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This course will expire or be updated on or before March 1, 2017.
ABOUT THIS COURSE
You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.
ACCREDITATION / APPROVAL
Wild Iris Medical Education is approved as a provider of nursing continuing education by the Florida Department of Health, Division of Quality Assurance, Board of Nursing. Florida Board of Nursing Accreditation #NCE3403.
Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. See our disclosures for more information.
This course meets the 1-hour Florida HIV/AIDS continuing education requirement for PTs, PTAs, and other healthcare professionals.
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Copyright © 2014 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to prepare Florida healthcare professionals to care for patients with HIV/AIDS based on evidence-based information on HIV/AIDS incidence in Florida, modes of transmission, different types of tests, clinical management, and Florida law governing testing and disclosure.
Upon completion of this course, you will be able to:
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.
Florida is ranked second nationally in the number of new HIV infection cases diagnosed in 2011, exceeded only by California. Additionally, all six of Florida’s large metropolitan statistical areas reported more cases individually than many states as a whole. For example, Miami reported more cases than all but eleven other states in the U.S.
In 2012, Florida reported 5,338 new HIV diagnoses and 2,775 new cases of AIDS. The five counties reporting the highest number of HIV cases were Miami-Dade, Broward, Duval, Palm Beach, and Orange, although the HIV/AIDS epidemic is prevalent throughout Florida.
HIV/AIDS has hit the black/African American population disproportionately hard.
In 2012, of the 40,901 persons living with HIV in Florida, 42% were seniors, and those aged 50 and older represented 23% of all new HIV infections and 30% of all new AIDS cases.
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. Healthcare workers may also be exposed to some other body fluids with high concentrations of HIV, including amniotic, cerebrospinal, pericardial, pleural, and synovial fluids. However, only four body fluids have been proven to transmit HIV infection:
Transmission of HIV occurs primarily through sexual contact with an infected person. This includes anal, oral, and vaginal contact. The risk of transmission depends on sexual practices. Receptive anal contact without a latex condom carries the greatest risk, probably because of the larger surface area of mucous membranes involved. Receptive partners are at greater risk for transmission of any sexually transmitted disease, including HIV.
Sharing injection needles, syringes, and other paraphernalia with an HIV-infected person can send HIV directly into the user’s bloodstream (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 from a dirty syringe back into the drug cooker and/or someone else’s syringe, or sharing a common filter or rinse water.
To control the rising costs of medications such as insulin, some seniors share needles for insulin and other prescription drugs, which also poses a risk of HIV transmission.
Healthcare workers may be infected with HIV through needlesticks or direct contact with HIV-infected blood—for example, through a break in the skin or through the eyes or the mucosal lining of the nose.
The risk of developing HIV infection from a needlestick with infected blood is about 1 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.
Since 1985, transmission of HIV through transfusion has been uncommon in the United States 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.
A pregnant woman who is infected can transmit HIV to her fetus. After delivery, an infected mother can also 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% (CDC, 2013b).
People who do not know they are infected transmit most HIV infections. Therefore, HIV testing is the first step in halting the 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 the 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.
In addition to the above primary high-risk groups, Florida law provides for testing special populations.
In Florida, the Targeted Outreach for Pregnant Women Act (TOPWA) was established in 1999 by Florida statute 381.0045 with a goal of eliminating perinatal transmission of HIV. TOPWA is a unique street outreach program offering HIV testing and counseling to pregnant women who may be at risk for HIV infection. TOPWA outreach workers go into the community and seek out pregnant women in housing projects, laundromats, bars, or other public places.
The TOPWA program has increased poor women’s access to prenatal care, including HIV testing and antiviral therapy, reducing the number of babies born with HIV infection (Florida Statutes, 2013). Since 1999, 100% of babies whose mothers are HIV positive and enrolled in TOPWA have been born HIV negative and remained negative after 6 months. Since its inception, TOPWA has enrolled over 32,000 pregnant women (Families First, 2014).
