COURSE PRICE: $65.00
CONTACT HOURS: 7
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This program has been pre-approved by The Commission for Case Manager Certification to provide continuing education credit to CCM® board certified case managers.
Nurse practitioners may apply these contact hours to pharmacy continuing education and prescriptive authorization.
Course Availability: Expires March 1, 2017. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. 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 healthcare. Medical Disclaimer Legal Disclaimer Disclosures
This course fulfills the requirement for 7 hours of HIV/AIDS training for RNs, LPNs, ARNPs, and other healthcare professionals in Washington state.
Copyright © 2014 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to prepare Washington healthcare professionals to care for those with HIV/AIDS, based on a review of HIV etiology and epidemiology, transmission of HIV and infection control, Washington State law concerning confidentiality and testing, clinical manifestations and treatment, legal and ethical issues, and psychosocial issues associated with this disease process.
Upon completion of this course, you will be able to:
The material presented in this course is based on the KNOW Curriculum (6th ed.), current articles in the scientific literature, and updates from the CDC and other government agencies.
Upon completion of this section, you will be able to discuss the etiology and epidemiology of HIV worldwide, in the United States, and in Washington.
The human immunodeficiency virus (HIV) is like most other viruses contracted by humans, but with one important difference—the body’s immune system can destroy most viruses and clear them from the body, but that is not true for HIV. The immune system cannot get rid of HIV because the virus attacks a key component of the system (the T-cells or CD4 cells), invades them, uses them to produce copies of itself, and then destroys them.
AIDS (acquired immunodeficiency syndrome) is a complex condition caused by HIV, which kills or impairs cells of the immune system and progressively destroys the body’s ability to fight infection and disease. People with damaged immune systems are vulnerable to diseases that do not threaten people with healthy immune systems. The term AIDS applies to the most advanced stages of HIV infection. Medical treatment is available to delay the onset of AIDS.
AIDS is acquired. This disease is not hereditary. It is not passed casually from one person to another. To infect someone, the human immunodeficiency virus must enter the bloodstream. The virus causes an immune deficiency, and the body cannot defend against infection and disease. Over time, a person with a deficient immune system may become vulnerable to infections by disease-causing organisms such as bacteria, viruses, parasites, or yeasts. These opportunistic infections may cause life-threatening illnesses. HIV infection causes a combination of symptoms, infections, and diseases. This combination of health effects is known as a syndrome.
DNA analysis has identified the HIV-1 virus as originating in a substrain of chimpanzees in west equatorial Africa (Gao et al., 1999). Scientists theorize that HIV-1 moved from chimps to humans when hunters were exposed to infected blood while handling bush meat (the flesh of various primates, including chimps and gorillas). Once in the human population, HIV quickly became a global pandemic, driven by travel and migration patterns, sexual practices, drug use, war, and economics.
There are at least two types of HIV virus: HIV-1 is the cause of AIDS, and HIV-2 is a related group of viruses found in West African patients that is less easily transmitted. Worldwide, the predominant virus is HIV-1. Most of the West Africans infected with HIV-2 show none of the symptoms of classical AIDS. Viral load tends to be lower in persons infected with HIV-2, which may explain this type’s lower transmission rates and nearly complete absence of perinatal transmission. Most persons infected with HIV-2 do not develop AIDS, although when they do, the symptoms are indistinguishable from HIV-1. A few cases of HIV-2 infections have been found in people in the United States.
HIV mutates readily, leading to many different strains of HIV, even within the body of a single infected person. Based on genetic similarities, the numerous viral strains may be classified into types, groups, and subtypes. HIV-1 comprises four distinct groups: M, N, O, and P. Group M was the first to be discovered and represents the pandemic form of HIV-1 (Sharp & Hahn, 2011).
Although the mechanisms of HIV and the way it affects the immune system are not fully understood, the primary event is the entrance of HIV into the body’s CD4 cells (T-Helper lymphocytes, also called T4 cells). These white blood cells are essential to the function of the immune system in fighting infection. Once inside a T4 cell, HIV replicates and signals other cells that produce antibodies, which are essential for immune system function. It is not known whether HIV replication directly kills the infected cells or the anti-HIV immune response destroys them, but HIV demolishes the T4 cells and damages their ability to signal for antibody production. Thus, it steadily deactivates the immune system, leading to dysfunction of various organ systems.
Acute HIV infection is the time period immediately following infection with the virus. HIV replication is very rapid in the 6–8 weeks after acquiring the HIV infection and results in a high amount of HIV in the blood (viral load). During this time, the infected person may be symptom-free and unaware of the infection, but the viral load is the highest it will ever be because the body’s defenses have not yet responded. It is at this time when the risk of contagion is much higher than that from patients with established infections (Cohen et al., 2011). Once infected, the person remains infectious for life.
Some researchers use the term acute HIV infection to describe the 6- to 12-week interval between initial infection and production of antibodies that can be detected by an HIV test. Others refer to this period as primary HIV infection, acute retroviral syndrome, or acute HIV syndrome. This interval is also called the window period. During this period the person can infect other people through unprotected anal or vaginal sex, oral sex, or sharing of needles. Following this period, the person can remain asymptomatic for many years before the start of symptomatic AIDS.
Since the first case of AIDS was diagnosed in 1981, AIDS has killed more than 630,000 Americans (CDC, 2013a). The daunting human and economic costs of this disease in the United States are eclipsed only by its international impact. Since 1981, 33.4 million people worldwide have died from AIDS, and an estimated 35.3 million people were living with HIV in 2012. Although HIV infection rates are declining globally, AIDS deaths totaled 1.6 million in 2012.
Almost all (95%) of the newly infected people live in the developing world, particularly southern Africa, where it is the leading cause of death. Sixty-nine percent of all people living with HIV are living in this region, and nearly 1 in every 20 adults is infected with HIV (amfAR, 2013). In 2012 more than 9.7 million people were receiving AIDS drugs in low- and middle-income countries, and the United Nations has set a target to raise that to 15 million by 2015 (WHO, 2013).
Source: WHO, 2013.
In 1984, the Centers for Disease Control and Prevention (CDC) began to develop a surveillance system in order to uniformly track the HIV/AIDS epidemic in the United States. Information is collected from state and local health departments and reported to the CDC for analysis to determine who is being affected and why. The main goal is to have in a place a nationwide system that combines information on AIDS cases, new HIV infections, and the behaviors and characteristics of people at high risk. As of 2013, all 50 states, the District of Columbia, and six U.S. dependent areas use a uniform HIV infection reporting system for collecting data on HIV infection (CDC, 2013b). The HIV Surveillance Report for 2012 (issued in 2014) will be the first time the data from all these areas will be included in the estimates.
The CDC estimates that more than 1.1 million people in the United States are currently infected with HIV. More than 200,000 of them do not know they are infected and are at high risk for transmitting the virus to others. While antiretroviral drugs have reduced deaths from AIDS, the number of new infections has not changed since the late 1990s. The estimated incidence of HIV has remained stable overall in recent years, at about 50,000 new HIV infections per year and 15,000 deaths from AIDS in the United States (CDC, 2013b).
HIV has been reported in all 50 states, the District of Columbia, and U.S. dependencies. It has not, however, been uniformly distributed. In 2011 ten states accounted for about 65% of HIV diagnoses, and the South accounted for about 48% of HIV diagnoses. The state with the highest number of cases diagnosed in 2011 was California, reporting 5,965 new infections; the District of Columbia had the highest number of HIV diagnoses per 100,000 population (177.9) (Henry J. Kaiser Family Foundation, 2013).
New HIV cases center primarily in large U.S. metropolitan areas (81%), with New York, Los Angeles, and Miami at the top of the list (CDC, 2013b). The epidemic’s scope varies across the country and continues to have a disproportionate impact on certain populations, in particular racial and ethnic minorities and gay and bisexual men.
HIV transmission patterns have shifted over time. New infections among men who have sex with men, who represent about 4% of the population, increased between 2008 and 2010 by 12%. Heterosexual sex has accounted for a growing share of transmissions over time, representing 25% of new infections in 2010. A 3% reduction in infections has occurred among men who have sex with men and also have a history of injection drug use. New infections related to injection drug use also have declined, accounting for 8% of new infections in 2010 (CDC, 2012a).
Source: CDC, 2013b.
In the United States, HIV/AIDS has forever altered the landscape of healthcare. Patient activism early in the epidemic spurred a massive research effort that led to greater understanding of AIDS and accelerated the development of innovative drugs. These drugs have slowed the death rate from AIDS in the United States and other countries since 1996, but without a cure and/or increased emphasis on prevention, there is no end in sight to the epidemic.
Antiretroviral drugs have reduced not only morbidity and mortality from AIDS. They have also reduced the public’s level of concern about the deadly nature of this epidemic, creating widespread complacency about the disease. This complacency, coupled with our society’s belief in the power of pharmaceuticals, has undermined prevention efforts. By extending the lives of people with HIV infection, drug treatment has also increased the prevalence (or number of cases per 100,000 people) of the disease and increased the likelihood of transmission. The CDC (2012a) reports that of Americans with HIV, only 28% are currently being treated effectively. Effective treatment reduces the level of virus in the body so transmission to others is less likely to occur.
In 2010, the government outlined the National HIV/AIDS Strategy for the United States (NHAS), which has three overarching goals:
The NHAS envisions a future in which “the United States will become a place where new HIV infections are rare and, when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socioeconomic circumstance, will have unfettered access to high-quality, life-extending care, free from stigma and discrimination” (White House, 2010).
The NHAS includes major outcomes to be achieved by 2015, such as:
If the NHAS target outcomes are achieved, then approximately 76,000 infections will be prevented and an estimated 219,000 more people living with HIV will be in care by 2015. Achieving these outcomes would substantially alter the trajectory of the epidemic in the United States and could prevent a total of nearly 238,000 infections through 2020 (Holtgrave, 2010).
Since 2010, NHAS has become a significant factor in the progressive change occurring to improve the United States’ approach to ending the HIV epidemic here at home. There are successful, innovative programs being implemented across the country to get more people tested, treated, and engaged in care. In addition, the discovery that medical treatment for persons living with HIV can significantly reduce the rate of HIV transmission provides an additional reason for integrating prevention and care. The success so far bolsters the belief that we can achieve remarkable progress against the epidemic.
See also “National HIV/AIDS Strategy” under “Resources” at the end of this course.
In Washington State, AIDS cases have been reported since 1984, but HIV cases have only been reported since 1999. By 2011 new HIV cases had decreased significantly, and rates based on reported cases dropped to about 0.4 cases per 100,000 each year since 2007 (WA DOH, 2013a).
Source: WA DOH, 2013a.
Over half of persons recently infected with HIV in Washington reside in King County, and more than one third are men who have sex with men (MSM) or men who have sex with men and are injection drug users (MSM/IDU) who live in Seattle. More than 1 in 3 HIV infections occur among racial/ethnic minorities (WA DOH, 2013a).
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. Since 2002, there have been only three confirmed cases of perinatal (mother-to-child) HIV transmission (WA DOH, 2013b).
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:
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.
Although MSM are only a small percentage of the population, they account for more than half of all estimated new HIV infections. It is estimated that about 1 in 5 MSM is living with HIV. In 2010 MSM accounted for 63% of estimated new HIV infections in the United States and 78% of infections among all newly infected men (CDC, 2013c).
Among MSM, whites account for the highest number of new infections. In 2011 MSM HIV prevalence was highest among older age groups, blacks, and men with lower education and income. Black MSM had the highest HIV prevalence but the lowest awareness among racial/ethnic groups. HIV-positive MSM overall are increasingly aware of their infections (Wejnert et al., 2013).
The age of acquiring HIV infection among MSM varies by race. The majority of new infections among young African American MSM occur between ages 13–24; the largest number of new infections in Hispanic/Latino MSM (39%) occur between ages 25–34; and the most infections among young white MSM occur during their 20s and 30s (CDC, 2013d).
Although MSM comprise less than 3% of Washington State’s male population, they account for approximately 75% of all HIV infections (WA DOH, 2013b).
Source: CDC, 2013e.
According to the CDC (2013d), several factors increase the risk of HIV transmission among MSM. These include the following:
In 2011 injecting drug users accounted for 6% of new HIV diagnoses in the United States and its six dependent areas, and MSM and injecting drug users accounted for 4%. Of all newly diagnosed HIV infections among injecting drug users, 47% occurred in African Americans, 25% in Hispanic/Latino(a), and 24.5% in whites. All other races accounted for 3.4% (CDC, 2013f).
In Washington State during the years 2008–2012, 15% of all new HIV diagnoses were reported by individuals who inject drugs (WA DOH, 2013b).
Mainstream America disapproves of illegal drug use and those who become addicted. The methamphetamine epidemic has increased the risk of HIV transmission because the drug is so cheap and accessible. Successful efforts to prevent the spread of HIV/AIDS, HBV, and HCV among injection drug users (e.g., syringe exchange programs) remain controversial because some people equate these programs with “approval” of drug use.
Injection drug use (IDU) often coexists with poverty, low self-esteem, anxiety, depression, and mental illness. While drugs offer temporary relief from the realities of harsh living conditions, they create a tangled web of problems, including risk-taking behaviors like unprotected sex. Drug users who would like to stop using often lack access to inpatient treatment facilities. Waiting lists for drug treatment programs are long, and by the time a place is available, users may be lost to follow-up.
Those drug users who do seek treatment for HIV may find the cost of the drugs prohibitive or the complex multidrug regimens beyond their ability to manage. In addition, street drugs and drugs unapproved by FDA, but available through online pharmacies, may have dangerous interactions with AIDS medications.
Among races/ethnicities, African Americans continue to be disproportionately affected. The estimated rate of new HIV infection for U.S. black men is seven times higher than that of white men, two times higher than Latino men, and almost three times higher than black women. Black gay, bisexual, and other MSM account for an estimated 72% of new infections among all black men (CDC, 2013c). Black women represent 29% of estimated new HIV infections among all adult and adolescent blacks. This is twenty times higher than for white women and nearly five times as high as for Latinas.
It is estimated that 1 in 16 black men and 1 in 32 black women will be diagnosed with HIV infection. In 2010, blacks accounted for about half (48%) of deaths among those diagnosed with HIV. It is the fourth leading cause of death for black men and women ages 25–44 (CDC, 2013c).
In Washington State, African Americans make up nearly 30% of all new HIV infections, and 1 in 5 new HIV cases is African American (WA DOH, 2013b).
At the end of 2011, 1 in 4 people living with HIV infection in the United States was female, and women accounted for 20% of the estimated new HIV infections. In 2010, HIV was among the top-10 leading causes of death for black/African American women ages 15–64 and Hispanic/Latino women ages 25–44 (CDC, 2013i).
