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Washington State: HIV/AIDS (2 units)

Incorporating the KNOW Curriculum

Nancy Evans, BS

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

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

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

WHO HAS AIDS?

In the twenty-five years since the first case of acquired immune deficiency syndrome (AIDS) was diagnosed, AIDS has killed more than half a million Americans (CDC, 2007). As staggering as that is, the impact of AIDS globally has been much greater.

Almost all of the newly infected people live in the developing world, particularly southern Africa, where HIV/AIDS is the leading cause of death (see Wild Iris course, HIV in Africa). The majority are young adults, many of whom do not know they are infected.

Since 1981 nearly 28 million people worldwide have died from AIDS and more than 39 million are infected with the virus. Since 2004 the number of people living with HIV has increased in every region of the world (UNAIDS, 2006).

In the United States, HIV/AIDS has forever changed the landscape of healthcare. Patient activism early in the epidemic spurred a massive research effort that led to greater understanding of AIDS and faster development of new drugs. This has slowed the death rate from AIDS but—without a cure or a preventive vaccine—there is no end in sight to the epidemic.

HIV/AIDS in the United States

The Centers for Disease Control and Prevention (CDC) estimate that more than a million people in the United States are currently infected with HIV. At least one-fourth of them do not know they are infected, which means they are more likely to transmit the virus to others.

Although the development of antiretroviral drugs has reduced deaths from AIDS, the number of new infections has not changed since the late 1990s. Each year another 40,000 people are infected with HIV—approximately 1 new infection every 12 minutes. Nearly half of the HIV-positive population in the United States is not being treated, either because they lack access to care or because they have not been tested (CDC, 2007).

HIV/AIDS IN WASHINGTON STATE

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

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

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

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

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

WHO IS AT RISK FOR AIDS?

AIDS is a changing epidemic. Initially considered a disease of gay white men, HIV/AIDS is now spreading among young people of color, particularly African Americans. According to the CDC, more than 50 percent of new HIV infections occur among African Americans, even though this group represents only 13 percent of the U.S. population.

In the African American population, heterosexual transmission accounts for 11 percent of male infections, but more than 50 percent of female infections.

Nearly half of all newly reported HIV/AIDS diagnoses are in men who have sex with men (MSM), and young men are at the highest risk. HIV/AIDS is higher among MSM from racial and ethnic minorities than among white MSM.

Young urban men among Asians and Pacific Islanders (API) may be at high risk for the virus. Washington State is 1 of 10 states that account for three-fourths of all API populations. The so-called APIs include many nationalities—Chinese, Filipinos, Koreans, Hawaiians, Asian Indians, Japanese, Samoans, Vietnamese, and others—with more than one hundred languages, dialects, cultures, and histories. Such diversity makes it a special challenge to create effective public health messages.

WHAT CAUSES AIDS?

AIDS is caused by the human immunodeficiency virus (HIV). By attacking the immune system, HIV makes the body vulnerable to a number of infections caused by viruses, bacteria, and yeasts that would not be serious in a person with a normal immune system. With a weakened immune system, however, these infections can be life-threatening. HIV infection progresses to AIDS when the patient begins to have symptoms of diseases associated with the virus (for example, Kaposi's sarcoma).

Varying levels of HIV have been found in most body fluids: 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.

Scientists don't fully understand why HIV weakens our immune systems. We know that the virus attacks our white blood cells, which are responsible for fighting off infections. Once inside the white blood cell, the virus makes copies of itself and spreads throughout the body. As the virus spreads, it weakens the immune system further, making it easier for infections to take hold.

HOW DOES SOMEONE GET HIV/AIDS?

Many incorrect beliefs persist about the way HIV/AIDS is acquired. HIV is not transmitted by casual contact such as hugging, nonsexual touching, or the shared handling of objects. Insects do not carry HIV. The virus is not transmitted through air or water.

Once outside the human body, HIV dies quickly, which makes most medical procedures and caregiving activities safe if standard infection control procedures are followed.

Sexual Contact

You can get HIV through sexual contact with an HIV-positive person. The virus can be transmitted by anal, oral, and vaginal sex. Anal sex without a latex condom is very risky, especially for the person being penetrated. Sexual partners of either sex who are being penetrated get HIV and other STDs more easily than the partner doing the penetration.

