.e., needlesticks, splashes, etc.) to HIV, hepatitis, and other bloodborne pathogens. Clinicians will help assess the risk of the exposure, discuss the most recent PEP protocols, and review specific treatment and follow-up options. Written materials supporting the telephone discussion are sent by mail or fax whenever needed.
PEPline clinicians will respond to calls between 9 a.m. and 2 a.m. ET. Emergency calls made during other hours are answered when live service resumes the following morning.
The PEPline is an invaluable resource for healthcare workers and their agencies, especially in rural areas. The phone number and website should be listed in appropriate locations, and a plan put in place to contact the PEPline using a relay of information if cellular and/or internet service is not available in all areas in which workers may be exposed.
Source: CDC, 2013t.
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 as soon as feasible. Such testing may or may not require the consent of the source individual, depending on 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.
INFECTION CONTROL IN THE HOME
Healthcare professionals 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, nursing assistants, personal care assistants (PCAs), and family members experience percutaneous injuries and other exposures to blood and body fluids during care of an HIV-infected person.
Medical procedures contributing to percutaneous injuries 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.
Healthcare workers 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 nonintact 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 cleaned using either soap and water or an alcohol-based hand sanitizer 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 household bleach freshly mixed with 9 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 into 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.
PREPARING A 1:10 SOLUTION OF HOUSEHOLD BLEACH
A 1:10 solution of household bleach includes 1 part bleach and 9 parts water. The key is using the same volume as a “part”—i.e., a measuring tablespoon or a measuring cup.
- Working in well-ventilated area, measure 9 parts water into a closable container that will hold the total volume of solution.
- Measure 1 part of household bleach into the same container.
- Close and label the container with the name of the solution (one which everyone in the household can read and understand), the date and time prepared, and an identifier for the person preparing the solution.
- Prepare only as much solution as needed for 24 hours.
- When using, pour solution from the container.
- Do not return used solution to the container.
- Discard any unused solution within 24 hours, rinse the container, and prepare new solution as needed.
Source: CDC, 2009.
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. If necessary, 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 dry-cleaned 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 1:10 bleach solution. 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.
Electronic thermometers with disposable covers do not need to be cleaned between uses for the same individual unless visibly soiled or if there is evidence that the cover integrity has been compromised. 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, after each use it should be soaked in 70%–90% ethyl alcohol for 30 minutes, then rinsed under a stream of warm water.
Personal Hygiene Items
People should not share razors, toothbrushes, personal towels or washcloths, dental hygiene tools, vibrators, enema or douche equipment, or other personal care items.
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 circumstances, so it is essential to check with the local health department to see which option applies to any given 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 the body.
- Do not break the needle off from the syringe.
- Place used sharps and syringes in a safe container with at least a one-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.
PROTECTING THE PERSON WITH HIV/AIDS IN THE HOME
Kitchens can harbor bacteria that may prove life threatening to a person with HIV/AIDS due to his or her compromised immune system. 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.
- 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.
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.
Someone who is not immunocompromised should care for pets. 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. 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.
- All pet care should be followed by thorough handwashing.
- Cats’ claws and dogs’ nails should be kept trimmed.
- Latex or nitrile gloves should be worn to clean up any pet urine, feces, vomit, or OPIM. The soiled area should be cleaned with a fresh 1:10 bleach solution.
- 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, even if using “clumping” litter.
- Fish tanks should be kept clean. Heavy latex gloves that reach to the upper arms, such as “calf-birthing” gloves, can be purchased from a veterinarian for immunocompromised individuals to wear to clean a fish tank.
- Pets should not be allowed to drink from the toilet or eat other animal feces, any type of dead animal, or garbage.
- Cats should be restricted to indoors. Dogs should be kept indoors or on a leash.
HIV TESTING AND COUNSELING
Upon completion of this section, you will be able to discuss accepted procedures and regulations for HIV testing and post-test counseling.
People who do not know they are infected transmit most HIV infections. Therefore, HIV testing is the first step in halting spread of the virus. Testing is critical to the country’s prevention strategy. It is the only way the nearly 1 in 6 Americans living with HIV who do not know they are infected can be diagnosed, and it is the first step in connecting them to the services for prevention, care, and treatment that they require. Detection and early intervention are associated with a significantly reduced risk for progression to AIDS, AIDS-related events, and death in persons with immunologically advanced disease.
Testing is essential for anyone who has had a potential exposure to HIV. This includes anyone who has had unprotected anal, vaginal, or oral sex; who has shared needles or other injection drug preparation equipment; or who has had an occupational exposure. People with partners who have such risk factors should also consider testing.
The U.S. Preventive Services Task Force (2013) recommends that clinicians screen for HIV infection in adolescents and adults ages 15–65 years. Younger adolescents and older adults who are at increased risk should also be screened. It is also recommended that all pregnant women be screened for HIV—including those who present in labor who are untested and whose HIV status is unknown—and be rescreened with each subsequent pregnancy.
The CDC (2013r) recommends the following:
- Notify the patient that testing will be performed unless he or she declines (opt-out screening).
- Do not require written consent for HIV testing; general consent for medical care should be considered sufficient to encompass consent for HIV testing.
- Screen persons at high risk for HIV infection at least annually.
- Do not require prevention counseling with HIV diagnostic testing or as part of HIV screening programs in healthcare settings.
- Include HIV screening in the routine panel of prenatal screening tests for all pregnant women. Repeat screening in the third trimester is recommended in certain jurisdictions with elevated rates of HIV infection among pregnant women.
Research has shown that when people learn they are infected, they take steps to protect their own health and prevent HIV transmission to others. According to the CDC (2013s), the proportion of adults who have ever been tested for HIV increased from 37% in 2000 to 45% in 2010. However, the CDC (2012a) reports that:
Although HIV testing rates have steadily increased, it is estimated that more than half of Americans still have not been tested for HIV in their lifetime. Lack of access to healthcare, fear, and misperceptions about HIV risk and the testing process itself are key barriers to increasing HIV testing. In addition, some healthcare settings have not yet made HIV testing a routine part of medical care.
There remain far too few tests being conducted even among high-risk groups, including males who have sex with males, African Americans, and young people. Although half of high school students report having had sex, the CDC data reveals that only 13% have ever been tested for HIV (CDC, 2012a).
Testing Special Populations
HIV-infected women who do not get tested often transmit HIV to their infants. Thus, the CDC recommends that all pregnant women be tested for HIV and, if found to be infected, offered treatment for themselves to improve their health and to prevent passing the virus to their infant.
There are two different approaches to HIV testing of pregnant women. With the “opt-in” approach, pregnant women must agree to receive an HIV test, usually in writing. With the “opt-out” approach, the women are told that an HIV test will be included in the standard group of prenatal tests given to all pregnant women unless they specifically decline the HIV test.
It is up to each state to establish laws governing HIV testing of pregnant women; some have chosen the opt-in approach, and others the opt-out approach. The CDC recommends the opt-out approach to testing for all adult and adolescent patients in healthcare settings, including pregnant women. These recommendations emphasize:
- Universal “opt-out” HIV testing for all pregnant women early in every pregnancy
- A second test in the third trimester in certain geographic areas or for women who are known to be at high risk of becoming infected (e.g., injection-drug users and their sex partners, women who exchange sex for money or drugs, women who are sex partners of HIV-infected persons, and women who have had a new or more than one sex partner during this pregnancy)
- Rapid HIV testing at labor and delivery for women without a prenatal test result
- Exploration of reasons that women decline testing
Studies show that the opt-out approach increases testing rates among pregnant women. This in turn increases the number of pregnant women who know their HIV status and are offered treatment, and likewise reduces HIV transmission to their babies (CDC, 2006).
SURVIVORS OF SEXUAL ASSAULT OR ABUSE
Survivors of rape (sexual assault) are at risk for infection with HIV and other STDs. Nearly 1 in 5 women and 1 in 71 men in the United States have been raped some times in their lives, and nearly 1 in 2 women and 1 in 5 men experienced sexual violence victimization other than rape at some point in their lives (CDC, 2010c).