Between 2008–2012 women accounted for an average of 81 per 100,000 population new HIV diagnoses each year. However, non-Hispanic African American women accounted for 31.8 new HIV cases per 100,000 population, which was more than 20 times higher than for white non-Hispanic women. The median age among new female cases was 36, and about 40% were over the age of forty. Approximately 10% were infants or children (WA DOH, 2013c).
In Washington State, the number of women newly diagnosed with HIV each year has remained steady at about two new HIV cases per 100,000 (WA DOH, 2013b).
Women may be unaware of their partner’s risk factors, and women who have experienced sexual abuse are more likely to engage in high-risk sexual behaviors. Unprotected vaginal sex is a much higher risk for HIV for women than for men, and unprotected anal sex is riskier for women than unprotected vaginal sex. Injection drug and other substance use either directly or indirectly increase the risk. Some women may not insist on a condom due to fear of the loss of their partners or even physical abuse by them (CDC, 2013i).
Female adolescents and young women under the age of 25 are at higher risk for HIV/AIDS and other sexually transmitted diseases (STDs) than older women. Having sex with multiple partners, engaging in risky behaviors such as alcohol and drug use, and/or being unable to negotiate safer sex practices with partners all contribute to this heightened risk (CDC, 2013j).
The most common route of HIV infection in children is perinatal, either during pregnancy, labor and delivery, or breastfeeding. Although the incidence of mother-infant transmission has decreased greatly among whites, it remains a challenge in the African American community.
According to CDC (2013k), between 2010 and 2011, people aged 50 and older in the United States accounted for:
Of new infections during this time period:
In Washington State, 40 new HIV diagnoses were among persons 55 and older; 832 persons over 55 are living with HIV and 1,762 are living with AIDS. More than a quarter of all new HIV cases in Washington are among adults 45 and older (WA DOH, 2013b). The recent increase in HIV among people over age 50 is partly due to antiretroviral therapy, which has extended the lives of HIV-infected people, and partly due to newly diagnosed infections in older people.
Health professionals also may fail to diagnose AIDS in seniors because symptoms can mimic those of normal aging, such as fatigue, weight loss, forgetfulness, and/or confusion. As a result, many seniors are diagnosed only in the late stages of the disease—or not at all.
Stereotypes about aging and about HIV/AIDS put seniors at risk for transmission. Many seniors are sexually active well into their seventies and eighties, a fact sometimes overlooked by health professionals. Thus, physicians and other healthcare workers may fail to ask patients about unprotected sex or to offer voluntary HIV testing.
Most sexually active older couples do not use condoms because they are unconcerned about pregnancy. Unless a couple is monogamous, however, unprotected sex increases the risk of infection with HIV or other sexually transmitted diseases from multiple sexual partners. Older women face a higher risk than older men because age-related vaginal thinning and dryness can cause tears in the vaginal area.
Perceived barriers to condom use among seniors include the following factors:
Studies indicate these beliefs exist in all races and ethnic groups.
Since Viagra and other drugs for erectile dysfunction entered the marketplace in the late 1990s, rates of HIV/AIDS and gonorrhea increased more rapidly in middle-aged and older heterosexual adults than in those under age 40 (Jena et al., 2010).
Unprotected sexual activity is not the only risk factor among seniors. To control the rising costs of medications such as insulin, some seniors share needles for insulin and other prescription drugs.
The stigma of HIV/AIDS may be much more severe among seniors, leading them to hide their diagnosis from family and friends. Keeping their diagnosis a secret can limit or eliminate potential emotional and practical support.
More than 2 million people are incarcerated in the United States, and these people are at increased risk for acquiring and transmitting HIV. Each year, 1 in 7 persons living with HIV pass through a correctional facility. Most acquired HIV in the community (CDC, 2013g).
Many prison inmates engage in high-risk behaviors before being incarcerated, including unprotected sexual intercourse and drug and alcohol abuse, behaviors that often continue inside prisons, even though sex and drugs are prohibited. Most U.S. prisons fail to follow recommendations from the World Health Organization (WHO) that condoms be made available to prisoners, that prisoners have access to bleach for cleaning injection equipment, and that needle exchange programs be considered.
HIV testing is available to all correctional populations in the United States, but policies and specific procedures differ. In some cases, testing is mandatory. For example, Washington State law mandates HIV testing for anyone convicted of a sexual offense, prostitution or offenses relating to prostitution, or drug offenses associated with the use of hypodermic needles. Since March 2010, the Washington State Department of Corrections has notified all inmates that HIV screening will be performed during the prison intake medical evaluation unless they decline (CDC, 2011a).
Currently, eleven states mandate HIV testing upon intake as part of a comprehensive medical assessment and diagnostic screening. These states are Colorado, Georgia, Indiana, Michigan, Missouri, Nebraska, Nevada, Ohio, Rhode Island, Tennessee, and Utah. Other states have mandatory testing upon release, and include Florida, Idaho, Mississippi, Missouri, Nebraska, Oregon, Rhode Island, and Texas. The states of Missouri, Nebraska, and Rhode Island require mandatory testing both on intake and release (Dwyer et al., 2011).
The mathematical reality that sex workers have hundreds of partners each year makes this population a critical element in the spread of HIV throughout the wider community. However, there is little research on HIV and other STDs among commercial sex workers in the United States.
The CDC reported in 2013 that many socioeconomic factors are involved in sex work, including mental health issues, incarceration, prior physical/emotional/sexual abuse, drug use, and selling of sex for survival. Among this population, there is high-risk drug and alcohol use. Many sex workers are unaware of services such as HIV testing and do not know their HIV status. Use of condoms among sex workers is not consistent and may be the result of economics, type of partner, power dynamics, and the fact that many sex workers may receive more money for unprotected vaginal and anal sex.
Because sex work is illegal, sex workers often distrust both police and public health authorities. (In the United States, prostitution is legal and regulated only in the state of Nevada.) This contributes to a lack of data regarding sex work and a significant barrier to HIV prevention efforts and other services (CDC, 2013h).
Many police practices increase the risk for HIV among sex workers. Human Rights Watch (2012) reported that New York, Los Angeles, Washington, DC, and San Francisco were confiscating condoms from sex workers and transgender women as evidence of prostitution. Such policies can defeat HIV prevention programs in which free condoms are made available to sex workers. In one study, 52% of sex workers said there had been times when they chose not to carry condoms because they were afraid it would mean problems with the police (Open Society Foundations, 2012).
Transgender is an inclusive term for persons whose gender identity, expression, or behavior differs from the norms expected from their birth sex. The American Psychological Association (2014) writes, “The ways that transgender people are talked about in popular culture, academia, and science are constantly changing … and the meaning of gender nonconformity may vary from culture to culture.” Currently, gender identities within this category include transgender woman, transgender man, male-to-female (MTF), female-to-male (FTM), transsexual, transvestite, drag queen/king, and genderqueer. The exact definitions of these terms vary from person to person.
In 2011, a National Gay and Lesbian Task Force and the National Center for Transgender Equality survey found that transgender people had over four times the national average of HIV infection than the general population, with rates higher among transgender people of color (Grant et al., 2011). Similarly, the results of a meta-analysis of studies from 15 countries “were surprising in terms of the magnitude of the increased odds—nearly 50 times—of transgender women having HIV compared to other adults of reproductive age” (Baral, 2013).
The CDC (2013l) reported that in 2010 the highest percentage of newly identified HIV-positive test results was among transgender people. Behaviors and factors contributing to this high risk of HIV infection included “higher rates of drug and alcohol abuse, sex work, incarceration, homelessness, attempted suicide, unemployment, lack of familial support, violence, stigma and discrimination, limited healthcare access, and negative healthcare encounters.”
Additionally, some transgender people (and others) gather at “pump parties” for body modification in which a non-professional injects industrial silicone mixed with other substances into their breasts, cheeks, hips, and/or buttocks. Others use injectable hormones for body modification. In these street settings, it is not unusual for syringes and needles to be shared, placing the persons at high risk for HIV and other infectious diseases (USDHHS, 2012a).
Upon completion of this section, you will be able to list the risk factors for transmission of HIV in general and among healthcare workers in particular, and identify preventive and control measures for HIV/AIDS.
Contrary to myths and misinformation, HIV is not transmitted by casual contact such as hugging, other nonsexual touching, and the shared handling of objects. Insects do not carry HIV, nor is the virus transmitted through air or water. HIV is a relatively fragile virus. Once outside the human body, HIV has a very short lifespan, which makes most medical procedures and caregiving activities safe if standard infection control procedures are followed.
In terms of the classic “chain of infection,” three links are necessary for the transmission of HIV:
Varying levels and concentrations of HIV have been found in most body fluids of infected persons, including blood, semen, saliva, tears, breast milk, and vaginal and cervical secretions. However, only blood, semen, breast milk, and vaginal and cervical secretions have been proven to transmit HIV infection. Healthcare workers, however, may be exposed to some other body fluids with high concentrations of HIV, including amniotic, cerebrospinal, pericardial, pleural, and synovial fluids.
Transmission of HIV occurs primarily through sexual contact with an infected person. This includes anal, oral, and vaginal contact. The risk of transmission depends on sexual practices. Receptive anal contact without a latex condom carries the greatest risk, probably because of the larger surface area of mucous membranes involved. Receptive partners are at greater risk for transmission of any sexually transmitted disease, including HIV.
Since last reported in 2006, there have been no confirmed cases of female-to-female transmission of HIV, but female sexual contact should be considered a possible means of transmission of HIV.
Health professionals need to remember that sexual identity and gender preference do not always predict behavior and that women who identify as lesbian may still be at risk for HIV through unprotected sex with men or with injection drug users.
Sharing injection needles, syringes, and other paraphernalia with an HIV-infected person can send HIV directly into the user’s bloodstream (along with hepatitis B and C viruses and other bloodborne diseases). Paraphernalia with the potential for transmission include the syringe, needle, “cooker,” cotton, and/or rinse water (sometimes called works).
Transmission also occurs through indirect sharing of contaminated paraphernalia and/or dividing a shared or jointly purchased drug while preparing and injecting it. “Indirect sharing” includes squirting the drug back from a dirty syringe into the drug cooker and/or someone else’s syringe, or sharing a common filter or rinse water.
Transmission of HIV through transfusion has been uncommon in the United States since 1985 and in other countries where blood is screened for HIV antibodies. In 1999, about 1% of U.S. AIDS cases were caused by transfusions or use of contaminated blood products. The majority of those cases were in people who received blood or blood products before 1985.
Donor screening, blood testing, and other processing methods have reduced the risk of transfusion-caused HIV transmission. All donated blood is tested for HIV. Also, other measures are used to screen possible donors. For example, donors are questioned about whether they have any signs and symptoms of HIV or HIV risk factors. Only about 1 in 2 million donations might carry HIV and transmit HIV if given to a patient (NIH, 2012).
HIV can be transmitted during tattooing or during blood-sharing activities such as “blood brothers/sisters” rituals or ceremonies where blood is exchanged or unsterilized equipment contaminated with blood is shared. The CDC reported no cases of HIV transmission documented from tattooing or body piercing, but these activities do present a risk if new needles, ink, and other supplies are not used and the person doing the procedure is not properly trained and licensed.
A pregnant woman who is infected can transmit HIV to her fetus. After delivery, an infected mother can transmit HIV to her infant while breastfeeding. Women newly or recently infected with HIV, or those in the later stages of AIDS, tend to have higher viral loads and may be more infectious.
When a woman’s healthcare is monitored closely and she receives a combination of antiretroviral therapy, the risk of perinatal transmission to the newborn drops below 1%. Other measures to prevent perinatal transmission include the use of prophylactic cesarean delivery before onset of labor or rupture of membranes and avoidance of breastfeeding by HIV-infected mothers (CDC, 2013j). Alternatively, a simple method of flash-heating pumped breast milk has been shown to inactivate the HIV virus (Israel-Ballard et al., 2007). In addition, the infant is treated for the first six weeks of life (NIH, 2013a).
Washington State law requires that pregnant women be counseled concerning risks about HIV and offered voluntary HIV testing. A healthcare practitioner experienced in treating HIV-infected women should give advice about medications and cesarean delivery on a case-by-case basis.
Source: Israel-Ballard et al., 2007.
Biting poses little risk of HIV transmission unless the person who is biting and the person who is bitten have an exchange of blood (such as through bleeding gums or open sores in the mouth). However, bites can transmit other infections and should be treated immediately by thorough washing of bitten skin with soap and warm water and disinfection with antibiotic skin ointment.
|Type of Exposure||HIV Infection Risk|
|Source: CDC, 2013m.|
|HIV-infected blood transfusion||90%|
|Needle-sharing during injection drug use||0.67%|
|Receptive anal intercourse||0.5%|
|Receptive penile-vaginal intercourse||0.1%|
|Insertive anal intercourse||0.07%|
|Insertive penile-vaginal intercourse||0.05%|
|Receptive oral intercourse||Low|
|Insertive oral intercourse||Low|
|Throwing body fluids (including semen or saliva)||Negligible|
|Sharing sex toys, razors, toothbrushes||Negligible|
|1% risk means a likelihood of 1 in 100 for infection to occur; 0.1% means a likelihood of 1 in 1,000.|
Many other factors, alone or in combination, affect the risk of HIV transmission.
Infectious organisms transmitted during sexual activity—and the clinical manifestations arising from them—cause sexually transmitted diseases. Bacteria, parasites, and viruses cause STDs. There are more than 20 types of STDs, including:
Sexually transmitted diseases increase the risk of acquiring HIV infection because they can cause lesions that make it easier for HIV to enter the body. They can also cause inflammation triggered by the immune system. Because HIV prefers to infect immune cells, any disease causing an increase in these cells will make it easier for a person to become infected with HIV. HIV-positive individuals with STDs are also more infectious and are 3 to 5 times more likely to transmit HIV during sexual activities (CDC, 2010a).
Prevention of HIV/AIDS should be part of a general program of STD prevention because other preventable STDs, most of which are curable, have also reached epidemic proportions, particularly among sexually active young people. For example, rates of primary and secondary syphilis (the stages when syphilis is most infectious) in males have increased each year between 2000–2011. Seventy-two percent of all primary and secondary syphilis cases were among MSM (CDC, 2013n).
Screening for STDs is also critical since many of those infected do not show symptoms. This includes Pap tests for sexually active women and a thorough history of STDs during medical diagnostic studies for both women and men. Prompt treatment should follow for any persons who test positive for STDs. Treatments vary with each disease or syndrome. Because of the risk of developing resistance to medications for certain STDs, healthcare providers should check the latest STD treatment guidelines, available on the CDC website.
