HIV/AIDS for Kentucky Nurses
Online Continuing Education Course
HIV/AIDS CE covers risk factors, infection control and prevention, clinical manifestations, treatment; includes information on Kentucky law regarding testing, disclosure, and notification requirements.
Course Price: $18.00
Contact Hours: 2
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HIV/AIDS for Kentucky Nurses
Copyright © 2014 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to prepare Kentucky nurses to care for patients with HIV/AIDS based on evidence-based information on the etiology, epidemiology, transmission, infection control, clinical manifestations, and treatment of HIV/AIDS; and to review Kentucky state law governing HIV/AIDS-related issues such as testing, confidentiality, and disclosure.
Upon completion of this course, you will be able to:
- Identify the risk factors for HIV transmission in general and among healthcare workers in particular.
- Review the guidelines for HIV infection control and prevention.
- Recognize the different types of tests for HIV and the associated legal issues.
- Discuss the clinical manifestations of HIV/AIDS.
- Describe the treatment guidelines for HIV/AIDS.
TABLE OF CONTENTS
Since the first case of AIDS was diagnosed in 1981, AIDS has killed more than 630,000 Americans (CDC, 2013a). The 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.
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.
HIV/AIDS in the United States
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).
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.
HIV/AIDS in Kentucky
In 2004, Kentucky passed legislation mandating confidential, name-based reporting of HIV infection (including AIDS), resulting in increased reporting since then. Since 2002, 3,423 new HIV infections have been diagnosed, and as of 2012, 1,576 (46%) had progressed to AIDS. In the first half of 2012, there were a total of 119 new HIV infections diagnosed: 88 without AIDS and 31 with AIDS. In 2010, Kentucky had an estimated annual HIV infection rate of 9.0 per 100,000. As of 2012, Kentucky ranked 25th among the states in the annual number of HIV cases diagnosed (CHFS, 2012).
Although the HIV/AIDS epidemic has touched every part of Kentucky, the cities of Louisville and Lexington have been hardest hit. Through June 30, 2012, the highest number of cumulative HIV infections (4,208, or 49%) was at the time of diagnosis in the KIPDA Area Development District (ADD), which includes the city of Louisville. The Bluegrass ADD, including the city of Lexington, had the second highest cumulative number of HIV infections (1,603, or 19%). The Northern Kentucky ADD ranked third in cumulative number of HIV infections (700, or 8%) (CHFS, 2012).
Cumulative HIV Diagnoses by Kentucky Area Development District (ADD) through June 30, 2012. (Source: CHFS, 2012.)
Nationally, HIV/AIDS takes a heavy toll on people of all ethnicities, genders, ages, and income levels. However, three primary risk groups account for nearly three quarters (73%) of new HIV infections in the United States:
- Men who have sex with men (MSM) (63%)
- Injecting-drug users (IDUs) (6%)
- MSM who also use injection drugs (4%)
Heterosexual transmission accounts for the remainder (27%) of new cases.
Other important groups at risk for HIV include blacks, women and children, seniors, incarcerated populations, commercial sex workers, and transgender (TG) people. Each of these groups has unique needs for outreach and education on prevention and treatment of HIV infection.
MEN WHO HAVE SEX WITH MEN (MSM)
Although MSM are only a small percentage of the population, they account for more than half of all estimated new HIV infections. It is estimated that about 1 in 5 MSM is living with HIV. In 2010 MSM accounted for 63% of estimated new HIV infections in the United States and 78% of infections among all newly infected men (CDC, 2013c).
Among MSM, whites account for the highest number of new infections. In 2011, MSM HIV prevalence was highest among older age groups, blacks, and men with lower education and income. Black MSM had the highest HIV prevalence, but the lowest awareness of their infection among all racial-ethnic groups. Overall, MSM who are HIV-positive are increasingly aware of their infection (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).
In Kentucky, MSM accounted for the largest number of HIV infections diagnosed each year from 2006 to 2010. Since the start of the epidemic through June 30, 2012, 54% of the cumulative HIV infections diagnosed were in MSM, and 5% were in MSM who also use injection drugs. White males account for the majority (73%) of MSM with HIV infection diagnosed during this same period (CHFS, 2012).
INJECTING-DRUG USERS (IDUs)
In 2011 injecting-drug users accounted for 6% of new HIV diagnoses in the United States and its six dependent areas, and MSM and injecting drug users accounted for 4%. Of all newly diagnosed HIV infections among injecting drug users, 47% occurred in African Americans, 25% in Hispanic/Latino(a), and 24.5% in whites. All other races accounted for 3.4% (CDC, 2013e).
Mainstream America disapproves of illegal drug use and those who become addicted. The methamphetamine epidemic has increased the risk of HIV transmission because the drug is so cheap and accessible. Successful efforts to prevent the spread of HIV/AIDS, HBV, and HCV among injection drug users (e.g., syringe exchange programs) remain controversial because some people equate these programs with “approval” of drug use.
