HIV/AIDS for Washington Healthcare Professionals (7 CH)

Part 1: Etiology and Epidemiology of HIV

EPIDEMIOLOGY

Since the first case of acquired immune deficiency syndrome (AIDS) was diagnosed in 1981, AIDS has killed nearly 600,000 Americans (CDC, 2010a). The daunting human and economic costs of this disease in the United States are eclipsed only by its international impact. Since 1981, 30 million people worldwide have died from AIDS and more than 33 million are infected with the virus. Although HIV infection rates are declining globally, another 2.7 million people were infected in 2008. At the end of 2008, an estimated 4 million people were receiving AIDS drugs and another 5 million needed treatment and were not receiving it (UNAIDS, 2009).

A Global Pandemic

Almost all (95%) of the newly infected people live in the developing world, particularly southern Africa. The majority are young adults, many of whom do not know they are infected. This disease is the leading cause of death in southern Africa. Worldwide, AIDS is the leading cause of death and lost years of productive life for adults ages 15 to 59 (UNAIDS, 2009).

HIV/AIDS: THE GLOBAL EPIDEMIC, 2008

Source: UNAIDS, 2009.
33.4 million people living with HIV/AIDS	31.3 million adults (15.7 million women) 2.1 million children under 15
More than 30 million dead of AIDS	24.2 million adults 5.6 million children under 15 14 million children orphaned in southern Africa alone
During the year 2008	2.7 million people newly infected with HIV, half between ages 15 and 24 2.0 million people died of AIDS-related illnesses 280,000 children under 15 died of AIDS-related illnesses

HIV/AIDS in the United States

The CDC estimates that 1.1 million people in the United States are currently infected with HIV. At least 1 in 5 of them does not know he or she is infected and is 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. Each year another 56,000 people are infected with HIV, approximately 1 new infection every 9.5 minutes (Hall et al., 2008). And each year more than 18,000 people die of AIDS in the U.S. (CDC, 2010a).

HIV IN THE UNITED STATES, 2010

1.1 million people living with HIV/AIDS	297,000 of them women 3,992 children under 13
Nearly 600,000 dead of AIDS since 1981	576,000 adults 5,200 children
During the year 2008	56,000 people newly infected with HIV 182 of them children under 13 18,000 people died of AIDS-related illnesses

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 U.S. 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.

AREAS OF HIGH PREVALENCE

The American epidemic of HIV/AIDS is characterized by “low prevalence in the general population, high prevalence among the disenfranchised and socially marginalized, with a concentration in geographic hotspots.…HIV infection in some U.S. populations now rivals that in some sub-Saharan African countries. For example, more than 1 in 30 adults in Washington, D.C., are HIV-infected—a prevalence higher than that reported in Ethiopia, Nigeria, or Rwanda” (El-Sadr et al., 2010).

Three-fourths of new HIV infections occur in just three groups: men who have sex with men (MSM), injection drug users, and MSM who also use injection drugs. These are primarily young men with no memory of the early epidemic. During the early 1980s, there were no effective drugs, and diagnosis of AIDS meant swift and certain death. Unaware of their HIV status, and of the serious side effects and prohibitive cost of drug treatment, today’s young MSM unknowingly infect others in their social network.

Once a disease of gay white men, HIV is now decimating young people of color, particularly among the black/African American population. According to CDC, nearly half of all new HIV infections occur among black/African Americans, even though they represent only 12% of the U.S. population.

Black men are diagnosed with HIV at more than six times the rate of white men, and black women at more than 15 times the rate of white women and more than 4 times the rate for Hispanic women. In the black/African American population, heterosexual transmission accounts for 11% of male infections but more than 50% of female infections (CDC, 2010a).

NATIONAL AIDS STRATEGY

We have learned what we can do to stop the spread of the disease. We’ve learned what we can do to extend the lives of people living with it. And we’ve been reminded of our obligations to one another—obligations that, like the virus itself, transcend barriers of race or station or sexual orientation or faith or nationality. So the question is not whether we know what to do, but whether we will do it.
—PRESIDENT BARACK OBAMA (White House, 2010)

After nearly three decades, the United States is no longer “in the embarrassing situation of having no overarching AIDS strategy for the country” (Holtgrave, 2010). Launched at the White House in July 2010, the National AIDS Strategy (NAS) has three overarching goals:

• Reducing infection rates
• Increasing access to care for those infected
• Eliminating disparities in prevalence, diagnosis, and treatment

The NAS envisions a future in which “the United States will become a place where new HIV infections are rare and, when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socioeconomic circumstance, will have unfettered access to high-quality, life-extending care, free from stigma and discrimination” (White House, 2010).

The NAS includes major outcomes to be achieved by 2015, such as:

• Reducing the number of new annual infections by 25%
• Increasing to 90% the percentage of people with HIV who know they are infected
• Increasing the proportion of newly diagnosed patients linked to care within 3 months from 65% to 85%
• Increasing by 20% the proportion of HIV-positive MSM, blacks, and Hispanics with undetectable viral loads

If the NAS target outcomes are achieved, then approximately 76,000 infections will be prevented and an estimated 219,000 more people living with HIV will be in care by 2015. Achieving these outcomes would substantially alter the trajectory of the epidemic in the United States and could prevent a total of nearly 238,000 infections through 2020 (Holtgrave, 2010).

Implementing the NAS will be costly, but experts believe that continuing on the current path would be even more costly, both financially and in human terms. CDC (2010b) estimates that a rapid scale up of HIV prevention efforts could most effectively reduce the number of new HIV infections and save the U.S. healthcare system up to 25 times the amount that would need to be invested in prevention.

CHANGES IN HIV SURVEILLANCE

Through 2007, more than 1 million cases of HIV/AIDS have been reported since CDC began tracking cases, and more than 576,000 people have died of the disease (CDC, 2010c). The statistics do not reflect the true magnitude of the epidemic, however, since the CDC considers reporting of cases to be only about 85% complete.

As of April 2008, all 50 states had implemented confidential name-based HIV infection reporting, but until that time only 37 states and some dependent territories had been reporting. The HIV Surveillance Report for 2012 (issued in 2014) will be the first time the data from all 50 states will be included in the estimates.

CDC has also changed some of the terminology in reporting surveillance of HIV. For example, “HIV/AIDS” has been replaced with “HIV infection,” and the term high-risk was removed from the “high-risk heterosexual contact” transmission category label to clarify that heterosexual contact itself is the mode of transmission for HIV infection. All data are presented by the year of diagnosis rather than the year they were reported to CDC.

HIV/AIDS in Washington State

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

Since the CDC began tracking AIDS cases, approximately 17,200 cases of HIV/AIDS have been reported in Washington State. More than 12,000 of those infected progressed to full blown AIDS, and more than 5,500 of them have died.

As of December 2008, more than 10,000 people in Washington were infected with HIV, and nearly 6,000 of them had been confirmed with AIDS. The annual incidence rate of HIV/AIDS in Washington is 9.3 per 100,000 (compared to 13.7 per 100,000 nationally) (Washington State DOH, 2009a).

King County accounts for about two thirds of the total AIDS cases reported in the state (Washington State Department of Health, 2009c). Despite continued outreach and awareness programs, the number of HIV diagnoses among Seattle men who have sex with men (MSM) has increased 8% each year since 2001, even though incidence has held stable in other populations. Diagnoses of other sexually transmitted diseases (STDs), such as gonorrhea, chlamydia, and syphilis, have also increased among MSM to levels last seen in the early- to mid-1980s (Grygiel, 2009).

More than half of all new HIV diagnoses in Washington State during 2003–2007 occurred among adults ages 35 and older, predominantly among white males. However, the proportion of new cases diagnosed in those under age 25 also increased during the same time period.  Although black/African Americans account for only 4% of the state’s population, they comprise nearly 20% of new HIV infections.

The prevalence of HIV among Washington State women has increased by an average of 6% per year. At the end of December 2008, there were almost 1,400 women with HIV disease in Washington State, more than half of whom had AIDS (Washington State DOH, 2009b).

Efforts to screen pregnant women for HIV and to treat those women who test positive for the virus have markedly reduced the incidence of pediatric HIV/AIDS in Washington. Since 2001, there have been only three confirmed cases of perinatal (mother-to-child) HIV transmission in Washington State (Washington DOH, 2009a).

RISK GROUPS

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

Three primary risk groups account for 75% of new HIV infections in the United States:

1. Men who have sex with men (MSM)
2. Injecting-drug users (IDUs)
3. MSM who also use injection drugs

Heterosexual transmission accounts for the remainder of new cases. Although HIV infection among IDUs has declined since the early 1980s, continued efforts to prevent transmission of HIV and other STDs are needed (Hall et al., 2008). Poverty, unemployment, lack of education, limited access to healthcare, incarceration, and disrupted social networks further increase risk among each of these groups.

Other important groups at risk for HIV include women and children, seniors, commercial sex workers, incarcerated populations, 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)

Men who have sex with men account for more than half of all newly reported HIV infections, and young men are at highest risk. MSM account for just 4% of the U.S. male population aged 13 years and older; however, the rate of new HIV diagnoses among MSM is more than 44 times that of other men. Although new infections have declined among both heterosexuals and injection drug users, the annual number of new infections among MSM has increased steadily since the early 1990s (CDC, 2010e). They are the only risk group in the United States in which new HIV infections are increasing.

Nearly half of HIV-infected young MSM do not know they are infected. A survey of MSM in 21 U.S. cities found that 1 in 5 of those surveyed was HIV-positive and nearly half of them (44%) were unaware of their HIV status. The highest HIV prevalence and infection unawareness were among young and minority MSM (CDC, 2010e).

INFECTION BY RACE

The age of acquiring HIV infection among MSM varies by race. The majority of new infections among young black MSM occur between ages 13–29, while infections among young white men occur during their 20s and 30s. Among young Hispanic MSM, most new infections occur in the youngest cohort, although a substantial number occur during their 30s (CDC, 2010e).

Estimated Number* of New HIV Infections in Men Who Have Sex with Men, by Race/Ethnicity and Age Group, United States, 2006.
* Incidence estimates are adjusted for reporting delays and reclassification of cases reported without a known risk factor for HIV but not for underreporting.
† Non-Hispanic whites and non-Hispanic blacks are referred to as white and black, respectively. Persons of Hispanic ethnicity might be of any race.
Note: The “I” bars denote the data range for each confidence interval.
Source: CDC, 2010h.

The prevalence of HIV among Asians and Pacific Islander (API) MSM is estimated at 3%, and API represent only 1% of the total HIV-infected population in the United States. However, prevalence varies widely by ethnicity, ranging from 0% for Vietnamese MSM to 13.6% for Thai MSM (CDC, 2008a). A survey of API MSM in Seattle indicated that 90% of them perceived themselves to be at some risk for HIV infection, yet fewer than half of those surveyed had been tested during the past year (Kahle et al., 2005).

FACTORS THAT INCREASE RISK AMONG MSM

According to CDC (2010c), several factors increase the risk of HIV/AIDS transmission among MSM. These include the following:

• High prevalence of HIV and multiple partners: The risk of exposure to infection increases with each sexual encounter.
• Lack of knowledge of HIV status: Those who know they are infected are more likely to take precautions to protect their partners. Those who don’t know they are infected may unknowingly transmit the virus to others.
• Complacency about risk: Young men who did not experience the early AIDS epidemic may believe that HIV drugs mean that AIDS is no longer a serious health risk. They fail to understand that HIV drug regimens are expensive, complex, and can have disabling, disfiguring side effects.
• Social discrimination and cultural issues: For some, ignorance, homophobia, stigma, and lack of access to healthcare may increase risky behaviors or act as a barrier to testing and other prevention services.
• Substance abuse: Some MSM use alcohol and other drugs, including methamphetamines, increasing risky behaviors while under the influence; this includes sharing needles or other injection equipment.

