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This course will expire or be updated on or before March 3, 2014.
ABOUT THIS COURSE
You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.
ACCREDITATION / APPROVAL
Wild Iris Medical Education is approved as a provider of nursing continuing education by the Florida Department of Health, Division of Quality Assurance, Board of Nursing. Florida Board of Nursing Accreditation #NCE3403.
Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. See our disclosures for more information.
This course meets the HIV/AIDS continuing education requirement for many Florida healthcare professionals.
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Copyright © 2011 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to provide a review of HIV/AIDS incidence in Florida, modes of transmission, types of HIV tests, clinical management of HIV/AIDS, and Florida law governing HIV/AIDS testing and disclosure.
Upon completion of this course, you will be able to:
Florida has the third highest incidence of HIV/AIDS in the United States, exceeded only by California and New York. The Florida Department of Health (2009a) estimates that approximately 125,000 persons in the state are living with HIV infection (including AIDS). In 2009, Florida reported 5,508 new HIV diagnoses, and 4,369 cases of AIDS. Although the HIV/AIDS epidemic is prevalent throughout Florida, the majority of cases (76%) were reported in nine counties: Broward, Duval, Hillsborough, Lee, Miami-Dade, Orange, Palm Beach, Pinellas, and Polk.
HIV/AIDS is more prevalent among women in Florida than in women nationally and also more prevalent among blacks. However, the prevalence among men who have sex with men (MSM) in Florida is lower than among MSM nationally. The prevalence of AIDS among heterosexual populations in Florida is much higher than among heterosexuals nationally (38% vs. 24%) (Florida Department of Health, 2009a).
Blacks account for nearly half of Florida’s HIV-positive population and nearly half of the AIDS cases, even though they comprise only 14 percent of the state’s population. HIV is the leading cause of death for black women between the ages of 25 and 44 and the third leading cause of death for black men in this age group (Florida Department of Health, 2009b). HIV is the third leading cause of death among Hispanic women in this age group and the ninth leading cause of death among white women in this age group (Florida Department of Health, 2009c).
Seniors represent 27% of the HIV-infected population in Florida and in the United States. Males account for three-fourths of cases and females accounted for a fourth. Half of HIV-infected seniors are black, a third are white, and the remainder are Hispanic. Nearly two-thirds of all Florida senior HIV/AIDS cases reported through April 2010 came from four counties: Miami-Dade, Broward, Palm Beach, and Orange. Of the nearly 2,500 HIV-related deaths in 2008, almost half were among people age 50 or older (Florida Department of Health, 2009d).
Contrary to myths and misinformation, HIV is not transmitted by casual contact such as hugging, other nonsexual touching, and the shared handling of objects. Insects do not carry HIV, nor is the virus transmitted through air or water. HIV is a relatively fragile virus. Once outside the human body, HIV has a very short lifespan, which makes most medical procedures and caregiving activities safe if standard infection control procedures are followed.
Three conditions are necessary for HIV to be transmitted:
Varying levels and concentrations of HIV have been found in most bodily fluids of infected persons, including blood, semen, saliva, tears, breast milk, and vaginal and cervical secretions. However, only blood, semen, breast milk, and vaginal and cervical secretions have been proven to transmit HIV infection.
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.)
Sharing injection needles, syringes, and other paraphernalia with an HIV-infected person can send HIV directly into the user’s bloodstream. 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.
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. The risk of developing HIV infection from a needlestick with infected blood is about 1:300 without prompt antiretroviral treatment, and the risk increases with deep punctures, hollow bore needles, visible blood on the needle, and high viral load in the source. (Comparatively, the risk after a mucous membrane exposure is about 1:9,000, and the risk of HIV transmission after nonintact skin exposure is estimated to be less than the risk for mucous membrane exposure.)
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.
An infected pregnant woman can transmit HIV to her fetus, and an infected mother can infect her breastfeeding infant. However, the incidence of perinatally acquired HIV peaked in 1992 and has decreased to 2% nationally in recent years. Implementation of Public Health Service guidelines for universal counseling and voluntary HIV testing of pregnant women, scheduled cesarean delivery, avoidance of breastfeeding, and the use of antiretroviral therapy by pregnant women and administered to newborn infants primarily account for the decline.