The probability of HIV transmission during a single act of intercourse with an HIV-infected person is probably low according to the CDC (2013m) and depends on many factors. These factors include: type of intercourse (oral, vaginal, anal); presence of oral, vaginal, or anal trauma (including bleeding); site of exposure to ejaculate; viral load in ejaculate; and presence of an STD or genital lesions in the assailant or survivor.
Sexual assault also puts adolescent girls and women at risk of becoming pregnant, so emergency contraception is part of the medical protocol for female rape survivors. Counselors must provide survivors with the toll-free number for the emergency contraception hotline (1-888-NOT-2-LATE or 1-888-668-2528).
A sexual assault survivor should go directly to the nearest hospital emergency department (ED) without changing clothing and without bathing or showering, which might remove evidence that could incriminate the assailant. Trained ED staff will counsel the survivor and also offer testing or referral for HIV, STDs, and pregnancy.
Testing the survivor of sexual assault for HIV immediately after the event can establish that the survivor was not infected at the time of the assault. However, it is important to consider the window period and retest later if the assailant proves to be HIV-positive. In the rare case that an assault survivor is infected by the assailant, the earlier test can serve as evidence in criminal court.
The standard protocol is for the ED physician to take DNA samples of blood or semen from the vagina, rectum, or elsewhere, as indicated, which can be used as evidence for legal and criminal action. Some emergency departments may refer sexual assault survivors to the local health jurisdiction for HIV testing.
Questioning sexual assault survivors in the ED about their sexual risks can be difficult and unpleasant. However, testing shortly after a sexual assault provides useful baseline information on the various infections—especially for follow-up care and treatment.
ASSESSING ADOLESCENT AND ADULT SURVIVORS
Postexposure assessment of adolescent and adult survivors includes the following steps to be taken within 72 hours of sexual assault:
- Assess risk for HIV infection in the assailant.
- Evaluate characteristics of the assault event that might affect risk for HIV transmission.
- Consult with a specialist in HIV treatment if PEP is considered.
- If the survivor appears to be at risk for HIV transmission from the assault, discuss PEP, including toxicity and unknown efficacy.
- If the survivor chooses to receive PEP, provide enough medication to last until the return visit; reevaluate the survivor 3–7 days after initial assessment and assess tolerance of medications.
- If PEP is started, perform CBC and serum chemistry at baseline (initiation of PEP should not be delayed pending results).
- Perform HIV antibody test at original assessment; repeat at 6 weeks, 3 months, and 6 months.
Source: CDC, 2011c.
HIV and Child Sexual Assault
Children may be at higher risk for HIV transmission from sexual assault because child sexual abuse is often associated with multiple episodes of assault and may result in mucosal trauma. The CDC has identified certain situations involving high risk for STD transmission to children, including HIV, and these constitute a strong indication for testing:
- The child has or has had symptoms or signs of an STD or of an infection that can be sexually transmitted, even in the absence of suspicion of sexual abuse. Signs that may be associated with a confirmed STD diagnosis are vaginal discharge or pain, genital itching or odor, urinary symptoms, and genital ulcers or lesions.
- A suspected assailant is known to have an STD or to be at high risk for STDs (has multiple sex partners, a history of STDs)
- A sibling or another child or adult in the household or immediate environment has an STD
- The patient or parent requests testing
- The prevalence of STDs in the community is high
- Evidence of genital, oral, or anal penetration or ejaculation is present
ASSESSING CHILD SURVIVORS
Postexposure assessment of child survivors includes the following steps to be taken within 72 hours of sexual assault:
- Review HIV/AIDS local epidemiology and assess risk for HIV infection in the assailant.
- Evaluate circumstances of assault that may affect risk for HIV transmission.
- Consult with a specialist in treating HIV-infected children if PEP is considered.
- If the child appears to be at risk for HIV transmission from the assault, discuss PEP with the caregiver(s), including its toxicity and its unknown efficacy.
- If caregivers choose for the child to receive PEP, provide enough medication to last until the return visit at 3–7 days after initial assessment to reevaluate the child and to assess tolerance of medication; dosages should not exceed those for adults.
- Perform HIV antibody test at original assessment, 6 weeks, 3 months, and 6 months.
Source: CDC, 2011b.
PATIENTS SEEKING TREATMENT OF AN STD
The CDC (2011d) recommends that all persons who seek evaluation and treatment of STDs be screened for HIV infection. Testing should be done routinely, regardless if the patient is known or suspected to have specific behavioral risks for HIV.
INDIVIDUALS IN DRUG TREATMENT PROGRAMS
Patients are significantly more likely to receive an HIV test if done at a drug treatment facility as opposed to being referred elsewhere for testing. A study found that about 80% of members of two patient groups offered on-site HIV tests actually were tested and received their results, compared with only 18.4% of a group referred for testing off-site (Enos, 2012).
HIV/AIDS testing is available in a variety of settings:
- Public health departments
- Medical providers
- Family planning clinics
- STD clinics
- Some community clinics
TYPES OF HIV TESTS
There are three main types of HIV tests:
- Antibody tests
- Antigen or RNA tests
- Combination tests
Antibody tests are the most commonly used. They look for antibodies in blood, saliva, or urine produced by the host body rather than looking for the HIV itself. Antibodies usually appear within 6–12 weeks after infection but in rare instances can take up to 6 months to appear. The window period for an antibody test is estimated to be three months after exposure. These tests are very accurate and sensitive. The presence of antibodies is a marker showing infection with HIV.
Antigen (p24) or RNA tests detect the presence of a protein, p24, which is part of the core of the HIV. It is the substance that provokes an antibody response. It is produced in excess in early HIV infection and can be detected in blood serum. As the virus becomes more fully established, however, p24 will fade to undetectable levels. This type of test uses a polymerase chain reaction that can identify HIV in the blood within 2–3 weeks of infection, before antibodies have had time to develop. These tests are expensive, not very sensitive, and therefore not routinely used for screening.
HIV combination tests are able to detect antibodies directed against HIV-1 or HIV-2 as well as the protein p24. The tests use a reaction called chemiluminescence. When either the antibody or the p24 protein is present, this test reaction emits light that is registered on a detector. These tests allow for earlier and more accurate detection of HIV infection.
RAPID HIV TESTS
Until 2002, testing for HIV antibodies relied on an enzyme-linked immunosorbent assay (ELISA) of blood. Since then, nine rapid HIV tests have been approved by the FDA, all of which are interpreted visually. Four of the tests have been approved for use outside of a clinical laboratory.
|OraQuick ADVANCE Rapid HIV-1/HIV-2 Antibody Test||Detects HIV antibodies in oral fluid as well as in blood|
|Uni-Gold Recombigen HIV Test||Detects HIV-1 antibodies in whole blood, serum, and plasma; results take from 10–12 minutes|
|Reveal G3 Rapid HIV-1 Antibody Test||Detects HIV antibodies in serum or plasma; although test takes only 3 minutes to run, it is categorized as a moderately complex test and is usually done in a clinical laboratory|
|Multispot HIV-1/HIV-2 Rapid Test||Uses fresh or frozen serum and plasma to detect HIV-1 and HIV-2 and distinguish one from the other; results available in 20 minutes; also a moderately complex test, it is usually done in a clinical laboratory|
|Clearview HIV-1/HIV-2 STAT-PAK||Uses whole blood or serum and plasma; results available in 15 minutes; requires no training to use|
|Clearview HIV-1/HIV-2 Complete||A single-use, self-contained closed system for the collection, processing, and analysis of a whole blood, serum, or plasma sample; results available in 15 minutes|
|Alere Determine HIV-1/2 Ag/Ab Combo Test||Can detect HIV-1 and -2 antibodies and HIV-1 p24 antigen in human serum, plasma, and venous or fingerstick whole-blood specimens|
|Chembio DPP HIV-1/2||Detects antibodies to HIV-1 and -2 and gives results in 15 minutes from fingerstick or venous whole blood, plasma, serum, or oral fluid swab|
|INSTI HIV-1 Antibody Test||Detects HIV-1 antibodies in plasma and gives results in less than 2 minutes|
Until these rapid tests became available, many people undergoing testing in public clinics did not return to get their test results. Making results available during the testing appointment means that people can take immediate precautions to prevent transmission to their sexual partners. In addition, the oral fluid test offers another option for those people who may fear a blood test.