Injecting-Drug Users (IDUs)

Injecting-drug use is the third most frequently reported risk factor for HIV infection in the United States. During 2004–2007, approximately two thirds of newly infected IDUs were males, more than half were black/African Americans, and three fourths lived in urban areas. Many IDUs continue to engage in high-risk behaviors such as sharing syringes and/or having unprotected sex. The highest prevalence of having unprotected vaginal sex was among those 18–24 years (CDC, 2009a).

Mainstream America disapproves of illegal drug use and those who become addicted. The methamphetamine epidemic has increased the risk of HIV transmission because the drug is so cheap and accessible. Successful efforts to prevent the spread of HIV/AIDS, HBV, and HCV among injection drug users (e.g., syringe exchange programs) remain controversial because some people equate these programs with “approval” of drug use.

Injection-drug use (IDU) often coexists with poverty, low self-esteem, anxiety, depression, and mental illness. While drugs offer temporary relief from the realities of harsh living conditions, they create a tangled web of problems, including risk-taking behaviors like unprotected sex. Drug users who would like to stop using often lack access to inpatient treatment facilities. Waiting lists for drug treatment programs are long, and by the time a place is available, users may be lost to follow-up.

Those drug users who do seek treatment for HIV may find the cost of the drugs prohibitive or the complex multidrug regimens beyond their ability to manage. In addition, street drugs and drugs unapproved by FDA but available through online pharmacies may have dangerous interactions with AIDS medications.

Correctional Populations

Increasing access to HIV and STI [sexually transmitted infections] prevention and care services for incarcerated men and women has important public health benefits. It can help avert the spread of HIV infection and STIs among incarcerated persons and to their sexual partners and drug-using partners after their release.
—KACANEK ET AL. (2007)

Incarcerated individuals in the United States have 2.5 times the rate of confirmed AIDS cases than among the general population (Bureau of Justice Statistics, 2009). They also have higher rates of other STDs, hepatitis C, and tuberculosis.

Many prison inmates engage in high-risk behaviors before being incarcerated, including unprotected sexual intercourse and drug and alcohol abuse, behaviors that often continue inside prisons, even though sex and drugs are prohibited. Most U.S. prisons fail to follow recommendations from the World Health Organization (WHO) that condoms be made available to prisoners, that prisoners have access to bleach for cleaning injection equipment, and that needle exchange programs be considered.

HIV testing is available to all correctional populations in the United States, but policies and specific procedures differ. In some cases, testing is mandatory. For example, Washington State law mandates HIV testing for anyone convicted of a sexual offense, prostitution or offenses relating to prostitution, or drug offenses associated with the use of hypodermic needles. In Mississippi, HIV testing is mandatory for all incarcerated individuals upon entry into prison. In Rhode Island, HIV testing is mandatory for all sentenced people.

Commercial Sex Workers

There is little research on HIV and other STDs among commercial sex workers in the United States. Yet 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. One international meta-analysis showed that “it is the number of infected prostitutes in a country that is highly significant and robust in explaining HIV prevalence levels across countries” (Talbott, 2007).

The Center for AIDS Prevention Studies (2008) stated: “Male, female, and transgender sex workers who are most vulnerable to HIV are street-based workers, most of whom are poor or homeless and likely to have had a history of sexual or physical abuse.” The use of drugs, particularly injection drugs, among street-based sex workers heightens the HIV risk. One study of drug-using female sex workers in Miami found that more than 22% of the women were HIV positive (Inciardi et al., 2006). One-fourth of male sex workers in Houston were found to be HIV positive (Timpson et al., 2007).

When sex work occurs in brothels, massage parlors, private homes or through escort services, workers (and clients) are at lower risk of HIV transmission because workers have more control over their working conditions and are more likely to use condoms. However, both street workers and Internet-based escorts report inconsistent condom use, high rates of unprotected sex, and low rates of HIV status disclosure (Mimiaga et al., 2008).

Because sex work is illegal, sex workers often distrust both police and public health authorities. This makes it difficult to conduct prevention outreach, education, or research.

Women and Children

Women now constitute more than 25% of the HIV/AIDS-infected population nationwide and nearly 75% of new AIDS cases. Three-fourths of the women and girls living with AIDS in the United States are African American and Hispanic, even though these populations account for only a fourth of U.S. females. HIV/AIDS is the leading cause of death of black/African American women aged 25 to 34. Women are primarily infected through heterosexual intercourse, although injection drug use accounts for a fourth of female cases (CDC, 2008b).

In Washington State between 2003–2007, women accounted for 16% of new HIV diagnoses, significantly less than the national average. However, black/African American women in Washington State accounted for 38% of new HIV infections. More than half the new HIV diagnoses occur in women over 30 (Washington State DOH, 2009b), slightly less than the national average.

Ninety percent of children with AIDS are infected by their mothers. Although the incidence of mother-infant transmission has decreased greatly among whites, it remains a challenge in the African American community. Nationwide, two thirds of infected children younger than 5 years old are black.

Female adolescents and young women under the age of 25 are at higher risk for HIV/AIDS and other STDs than older women. Having sex with multiple partners, engaging in risky behaviors such as alcohol and drug use, and/or being unable to negotiate safer sex practices with partners all contribute to this heightened risk.

Seniors (Aged 50 and Older)

According to CDC (2008d), people over 50 in the United States account for:

• 15% of new HIV diagnoses
• Nearly 25% of persons living with HIV
• Nearly 20% of all AIDS diagnoses
• More than a third of all deaths of persons with AIDS

Seniors represent 27% of the HIV-infected population in the United States. Males account for three fourths of cases and females account for a fourth. Half of HIV-infected seniors are black, a third are white, and the remainder are Hispanic.

The recent increase in HIV among people over 50 is partly due to antiretroviral therapy, which has extended the lives of HIV-infected people, and partly due to newly diagnosed infections in older people.

In December 2009, the Centers for Medicare and Medicaid Services (CMS) announced its decision to cover HIV infection screening for Medicare and Medicaid beneficiaries who are at increased risk for the infection, including pregnant women and Medicare beneficiaries of any age who voluntarily request the service.

Stereotypes about aging and about HIV/AIDS put seniors at risk for transmission. Many seniors are sexually active well into their seventies and eighties, a fact sometimes overlooked by health professionals. Thus, physicians and other healthcare workers may fail to ask patients about unprotected sex or to offer voluntary HIV testing.

Health professionals also may fail to diagnose AIDS in seniors because symptoms can mimic those of normal aging, such as fatigue, weight loss, forgetfulness, and/or confusion. As a result, many seniors are diagnosed only in the late stages of the disease—or not at all.

Most sexually active older couples do not use condoms because they are unconcerned about pregnancy. Unless a couple is monogamous, however, unprotected sex increases the risk of infection with HIV or other sexually transmitted diseases from multiple sexual partners. Older women face a higher risk than older men because age-related vaginal thinning and dryness can cause tears in the vaginal area.

Perceived barriers to condom use among seniors include the following factors:

• Drug and/or alcohol use before or during sexual activity
• Belief that unprotected sexual activity is more exciting and that condoms reduce sexual pleasure
• Lack of knowledge about effective use of condoms
• HIV conspiracy beliefs
• Belief that known and/or trusted partners are “safe”

Since Viagra and other drugs for erectile dysfunction entered the marketplace in the late 1990s, rates of HIV/AIDS and gonorrhea increased more rapidly in middle-aged and older heterosexual adults than in people under age 40 (Jena et al., 2010).

Unprotected sexual activity is not the only risk factor among seniors. To control the rising costs of medications such as insulin, some seniors share needles for insulin and other prescription drugs.

The stigma of HIV/AIDS may be much more severe among seniors, leading them to hide their diagnosis from family and friends. Keeping their diagnosis a secret can limit or eliminate potential emotional and practical support.

Transgender (TG) People

According to the San Francisco AIDS Foundation (2009), transgender is an inclusive term for persons those whose gender identity, expression, or behavior differs from the norms expected from their birth sex. Gender identities within this category include transgender woman, transgender man, male-to-female (MTF), female-to-male (FTM), transsexual, transvestite, drag queen/king, and gender queer.

Transgender people face multiple challenges that increase their risk for HIV infection. Marginalized by society and institutions, sometimes rejected by their families, transgender people often suffer low self-esteem, job discrimination, precarious economic status, and lack of social support. Nearly two thirds of TG people ages 16–25 are unemployed (Garofalo, 2006), and some choose commercial sex work as a means of economic support and substance abuse as a coping mechanism.

According to CDC (2007), there are no reliable data on the number of TG individuals in the United States. However, there is consensus that the HIV prevalence is high, based on several studies. Estimated infection rates range from 14% to 69% among specific TG populations. The highest rates may be among male-to-female (MTF) sex workers. A 2008 meta-analysis estimated national HIV prevalence at 27.7% among MTF (Herbst et al., 2008).

Seattle and King County Public Health (2009) reports that of the 6,283 HIV-infected persons in King County, 27 identify as transgender. Almost all were born male but consider their current gender to be female. One to three diagnoses of HIV among this population have been reported each year since 2004.

Part 2: Transmission and Infection Control

THE AIDS VIRUS

AIDS is caused by the human immunodeficiency virus (HIV). DNA analysis has identified HIV-1 as originating in a substrain of chimpanzees in west equatorial Africa (Gao et al., 1999). Scientists theorize that HIV-1 moved from chimps to humans when hunters were exposed to infected blood while handling bush meat (the flesh of various primates, including chimps and gorillas). Once in the human population, HIV quickly became a global pandemic, driven by travel and migration patterns, sexual practices, drug use, war, and economics.

Strains of HIV

There are at least two types of HIV virus: HIV-1 is the cause of AIDS, and HIV-2 is a related group of viruses found in West African patients. Worldwide, the predominant virus is HIV-1. Most of the West Africans infected with HIV-2 show none of the symptoms of classical AIDS. A few cases of HIV-2 infections have been found in people in the United States. It is unclear at this time whether HIV-2 is a less serious infection or whether it simply has a longer latency preceding the onset of AIDS.

HIV mutates readily, leading to many different strains of HIV, even within the body of a single infected person. Based on genetic similarities, the numerous viral strains may be classified into types, groups, and subtypes.

Both HIV-1 and HIV-2 have several known subtypes, and more subtypes are certain to be discovered as the virus evolves and mutates. As of 2001, blood testing in the United States could detect both strains and all known subtypes of HIV.

Disease Mechanism

By attacking the immune system, HIV makes the body vulnerable to a number of opportunistic infections caused by viruses, bacteria, and yeasts that would pose no threat to a person with a normal immune system. With a weakened immune system, however, these infections are life-threatening.

Although the mechanisms of HIV and the way it affects the immune system are not fully understood, the primary event is the entrance of HIV into the body’s CD4+ cells (“T-Helper lymphocytes,” also called T4 cells), which are white blood cells essential to the function of the immune system in fighting infection.

Once inside a T4 cell, the virus replicates and signals other cells that produce antibodies. Producing antibodies is an essential immune system function. HIV infects and destroys the T4 cells and damages their ability to signal for antibody production. Thus, it steadily deactivates the immune system, leading to dysfunction of various organ systems, including the endocrine, gastrointestinal, and nervous systems.

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.

Three conditions are necessary for HIV to be transmitted:

1. An HIV source
2. A sufficient dose (viral load) of virus
3. Access to the bloodstream of another person

Varying levels and concentrations of HIV have been found in most bodily fluids of infected persons, including blood, semen, saliva, tears, breast milk, and vaginal and cervical secretions. However, only blood, semen, breast milk, and vaginal and cervical secretions have been proven to transmit HIV infection.

The first week or two after infection with HIV constitute the acute or primary HIV infection stage. During this time, infected persons may be symptom-free and unaware of the infection but highly infectious because of the viral load (high levels of the virus) in the bloodstream. Once infected, the person remains infectious for life.