Injection drug use 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.
OTHER HIGH-RISK POPULATIONS
Blacks/African Americans are disproportionately affected by HIV/AIDS in Kentucky. In 2010, blacks represented 45% of new HIV infections in Kentucky but only 8% of the general population. Between 2006 and 2010, the HIV diagnosis rate for blacks fluctuated between 6 and 11 times higher than for whites. The rate among black females was 7.6 to 20.6 times higher than for white females. As of June 30, 2012, there were 57 reported perinatal exposures, 60% of which were black babies born to HIV-infected mothers (CHFS, 2012).
Incarcerated individuals in the United States have 2.5 times the rate of confirmed AIDS cases than among the general population, as well as higher rates of other sexually transmitted diseases. Women account for almost 7% of the prison population in the United States, and incarceration increasingly affects women of color. The percentage of female inmates with known HIV infections is higher than for incarcerated males. At the end of 2012, Kentucky’s prison population totaled 22,110 (Dwyer et al., 2011).
Women accounted for 20% of the estimated new HIV infections, and at the end of 2011, 1 in 4 people living with HIV infection in the United States was female. In 2010, HIV was among the top-10 leading causes of death for black/African American women aged 15 to 64 and Hispanic/Latino women aged 25 to 44 (CDC, 2013f).
According to CDC (2013k), between 2010 and 2011, people aged 50 and older in the United States accounted for:
- 5% of new HIV diagnoses
- Nearly 19% of persons living with HIV
- Nearly 24% of all AIDS diagnoses
- 53% of deaths among persons living with HIV
Of new infections during this time period:
- 36% were in white men and 4% were in white women
- 24% were in black men and 15% were in black women
- 12% were in Hispanic/Latino men and 4% were in Hispanic/Latina women
- 44% of the new infections among people aged 50 and older were among gay, bisexual, or other MSM
- Among MSM 67% were in white MSM, 16% in Hispanic/Latino MSM, and 15% in black MSM
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. 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.
TRANSMISSION OF HIV
Contrary to myths and misinformation, HIV is not transmitted by casual contact such as hugging, other nonsexual touching, and the shared handling of objects. Insects do not carry HIV, nor is the virus transmitted through air or water. HIV is a relatively fragile virus. Once outside the human body, HIV has a very short lifespan, which makes most medical procedures and caregiving activities safe if standard infection control procedures are followed.
In terms of the classic “chain of infection,” three links are necessary for the transmission of HIV:
- An HIV source
- A sufficient dose (viral load) of virus
- Access to the bloodstream of another person
Varying levels and concentrations of HIV have been found in most body fluids of infected persons, including blood, semen, saliva, tears, breast milk, and vaginal and cervical secretions. However, only blood, semen, breast milk, and vaginal and cervical secretions have been proven to transmit HIV infection. Healthcare workers, however, may be exposed to some other body fluids with high concentrations of HIV, including amniotic, cerebrospinal, pericardial, pleural, and synovial fluids.
Transmission of HIV occurs primarily through sexual contact with an infected person. This includes anal, oral, and vaginal contact. The risk of transmission depends on sexual practices. Receptive anal contact without a latex condom carries the greatest risk, probably because of the larger surface area of mucous membranes involved. Receptive partners are at greater risk for transmission of any sexually transmitted disease, including HIV.
Since last reported in 2006, there have been no confirmed cases of female-to-female transmission of HIV, but female sexual contact should be considered a possible means of transmission of HIV.
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.
INJECTION DRUG USE
Sharing injection needles, syringes, and other paraphernalia with an HIV-infected person can send HIV directly into the user’s bloodstream (along with hepatitis B and C viruses and other bloodborne diseases). Paraphernalia with the potential for transmission include the syringe, needle, “cooker,” cotton, and/or rinse water (sometimes called works).
Transmission also occurs through indirect sharing of contaminated paraphernalia and/or dividing a shared or jointly purchased drug while preparing and injecting it. “Indirect sharing” includes squirting the drug from a dirty syringe back into the drug cooker and/or someone else’s syringe, or sharing a common filter or rinse water.
LESS COMMON MEANS OF TRANSMISSION
Transmission of HIV through transfusion has been uncommon in the United States since 1985 and in other countries where blood is screened for HIV antibodies. In 1999, about 1% of U.S. AIDS cases were caused by transfusions or use of contaminated blood products. The majority of those cases were in people who received blood or blood products before 1985.
Donor screening, blood testing, and other processing methods have 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% (CDC, 2013g).
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.
Factors Affecting Transmission Risk
Infectious organisms (bacteria, parasites, viruses) transmitted during sexual activity—and the clinical manifestations arising from them—cause sexually transmitted diseases. 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).
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).