Most HIV infections are transmitted by people who do not know they are infected. Therefore, HIV testing is the first step in halting spread of the virus. Research shows that people who are unaware of their HIV infection have a transmission rate of almost 11 percent compared with a rate of less than 2 percent in those who know they are HIV-positive. When counseling services are available and effective, that rate falls to near zero (Holtgrave & Anderson, 2004).
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.
In addition to the primary high-risk groups, Florida law provides for testing special populations.
In Florida, the Targeted Outreach for Pregnant Women Act (TOPWA), established in 1999 by Florida statute 381.0045, requires that healthcare providers counsel and offer HIV testing to all pregnant women on their initial prenatal visit and again at 28 to 32 weeks’ gestation. TOPWA outreach workers go into the community and seek out pregnant women in housing projects, laundromats, bars, or other public places. The TOPWA program has increased poor women’s access to prenatal care, including HIV testing and antiviral therapy, reducing the number of babies born with HIV infection. Through July 2009, more than 32,000 pregnant high-risk or HIV-infected women have been enrolled in TOPWA.
Florida Statute 495.355 mandates that prisons test inmates for HIV within 60 days before they are released back into the community. (Unlike prisons, jails are not required to test inmates unless they have been convicted of a sex-related crime.) Those who test positive must be provided with transitional assistance, which includes:
HIV testing is a two-step process that includes a screening test and, when the screening test is reactive (positive), a confirmatory test. Until 2002, testing for HIV antibodies relied on an enzyme-linked immunosorbent assay (ELISA) of blood. Since then, six 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. The FDA and the Centers for Medicare and Medicaid Services have also issued guidelines for a rapid HIV test quality-assurance program (Greenwald et al., 2006). All positive (reactive) rapid HIV tests require repeat testing for confirmation.
Tests are now available for self-testing of HIV serostatus. Home Access Express HIV-1 Test System is the only FDA-approved home test kit currently on the market, but several unapproved kits are marketed on the Internet. This 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 telephone and using the assigned PIN. Post-test counseling is available by telephone for everyone tested, whether the results are positive or negative.
Home testing is a controversial issue, primarily because of the need for counseling. The FDA has expressed concern that people who have not been appropriately counseled by experienced staff in a culturally competent way before they receive the news that they are HIV-positive may commit suicide. Counseling needs to help reduce anxiety and risk-taking behavior as well as link individuals to services. However, at least one survey showed that nearly 1/4 of clients at public testing services would choose a home self-test.
Florida’s Omnibus AIDS Act of 1988 and its 1998 update are essential for doctors, nurses, and other healthcare providers to understand. This legislation corresponds closely with federal guidelines and accepted medical practice. Violations are heavily penalized, and good-faith efforts at compliance do not ensure anyone against legal difficulties.
The principal methods for dealing with the HIV/AIDS epidemic as stipulated in the Florida Omnibus Aids Act are education and testing that is informed, voluntary, and confidential. Florida legislation stipulates four reasons for deviation from traditional educational and testing methods:
Before anyone can be tested for HIV in Florida, they must explicitly consent to be tested. 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.
A general consent to draw a patient’s blood and run unspecified tests does not meet the Florida criteria of informed consent for HIV testing. The healthcare provider must explain the HIV test in a manner appropriate to the age, mental capacity, and language skill of the subject. The explanation should include the following information (Department of Health Rule 64D-2.004, F.A.C):
A separate statute, designed to eliminate “unnecessary diagnostic testing,” may make an HIV test illegal even when informed consent is granted. The law forbids diagnostic tests “which are not reasonably calculated to assist the healthcare provider in arriving at a diagnosis and treatment of a patient’s condition.” It is also forbidden to test for evidence of HIV infection “solely for the purpose of protecting healthcare workers.”
Children under 18 are considered adults for the purpose of consenting to, or refusing, an HIV test. Parental permission is not required for a child judged by the healthcare provider to be sufficiently mature to consent or refuse an HIV test. Florida law forbids informing parents of a minor’s HIV test results either directly or indirectly (such as sending a bill for testing or treatment without the minor’s consent). It is up to the healthcare provider to decide whether the minor is capable of understanding the risks and benefits of the test or treatment.