Some researchers use the term acute HIV infection to describe the 6- to 12-week interval between initial infection and production of antibodies that can be detected by an HIV test. This interval is also called the window period.

Although a high viral load is present during the acute stage of HIV, one study indicates that those in the asymptomatic stage of HIV with medium levels of the virus have the greatest risk of infecting others. The asymptomatic stage lasts for years, rather than weeks, during which time those infected but untested may continue to unknowingly spread the virus (Fraser et al., 2007).

Sexual Contact

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.)

Female-to-female transmission of HIV appears to be rare. However, some case reports of female-to-female transmission—and the well-documented risk of female-to-male transmission—suggest that women who have sex with women (WSW) should consider female sexual contact a possible means of transmission of HIV (CDC, 2006a).

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 back from a dirty syringe into the drug cooker and/or someone else’s syringe, or sharing a common filter or rinse water.

Transfusions of Infected Blood or Blood Clotting Factors

Transmission of HIV through transfusion has been uncommon in the United States since 1985 and in other countries where blood is screened for HIV antibodies. In 1999, about 1% 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 to between 1 in 450,000 to 1 in 600,000 transfusions in the United States. Donating blood in the United States is always safe because sterile needles and other equipment are used.

Tattooing and Blood-Sharing Activities

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

Pregnancy and Breastfeeding

A pregnant woman 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 therapies during the last two trimesters of pregnancy and during delivery, the risk of perinatal transmission to the newborn drops below 2%. Other measures to prevent perinatal transmission include the use of prophylactic cesarean delivery before onset of labor or rupture of membranes and avoidance of breastfeeding by HIV-infected mothers. In addition, the infant is treated for the first six weeks of life (Public Health Service Task Force, 2009).

Washington State law requires that pregnant women be counseled concerning risks about HIV and offered voluntary HIV testing. Advice about medications and cesarean delivery should be given on a case-by-case basis by a healthcare provider experienced in treating HIV-infected women.

Biting

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

PROBABILITIES OF HIV INFECTION (per one exposure to HIV)

Type of Exposure	HIV Infection Risk*
Source: CDC, 2005.
Contaminated blood transfusion (prior to 1986)	95%
One intravenous syringe or needle exposure	0.67%
One percutaneous exposure (e.g., needlestick)	0.4%
One episode of receptive anal intercourse	0.1%–3%
One episode of receptive vaginal intercourse	0.1%–0.2%
One episode of insertive vaginal intercourse	0.03%–0.09%
* 1% risk means a likelihood of 1 in 100 for infection to occur; 0.1% means a likelihood of 1 in 1,000.

FACTORS AFFECTING RISK OF HIV TRANSMISSION

Additional factors affect the risk of HIV transmission. For instance, coexisting infections may increase the risk of transmission of HIV and make its treatment more complex.

Other Sexually Transmitted Diseases (STDs)

People who are HIV-positive often have other sexually transmitted diseases, such as syphilis, gonorrhea, genital warts, human papilloma virus (HPV), trichomoniasis, scabies, herpes, and chlamydia. Sores, lesions, or inflammation from STDs make the skin or mucous membrane more vulnerable to other infections. Skin-to-skin contact can transmit these infections, which increases the risk of HIV transmission. The immune suppression caused by HIV facilitates infection with other STDs, creating a destructive synergy.

Prevention of HIV/AIDS should be part of a general program of sexually transmitted disease (STD) prevention because other preventable STDs, most of which are curable, have also reached epidemic proportions, particularly among sexually active young people. For example, rates of primary and secondary syphilis (the stages when syphilis is most infectious) in males have increased each year between 2000 and 2006. Two-thirds of the cases diagnosed in 2006 were among MSM (CDC, 2007a).

Screening for STDs is also critical since many of those infected do not show symptoms. This includes Pap tests for sexually active women and a thorough history of STDs during medical workups for both women and men. Prompt treatment should follow for any persons who test positive for STDs. Treatments vary with each disease or syndrome. Because of the risk of developing resistance to medications for certain STDs, healthcare providers should check the latest STD treatment guidelines, available on the CDC website.

Human papilloma virus (HPV) is highly prevalent among HIV-infected women and men, increasing viral shedding and raising the risk of cervical and anal cancers. Multiple strains of this virus are often present in HIV-positive women. The HPV vaccine (Gardasil) has not been tested in HIV-positive women, so no data is available on its safety or efficacy in this population. However, Gardasil and Cervarix have been found safe for use in HIV-positive patients with high-grade anal intraepithelial neoplasia (AIN), a precancerous condition caused by infection with high-risk forms of HPV. In October 2009, the FDA approved Gardasil to prevent HPV in boys and men, ages 9 through 26 (FDA, 2009).

Genital herpes (HSV-2) also appears to be a major risk factor for acquiring HIV infection, increasing the risk more than three-fold. According to the CDC (2010j), 8 out of 10 of those infected with HSV-2 have not been diagnosed. Many of them have mild or unrecognized infections but shed virus intermittently in the genital tract. These are the individuals most likely to transmit the infection. Diagnosis of HSV-2 should be confirmed by type-specific laboratory testing, and anyone infected with HSV-2 should also be tested for HIV. Treatment of HSV-2 with antiviral agents reduces but does not eliminate subclinical virus shedding.

Both oral and anal sex can result in the transmission of gonorrhea and chlamydia as well as HIV (Johnson, Ghanem & Erbelding, 2006). A rare and virulent strain of chlamydia appears to be spreading in the United States, Western Europe, and the United Kingdom, primarily among MSM. More common to Africa and Southeast Asia, the strain is called lymphogranuloma venereum chlamydia (LGV), and it can cause genital ulcers, swollen lymph glands in the groin, flu-like symptoms, and gastrointestinal distress. Rectal symptoms among MSM, including bleeding of the rectum and colon, likely result from unprotected anal intercourse. These lesions increase the risk of transmitting or contracting HIV or other bloodborne diseases (Stark et al., 2007).

Multiple Partners

The individual with multiple sex or injection drug-sharing partners is at great risk for exposure to HIV/AIDS. 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 Noninjecting Drugs

Use of any mood-altering substance, including alcohol or non-injectable 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.

Research shows that both meth and HIV infection cause significant changes in the brain, impairing cognitive function (Jernigan et al., 2005). Many MSM who use methamphetamine also use other drugs such as marijuana, “poppers,” cocaine, heroin, hallucinogens, and ketamine (Patterson et al., 2005).

Certain substances can mask pain and/or create oral and genital sores, which create additional entry points for HIV and other STDs.

Gender, Culture, and Equality Issues

The balance of power in an intimate relationship can affect an individual’s ability to insist on safer sex practices such as condom use. Women who are socially and economically dependent on men may be unable to negotiate condom use or to leave a relationship that puts them at risk.

Culturally imposed ignorance about their bodies, especially about sexuality and reproduction, can make women even more vulnerable to HIV-infection. Some cultures endorse the concept of multiple sexual partners for men but monogamous relationships for women.

A history of childhood sexual abuse and family violence is associated with HIV-related risk in adulthood. In one study, researchers found that a history of trauma was a general risk factor for HIV, regardless of race/ethnicity. Limited material resources, exposure to violence, and high-risk sexual behaviors were the best predictors of  HIV risk (Wyatt et al., 2002).

PREVENTION AND RISK REDUCTION

HIV/AIDS is preventable. For example, screening of blood and blood products for the HIV virus has reduced the risk of HIV transmission with transfusion to 1:1,000,000. Mother-to-baby transmission has dropped by two thirds (CDC, 2006a). Following universal precautions in healthcare has unquestionably prevented thousands, if not millions, of cases of HIV/AIDS in the United States. But, because the virus is transmitted through behaviors that many people find pleasurable—sexual activity and injection drug use—prevention is difficult.

Prevention of HIV/AIDS saves money as well as lives. The CDC estimates that the average cost of lifetime treatment for one person with HIV infection is $618,900 (Schackman et al., 2006).

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

Safer sex practices include:

• Abstinence from sexual contact
• Mutual monogamy
• Correct use of latex condoms for all sexual intercourse (anal, oral, and vaginal)

Both women and men may need instruction in the correct use of condoms:

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

Women who have sex with women (WSW) need to take precautions during oral sex, even though female-to-female transmission appears to be rare. According to the CDC, “vaginal secretions and menstrual blood are potentially infectious and mucous membrane (e.g., oral, vaginal) exposure to these secretions have the potential to lead to HIV infection” (CDC, 2006a). Precautionary measures include:

• Using condoms consistently and correctly each and every time for sexual contact with men or when using sex toys; not sharing sex toys
• Using natural-rubber latex sheets, dental dams, cut-open condoms, or plastic wrap during oral sex; however, no barrier methods for use during oral sex have been shown to be effective by the FDA
• Knowing one’s own and one’s partner’s HIV status; this can help uninfected women reduce their risk of becoming infected and assist those who are infected to get early treatment and avoid transmitting the virus to others

Injection Precautions

Injection drug users who refuse treatment or who have no treatment programs available to them need instructions about precautions:

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

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

In December 2009, new U.S. legislation ended the 20-year ban on federal funding for needle exchange programs, making additional resources available to states and communities. HIV experts called this a crucial, lifesaving step forward for HIV prevention. “The science could not be more clear: Needle exchange programs are cost effective, save lives, and do not promote drug use. They connect hard-to-reach populations to primary care and to the addiction treatment they need” (Saag, 2009).

Syringe exchange or needle exchange programs also help prevent spread of hepatitis and other bloodborne pathogens. Many local health departments in Washington State operate syringe exchanges in their communities.

Preventing Transmission to Uninfected Partners

Optimal care of people with HIV/AIDS includes not only antiviral therapies, health maintenance, and referral to support services, but also an emphasis on prevention of transmission to uninfected partners. The CDC recommends that anyone with HIV/AIDS use prevention strategies even if his or her partner is also HIV infected.The partner may have a different strain of the virus that could behave differently in each individual or that could be resistant to different anti-HIV medications.

Implementing preventive strategies begins at the initial visit and continues throughout subsequent visits or periodically, at least once a year. Care providers should use a straightforward, nonjudgmental approach and open-ended questions to screen and assess patient behaviors associated with HIV transmission. Other strategies include self-administered questionnaires and computer-, audio-, or video-assisted questionnaires.

Initial and periodic screening for STDs should also be performed. At the initial visit, both men and women should have laboratory tests for syphilis. Women should also be screened for trichomoniasis, and women age 25 and younger should be screened for cervical chlamydia, the most common STD among women. Screening for STDs, particularly for chlamydia, should be repeated periodically if the patient is sexually active. Women younger than 19 are often reinfected with chlamydia, probably by male partners who have not been diagnosed and treated because the disease is asymptomatic.

HIV-positive women of childbearing age should be screened for pregnancy at initial and subsequent visits and asked about interest in future pregnancy and use of contraceptives. Counseling about reproductive healthcare or prenatal care, as appropriate, should be offered.

Intravenous drug users (IDUs) should be referred for substance abuse treatment. Those who refuse treatment should be counseled to use once-only sterile syringes and not to share needles with others.

Prevention among People of Color

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

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

Prevention messages need to be culturally appropriate and relevant and they must be delivered through channels appropriate to individual communities. These channels may include religious institutions or respected elders in the community.

Male Circumcision

Male circumcision is being discussed as a possible measure to reduce the risk of male-to-female HIV transmission. International observational studies and three clinical trials have found that male circumcision is associated with a lower risk for HIV infection as well as other STDs and urinary tract infections. CDC is reviewing recommendations related to neonatal circumcision of male newborns as well as post-neonatal male circumcision (CDC, 2008c).