Female-to-female transmission of HIV appears to be rare, but there have been some reports of women transmitting HIV to other women and to men. This means that vaginal secretions and menstrual blood are potentially infectious fluids. If mucous membranes of the mouth, anus, or vagina are exposed, then HIV infection can occur. Therefore, women who have sex with women (WSW) should consider female sexual contact a possible means of transmission of HIV.

Injection Drug Use

You can get HIV by using contaminated needles. The virus can also be transmitted through blood transfusions, although this is much less common in the United States today because blood is carefully screened for HIV.

Transfusions of Infected Blood or Blood Clotting Factors

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

Tattooing and Blood-Sharing Activities

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

Pregnancy and Breastfeeding

A pregnant woman can transmit HIV to her unborn child. She can also infect her child through breastfeeding. The number of unborn infants infected with HIV has decreased since 1992. Voluntary HIV testing, universal counseling, and giving AZT to pregnant women and newborns account primarily for the decline.

Biting

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

Risk Factors

CO-EXISTING INFECTIONS

People who are HIV-positive often have other sexually transmitted diseases (STDs) such as syphilis, gonorrhea, herpes, and chlamydia. If you have an STD, you have a greater risk of passing HIV to another person. You are also at a greater risk for getting HIV yourself.

If you have genital herpes (HSV2), for example, you are three times more likely to get HIV (Reynolds, 2002). Yet the CDC reports that most people with genital herpes don't know they have it. Genital herpes must be confirmed by a laboratory test; treatment can suppress the virus but not completely eliminate it.

Tuberculosis (TB) is the most common and most deadly infection for people who are HIV-positive. According to the CDC, TB is the cause of death for 1 of every 3 people with AIDS worldwide.

Many people who have HIV also have hepatitis C (HCV). Hepatitis C is a virus that causes liver disease and is spread by contact with blood. Although antiretroviral drugs have helped people with HIV, liver disease is still a major cause of death among people with HIV.

ACUTE HIV INFECTION

The first few weeks after infection with HIV are the acute HIV infection stage. During this time, sometimes called the "window" period, infected individuals may be symptom-free and unaware of the infection, but they are highly infectious because of the viral load (high levels of the virus) in the bloodstream.

MULTIPLE PARTNERS

A person with multiple sex partners, or injection drug–sharing partners, is at very high risk for exposure to HIV. Anyone having unprotected sex with multiple partners—defined as six or more partners in a year—is considered at high risk. But even unprotected sex with one partner who is HIV-positive involves risk of transmission.

SUBSTANCE USE

Use of any mood-altering substance, including alcohol or street drugs, can increase risk of HIV transmission by impairing judgment, which can lead to risky behaviors such as unprotected sex. Methamphetamine abuse is growing among MSM, especially younger MSM. Research shows that both meth and HIV infection cause significant changes in the brain, impairing cognitive function (Jernigan et al., 2005).

In addition, certain substances have both physiologic and biological effects on the body, such as masking pain and/or creating sores on the mouth and genitals, which creates additional entry points for HIV and other STDs.

GENDER AND EQUALITY ISSUES

If you are in a relationship where someone doesn't let you make decisions for yourself, you might not be able to insist on safe sex practices. If a woman depends on a man for social and financial support, she might not be in a position to insist that the man use a condom.

If a woman doesn't know much about sex and pregnancy, she is at greater risk for HIV infection.

Cultures that accept many sexual partners for men but only one for women place women at a high risk for infection even thought the woman remains faithful to her partner.

Reducing Risk for HIV Infection

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

HIV/AIDS is preventable. For example, screening of blood and blood products for the HIV virus has reduced the risk of HIV transmission with transfusion to 1 in a million. Mother-to-baby transmission has dropped by two-thirds (CDC, 2006). Following Universal Precautions has prevented thousands, if not millions, of cases of HIV/AIDS in the United States.

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

SAFER SEX PRACTICES

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

CORRECT USE OF CONDOMS

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

INJECTION DRUG USERS

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

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

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

WOMEN WHO HAVE SEX WITH WOMEN

• Use condoms consistently and correctly each and every time for sexual contact with men or when using sex toys. Sex toys should not be shared.
• Use natural rubber latex sheets, dental dams, cut open condoms, or plastic wrap during oral sex. However, no barrier methods for use during oral sex have been shown to be effective by the FDA.
• Know your own and your partner's HIV status. If you are uninfected, this knowledge reduces your risk of becoming infected and assists those who are infected to get early treatment and avoid transmitting the virus to others.