Rapid HIV testing is a two-step process that includes a screening test and, when the screening test is reactive (positive), a confirmatory test.
All positive (reactive) rapid HIV tests require repeat testing for confirmation. The CDC (2004) described protocols for confirming reactive rapid HIV tests based on a consultation convened in January 2003 with expert laboratory scientists, the FDA, and the Centers for Medicare and Medicaid Services. These protocols remain in effect and recommend 1) confirmation of all reactive rapid HIV test results with either Western Blot (WB) or immunofluorescent assay (IFA), even if an enzyme immunoassay (EIA) screening test is negative, and 2) follow-up testing for persons with negative or indeterminate confirmatory test results, with a blood specimen collected four weeks after the initial reactive rapid test result.
To ensure accuracy of test results, all laboratory testing is regulated under the federal Clinical Laboratory Improvement Amendments of 1988 (CLIA), which classify tests according to their complexity. Tests may receive a CLIA waiver if they use direct, unprocessed specimens such as whole blood or oral fluid, are easy to perform, and have a negligible chance of error. This waiver permits personnel without training in laboratory procedures to perform the tests outside a traditional laboratory setting.
OTHER HIV TESTS
Enzyme-Linked Immunosorbent Assay (ELISA)
Before HIV rapid tests became available, HIV antibody testing relied on an enzyme-linked immunosorbent assay (ELISA or EIA). This test overpredicts positives; consequently, a negative HIV antibody test is considered definitive and no further testing is required. If the results are positive, CDC recommends against telling a person he or she is HIV-positive based only on ELISA test results.
The HIV Western Blot detects antibodies to individual proteins that make up HIV. This test is much more specific and more expensive than the ELISA screening tests and considered more definitive.
A test to detect HIV antibodies in the urine is available for use only in doctors’ offices or medical clinics. Even though HIV antibodies can be detected in urine, urine is not considered a viable medium for transmitting the virus. A positive urine HIV test must be confirmed with a Western Blot test, which can be done on the same specimen.
HIV Viral Load
This test measures the amount of HIV in the blood of an infected person. It is seldom used to diagnose HIV infection; rather, it is used to measure the effectiveness of antiretroviral medications that treat HIV infection.
HOME TESTING KITS
Tests are now available for self-testing of HIV serostatus. There are two FDA-approved home test kits on the market: Home Access Express and OraQuick In-Home.
The Home Access Express product is really an in-home sample collection system rather than a test with readily visible results. The person who wants to test at home pricks a finger and collects blood spots on special paper. The paper is mailed to a certified clinical laboratory with a confidential and anonymous personal identification number (PIN) and then tested using a standard ELISA process. If the initial test result is positive, the results are confirmed by a Western Blot test. The person tested obtains the results by calling a toll-free phone number and using the assigned PIN. Post-test counseling is available by telephone for everyone tested, whether the results are positive or negative.
In 2012, the FDA approved the first rapid home-use HIV kit that does not require sending a sample to a laboratory for analysis. The OraQuick In-Home HIV test uses a sample of fluid from the mouth and provides results in 20–40 minutes. In this case also, the FDA wants consumers to know that positive test results using the OraQuick test must be confirmed by follow-up, laboratory-based testing.
The FDA has predicted that this test will reach many who would not otherwise be tested because of reluctance to visit their doctor or healthcare facility for testing. It will contribute noticeably to public health by helping more infected people to become aware of their HIV status, resulting in a reduction of HIV transmission. However, the test is available legally only to people aged 17 years and older.
HIV Antibody Test Results
HIV test results can be one of three types: negative, positive, or indeterminate. A person may test negative for HIV antibodies even though recently infected. As stated earlier, newly infected persons may have high levels of the virus in their blood, making them highly infectious even though test results are negative.
CDC (2006) recommendations state that test results should be conveyed to patients in the same manner as for other routine diagnostic tests, either by telephone or by mail, followed by later counseling, if needed.
It is recommended that clients tested with rapid HIV tests be advised that their preliminary results will be available in the same visit and that confirmatory testing will be needed if the rapid test result is positive. In addition, retesting within three months should be recommended even if the rapid test result is negative.
NEGATIVE TEST RESULTS
If the test result is negative, it means either 1) the person is not infected with the virus, or 2) the person became infected recently and antibodies have not yet appeared. A person who tests negative for HIV but remains concerned about a possible recent infection should test again in 3–6 months and practice safer behaviors in the meantime. If risky behavior continues, infection may still occur.
Additional testing is recommended as follows:
- If the original confirmatory test specimen was a blood specimen, repeat the confirmatory test with a new blood specimen to rule out specimen mix-up.
- If the original confirmatory test specimen was an oral fluid specimen, repeat the confirmatory test using a blood specimen.
POSITIVE TEST RESULTS
A positive test result shows the presence of HIV antibodies, which means that:
- The person is infected with HIV
- The person can transmit the virus to others through unsafe sexual practices, sharing contaminated injection equipment, and/or breastfeeding
- The person is infected for life
INDETERMINATE TEST RESULTS
Occasionally a rapid test or an enzyme immunoassay test will show an “indeterminate” or “inconclusive” test result. This may mean that the person is recently infected and is developing antibodies, a process called seroconversion. Indeterminate test results can also be caused by other factors, including but not limited to pregnancy, autoimmune diseases, blood transfusions, recent influenza vaccinations, or organ transplants.
- If the confirmatory test is indeterminate based on a blood specimen, advise the client to return for repeat testing in one month and at three months from the last possible exposure to verify that he or she is not infected.
- If the confirmatory test is indeterminate based on an oral fluid specimen, repeat the confirmatory test using a blood specimen.
- If the repeat blood specimen confirmatory test is also indeterminate, advise the client to return for repeat testing in one month.
Research has shown that only about 20% of people with indeterminate test results go on to become truly HIV positive. Only rarely do people remain indeterminate throughout their lives.
All testing offers an opportunity for counseling patients. If test results are negative, counseling efforts typically focus on avoiding exposure to HIV through safer sex practices and not sharing needles. If results are positive, counseling typically focuses on preventing transmission of the virus to others and referring the patient to resources for treatment, education, and support.
Any person who requests pretest counseling and anyone defined as at increased risk for HIV should be offered or referred for pretest counseling. If the provider determines the individual is at high risk for HIV infection, counseling should be based on assessment of the individual client as outlined below.
All individuals tested for HIV should also be offered an opportunity to receive post-test counseling.
PROVIDING RISK ASSESSMENT AND BEHAVIOR CHANGE GOALS
A client’s individual HIV risk can be determined through risk screening based on self-reported behavioral risk and clinical signs or symptoms. Behavioral risks include injection drug use or unprotected intercourse with a person at increased risk for HIV. Clinical signs and symptoms include those suggestive of HIV infection and other STDs.
Risk Assessment Questions
Behavioral risks can be identified either through open-ended questions by the provider or through screening questions (i.e., a self-administered questionnaire).
An example of an open-ended question is: “What are you doing now or what have you done in the past that you think may put you at risk of HIV infection?”
While not a comprehensive list, examples of other screening questions are:
“Since your last HIV test (if ever) have you:
- “Injected drugs and shared equipment such as needles, syringes, cotton, or water with others?”
- “Had unprotected intercourse with someone who you think might be infected?”
- “Had unprotected vaginal or anal intercourse with more than one sex partner?”
Risk Reduction and Support
Behavior change goals should be: 1) based on the individual’s risk; 2) perceived as realistic by the individual; and 3) based on the individual’s readiness and capability to change behavior. The goals of post-test counseling should be to: 1) increase the individual’s understanding of HIV infection; 2) change the individual’s behavior; and 3) if necessary, encourage the individual to notify people with whom there has been potential transmission of HIV.
Depending on the person’s readiness for change, counseling can be simple and brief or complex and lengthy. In many clinical practice settings, time restraints only permit brief and simple counseling.
As an example, for a person who has yet to contemplate behavior change, a realistic goal might be helping the person recognize which behaviors place them at risk for HIV. Skill building could help the person self-identify situations where the risk behavior is practiced.
Other individuals may be further along the behavior change continuum and have identified specific behaviors they wish to change. Support for those identified changes is appropriate. A relevant goal might be to identify barriers to the behavior change and help the person self-identify solutions. Demonstrating how to use a condom or how to discuss condom use with a new partner could be examples of building skills.