Challenges to Prevention

The CDC (2010c) has identified challenges to prevention of HIV transmission among MSM, particularly those aged 15–49 years old. They include:

• Unprotected sex
• Use of alcohol and other drugs
• Lack of awareness of HIV infection
• Stigma and internalized homophobia
• Social isolation
• Racism, poverty, and lack of access to healthcare
• Complacency about HIV based on ignorance

Complacency about HIV among young MSM stems from two key factors. The first is their lack of experience with the severity of the early HIV epidemic. The second is their mistaken belief that advances in treatment and decreased mortality mean that HIV is no longer a serious threat. They also fail to recognize that antiretroviral drugs are very expensive and may have serious, even life-threatening side effects.

Prevention Research

In late 2010 researchers reported that daily use of the antiretroviral pill Truvada, currently used to treat HIV, can also be used for preexposure prophylaxis (PrEP) to prevent new infections. This large multinational trial showed that the drug reduced the risk of HIV transmission by 44% and reduced new infections by as much as 73% among those who used the drug most (Grant et al., 2010). (Because the trial enrolled only men and transgender women who have sex with men, the drug’s efficacy in women or intravenous drug users is unknown.)

While the FDA has not yet approved the drug for preventive use, the CDC has released interim guidelines for healthcare providers electing to provide PrEP to high-risk MSM (CDC, 2011). These state that PrEP has the potential to contribute to effective and safe HIV prevention under the following conditions:

• It is targeted to MSM at high risk for HIV acquisition
• It is delivered as part of a comprehensive set of prevention services, including risk-reduction and PrEP medication adherence counseling, ready access to condoms, and diagnosis and treatment of sexually transmitted infections
• It is accompanied by monitoring of HIV status, side effects, adherence, and risk behaviors at regular intervals

The cost of PrEP is a major concern for public health agencies and private insurers, since Truvada costs about $1,000 per month when used to treat HIV, which will prove prohibitive for the populations at highest risk of infection. However, “a generic version is available overseas that costs about 40 cents a day” (Allday, 2010).

INFECTION CONTROL

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. According to the CDC, of all adults reported with AIDS in the United States through December 2002, 5.1% of the AIDS cases reported to the CDC for whom occupational information was known had been employed in healthcare.

In 2007 the CDC reported that “57 healthcare personnel in the United States have been documented as having seroconverted to HIV following occupational exposures. In addition, 140 possible cases of HIV infection or AIDS have occurred among healthcare personnel…. More than 90% of healthcare personnel infected with HVI have nonoccupational risk factors for acquiring their infection.”

Healthcare providers 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; and public service employees.

NEEDLESTICK INJURIES

The risk of developing HIV infection from a needlestick with infected blood is about 1:300 without prompt antiretroviral treatment, and the risk increases with deep punctures, hollow bore needles, visible blood on the needle, and high viral load in the source. (Comparatively, the risk after a mucous membrane exposure is about 1:9,000, and the risk of HIV transmission after nonintact skin exposure is estimated to be less than the risk for mucous membrane exposure.)

According to the CDC, the risk of infection varies on a case-by-case basis. Factors affecting the risk include: whether the exposure was from a hollow-bore needle or other sharp instrument; whether to nonintact skin or mucous membranes (such as eyes, nose, and/or mouth); the amount of blood involved; and the amount of virus present in the source’s blood.

Needlestick injuries, also called percutaneous injuries (PIs), are a critical issue for nurses, according to a nationwide survey of more than 700 nurses. More than two thirds of nurses surveyed said that PIs and bloodborne infections remain major concerns, and more than half believe their workplace safety climate threatens their personal safety. Reduced staffing, increased workloads, and workplace stress all affect workplace safety, increasing the potential for errors and shortcuts (ANA, 2008). Improving these working conditions could reduce needlestick injuries (Trinkoff et al., 2007).

Needlestick injuries and other occupational exposures to potentially life-threatening infections can have profound implications for mental as well as physical health. This aspect of post-exposure care is barely mentioned in the CDC counseling guidelines for postexposure prophylaxis (PEP) (2005). Mental health issues can include sleep disruption, anxiety, panic attacks, and posttraumatic stress disorder (PTSD) (Shalo, 2007).

IN CORRECTIONAL INSTITUTIONS

The high prevalence of HIV infections in correctional institutions increases the risk of exposure, as does the environment itself. CDC (2009d) 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.

Workplace Standards

Standards have been developed to protect workers from bloodborne pathogens such as HIV.

DEFINING BLOODBORNE PATHOGENS

Bloodborne pathogens include any human pathogen present in human blood or other potentially infectious materials (OPIM). Other bloodborne pathogens include HBV, HCV, hepatitis D, malaria, syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections, relapsing fever, Creutzfeldt-Jakob disease, adult T-cell leukemia/lymphoma (caused by HTLV-I), HTLV-I-associated myelopathy, diseases associated with HTLV-II, and viral hemorrhagic fever.

EXPOSURE CONTROL PLAN (ECP)

Each employer covered under WAC 296-823 must develop an Exposure Control Plan (ECP). The ECP shall contain at least the following elements:

• A written “exposure determination” that includes those job classifications and positions in which employees have potential for occupational exposures. The exposure determination shall have been made without taking into consideration the use of personal protective clothing or equipment. It is important to include those employees who are required or expected to administer first aid.
• The procedure for evaluating the circumstances surrounding exposure incidents, including maintenance of a “Sharps Injury Log.” The Sharps Injury Log must contain, at a minimum: the type and brand of device involved in the incident; the department or work area where the exposure incident occurred; and an explanation of how the incident occurred.
• The infection control system used in the workplace.
• Documentation of consideration and implementation of appropriate, commercially available safer medical devices designed to eliminate or minimize occupational exposure.
• An update at least annually and whenever changes occur that affect occupational exposure.

EMPLOYEE TRAINING

Bloodborne pathogens training is mandated for all new employees or employees being transferred into jobs involving tasks or activities with potential exposure to blood and/or OPIM. This training must take place prior to assignment to tasks where occupational exposure may occur, and must include:

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

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

Employees must be provided access to a qualified trainer during the training session to ask and have answered questions as they arise.

Infection Control Systems

To prevent HIV transmission in healthcare settings, CDC instituted universal precautions (blood and body fluid precautions). Under universal precautions, healthcare personnel should assume that the blood and other body fluids from all patients are potentially infectious and therefore follow infection-control precautions at all times and in all settings.

Standard precautions is a newer term that hospitals and other agencies are moving toward. It includes all recommendations for universal precautions plus body substance isolation (BSI) when other potentially infectious materials (OPIM) are present.

These precautions include:

• 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, and
• Careful handling and disposing of sharp instruments during and after use

USE OF BARRIERS

Gloves, masks, protective eyewear, and chin-length plastic face shields are examples of personal protective equipment (PPE). PPE shall be provided and worn by employees in all instances where they will or may come into contact with blood or OPIM. This includes, but is not limited to, dentistry, phlebotomy, processing of any bodily fluid specimen, and postmortem (after death) procedures.

Latex gloves are recommended when dealing with blood or OPIM. However, people with allergies to latex must be provided with nitrile, vinyl, or other glove alternatives that meet the definition of “appropriate” gloves. Gloves must be changed after each client.

Gloves should be worn:

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

Caregivers with weeping dermatitis (such as poison ivy or poison oak) or exudative lesions must be prohibited from all patient care and/or handling of patient care equipment or supplies.

Masks, goggles, face shields, and gowns should be worn:

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

Reusable PPE must be cleaned and decontaminated or laundered by the employer. Lab coats and scrubs are generally considered to be worn as uniforms or personal clothing. When contamination is reasonably likely, protective gowns should be worn. If lab coats or scrubs are worn as PPE, they must be removed as soon as practical and laundered by the employer.

HANDWASHING

Soap-and-water handwashing must be performed whenever hands are visibly contaminated or there is a reasonable likelihood of contamination. Universal precautions also include frequent handwashing with warm water and soap (or a waterless, alcohol-based hand rub):

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

It is advisable to keep fingernails short and wear as little jewelry as possible.

Additional information on hand hygiene can be found in the CDC “Guideline for Hand Hygiene in Healthcare Settings.”

SHARPS DISPOSAL

Needles are not to be recapped, purposely bent or broken, removed, or otherwise manipulated by hand. After they are used, disposable syringes, needles, and scalpel blades are to be immediately placed in puncture-resistant, labeled containers for disposal.

Phlebotomy needles must not be removed from holders unless required by a medical procedure. The intact phlebotomy needle/holder must be placed directly into an appropriate sharps container.

Adhere to agency protocols for disposal of infectious waste.

HOUSEKEEPING AND WASTE DISPOSAL

The work area of the facility is to be maintained in a clean and sanitary condition. The employer is required to determine and implement a written schedule for cleaning and disinfection, based on the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed.

Disinfectants

All equipment and all environmental and working surfaces must be properly cleaned and disinfected after contact with blood or OPIM. Chemical germicides and disinfectants in recommended dilutions must be used to decontaminate spills of blood and other body fluids. Consult the Environmental Protection Agency (EPA) for lists of registered sterilants, tuberculocidal disinfectants, and antimicrobials with HIV/HBV efficacy claims to verify that the product used is appropriate. Lists are available from EPA at http://www.epa.gov/oppad001/chemregindex.htm.

Laundry

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

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

Regulated Waste

Potentially contaminated broken glassware must be removed using mechanical means, such as a brush and dustpan or vacuum cleaner.

All regulated waste must be placed in closeable, leak-proof containers or bags that are color-coded (red-bagged) or labeled as required by law to prevent leakage during handling, storage, and transport. Disposal of waste shall be in accordance with federal, state, and local regulations.

Regulated waste is defined as any of the following:

• Liquid or semiliquid blood or other potentially infectious materials (OPIM)
• Contaminated items that would release blood or OPIM in a liquid or semiliquid state, if compressed
• Items that are caked with dried blood or OPIM and are capable of releasing these materials during handling
• Contaminated sharps
• Pathological and microbiological wastes containing blood or OPIM

PERSONAL ACTIVITIES

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

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

Protocols for Healthcare Workers Exposed to 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 CDC (2005).

IMMEDIATE RESPONSE

Immediately after exposure to blood of 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 your employer’s procedures for cleaning these fluids.

REPORTING THE INCIDENT

Immediately report the incident to the department (e.g., occupational health, infection control) within your 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. You should have already received the hepatitis B vaccine, which is extremely safe and effective in preventing HBV infection.

In Washington, employers must make a confidential postexposure medical evaluation available to employees who report an exposure incident. This evaluation must be:

• Made immediately available
• Kept confidential
• Provided at no cost to the employee
• Provided according to current U.S. Public Health Service recommendations

In addition, the following information must be provided to the evaluating healthcare professional:

• A copy of WAC 296-823-160
• A description of the job duties the employee was performing when exposed
• Documentation of the routes of exposure and circumstances under which exposure occurred
• Results of the source person’s blood testing, if available
• All medical records, including vaccination status, relevant to the appropriate treatment of the employee

(Note: HIV and hepatitis infection are notifiable conditions under WAC 246-101.)

Workers have a right to file a worker’s compensation claim for exposure to bloodborne pathogens. Industrial insurance covers the cost of postexposure prophylaxis and follow-up care for the injured worker.

POSTEXPOSURE PROPHYLAXSIS (PEP)

The CDC recommends that postexposure prophylaxis (PEP) begin as soon as possible, ideally within 24 hours after the exposure and no later than 7 days (CDC, 2005). Animal studies indicate that cellular HIV infection occurs within 2 days of exposure to HIV. Virus in blood is detectable within 5 days. Therefore, prompt initiation of PEP is essential and should be continued for 28 days. PEP for HIV does not prevent other bloodborne diseases such as HBV or HCV.