Human papilloma virus (HPV) is highly prevalent among HIV-infected women and men, increasing viral shedding and raising the risk of cervical and anal cancers. Multiple strains of this virus are often present in HIV-positive women. Pre-existing HPV infection in women is associated with a two-fold increase in the risk of HIV acquisition. HPV infection of the penis among heterosexual men almost doubles the risk of contracting HIV, and anal HPV infection among gay/bisexual men more than triples the risk of contracting HIV (Houlihan et al., 2012).
A study completed in 2012 supports recommendations to vaccinate young HIV-positive women with Gardasil and to target vaccination to 11- and 12-year-olds, who are less likely to have acquired HIV behaviorally (Mascolini, 2012). Gardasil and Cervarix have been found safe for use in HIV-positive patients with high-grade anal intraepithelial neoplasia (AIN), a precancerous condition caused by infection with high-risk forms of HPV. In October 2009, the FDA approved Gardasil to prevent HPV in boys and men ages 9–26; and in 2010 the CDC recommended vaccination of boys and men ages 9–26 to reduce their likelihood of acquiring genital warts (CDC, 2010b).
Genital herpes (HSV-1 and -2) also appear to be a major risk factor for acquiring HIV infection, increasing the risk more than two-fold. The CDC (2011b) estimates that 776,000 people in the United States get new herpes infections every year. One out of 6 people aged 14–49 are estimated to have genital HSV-2 nationwide. Genital HSV-2 infection is more common in women than in men. Most have not been diagnosed. Many of them have mild or unrecognized infections but shed virus intermittently in the genital tract. These individuals are more likely to transmit the infection.
Two large, randomized controlled trials found that, for people with HSV-2 infection, taking daily treatment to suppress herpes infection did not lower the chances of getting HIV infection. Thus, testing for genital herpes and treatment with herpes medications will not diminish the potential risk of HIV acquisition due to HSV-2 infection (CDC, 2011b).
In 2012 chlamydia was the most frequently reported bacterial sexually transmitted infection in the United States. Untreated chlamydia may increase a person’s chances of acquiring or transmitting HIV (CDC, 2014). It is estimated that 1 in 15 sexually active females aged 14–19 has chlamydia, which is transmitted through anal, vaginal, or oral sex and can be passed from an infected woman to her baby during childbirth. Gonorrhea often occurs along with chlamydia. It is spread by contact with infected body fluid and can be passed from a woman to her newborn during childbirth. It is estimated that less than half of all new cases are reported to the CDC, as gonorrhea may be asymptomatic. Sexually active teenagers have one of the highest rates of reported infections.
The individual with multiple sex or injection drug–sharing partners is at great risk for exposure to HIV. Anyone having unprotected sex with multiple partners (defined by CDC as six or more partners in a year) is considered at high risk for HIV/AIDS infection. However, unprotected sex with even one infected partner risks transmission.
Use of any mood-altering substance—including prescribed medications, alcohol, or noninjectable street drugs such as methamphetamine—can increase risk of HIV transmission by impairing judgment, thereby leading to risky behaviors such as unprotected sex. Methamphetamine abuse is growing among MSM, especially younger MSM.
Certain substances can mask pain and/or create oral and genital sores. For example, methamphetamine dries mucous membranes and increases the risk of abrasions (Hussain et al., 2012).
The balance of power in an intimate relationship can affect an individual’s ability to insist on safer sex practices such as condom use. Women who are socially and economically dependent on men may be unable to negotiate condom use or to leave a relationship that puts them at risk.
Culturally imposed ignorance about their bodies, especially about sexuality and reproduction, can make women even more vulnerable to HIV infection. Some cultures endorse the concept of multiple sexual partners for men but monogamous relationships for women.
HIV infection is preventable. For example, screening of blood and blood products for the HIV virus has reduced the risk of HIV transmission with transfusion to 1:1,000,000. Mother-to-baby transmission has dropped to a rate of less than 1% and less than 1 transmission per 100,000 live births (CDC, 2013j). Following standard precautions in healthcare has unquestionably prevented thousands, if not millions, of cases of HIV/AIDS in the United States. But, because the virus is transmitted through behaviors that many people find pleasurable—sexual activity and injection drug use—prevention is difficult.
Prevention of HIV/AIDS saves money as well as lives. The CDC estimates that the average cost of lifetime treatment for one person with HIV infection varies from $253,000 to $402,000 (Farnham et al., 2013).
Prevention of HIV begins with education and counseling about sexual practices and injection drug use. People unable to “just say no” need basic, practical, how-to information.
Safer sex practices include:
Latex condoms are highly effective against HIV. If a partner is allergic to latex, polyurethane or polyisoprene condoms can be used. “Skins,” or natural-membrane condoms, used for birth control, however, will not protect against the virus.
Although there have been no confirmed cases of female-to-female transmission of HIV, women who have sex with women (WSW) should take precautions, as vaginal secretions and menstrual blood are potentially infectious. Precautionary measures include:
Both women and men may need instruction in the correct use of condoms:
Injection drug users who refuse treatment or who have no treatment programs available to them need instructions about precautions:
These risk-reduction measures also apply to people who use needles to inject insulin, vitamins, steroids, or prescription or nonprescription drugs.
In December 2009, new U.S. legislation ended the ban on federal funding for needle exchange programs, making additional resources available to states and communities. HIV experts called this a crucial, lifesaving step forward for HIV prevention. But in 2011, only two years after a landmark decision to allow federal funding for syringe exchange programs, the ban was renewed as part of a political compromise on a general spending bill. The reinstatement of the ban fails to take into account countless studies on the efficacy of such programs as HIV-prevention strategies.
Syringe exchange or needle exchange programs also help prevent spread of hepatitis and other bloodborne pathogens. Currently, 29 states have syringe or needle exchange programs, including many local health departments in Washington State.
Optimal care of people with HIV/AIDS includes not only antiviral therapies, health maintenance, and referral to support services, but also an emphasis on prevention of transmission to uninfected partners. The CDC recommends that anyone with HIV/AIDS use prevention strategies even if his or her partner is also HIV infected.The partner may have a different strain of the virus that could behave differently in each individual or that could be resistant to different anti-HIV medications.
Healthcare practitioners should implement preventive strategies with their patients beginning with the initial visit and continuing throughout subsequent visits or periodically, at least once a year. A straightforward, nonjudgmental approach and open-ended questions should be used to screen and assess patient behaviors associated with HIV transmission. Other strategies include self-administered questionnaires and computer-, audio-, or video-assisted questionnaires.
Initial and periodic screening for STDs should also be performed. At the initial visit, both men and women should have laboratory tests for syphilis. Women should also be screened for trichomoniasis, and women age 25 and younger should be screened for cervical chlamydia, the most common STD among women. Screening for STDs, particularly for chlamydia, should be repeated periodically if the patient is sexually active. Women younger than 19 are often reinfected with chlamydia, probably by male partners who have not been diagnosed and treated because the disease is asymptomatic.
HIV-positive women of childbearing age should be screened for pregnancy at initial and subsequent visits and asked about interest in future pregnancy and use of contraceptives. Counseling about reproductive healthcare or prenatal care, as appropriate, should be offered.
Injection drug users should be referred for substance abuse treatment. Those who refuse treatment should be counseled to use once-only sterile syringes and not to share needles with others.
African Americans and Hispanics of both sexes have disproportionately higher rates of HIV/AIDS in the United States. There are no biologic reasons for these disparities, and there is no single reason why these disparities exist. However, there are a number of contributing factors, including:
Prevention messages need to be culturally appropriate and relevant and they must be delivered through channels appropriate to individual communities. These channels may include religious institutions or respected elders in the community.
Research has documented that male circumcision significantly reduces the risk of contracting HIV through penile-vaginal sex. Studies have shown circumcised men had a 58% lower incidence of HIV infection compared with uncircumcised men. Male circumcision also lowers the risk for other STDs (CDC, 2013o).
In July 2012, the U.S. Food and Drug Administration (FDA) approved the combination medication tenofovir disoproxil fumerate plus emtricitabine (TDF/FTC), a combination pill known as Truvada, for use as preexposure prophylaxis (PrEP) to prevent new infections. In addition, in 2013 the CDC reported that daily medication with tenofovir disoproxil fumerate has now been proven to reduce the risk of acquiring HIV among all groups at high risk, including people who inject drugs, by 49% (CDC, 2013p).
The cost of PrEP is a major concern for public health agencies and private insurers, since Truvada costs about $1,200 per month. In addition, possible side effects include diarrhea, kidney, and bone damage. It is warned that this drug should not replace safer sex that includes using condoms and preventing impaired judgment.
Healthcare workers may be infected with HIV through needlesticks or direct contact with HIV-infected blood—for example, through a break in the skin or through the eyes or the mucosal lining of the nose.
In 2013 the CDC reported that 57 healthcare personnel in the United States have been documented as having seroconverted to HIV following occupational exposures. In addition, 143 possible cases of HIV infection or AIDS have occurred among healthcare personnel. However, there have been no confirmed cases of occupational HIV transmission to healthcare workers reported since 1999. Healthcare workers exposed to HIV-infected blood at work have a 0.3% risk of becoming infected (CDC, 2013q).
Healthcare professionals who work in correctional institutions and in home care are at higher risk for occupational exposure to HIV and other bloodborne pathogens than those who work in other settings. Other occupational groups with potential exposure to HIV (as well as HBV and HCV) include, but are not limited to:
The risk of developing HIV infection from a needlestick with infected blood is about 1 in 300 without prompt antiretroviral treatment, and the risk increases with:
(Comparatively, the risk after a mucous membrane exposure is about 1 in 9,000, and the risk of HIV transmission after nonintact skin exposure is estimated to be less than the risk for mucous membrane exposure.)
According to the CDC, the risk of infection varies on a case-by-case basis. Factors affecting the risk include:
The high prevalence of HIV infections in correctional institutions increases the risk of exposure, as does the environment itself. The CDC and the National Institute for Occupational Safety and Health (NIOSH) cite these challenges:
Correctional healthcare workers can be bitten or stabbed during an inmate assault, punctured with a used needle, or splashed in the face with blood. Exposure to bloodborne pathogens can happen in any of these situations.
Special Note Regarding WAC 296-823
Washington Administrative Code (WAC) 296-823, Occupational Exposure to Bloodborne Pathogens, mandates certain standards and procedures to protect employees from exposure to blood or other potentially infectious materials (OPIM) that may contain bloodborne pathogens. The state’s Department of Labor and Industries (L&I) Division of Occupational Safety and Health enforces these requirements. Failure to comply with these requirements may result in citations or penalties.
This course contains a brief summary and is not meant to provide direction on compliance with WAC 296-823.
The federal Occupational Safety and Health Administration (OSHA) compliance directive on occupational exposure to bloodborne pathogens, CPL 2–2.69, may be referenced for additional direction. More information or assistance is also available from L&I consultants, who can be contacted via a 24-hour toll-free line (1-800-BE-SAFE) or online at lni.wa.gov.
Standards have been developed to protect workers from bloodborne pathogens such as HIV.
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:
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.
Each employer covered under WAC 296-823 must develop an Exposure Control Plan (ECP). The ECP shall contain at least the following elements:
Bloodborne pathogens training is mandated for all new employees or employees being transferred into jobs involving tasks or activities with potential exposure to blood and/or OPIM. This training must take place prior to assignment to tasks where occupational exposure may occur, and must include:
Retraining is required annually or when changes in procedures or tasks affecting occupational exposure occur.
Employees must be provided access to a qualified trainer during the training session to ask and receive answers to questions as they arise.
To prevent HIV transmission in healthcare settings, the CDC instituted “universal precautions” (blood and body fluid precautions) in the 1980s. Under universal precautions, healthcare personnel assumed that the blood and other body fluids from all patients were potentially infectious and therefore followed infection-control precautions at all times and in all settings.
In 1996, this practice was replaced. Standard precautions is the current terminology, and it includes:
The emphasis has shifted to a more pragmatic focus on what healthcare professionals need to do with specific patients with specific modes of transmission associated with their diagnosis.
These precautions include:
Gloves, masks, protective eyewear, and chin-length plastic face shields are examples of personal protective equipment (PPE). PPE shall be provided and worn by employees in all instances where they will or may come into contact with blood or OPIM. This includes, but is not limited to, dentistry, phlebotomy, processing of any body fluid specimen, and postmortem (after death) procedures.
Latex gloves are recommended when dealing with blood or OPIM. However, people with allergies to latex must be provided with nitrile, vinyl, or other glove alternatives that meet the definition of “appropriate” gloves. Gloves must be changed after each client.
Gloves should be worn:
Clinicians with weeping dermatitis (such as poison ivy or poison oak) or exudative lesions must be prohibited from all patient care and/or handling of patient care equipment or supplies.
Masks, goggles, face shields, and gowns should be worn:
Reusable PPE must be cleaned and decontaminated or laundered by the employer. Lab coats and scrubs are generally considered to be worn as uniforms or personal clothing. When contamination is reasonably likely, protective gowns should be worn. If lab coats or scrubs are worn as PPE, they must be removed as soon as practical and laundered by the employer.
Soap-and-water handwashing must be performed whenever hands are visibly contaminated or there is a reasonable likelihood of contamination. Standard precautions also include frequent handwashing with warm water and soap:
It is advisable to keep fingernails short and wear as little jewelry as possible.
Additional information on hand hygiene can be found in the CDC “Guideline for Hand Hygiene in Healthcare Settings” (CDC, 2002) (see “References” at the end of this course).
The use of an alcohol-based hand rub is appropriate in many, but not all, situations.
Sharps containers should be placed as close to the point of use as possible to enhance compliance with correct disposal policies.
Needles are not to be recapped, purposely bent or broken, removed, or otherwise manipulated by hand. After they are used, disposable syringes, needles, scalpel handle-blade units, and removable scalpel blades are to be immediately placed in puncture-resistant, labeled containers for disposal.
Phlebotomy or injection needles must not be removed from holders or syringes unless required by a medical procedure. The intact phlebotomy or injection needle and holder or syringe must be placed directly into an appropriate sharps container.
Adhere to agency protocols for disposal of infectious waste.
The work area of the facility is to be maintained in a clean and sanitary condition. The employer is required to determine and implement a written schedule for cleaning and disinfection, based on the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed.
Disinfectants. All equipment and all environmental and working surfaces must be properly cleaned and disinfected after contact with blood or OPIM. Chemical germicides and disinfectants in recommended dilutions must be used to decontaminate spills of blood and other body fluids. Consult the Environmental Protection Agency (EPA) for lists of registered sterilants, tuberculocidal disinfectants, and antimicrobials with HIV/HBV efficacy claims to verify that the product used is appropriate. Lists are available from the EPA at epa.gov/oppad001/chemregindex.htm.