For those who have complex needs beyond the provider’s counseling skills or time available, referral to other resources should be arranged.
HIV REPORTING REQUIREMENT AND PARTNER NOTIFICATION
AIDS and HIV infection are reportable conditions in most states. Reporting of HIV and AIDS cases assists local and state health officials in tracking the epidemic. The statistics also allow for more effective planning and intervention services to prevent further transmission of HIV and reduce the burden of this disease.
There are many states and cities that have partner-notification laws. If a person tests positive for HIV, the person or healthcare practitioner is legally required to notify sex or needle-sharing partners. In some states the person can be charged with a crime if partners are not told of positive HIV results. Some state health departments require healthcare practitioners to report names of sex and needle-sharing partners if they know who they are, even if the patient refuses to report that information. Other states also have “duty to warn” laws requiring healthcare practitioners to notify any third party they know to be at substantial risk for exposure from a person known to be infected with HIV (USDHHS, 2012b).
The CDC (2008) defines partner as person(s) with whom an infected patient has had sex or shared drug-injection equipment at least once.
CLINICAL MANIFESTATIONS AND TREATMENT
Upon completion of this section, you will be able to describe the clinical manifestations and treatment guidelines for HIV/AIDS.
The trajectory between infection with HIV and the development of full-blown AIDS can be steep or gradual and may take as long as a decade or more. If the infection is untreated, the average time from HIV infection to a diagnosis of AIDS can be 10–15 years. However, early detection and appropriate medical treatment may extend the lives of those infected and reduce the rates of HIV transmission.
Course of the Disease and Diagnosis
As the HIV virus suppresses immune function, the infected person becomes more vulnerable to opportunistic infections caused by a wide variety of bacteria, viruses, fungi, and other pathogens encountered in daily life. The physical results of these opportunistic infections are called clinical manifestations. For example, the opportunistic infection cytomegalovirus (CMV) often causes the clinical manifestation of blindness in people with AIDS.
Some conditions, called co-factors—including age, genetic factors, drug use, smoking, nutrition, and coinfection with hepatitis C virus (HCV) and/or tuberculosis (TB)—can affect the course of the disease progression.
HIV CLASSIFICATION SYSTEMS
Currently there are two major ways to classify HIV:
- For surveillance case definition purposes
- For clinical diagnosis purposes
In 2008 the CDC revised its earlier surveillance case definitions of HIV and AIDS to require laboratory-confirmed evidence of HIV infection for all those aged 18 months and older. The revised definition also emphasizes the central role of the CD4 T-lymphocyte counts and percentages in staging HIV disease. It is important to recognize that these case definitions are for surveillance purposes only and are not a guide for clinical diagnosis.
The CDC classification system identifies four stages of HIV infection, described in the following table.
|Source: CSTE, 2012.|
|Stage 3 (AIDS)||
The CDC, the U.S. Department of Health and Human Services, and other organizations such as the World Health Organization identify disease progression through three to five stages of clinical evidence for HIV/AIDS. The following is a synopsis of these various clinical stages.
|Stage 1: Acute Infection||
|Stage 2: Clinical Latency||
|Stage 3: Early-Stage AIDS||
|Stage 4: Middle-Stage AIDS||
|Stage 5: Late-Stage AIDS||
OPPORTUNISTIC INFECTIONS AND CANCERS (AIDS-DEFINING CONDITIONS)
People with normal immune systems have a natural resistance to microorganisms, but when the immune system is suppressed, viruses, fungi, protozoa, and bacteria take the opportunity to cause infection. The following are such “opportunistic infections” that can affect persons with HIV infection:
- Bacterial infections (multiple or recurrent)
- Candidiasis of bronchi, trachea, or lungs
- Candidiasis of esophagus
- Coccidioidomycosis, disseminated or extrapulmonary
- Cryptococcosis, extrapulmonary
- Cryptosporidiosis, chronic intestinal (>1 month’s duration)
- Cytomegalovirus disease (other than liver, spleen, or nodes)
- Cytomegalovirus retinitis (with loss of vision)
- Herpes simplex: chronic ulcers (>1 month’s duration) or bronchitis, pneumonitis, or esophagitis
- Histoplasmosis, disseminated or extrapulmonary
- Isosporiasis, chronic intestinal (>1 month’s duration)
- Lymphoid interstitial pneumonia or pulmonary lymphoid hyperplasia complex
- Mycobacterium avium complex (MAC) or M. kansasii, disseminated or extrapulmonary
- M. tuberculosis (TB) of any site, pulmonary, disseminated, or extrapulmonary
- Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
- Pneumocystis jirovecii pneumonia
- Pneumonia, recurrent
- Progressive multifocal leukoencephalopathy
- Salmonella septicemia, recurrent
- Toxoplasmosis of brain, onset at age >1 month
- Wasting syndrome attributed to HIV
People with HIV/AIDS are at high risk for developing certain cancers, such as Kaposi sarcoma, non-Hodgkin’s lymphoma, and cervical cancer. These three cancers are referred to as “AIDS-defining conditions,” and if a person has one of these cancers, it is very likely to signify HIV and the development of AIDS. The connection between HIV/AIDS and cancer is not completely understood but is believed to be the result of a weakened immune system. The following types of cancer are also common for people with HIV/AIDS:
- Hodgkin’s lymphoma
- Anal cancer
- Liver cancer
- Mouth or throat cancer
- Lung cancer
- Testicular cancer
- Colorectal cancer
- Multiple types of skin cancer including basal cell carcinoma, squamous cell carcinoma, and melanoma
(Robert H. Lurie Comprehensive Cancer Center, 2013)
MULTISYSTEM EFFECTS OF HIV/AIDS
HIV infection not only affects the immune system but also affects other body systems.
Respiratory tract defenses are affected by HIV. Alveolar macrophages in persons with HIV may serve as reservoirs for the virus. These protected viruses may infect other cells and may contribute to the accelerated HIV disease in the presence of opportunistic infections (Hopewell, 2011).
The gastrointestinal system is affected by AIDS enteropathy, a condition characterized by changes in the villus of the small bowel. This leads to malabsorption resulting in malnutrition and wasting (Barlett, 2011).
Integumentary system problems increase in frequency and severity. There may be pruritus without evident skin lesions. Herpes zoster may be a reliable sign of the presence and progression of HIV in a person who is otherwise asymptomatic. Necrotizing gingivitis and recurrent oral ulcers are common (Penneys, 2011).
The sensory system effects include visual impairment or blindness related to infectious or noninfectious ocular disorders, such as microvascular disease, retinitis, acute retinal necrosis syndrome, and optic nerve damage (Jacobson, 2011).
The effects on the hematologic system include morphologic abnormalities in the bone marrow resulting in cytopenias, most commonly anemia (Scadden, 2011).
Of great significance is the effect of HIV on the neurological system, resulting in HIV encephalopathy and AIDS dementia complex (ADC). The virus does not affect brain nerve cells but indirectly inflames or kills them. This occurs as CD4+ cell counts drop to less than 200. ADC varies from individual to individual, and symptoms may develop rapidly or slowly, affecting thinking abilities, behavior, coordination and movement, and mood. With the use of antiretroviral drugs, however, a less severe dysfunction known as minor cognitive motor disorder (MCMD) has become more common than ADC (Singh, 2013).
HIV-Related Conditions among Special Populations
HIV/AIDS imposes an additional burden on African Americans. The risk of end-stage renal disease (ERD) in HIV-infected black patients was 4–5 times greater than the risk of ERD in HIV-infected white patients. Studies reveal a gene variant that increases the risk of kidney disease in African Americans (NIH, 2011).
Children infected with HIV/AIDS may have different reactions to the virus, its progression, and their virologic and immunologic response. Without drug treatment, children may be developmentally delayed, experience failure to thrive, and be vulnerable to Pneumocystis jirovecii pneumonia and recurrent bacterial infections. Antiretroviral treatments available for adults with HIV/AIDS may not be available in pediatric formulations and may cause different side effects in children. (Pediatric HIV/AIDS is a specialty that is beyond the scope of this course.)