Prevention and Risk Reduction
HIV infection is preventable. 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 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:
- Abstinence from sexual contact
- Mutual monogamy
- Correct use of latex condoms for all sexual intercourse (anal, oral, and vaginal), even between two HIV-positive partners
- Getting tested and knowing the HIV status of one’s partner
Injection drug users who refuse treatment or who have no treatment programs available to them need instructions about injection precautions:
- Do not share needles or other paraphernalia.
- If sterile needles are not available, use bleach to clean needles.
- Be aware that anyone who knowingly exposes others to HIV/AIDS endangers the public health and may be taken into custody, tested for HIV without consent, hospitalized, and isolated.
These risk-reduction measures also apply to people who use needles to inject insulin, vitamins, steroids, or prescription or nonprescription drugs.
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, 2013h).
Risks for Occupational Exposure
Healthcare workers may be infected with HIV through needlesticks or direct contact with HIV-infected blood—for example, through a break in the skin or through the eyes or the mucosal lining of the nose.
In 2013 the CDC reported that 57 healthcare personnel in the United States have been documented as having seroconverted to HIV following occupational exposures. 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:
- Law enforcement
- Fire, ambulance, and other emergency responders
- Morticians and embalmers
- Ancillary medical facility personnel such as housekeeping, waste management, laundry staff
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:
- Deep punctures
- Hollow-bore needles
- Visible blood on the needle
- High viral load in the source
(Comparatively, the risk after a mucous membrane exposure is about 1 in 9,000, and the risk of HIV transmission after nonintact skin exposure is estimated to be less than the risk for mucous membrane exposure.)
The 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:
- Jails and prisons can be unpredictable work settings.
- Security issues are often a higher concern than infection control.
- Inmates may have a higher rate of bloodborne diseases.
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.
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).
OTHER POTENTIALLY INFECTIOUS MATERIALS (OPIM)
OPIM linked to transmission of HIV, HBV, and HCV are listed here. Standard precautions apply to all of the following:
- Blood and blood products
- Vaginal secretions
- Cerebrospinal fluid
- Synovial fluid
- Pleural fluid
- Peritoneal fluid
- Pericardial fluid
- Amniotic fluid
- Saliva in dental procedures
- Any body fluid visibly contaminated with blood
- All body fluids in situations where it is difficult or impossible to differentiate between body fluids
- Any unfixed tissue or organ (other than intact skin) from a human (living or dead)
- HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV
Body fluids such as urine, feces, and vomit are not considered OPIM unless visibly contaminated by blood. Similarly, wastewater (sewage) has not been implicated in the transmission of HIV, HBV, or HCV and is not considered to be either OPIM or regulated waste.
Infection Control Systems
To prevent HIV transmission in healthcare settings, the CDC 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, “universal precautions” was replaced. Standard precautions is the current terminology, and it includes:
- Precautions to be used with all patients at all times and in all settings
- Transmission-based precautions to be used when specific modes of transmission are present (e.g., contact precautions or droplet precautions)
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:
- Routine use of barriers (such as gloves and/or goggles) when anticipating contact with blood or body fluids
- Washing hands and other skin surfaces immediately after contact with blood or body fluids
- Careful handling and disposing of sharp instruments during and after use
Laundry that is or may be soiled with blood/OPIM must be treated as contaminated. All regulated waste must be placed in closeable, leak-proof containers or bags that are color-coded (red-bagged) or labeled as required by law to prevent leakage during handling, storage, and transport. Disposal of waste shall be in accordance with federal, state, and local regulations.
Tags or labels must be used as a means to protect employees from exposure to potentially hazardous biological agents.
INFECTION CONTROL AT HOME
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. Medical procedures contributing to percutaneous injuries in home care include injecting medications, performing fingersticks and heelsticks, and drawing blood. Other contributing factors include sharps disposal, contact with waste, and patient handling.
Healthcare workers and other caregivers who care for HIV patients should practice good hygiene techniques in preparing food, handling body fluids, and using medical equipment. Cuts, accidents, or other circumstances can result in spills of blood/OPIM on carpeting, vinyl flooring, clothing, skin, or other surfaces. Everyone, even young children, needs to have a basic understanding that they should not put their bare hands in or on another person’s blood.
Any healthcare worker who receives a needlestick or other significant exposure to potential HIV, HSV, or HBV infection should follow the employer’s protocol, which is based on guidelines issued by the U.S. Public Health Service (Kuhar, 2013).
Immediately after exposure to blood or OPIM from a patient:
- Wash the affected area(s) with soap and water. Application of antiseptics should not substitute for washing.
- Flush splashes to the nose, mouth, or skin with water.
- Irrigate eyes with clean water, saline, or sterile irrigants.
- Remove any potentially contaminated clothing as soon as possible.
- In the event of a sharps injury, wash the exposed area with soap and water.
- Do not “milk” or squeeze the wound.