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

HOW DO WE CONTROL HIV INFECTION?

Washington Regulations

WASHINGTON INDUSTRIAL SAFETY AND HEALTH ACT (WISHA)

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

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

Training in bloodborne pathogens must be given to all new employees or employees being transferred into jobs involving potential exposure to blood or other potentially infectious material (OPIM). This training must take place when tasks are first assigned in which occupational exposure may occur, and must include:

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

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

All employees whose jobs involve exposure to blood/OPIM must be offered the first of the hepatitis B vaccination series within 10 working days of employment and/or new assignment. The vaccination is to be provided free of charge. Testing to ensure that the vaccination was effective is recommended.

Enforcement procedures contained in WRD 11.40 are used to inspect any employer where employees' jobs involve potential exposure to blood/OPIM. Occupational groups with potential exposure to HBV or HIV include (but are not limited to) healthcare employees, law enforcement, firefighters, ambulance and other emergency-response and public service employees.

Although HBV and HIV are specifically identified, the law covers any organism present in human blood/OPIM that can cause disease in people exposed to it. Bloodborne pathogens may also include HCV, hepatitis C, malaria, syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections, relapsing fever, Creutzfeldt-Jakob disease, adult T-cell leukemia/lymphoma (caused by HTLV-I), HTLV-I–associated myelopathy, diseases associated with HTLV-II, and viral hemorrhagic fever.

EXPOSURE CONTROL PLAN (ECP)

Each employer covered under WAC 296-823-08001 must develop an Exposure Control Plan. This plan requires the employer to identify those tasks and procedures in which occupational exposure may occur. It also requires the employer to identify the individuals who will receive the training, protective equipment, vaccination, and other benefits of the standard.

Infection Control Systems

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

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

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

• Blood and blood products
• Semen
• Vaginal secretions
• Fluid from the brain and spinal cord
• Fluid from joints
• Fluid from the lining of the lungs
• Fluid from the abdominal cavity
• Fluid from the sac that surrounds the heart
• Fluid that surrounds the fetus during pregnancy
• Specimens with concentrated HIV, HBV and HCV viruses

Universal Precautions include wearing the following personal protective equipment (PPE):

GLOVES

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

Change gloves after each client.

Latex gloves are recommended when dealing with blood or OPIM. However, people with allergies to latex must be provided with nitrile, vinyl or other glove alternatives that meet the definition of "appropriate" gloves.

MASKS, GOGGLES, FACE SHIELDS, AND GOWNS

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

Universal Precautions also include frequent handwashing with warm water and soap (or a waterless alcohol based hand rub):

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

People who have been exposed to body fluids should wash their hands before as well as after using the toilet. A pump-type liquid soap is preferable to bar soap. A waterless handwashing product should be available for immediate use there is no sink in the home or work setting.

HOUSEKEEPING

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

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

DISINFECTANTS

Chemical germicides and disinfectants in recommended dilutions must be used to decontaminate spills of blood and other body fluids. Your agency must consult the Environmental Protection Agency (EPA) for lists of appropriate products.

LAUNDRY

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

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

WASTE DISPOSAL

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

TAGS AND LABELS

Tags or labels must be used to prevent accidental injury or illness to employees who are exposed to potentially hazardous conditions, equipment, or operations that are out of the ordinary, unexpected, or not readily apparent. Tags must be used until the identified hazard is eliminated or the hazardous operation is completed. 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).
  

PERSONAL ACTIVITIES

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

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

POST EXPOSURE MANAGEMENT

Risks for Healthcare Workers

The risk of developing HIV infection from a needle stick or direct contact with infected blood is about 1 in 300 without prompt antiretroviral treatment. In 2003 the CDC reported 57 documented cases of accidentally acquired HIV among healthcare workers in the United States. Twenty-six have since developed AIDS.

To prevent transmission of HIV to healthcare workers, the CDC recommends that post-exposure prophylaxis (PEP)—prompt treatment to avoid infection—begin within 1 to 2 hours after the exposure (CDC, 2005). Check with your supervisor or infection control nurse for specific guidelines.

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

PEP is not as simple as swallowing a single pill. The medications must be started as soon as possible and continued for 28 days. The antiviral drugs uses in PEP are potentially toxic and should not be used for exposures that pose a negligible risk. CDC recommends consultation with an infectious disease consultant or another physician experienced with antiretroviral drugs; however, consultation "should not delay timely initiation of PEP."