Laundry. Laundry that is or may be soiled with blood/OPIM must be treated as contaminated. Contaminated laundry must be bagged at the location where it was used and shall not be sorted or rinsed in patient-care areas. It must be placed and transported in bags that are labeled or color-coded (red-bagged).
Laundry workers must wear protective gloves and other appropriate personal protective clothing when handling potentially contaminated laundry. All contaminated laundry must be cleaned or laundered so that any infectious agents are destroyed.
Regulated Waste. Potentially contaminated broken glassware or sharp items must be removed using mechanical means, such as a brush and dustpan or vacuum cleaner. All regulated waste must be placed in closeable, leak-proof containers or bags that are color-coded (red-bagged) or labeled as required by law to prevent leakage during handling, storage, and transport. Disposal of waste shall be in accordance with federal, state, and local regulations.
Regulated waste is defined as any of the following:
Tags or labels must be used as a means to protect employees from exposure to potentially hazardous biological agents.
All required tags must meet the following specifications:
Personnel handling laundry and waste are to be aware that these items may contain sharps despite the most stringent policies and the best efforts of healthcare workers. They should be trained in immediate first aid for a needlestick or other break in skin integrity. They should immediately report any potential exposure to a supervisor with the knowledge and authority to implement the exposure control plan.
Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas that carry the potential for occupational exposure.
Food and drink must not be stored in refrigerators, freezers, or cabinets where blood or OPIM are stored or in other areas of possible contamination.
Any healthcare worker who receives a needlestick or other significant exposure to potential HIV, HSV, or HBV infection should follow the employer’s protocol, which is based on guidelines issued by the U.S. Public Health Service (Kuhar, 2013).
Immediately after exposure to blood or OPIM of a patient:
Immediately report the incident to a supervisor and to the department (e.g., occupational health, infection control) within the agency responsible for managing exposures. Prompt reporting is essential because in some cases postexposure prophylaxis (PEP) may be recommended and started as soon as possible. Discuss with a healthcare professional the extent of the exposure, treatment, follow-up care, personal prevention measures, the need for a tetanus shot, and other care. Employees should have already received the hepatitis B vaccine, which is extremely safe and effective in preventing HBV infection.
In Washington, employers must make a confidential postexposure medical evaluation available to employees who report an exposure incident. This evaluation must be:
In addition, the following information must be provided to the evaluating healthcare professional:
HIV and hepatitis infection are notifiable conditions under WAC 246-101.
Workers have a right to file a worker’s compensation claim for exposure to bloodborne pathogens. Industrial insurance covers the cost of postexposure prophylaxis and follow-up care for the injured worker.
Postexposure prophylaxis is recommended when occupational exposure to HIV occurs. The U.S. Public Health Service (USPHS) recommends the following guidelines:
Frequent advances in treatment make it impractical to list medications and dosages here. PEP can only be obtained from a licensed healthcare provider. The employing facility may have recommendations and procedures in place for staff members to obtain PEP. After evaluation, certain anti-HIV medications may be prescribed.
Round-the-clock information regarding the most current PEP regimen is available from the Post-Exposure Prophylaxis Hotline (PEPline): 1-888-448-4911.
The PEPline offers treating clinicians up-to-the-minute advice on managing occupational exposures (i.e., needlesticks, splashes, etc.) to HIV, hepatitis, and other bloodborne pathogens. Clinicians will help assess the risk of the exposure, discuss the most recent PEP protocols, and review specific treatment and follow-up options. Written materials supporting the telephone discussion are sent by mail or fax whenever needed.
PEPline clinicians will respond to calls between 9 a.m. and 2 a.m. ET. Emergency calls made during other hours are answered when live service resumes the following morning.
The PEPline is an invaluable resource for healthcare workers and their agencies, especially in rural areas. The phone number and website should be listed in appropriate locations, and a plan put in place to contact the PEPline using a relay of information if cellular and/or internet service is not available in all areas in which workers may be exposed.
Source: CDC, 2013t.
WAC 296-823-160 requires the employer to arrange to test the source individual—the person whose blood or OPIM an employee was exposed to—for HIV, HBV, and HCV as soon as feasible after obtaining that individual’s consent. If the employer does not get consent, the employer must document such and inform the employee. The employer may request assistance from the local health officer.
Because of an increased risk for HIV exposure, the Washington Revised Code 70.24.340 provides for HIV antibody testing of a source individual when a member of the following groups experiences an occupational exposure:
These individuals can request HIV testing of the source through their employer or local health officer.
Before issuing a health order for HIV testing of the source individual, the officer will first determine whether a substantial exposure occurred and if the exposure occurred on the job. Depending on the type of exposure and risks involved, the health officer may determine that source testing is unnecessary.
Source testing does not eliminate the need for baseline testing of the exposed individual for HIV, HBV, HCV, and liver enzymes. Initiating PEP should also not be contingent upon the results of a source’s test. Current recommendations are to provide immediate PEP in certain circumstances, with possible discontinuation of treatment based on the source’s test results.
(See also “Testing Without Informed Consent” below.)
Healthcare professionals and other caregivers who care for HIV patients at home or in home-like settings are also at risk of exposure to HIV and other bloodborne pathogens. Nurses, nursing assistants, personal care assistants (PCAs), and family members experience percutaneous injuries and other exposures to blood and body fluids during care of an HIV-infected person.
Medical procedures contributing to percutaneous injuries in home care include injecting medications, performing fingersticks and heelsticks, and drawing blood. Other contributing factors include sharps disposal, contact with waste, and patient handling.
Healthcare workers and other caregivers who care for HIV patients should practice good hygiene techniques in preparing food, handling body fluids, and using medical equipment. Cuts, accidents, or other circumstances can result in spills of blood/OPIM on carpeting, vinyl flooring, clothing, skin, or other surfaces. Everyone, even young children, needs to have a basic understanding that they should not put their bare hands in or on another person’s blood.
Gloves (latex, vinyl, or nitrile in the case of latex allergy) should be worn whenever a caregiver anticipates contact with any body substance (blood/OPIM) or nonintact skin. Gloves are not necessary for general care or during casual contact (serving food, bathing intact skin). Never rub the eyes, mouth, or face while wearing gloves.
Gloves should be properly removed and disposed of and hands washed as soon as possible after care of each patient. Disposable gloves should never be washed and reused. Correct handwashing is critically important.
Wear appropriate gloves when cleaning blood from skin surfaces. Use sterile gauze or other bandages and follow normal first-aid techniques to stop the bleeding. After applying the bandage, remove the gloves slowly so fluid particles do not splatter or become aerosolized. Hands should be cleaned using either soap and water or an alcohol-based hand sanitizer as soon as possible.
On bare floors, pretreat body fluid spills with full-strength liquid disinfectant or detergent; then wipe up with either a mop and hot soapy water or appropriate gloves and paper towels. Dispose of paper towels into a well-marked plastic bag or heavy-duty container. Broken glass should be swept up using a broom and dustpan (never bare hands).
Use a disinfectant (such as 1 part household bleach freshly mixed with 9 parts water) to disinfect the area where the spill occurred. If a mop was used for cleaning, soak it in a bucket of hot water and disinfectant for the recommended time. Empty mop water into the toilet, not the sink. Sponges and mops used to clean up body fluid spills should not be rinsed in the kitchen sink or in a location where food is prepared.
A 1:10 solution of household bleach includes 1 part bleach and 9 parts water. The key is using the same volume as a “part”—i.e., a measuring tablespoon or a measuring cup.
Source: CDC, 2009.
On carpeting, pour dry kitty litter or another absorbent material onto the spill to absorb the body fluid. Carefully pour carpet-safe liquid disinfectant onto the contaminated carpeting and leave it there for the amount of time indicated in manufacturer’s instructions. Using sturdy rubber gloves, blot the spill with paper towels until it is absorbed. Vacuum normally afterward.
Clothes, washable uniforms, towels, or other laundry stained with blood/OPIM should be washed and disinfected before further use. If possible, have the patient remove the clothing. If necessary, use appropriate gloves to assist with removing the clothes.
If the washing machine is not close by, transport the soiled items in a sturdy plastic bag. Then place the items in the washing machine and soak or wash them in cold, soapy water to remove any blood from the fabric. Hot water will permanently set blood stains.
Use hot water for a second washing cycle and include detergent, which will act as a disinfectant. Dry the items in a clothes dryer. Wool clothing or uniforms may be rinsed with cold soapy water, then dry-cleaned to remove and disinfect the stain.
It is safe to share toilets/toilet seats without special cleaning, unless the surface becomes contaminated with blood/OPIM. If this occurs, spray the surface with a solution of 1:10 bleach solution. Wearing gloves, wipe the seat dry with disposable paper towels.
Persons with open sores on their legs, thighs, or genitals should disinfect the toilet seat after each use. Urinals and bedpans should not be shared between family members unless these items are thoroughly disinfected after each person’s use.
Use a new pair of gloves to change diapers. Discard disposable diapers in an appropriate plastic bag or receptacle, along with gloves. Wash hands immediately after changing the diaper. Disinfect the diapering surface. Wash cloth diapers in very hot water with detergent and a cup of bleach, and dry them in a hot clothes dryer.
Electronic thermometers with disposable covers do not need to be cleaned between uses for the same individual unless visibly soiled or if there is evidence that the cover integrity has been compromised. Wipe the surface with a disinfectant if necessary. Glass thermometers should be washed with soap and warm water before and after each use. If the thermometer will be shared among family members, after each use it should be soaked in 70%–90% ethyl alcohol for 30 minutes, then rinsed under a stream of warm water.
People should not share razors, toothbrushes, personal towels or washcloths, dental hygiene tools, vibrators, enema or douche equipment, or other personal care items.
Syringes, needles, and lancets are called sharps, and their disposal is regulated. Sharps can carry hepatitis, HIV, and other bacteria and viruses that cause disease. Throwing them in the trash or flushing them down the toilet can pose health risks for others—such as sanitation (garbage) workers, other utility workers, and the public—from needlesticks and illness. Rules and disposal options vary according to circumstances, so it is essential to check with the local health department to see which option applies to any given situation.
Parents and caregivers should make sure that children understand never to touch a found needle or syringe but to immediately ask a responsible adult for help.
Safe disposal of found syringes should follow these guidelines:
Anyone with an accidental needlestick requires a prompt assessment by a medical professional. Testing for HIV, HCV, and HBV may be recommended. If someone finds and handles a syringe, but no needlestick occurs, testing for HIV is not necessary.
Kitchens can harbor bacteria that may prove life threatening to a person with HIV/AIDS due to his or her compromised immune system. Use the following precautions during food preparation and clean-up:
Certain animals can pose hazards for people with compromised immune systems. These animals include turtles, reptiles, birds, puppies and kittens under the age of eight months, wild animals, and pets without current immunizations or with illnesses of unknown origin. Pet cages and cat litter boxes can harbor infectious organisms that may become aerosolized. Pets can also spread disease by licking a person’s face or open wounds.
Someone who is not immunocompromised should care for pets. If this is not possible, a mask with a sealable nose clip and disposable latex gloves should be worn each time pet care is done. Many communities have volunteer groups and veterinarians who will assist people with HIV/AIDS in taking care of their pets if needed. Questions can be directed to a local veterinarian.
Upon completion of this section, you will be able to discuss accepted procedures and regulations for HIV testing and post-test counseling.
People who do not know they are infected transmit most HIV infections. Therefore, HIV testing is the first step in halting spread of the virus. Testing is critical to the country’s prevention strategy. It is the only way the nearly 1 in 6 Americans living with HIV who do not know they are infected can be diagnosed, and it is the first step in connecting them to the services for prevention, care, and treatment that they require. Detection and early intervention are associated with a significantly reduced risk for progression to AIDS, AIDS-related events, and death in persons with immunologically advanced disease.
Testing is essential for anyone who has had a potential exposure to HIV. This includes anyone who has had unprotected anal, vaginal, or oral sex; who has shared needles or other injection drug preparation equipment; or who has had an occupational exposure. People with partners who have such risk factors should also consider testing.
The U.S. Preventive Services Task Force (2013) recommends that clinicians screen for HIV infection in adolescents and adults ages 15–65 years. Younger adolescents and older adults who are at increased risk should also be screened. It is also recommended that all pregnant women be screened for HIV—including those who present in labor who are untested and whose HIV status is unknown—and be rescreened with each subsequent pregnancy.
The CDC (2013r) recommends the following:
Washington State rules reflect CDC recommendations and enhance access to HIV testing. However, CDC recommendations do not supersede Washington State rules regarding HIV testing and counseling.
Research has shown that when people learn they are infected, they take steps to protect their own health and prevent HIV transmission to others. According to the CDC (2013s), the proportion of adults who have ever been tested for HIV increased from 37% in 2000 to 45% in 2010. However, the CDC (2012a) reports that:
Although HIV testing rates have steadily increased, it is estimated that more than half of Americans still have not been tested for HIV in their lifetime. Lack of access to healthcare, fear, and misperceptions about HIV risk and the testing process itself are key barriers to increasing HIV testing. In addition, some healthcare settings have not yet made HIV testing a routine part of medical care.
There remain far too few tests being conducted even among high-risk groups, including males who have sex with males, African Americans, and young people. Although half of high school students report having had sex, the CDC data reveals that only 13% have ever been tested for HIV (CDC, 2012a).
Confidential means that the patient gives his or her real name to the healthcare practitioner but that test results are revealed only to the patient and to the provider or counselor who tests or provides services to that patient. Those who perform HIV counseling and testing in public health departments or health districts must sign strict confidentiality agreements. These agreements regulate the personal information that may be disclosed in counseling and testing sessions and in test results. HIV test results are kept in locked files, with only a few appropriate staff members having access to them. Positive HIV tests must be reported to local public health officials, however. Results and testing information are not released to others except when medically necessary or under special circumstances, including when the person signs a release for the results to be given to another person or agency.
Anonymous means that the client does not give a name and the health professional who orders or performs the test does not maintain a record of the name of the person being tested. Public health departments in Washington State must make anonymous HIV testing reasonably available. Anonymous testing may also be available through Planned Parenthood or other healthcare clinics. The Washington State HIV/AIDS hotline (1-800-272-2437) can provide information about anonymous testing locations. Positive HIV results obtained through anonymous testing are not reportable; however, should persons with positive results seek care for conditions related to HIV or AIDS, the providers are required to report the case to local health departments.
HIV testing can only be done with a person’s informed verbal or written consent, with rare exceptions. These exceptions include source testing relating to occupational exposures and legally mandated situations specified in Washington State law.
Consent may be contained within a comprehensive consent for medical treatment. However, before HIV testing is performed, patients must be told that this test is recommended and agree to HIV testing. They must be given the opportunity to ask questions and to decline testing. Receipt of consent must be documented, either in the patient’s regular medical record, in another record of services provided, or by written consent. Verbal consent is often used in anonymous testing situations.