- There is no evidence that antiseptics such as hydrogen peroxide will reduce the risk of transmission; however, use of antiseptics is not contraindicated.
- Seek emergency treatment if the wound needs suturing.
- For bites or scratch wounds, wash with soap and water and cover with a sterile dressing. All bite wounds should be evaluated by a healthcare professional.
- Exposure to urine, feces, vomitus, or sputum is not considered a bloodborne pathogens exposure unless the fluid is visibly contaminated with blood. Follow the employer’s procedures for cleaning these fluids.
REPORTING THE INCIDENT
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.
POSTEXPOSURE PROPHYLAXSIS (PEP)
The Occupational Safety and Health Administration (OSHA) requires employers to make immediate confidential medical evaluation and follow-up available at no cost for workers who have an exposure incident. Post-exposure prophylaxis for HIV must be offered according to the recommendations of the U.S. Public Health Service (OSHA, 2011):
- Determine, if possible, the HIV status of the exposure source patient to guide the need for HIV PEP.
- Start PEP medication regimens as soon as possible after exposure (24 hours) and continue for a 4-week duration.
- PEP medication regimens should contain three or more antiretroviral drugs for all occupational exposures to HIV.
- Expert consultation is recommended for any occupational exposure to HIV situation as defined by the USPHS.
- Close follow-up should be provided, including counseling, baseline and follow-up HIV testing, and monitoring for drug toxicity beginning 72 hours after exposure.
- If a fourth generation combination of HIV p24 antigen-HIV antibody test is used for follow-up HIV testing, testing may be ended four months following exposure. If a new testing platform is not available, follow-up HIV testing is to be concluded six months after exposure.
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.
The Post-Exposure Prophylaxis Hotline (PEPline), at 1-888-448-4911, offers 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. The PEPline is an invaluable resource for healthcare workers and their agencies, especially in rural areas (CDC, 2013i).
HIV TESTING AND COUNSELING
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 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.
Who Should Be Tested?
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 CDC (2013j) recommends the following:
- Notify the patient that testing will be performed unless he or she declines (opt-out screening).
- Do not require written consent for HIV testing; general consent for medical care should be considered sufficient to encompass consent for HIV testing.
- Screen persons at high risk for HIV infection at least annually.
- Do not require prevention counseling with HIV diagnostic testing or as part of HIV screening programs in healthcare settings.
- Include HIV screening in the routine panel of prenatal screening tests for all pregnant women. Repeat screening in the third trimester is recommended in certain jurisdictions with elevated rates of HIV infection among pregnant women.
Testing and Legal Issues
Kentucky has created legislation governing HIV testing and addressing issues such as informed consent, confidentiality, and notification requirements. All healthcare professionals must familiarize themselves with laws in their jurisdiction.
Kentucky Statute 214.625 states that testing for HIV should be informed, voluntary, and confidential. This legislation corresponds closely with federal guidelines and accepted medical practice. Violations are heavily penalized, and good-faith efforts at compliance do not insure anyone against legal difficulties.
Before anyone can be tested for HIV in Kentucky, they must explicitly consent to be tested. Testing without informed consent can result in disciplinary action by a healthcare provider’s licensing board, fines, suspension or revocation of license, and civil liability for negligence and invasion of privacy.
A person who signs a general consent form for the performance of medical procedures and tests is not required to sign a separate specific consent form for HIV testing during the time that the general consent form is in effect (KRS 214.181, 214.625). However, a general consent form shall instruct the patient that, as part of the medical procedures or tests, the patient may be tested for HIV, hepatitis, or any other bloodborne infectious disease if a doctor orders the test for diagnostic purposes. Except as otherwise provided in subsection (5)(c) of this section, the results of a test or procedure to determine HIV infection, antibodies to HIV, or infection with any probable causative agent of AIDS performed under the authorization of a general consent form shall be used only for diagnostic or other purposes directly related to medical treatment.
Informed consent must be preceded by an explanation of the test, including its purpose, potential uses, and limitations, and the meaning of its results. All registered testing programs, except for blood donor centers, shall provide pretest counseling on the meaning of a test for HIV, including medical indications for the test; the possibility of false positive or false negative results; the potential need for confirmatory testing; the potential social, medical, and economic consequences of a positive test result; and the need to eliminate high-risk behavior (KRS 214.625(7)(d-e)).
Kentucky statute 214.185 authorizes physicians to examine, diagnose, and treat children under 18 who seek care for disease, addictions, or other conditions, including sexually transmitted (venereal) diseases (STDs). Kentucky statute 214.410 includes HIV and AIDS in the definition of sexually transmitted diseases. Parental permission is not required for a child judged by the healthcare provider to be sufficiently mature to consent or refuse to have an HIV test.