A 1998 amendment to the Florida Omnibus AIDS Act requires the physician or midwife attending a woman for a condition related to pregnancy to offer HIV testing in conjunction with her required blood tests at the initial prenatal care visit and again at 28 to 32 weeks’ gestation, regardless of risk behaviors.
In 2005, the statute was amended to establish the current system of opt-out testing for all pregnant women. Under this system, all pregnant women are advised that their healthcare provider will conduct an HIV test but that they have the right to refuse testing. Any pregnant woman who refuses testing must do so in writing, and her refusal must be placed in her medical record (§384.31, F.S.).
Any pregnant woman who has positive test results should be referred to medical and support services related to HIV/AIDS as well as the Healthy Start Care Coordination System. Any pregnant woman who presents at delivery without a record of a blood test for HIV during pregnancy must be counseled and offered an HIV test.
HIV testing without informed consent may occur in the following circumstances:
Anonymous and confidential HIV tests are available at Florida county health departments and other registered testing sites. County health departments and registered testing sites are required to provide private pre-test and post-test counseling for all persons tested. Confidential HIV tests are also increasingly available in private-sector doctors’ offices and hospitals.
The legal requirements for counseling and testing are different for public- and private-sector facilities. County health departments must obtain written informed consent from the test subject. Registered testing sites and private-sector facilities are not required to obtain written consent, provided that the medical record includes documentation that the test was explained and consent was obtained. Written consent is preferable, nonetheless, because it provides practical advantages to the testing agency or facility and the healthcare worker in the event of litigation.
Medical records are, by law, confidential. The Florida Omnibus Aids Act designates information about HIV testing as superconfidential if the tests can be traced to an identifiable individual. All test results, positive or negative, are superconfidential, which means that the information is only made available to healthcare personnel on a need-to-know basis. Providers, in turn, must sign a legal document not to divulge this information except on a need-to-know basis.
However, the law uses a narrow definition of “HIV test result.” The superconfidentiality standard applies only to the part of a person’s medical record that documents an HIV test and the results, negative or positive, of that test. If the documented HIV status was based on a health department anonymous test or a home testing kit, that does not constitute “HIV test results” and is not covered by the superconfidentiality standard.
Providers’ clinical assessments of any medical conditions associated with AIDS are also exempt from the superconfidentiality standard because they do not constitute “HIV test results” unless they include laboratory reports or medical-record notes of an HIV test. For example, a patient’s chart documenting symptoms of AIDS and including the word AIDS throughout the chart, but without an HIV test result or report, is not considered superconfidential.
Disclosure of HIV test results is limited to the following:
The 1998 amendment to Florida’s Omnibus AIDS Act increased the penalty for breaches of confidentiality. Anyone who maliciously, or for monetary gain, breaches the confidentiality of sexually transmitted disease information commits a third-degree felony.
The healthcare provider ordering an HIV test must make all reasonable efforts to notify the person tested of the results. If the HIV-negative person fails to obtain the results, either by missing a scheduled visit or not calling in, the provider has met the “all reasonable efforts” standard.
However, if the test results show the person to be HIV-positive, the provider must exhaust all available means to contact the patient. If all efforts fail, the responsibility for notification can be transferred to the county health department through HIV infection–reporting requirements.
If test results are HIV-negative, notification should include appropriate information on preventing transmission of HIV. Information for high-risk test subjects may not be appropriate for low-risk test subjects and vice versa.
If test results are HIV-positive, counseling the test subject must include information on the following:
Counseling someone who has just learned of his or her HIV-positive status requires not only that the healthcare provider be familiar with local HIV health and social services but also that the provider have the ability to communicate with clarity, sensitivity, and compassion.
The Florida Department of Health has developed “Model Protocols on Counseling and Testing” that may be obtained through the website at http://www.floridaaids.org.
To prevent HIV transmission in healthcare settings, CDC instituted universal precautions (blood and body fluid precautions). Under universal precautions, healthcare personnel should assume that the blood and other body fluids from all patients are potentially infectious and therefore follow infection-control precautions at all times and in all settings.