Pretest prevention counseling is required only for persons who are at increased risk for HIV infection and for those who request counseling. Such counseling can be accomplished by referral to a local health department or other appropriate facility, such as a community-based organization that provides counseling services. Pretest counseling should be culturally, linguistically, developmentally, and medically appropriate and include information on:
(For additional information on confidentiality and informed consent, see “Legal and Ethical Issues” below.)
Survivors of rape (sexual assault) are at risk for infection with HIV and other STDs. Nearly 1 in 5 women and 1 in 71 men in the United States have been raped some times in their lives, and nearly 1 in 2 women and 1 in 5 men experienced sexual violence victimization other than rape at some point in their lives (CDC, 2010c).
The probability of HIV transmission during a single act of intercourse with an HIV-infected person is probably low according to the CDC (2013m) and depends on many factors. These factors include: type of intercourse (oral, vaginal, anal); presence of oral, vaginal, or anal trauma (including bleeding); site of exposure to ejaculate; viral load in ejaculate; and presence of an STD or genital lesions in the assailant or survivor.
Sexual assault also puts adolescent girls and women at risk of becoming pregnant, so emergency contraception is part of the medical protocol for female rape survivors. Counselors must provide survivors with the toll-free number for the emergency contraception hotline (1-888-NOT-2-LATE or 1-888-668-2528).
A sexual assault survivor should go directly to the nearest hospital emergency department (ED) without changing clothing and without bathing or showering, which might remove evidence that could incriminate the assailant. Trained ED staff will counsel the survivor and also offer testing or referral for HIV, STDs, and pregnancy.
Testing the survivor of sexual assault for HIV immediately after the event can establish that the survivor was not infected at the time of the assault. However, it is important to consider the window period and retest later if the assailant proves to be HIV-positive. In the rare case that an assault survivor is infected by the assailant, the earlier test can serve as evidence in criminal court.
The standard protocol is for the ED physician to take DNA samples of blood or semen from the vagina, rectum, or elsewhere, as indicated, which can be used as evidence for legal and criminal action. Some emergency departments may refer sexual assault survivors to the local health jurisdiction for HIV testing.
Questioning sexual assault survivors in the ED about their sexual risks can be difficult and unpleasant. However, testing shortly after a sexual assault provides useful baseline information on the various infections—especially for follow-up care and treatment.
Under Washington State law, only the survivors of convicted sexual offenders may learn the attacker’s HIV status. Thus, the survivor needs to decide whether to start PEP independently of the assailant’s test result, because the time between the attack and the conviction is likely to be longer than the 24–48 hours recommended for beginning PEP.
Postexposure assessment of adolescent and adult survivors includes the following steps to be taken within 72 hours of sexual assault:
Source: CDC, 2011c.
Children may be at higher risk for HIV transmission from sexual assault because child sexual abuse is often associated with multiple episodes of assault and may result in mucosal trauma. The CDC has identified certain situations involving high risk for STD transmission to children, including HIV, and these constitute a strong indication for testing:
Postexposure assessment of child survivors includes the following steps to be taken within 72 hours of sexual assault:
Source: CDC, 2011b.
The CDC (2011d) recommends that all persons who seek evaluation and treatment of STDs be screened for HIV infection. Testing should be done routinely, regardless if the patient is known or suspected to have specific behavioral risks for HIV.
In Washington State, principal healthcare providers must counsel or ensure AIDS counseling as defined in WAC 246-100-011(2) and offer and encourage HIV testing for each patient seeking treatment of an STD.
Patients are significantly more likely to receive an HIV test if done at a drug treatment facility as opposed to being referred elsewhere for testing. A study found that about 80% of members of two patient groups offered on-site HIV tests actually were tested and received their results, compared with only 18.4% of a group referred for testing off-site (Enos, 2012).
Washington State law requires that drug treatment programs under chapter 70.96A RCW provide or ensure provision of AIDS counseling as defined in WAC 246-100-011(2) for each person in a drug treatment program. This includes offering or referring for HIV testing and personalized risk reduction education.
HIV/AIDS testing is available in a variety of settings:
The Washington State HIV/AIDS hotline (1-800-272-2437) can provide referral to a public health, family planning, or community clinic in each county.
There are three main types of HIV tests:
Antibody tests are the most commonly used. They look for antibodies in blood, saliva, or urine produced by the host body rather than looking for the HIV itself. Antibodies usually appear within 6–12 weeks after infection but in rare instances can take up to 6 months to appear. The window period for an antibody test is estimated to be three months after exposure. These tests are very accurate and sensitive. The presence of antibodies is a marker showing infection with HIV.
Antigen (p24) or RNA tests detect the presence of a protein, p24, which is part of the core of the HIV. It is the substance that provokes an antibody response. It is produced in excess in early HIV infection and can be detected in blood serum. As the virus becomes more fully established, however, p24 will fade to undetectable levels. This type of test uses a polymerase chain reaction that can identify HIV in the blood within 2–3 weeks of infection, before antibodies have had time to develop. These tests are expensive, not very sensitive, and therefore not routinely used for screening.
HIV combination tests are able to detect antibodies directed against HIV-1 or HIV-2 as well as the protein p24. The tests use a reaction called chemiluminescence. When either the antibody or the p24 protein is present, this test reaction emits light that is registered on a detector. These tests allow for earlier and more accurate detection of HIV infection.
Until 2002, testing for HIV antibodies relied on an enzyme-linked immunosorbent assay (ELISA) of blood. Since then, nine rapid HIV tests have been approved by the FDA, all of which are interpreted visually. Four of the tests have been approved for use outside of a clinical laboratory.
|OraQuick ADVANCE Rapid HIV-1/HIV-2 Antibody Test||Detects HIV antibodies in oral fluid as well as in blood|
|Uni-Gold Recombigen HIV Test||Detects HIV-1 antibodies in whole blood, serum, and plasma; results take from 10–12 minutes|
|Reveal G3 Rapid HIV-1 Antibody Test||Detects HIV antibodies in serum or plasma; although test takes only 3 minutes to run, it is categorized as a moderately complex test and is usually done in a clinical laboratory|
|Multispot HIV-1/HIV-2 Rapid Test||Uses fresh or frozen serum and plasma to detect HIV-1 and HIV-2 and distinguish one from the other; results available in 20 minutes; also a moderately complex test, it is usually done in a clinical laboratory|
|Clearview HIV-1/HIV-2 STAT-PAK||Uses whole blood or serum and plasma; results available in 15 minutes; requires no training to use|
|Clearview HIV-1/HIV-2 Complete||A single-use, self-contained closed system for the collection, processing, and analysis of a whole blood, serum, or plasma sample; results available in 15 minutes|
|Alere Determine HIV-1/2 Ag/Ab Combo Test||Can detect HIV-1 and -2 antibodies and HIV-1 p24 antigen in human serum, plasma, and venous or fingerstick whole-blood specimens|
|Chembio DPP HIV-1/2||Detects antibodies to HIV-1 and -2 and gives results in 15 minutes from fingerstick or venous whole blood, plasma, serum, or oral fluid swab|
|INSTI HIV-1 Antibody Test||Detects HIV-1 antibodies in plasma and gives results in less than 2 minutes|
Until these rapid tests became available, many people undergoing testing in public clinics did not return to get their test results. Making results available during the testing appointment means that people can take immediate precautions to prevent transmission to their sexual partners. In addition, the oral fluid test offers another option for those people who may fear a blood test.
Rapid HIV testing is a two-step process that includes a screening test and, when the screening test is reactive (positive), a confirmatory test.
All positive (reactive) rapid HIV tests require repeat testing for confirmation. The CDC (2004) described protocols for confirming reactive rapid HIV tests based on a consultation convened in January 2003 with expert laboratory scientists, the FDA, and the Centers for Medicare and Medicaid Services. These protocols remain in effect and recommend 1) confirmation of all reactive rapid HIV test results with either Western Blot (WB) or immunofluorescent assay (IFA), even if an enzyme immunoassay (EIA) screening test is negative, and 2) follow-up testing for persons with negative or indeterminate confirmatory test results, with a blood specimen collected four weeks after the initial reactive rapid test result.
Washington State Department of Health Rapid Testing Recommendations
To minimize the risk of false positive results, the Washington State Department of Health recommends that, whenever practical, whole-blood fingerstick specimens be used for OraQuick Advance HIV-1/2 rapid testing, especially in populations with low prevalence (less than 1%). False positive means that the test result is positive but the client is not infected.
This recommendation is based on: 1) the difference between the sensitivity of OraQuick Advance testing of fingerstick whole-blood specimens and oral fluid specimens (99.6% vs. 99.3%, respectively); 2) the decrease in the positive predictive value of rapid HIV screening with low prevalence; and 3) the low prevalence of HIV in most populations in Washington State.
The low prevalence of HIV in Washington State means that most testing sites service client populations with less than 1% prevalence. In such cases, there is increased likelihood that reactive HIV tests will be false positives.
OraQuick Advance HIV-1/2 is also useful because it screens for both HIV-1 and HIV-2, the latter being extremely rare in Washington. To confirm an HIV-2 positive rapid test, a laboratory must use an HIV-2 Western Blot test.
To ensure accuracy of test results, all laboratory testing is regulated under the federal Clinical Laboratory Improvement Amendments of 1988 (CLIA), which classify tests according to their complexity. Tests may receive a CLIA waiver if they use direct, unprocessed specimens such as whole blood or oral fluid, are easy to perform, and have a negligible chance of error. This waiver permits personnel without training in laboratory procedures to perform the tests outside a traditional laboratory setting.
The standard procedure for Washington State laboratories is to conduct confirmatory testing for HIV-1, unless requested otherwise. However, in the case of clients who have had unprotected sex with, or have shared needles with, someone from an African country, confirmatory testing for both HIV-1 and HIV-2 must be requested.
Washington State law (RCW 70.42) requires that all sites performing clinical laboratory testing obtain a state medical test site (MTS) license. All agencies conducting waived rapid testing must obtain an MTS license (category: certificate of waiver). The MTS license takes the place of a federal CLIA certificate.
WHO CAN COLLECT BLOOD SPECIMENS?
In Washington State, three categories of healthcare professionals are authorized to collect blood specimens through fingersticks and venipuncture:
*Sexually Transmitted Disease Case Investigators are individuals who: 1) are employed by public health authorities; 2) have been trained by a physician in proper specimen collection procedure; and 3) possess a statement signed by the instructing physician that this training has been completed (RCW 70.24.120). No further licensing is required.
Before HIV rapid tests became available, HIV antibody testing relied on an enzyme-linked immunosorbent assay (ELISA or EIA). This test overpredicts positives; consequently, a negative HIV antibody test is considered definitive and no further testing is required. If the results are positive, however, Washington State law (WAC 246-100-207) prohibits telling a person he or she is HIV-positive based only on ELISA test results. This law reflects CDC recommendations. If a person has three reactive (positive) ELISA tests on the same blood sample, a separate confirmatory test is required, commonly a Western Blot test.
The HIV Western Blot detects antibodies to individual proteins that make up HIV. This test is much more specific and more expensive than the ELISA screening tests and considered more definitive.
A test to detect HIV antibodies in the urine is available for use only in doctors’ offices or medical clinics. Even though HIV antibodies can be detected in urine, urine is not considered a viable medium for transmitting the virus. A positive urine HIV test must be confirmed with a Western Blot test, which can be done on the same specimen.
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.
Tests are now available for self-testing of HIV serostatus. There are two FDA-approved home test kits on the market: Home Access Express and OraQuick In-Home.
The Home Access Express product is really an in-home sample collection system rather than a test with readily visible results. The person who wants to test at home pricks a finger and collects blood spots on special paper. The paper is mailed to a certified clinical laboratory with a confidential and anonymous personal identification number (PIN) and then tested using a standard ELISA process. If the initial test result is positive, the results are confirmed by a Western Blot test. The person tested obtains the results by calling a toll-free phone number and using the assigned PIN. Post-test counseling is available by telephone for everyone tested, whether the results are positive or negative.
In 2012, the FDA approved the first rapid home-use HIV kit that does not require sending a sample to a laboratory for analysis. The OraQuick In-Home HIV test uses a sample of fluid from the mouth and provides results in 20–40 minutes. In this case also, the FDA wants consumers to know that positive test results using the OraQuick test must be confirmed by follow-up, laboratory-based testing.
The FDA has predicted that this test will reach many who would not otherwise be tested because of reluctance to visit their doctor or healthcare facility for testing. It will contribute noticeably to public health by helping more infected people to become aware of their HIV status, resulting in a reduction of HIV transmission. However, the test is available legally only to people aged 17 years and older.
HIV test results can be one of three types: negative, positive, or indeterminate. A person may test negative for HIV antibodies even though recently infected. As stated earlier, newly infected persons may have high levels of the virus in their blood, making them highly infectious even though test results are negative.
Washington State rules allow for test results to be conveyed to patients in person or by telephone, followed by later counseling, if needed. 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 clients test negative for HIV, providers can report results to them by telephone and discuss the 1- to 3-month window period (the time between infection with HIV and production of enough antibodies to be detected by antibody tests), and if applicable, the need for retesting. However, specific efforts need not be made to contact persons with negative results who do not return or telephone for their results.
If clients test positive for HIV, Washington State law (WAC 246-100-207 and -209) requires that HIV post-test prevention counseling be provided. Providers should discuss HIV transmission, ways to protect partners, and disclosure of status to others. Assertive efforts should be made to contact persons with positive results who do not telephone or return for their results.
It is recommended that clients tested with rapid HIV tests be advised that their preliminary results will be available in the same visit and that confirmatory testing will be needed if the rapid test result is positive. In addition, retesting within three months should be recommended even if the rapid test result is negative.
If the test result is negative, it means either 1) the person is not infected with the virus, or 2) the person became infected recently and antibodies have not yet appeared. A person who tests negative for HIV but remains concerned about a possible recent infection should test again in 3–6 months and practice safer behaviors in the meantime. If risky behavior continues, infection may still occur.
Additional testing is recommended as follows:
A positive test result shows the presence of HIV antibodies, which means that:
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. Anyone declining pretest counseling may not later be denied HIV testing (WAC 246-100-207). If the provider determines the individual is at high risk for HIV infection, counseling should be based on assessment of the individual client as outlined below.
All individuals tested for HIV should also be offered an opportunity to receive post-test counseling. Those who test positive for HIV must be provided with post-test counseling (WAC 246-100-209).
Washington State revised rules (WAC 246-100-209) require a client-centered approach to pre- and post-test HIV counseling. Counseling must follow CDC recommendations and must assist the person to set a realistic goal for behavior change, establish strategies for reducing risk of acquiring and transmitting HIV, and provide appropriate risk-reduction, skills-building opportunities to support the behavior change goal. Referrals should be provided for other appropriate prevention, support, or medical services.