Unlike many other states, Kentucky does not have an opt-out system for HIV testing of pregnant women. Under an opt-out system, all pregnant women are advised that their healthcare provider will conduct an HIV test but that they have the right to refuse testing. Instead, Kentucky has an opt-in system, which requires pregnant women to choose to be tested for HIV. Any physician or midwife attending a woman for any pregnancy-related condition should offer HIV testing in conjunction with other required blood tests at the initial prenatal care visit and again at 28 to 32 weeks’ gestation, regardless of risk behaviors.
When Donating Blood or Human Tissue
All patients donating blood must sign a consent form to have their blood tested for HIV (KRS 214.452). When donating organs, skin, or other human tissue to specialty banks, a written informed consent for HIV testing is required from the potential donor or the donor’s legal representative. Every donation of organs, skin, or other human tissue for transplantation to another shall be tested prior to use for HIV and other communicable diseases specified by the United Network for Organ Sharing, American Association of Tissue Banks, and Eye Bank Association of America by the agency responsible for procuring the tissue (KRS 311.281). If consent is not given, the person is not to be accepted as a donor.
Any tissue found to be HIV-positive shall be rendered noncommunicable by the person holding the tissue or shall be destroyed, unless the tissue is specifically labeled as HIV-positive and (a) is used for research purposes; or (b) is used to save the life of another and is transferred with the recipient’s informed consent.
Any HIV-positive results must be communicated to the donor in person. Negative test results shall be communicated either in person, by registered mail, or by phone. Notification is the responsibility of the agency procuring the tissue.
Under KRS 311.990, any person infected with HIV, knowing that he or she is infected and having been informed of the possibility of communicating the infection by donating human organs, skin, or other human tissues, who donates organs, skin, or other human tissue is guilty of a class D felony.
Kentucky Revised Statute (KRS) 197.055 requires an introductory and continuing education program on HIV/AIDS for all inmates. If there is evidence that an inmate is engaging in high-risk behavior such as sexual contact with any person in the institution, use of injection drugs, or tattooing, that inmate will be tested for HIV. If an inmate has been involved in a situation with a department employee that could result in transmission of HIV infection, the inmate shall be tested. The results of the tests shall become a part of that inmate’s medical file, accessible only to persons designated by agency administrative regulations.
TESTING WITHOUT INFORMED CONSENT
HIV testing without informed consent is permissible in the following circumstances:
- Bona fide medical emergencies in which treatment is indicated by HIV status. (KRS 214.625(3))
- When there has been significant exposure to medical personnel or a victim of a crime to the blood or body fluids of a criminal defendant, inmate, parolee, probationer, or patient or resident of any healthcare facility owned or operated by the Commonwealth, the source shall be ordered to submit to testing for HIV, hepatitis B and C viruses, and any other disease if testing for that disease is recommended by the most current guidelines of CDC. (KRS 438.250)
- When a person is charged with sexual offenses or offenses which have sexual contact as an element when the circumstances of the case demonstrate a possibility of transmission of HIV. (KRS 438.250)
- When a person is convicted of prostitution or procuring prostitution with knowledge of sexually transmitted disease or HIV. Any person who commits, offers, or agrees to commit prostitution by engaging in sexual activity likely to transmit HIV, knowing that he or she is HIV-positive and could possibly transmit this infection to another person, is guilty of a Class D felony. (KRS 529.090)
Anonymous and confidential HIV tests are available at Kentucky 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.
Disclosure of HIV test results (KRS 214.625) is limited to the following:
- The test subject and his or her representative
- A physician, nurse, or other healthcare provider who has a legitimate need to know the test result to protect himself or herself and to provide for the patient’s health and welfare
- The Department of Health
- The Cabinet for Health and Family Services
- Healthcare providers consulting among themselves or with healthcare facilities to determine diagnosis and treatment
- Authorized medical or epidemiologic researchers who shall not further disclose any identifying characteristics or information
- Hospital staff, administrators, and healthcare workers who provide aid and care to the subject, on a need-to-know basis. (This is especially important in cases of significant exposure to body fluids by healthcare workers.)
- A health facility or healthcare provider which procures, processes, distributes, or uses (a) a human body part from a deceased person, with respect to medical information regarding that person; or (b) semen provided prior to July 13, 1990, for the purpose of artificial insemination
- Health facility staff committees for the purposes of conducting program monitoring, program evaluation, or service reviews
- A parent, foster parent, or legal guardian of a minor; a crime victim; or a person specified in KRS 438.250
- A person allowed access by a court order, which imposes safeguards against unauthorized disclosure of test results, specifying the persons who may have access to the information, the purposes for which information shall be used, and appropriate prohibitions on future disclosure. When disclosure is made pursuant to this subsection, it shall be accompanied by a written statement that includes the following or similar language: “This information has been disclosed to you from records whose confidentiality is protected by state law. State law prohibits you from making any further disclosure of such information without the specific written consent of the person to whom such information pertains, or as otherwise permitted by state law. A general authorization for the release of medical or other information is NOT sufficient for this purpose.” An oral disclosure shall be accompanied by oral notice and followed by a written notice within ten (10) days (KRS 214.625 (5)(10)(e).