Standard precautions is a newer term that hospitals and other agencies are moving toward. It includes all recommendations for universal precautions plus body substance isolation (BSI) when other potentially infectious materials (OPIM) are present.
These precautions include:
Any healthcare worker who receives a needlestick or other significant exposure to potential HIV infection should follow the employer’s protocol, which is based on guidelines issued by the CDC (2005). Prompt reporting of the incident 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.
The CDC recommends that postexposure prophylaxis (PEP) begin as soon as possible, ideally within 24 hours after the exposure and no later than 7 days. Animal studies indicate that cellular HIV infection occurs within 2 days of exposure to HIV. Virus in blood is detectable within 5 days.
For exposure to HIV-positive blood, recommendation is for a four-week course combining either two antiretroviral drugs for most HIV exposures, or three antiretroviral drugs for exposures that may pose a greater risk for transmitting HIV (e.g., those involving a larger volume of blood with a larger amount of HIV or a concern about drug-resistant HIV). The antiviral drugs used in PEP are potentially toxic and should not be used for exposures that pose a negligible risk. CDC recommends consultation with an infectious disease consultant or another physician experienced with antiretroviral drugs; however, consultation “should not delay timely initiation of PEP.”
Antiretroviral therapy (ART) has become the gold standard for treatment of HIV/AIDS. Antiretroviral drugs are administered in “cocktails” of three or more. The primary goal of ART is to reduce HIV-associated morbidity and mortality by suppressing the individual’s viral load to below detectable levels. 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.
Five major classes of drugs are used to treat HIV/AIDS:
*CCR5 stands for chemokine (C-C motif) receptor 5, one of the two known points of entry used by the HIV virus to penetrate the CD4 T-cells. CCR5 antagonists are designed to block this receptor. The first of these drugs was approved by the FDA in August 2007 for use in treatment-experienced patients who have detectable HIV RNA and multidrug resistance to antiretrovirals.
**The first of these newest drugs, raltegravir (Isentress), was approved by the FDA on October 12, 2007. This class of drugs is designed to slow the progression of HIV by blocking the HIV integrase enzyme that the virus needs in order to multiply.
Discontinuing or interrupting ART may become necessary due to factors such as serious drug toxicity, intervening illness, surgery, or unavailability of medications. Although unplanned short-term interruption of therapy may be unavoidable, planned interruption is no longer recommended. Interrupting therapy increases the risk of AIDS-related complications, declining CD4 counts, and other non–AIDS-related complications such as heart attack and liver failure.
While extending and improving lives of people with HIV, long-term use of some of these drugs increases the risk of liver problems, high cholesterol, stroke, heart disease, osteoporosis, diabetes, pancreatitis, neuropathy, and skin rashes. Some of the skin rashes can be life-threatening, such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), which are two different forms of the same kind of skin rash. TEN may involve as much as 30% of the total body skin area. Both these severe rashes must be treated by a physician.
Antiretroviral drugs may also interact with other drugs used to treat opportunistic infections. For example, researchers reported that using oral erythromycin while taking protease inhibitors increased the risk of sudden death from cardiac causes (Ray et al., 2004). As patients live longer with HIV/AIDS, many develop drug-resistant strains of the virus, which further complicates treatment.
The economic downturn since 2008 has affected both federal and state budgets, creating a drug access crisis in many states. As of June 2010, the AIDS Drug Assistance Program (ADAP) in Florida reported that nearly 1,800 HIV patients were waiting for access to lifesaving drug treatment. In late summer, the program received a $6.9 million federal grant, enough for three weeks’ worth of medications (Tasker, 2010). Meanwhile, the cost of HIV drugs almost tripled between 1999 and 2009 (National ADAP Monitoring Project, 2010).
Thousands of people are living with HIV/AIDS in Florida, which has the third highest prevalence of HIV/AIDS in the country. Despite this ongoing tragedy, the public no longer has a sense of urgency or importance about AIDS. Research has produced drugs that slow but do not stop the carnage, and the cost of these drugs has tripled during the past 10 years.