Washington State revised rules (RCW 70.24.095 and WAC 246-100-208) require that all healthcare providers caring for pregnant women provide or ensure HIV/AIDS counseling for each pregnant woman who seeks prenatal care with the intent of continuing the pregnancy. Counseling is to include the following:
If a pregnant woman refuses a confidential test, her reasons for refusal, as well as the provision of education on the benefits of HIV testing, must be discussed and documented in the medical record.
If screening suggests a high risk of HIV, the provider should provide or refer for behavioral change counseling, women who:
Behavioral change counseling should be based on the standards defined in WAC 246-100-209 and the CDC recommendations in “Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings” (see “References” at the end of this course).
The provider should also offer referrals and provide follow-up to other necessary medical, social, and HIV prevention services.
A client’s individual HIV risk can be determined through risk screening based on self-reported behavioral risk and clinical signs or symptoms. Behavioral risks include injection drug use or unprotected intercourse with a person at increased risk for HIV. Clinical signs and symptoms include those suggestive of HIV infection and other STDs.
Behavioral risks can be identified either through open-ended questions by the provider or through screening questions (i.e., a self-administered questionnaire).
An example of an open-ended question is: “What are you doing now or what have you done in the past that you think may put you at risk of HIV infection?”
While not a comprehensive list, examples of other screening questions are:
“Since your last HIV test (if ever) have you:
Behavior change goals should be: 1) based on the individual’s risk; 2) perceived as realistic by the individual; and 3) based on the individual’s readiness and capability to change behavior. The goals of post-test counseling should be to: 1) increase the individual’s understanding of HIV infection; 2) change the individual’s behavior; and 3) if necessary, encourage the individual to notify people with whom there has been potential transmission of HIV.
Depending on the person’s readiness for change, counseling can be simple and brief or complex and lengthy. In many clinical practice settings, time restraints only permit brief and simple counseling.
As an example, for a person who has yet to contemplate behavior change, a realistic goal might be helping the person recognize which behaviors place them at risk for HIV. Skill building could help the person self-identify situations where the risk behavior is practiced.
Other individuals may be further along the behavior change continuum and have identified specific behaviors they wish to change. Support for those identified changes is appropriate. A relevant goal might be to identify barriers to the behavior change and help the person self-identify solutions. Demonstrating how to use a condom or how to discuss condom use with a new partner could be examples of building skills.
For those who have complex needs beyond the provider’s counseling skills or time available, referral to other resources should be arranged.
Positive HIV test results must be reported confidentially to the state or local health officer unless the individual has been tested anonymously. People who test positive should be reminded about this legal reporting requirement.
If a person who tests positive for HIV infection fails to return for test results, the healthcare practitioner must provide the local health officer with the name of the individual and any information that could help locate him or her. The health officer will follow up to assure that post-test counseling and partner notification assistance are provided (WAC-246-10-207).
The CDC (2008) defines partner as person(s) with whom an infected patient has had sex or shared drug-injection equipment at least once.
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).
In Washington State, the rules for partner notification apply only when an HIV/AIDS test is confirmed positive. Therefore, it is not necessary to discuss partner notification at the preliminary reactive rapid test result session. Instead, providers must ensure compliance with the rules for partner notification at the post-test (confirmed) positive counseling session. (Procedures and guidance for partner notification can be found in WAC 246-100-072.)
In Washington State, the Department of Public Health is responsible for providing partner notification services to the infected client and exposed partners. It is a voluntary, confidential service that uses a variety of strategies to make sure exposed partners are notified of their exposure to HIV and receive appropriate counseling in a way that respects the confidentiality of the source patient.
Those who test positive for HIV should be given the choice to either:
The principal healthcare provider may take responsibility for partner notification based on consultation with the local health officer. Providers accepting partner notification responsibility must ensure that these efforts are carried out as described in WAC 246-100-072.
Washington State revised rules allow the local health officer to contact a person newly reported with HIV infection for the purpose of offering partner notification assistance after consultation with the principal healthcare provider.
Upon completion of this section, you will be able to describe the clinical manifestations and treatment guidelines for HIV/AIDS.
The trajectory between infection with HIV and the development of full-blown AIDS can be steep or gradual and may take as long as a decade or more. If the infection is untreated, the average time from HIV infection to a diagnosis of AIDS can be 10–15 years. However, early detection and appropriate medical treatment may extend the lives of those infected and reduce the rates of HIV transmission.
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.
Currently there are two major ways to classify HIV:
In 2008 the CDC revised its earlier surveillance case definitions of HIV and AIDS to require laboratory-confirmed evidence of HIV infection for all those aged 18 months and older. The revised definition also emphasizes the central role of the CD4 T-lymphocyte counts and percentages in staging HIV disease. It is important to recognize that these case definitions are for surveillance purposes only and are not a guide for clinical diagnosis.
The CDC classification system identifies four stages of HIV infection, described in the following table.
|Source: CSTE, 2012.|
|Stage 3 (AIDS)||
The CDC, the U.S. Department of Health and Human Services, and other organizations such as the World Health Organization identify disease progression through three to five stages of clinical evidence for HIV/AIDS. The following is a synopsis of these various clinical stages.
|Stage 1: Acute Infection||
|Stage 2: Clinical Latency||
|Stage 3: Early-Stage AIDS||
|Stage 4: Middle-Stage AIDS||
|Stage 5: Late-Stage AIDS||
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:
People with HIV/AIDS are at high risk for developing certain cancers, such as Kaposi sarcoma, non-Hodgkin’s lymphoma, and cervical cancer. These three cancers are referred to as “AIDS-defining conditions,” and if a person has one of these cancers, it is very likely to signify HIV and the development of AIDS. The connection between HIV/AIDS and cancer is not completely understood but is believed to be the result of a weakened immune system. The following types of cancer are also common for people with HIV/AIDS:
HIV infection not only affects the immune system but also affects other body systems.
Respiratory tract defenses are affected by HIV. Alveolar macrophages in persons with HIV may serve as reservoirs for the virus. These protected viruses may infect other cells and may contribute to the accelerated HIV disease in the presence of opportunistic infections (Hopewell, 2011).
The gastrointestinal system is affected by AIDS enteropathy, a condition characterized by changes in the villus of the small bowel. This leads to malabsorption resulting in malnutrition and wasting (Barlett, 2011).
Integumentary system problems increase in frequency and severity. There may be pruritus without evident skin lesions. Herpes zoster may be a reliable sign of the presence and progression of HIV in a person who is otherwise asymptomatic. Necrotizing gingivitis and recurrent oral ulcers are common (Penneys, 2011).
The sensory system effects include visual impairment or blindness related to infectious or noninfectious ocular disorders, such as microvascular disease, retinitis, acute retinal necrosis syndrome, and optic nerve damage (Jacobson, 2011).
The effects on the hematologic system include morphologic abnormalities in the bone marrow resulting in cytopenias, most commonly anemia (Scadden, 2011).
Of great significance is the effect of HIV on the neurological system, resulting in HIV encephalopathy and AIDS dementia complex (ADC). The virus does not affect brain nerve cells but indirectly inflames or kills them. This occurs as CD4+ cell counts drop to less than 200. ADC varies from individual to individual, and symptoms may develop rapidly or slowly, affecting thinking abilities, behavior, coordination and movement, and mood. With the use of antiretroviral drugs, however, a less severe dysfunction known as minor cognitive motor disorder (MCMD) has become more common than ADC (Singh, 2013).
HIV/AIDS imposes an additional burden on African Americans. The risk of end-stage renal disease (ERD) in HIV-infected black patients was 4–5 times greater than the risk of ERD in HIV-infected white patients. Studies reveal a gene variant that increases the risk of kidney disease in African Americans (NIH, 2011).
Children infected with HIV/AIDS may have different reactions to the virus, its progression, and their virologic and immunologic response. Without drug treatment, children may be developmentally delayed, experience failure to thrive, and be vulnerable to Pneumocystis jirovecii pneumonia and recurrent bacterial infections. Antiretroviral treatments available for adults with HIV/AIDS may not be available in pediatric formulations and may cause different side effects in children. (Pediatric HIV/AIDS is a specialty that is beyond the scope of this course.)
Optimal care of people with HIV/AIDS includes antiviral therapies, health maintenance, and referral to support services in addition to an emphasis on prevention of transmission to uninfected partners.
The Institute for Healthcare Improvement (2013) notes that it is extremely important that patients with HIV/AIDS play a major role in managing their condition. Each patient has unique desired outcomes and needs that require appropriate interventions. Each patient should be given basic information about HIV/AIDS and its treatment; assistance with self-management skill building; and ongoing support from the healthcare team, family, friends, and community.
The Institute recommends that self-management include:
HIV/AIDS has proved to be a moving target, spreading beyond gay white men in cities to women, children, and seniors in small towns and rural areas. As people with HIV live longer, needs for healthcare services are changing. Depending on their personal support system and other resources, some people may require the assistance of a case manager to link them with various care services.
Case managers 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 (see “Resources” at the end of this course).
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 in Washington State. Local community-based organizations, like the Northwest Family Center in Seattle, and specialty hospitals, like Children’s Medical Center in Seattle, may provide additional support to children and families.
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 has become the gold standard for treatment of HIV/AIDS, with antiretroviral drugs administered in “cocktails” of three or more. (ART is also sometimes referred to as highly active antiretroviral therapy, or HAART.) People with HIV may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia.
ART has dramatically reduced HIV-associated morbidity and mortality and has transformed HIV disease into a chronic, manageable condition. In addition, effective treatment of HIV-infected individuals with ART is highly effective at preventing transmission to sexual partners. However, less than one third of HIV-infected individuals in the United States have suppressed viral loads, which is mostly a result of undiagnosed HIV infection and failure to link or retain diagnosed patients in care. Despite remarkable improvements in HIV treatment and prevention, economic and social barriers that result in continued morbidity, mortality, and new HIV infections persist (NIH, 2013b).
Antiretroviral treatment of people with HIV continues to prove complex, controversial, dynamic, and expensive. These drugs do not constitute a “cure” for HIV/AIDS. If therapy is discontinued, viral load will increase. Even during treatment, the virus is replicating and the person remains infectious to others.
Seven major classes of drugs are used to treat HIV/AIDS:
Source: U.S. FDA, 2013.
In 1996, tests to measure an individual’s viral load became available, providing objective criteria for treatment decisions. Following are treatment recommendations by the Panel on Antiretroviral Guidelines for Adults and Adolescents (NIH, 2013a):
Once ART therapy has begun, CDC recommends these goals of therapy:
Current recommendations for female patients with HIV who are pregnant are to start antiviral therapy during the second trimester. Those women who seek perinatal care after the second trimester should start treatment as soon as possible thereafter. Choice of therapy regimen should consider not only the effectiveness of drug treatment for maternal disease but also possible teratogenic effects of the drugs on the infant.
Public Health Service guidelines emphasize that combination drug regimens—rather than zidovudine (ZDV) alone—are considered the standard of care both for treatment of maternal HIV infection and for prevention of perinatal HIV transmission (NIH, 2010).
The efficacy of ART can be measured by plasma HIV RNA testing. Optimal viral suppression is defined as a viral load consistently below the level of detection (<20 to 75 copies/mL). Treatment failure at this point may be due to nonadherence, inadequate potency of drugs, suboptimal levels of antiretroviral agents, viral resistance, or other factors not completely understood.
Patients whose treatment fails despite careful adherence to the regimen should have their regimen changed. A thorough drug treatment history plus drug resistance testing should guide the design of the new regimen.
Patients who are cared for by clinicians with expertise in HIV/AIDS have better outcomes—in mortality, rate of hospitalizations, compliance with guidelines, cost of care, and adherence to medication regimens—than those cared for by less-experienced providers. Expertise is defined in terms of the number of patients actually managed. The DHHS panel recommends HIV primary care by a clinician with at least 20 HIV-infected patients and preferably at least 50 HIV-infected patients.
Many new medications for HIV/AIDS are in clinical trials. Patients experiencing drug resistance may be appropriate candidates for drugs still in trials. Physicians without extensive experience in treating HIV/AIDS are strongly urged to consult with specialists in this area when considering clinical trials for their patients.
Discontinuing or interrupting ART may become necessary due to factors such as serious drug toxicity, intervening illness, surgery, or unavailability of medications. Although unplanned short-term interruption of therapy may be unavoidable, planned interruption is no longer recommended. Interrupting therapy increases the risk of AIDS-related complications, declining CD4 counts, and other non-AIDS-related complications such as heart attack and liver failure.
While extending and improving lives of people with HIV, long-term use of some of these drugs increases the risk of liver problems, high cholesterol, stroke, heart disease, osteoporosis, diabetes, pancreatitis, neuropathy, and skin rashes. Some of the skin rashes can be life-threatening, such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), which are two different forms of the same kind of skin rash. TEN may involve as much as 30% of the total body skin area. Both these severe rashes must be treated by a physician.
Antiretroviral drugs may also interact with other drugs used to treat opportunistic infections. For example, taking oral erythromycin along with protease inhibitors increases the risk of sudden death from cardiac arrest. As patients live longer with HIV/AIDS, many develop drug-resistant strains of the virus, which further complicates treatment.
HIV drug resistance 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.
HIV drug-resistance mutations, known as “wild-type” viruses, can occur before or during treatment and can happen with transmission of drug-resistant HIV from one person to another. In countries where HIV treatment is in wide use, between 5%–10% of new HIV cases involve drug-resistant strains of virus.
Mutations can also occur while using pre-exposure prophylaxis. HIV-negative people taking FDA-approved Truvada (emtricitabine/tenofovir disoproxil fumerate) are at risk if they become infected and are not diagnosed right away. If they continue to take the drug, their newly acquired virus may develop resistance to one or both of the medications in Truvada.
Drug resistance mutations can occur during treatment because genetic changes still occur over time and there may be a large mixture of virus in the body. Some of the variants may contain mutations that can partially or fully resist an antiretroviral drug. This is why one-drug treatment should never be used to treat HIV. With the development of combination HIV drug treatment, the amount of wild-type virus is dramatically reduced.
Of concern is that the mutations can cause cross-resistance. This means that the HIV that becomes resistant to one drug can cause resistance to other drugs in the same class.
Another reason for the occurrence of HIV drug resistance is poor treatment adherence. Successful treatment not only requires the patient to have significant financial resources but also the ability to understand and comply with a complex regimen. Unfortunately, many of the patients with the greatest need for treatment lack the necessary financial resources to make treatment a reality. However, patient demographics, such as race/ethnicity, sex, age, and socioeconomic status, do not predict who will adhere to a treatment regimen.