Management and Care
Optimal care of people with HIV/AIDS includes antiviral therapies, health maintenance, and referral to support services in addition to an emphasis on prevention of transmission to uninfected partners.
The Institute for Healthcare Improvement (2013) notes that it is extremely important that patients with HIV/AIDS play a major role in managing their condition. Each patient has unique desired outcomes and needs that require appropriate interventions. Each patient should be given basic information about HIV/AIDS and its treatment; assistance with self-management skill building; and ongoing support from the healthcare team, family, friends, and community.
The Institute recommends that self-management include:
- Collaborative goal setting
- Monitoring of symptoms
- Lifestyle modifications to improve overall health and well-being
- Adherence to the medication regimen
- Good communication with the healthcare team, family members, and others
- Involvement in ongoing problem-solving to overcome potential barriers
HIV/AIDS has proved to be a moving target, spreading beyond gay white men in cities to women, children, and seniors in small towns and rural areas. As people with HIV live longer, needs for healthcare services are changing. Depending on their personal support system and other resources, some people may require the assistance of a case manager to link them with various care services.
Case managers are often 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. Local community-based organizations may also provide additional support to adults, children, and families who are dealing with HIV/AIDS.
Evolving Treatment Guidelines
Treatment guidelines are revised frequently based on ongoing research findings. The most up-to-date information can be found online at aidsinfo.nih.gov/guidelines.
Antiretroviral Therapy (ART)
Antiretroviral therapy has become the gold standard for treatment of HIV/AIDS, with antiretroviral drugs administered in “cocktails” of three or more. (ART is also sometimes referred to as highly active antiretroviral therapy, or HAART.) People with HIV may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia.
ART has dramatically reduced HIV-associated morbidity and mortality and has transformed HIV disease into a chronic, manageable condition. In addition, effective treatment of HIV-infected individuals with ART is highly effective at preventing transmission to sexual partners. However, less than one third of HIV-infected individuals in the United States have suppressed viral loads, which is mostly a result of undiagnosed HIV infection and failure to link or retain diagnosed patients in care. Despite remarkable improvements in HIV treatment and prevention, economic and social barriers that result in continued morbidity, mortality, and new HIV infections persist (NIH, 2013b).
Antiretroviral treatment of people with HIV continues to prove complex, controversial, dynamic, and expensive. These drugs do not constitute a “cure” for HIV/AIDS. If therapy is discontinued, viral load will increase. Even during treatment, the virus is replicating and the person remains infectious to others.
Seven major classes of drugs are used to treat HIV/AIDS:
- Nucleoside reverse transcriptase inhibitors (NRTIs)
- Nonnucleoside reverse transcriptase inhibitors (NNRTIs)
- Protease inhibitors (PIs)
- Fusion inhibitors
- HIV integrase strand transfer inhibitors
- Entry inhibitors, CCR5 co-receptor antagonists
- Multi-class combination products
Source: U.S. FDA, 2013.
In 1996, tests to measure an individual’s viral load became available, providing objective criteria for treatment decisions. Following are treatment recommendations by the Panel on Antiretroviral Guidelines for Adults and Adolescents (NIH, 2013a):
- Antiretroviral therapy (ART) is recommended for all HIV-infected individuals regardless of CD4 count to decrease the risk of disease progression.
- ART also is recommended for HIV-infected individuals for the prevention of prenatal and behavior-associated HIV transmission.
- Patients initiating ART should be willing and able to commit to lifelong treatment and should understand the benefits and risks of therapy and the importance of adherence. Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy based on clinical and/or psychosocial factors.
ART TREATMENT GOALS
Once ART therapy has begun, CDC recommends these goals of therapy:
- Maximal and durable suppression of viral load
- Reduction of HIV-related morbidity and prolonging survival
- Improvement in quality of life
- Restoration and/or preservation of immunologic function
- Prevention of HIV transmission
ART FOR PREGNANT WOMEN
Current recommendations for female patients with HIV who are pregnant are to start antiviral therapy during the second trimester. Those women who seek perinatal care after the second trimester should start treatment as soon as possible thereafter. Choice of therapy regimen should consider not only the effectiveness of drug treatment for maternal disease but also possible teratogenic effects of the drugs on the infant.
Public Health Service guidelines emphasize that combination drug regimens—rather than zidovudine (ZDV) alone—are considered the standard of care both for treatment of maternal HIV infection and for prevention of perinatal HIV transmission (NIH, 2010).
The efficacy of ART can be measured by plasma HIV RNA testing. Optimal viral suppression is defined as a viral load consistently below the level of detection (<20 to 75 copies/mL). Treatment failure at this point may be due to nonadherence, inadequate potency of drugs, suboptimal levels of antiretroviral agents, viral resistance, or other factors not completely understood.
Patients whose treatment fails despite careful adherence to the regimen should have their regimen changed. A thorough drug treatment history plus drug resistance testing should guide the design of the new regimen.
Patients who are cared for by clinicians with expertise in HIV/AIDS have better outcomes—in mortality, rate of hospitalizations, compliance with guidelines, cost of care, and adherence to medication regimens—than those cared for by less-experienced providers. Expertise is defined in terms of the number of patients actually managed. The DHHS panel recommends HIV primary care by a clinician with at least 20 HIV-infected patients and preferably at least 50 HIV-infected patients.
Many new medications for HIV/AIDS are in clinical trials. Patients experiencing drug resistance may be appropriate candidates for drugs still in trials. Physicians without extensive experience in treating HIV/AIDS are strongly urged to consult with specialists in this area when considering clinical trials for their patients.
Discontinuing or interrupting ART may become necessary due to factors such as serious drug toxicity, intervening illness, surgery, or unavailability of medications. Although unplanned short-term interruption of therapy may be unavoidable, planned interruption is no longer recommended. Interrupting therapy increases the risk of AIDS-related complications, declining CD4 counts, and other non-AIDS-related complications such as heart attack and liver failure.
While extending and improving lives of people with HIV, long-term use of some of these drugs increases the risk of liver problems, high cholesterol, stroke, heart disease, osteoporosis, diabetes, pancreatitis, neuropathy, and skin rashes. Some of the skin rashes can be life-threatening, such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), which are two different forms of the same kind of skin rash. TEN may involve as much as 30% of the total body skin area. Both these severe rashes must be treated by a physician.
Antiretroviral drugs may also interact with other drugs used to treat opportunistic infections. For example, taking oral erythromycin along with protease inhibitors increases the risk of sudden death from cardiac arrest. As patients live longer with HIV/AIDS, many develop drug-resistant strains of the virus, which further complicates treatment.
HIV DRUG RESISTANCE
HIV drug resistance is caused by mutations in the virus’s genetic structure. Such mutations are common in HIV because the virus replicates at a very rapid rate and does not contain the proteins needed to correct mistakes made during copying. Most mutations are harmless and actually reduce the virus’s ability to infect CD4 cells. However, some mutations can give HIV an advantage for survival when HIV medications are being taken. For persons with HIV, drug resistance can cause drugs to be less effective or even completely ineffective, resulting in reduced treatment options.
When Mutations Can Occur
HIV drug-resistance mutations, known as “wild-type” viruses, can occur before or during treatment and can happen with transmission of drug-resistant HIV from one person to another. In countries where HIV treatment is in wide use, between 5%–10% of new HIV cases involve drug-resistant strains of virus.
Mutations can also occur while using pre-exposure prophylaxis. HIV-negative people taking FDA-approved Truvada (emtricitabine/tenofovir disoproxil fumerate) are at risk if they become infected and are not diagnosed right away. If they continue to take the drug, their newly acquired virus may develop resistance to one or both of the medications in Truvada.
Drug resistance mutations can occur during treatment because genetic changes still occur over time and there may be a large mixture of virus in the body. Some of the variants may contain mutations that can partially or fully resist an antiretroviral drug. This is why one-drug treatment should never be used to treat HIV. With the development of combination HIV drug treatment, the amount of wild-type virus is dramatically reduced.
Of concern is that the mutations can cause cross-resistance. This means that the HIV that becomes resistant to one drug can cause resistance to other drugs in the same class.