No vaccine has proved effective in preventing HIV. So the epidemic continues to spread, primarily among disadvantaged and marginalized populations: 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.
Ignorance, prejudice, and lack of access to healthcare are fueling the epidemic. Therefore, health professionals have a critical role in screening, testing, and educating patients, families, and communities about prevention. Health professionals can also teach by example, through offering nonjudgmental, compassionate care to those affected by this deadly virus.
Act Against AIDS
AIDS Education Global Information System (AEGIS)
AIDSinfo (Comprehensive site of the USDHHS)
Black AIDS Institute
The Body (HIV/AIDS Resource)
Centers for Disease Control and Prevention (CDC)
CDC National STD and AIDS Hotlines
English: 800-342-2437 or 800-227-8922
HIV InSite, University of California San Francisco (HIV/AIDS Treatment, Prevention, Policy)
HIV Wisdom for Older Women
National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPLINE)
National Minority AIDS Council
National Perinatal HIV Consultation and Referral Hotline
The Well Project (Women with HIV)
Women Organized to Respond to Life-threatening Disease (WORLD)
Resources in Florida
Center for Multicultural Wellness and Prevention
Family Health Line
Florida Department of Health, Bureau of HIV/AIDS
Florida HIV/AIDS Hotlines
English: 800-FLA-AIDS (800-352-2437)
Spanish: 800-545-SIDA (800-545-7432)
Creole: 800-AUDS, 101 (800-243-7101)
Jacksonville Area Sexual Minority Youth Network (JASMYN)
Sembrando Flores (HIV/AIDS Latino Ministry)
Shadowood II, Inc.
Centers for Disease Control and Prevention (CDC). (2005). Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR, 54(RR-9), 1–17. Retrieved May 12, 2006, from http://www.cdc.gov/mmwr/PDF/rr/rr5409.pdf.
Florida Department of Health, Bureau of HIV/AIDS. (2009a). Florida annual report 2009: Acquired immune deficiency syndrome/human immunodeficiency virus. Retrieved September 3, 2010, from http://www.doh.state.fl.us/disease_ctrl/aids/trends/trends.html.
Florida Department of Health, Bureau of HIV/AIDS. (2009b). Targeted outreach for pregnant women — 10 years of TOPWA. Retrieved September 3, 2010, from www.doh.state.fl.us/disease_ctrl/aids/updates/facts/BW04Women.pdf.
Florida Department of Health, Bureau of HIV/AIDS. (2009c). HIV/AIDS among Blacks. Retrieved September 3, 2010, from http://www.doh.state.fl.us/disease_ctrl/aids/updates/facts/09Facts/2009_BlackFactSheet.pdf.
Florida Department of Health, Bureau of HIV/AIDS. (2009d). HIV/AIDS among persons age 50+ in Florida. Retrieved September 3, 2010, from http://www.doh.state.fl.us/Disease_ctrl/aids/updates/facts/09Facts/2009_50_plus_FactSheet.pdf.
Food and Drug Administration (FDA). (2008). HIV testing. Retrieved September 15, 2010, from http://www.fda.gov/oashi/aids/test.html.
Greenwald J, Burstein G, Pincus J., & Branson B. (2006). A rapid review of rapid HIV antibody tests. Current Infectious Disease Reports, 8, 125–31.
Hall HI, Song R, Rhodes P, et al. (2008). Estimation of HIV incidence in the United States. Journal of the American Medical Association, 300(5), 520–529.
Holtgrave D & Anderson T. (2004). Utilizing HIV transmission rates to assist in prioritizing HIV prevention services. Journal of Sexually Transmitted Diseases and AIDS, 15 ,789–92.
National ADAP Monitoring Project. (2010). Annual Report 1999–2010. Retrieved August 20, 2010, from http://www.kff.org/hivaids/ADAP.cfm.
Ray W, Murray K, Meredith S, et al. (2004). Oral erythromycin and the risk of sudden death from cardiac causes. New England Journal of Medicine, 351, 1089–96.
Tasker F. (2010). Florida: AIDS, HIV patients getting help from pharmaceutical companies. Miami Herald, September 27, 2010.
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