Drug resistance can also be the result of poor absorption, which can be affected by diet or diarrhea and vomiting. The latter can cause drugs to be expelled too quickly, thus affecting absorption. Varying pharmacokinetics can cause interactions between drugs, affecting how a drug is absorbed, distributed, broken down, and removed from the body.
Recent studies have identified novel compounds that may lead to new, cost-effective HIV treatments and a means for combating resistance to today’s antiretrovirals (Dapp et al., 2013).
Experts recommend that pretreatment drug-resistance testing be done with patients when HIV infection is first diagnosed, when changing antiretroviral regimens after drugs cease to be effective (treatment failure), and during pregnancy. Resistance testing helps clinicians better predict viral response to newly initiated therapy.
HIV drug-resistance testing should be performed:
In cases of virologic failure, drug resistance testing should be performed while the patient is taking his or her drugs or within four weeks of discontinuing therapy.
Two types of resistance assays are used: genotypic and phenotypic assays. Genotypic assays detect drug resistance mutations in the viral genes, while phenotypic assays measure a virus’s ability to grow in different concentrations of antiretroviral drugs. Genotypic assays take 1–2 weeks and phenotypic assays, 2–4 weeks. A genotypic assay is generally recommended for patients who have never had antiretroviral therapy. Genotypic resistance testing also is recommended for all pregnant women prior to initiation of therapy and for those entering pregnancy with detectable HIV RNA levels while on therapy.
In addition to ART, people with HIV/AIDS may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia. Some of these medications may have serious interactions with ART, so prescribing physicians need to be familiar with all ART medications, as well as with their potential toxicities, when administered with other drugs.
Some people with HIV infection supplement their prescription drugs with vitamins, acupuncture, massage, yoga, meditation, herbs, naturopathic remedies, and other complementary therapies. People who turn away from prescription HIV medications and choose only herbs, vitamins, and other supplements are said to be using alternative therapies. Many of these remedies have not been studied to see if they offer any real benefit.
Therapies such as yoga, meditation and massage can help reduce stress and enhance quality of life. However, herbs and other “natural” remedies may also interact with prescription medication. For example, St. John’s wort has major interactions with HIV medications. Therefore, people on HIV medications need to tell their physician, pharmacist, and social worker about all other supplements and nonprescription drugs they take.
Infections that are commonly found in HIV-positive patients include a number of other sexually transmitted diseases, TB, and hepatitis. Coexisting infections may increase the risk of transmission of HIV and make its treatment more complex.
Mycobacterium tuberculosis (M. tuberculosis, or TB) is the most common and most deadly coexisting infection for HIV-positive individuals. TB can also hasten the progression of HIV infection. Likewise, the spread of HIV/AIDS has helped fuel the TB epidemic.
One third of the people living with HIV/AIDS globally are also infected with tuberculosis. In high-burden countries, people with HIV/AIDS are 20 times more likely to contract TB. Globally, there were 8.6 million new TB cases in 2012 and 1.3 million TB deaths. Of these, 0.3 million deaths were HIV associated (TB Alliance, 2014). In Washington State there were 200 cases of tuberculosis reported, of which 6 (3.5%) had positive HIV status (CDC, 2012b).
In an HIV-infected person, TB disease can develop in either of two ways. A person who already has latent TB infection can become infected with HIV, and then TB disease can develop as the immune system is weakened. Or, a person who has HIV infection can become infected with M. tuberculosis and TB disease can then rapidly develop because their immune system is not functioning.
Antiretroviral therapy is the most effective treatment for controlling the progression of HIV; however, drug-drug interactions between the current first-line TB regimen and certain commonly used HIV drugs complicate treatment. To avoid these interactions in infected patients, new treatment regimens are desperately needed.
TB is transmitted by airborne droplets from people with active pulmonary or laryngeal TB during coughing, sneezing, or talking. When these infected droplets are inhaled, the bacteria enter the bloodstream and lymphatic system and circulate throughout the body.
Most of the bacteria settle in the lungs, where they multiply and may cause pneumonia-like symptoms. This process is called primary infection and in most cases resolves by itself within 4–12 weeks, after which a latent state of TB develops. Nine out of 10 people with latent TB never experience subsequent disease and are not infectious to others. The only evidence of TB infection is a positive tuberculin skin test.
In 10% of infected individuals, the TB infection undergoes reactivation at some point, causing active TB disease. Progression to active disease and obvious symptoms (cough, weight loss, and fever) usually occurs within the first two years after infection but may occur at any time.
All people infected with HIV should be tested for TB and, if infected, begin complete therapy as soon as possible to prevent active TB disease. HIV-infected persons with either latent TB infection or active TB disease can be effectively treated. The first step is to ensure that HIV-infected persons are tested for TB. The second step is to help those infected with TB to get proper treatment and prevent rapid progression from latent TB infection to active TB disease.
Treatment of HIV/TB coinfected patients involves a complex 6- or 9-month multidrug regimen. All these drugs have significant side effects, which can lead to nonadherence and development of multidrug-resistant TB (MDR-TB) or extensively drug-resistant TB (XDR TB), which is much more difficult to treat successfully. Extensively drug-resistant TB is of special concern for persons with HIV infection. Coinfected individuals are at increased risk of developing active TB disease once they are infected and also have a higher risk of death once they develop TB.
Hepatitis is inflammation of the liver that may be caused by drugs and toxic agents or by one of several viruses, including hepatitis A, B, C, D, and others. People who are HIV positive are at risk for hepatitis A, B, and C infection. Hepatitis A is transmitted by fecal/oral route, usually by contamination of water or food due to poor sanitation. Hepatitis B (HBV) and C (HCV) are transmitted by the blood and body fluids of an infected person.
HIV-infected people should be tested for both A and B viruses, and if they test negative, should receive vaccines against both. However, there is no vaccine for HCV.
|Source: WA DOH, 2007.|
|Transmission by blood||Yes||Yes||Yes|
|Transmission by semen||Yes||Yes||Rarely (more likely if blood present)|
|Transmission by vaginal fluid||Yes||Yes||Rarely (more likely if blood present)|
|Transmission by breast milk||Yes||No (but may be transmitted if blood is present)||No (but may be transmitted if blood is present)|
|Transmission by saliva||No||No||No|
|Target in the body||Immune System||Liver||Liver|
|Risk of infection after needlestick exposure to infected blood||0.5%||1%–31%||2%–3%|
Hepatitis B can cause chronic liver disease or liver cancer, which makes vaccination essential to prevention. HBV vaccine is relatively inexpensive for infants and children and commonly administered to most infants before their first birthday. It is critical that infants whose mothers are HBV positive receive the vaccine; otherwise, they have a 90% chance of developing the disease. Adult doses of HBV vaccine cost about $139 per person, which may explain why most adults are not vaccinated against HBV.
In 2011 there were a total of 2,890 cases of acute hepatitis B reported to the CDC. The overall incidence rate for 2011 was 0.9 cases per 100,000. In 2011 a total of 39,636 cases of chronic hepatitis B was reported to the CDC. The greatest number (80%) of all reports received were from California. From 2000 to 2011 there were a total of 15,664 cases of chronic HBV reported from the state of Washington, the highest number coming from King County (WA DOH, 2013d).
Coinfection with hepatitis B and HIV is common. In the United States 70%–90% of HIV-infected persons have evidence of past or active HBV infection. HBV is often acquired via sexual contact or injection drug use. Chronic HBV infection occurs in 5%–10% of HIV-infected persons exposed to HBV. This is 10 times higher than for the general population. HIV increases the risk of cirrhosis and end-stage liver disease in HBV infection.
It is important to inform HIV/HBV-coinfected patients that HBV can be more infectious than HIV and can be transmitted to others in a household via dried blood, open cuts, and shared toothbrushes or razors.
Because of the elevated rates of HBV among people infected with HIV and the shared transmission routes between the two viruses, all HIV-infected individuals should be screened for HBV coinfection with HBsAG testing.
Those who receive hepatitis B vaccine should be tested for antibodies to hepatitis B surface antigen (antiHBs) 1–2 months after completion of the primary series of hepatitis B vaccine. Those who fail to respond should be revaccinated with up to three additional doses.
Risk factors for HBV include:
There are no medications available for recently acquired (acute) HBV infection. There are antiviral drugs available for the treatment of chronic HBV infection, but they are not always effective.
Hepatitis C is the most common chronic bloodborne infection in the United States and a leading cause of chronic liver disease. HCV was discovered in the late 1980s, although it was probably being spread for decades prior to that. People infected with HCV may have no symptoms for decades. When symptoms do appear, they are similar to those of HBV.
The CDC (2012b) reports an estimated 17,000 new infections in 2010. An estimated 3.2 million Americans are infected with HCV, many of them from blood transfusions; half of them do not know they are HCV positive. (Since 1992, all blood donations in the United States have been tested for HCV.) Each year more than 8,000 people die from HCV-associated liver disease. In Washington State, approximately 15,664 cases of chronic HCV were diagnosed from 2000 to 2011 (WA DOH, 2013d).
An estimated one third of HIV-positive people in the United States are also infected with HCV. Incidence is even higher among HIV-positive injection drug users (50%–90%). Coinfection with HIV and HCV is associated with higher titers of HCV, more rapid progression to HCV-related liver disease, and increased risk for cirrhosis of the liver.
Liver disease from chronic HCV is now one of the leading causes of death among people living with HIV. Individuals coinfected with HIV and HCV should restrict alcohol consumption and, if possible, avoid alcohol altogether because of potential liver damage.
The National Institutes of Health (2014) recommends that all HIV-infected persons be screened for HCV infection. Other people who will benefit from HCV testing include:
Coinfected patients also need to consult their health professional before taking any new medications—including over-the-counter, alternative/complementary, or herbal medicines—because of their possible effects on the liver. Those receiving ART may also be at risk for drug-induced liver injury (DILI) and should be carefully monitored.
Combined treatment of HIV and HCV can be complicated due to large pill burden, drug interactions, and overlapping toxicities. ART should be initiated for most coinfected patients, however, some clinicians may elect to defer ART until HCV treatment is completed in patients with CD4 counts >500 cell/mm3. In coinfected patients with lower CD4 counts (<200 cell/mm3), it may be preferable to initiate antiretroviral therapy and delay HCV therapy until CD4 counts increase.
The HIV Medicine Association of the Infectious Diseases Society of American (Aberg et al., 2013) updated the primary care guidelines to recommend the following:
Upon completion of this section, you will be able to explain confidentiality and legal reporting requirements in Washington State for HIV/AIDS.
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.
Providers who diagnose an individual with AIDS must submit a confidential case report to the local health jurisdiction within three days. Providers who receive notice of an individual’s positive HIV test must report this information, including the individual’s name, to the local health jurisdiction within three days. In some local health jurisdictions, the state Department of Health fulfills this function for local authorities.
Positive HIV results obtained through anonymous testing are not reportable until the patient seeks medical care for conditions related to HIV or AIDS. At that time, the provider is required to report the case to the local health department.
Confidentiality is a paramount concern for people with HIV/AIDS. This infection not only carries the stigma of a sexually transmitted disease but also the association with homosexuality and/or injection drug use. Workplace, housing, and insurance discrimination have been (and, in some areas, continue to be) barriers to disclosure of HIV status and seeking treatment. Children with AIDS have sometimes been barred from attending classes, and in at least one instance, a family home was burned after one member of the family developed AIDS.
All medical records are confidential and must be maintained in a manner that protects that confidentiality, using an approach consistent with Washington law (RCW 70.02 and RCW 70.24) and, if applicable, the Privacy and Security Rules promulgated by the federal government in the Health Insurance Portability and Accountability Act (HIPAA). Client information must be kept strictly confidential, and records should be managed and stored in a secure manner. Special requirements for HIV and AIDS are found in WAC 246-100 and RCW 70.24.105.
Confidential information includes any material, whether oral or recorded in any form or medium, that identifies (or can readily be associated with the identity of) a person and is directly related to their health and care. All information related to an individual’s HIV/AIDS status is protected under medical confidentiality guidelines and legal regulations. Recognizing the sensitive nature of these conditions, medical record protection for HIV and AIDS, like those for substance abuse and mental health, are protected more rigorously than other medical information.
Confidentiality of medical information means that any information that can be related to a specific patient may not be disclosed to anyone except under specific circumstances. This usually means that the individual signs a release-of-information form, but there are exceptions. The most common circumstances permitting disclosure of confidential patient information are:
Anyone who violates the confidentiality laws may be found guilty of a gross misdemeanor punishable by imprisonment for a maximum of 364 days, a fine of up to $5,000, or both. Any person affected by such negligent violation may recover $1,000 or actual damages, whichever is greater. For any intentional or reckless violation, an aggrieved person may recover $10,000 or actual damages, whichever is greater, for each violation (RCW 70.24.080, RCW 9A.20.021, RCW 70.24.084).
The county health officer has the responsibility to investigate potential breaches of confidentiality of HIV-identifying information and report those breaches to the Department of Health.
In general, before HIV testing is performed, patients must be explicitly told that HIV testing is recommended and the patient must agree to the HIV testing.
HIV testing without informed consent, except in legally mandated situations described below, can result in disciplinary action by a healthcare provider’s licensing board, fines, suspension or revocation of license, and civil liability for negligence and invasion of privacy (WA DOH, 2005).
Washington State law (RCW 70.24.110) specifies that children 14 years of age or older who may have come in contact with any sexually transmitted disease or suspected sexually transmitted disease may give consent to the furnishing of hospital, medical, and surgical care related to the diagnosis or treatment of such disease.
Parental or legal guardian consent is not necessary, and parent(s) or legal guardians are not liable for payment for any care rendered. Washington State law forbids informing the subject’s parents of the test, or of the results, without the subject’s permission.
HIV testing without informed consent may occur in the following circumstances:
Under Washington State law (WAC 246-100-205), someone who has experienced a substantial exposure to another person’s body fluids in a manner that creates a possible risk of HIV transmission, and that exposure occurred while on the job in certain categories of employment deemed at substantial risk for HIV exposure, may ask a state or local health officer to order pretest counseling, HIV testing, and post-test counseling of the source person, in accordance with RCW 70.24.340.
Source persons who may be tested for HIV without informed consent include those convicted of a sexual offense (RCW 9A.44), prostitution (RCW 9A.88), or drug offenses involving hypodermic needles (RCW 69.50). This law does not apply to the Department of Corrections or to inmates in its custody or subject to its jurisdiction.
Substantial exposure that presents a possible risk of transmission is limited to:
Categories of employment at substantial risk for HIV exposure include:
If the health officer refuses to order counseling and testing, the exposed person may petition the superior court for a hearing to determine whether an order shall be issued.