For exposure to HIV-positive blood, recommendation is for a four-week course combining either two antiretroviral drugs for most HIV exposures, or three antiretroviral drugs for exposures that may pose a greater risk for transmitting HIV (e.g., those involving a larger volume of blood with a larger amount of HIV or a concern about drug-resistant HIV). The antiviral drugs used in PEP are potentially toxic and should not be used for exposures that pose a negligible risk. CDC recommends consultation with an infectious disease consultant or another physician experienced with antiretroviral drugs; however, consultation “should not delay timely initiation of PEP” (CDC, 2005).

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 National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline) offers treating clinicians up-to-the-minute advice on managing occupational exposures (i.e., needlesticks, splashes, etc.) to HIV, hepatitis, and other bloodborne pathogens. In rural areas, police, firefighters and other at-risk emergency responders should identify a 24-hour source for PEP.

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

SOURCE TESTING

WAC 296-823-160 requires the employer to arrange to test the “source individual”—the person whose blood or OPIM an employee was exposed to—for HIV, HBV, and HCV as soon as feasible after obtaining their consent. If the employer does not get consent, the employer must document such and inform the employee. The employer may request assistance from the local health officer.

Because of an increased risk for HIV exposure, the Revised Code of Washington 70.24.340 provides for HIV antibody testing of a “source individual” when a member of the following groups experiences an occupational exposure:

• Healthcare provider
• Staff of healthcare facilities
• Law enforcement officer
• Firefighter
• Funeral director
• Embalmer

These individuals can request HIV testing of the source through their employer or local health officer.

Before issuing a health order for HIV testing of the source individual, the officer will first determine whether a substantial exposure occurred and if the exposure occurred on the job. Depending on the type of exposure and risks involved, the health officer may determine that source testing is unnecessary.

Source testing does not eliminate the need for baseline testing of the exposed individual for HIV, HBV, HCV, and liver enzymes. Initiating PEP should also not be contingent upon the results of a source’s test. Current recommendations are to provide immediate PEP in certain circumstances, with possible discontinuation of treatment based on the source’s test results.

(See also “Testing Without Informed Consent” below.)

FOLLOW-UP

CDC recommends that “healthcare personnel with occupational exposure to HIV receive follow-up counseling, postexposure testing, and medical evaluation regardless of whether they receive PEP. HIV-antibody testing by enzyme immunoassay should be used to monitor healthcare personnel for seroconversion for >6 months after occupational exposure” (CDC, 2005).

After baseline testing at the time of exposure, follow-up testing is recommended to be performed at 6 weeks, 12 weeks, and 6 months after exposure. Extended HIV follow-up (e.g., for 12 months) is recommended for those who become infected with HCV after exposure to a source coinfected with HIV. Extended follow-up in other circumstances (such as those persons with impaired immunity) may also be considered.

• Healthcare personnel undergoing PEP should be monitored for drug toxicity by testing at baseline and again 2 weeks after starting PEP.
• It is important to complete the full 4 weeks of PEP, despite side effects, which can include nausea, malaise, and fatigue. Many healthcare personnel, perhaps as many as 47%, do not complete the full course of therapy because of an inability to tolerate the drugs.

Infection Control Procedures at Home

Healthcare providers and other caregivers who care for HIV patients at home or in home-like settings are also at risk of exposure to HIV and other bloodborne pathogens. Nurses, nurses’ aides, and personal care assistants (PCAs) experience PIs and other exposures to blood and body fluids during home care. However, more than half of these exposures go unreported (Gershon et al., 2009; Scharf et al., 2009).

Medical procedures contributing to PIs 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. PCAs appear to be at increased risk when performing procedures for which they are inexperienced and/or lack training (Lipscomb et al., 2009). One study found that sharps with safety features often were not used, possibly due to their expense (Quinn et al., 2009).

Healthcare providers and other caregivers who care for HIV patients should practice good hygiene techniques in preparing food, handling body fluids, and using medical equipment. Cuts, accidents, or other circumstances can result in spills of blood/OPIM on carpeting, vinyl flooring, clothing, skin, or other surfaces. Everyone, even young children, needs to have a basic understanding that they should not put their bare hands in or on another person’s blood.

GLOVES AND HANDWASHING

Gloves (latex, vinyl, or nitrile in the case of latex allergy) should be worn whenever a caregiver anticipates contact with any body substance (blood/OPIM) or non-intact skin. Gloves are not necessary for general care or during casual contact (serving food, bathing intact skin). Never rub the eyes, mouth, or face while wearing gloves.

Gloves should be properly removed and disposed of and hands washed as soon as possible after care of each patient. Disposable gloves should never be washed and reused. Correct handwashing is critically important.

CLEANING BLOOD/OPIM FROM SURFACES

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

On bare floors, pretreat body fluid spills with full-strength liquid disinfectant or detergent; then wipe up with either a mop and hot soapy water or appropriate gloves and paper towels. Dispose of paper towels into a well-marked plastic bag or heavy-duty container. Broken glass should be swept up using a broom and dustpan (never bare hands).

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

On carpeting, pour dry kitty litter or another absorbent material onto the spill to absorb the body fluid. Carefully pour carpet-safe liquid disinfectant onto the contaminated carpeting and leave it there for the amount of time indicated in manufacturer’s instructions. Using sturdy rubber gloves, blot the spill with paper towels until it is absorbed. Vacuum normally afterward.

CLOTHING AND OTHER LAUNDRY

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

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

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

TOILET AND BEDPAN SAFETY

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

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

Use a new pair of gloves to change diapers. Discard disposable diapers in an appropriate plastic bag or receptacle, along with gloves. Wash hands immediately after changing the diaper. Disinfect the diapering surface. Wash cloth diapers in very hot water with detergent and a cup of bleach, and dry them in a hot clothes dryer.

THERMOMETERS

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

PERSONAL HYGIENE ITEMS

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

FOOD PREPARATION

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

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

SAFE AND LEGAL DISPOSAL OF SHARPS

Syringes, needles, and lancets are called “sharps,” and their disposal is regulated. Sharps can carry hepatitis, HIV, and other bacteria and viruses that cause disease. Throwing them in the trash or flushing them down the toilet can pose health risks for others—such as sanitation (garbage) workers, other utility workers, and the public—from needlesticks and illness. Rules and disposal options vary according to circumstance, so it is essential to check with your local health department to see which option applies to your situation.

Parents and caregivers should make sure that children understand never to touch a found needle or syringe, but to immediately ask a responsible adult for help.

Safe disposal of found syringes should follow these guidelines:

• Do not pick up a found syringe or needle with bare hands. Use gloves and tongs, shovel, or a broom and dustpan to pick it up. Hold the needle away from your body.
• Do not break the needle off from the syringe.
• Place used sharps and syringes in a safe container with at least a 1-inch opening and a lid that will seal tightly, such as an empty plastic laundry detergent container or glass bottle or jar. If a glass jar is used, place it in a larger plastic bucket or container that has a tight-fitting lid. Soda cans are not good containers to use because people often try to recycle discarded cans. Do not flush needles or syringes down the toilet.
• Tape the container shut for added safety and label it with the warning: “SHARPS, DO NOT RECYCLE!” Place it well out of reach of children.
• Call the local health department to determine what disposal sites are available.

Anyone with an accidental needlestick requires a prompt assessment by a medical professional. Testing for HIV, HCV, and HBV may be recommended. If someone finds and handles a syringe, but no needlestick occurs, testing for HIV is not necessary.

PET CARE

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

Pet cages and cat litter boxes can harbor infectious organisms that may become aerosolized. Pets can also spread disease by licking a person’s face or open wounds. Wash hands after stroking or other contact with pets.

Pets should be cared for by someone who is not immunocompromised. If this is not possible, a mask with a sealable nose clip and disposable latex gloves should be worn each time pet care is done.

All pet care should be followed by thorough handwashing. Cats’ and dogs’ nails should be kept trimmed. Wear latex or nitrile gloves to clean up any pet urine, feces, vomit, or OPIM. Clean the soiled area with a fresh solution of 1:10 bleach.

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

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

Part 3: HIV Testing and Counseling

TESTING RECOMMENDATIONS

Most HIV infections are transmitted by people who do not know they are infected. Therefore, HIV testing is the first step in halting spread of the virus. Research shows that people who are unaware of their HIV infection have a transmission rate of almost 11% compared with a rate of less than 2% in those who know they are HIV-positive. When counseling services are available and effective, that rate falls to near zero (Holtgrave & Anderson, 2004).

Testing is essential for anyone who has had a potential exposure to HIV. This includes anyone who has had unprotected anal, vaginal, or oral sex; who has shared needles or other injection drug preparation equipment; or who has had an occupational exposure. People with partners who have such risk factors should also consider testing.

The CDC (2006c) recommends routine voluntary HIV screening of patients aged 13–64 in all healthcare settings. Recommendations also include 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.

Washington State rules were revised effective June 18, 2005, to reflect the new CDC recommendations and enhance access to HIV testing. However, the CDC recommendations do not supersede Washington State rules regarding HIV testing and counseling.

According to the CDC (2006b), in 2006, about 40% of Americans aged 18–64 reported that they had been tested for HIV at some time in their lives. By 2009, that percentage grew to 45%. Offering rapid HIV tests to patients in community health centers as part of their primary care visits can greatly increase the number of people screened for HIV. Researchers found that the numbers of patients screened for HIV in six centers increased more than threefold (Myers et al., 2009).

Four years after the CDC recommendations, however, at least one study shows that HIV testing is far from routine outside of high-risk groups. Only one third of the internal medicine residents interviewed were aware of the 2006 guidelines and two thirds had ordered only 10 HIV tests within the prior six months. Only one third of those who did order HIV tests used the routine (opt-out) testing approach (Jain et al., 2009).

CONFIDENTIALITY AND INFORMED CONSENT

Confidential means that the patient gives his or her real name to the healthcare provider but that test results are revealed only to the patient and to the provider or counselor who tests or provides services to that patient. Those who perform HIV counseling and testing in public health departments or health districts must sign strict confidentiality agreements. These agreements regulate the personal information that may be disclosed in counseling and testing sessions and in test results. HIV test results are kept in locked files, with only a few appropriate staff members having access to them. Positive HIV tests must be reported to local public health officials, however.

Anonymous means that the health professional who orders or performs the test does not maintain a record of the name of the person being tested. Public health departments in Washington State must make anonymous HIV testing reasonably available. Anonymous testing may also be available through Planned Parenthood or other healthcare clinics. The Washington State HIV/AIDS hotline (1-800-272-2437) can provide information about anonymous testing locations.

HIV testing can only be done with a person’s informed consent, with rare exceptions. These exceptions include source testing relating to occupational exposures and legally mandated situations specified in Washington State law.

Consent may be contained within a comprehensive consent for medical treatment. Washington State revised rules (2005) eliminate language requiring “separate” informed consent. However, before HIV testing is performed, patients must be explicitly told that this test is recommended and agree to HIV testing. Receipt of consent must be documented, either in the patient’s regular medical record, in another record of services provided, or by written consent. Verbal consent is often used in anonymous testing situations.

Pretest prevention counseling is required only for persons who are at increased risk for HIV infection and for those who request counseling. Such counseling can be accomplished by referral to a local health department or other appropriate facility, such as a community-based organization that provides counseling services. Pretest counseling should be culturally, linguistically, developmentally, and medically appropriate and include information on:

• The benefits of learning HIV status and the potential dangers of the disease
• The ways in which HIV is transmitted and can be prevented
• The meaning of HIV test results and the importance of obtaining test results
• As appropriate, the availability of anonymous HIV testing and the differences between anonymous and confidential testing (WAC 246-100-27). For example, anonymous testing may not be a medically appropriate option for a patient presenting with signs or symptoms of HIV infection (Washington State Department of Health, 2005).

(For additional information on confidentiality and informed consent, see “Legal and Ethical Issues” below.)