Florida Statute 945.355 mandates that prisons test inmates for HIV within 60 days before they are released back into the community. (Unlike prisons, jails are not required to test inmates unless they have been convicted of a sex-related crime.) Those who test positive must be provided with transitional assistance, which includes:
There are three main types of HIV tests:
Until 2002, testing for HIV antibodies relied on an enzyme-linked immunosorbent assay (ELISA) of blood. Since then, nine rapid HIV tests have been approved by the FDA, all of which are interpreted visually. Four of the tests have been approved for use outside of a clinical laboratory.
|OraQuick ADVANCE Rapid HIV-1/HIV-2 Antibody Test||Detects HIV antibodies in oral fluid as well as in blood|
|Uni-Gold Recombigen HIV Test||Detects HIV-1 antibodies in whole blood, serum, and plasma; results take from 10–12 minutes|
|Reveal G3 Rapid HIV-1 Antibody Test||Detects HIV antibodies in serum or plasma; although test takes only 3 minutes to run, it is categorized as a moderately complex test and is usually done in a clinical laboratory|
|Multispot HIV-1/HIV-2 Rapid Test||Uses fresh or frozen serum and plasma to detect HIV-1 and HIV-2 and distinguish one from the other; results available in 20 minutes; also a moderately complex test, it is usually done in a clinical laboratory|
|Clearview HIV-1/HIV-2 STAT-PAK||Uses whole blood or serum and plasma; results available in 15 minutes; requires no training to use|
|Clearview HIV-1/HIV-2 Complete||A single-use, self-contained closed system for the collection, processing, and analysis of a whole blood, serum, or plasma sample; results available in 15 minutes|
|Alere Determine HIV-1/2 Ag/Ab Combo Test||Can detect HIV-1 and -2 antibodies and HIV-1 p24 antigen in human serum, plasma, and venous or fingerstick whole-blood specimens|
|Chembio DPP HIV-1/2||Detects antibodies to HIV-1 and -2 and gives results in 15 minutes from fingerstick or venous whole blood, plasma, serum, or oral fluid swab|
|INSTI HIV-1 Antibody Test||Detects HIV-1 antibodies in plasma and gives results in less than 2 minutes|
Until these rapid tests became available, many people being tested 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.
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.
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.
Florida’s Omnibus AIDS Act of 1988 and its 1998 update are essential for doctors, nurses, and other healthcare professionals to understand. This legislation corresponds closely with federal guidelines and accepted medical practice. Violations are heavily penalized, and good-faith efforts at compliance do not ensure anyone against legal difficulties.
The principal methods for dealing with the HIV/AIDS epidemic as stipulated in the Florida Omnibus AIDS Act are education and testing that is informed, voluntary, and confidential. Florida legislation stipulates four reasons for deviation from traditional educational and testing methods:
Before anyone can be tested for HIV in Florida, they must be informed about and explicitly consent to be tested. Consent need not be in writing provided there is documentation in the medical record that the test has been explained and consent given. Testing without informed consent can result in disciplinary action by a healthcare professional’s licensing board, fines, suspension or revocation of license, and civil liability for negligence and invasion of privacy.
A general consent to draw a patient’s blood and run unspecified tests does not meet the Florida criteria of informed consent for HIV testing.
The healthcare professional must explain the HIV test in a manner appropriate to the age, mental capacity, and language skill of the subject. The explanation should include the following information from Department of Health Rule 64D-2.004, F.A.C:
A separate statute designed to eliminate “unnecessary diagnostic testing” may make an HIV test illegal even when informed consent is granted. This law forbids diagnostic tests “which are not reasonably calculated to assist the healthcare provider in arriving at a diagnosis and treatment of a patient’s condition.” It is also forbidden to test for evidence of HIV infection “solely for the purpose of protecting healthcare workers.”
Children under 18 are considered adults for the purpose of consenting to, or refusing, an HIV test. Parental permission is not required for a child judged by the healthcare professional to be sufficiently mature to consent to or refuse an HIV test. Florida law forbids informing parents of a minor’s HIV test results either directly or indirectly (such as sending a bill for testing or treatment without the minor’s consent). It is up to the healthcare professional to decide whether the minor is capable of understanding the risks and benefits of the test or treatment.
A 1998 amendment to the Florida Omnibus AIDS Act requires the physician or midwife attending a woman for a condition related to pregnancy to offer HIV testing in conjunction with her required blood tests at the initial prenatal care visit and again at 28 to 32 weeks’ gestation, regardless of risk behaviors.
In 2005, the statute was amended to establish the current system of opt-out testing for all women who are pregnant. Under this system, women who are pregnant are advised that their healthcare professional will conduct an HIV test but that they have the right to refuse testing. Any woman who is pregnant may submit a written refusal for testing, and her refusal must be placed in her medical record (§384.31, F.S.).