Washington State law (RCW 49.60) prohibits discrimination based on age, creed, religion, race, color, national origin, sex, sexual orientation and gender identity, HIV and hepatitis C status, whistleblower retaliation, marital status (housing and employment), families with children (housing), or the presence of any sensory, mental, or physical disability or the use of a trained dog guide or service.
Exceptions to this law are applicants for the U.S. Military, the Peace Corps, and the Job Corps, under federal law, which supersedes state law.
Effective January 4, 2010, foreign visitors with HIV/AIDS can legally enter the United States without their infection being considered, and testing is no longer required for immigration. CDC removed HIV/AIDS from the inadmissible diseases list in 2009.
People with HIV/AIDS are protected by federal law under the Americans with Disability Act (1990) and Section 504 of the Federal Rehabilitation Act of 1973, as amended. The Washington Law Against Discrimination (WLAD-RCW 49.60.174) regulates “disabled” status. These laws make it illegal to discriminate against someone with AIDS or who has HIV or hepatitis C infection. It is also illegal to discriminate against someone “believed” to have HIV/AIDS, even though that person is not infected. The areas encompassed in the laws include:
(Note: Federal and state jurisdictions differ.)
Laws protect people diagnosed with HIV/AIDS from employment discrimination, including:
Employers are required to provide and maintain a working environment free of discrimination. They must ensure that no harassment, intimidation, or personnel distinction is made in terms and conditions of employment. If a worksite situation poses the threat of discrimination, the employer is required to educate and supervise employees to end the harassment and any use of slurs and/or intimidation. An employer should promptly investigate allegations of discrimination, take appropriate action, and not retaliate against the person who complained.
Employers are responsible for providing reasonable worksite accommodations that will enable a qualified employee or job applicant with a disability to perform the essential tasks of a particular job. Reasonable accommodation means relatively inexpensive and minimal modifications in the context of the entire employer’s operation, such as:
An employee with a disability must self-identify and request a reasonable accommodation. The employer must engage in an interactive process with the requestor. The reasonable accommodation grant may not be exactly the same one as requested by the employee but can be equally effective. The employer does not have to change the essential nature of its work or engage in undue hardship or heavy administrative burdens. The essential functions of the job must be accomplished, with or without reasonable accommodations.
Employees who feel they are being discriminated against should first document the discrimination, speak with their supervisor, and follow the entity’s internal process to file a discrimination charge. However, it is not necessary to file an internal grievance process. If these remedies do not work, the employee should contact the federal Office for Civil Rights, U.S. Department of Health and Human Services, 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.
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:
Washington State law (RCW 70.24) and rules (WAC 246-100 and 246-101) give state and local health officers the authority and responsibility to carry out certain measures to protect public health from the spread of sexually transmitted diseases (STDs), including HIV/AIDS.
The local health officer is the physician who directs the operations of the local county’s health department or health district. The responsibilities of the health officer include the authority to:
Court enforcement may be necessary. State law specifies the standards that must be met before the health officer may take action.
Washington State law 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.
Knowingly transmitting HIV/AIDS is a Class A felony in Washington (RCW 9A.36.011(1)(b).
Washington State law requires that healthcare professionals offer instruction on infection-control measures to any patient diagnosed with a communicable disease. Providers are also required to report to the local health officer any impediments or refusal to comply with prescribed infection-control measures.
For example, if a healthcare professional knows that a specific patient is failing to comply with infection-control measures (failing to disclose HIV status to sexual or needle-sharing partners or selling HIV-infected blood), that professional should contact the local health officer to discuss the case and determine if the name of the person should be reported for investigation and follow-up.
If credible evidence exists that an HIV-infected person is engaging in conduct that endangers public health, the health officer or other authorized representative will investigate the case.
There are other laws and regulations concerning endangering the public health and occupational exposures that may be specific to certain professions and to the jurisdictions of public health officers. The Washington State HIV/AIDS Hotline (1-800-272-2437) can provide additional information.
Upon completion of this section, you will be able to summarize the psychosocial issues associated with HIV/AIDS.
HIV/AIDS is a chronic disease that can produce psychological problems in four broad areas:
These concerns can lead to several psychological and social manifestations.
People with HIV/AIDS face a host of personal challenges: unpredictable cycles of illness and wellness; feelings of loss, grief, anger, and depression; expensive, complicated, sometimes disfiguring treatments; and, finally, deteriorating health and premature death. The fortunate ones have families and friends who share the experience and offer support as needed. For those without a support system, the challenges can seem insurmountable.
HIV-infected individuals may live for 10 or more years before symptoms develop. For those who know they are infected, a decade of uncertainty can be unsettling, even overwhelming. Despite more effective treatment, most people with HIV still die prematurely. Many are in the prime of life, which makes it more difficult to deal with the diagnosis of a fatal disease.
Depression can be immobilizing and interfere with adherence to the treatment regimen, leading indirectly to drug resistance and poor management of the disease. Symptoms of depression include:
Depression is treated with both antidepressant medications and psychotherapy. Recognizing the symptoms of depression and referring patients for appropriate treatment may greatly improve their quality of life.
In many areas of the United States, homosexuality and use of illegal drugs carry an indelible stigma and lead to social and employment discrimination. A diagnosis of HIV/AIDS adds another layer of social pressure and stress for MSM and injection drug users. Failure of family, friends, or coworkers to accept and support the person with HIV/AIDS can evoke painful guilt about the disease, about past behaviors, or about possibly having infected someone else. The need to practice safer sex can also affect self-esteem and self-image.
HIV-infected people tend to experience more anxiety than the general population. Adjustment disorder is common after receiving an HIV diagnosis. Anxiety can cause physical symptoms such as shortness of breath, chest pain, racing heart, dizziness, numbness or tingling, nausea, or a sensation of choking. Anxiety disorders are a major cause of nonadherence to medication.
HIV/AIDS can cause dramatic changes in a person’s appearance, including severe weight loss and a wasted appearance. Concurrent infections and malignancies, as well as some of the treatments, can cause major alterations in body image. For example, antiretroviral drugs can lead to lipodystrophy, the redistribution of body fat. There are two types of lipodystrophy: fat wasting and fat accumulation. A person with fat wasting (also called lipoatrophy) loses fat from particular areas of the body, especially the arms, legs, face, and buttocks. Someone with fat accumulation (also called hyperadiposity) experiences fat build-up, especially in the belly, breasts, and back of the neck.
People with HIV/AIDS may feel angry with themselves for contracting the disease as well as anger at the person who transmitted it. Their once-normal lives are now organized around medication schedules, medical appointments, and dealing with side effects such as intractable diarrhea and nausea. Expensive medications can create financial hardship, even for those with health insurance.
It is not uncommon when people learn they are HIV positive to choose to deal with the news by denying it. This is natural and normal and at first may be helpful as it allows time to get used to the idea of being infected. However, if denial is not dealt with, the person may fail to take appropriate precautions to prevent transmission to others and may not seek medical help and support.
Living with HIV/AIDS involves loss of many kinds, including loss of:
Grief—the normal response to loss—is universal, individual, and unpredictable. Although Elizabeth Kübler-Ross and others have described stages of grief, each person experiences these stages in a different order and at a different pace, depending on their values, cultural norms, and circumstances.
In uncomplicated grief, an individual is able to move through the stages and emerge from the process ready to move on with life. In complicated grief (also called chronic grief), the normal process of grieving is prolonged. Complicated grief often results from multiple losses that leave too little time and emotional energy to reintegrate and move on, and can lead to feelings of guilt, helplessness, hopelessness, withdrawal, isolation, rage, and emotional numbness.
People who live or work with the HIV/AIDS community for several years may themselves experience chronic grief from the seemingly endless repetition of deaths, funerals, and lost friends.
The psychological suffering and grief experienced by people with HIV/AIDS is also shared by family members, friends, caregivers, and partners. These feelings may manifest as physical symptoms, clinical depression, hypochondria, anxiety, insomnia, and the inability to derive pleasure from normal daily activities. Coping with these issues may lead to self-destructive behaviors such as alcohol or drug abuse.
Caregivers often mirror the feelings of their patient, such as a sense of vulnerability, helplessness, or isolation. Access to a support system, including a qualified counselor, can be as important for the caregiver as for the patient. Support from coworkers is also especially important.
HIV/AIDS takes a heavy toll on all ethnicities, genders, ages, and income levels. However, some populations have been uniquely affected by the epidemic. Some of these populations include men who have sex with men, people who use injection drugs, people with hemophilia, women, and people of color.
America’s HIV/AIDS epidemic deepened the nation’s longstanding prejudice toward homosexuality. Some religious groups see the epidemic as divine retribution for “unacceptable” and “unnatural” behavior. Many men with HIV/AIDS report lack of support from their church communities because of the stigma attached to homosexuality.
Societal attitudes toward MSM have made it more difficult to live and die with HIV/AIDS. Self-esteem and other psychological issues related to HIV infections complicate the lives of MSM. Grief and loss are not always validated when relationships are judged “unacceptable.”
People who use injection drugs often are seen as “deserving” their infection, rather than deserving treatment for their addiction. Successful efforts to prevent the spread of HIV/AIDS, HBV, and HCV among these individuals, such as syringe exchange programs, exist today even though some equate these programs with approval of drug use.
Many people who use injection drugs would like to stop using but do not have access to inpatient treatment facilities. Waiting lists for treatment programs are long, and by the time a space is available, the individual may be lost to follow-up. Those who do seek treatment for HIV may find the regimens too complex and financially prohibitive.
During the 1980s, 90% of people with severe hemophilia were infected by HIV and/or HCV through use of clotting factor concentrates, which are made from pooled, donated blood. This created understandable anger among the affected community because evidence indicated that the companies manufacturing the concentrates knew the dangers of contamination but continued to distribute them anyhow.
Although considered by some to be innocent victims of HIV/AIDS, people with hemophilia have not escaped discrimination. The Ryan White Care Act, which funds HIV/AIDS services, and the Ricky Ray Act, which provides compensation to hemophiliacs infected with HIV, were named for HIV-positive boys with hemophilia who suffered serious discrimination (arson, refusal of admittance to grade school) before they died of AIDS.
Women of color, particularly African American women, are disproportionately affected by HIV/AIDS. They represent the majority of new HIV infections and AIDS cases among women. Many women with HIV are low-income and most have children under the age of 18.
According to the CDC, young women (ages 13–39) represent nearly two thirds of new HIV infections among women. Having sex with multiple partners, engaging in risky behaviors such as alcohol and drug use, and/or being unable to negotiate safer sex practices with partners all contribute to this heightened risk of contracting HIV/AIDS.
Taking care of others’ needs—children or other family members—often prevents women with HIV/AIDS from taking care of themselves. Postponing medications or missing medical appointments may also be due to financial or transportation problems. Infection with HIV/AIDS may not seem to be a woman’s most serious problem. Income, housing, access to healthcare, possible abusive relationships, and concerns about her children seem more urgent and important, especially when HIV/AIDS symptoms are mild and manageable. Single mothers are especially vulnerable because they lack adequate financial and emotional support.
Older women with HIV/AIDS face complex challenges in addition to the common chronic health problems of this group—osteoporosis, high cholesterol, high blood pressure, obesity, and heart disease. Many of the antiretroviral drugs can exacerbate these conditions.
African Americans and Hispanics have disproportionately higher rates of HIV/AIDS in the United States. There are no biologic reasons for these disparities in incidence and no single reason why these disparities exist, but there are a number of contributing factors, including:
Prevention messages need to be culturally appropriate and relevant and they must be delivered through channels appropriate to individual communities. These channels may include religious institutions and respected elders in the community. Ironically, some of these same institutions or elders may have contributed to the misinformation and stigma associated with HIV/AIDS.
The AIDS epidemic has claimed the lives of more than 30 million people across the globe, more than 600,000 of them in the United States. More than a million people are living with HIV/AIDS in the United States, and every year another 50,000 Americans are infected with HIV.
Despite this ongoing tragedy, the public no longer has a sense of urgency or importance about AIDS. The title of a 2010 editorial in the New England Journal of Medicine best describes the situation—“AIDS in America: Forgotten but Not Gone.” Research has produced drugs that slow but do not stop the disease, and the cost of these drugs has tripled during the past 10 years. No vaccine has proved effective in preventing HIV. So the epidemic continues to spread, primarily among those high-risk persons living in disadvantaged and marginalized groups: the poor, people of color, people in prison, injection drug users, and men who have sex with men. Many do not realize they are infected and unknowingly transmit the virus to others.
The key to controlling this epidemic is prevention. Since most HIV infection is the result of sexual transmission, the most important prevention method is to refrain from having unprotected sexual intercourse—vaginal, anal, or oral—unless it takes place within a monogamous relationship. The CDC recommends using latex condoms consistently and correctly and, when considering a sexual relationship, avoiding any type of sexual contact with someone you don’t know, is known to have had several sexual partners, or regularly uses syringes to inject drugs. Secondly, HIV is spread among injection drug users by the sharing of needles. Education and intervention must extend to these individuals to discourage the sharing of any type of drug-use paraphernalia.
It must be emphasized that individuals should learn their HIV status through routine testing, and efforts should continue to increase the numbers of individuals undergoing testing.
It is well documented that antiretroviral treatment improves the health and prolongs the lives of people with HIV as well as reduces the risk of sexual transmission to others. However, only half of persons with HIV are under treatment, and only a quarter of all persons with HIV have suppressed viral loads. It is essential to develop strategies to increase the number of persons receiving treatment and to increase ways to maintain good adherence over the long term.
Ignorance, prejudice, and lack of access to healthcare are fueling the epidemic. Therefore, health professionals have a critical role in screening and in educating patients, families, and communities about prevention. Only by making prevention a priority will we achieve the goals of the National AIDS Strategy to reduce infection rates; increase access to care for those infected; and eliminate disparities in prevalence, diagnosis, and treatment.
AIDSinfo (US DHHS)
HIV/AIDS (Office of Women’s Health)
National Perinatal HIV Consultation and Referral Hotline
National Prevention Information Network (CDC)
Post-Exposure Prophylaxis Hotline (PEPLINE)
STD and AIDS Hotlines (CDC)
English: 800-342-2437 or 800-227-8922
HIV/AIDS (Washington State Department of Health)
Client Services: 1-877-376-9316
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).
Aberg JA, Gallant, Ghanem KG, Emmanuel P, et al. (2013). Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV Medicine Association of the Infectious Diseases Society of America. Retrieved from http://cid.oxfordjournals.org
American Psychological Association (APA). (2014). What are some categories or types of transgender people? Retrieved from http://www.apa.org
amfAR (Foundation for AIDS Research). (2013). Statistics: worldwide. Retrieved from http://www.amfar.org
Baral S. (2013). High HIV burden identified in transgender women. Lancet Infect Dis, 12, 214–22.
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