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

Washington state workers have a right to file a worker's compensation claim for exposure to bloodborne pathogens. Industrial insurance covers the cost of post-exposure prophylaxis (PEP) and follow-up care for the injured worker.

Care at Home or in Home-Like Settings

Healthcare professionals who care for patients at home or in home-like settings should practice good hygiene techniques in preparing food, handling body fluids, and using medical equipment. Accidents can result in spills of blood/OPIM on carpeting, vinyl flooring, clothing, skin, or other surfaces. Everyone, even young children, needs to have a basic understanding that they should not put their bare hands in or on another person's blood.

GLOVES

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

• When you anticipate contact with any body substance (blood/OPIM)
• When you anticipate contact with any non-intact skin

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

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

HANDWASHING

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

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

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

PERSONAL HYGIENE ITEMS

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

CLEANING BLOOD/OPIM FROM SKIN SURFACES

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

CLEANING BODY FLUID SPILLS ON VINYL FLOORS

Broken glass should be swept up using a broom and dustpan (Never bare hands!). Dustpans should be emptied in a well-marked plastic bag or heavy-duty container. The body fluid spill should be pre-treated with full-strength liquid disinfectant or detergent and then be wiped up with either a mop and hot soapy water or appropriate gloves and paper towels. Paper towels should be disposed of in the plastic bag.

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

CLEANING BODY FLUID SPILLS ON CARPETING

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

Carefully pour carpet-safe liquid disinfectant on the contaminated carpeting and leave it there for the amount of time indicated in manufacturer's instructions. Using sturdy rubber gloves, blot the spill with paper towels until it is absorbed. Vacuum normally afterward.

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

CLOTHING AND OTHER LAUNDRY

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

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

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

DIAPER CHANGES

Care providers should use a new pair of gloves to change diapers. Disposable diapers should be discarded in an appropriate plastic bag or receptacle, along with gloves. Hands should be washed immediately after changing the diaper. The diapering surface should be disinfected. Cloth diapers should be washed in very hot water with detergent and a cup of bleach, and dried in a hot clothes dryer.

TOILET AND BEDPAN SAFETY

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

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

THERMOMETERS

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

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

FOOD PREPARATION

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

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

PET CARE

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

Pet cages and cat litter boxes can harbor infectious organisms that may become aerosolized. These items should be cared for by someone who is not immunocompromised. If this is not possible, a mask with a sealable nose clip and disposable latex gloves should be worn each time pet care is done. All pet care should be followed by thorough handwashing.

Pets can spread disease by licking their person's face or open wounds. Wash hands after stroking or other contact with pets. Cats' and dogs' nails should be kept trimmed. Wear latex or nitrile gloves to clean up any pet urine, feces, vomit, or OPIM. Clean the soiled area with a fresh solution of 1:10 bleach.

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

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

LEGAL AND ETHICAL ISSUES

Legal Reporting Requirements

AIDS and HIV infection are reportable conditions in Washington State (WAC 246-101). Medically diagnosed AIDS has been a reportable condition since 1984. Symptomatic HIV was designated as a reportable condition in 1993, and in 1999 asymptomatic HIV infection also became reportable.

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.

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

Confidentiality

Confidentiality—knowing that their health status is kept private—is a huge concern for people with HIV/AIDS. This infection not only carries the shame of an STD but it is also associated with homosexuality and injection drug use. Workplace, housing, and insurance discrimination have kept infected individuals from disclosing their HIV status and seeking treatment.

Children with AIDS have sometimes been barred from attending classes and, in at least one instance, a family's home was burned after a family member developed AIDS.

Washington State requires that all medical records be confidential and maintained in a manner that protects the patient's privacy. Special requirements about HIV and AIDS are found in WAC 246-100 and RCW 70.24.105.

Confidentiality means that any information that can be related to a specific patient may not be disclosed to anyone, with only a few exceptions. Other circumstances that allow disclosure of confidential patient information are:

• Existence of a separate, patient-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 conditions to the local department of health as required

Violation of confidentiality laws is a misdemeanor and it may result in a civil action for reckless or intentional disclosure up to a maximum of $10,000, or actual damages, whichever is greater (Washington State Department of Health, 2005).