Any woman who is pregnant with positive HIV test results should be referred to medical and support services as well as to the Healthy Start Care Coordination System. Any pregnant woman who presents at delivery without a record of a blood test for HIV during pregnancy must be counseled and offered an HIV test.
HIV testing without informed consent may occur in the following circumstances:
Anonymous and confidential HIV tests are available at Florida county health departments and other registered testing sites. County health departments and registered testing sites are required to provide private pre- and post-test counseling for all persons tested. Confidential HIV tests are also increasingly available in private-sector doctors’ offices and hospitals.
Medical records are, by law, confidential. The Florida Omnibus AIDS Act designates information about HIV testing as superconfidential if the tests can be traced to an identifiable individual. All test results, positive or negative, are superconfidential, which means that the information is only made available to healthcare personnel on a need-to-know basis. Providers, in turn, must sign a legal document not to divulge this information except on a need-to-know basis.
However, the law uses a narrow definition of “HIV test result.” The superconfidentiality standard applies only to the part of a person’s medical record that documents an HIV test and the results, negative or positive, of that test. If the documented HIV status was based on a health department anonymous test or a home testing kit, that does not constitute “HIV test results” and is not covered by the superconfidentiality standard.
Providers’ clinical assessments of any medical conditions associated with AIDS are also exempt from the superconfidentiality standard because they do not constitute “HIV test results” unless they include laboratory reports or medical-record notes of an HIV test. For example, a patient’s chart documenting symptoms of AIDS and including the word AIDS throughout the chart, but without an HIV test result or report, is not considered superconfidential.
Disclosure of HIV test results is limited to the following:
It is a first-degree misdemeanor (subject to up to one year of imprisonment) for anyone, whether a licensed professional or not, to violate the Florida Omnibus AIDS Act confidentiality requirements; the language does not require the violation to be intentional. In 1998, an amendment to the Act makes it a third-degree felony for anyone who maliciously, or for monetary gain, breaches the confidentiality of sexually transmitted disease information. In addition, the Florida Supreme Court held that anyone may be sued for negligence and other causes of action based on violation of the Act’s duty of confidentiality.
The healthcare professional ordering an HIV test must make all reasonable efforts to notify the person tested of the results. If the HIV-negative person fails to obtain the results, either by missing a scheduled visit or not calling in, the professional has met the “all reasonable efforts” standard.
However, if the test results show the person to be HIV-positive, the healthcare professional must exhaust all available means to contact the patient. If all efforts fail, the responsibility for notification can be transferred to the county health department through HIV infection-reporting requirements.
If test results are HIV-negative, notification should include appropriate information on preventing transmission of HIV. Information for high-risk test subjects may not be appropriate for low-risk test subjects and vice versa.
If test results are HIV-positive, counseling the test subject must include information on the following:
Counseling someone who has just learned of his or her HIV-positive status requires not only that the healthcare professional be familiar with local HIV health and social services but also that the caregiver have the ability to communicate with clarity, sensitivity, and compassion.
(The Florida Department of Health has developed “Model Protocols on Counseling and Testing” that may be obtained through their website. See “Resources” at the end of this course.)
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:
Any healthcare worker who receives a needlestick or other significant exposure to potential HIV, herpes simplex virus (HSV), or hepatitis B virus (HBV) infection should follow the employer’s protocol, which is based on guidelines issued by the U.S. Public Health Service (Kuhar, 2013).
Prompt reporting is essential because in some cases postexposure prophylaxis (PEP) may be recommended to start as soon as possible. Discuss the extent of the exposure, treatment, follow-up care, personal prevention measures, need for a tetanus shot, and other care matters with a healthcare professional.
When occupational exposure to HIV occurs, the U.S. Public Health (USPHS) recommends the following postexposure prophylaxis guidelines:
Antiretroviral therapy (ART) has become the gold standard for treatment of HIV/AIDS, with antiretroviral drugs administered in “cocktails” of three or more. (ART is also sometimes referred to as highly active antiretroviral therapy, or HAART.) People with HIV may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia.
Antiretroviral treatment of people with HIV continues to prove complex, controversial, dynamic, and expensive. These drugs do not constitute a cure for HIV/AIDS. If therapy is discontinued, viral load will increase. Even during treatment, the virus is replicating and the person remains infectious to others.
Seven major classes of drugs are used to treat HIV/AIDS:
Source: U.S. FDA, 2013.
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. A physician must treat both of these severe rashes.