Another reason for the occurrence of HIV drug resistance is poor treatment adherence. Successful treatment not only requires the patient to have significant financial resources but also the ability to understand and comply with a complex regimen. Unfortunately, many of the patients with the greatest need for treatment lack the necessary financial resources to make treatment a reality. However, patient demographics, such as race/ethnicity, sex, age, and socioeconomic status, do not predict who will adhere to a treatment regimen.
Drug resistance can also be the result of poor absorption, which can be affected by diet or diarrhea and vomiting. The latter can cause drugs to be expelled too quickly, thus affecting absorption. Varying pharmacokinetics can cause interactions between drugs, affecting how a drug is absorbed, distributed, broken down, and removed from the body.
Recent studies have identified novel compounds that may lead to new, cost-effective HIV treatments and a means for combating resistance to today’s antiretrovirals (Dapp et al., 2013).
Experts recommend that pretreatment drug-resistance testing be done with patients when HIV infection is first diagnosed, when changing antiretroviral regimens after drugs cease to be effective (treatment failure), and during pregnancy. Resistance testing helps clinicians better predict viral response to newly initiated therapy.
HIV drug-resistance testing should be performed:
- To assist in selecting active drugs when changing antiretroviral regimens in cases of virologic failure
- When managing suboptimal viral load reduction
In cases of virologic failure, drug resistance testing should be performed while the patient is taking his or her drugs or within four weeks of discontinuing therapy.
Two types of resistance assays are used: genotypic and phenotypic assays. Genotypic assays detect drug resistance mutations in the viral genes, while phenotypic assays measure a virus’s ability to grow in different concentrations of antiretroviral drugs. Genotypic assays take 1–2 weeks and phenotypic assays, 2–4 weeks. A genotypic assay is generally recommended for patients who have never had antiretroviral therapy. Genotypic resistance testing also is recommended for all pregnant women prior to initiation of therapy and for those entering pregnancy with detectable HIV RNA levels while on therapy.
Other Medications and Therapies
In addition to ART, people with HIV/AIDS may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia. Some of these medications may have serious interactions with ART, so prescribing physicians need to be familiar with all ART medications, as well as with their potential toxicities, when administered with other drugs.
Some people with HIV infection supplement their prescription drugs with vitamins, acupuncture, massage, yoga, meditation, herbs, naturopathic remedies, and other complementary therapies. People who turn away from prescription HIV medications and choose only herbs, vitamins, and other supplements are said to be using alternative therapies. Many of these remedies have not been studied to see if they offer any real benefit.
Therapies such as yoga, meditation and massage can help reduce stress and enhance quality of life. However, herbs and other “natural” remedies may also interact with prescription medication. For example, St. John’s wort has major interactions with HIV medications. Therefore, people on HIV medications need to tell their physician, pharmacist, and social worker about all other supplements and nonprescription drugs they take.
Infections that are commonly found in HIV-positive patients include a number of other sexually transmitted diseases, TB, and hepatitis. Coexisting infections may increase the risk of transmission of HIV and make its treatment more complex.
Mycobacterium tuberculosis (M. tuberculosis, or TB) is the most common and most deadly coexisting infection for HIV-positive individuals. TB can also hasten the progression of HIV infection. Likewise, the spread of HIV/AIDS has helped fuel the TB epidemic.
One third of the people living with HIV/AIDS globally are also infected with tuberculosis. In high-burden countries, people with HIV/AIDS are 20 times more likely to contract TB. Globally, there were 8.6 million new TB cases in 2012 and 1.3 million TB deaths. Of these, 0.3 million deaths were HIV associated (TB Alliance, 2014).
In an HIV-infected person, TB disease can develop in either of two ways. A person who already has latent TB infection can become infected with HIV, and then TB disease can develop as the immune system is weakened. Or, a person who has HIV infection can become infected with M. tuberculosis and TB disease can then rapidly develop because their immune system is not functioning.
Antiretroviral therapy is the most effective treatment for controlling the progression of HIV; however, drug-drug interactions between the current first-line TB regimen and certain commonly used HIV drugs complicate treatment. To avoid these interactions in infected patients, new treatment regimens are desperately needed.
TB is transmitted by airborne droplets from people with active pulmonary or laryngeal TB during coughing, sneezing, or talking. When these infected droplets are inhaled, the bacteria enter the bloodstream and lymphatic system and circulate throughout the body.
Most of the bacteria settle in the lungs, where they multiply and may cause pneumonia-like symptoms. This process is called primary infection and in most cases resolves by itself within 4–12 weeks, after which a latent state of TB develops. Nine out of 10 people with latent TB never experience subsequent disease and are not infectious to others. The only evidence of TB infection is a positive tuberculin skin test.
In 10% of infected individuals, the TB infection undergoes reactivation at some point, causing active TB disease. Progression to active disease and obvious symptoms (cough, weight loss, and fever) usually occurs within the first two years after infection but may occur at any time.
TB Testing and Treatment
All people infected with HIV should be tested for TB and, if infected, begin complete therapy as soon as possible to prevent active TB disease. HIV-infected persons with either latent TB infection or active TB disease can be effectively treated. The first step is to ensure that HIV-infected persons are tested for TB. The second step is to help those infected with TB to get proper treatment and prevent rapid progression from latent TB infection to active TB disease.
Treatment of HIV/TB coinfected patients involves a complex 6- or 9-month multidrug regimen. All these drugs have significant side effects, which can lead to nonadherence and development of multidrug-resistant TB (MDR-TB) or extensively drug-resistant TB (XDR TB), which is much more difficult to treat successfully. Extensively drug-resistant TB is of special concern for persons with HIV infection. Coinfected individuals are at increased risk of developing active TB disease once they are infected and also have a higher risk of death once they develop TB.
Hepatitis is inflammation of the liver that may be caused by drugs and toxic agents or by one of several viruses, including hepatitis A, B, C, D, and others. People who are HIV positive are at risk for hepatitis A, B, and C infection. Hepatitis A is transmitted by fecal/oral route, usually by contamination of water or food due to poor sanitation. Hepatitis B (HBV) and C (HCV) are transmitted by the blood and body fluids of an infected person.
HIV-infected people should be tested for both A and B viruses, and if they test negative, should receive vaccines against both. However, there is no vaccine for HCV.
|Source: WA DOH, 2007.|
|Transmission by blood||Yes||Yes||Yes|
|Transmission by semen||Yes||Yes||Rarely (more likely if blood present)|
|Transmission by vaginal fluid||Yes||Yes||Rarely (more likely if blood present)|
|Transmission by breast milk||Yes||No (but may be transmitted if blood is present)||No (but may be transmitted if blood is present)|
|Transmission by saliva||No||No||No|
|Target in the body||Immune System||Liver||Liver|
|Risk of infection after needlestick exposure to infected blood||0.5%||1%–31%||2%–3%|
Hepatitis B can cause chronic liver disease or liver cancer, which makes vaccination essential to prevention. HBV vaccine is relatively inexpensive for infants and children and commonly administered to most infants before their first birthday. It is critical that infants whose mothers are HBV positive receive the vaccine; otherwise, they have a 90% chance of developing the disease. Adult doses of HBV vaccine cost about $139 per person, which may explain why most adults are not vaccinated against HBV.
In 2011 there were a total of 2,890 cases of acute hepatitis B reported to the CDC. The overall incidence rate for 2011 was 0.9 cases per 100,000. In 2011 a total of 39,636 cases of chronic hepatitis B was reported to the CDC. The greatest number (80%) of all reports received were from California.
Coinfection with hepatitis B and HIV is common. In the United States 70%–90% of HIV-infected persons have evidence of past or active HBV infection. HBV is often acquired via sexual contact or injection drug use. Chronic HBV infection occurs in 5%–10% of HIV-infected persons exposed to HBV. This is 10 times higher than for the general population. HIV increases the risk of cirrhosis and end-stage liver disease in HBV infection.
It is important to inform HIV/HBV-coinfected patients that HBV can be more infectious than HIV and can be transmitted to others in a household via dried blood, open cuts, and shared toothbrushes or razors.
Because of the elevated rates of HBV among people infected with HIV and the shared transmission routes between the two viruses, all HIV-infected individuals should be screened for HBV coinfection with HBsAG testing.
Those who receive hepatitis B vaccine should be tested for antibodies to hepatitis B surface antigen (antiHBs) 1–2 months after completion of the primary series of hepatitis B vaccine. Those who fail to respond should be revaccinated with up to three additional doses.
