HIV/AIDS Prevention, Testing, and Patient Care
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HIV/AIDS Prevention, Testing, and Patient Care
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 people with HIV/AIDS based on a review of HIV etiology and epidemiology, transmission, prevention, infection control, testing, clinical manifestations and treatment, and legal and ethical issues.
Upon completion of this course, you will be able to:
- Discuss the etiology and epidemiology of HIV 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.
TABLE OF CONTENTS
Since the first case of AIDS was diagnosed in 1981, AIDS has killed more than 630,000 Americans (CDC, 2013a). 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, 2012).
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 (MSM)
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 to 24; the largest number of new infections in Hispanic/Latino MSM (39%) occur between ages 25 to 34; and the most infections among young white MSM occur during their 20s and 30s (CDC, 2013d).
RISK FACTORS AMONG MSM
- 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.
Source: CDC, 2013d.
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, 2013e).
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 injecting drug users (e.g., syringe exchange programs) remain controversial because some people equate these programs with “approval” of drug use.
OTHER HIGH-RISK POPULATIONS
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 and two times higher than Latino men. 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).
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 to 64 and Hispanic/Latina women ages 25 to 44 (CDC, 2013g). The median age among new female cases was 36, and about 40% were over the age of forty. Approximately 10% were infants or children (WHO, 2013).
According to CDC (2013i), 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, and 53% of deaths among persons living with HIV. Health professionals 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.
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, 2013f). 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.
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.
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). The CDC (2013j) 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.”
TRANSMISSION AND PREVENTION
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. Sexual identity and gender preference do not always predict behavior, and women who identify as lesbian may also 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.
LESS COMMON MEANS OF TRANSMISSION
Transmission of HIV through transfusion has been uncommon in the United States since 1985 and in other countries where blood is screened for HIV antibodies. In 1999, about 1% of U.S. AIDS cases were caused by transfusions or use of contaminated blood products. The majority of those cases were in people who received blood or blood products before 1985. Donor screening, blood testing, and other processing methods have greatly reduced the risk of transfusion-caused HIV transmission.
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, 2013h).
|Type of Exposure||HIV Infection Risk*|
|Source: CDC, 2013k.|
|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.
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 tends 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, 2010).
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 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.
Prevention and Risk Reduction
HIV/AIDS is preventable, but because the virus is transmitted through behaviors that many people find pleasurable—sexual activity and injection drug use—prevention is difficult. Healthcare practitioners should implement preventive strategies with their patients. A straightforward, nonjudgmental approach and open-ended questions should be used to screen and assess patient behaviors associated with HIV transmission.
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
Injection drug users who refuse treatment or who have no treatment programs available to them need instructions about injection 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.
Optimal care of people with HIV/AIDS includes an emphasis on prevention of transmission to uninfected partners. The CDC recommends that anyone with HIV/AIDS use prevention strategies even if his or her partner is also HIV infected. The partner may have a different strain of the virus that could behave differently in each individual or that could be resistant to different anti-HIV medications.
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, 2013l).
In July 2012, the U.S. Food and Drug Administration approved the combination medication tenofovir disoproxil fumerate plus emtricitabine (TDF/FTC), 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, 2013m). This drug should not replace safer sex practices that include 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. 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, 2013n). 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.
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, 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.
OTHER POTENTIALLY INFECTIOUS MATERIALS
Bloodborne pathogens include any human pathogen present in human blood or other potentially infectious materials (OPIM). 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 recommends the use of Standard Precautions, which 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
Additional transmission-based precautions are to be used when specific modes of transmission are present (e.g., Contact Precautions or Droplet Precautions).
Other precautions are recommended in the areas of housekeeping and waste disposal. The work area of the facility is to be maintained in a clean and sanitary condition.
- All equipment and all environmental and working surfaces must be properly cleaned and disinfected after contact with blood or OPIM.
- Laundry that is or may be soiled with blood/OPIM must be treated as contaminated.
- 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.
Tags or labels must be used as a means to protect employees from exposure to potentially hazardous biological agents. (Source: OSHA.)
INFECTION CONTROL IN THE HOME
Healthcare professionals and others who care for HIV patients at home or in home-like settings are also at risk of exposure to HIV.
Nurses, nursing assistants, personal care assistants, and family members may 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.
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 et al, 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.
- 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.