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

Informed Consent

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

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

Consult your employer for guidance regarding informed consent from minors and for what is acceptable in the absence of informed consent.

Disability and Discrimination

People with HIV/AIDS are protected by both federal law and Washington State law. These laws make it illegal to discriminate against someone who has HIV infection or AIDS. It is also illegal to discriminate against someone "believed" to have HIV/AIDS, even though that person is not infected. This has far-reaching effects in employment, and employers are required to know the laws that apply to people with HIV/AIDS.

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

• Cannot ask an applicant or an employee questions about the possibility of their having HIV/AIDS
• Cannot require a blood test to determine HIV infection (with a few exceptions)
• Cannot require a physical exam to identify HIV infection, except where necessary for reasonable accommodation or specific job-related conditions.
• Cannot ask questions about lifestyle, living arrangements, or sexual orientation.

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

Employees in a situation in which they 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 Office for Civil Rights or the Washington State Human Rights Commission. An aggrieved person can also file directly in state court. A complaint must be filed within 180 days of the alleged discriminatory incident.

Behaviors Endangering Public Health

Washington State law gives state and local health officers the authority and responsibility to carry out certain measures to protect public health from the spread of STDs, including HIV/AIDS. The responsibilities of the health officer, who is a physician, include the authority to:

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

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

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

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

Civil Rights

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

LIVING WITH HIV/AIDS

As people with HIV/AIDS live longer, their needs for healthcare services change. Depending on their personal support system and other resources, some people may require the assistance of a case manager to link them with various care services.

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

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

Personal Impact of HIV/AIDS

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

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

DEPRESSION

Depression can interfere with a person's ability to comply with a drug regimen, which can lead to drug resistance and poor management of the diseases. Depression is treatable, both with antidepressant medications and with psychotherapy. Recognizing the symptoms in people with HIV/AIDS and helping them to get appropriate treatment can greatly improve their quality of life.

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

REJECTION

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

ALTERED BODY IMAGE

Over time, HIV/AIDS can dramatically change a person's appearance. The disease itself can cause severe weight loss and a wasted appearance. Concurrent infections and malignancies as well as some of the treatments can cause major alterations in body image. For example, antiretroviral drugs can lead to lipodystrophy, the redistribution of body fat.

ANGER

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

LOSS AND GRIEF

HIV/AIDS can involve many losses, including loss of physical and mental capabilities, financial resources, and support of friends or family. Dealing with multiple losses may lead to feelings of guilt, helplessness, hopelessness, rage, or emotional shutdown. Physical weakness and pain can also diminish the ability to cope with psychological stresses.

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

Complicated grief (also called chronic grief) is an exaggeration of the normal process of grieving, often resulting from multiple losses, that can make it difficult for an individual to move on. Many people who have HIV/AIDS or work with it experience chronic grief as the result of a seemingly endless repetition of funerals and lost friends.

Issues for Caregivers and Families

The suffering experienced by people with HIV/AIDS is 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 sometimes lead to self-destructive behaviors such as alcohol or drug abuse.

Caregivers often mirror the feelings of their patient; they may feel vulnerable, helpless, or isolated. Access to a support system, including a qualified counselor, can be equally as important for the caregiver as for the patient. Support from coworkers is especially important. Strategies for caregiver support are summarized in the box below.

Special Populations

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

MEN WHO HAVE SEX WITH MEN (MSM)

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

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

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

INJECTION DRUG USERS

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

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

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

PEOPLE WITH HEMOPHILIA

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

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

WOMEN

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

Young and minority women are also disproportionately affected by other STDs—gonorrhea, syphilis, and chlamydia, for example—that make them more vulnerable to HIV infection. Improved STD treatment can help slow the heterosexual spread of HIV.

San Francisco's Project Inform, an information and advocacy organization, publishes an online newsletter for women with HIV/AIDS. Called "Wise Words," the publication offers women important tools to make HIV treatment decisions and covers prevention and treatment of opportunistic infections, gynecologic health, and more. It also discusses current research and public policy issues that may affect women with HIV/AIDS (http://projectinform.org/pub/ww_index.html).

CHILDREN

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

PEOPLE OF COLOR

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

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

Prevention messages for all minority populations need to be delivered through channels appropriate to individual communities. These channels may include religious institutions or respected elders.

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

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

Posted March 31, 2008

Expires March 1, 2010

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