TESTING SPECIAL POPULATIONS

The 2006 CDC recommendations for pregnant women include the following:

• HIV screening should be included 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.

COUNSELING REQUIREMENTS

Washington State revised rules (RCW 70.24.095 and WAC 246-100-208) require that all healthcare providers caring for pregnant women provide or ensure HIV/AIDS counseling for each pregnant woman who seeks prenatal care with the intent of continuing the pregnancy. Counseling is to include the following:

• Performing a risk screening that includes an assessment of sexual and drug-use history as part of the intake process
• Providing written or verbal information on HIV infection that encompasses the following:
  • The recommendation that all pregnant women be tested for HIV
  • Information on HIV transmission and that it is the cause of AIDS
  • That a woman may be at risk of HIV and not know it
  • Treatments that reduce mother-to-baby transmission
  • Availability of anonymous testing and why confidential testing is recommended for pregnant women
  • Legal requirement to report HIV infection
  • Availability of public funds to assist eligible HV-infected women to receive medical care and other assistance
  • That women who decline the test will not be denied care for themselves or their infants
• Obtaining informed consent, either separately or as part of the consent for a battery of other routine tests, provided that the woman is explicitly informed in writing or verbally that HIV testing is included
• Providing testing unless the woman refuses
• Documenting refusal
• If risk screening indicates, referring for behavioral change, based on criteria listed below
• Offering referrals and providing follow-up to other necessary medical, social, and HIV prevention services

If a pregnant woman refuses a confidential test, her reasons for refusal, as well as the provision of education on the benefits of HIV testing, must be discussed and documented in the medical record.

BEHAVIORAL CHANGE COUNSELING

If screening suggests a high risk of HIV, the provider should provide or refer for behavioral change counseling, women who:

• Have or recently had a sexual partner(s) known to be HIV-infected or to be a man who has sex with other men or who is an injection drug user
• Use or have recently used injection drugs
• Have signs or symptoms of HIV seroconversion
• Have recently exchanged sex for drugs or money or had an STD or multiple sex partners
• Express a need for further more intensive counseling

Behavioral change counseling should be based on the standards defined in WAC 246-100-209 and the CDC recommendations in Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings, September 22, 2006.

The provider should also offer referrals and provide follow-up to other necessary medical, social, and HIV prevention services.

Patients Seeking Treatment of an STD

Principal healthcare providers must counsel or ensure AIDS counseling as defined in WAC 246-100-011(2) and offer and encourage HIV testing for each patient seeking treatment of a sexually transmitted disease (STD).

Individuals in Drug Treatment Programs

Washington State law requires that drug treatment programs under chapter 70.96A RCW provide or ensure provision of AIDS counseling as defined in WAC 246-100-011(2) for each person in a drug treatment program. This includes offering, or referring for, HIV testing and personalized risk reduction education.

Survivors of Sexual Assault or Abuse

Survivors of rape (sexual assault) are at risk for infection with HIV and other STDs. Each year more than 237,000 women and 11,000 men are sexually assaulted in the United States. More than 36,000 of them are age 19 or younger (BJS, 2008). The CDC estimates that the risk of HIV infection from a sexual assault in the United States is 2 in 1,000. (The risk of infection with other STDs is higher.)

The probability of HIV transmission during a single act of intercourse with an HIV-infected person depends on many factors. These factors include: type of intercourse (oral, vaginal, anal); presence of oral, vaginal, or anal trauma (including bleeding); site of exposure to ejaculate; viral load in ejaculate; and presence of an STD or genital lesions in the assailant or survivor.

Sexual assault also puts adolescent girls and women at risk of becoming pregnant, so emergency contraception is part of the medical protocol for female rape survivors. Counselors must provide survivors with the toll-free number for the emergency contraception hotline (1-888-NOT-2-LATE or 1-888-668-2528).

ASSESSMENT PROTOCOL

A sexual assault survivor should go directly to the nearest hospital emergency department (ED) without changing clothing and without bathing or showering, which might remove evidence that could incriminate the assailant. Trained ED staff will counsel the survivor and also offer testing or referral for HIV, STDs, and pregnancy.

Testing the survivor of sexual assault for HIV immediately after the event can establish that the survivor was not infected at the time of the assault. However, it is important to consider the window period and retest later if the assailant proves to be HIV-positive. In the rare case that an assault survivor is infected by the assailant, the earlier test can serve as evidence in criminal court.

The standard protocol is for the ED physician to take DNA samples of blood or semen from the vagina, rectum, or elsewhere, as indicated, which can be used as evidence for legal and criminal action. Some emergency departments may refer sexual assault survivors to the local health jurisdiction for HIV testing.

Questioning sexual assault survivors in the ED about their sexual risks can be difficult and unpleasant. However, testing shortly after a sexual assault provides useful baseline information on the various infections—especially for follow-up care and treatment.

Under Washington State law, survivors of sexual assault cannot force an assailant to be tested for HIV antibodies unless that assailant is a convicted sex offender or convicted of prostitution or of a drug offense involving a hypodermic syringe. Thus, the survivor needs to decide whether to start PEP independently of the assailant’s test result, because the time between the attack and the conviction is likely to be longer than the 24 to 48 hours recommended for beginning PEP.

Depending on the location, providers may not be familiar with the idea of providing PEP to survivors of sexual assault. (More information is available from the University of California at San Francisco, which operates a PEP clinic for nonoccupational exposure.)

HIV AND CHILD SEXUAL ASSAULT

Children may be at higher risk for HIV transmission from sexual assault because child sexual abuse is often associated with multiple episodes of assault and may result in mucosal trauma. The CDC has identified certain situations involving high risk for STD transmission to children, including HIV, and these constitute a strong indication for testing:

• The child has or has had symptoms or signs of an STD or of an infection that can be sexually transmitted, even in the absence of suspicion of sexual abuse. Signs that may be associated with a confirmed STD diagnosis are vaginal discharge or pain, genital itching or odor, urinary symptoms, and genital ulcers or lesions.
• A suspected assailant is known to have an STD or to be at high risk for STDs (has multiple sex partners, a history of STDs)
• A sibling or another child or adult in the household or immediate environment has an STD
• The patient or parent requests testing
• The prevalence of STDs in the community is high
• Evidence of genital, oral, or anal penetration or ejaculation is present

HIV TESTS

HIV/AIDS testing is available in a variety of settings:

• Home
• Public health departments
• Medical providers
• Family planning clinics
• STD clinics
• Some community clinics

The Washington State HIV/AIDS hotline (1-800-272-2437) can provide referral to a public health, family planning, or community clinic in each county.

Types of HIV Tests

HIV testing is a two-step process that includes a screening test and, when the screening test is reactive (positive), a confirmatory test.

Until 2002, testing for HIV antibodies relied on an enzyme-linked immunosorbent assay (ELISA) of blood. Since then, six rapid HIV tests have been approved by the FDA, all of which are interpreted visually. Four of the tests have been approved for use outside of a clinical laboratory. The FDA and the Centers for Medicare and Medicaid Services have also issued guidelines for a rapid HIV test quality-assurance program (Greenwald et al., 2006).

RAPID HIV TESTS

1. OraQuick ADVANCE Rapid HIV-1/HIV-2 Antibody Test detects HIV-antibodies in oral fluid as well as in blood.
2. Uni-Gold Recombigen HIV Test detects HIV-1 antibodies in whole blood, serum, and plasma; results take from 10 to 12 minutes.
3. Reveal G3 Rapid HIV-1 Antibody Test detects HIV antibodies in serum or plasma; although the test takes only 3 minutes to run, it is categorized as a moderately complex test and is usually done in a clinical laboratory.
4. 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 are available in 20 minutes. Also a moderately complex test, it is usually done in a clinical laboratory (FDA, 2008).
5. Clearview HIV-1/HIV-2 STAT-PAK uses whole blood or serum and plasma; results are available in 15 minutes; requires no training to use.
6. Clearview HIV-1/HIV-2 Complete is a single-use, self-contained closed system for the collection, processing, and analysis of a whole blood, serum, or plasma sample; results are available in 15 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.

All positive (reactive) rapid HIV tests require repeat testing for confirmation. The CDC 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 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 4 weeks after the initial reactive rapid test result (CDC, 2004).

FDA-APPROVED RAPID HIV ANTIBODY SCREENING TESTS

Test	Specimen Type	CLIA Category*	Sensitivity** (95% CI)	Specificity** (95% CI)
Source: CDC, 2008e.
OraQuick ADVANCE Rapid HIV-1/2 Antibody Test	Oral fluid	Waived	99.3% (98.4–99.7)	99.8% (99.6–99.9)
	Whole Blood (finger stick or venipuncture)	Waived	99.6% (98.5–99.9)	100% (99.7–100)
	Plasma	Moderate Complexity	99.6% (98.9–99.8)	99.9% (99.6–99.9)
Uni-Gold Recombigen HIV	Whole blood (finger stick or venipuncture)	Waived	100% (99.5–100)	99.7% (99.0–100)
	Serum and Plasma	Moderate Complexity	100% (99.5–100)	99.8% (99.3–100)
Reveal G-3 Rapid HIV-1 Antibody Test	Serum	Moderate Complexity	99.8% (99.2–100)	99.1% (98.8–99.4)
	Plasma	Moderate Complexity	99.8% (99.0–100)	98.6% (98.4–98.8)
MultiSpot HIV-1/HIV-2 Rapid Test	Serum	Moderate Complexity	100% (99.94–100)	99.93 (99.79–100)
	Plasma	Moderate Complexity	100% (99.94–100)	99.91 (99.77–100)
Clearview HIV-1/2 STAT-PAK	Whole Blood (finger stick or venipuncture)	Waived	99.7% (98.9–100)	99.9% (99.6–100)
	Serum and Plasma	Non-waived	99.7% (98.9–100)	99.9% (99.6–100)
Clearview COMPLETE HIV-1/2	Whole Blood (finger stick or venipuncture)	Waived	99.7% (98.9–100)	99.9% (99.6–100)
	Serum and Plasma	Non-waived	99.7% (98.9–100)	99.9% (99.6–100)
*Clinical Laboratory Improvement Amendments: CLIA regulations identify three categories of tests: waived, moderate complexity, or high complexity. (See below for more information on CLIA.)
** Sensitivity is the probability that the test result will be reactive if the specimen is a true positive; specificity if the probability that the test result will be nonreactive if the specimen is a true negative. Data are from the FDA summary basis of approval, for HIV-1 only. For HIV-2 information, see package inserts.

To ensure accuracy of test results, all laboratory testing is regulated under the federal Clinical Laboratory Improvement Amendments of 1988 (CLIA), which classifies tests according to their complexity. Tests that use direct, unprocessed specimens such as whole blood or oral fluid, are easy to perform, and have a negligible chance of error may receive a CLIA waiver. This waiver permits personnel without training in laboratory procedures to perform the tests outside a traditional laboratory setting.

The OraQuick, Uni-Gold and Clearview tests using whole blood have received a CLIA waiver, but the other two rapid tests mentioned above must be performed in laboratories that meet more stringent standards for personnel, supervision, quality assurance, and proficiency testing.

The standard procedure for Washington State laboratories is to conduct confirmatory testing for HIV-1, unless requested otherwise. However, in the case of clients who have had unprotected sex with, or have shared needles with, someone from an African country, confirmatory testing for both HIV-1 and HIV-2 must be requested.

Washington State law (RCW 70.42) requires that all sites performing clinical laboratory testing obtain a state medical test site (MTS) license. All agencies conducting waived rapid testing must obtain an MTS license (Category: certificate of waiver). The MTS license takes the place of a federal CLIA certificate.

OTHER TESTS

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 over predicts positives; consequently, a negative HIV antibody test is considered definitive and no further testing is required. If the results are positive, however, Washington State law (WAC 246-100-207) prohibits telling a person he or she is HIV-positive based only on ELISA test results. This law reflects CDC recommendations.