The result of a serologic test conducted under the auspices of the Cabinet shall not be used to determine if a person may be insured for disability, health, or life insurance or to screen or determine suitability for, or to discharge a person from, employment. Any person who violates the provisions of this subsection shall be guilty of a Class A misdemeanor (KRS 214.625 (6)(d).
Breaches of Confidentiality
Under KRS 214.420 and 214.625, all information in the possession of local health departments or the Cabinet concerning persons tested for, having, or suspected of having sexually transmitted diseases or identified in an epidemiologic investigation for sexually transmitted diseases, is strictly confidential. A general authorization for the release of medical or other information is not sufficient to authorize release of this information. Breach of this confidentiality is considered a violation under KRS 214.990(6).
Breach of confidentiality can result in disciplinary action, up to and including dismissal, as well as civil and criminal liability. A person who discloses the identity of a person upon whom a test to detect HIV infection has been conducted shall be guilty of a Class A misdemeanor. Anyone who intentionally releases any name or other identifying information shall be guilty of a Class A misdemeanor (KRS 214.995).
The physician who ordered the test or the attending physician is responsible for informing the patient of HIV-positive test results. The physician is also responsible for post-test counseling or referral to another appropriate professional for counseling (KRS 214.181, 214.625).
Federal Public Law 104-146 requires any state receiving Ryan White Title II funding to make a good-faith attempt to notify the spouse and partners of an HIV-infected individual. Spouse is defined as the person(s) in a marriage relationship with the infected person up to 10 years prior to the HIV test. Partner notification also includes sex and/or injection equipment-sharing partners.
In Kentucky (KAR 2:020, section 7, and KRS 214.010), every physician, advanced practice registered nurse, and medical laboratory must report to the appropriate health department:
- A positive test result for HIV infection that has been corroborated by a result from one of the following:
- Western Blot
- HIV antigen or
- HIV culture
- CD4+ assay, including absolute CD4+ cell counts and CD4+%
- HIV detectable Viral Load Assay
- A positive serologic test result for HIV infection or a diagnosis of AIDS that meets the definition of AIDS established within the Centers for Disease Control and Prevention (CDC) guidelines and reported in the:
- “Adult HIV/AIDS Confidential Case Report Form” or
- “Pediatric HIV/AIDS Confidential Case Report Form”
An HIV infection or AIDS diagnosis must be reported within 5 business days and, if possible, on the “Adult HIV/AIDS Confidential Case Report Form” or on the “Pediatric HIV/AIDS Confidential Case Report Form.” (Detailed information, including case report forms, is available at chfs.ky.gov/dph/epi/HIVAIDS/surveillance.htm.)
Types of HIV Tests
There are three main types of HIV tests:
- Antibody tests
- Antigen or RNA tests
- Combination 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. 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.
Enzyme-Linked Immunosorbent Assay (ELISA)
Before HIV rapid tests became available, HIV antibody testing relied on an enzyme-linked immunosorbent assay (ELISA or EIA). This test overpredicts positives; consequently, a negative HIV antibody test is considered definitive and no further testing is required. If the results are positive, however, CDC recommends not telling a person he or she is HIV-positive based only on ELISA test results. 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.
HIV Viral Load
This test measures the amount of HIV in the blood of an infected person. It is seldom used to diagnose HIV infection; rather, it is used to measure the effectiveness of antiretroviral medications that treat HIV infection.
HOME TESTING KITS
Tests are now available for self-testing of HIV serostatus. There are two FDA-approved home test kits on the market: Home Access Express and OraQuick In-Home.
The Home Access Express product is really an in-home sample collection system rather than a test with readily visible results. The person who wants to test at home pricks a finger and collects blood spots on special paper. The paper is mailed to a certified clinical laboratory with a confidential and anonymous personal identification number (PIN) and then tested using a standard ELISA process. If the initial test result is positive, the results are confirmed by a Western Blot test. The person tested obtains the results by calling a toll-free phone number and using the assigned PIN. Post-test counseling is available by telephone for everyone tested, whether the results are positive or negative.
In 2012, the FDA approved the first rapid home-use HIV kit that does not require sending a sample to a laboratory for analysis. The OraQuick In-Home HIV test uses a sample of fluid from the mouth and provides results in 20–40 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 Antibody Test Results
HIV test results can be one of three types: negative, positive, or indeterminate. A person may test negative for HIV antibodies even though recently infected. 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.
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.