Risk factors for HBV include:
- Being born in areas with a high prevalence of HBV (China, Southeast Asia, Africa, the Pacific Islands, the Middle East, South America, and Alaska)
- Sharing injection paraphernalia
- Having sexual intercourse with an infected person or with multiple partners
- Men having sex with men
- Occupational exposures that involve contact with blood or body fluids, such as in a healthcare setting or prison
- Sharing personal care items such as razors or toothbrushes with an infected person
- Being on kidney dialysis
- Getting a tattoo or body piercing with equipment contaminated with the blood of someone infected with HBV
There are no medications available for recently acquired (acute) HBV infection. There are antiviral drugs available for the treatment of chronic HBV infection, but they are not always effective.
Hepatitis C is the most common chronic bloodborne infection in the United States and a leading cause of chronic liver disease. HCV was discovered in the late 1980s, although it was probably being spread for decades prior to that. People infected with HCV may have no symptoms for decades. When symptoms do appear, they are similar to those of HBV.
The CDC (2012b) reports an estimated 17,000 new infections in 2010. An estimated 3.2 million Americans are infected with HCV, many of them from blood transfusions; half of them do not know they are HCV positive. (Since 1992, all blood donations in the United States have been tested for HCV.) Each year more than 8,000 people die from HCV-associated liver disease.
An estimated one third of HIV-positive people in the United States are also infected with HCV. Incidence is even higher among HIV-positive injection drug users (50%–90%). Coinfection with HIV and HCV is associated with higher titers of HCV, more rapid progression to HCV-related liver disease, and increased risk for cirrhosis of the liver.
Liver disease from chronic HCV is now one of the leading causes of death among people living with HIV. Individuals coinfected with HIV and HCV should restrict alcohol consumption and, if possible, avoid alcohol altogether because of potential liver damage.
The National Institutes of Health (2014) recommends that all HIV-infected persons be screened for HCV infection. Other people who will benefit from HCV testing include:
- Current or former injection drug users
- Those who received blood transfusions or an organ transplant prior to 1992
- People with hemophilia who received clotting factor concentrates produced before 1987
- Those who received chronic hemodialysis
- Infants born to infected mothers
- Healthcare workers who have been occupationally exposed to blood or who have had accidental needlesticks
- Sex partners of people with HCV
- People with type 2 diabetes
Coinfected patients also need to consult their health professional before taking any new medications—including over-the-counter, alternative/complementary, or herbal medicines—because of their possible effects on the liver. Those receiving ART may also be at risk for drug-induced liver injury (DILI) and should be carefully monitored.
Combined treatment of HIV and HCV can be complicated due to large pill burden, drug interactions, and overlapping toxicities. ART should be initiated for most coinfected patients, however, some clinicians may elect to defer ART until HCV treatment is completed in patients with CD4 counts >500 cell/mm3. In coinfected patients with lower CD4 counts (<200 cell/mm3), it may be preferable to initiate antiretroviral therapy and delay HCV therapy until CD4 counts increase.
Health Management Guidelines for HIV-Infected Persons
The HIV Medicine Association of the Infectious Diseases Society of American (Aberg et al., 2013) updated the primary care guidelines to recommend the following:
- Comprehensive history, physical, and review of systems
- HIV tests
- Serologic test
- CD4+ cell counts and percentages every 3–4 months
- Viral load every 3–4 months
- Plasma HIV RNA levels
- HIV resistance testing
- Laboratory tests
- Routine complete blood count and chemistry panel
- Glucose-6-phosphate dehydrogenase
- Fasting lipid panel
- Urinalysis and creatinine clearance
- Coinfection and comorbidity screening
- Tuberculosis (follow-up chest x-ray if positive PPD) repeated periodically
- Toxoplasma gondii
- Viral hepatitis
- Herpes viruses
- Syphilis (RPR or VDRL)
- Other STDs
- Cervical cancer
- Anal human papillomavirus
- Breast cancer
- Vaccine recommendations
- Pneumococcal infection
- Hepatitis A and B
- Human papilloma virus (HPV)
- Tetanus toxoid
- Primary varicella
LEGAL AND ETHICAL ISSUES
Upon completion of this section, you will be able to explain legal and ethical issues related to HIV/AIDS.
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 home was burned after one member of the family developed AIDS.
All medical records are confidential and must be maintained in a manner that protects that confidentiality, using an approach consistent with the Privacy and Security Rules promulgated by the federal government in the Health Insurance Portability and Accountability Act (HIPAA). Client information must be kept strictly confidential, and records should be managed and stored in a secure manner.
Confidential information includes any material, whether oral or recorded in any form or medium, that identifies (or can readily be associated with the identity of) a person and is directly related to their health and care. All information related to an individual’s HIV/AIDS status is protected under medical confidentiality guidelines and legal regulations. Recognizing the sensitive nature of these conditions, medical record protection for HIV and AIDS, like those for substance abuse and mental health, are protected more rigorously than other medical information.
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
Most states have specific laws that address issues around obtaining consent for HIV testing. In general, before HIV testing is performed, patients must be explicitly told that HIV testing is recommended and the patient must agree to the testing. HIV testing without informed consent, except in some legally mandated situations, 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.
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. 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.)
Laws protect people diagnosed with HIV/AIDS from employment discrimination, including:
- Job assignments
- Leaves of absence, sick leave, any other leave or fringe benefits available by virtue of employment
Employers are required to provide and maintain a working environment free of discrimination. They must ensure that no harassment, intimidation, or personnel distinction is made in terms and conditions of employment. If a worksite situation poses the threat of discrimination, the employer is required to educate and supervise employees to end the harassment and any use of slurs and/or intimidation. An employer should promptly investigate allegations of discrimination, take appropriate action, and not retaliate against the person who complained.
Employers are responsible for providing reasonable worksite accommodations that will enable a qualified employee or job applicant with a disability 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.
Employees who feel they are being discriminated against should first document the discrimination, speak with their supervisor, and follow the entity’s internal process to file a discrimination charge. However, it is not necessary to file an internal grievance process. If these remedies do not work, the employee should contact the federal Office for Civil Rights, U.S. Department of Health and Human Services. A complaint must be filed within 180 days of the alleged discriminatory incident.
EMPLOYER BEST PRACTICES
Employers do not have the right to 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 (e.g., 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
Upon completion of this section, you will be able to summarize the psychosocial issues associated with HIV/AIDS.
HIV/AIDS is a chronic disease that can produce psychological problems in four broad areas:
- Issues surrounding the meaning of life and spirituality
- A perception of HIV as a threat or persecutor
- Feelings of vulnerability and loss of control
- Death-related fears and concerns
These concerns can lead to several psychological and social manifestations.
Personal Impact of HIV/AIDS
People with HIV/AIDS face a host of personal challenges: unpredictable cycles of illness and wellness; feelings of loss, grief, anger, and depression; expensive, complicated, sometimes disfiguring treatments; and, finally, deteriorating health and premature death. The fortunate ones have families and friends who share the experience and offer support as needed. For those without a support system, the challenges can seem insurmountable.
HIV-infected individuals may live for 10 or more years before symptoms develop. For those who know they are infected, a decade of uncertainty can be unsettling, even overwhelming. Despite more effective treatment, most people with HIV still die prematurely. Many are in the prime of life, which makes it more difficult to deal with the diagnosis of a fatal disease.
Depression can be immobilizing and interfere with adherence to the treatment regimen, leading indirectly to drug resistance and poor management of the disease. Symptoms of depression include:
- Feeling sad, anxious, or “empty” most of the day, almost every day
- Lack of interest or pleasure in almost all activities, including sex
- Changes in appetite and/or weight
- Altered sleep patterns
- Changes in physical activity, ranging from slowing down to agitation or hyperactivity
- Feelings of worthlessness or excessive guilt
- Inability to concentrate or make decisions
- Recurrent thoughts of death or suicide, or suicide attempts
Depression is treated with both antidepressant medications and psychotherapy. Recognizing the symptoms of depression and referring patients for appropriate treatment may greatly improve their quality of life.