Western Blot

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. 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.

Urine HIV

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.

p24 Antigen

This blood test is used to measure a core protein of HIV that occurs during primary infection. This protein may disappear as soon as HIV antibodies appear. The transitory nature of this protein and the expense of the test limit the usefulness of the p24 antigen test.

Plasma HIV RNA or Proviral DNA

These blood tests may be used in people with suspected new HIV infection. Their expense prohibits the use of these tests as screening tests for the general public. However, anyone who has had a potential exposure to HIV through unprotected sex or sharing needles and who presents with symptoms of primary infection (usually seen within the first two weeks of infection) should consult their healthcare professional about this test.

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. Home Access Express HIV-1 Test System is the only FDA-approved home test kit currently on the market, but several unapproved kits are marketed on the Internet. This Home Access Express product is really an in-home sample collection system rather than a test with readily visible results. The person who wants to test at home pricks a finger and collects blood spots on special paper. The paper is mailed to a certified clinical laboratory with a confidential and anonymous personal identification number (PIN) and then tested using a standard ELISA process.

If the initial test result is positive, the results are confirmed by a Western blot test. The person tested obtains the results by calling a toll-free telephone and using the assigned PIN. Post-test counseling is available by telephone for everyone tested, whether the results are positive or negative.

Home testing is a controversial issue, primarily because of the need for counseling. The FDA has expressed concern that people who have not been appropriately counseled by experienced staff in a culturally competent way before they receive the news that they are HIV-positive may commit suicide. Counseling needs to help reduce anxiety and risk-taking behavior as well as link individuals to services. However, at least one survey showed that nearly 1/4 of clients at public testing services would choose a home self-test.

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.

Washington State rules allow for test results to be conveyed to patients in person or by telephone, followed by later counseling, if needed. CDC recommendations state that test results should be conveyed to patients in the same manner as for other routine diagnostic tests, either by telephone or by mail, followed by later counseling, if needed.

If clients test negative for HIV, providers can report results to them by telephone and discuss the 1- to 3-month window period, and if applicable, the need for retesting. However, specific efforts need not be made to contact persons with negative results who do not return or telephone for their results.

If clients test positive for HIV, Washington State law (WAC 246-100-207 and -209) requires that HIV post-test prevention counseling be provided. Providers should discuss HIV transmission, ways to protect partners, and disclosure of status to others. Assertive efforts should be made to contact persons with positive results who do not telephone or return for their results.

CDC (2008) recommends that clients tested with rapid HIV tests be advised that their preliminary results will be available in the same visit and that confirmatory testing will be needed if the rapid test result is positive. In addition, retesting within 3 months should be recommended even if the rapid test result is negative.

NEGATIVE TEST RESULTS

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 to 6 months and practice safer behaviors in the meantime. If risky behavior continues, infection may still occur.

Additional testing is recommended as follows:

• If the original confirmatory test specimen was a blood specimen, repeat the confirmatory test with a new blood specimen to rule out specimen mix-up.
• If the original confirmatory test specimen was an oral fluid specimen, repeat the confirmatory test using a blood specimen.

POSITIVE TEST RESULTS

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

INDETERMINATE TEST RESULTS

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.

• If the confirmatory test is indeterminate based on a blood specimen, advise the client to return for repeat testing in one month and at three months from the last possible exposure to verify that they are not infected.
• If the confirmatory test is indeterminate based on an oral fluid specimen, repeat the confirmatory test using a blood specimen.
• If the repeat blood specimen confirmatory test is also indeterminate, advise the client to return for repeat testing in one month.

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.

COUNSELING

All testing offers an opportunity for counseling patients. If test results are negative, counseling efforts typically focus on avoiding exposure to HIV through safer sex practices and not sharing needles. If results are positive, counseling typically focuses on preventing transmission of the virus to others and referring the patient to resources for treatment, education, and support.

Any person who requests pretest counseling and anyone defined as at increased risk for HIV should be offered or referred for pretest counseling. Anyone declining pretest counseling may not later be denied HIV testing (WAC 246-100-207). If the provider determines the individual is at high risk for HIV infection, counseling should be based on assessment of the individual client as outlined below.

All individuals tested for HIV should also be offered an opportunity to receive post-test counseling. Those who test positive for HIV must be provided with post-test counseling (WAC 246-100-209).

Washington State revised rules (WAC 246-100-209) require a client-centered approach to pre- and post-test HIV counseling. The rules state: “Required elements of counseling include: (1) an individualized risk assessment, and (2) assisting the patient to establish realistic behavior change goals that reduce the risk of transmitting or acquiring HIV and providing risk reduction skills opportunities” (Washington State Department of Health, 2005).

Washington rules also state that those conducting HIV tests do not have to provide the counseling themselves; they can refer the client to another person or agency for counseling.

Risk Assessment and Behavior Change Goals

A client’s individual HIV risk can be determined through risk screening based on self-reported behavioral risk and clinical signs or symptoms. Behavioral risks include injection drug use or unprotected intercourse with a person at increased risk for HIV. Clinical signs and symptoms include those suggestive of HIV infection and other STDs.

RISK ASSESSMENT QUESTIONS

Behavioral risks can be identified either through open-ended questions by the provider or through screening questions (i.e., a self-administered questionnaire).

An example of an open-ended question is: “What are you doing now or what have you done in the past that you think may put you at risk of HIV infection?”

Examples of screening questions are:

“Since your last HIV test (if ever) have you:

• Injected drugs and shared equipment such as needles, syringes, cotton, water with others?”
• Had unprotected intercourse with someone who you think might be infected?”
• Had unprotected vaginal or anal intercourse with more than one sex partner?”
  
  (This is not a comprehensive list of risk screening questions.)

RISK REDUCTION GOALS AND SUPPORT SKILLS

Bahavior change goals should be: (1) based on the individual’s risk; (2) perceived as realistic by the patient; and (3) based on the person’s readiness and capability to change behavior.

Depending on the person’s readiness for change, counseling can be simple and brief or complex and lengthy. In many clinical practice settings, time restraints only permit brief and simple counseling.

As an example, for a patient who has yet to contemplate behavior change, a realistic goal might be helping patients recognize which behaviors place them at risk for HIV. Skill building could help the patient self-identify situations where the risk behavior is practiced.

Other patients may be further along the behavior change continuum and have identified specific behaviors they wish to change. Support for those identified changes is appropriate. A relevant goal might be to identify barriers to the behavior change and help the patient self-identify solutions. Demonstrating how to use a condom or how to discuss condom use with a new partner could be examples of building skills.

For those patients who have complex needs beyond the provider’s counseling skills or time available, referral to other resources should be arranged.

Post-Test Counseling

The goals of post-test counseling are to increase the individual’s understanding of HIV infection, change the individual’s behavior, and, if necessary, encourage the individual to notify people with whom there has been potential transmission of HIV.

REPORTING REQUIREMENT

Positive HIV test results must be reported confidentially to the state or local health officer, unless the individual has been tested anonymously. People who test positive should be reminded about this legal reporting requirement.

If a person who tests positive for HIV infection fails to return for test results, the healthcare provider must provide the local health officer with the name of the individual and any information that could help locate him or her. The health officer will follow up to assure that post-test counseling and partner notification assistance are provided (WAC-246-10-207).

SPOUSE/PARTNER NOTIFICATION

Both federal and state laws require that a good-faith attempt be made 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 Washington State, the rules for spouse/partner notification apply only when an HIV/AIDS test is confirmed positive.Therefore, it is not necessary to discuss spouse/partner notification at the preliminary reactive rapid test result session. Instead, providers must ensure compliance with the rules for partner notification at the post-test (confirmed) positive counseling session. (Procedures and guidance for partner notification can be found in WAC 246-100-072.)

In Washington State, Public Health is responsible for providing spouse/partner notification services to the infected client and exposed partners. It is a voluntary, confidential service that uses a variety of strategies to make sure exposed partners are notified of their exposure to HIV and receive appropriate counseling in a way that respects the confidentiality of the source patient.

Those who test positive for HIV should be given the choice to notify their partner(s) or to allow the healthcare provider to notify the partner(s). Or, they may be referred to the local health jurisdiction for assistance in notifying the partner(s).

The principal healthcare provider may take responsibility for partner notification based on consultation with the local health officer. Providers accepting partner notification responsibility must ensure that these efforts are carried out as described in WAC 246-100-072.

Washington State revised rules allow the local health officer directly to contact a person newly reported with HIV infection for the purpose of offering partner notification assistance after consultation with the principal healthcare provider.

Part 4: 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 death is 10 to 12 years. However, early detection and appropriate medical treatment may extend the lives of those infected and reduce the rates of HIV transmission.

COURSE OF THE DISEASE AND DIAGNOSIS

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, can affect the course of disease progression, including age, genetic factors, drug use, smoking, nutrition, and coinfection with hepatitis C virus (HCV) and/or tuberculosis (TB).

Stages of HIV/AIDS

Although the slope of the disease trajectory varies with each individual, HIV/AIDS progresses through five stages:

1. Viral transmission: the initial infection with HIV, also called acute HIV infection. Persons may become infectious to others within days of transmission and before any symptoms appear. Once infected, a person is always infectious to others. During acute HIV infection, high levels of virus circulate in the bloodstream. Symptoms are nonspecific and may include fever, swollen lymph glands, rash, fatigue, and sore throat. This is sometimes called seroconversion syndrome or seroconversion sickness. Initial symptoms resolve in a few weeks but the person remains infectious for life.
2. Seroconversion: the time period from infection to the production of antibodies detectable on an HIV test, usually within 3 to 6 months of transmission.
3. Asymptomatic HIV infection: a variable time period, sometimes 10 years or longer, during which an HIV-infected person has no noticeable signs or symptoms and appears healthy, but can transmit the virus to others. Unless tested for HIV, the person will not be aware of being infected.
4. Symptomatic HIV infection: the stage during which noticeable physical symptoms of HIV are present. The most common symptoms include:
   • Persistent low-grade fever
   • Pronounced weight loss not due to dieting
   • Persistent headaches
   • Diarrhea lasting more than 1 month
   • Difficulty recovering from colds and flu
   • More acute illness than normal
   • Recurrent vaginal yeast infections in women
   • Oral thrush (candidiasis) coating the mouth or tongue
5. AIDS: diagnosis can be made only by a licensed healthcare provider. The diagnosis is based on the result of HIV-specific blood tests and the person’s physical condition. Once diagnosed with AIDS, a person is always considered to have AIDS, even if their health seems to improve. Over time, people with AIDS frequently have a reduced white-blood-cell count and deteriorating health. They also may have a significant amount of virus present in their blood, measured as viral load.