A positive test result shows the presence of HIV antibodies, which means that:
- The person is infected with HIV
- The person can transmit the virus to others through unsafe sexual practices, sharing contaminated injection equipment, and/or breastfeeding
- The person is infected for life
Occasionally a rapid test or an enzyme immunoassay test will show an indeterminate or inconclusive test result. This may mean that the person is recently infected and is developing antibodies, a process called seroconversion. Indeterminate test results can also be caused by other factors, including but not limited to pregnancy, autoimmune diseases, blood transfusions, recent influenza vaccinations, or organ transplants. Research has shown that only about 20% of people with indeterminate test results go on to become truly HIV positive. Only rarely do people remain indeterminate throughout their lives.
All testing offers an opportunity for counseling patients. If test results are negative, counseling efforts typically focus on avoiding exposure to HIV through safer sex practices and not sharing needles. If results are positive, counseling typically focuses on preventing transmission of the virus to others and referring the patient to resources for treatment, education, and support.
Counseling someone who has just learned of his or her HIV-positive status requires not only that the healthcare provider be familiar with local HIV health and social services but also that the provider have the ability to communicate with clarity, sensitivity, and compassion.
CLINICAL MANIFESTATIONS AND TREATMENT
The trajectory between infection with HIV and the development of full-blown AIDS can be steep or gradual and may take as long as a decade or more. If the infection is untreated, the average time from HIV infection to a diagnosis of AIDS can be 10–15 years. However, early detection and appropriate medical treatment may extend the lives of those infected and reduce the rates of HIV transmission.
As the HIV virus suppresses immune function, the infected person becomes more vulnerable to “opportunistic infections” caused by a wide variety of bacteria, viruses, fungi, and other pathogens encountered in daily life. The physical results of these opportunistic infections are called clinical manifestations. For example, the opportunistic infection cytomegalovirus (CMV) often causes the clinical manifestation of blindness in people with AIDS.
Some conditions, called co-factors—including age, genetic factors, drug use, smoking, nutrition, and coinfection with hepatitis C virus (HCV) and/or tuberculosis (TB)—can affect the course of the disease progression.
HIV Classification Systems
Currently there are two major ways to classify HIV:
- For surveillance case definition purposes
- For clinical diagnosis purposes
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||
Opportunistic Infections and Cancers (AIDS-Defining Conditions)
People with normal immune systems have a natural resistance to microorganisms, but when the immune system is suppressed, viruses, fungi, protozoa, and bacteria take the opportunity to cause infection. The following are such “opportunistic infections” that can affect persons with HIV infection:
- Bacterial infections (multiple or recurrent)
- Candidiasis of bronchi, trachea, or lungs
- Candidiasis of esophagus
- Coccidioidomycosis, disseminated or extrapulmonary
- Cryptococcosis, extrapulmonary
- Cryptosporidiosis, chronic intestinal (>1 month’s duration)
- Cytomegalovirus disease (other than liver, spleen, or nodes)
- Cytomegalovirus retinitis (with loss of vision)
- Herpes simplex: chronic ulcers (>1 month’s duration) or bronchitis, pneumonitis, or esophagitis
- Histoplasmosis, disseminated or extrapulmonary
- Isosporiasis, chronic intestinal (>1 month’s duration)
- Lymphoid interstitial pneumonia or pulmonary lymphoid hyperplasia complex
- Mycobacterium avium complex (MAC) or M. kansasii, disseminated or extrapulmonary
- M. tuberculosis (TB) of any site, pulmonary, disseminated, or extrapulmonary
- Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
- Pneumocystis jirovecii pneumonia
- Pneumonia, recurrent
- Progressive multifocal leukoencephalopathy
- Salmonella septicemia, recurrent
- Toxoplasmosis of brain, onset at age >1 month
- Wasting syndrome attributed to HIV
People with HIV/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:
- Hodgkin’s lymphoma
- Anal cancer
- Liver cancer
- Mouth or throat cancer
- Lung cancer
- Testicular cancer
- Colorectal cancer
- Multiple types of skin cancer including basal cell carcinoma, squamous cell carcinoma, and melanoma
(Robert H. Lurie Comprehensive Cancer Center, 2013)
Evolving Treatment Guidelines
Treatment guidelines are revised frequently based on ongoing research findings. The most up-to-date information can be found online at aidsinfo.nih.gov/guidelines.
Antiretroviral Therapy (ART)
Antiretroviral therapy has become the gold standard for treatment of HIV/AIDS, with antiretroviral drugs administered in “cocktails” of three or more. (ART is also sometimes referred to as highly active antiretroviral therapy, or HAART.) People with HIV may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia.
Antiretroviral treatment of people with HIV continues to prove complex, controversial, dynamic, and expensive. These drugs do not constitute a “cure” for HIV/AIDS. If therapy is discontinued, viral load will increase. Even during treatment, the virus is replicating and the person remains infectious to others.