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.
The economic downturn since 2008 has affected both federal and state budgets, creating a drug access crisis in many states. As of 2013, the AIDS Drug Assistance Program (ADAP) in Florida reported that nearly 2,715 patients with HIV were waiting for access to lifesaving drug treatment. In 2013, more than $1.9 billion in grants had been awarded through the Ryan White HIV/AIDS Program, of which Florida received $8,912,143 (USDHHS, 2013).
Approximately 130,000 people are living with HIV/AIDS in Florida, which ranks second in the nation for new HIV infections. Despite this ongoing tragedy, the public no longer has a sense of urgency or importance about AIDS. Research has produced drugs that slow but do not stop the disease, and no vaccine has proved effective in preventing HIV.
HIV continues to spread primarily among disadvantaged and marginalized populations, many of whom do not realize they are infected and unknowingly transmit the virus to others. 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.
The key to controlling the 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 unless it takes place within a monogamous relationship. 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.
Ignorance, prejudice, and lack of access to healthcare are fueling the epidemic. Healthcare professionals have a critical role in screening and educating patients, families, and communities about prevention. Healthcare professionals can offer nonjudgmental, compassionate care to those affected by this deadly virus.
AIDS Education Global Information System (AEGIS)
AIDSinfo(Comprehensive site of the USDHHS)
Centers for Disease Control and Prevention (CDC)
CDC National Prevention Information Network
CDC STD and AIDS Hotlines
English: 800-342-2437 or 800-227-8922
Post-Exposure Prophylaxis Hotline (PEPLINE)
Family Health Line
Florida Department of Health, Bureau of HIV/AIDS
Centers for Disease Control and Prevention (CDC). (2013a). HIV diagnosis data are estimates from all 50 states, the District of Columbia, and 6 U.S. dependent areas. HIV Surveillance Report, 23(February). Retrieved from http://www.cdc.gov/hiv/statistics/basics/ataglance.html.
Centers for Disease Control and Prevention (CDC). (2013b). HIV among pregnant women, infants, and children. Retrieved from http://www.cdc.gov/hiv/risk/gender/pregnantwomen/facts/.
Centers for Disease Control and Prevention (CDC). (2013c). HIV in correctional settings. Retrieved from http://www.cdc.gov/hiv/risk/other/correctional.html.
First Families of Palm Beach County. (2014). Targeted Outreach for Pregnant Women (TOPWA). Retrieved from http://www.familiesfirstpbc.org/index.cfm?fuseaction=pages.TOPWA.
Florida Department of Health (FL DOH). (2013a). HIV disease: United States vs. Florida. Retrieved from http://www.floridahealth.gov/diseases-and-conditions/aids/surveillance/_documents/fact-sheet/2012-US-VS-FL-Fact-Sheet1.pdf.
Florida Department of Health (FL DOH). (2013b). HIV among blacks. Retrieved from http://www.floridahealth.gov/diseases-and-conditions/aids/surveillance/_documents/fact-sheet/2012-Black-Fact-Sheet.pdf.
Florida Department of Health (FL DOH). (2013c). Epidemiology of HIV infection trends in Florida reported through 2012. Retrieved from http://www.floridahealth.gov/diseases-and-conditions/aids/surveillance/_documents/HIV-AIDS-slide%20sets/State_Trends_2012.pdf.
Florida Department of Health (FL DOH). (2013d). HIV/AIDS among persons aged 50 and older. Retrieved from http://www.floridahealth.gov/diseases-and-conditions/aids/surveillance/_documents/fact-sheet/2012-50plusFact-Sheet.pdf.
Florida Statutes. (2013). Chapter 381. Public health: general provisions. Retrieved from http://www.leg.state.fl.us/statutes/index.cfm.
Kuhar DT, Henderson DK, Struble KA, Heneine W, Thomas V, et al. (2013). Updated U.S. Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol, 34(9), 875–92. doi:10.1086/672271.
U.S. Department of Health and Human Services (USDHHS). Health Resources Services Administration. (2013). FY 2013 Ryan White part C awards. Retrieved from http://www.hrsa.gov/about/news/2013tables/ryanwhiteabc/partc.html.
U.S. Food and Drug Administration. (2013). Antiretroviral drugs used in the treatment of HIV infection. Retrieved from http://www.fda.gov/ForConsumers/byAudience/ForPatientAdvocates/HIVandAIDSActivities/ucm118915.htm.
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