There is no evidence that antiseptics such as hydrogen peroxide will reduce the risk of transmission; however, use of antiseptics is not contraindicated.
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
Exposure incidents should be reported immediately 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.
(Kuhar et al., 2013)
Frequent advances in treatment make it impractical to list medications and dosages in this course. 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): 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. Eastern time. 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, 2013q.
HIV TESTING AND COUNSELING
Who Should Be Tested?
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 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 to 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 (2013o) 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 (e.g., patients with STDs, injection drug users).
- 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 (2013p), the proportion of adults who have ever been tested for HIV increased from 37% in 2000 to 45% in 2010. However, 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, CDC data reveals that only 13% have ever been tested for HIV (CDC, 2012a).
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 HIV itself. Antibodies usually appear within 6 to 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 3 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 the p24 protein, which is part of the core of the HIV and 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 to 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
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 the 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 are 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 are 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 are 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.|
Rapid HIV testing is a two-step process that includes a screening test and, when the screening test is positive (reactive), 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 4 weeks after the initial reactive rapid test result.
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 over-predicts 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 physicians’ 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 to 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.
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. 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.
If the test result is negative, it means either 1) the person is not infected with the virus or 2) the person became infected recently and antibodies have not yet appeared. A person who tests negative for HIV but remains concerned about a possible recent infection should test again in 3 to 6 months and practice safer behaviors in the meantime. If risky behavior continues, infection may still occur.
A positive test result shows the presence of HIV antibodies, which means that 1) the person is infected with HIV; 2) the person can transmit the virus to others through unsafe sexual practices, sharing contaminated injection equipment, and/or breastfeeding; and 3) the person is infected for life.
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. 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.
All individuals tested for HIV should also be offered an opportunity to receive post-test counseling.
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 the 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
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 to 15 years. However, early detection and appropriate medical treatment may extend the lives of those infected and reduce the rates of HIV transmission.
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
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 infection 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
Source: Robert H. Lurie Comprehensive Cancer Center, 2013.
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.
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 (USDHHS, 2015):
- ART is recommended for all HIV-infected individuals to decrease the risk of disease progression.
- ART also is recommended for HIV-infected individuals for the prevention of HIV transmission.
- Patients initiating ART should be willing and able to commit to treatment and 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, the Panel recommends these goals of therapy:
- Maximal and durable suppression of plasma HIV 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
Recommendations for combination antiretroviral therapy (cART) during pregnancy include:
- All pregnant HIV-infected women should receive cART to prevent perinatal transmission.
- Combined antepartum, intrapartum, and infant antiretroviral (ARV) prophylaxis is recommended because ARV drugs reduce perinatal transmission.
- The known benefits and potential risks of ARV use during pregnancy should be discussed.
- ARV drug-resistance studies should be performed as indicated in the guidelines.
- Coordination of services among prenatal, primary, HIV specialty care providers, and others is essential to ensure ARV treatment adherence.
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 of 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.
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.
M. tuberculosis (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.
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.
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. 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.
Coinfection with hepatitis B and HIV is common. In the United States 70% to 90% of HIV-infected persons have evidence of past or active HBV infection. Chronic HBV infection occurs in 5% to 10% of HIV-infected persons exposed to HBV. This is ten times higher than for the general population. 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.
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% to 90%). Liver disease from chronic HCV is now one of the leading causes of death among people living with HIV. The National Institutes of Health (2014) recommends that all HIV-infected persons be screened for HCV infection.
HIV-HCV 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. Combined treatment of HIV and HCV can be complicated due to large pill burden, drug interactions, and overlapping toxicities.
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 to 4 months
- Viral load every 3 to 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
Confidentiality is a paramount concern for people with HIV/AIDS. Workplace, housing, and insurance discrimination have been (and, in some areas, continue to be) barriers to disclosure of HIV status and seeking treatment.
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.
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. Healthcare professionals should be knowledgeable regarding HIV testing laws in their state.
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:
- Rental, purchase, or sale of apartment, house, or other real estate
- Access to public places (restaurants, theaters)
- Access to 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
Federal and state jurisdictions differ.
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)
- 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
The HIV/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.
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. Therefore, health professionals have a critical role in screening and educating patients, families, and communities about prevention.
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.
AIDSinfo (U.S. DHHS)
Post-Exposure Prophylaxis Hotline (PEPline)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
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