Seven major classes of drugs are used to treat HIV/AIDS:
- Nucleoside reverse transcriptase inhibitors (NRTIs)
- Nonnucleoside reverse transcriptase inhibitors (NNRTIs)
- Protease inhibitors (PIs)
- Fusion inhibitors
- HIV integrase strand transfer inhibitors
- Entry inhibitors, CCR5 co-receptor antagonists
- Multi-class combination products
Source: U.S. FDA, 2013.
In 1996, tests to measure an individual’s viral load became available, providing objective criteria for treatment decisions. Following are treatment recommendations by the Panel on Antiretroviral Guidelines for Adults and Adolescents (NIH, 2013):
- Antiretroviral therapy (ART) is recommended for all HIV-infected individuals regardless of CD4 count to decrease the risk of disease progression.
- ART also is recommended for HIV-infected individuals for the prevention of prenatal and behavior-associated HIV transmission.
- Patients initiating ART should be willing and able to commit to lifelong treatment and should understand the benefits and risks of therapy and the importance of adherence. Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy based on clinical and/or psychosocial factors.
TREATMENT GOALS AND GUIDELINES
Once ART therapy has begun, CDC recommends these goals of therapy:
- Maximal and durable suppression of viral load
- Reduction of HIV-related morbidity and prolonging survival
- Improvement in quality of life
- Restoration and/or preservation of immunologic function
- Prevention of HIV transmission
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. 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.
ART FOR PREGNANT WOMEN
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).
Other Medications and Therapies
In addition to ART, people with HIV/AIDS may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia. Some of these medications may have serious interactions with ART, so prescribing physicians need to be familiar with all ART medications, as well as with their potential toxicities, when administered with other drugs.
Some people with HIV infection supplement their prescription drugs with vitamins, acupuncture, massage, yoga, meditation, herbs, naturopathic remedies, and other complementary therapies. People who turn away from prescription HIV medications and choose only herbs, vitamins, and other supplements are said to be using alternative therapies. Many of these remedies have not been studied to see if they offer any real benefit.
Therapies such as yoga, meditation, and massage can help reduce stress and enhance quality of life. However, herbs and other “natural” remedies may also interact with prescription medication. For example, St. John’s wort has major interactions with HIV medications. Therefore, people on HIV medications need to tell their physician, pharmacist, and social worker about all other supplements and nonprescription drugs they take.
Infections that are commonly found in HIV-positive patients include a number of other sexually transmitted diseases, tuberculosis, 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 (CDC, 2012b).
All people infected with HIV should be tested for TB and, if infected, begin complete therapy as soon as possible to prevent active TB disease. HIV-infected persons with either latent TB infection or active TB disease can be effectively treated. The first step is to ensure that HIV-infected persons are tested for TB. The second step is to help those infected with TB to get proper treatment and prevent rapid progression from latent TB infection to active TB disease.
Hepatitis is inflammation of the liver that may be caused by drugs and toxic agents or by one of several viruses, including hepatitis A, B, C, D, and others. People who are HIV positive are at risk for hepatitis A, B, and C infection. 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.
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.
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.
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. Since 2002, 3,423 new HIV infections have been diagnosed in Kentucky, with Kentucky ranked 25th among the states in the annual number of HIV cases diagnosed.
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 avoiding any type of sexual contact with someone who you do not 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)
National Prevention Information Network (CDC)
Post-Exposure Prophylaxis Hotline (PEPLINE)
STD and AIDS Hotlines (CDC)
English: 800-342-2437 or 800-227-8922
AIDS Volunteers, Inc. (AVOL)
Kentucky Department for Public Health HIV/AIDS Branch
866-510-0005 (Case reporting only)
WINGS Medical Clinic
Ryan White HIV Programs
University of Louisville Health Sciences Center
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).
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
Centers for Disease Control and Prevention (CDC). (2013b). Diagnosis of HIV infection in the United States and dependent areas, 2011 surveillance report. Surveillance Reports–HIV/AIDS, 23. Retrieved from www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2013c). Fact sheet: CDC 2013 fast facts. Retrieved from http://www.cdc.gov
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Council of State and Territorial Epidemiologists (CSTE). (2012). HIV surveillance training manual. Retrieved from http://c.ymcdn.com
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National Institutes of Health (NIH). (2013). Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States: postpartum care: infant antiretroviral prophylaxis. Retrieved from http://aidsinfo.nih.gov
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National Institutes of Health. (2010). Recommendations for the use of antiretroviral drugs in pregnant HIV1-infected women for maternal health and interventions to reduce perinatal HIV-1 transmission in the United States. Retrieved from http://aidsinfo.nih.gov
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Robert H. Lurie Comprehensive Cancer Center. (2013). Types of cancer: AIDS/HIV-related malignancies. Retrieved from http://cancer.northwestern.edu
U.S. Food and Drug Administration. (2013). Antiretroviral drugs used in the treatment of HIV infection. Retrieved from http://www.fda.gov
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