In many areas of the United States, homosexuality and use of illegal drugs carry an indelible stigma and lead to social and employment discrimination. A diagnosis of HIV/AIDS adds another layer of social pressure and stress for MSM and injection drug users. Failure of family, friends, or coworkers to accept and support the person with HIV/AIDS can evoke painful guilt about the disease, about past behaviors, or about possibly having infected someone else. The need to practice safer sex can also affect self-esteem and self-image.
HIV-infected people tend to experience more anxiety than the general population. Adjustment disorder is common after receiving an HIV diagnosis. Anxiety can cause physical symptoms such as shortness of breath, chest pain, racing heart, dizziness, numbness or tingling, nausea, or a sensation of choking. Anxiety disorders are a major cause of nonadherence to medication.
ALTERED BODY IMAGE
HIV/AIDS can cause dramatic changes in a person’s appearance, including severe weight loss and a wasted appearance. Concurrent infections and malignancies, as well as some of the treatments, can cause major alterations in body image. For example, antiretroviral drugs can lead to lipodystrophy, the redistribution of body fat. There are two types of lipodystrophy: fat wasting and fat accumulation. A person with fat wasting (also called lipoatrophy) loses fat from particular areas of the body, especially the arms, legs, face, and buttocks. Someone with fat accumulation (also called hyperadiposity) experiences fat build-up, especially in the belly, breasts, and back of the neck.
People with HIV/AIDS may feel angry with themselves for contracting the disease as well as anger at the person who transmitted it. Their once-normal lives are now organized around medication schedules, medical appointments, and dealing with side effects such as intractable diarrhea and nausea. Expensive medications can create financial hardship, even for those with health insurance.
It is not uncommon when people learn they are HIV positive to choose to deal with the news by denying it. This is natural and normal and at first may be helpful as it allows time to get used to the idea of being infected. However, if denial is not dealt with, the person may fail to take appropriate precautions to prevent transmission to others and may not seek medical help and support.
LOSS AND GRIEF
Living with HIV/AIDS involves loss of many kinds, including loss of:
- Physical strength and abilities, sometimes including vision
- Mental acuity (confusion/dementia)
- Income and savings
- Health insurance
- Housing and personal possessions (including pets)
- Emotional support from family, friends, colleagues, and religious and social institutions
- Self-sufficiency and privacy
- Social contacts/roles
Grief—the normal response to loss—is universal, individual, and unpredictable. Although Elizabeth Kübler-Ross and others have described stages of grief, each person experiences these stages in a different order and at a different pace, depending on their values, cultural norms, and circumstances.
In uncomplicated grief, an individual is able to move through the stages and emerge from the process ready to move on with life. In complicated grief (also called chronic grief), the normal process of grieving is prolonged. Complicated grief often results from multiple losses that leave too little time and emotional energy to reintegrate and move on, and can lead to feelings of guilt, helplessness, hopelessness, withdrawal, isolation, rage, and emotional numbness.
People who live or work with the HIV/AIDS community for several years may themselves experience chronic grief from the seemingly endless repetition of deaths, funerals, and lost friends.
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, helplessness, or isolation. Access to a support system, including a qualified counselor, can be as important for the caregiver as for the patient. Support from coworkers is also especially important.
DO’S AND DON’T’S FOR CAREGIVER SUPPORT
- Do meet with a support person, group, or counselor on a regular basis to discuss your experiences and feelings.
Don’t isolate yourself.
- Do set limits in caregiving time and responsibility and stick to those limits.
Don’t try to be all things to all people.
- Do allow yourself to have questions. Let “not knowing” be OK.
Don’t expect to have all the answers.
- Do get the information and support you deserve and need.
Don’t deny your own fears about AIDS or dying.
- Do discuss with your employer some strategies for performing your job in ways that reduce stress and burnout.
Don’t continue to work in an area where you “can’t cope.”
- Do remember that Standard Precautions are for the patient’s health and welfare as well as your own.
Don’t dismiss Standard Precautions because you “know” the patient.
Issues Affecting 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. Some of these populations include men who have sex with men, people who use injection drugs, people with hemophilia, women, and people of color.
MEN WHO HAVE SEX WITH MEN
America’s HIV/AIDS epidemic deepened the nation’s longstanding prejudice toward homosexuality. Some religious groups see the epidemic as divine retribution for “unacceptable” and “unnatural” behavior. Many men with HIV/AIDS report lack of support from their church communities 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.”
PEOPLE WHO USE INJECTION DRUGS
People who use injection drugs often are seen as “deserving” their infection, rather than deserving treatment for their addiction. Successful efforts to prevent the spread of HIV/AIDS, HBV, and HCV among these individuals, such as syringe exchange programs, exist today even though some equate these programs with approval of drug use.
Many people who use injection drugs would like to stop using but do not have access to inpatient treatment facilities. Waiting lists for treatment programs are long, and by the time a space is available, the individual may be lost to follow-up. Those who do seek treatment for HIV may find the regimens too complex and financially prohibitive.
PEOPLE WITH HEMOPHILIA
During the 1980s, 90% of people with severe hemophilia were infected by HIV and/or HCV through use of clotting factor concentrates, which are made from pooled, donated blood. This created understandable anger among the affected community because evidence indicated 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) before they died of AIDS.
Women of color, particularly African American women, are disproportionately affected by HIV/AIDS. They represent the majority of new HIV infections and AIDS cases among women. Many women with HIV are low-income and most have children under the age of 18.
According to the CDC, young women (ages 13–39) represent nearly two thirds of new HIV infections among women. Having sex with multiple partners, engaging in risky behaviors such as alcohol and drug use, and/or being unable to negotiate safer sex practices with partners all contribute to this heightened risk of contracting HIV/AIDS.
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 be a woman’s 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. 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.
PEOPLE OF COLOR
African Americans and Hispanics have disproportionately higher rates of HIV/AIDS in the United States. There are no biologic reasons for these disparities in incidence and no single reason why these disparities exist, but 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 AIDS epidemic has claimed the lives of more than 30 million people across the globe, more than 600,000 of them in the United States. More than a million people are living with HIV/AIDS in the United States, and every year another 50,000 Americans are infected with HIV.
Despite this ongoing tragedy, the public no longer has a sense of urgency or importance about AIDS. The title of a 2010 editorial in the New England Journal of Medicine best describes the situation—“AIDS in America: Forgotten but Not Gone.” Research has produced drugs that slow but do not stop the disease, and the cost of these drugs has tripled during the past 10 years. No vaccine has proved effective in preventing HIV. So the epidemic continues to spread, primarily among those high-risk persons living in disadvantaged and marginalized groups: the poor, people of color, people in prison, injection drug users, and men who have sex with men. Many do not realize they are infected and unknowingly transmit the virus to others.
The key to controlling this epidemic is prevention. Since most HIV infection is the result of sexual transmission, the most important prevention method is to refrain from having unprotected sexual intercourse—vaginal, anal, or oral—unless it takes place within a monogamous relationship. The CDC recommends using latex condoms consistently and correctly and, when considering a sexual relationship, avoiding any type of sexual contact with someone you don’t know, is known to have had several sexual partners, or regularly uses syringes to inject drugs. Secondly, HIV is spread among injection drug users by the sharing of needles. Education and intervention must extend to these individuals to discourage the sharing of any type of drug-use paraphernalia.
It must be emphasized that individuals should learn their HIV status through routine testing, and efforts should continue to increase the numbers of individuals undergoing testing.
It is well documented that antiretroviral treatment improves the health and prolongs the lives of people with HIV as well as reduces the risk of sexual transmission to others. However, only half of persons with HIV are under treatment, and only a quarter of all persons with HIV have suppressed viral loads. It is essential to develop strategies to increase the number of persons receiving treatment and to increase ways to maintain good adherence over the long term.
Ignorance, prejudice, and lack of access to healthcare are fueling the epidemic. Therefore, health professionals have a critical role in screening and in educating patients, families, and communities about prevention. Only by making prevention a priority will we achieve the goals of the National AIDS Strategy to reduce infection rates; increase access to care for those infected; and eliminate disparities in prevalence, diagnosis, and treatment.
Post-Exposure Prophylaxis Hotline (PEPLINE)
National Perinatal HIV Consultation and Referral Hotline
Office of Women’s Health (womenshealth.gov)
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