CDC AIDS CASE DEFINITION FOR SURVEILLANCE OF ADULTS AND ADOLESCENTS

Source: Zolopa & Katz, 2010.
Definitive AIDS diagnoses with or without laboratory evidence of HIV infection	Candidiasis of esophagus, bronchi, trachea, or lungs Cryptococcosis, extrapulmonary Cryptosporidiosis, chronic intestinal (>1 month duration) Cytomegalovirus disease of an organ other than liver, spleen, or lymph nodes Herpes simplex virus infection causing a mucocutaneous ulcer(s) (>1 month duration) or bronchitis, pneumonitis, or esophagitis of any duration Kaposi’s sarcoma in a patient <60 years of age Lymphoma of the brain (primary) in a patient <60 years old Mycobacterium avium complex or disease caused by M. kansasii, disseminated (at a site other than or in addition to lungs, skin, or cervical or hilar lymph nodes) Pneumocystis jiroveci pneumonia Progressive multifocal leukoencephalopathy Toxoplasmosis of the brain
Definitive AIDS diagnoses with laboratory evidence of HIV infection	Coccidioidomycosis, disseminated (at a site other than or in addition to lungs or cervical or hilar lymph nodes) HIV encephalopathy Histoplasmosis, disseminated (at a site other than or in addition to lungs or cervical or hilar lymph nodes) Isosporiasis with diarrhea (>1 month duration) Kaposi’s sarcoma at any age Lymphoma of the brain (primary) at any age Other non-Hodgkin lymphoma of B cell or unknown immunologic phenotype Any mycobacterial disease caused by mycobacteria other than M. tuberculosis, disseminated (at a site other than or in addition to lungs, skin, or cervical or hilar lymph nodes) Disease caused by extrapulmonary M. tuberculosis Salmonella (non-typhoid) septicemia, recurrent HIV wasting syndrome CD4+ lymphocyte count below 200 cells per microliter or CD4 lymphocyte percentage below 14 percent Pulmonary tuberculosis Recurrent pneumonia Invasive cervical cancer
Presumptive AIDS diagnoses with laboratory evidence of HIV infection	Candidiasis of esophagus: (a) recent onset of retrosternal pain on swallowing; and (b) oral candidiasis Cytomegalovirus retinitis. A characteristic appearance on serial ophthalmoscopic examination Mycobacteriosis: Specimen from stool, normally sterile body fluids or tissue from a site other than lungs, skin, or cervical or hilar lymph nodes, showing acid-fast bacilli of a species not identified by culture Kaposi’s sarcoma: Erythematous or violaceous plaque-like lesion on skin or mucous membrane Pneumocystis jiroveci pneumonia: (a) a history of dyspnea on exertion or nonproductive cough of recent onset (within past 3 months); and (b) chest x-ray evidence of diffuse bilateral interstitial infiltrates or gallium-scan evidence of diffuse bilateral pulmonary disease; and (c) arterial blood gas analysis showing an arterial oxygen partial pressure of <70 mm Hg, or a low respiratory diffusing capacity of <80% of predicted values, or an increase in the alveolar-arterial oxygen tension gradient; and (d) no evidence of a bacterial pneumonia Toxoplasmosis of the brain: (a) recent onset of a focal neurologic abnormality consistent with intracranial disease or a reduced level of consciousness; and (b) brain imaging evidence of a lesion having a mass effect or the radiographic appearance of which is enhanced by injection of contrast medium; and (c) serum antibody to toxoplasmosis or successful response to therapy for toxoplasmosis Recurrent pneumonia: (a) more than one episode in a 1-year period; and (b) acute pneumonia (new symptoms, signs, or radiologic evidence not present earlier) diagnosed on clinical or radiologic grounds by the patient’s physician Pulmonary tuberculosis: (a) apical or miliary infiltrates; and (b) radiographic and clinical response to antituberculous therapy

Multisystem Effects of HIV/AIDS

HIV infection affects more than just the immune system. It also affects the cardiovascular, neurologic, and musculoskeletal systems as well as the body’s basic metabolism. These effects can alter:

• The kind and number of blood cells
• The amount and distribution of fat and muscles in the body
• The structure and function of the brain
• The basic metabolism of the body

HIV-RELATED CONDITIONS

Multisystem effects can lead to many painful or disruptive conditions, including:

• Confusion or dementia
• Vision or hearing loss
• Diarrhea, urinary or fecal incontinence
• Thrush (yeast infections in the mouth)
• Fatigue
• Fever
• Nausea or vomiting
• Painful joints, muscles, or nerve pain
• Difficult breathing
• Chronic pneumonias, sinusitis, or bronchitis
• Loss of muscle tissue and body weight

Dementia is a growing concern as HIV-infected people live longer. Using functional MRI, researchers measured the blood flow in the brains of people with HIV and found signs of premature aging. Whether this effect is the result of the virus or the antiviral drugs—or both—is unclear. However, the evidence of harm raises concern because, by 2015, people over 50 will account for more than half of all AIDS patients (Ances et al., 2010).

HIV/AIDS also increases the risk of certain cancers, four of which are included in the CDC classification of AIDS: Kaposi’s sarcoma, non-Hodgkin’s lymphoma, primary lymphoma of the brain, and invasive cervical carcinoma in women. Recent research shows that in HIV-infected men, antiretroviral therapy has a protective effect against first AIDS-defining cancers (Shiels et al., 2008). Cervical carcinoma seems to be more aggressive in HIV-infected women. Most women with cervical cancer die of that disease rather than AIDS (Zolopa & Katz, 2010).

Research has also shown that HIV infection is associated with a five-fold increase in the incidence of Hodgkin’s disease. Anal dysplasia and squamous cell carcinoma have also been associated with HIV infection in both men and women, many of whom are also infected with HPV. Dysplasia can progress quickly to invasive cancer in patients with compromised immune systems; therefore, some experts recommend anal Papanicolaou swabs in HIV patients.

HIV-RELATED CONDITIONS AMONG SPECIAL POPULATIONS

HIV/AIDS imposes an additional burden on African Americans. The risk of end-stage renal disease (ERD) in HIV-infected black patients was 4 to 5 times greater than the risk of ERD in HIV-infected white patients (Choi et al., 2007).

Children infected with HIV/AIDS may have different reactions to the virus, its progression, and their virologic and immunologic response. Without drug treatment, children may be developmentally delayed, experience failure to thrive, and be vulnerable to Pneumocystis jiroveci pneumonia and recurrent bacterial infections. Antiretroviral treatments available for adults with HIV/AIDS may not be available in pediatric formulations and may cause different side effects in children. (Pediatric HIV/AIDS is a specialty that is beyond the scope of this course.)

TREATMENT AND CARE

Optimal care of people with HIV/AIDS includes not only antiviral therapies, health maintenance, and referral to support services but also an emphasis on prevention of transmission to uninfected partners. (See also above under “Preventing Transmission to Uninfected Partners.”)

Case Management

Case managers in Washington State HIV/AIDS programs are the primary contact people for services, including medical care, insurance programs, volunteer groups, home care, hospice, and other types of care that may be needed during the course of a person’s or family’s living with HIV/AIDS. The HIV/AIDS program in a county health department or district can help patients find a case manager, as can the Washington State Department of Health Client Services (see “Resources” at the end of the course).

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

Antiretroviral Therapy

Antiretroviral therapy (ART) has become the gold standard for treatment of HIV/AIDS. People with HIV may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia.

ART Drugs

Antiretroviral drugs are administered in “cocktails” of three or more, a treatment referred to as antiretroviral therapy (ART). (ART is also sometimes referred to as highly active antiretroviral therapy, or HAART.) The primary goal of ART is to reduce HIV-associated morbidity and mortality by suppressing the individual’s viral load to below detectable levels.

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.

INITIATING ART

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 (2009):

• Antiretroviral therapy should be initiated in all patients with history of an AIDS-defining illness or with a CD4+ T cell count <350 cells/mm.
• Antiretroviral therapy should also be initiated in the following groups of patients regardless of CD4 T-cell count:
  • Pregnant women
  • Patients with HIV-associated nephropathy
  • Patients coinfected with HBV when treatment is indicated
• Antiretroviral therapy may be considered in all patients with CD4 T-cell counts between >350 and 500 cells/mm. (See detailed guidelines on the AIDSinfo website listed under “Resources” at the end of the course.)
• 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

Treatment guidelines are revised frequently based on ongoing research findings. The most up-to-date information can be found online at http://aidsinfo/nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

HEALTHCARE MAINTENANCE OF HIV-INFECTED INDIVIDUALS

Condition	Healthcare Maintenance
Source: Zolopa & Katz, 2010.
All HIV-infected individuals	CD4 counts every 3–6 months Viral load tests every 3–6 months and 1 month following a change in therapy PPD (to screen for tuberculosis) INH for those with positive PPD and normal chest x-ray RPR or VDRL (to screen for syphilis) Toxoplasma IgG serology Hepatitis serologies: hepatitis A antibody, hepatitis B surface antigen, hepatitis B surface antibody, hepatitis B core antibody, hepatitis C antibody Cytomegalovirus IgG serology Pneumococcal vaccine Inactivated influenza vaccine in season Hepatitis A vaccine for those without immunity to hepatitis A Tetanus/diphtheria vaccine Hepatitis B vaccine for those who are HB surface antigen and antibody negative. Haemophilus influenzae B vaccination Papanicolaou smears every 6 months for women Consider anal swabs for cytologic evaluation yearly for patients with history of receptive anal intercourse
HIV-infected individuals with CD4<200 cells/μL	P jiroveci prophylaxis
HIV-infected individuals with CD4<75 cells/μL	M avium complex prophylaxis
HIV-infected individuals with CD4<50 cells/μL	Consider CMV prophylaxis
PPD = purified protein derivative; INH = isonicotinic acid hydrazide (isoniazid); RPR = rapid plasma regain; VDRL = Venereal Disease Research Laboratories; IgG = immunoglobulin G; HBsAb = antibody to the hepatitis B surface antigen; CMV = cytomegalovirus

TREATMENT EFFICACY

The efficacy of ART can be measured by plasma HIV RNA testing. Four to six months after treatment begins, there should be no detectable virus (<50 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.

TREATMENT COMPLIANCE

Successful treatment not only requires the patient to have significant financial resources but also the ability to understand and comply with a complex regimen.

Unfortunately, many of the patients with the greatest need for treatment lack the necessary financial resources to make treatment a reality. However, patient demographics, such as race/ethnicity, sex, age, and socioeconomic status, do not predict who will adhere to a treatment regimen. Research in Africa among the poorest populations showed 90% adherence, as compared to 70% in the United States (McNeil, 2003).

ART COMPLICATIONS

Discontinuing or interrupting ART may become necessary due to factors such as serious drug toxicity, intervening illness, surgery, or unavailability of medications. Although unplanned short-term interruption of therapy may be unavoidable, planned interruption is no longer recommended. Interrupting therapy increases the risk of AIDS-related complications, declining CD4 counts, and other non-AIDS-related complications such as heart attack and liver failure.

While extending and improving lives of people with HIV, long-term use of some of these drugs increases the risk of liver problems, high cholesterol, stroke, heart disease, osteoporosis, diabetes, pancreatitis, neuropathy, and skin rashes. Some of the skin rashes can be life-threatening, such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), which are two different forms of the same kind of skin rash. TEN may involve as much as 30% of the total body skin area. Both these severe rashes must be treated by a physician.

Antiretroviral drugs may also interact with other drugs used to treat opportunistic infections. For example, researchers reported that using oral erythromycin while taking protease inhibitors increased the risk of sudden death from cardiac causes (Ray et al., 2004). As patients live longer with HIV/AIDS, many develop drug-resistant strains of the virus, which further complicates treatment.

DRUG RESISTANCE TESTING

Use of multi-drug ART by many people over time has allowed drug-resistant strains of the virus to develop. These drug resistant strains have been found in those receiving ART as well as in patients who have never received ART, which limits their treatment options at the outset.

Experts predict that drug-resistant infections are about to spike in developed countries. One recent study suggests that drug resistance will increase by about 30% in the next 3 to 5 years in San Francisco (Smith et al., 2010). Treating drug-resistant HIV requires a constantly changing cocktail of expensive new drugs, and adherence to such a complex regimen can be difficult for many patients. If drug resistance increases in developing countries, treatment would be unsustainable.

Experts recommend that pretreatment drug-resistance testing be done in persons with acute or chronic HIV infection and when changing antiretroviral regimens after drugs cease to be effective (treatment failure). Resistance testing helps clinicians better predict viral response to newly initiated therapy.

HIV drug resistance testing also should be performed:

• To assist in selecting active drugs when changing antiretroviral regimens in cases of virologic failure
• When managing suboptimal viral load reduction

In cases of virologic failure, drug resistance testing should be performed while the patient is taking his or her drugs or within 4 weeks of discontinuing therapy.

Two types of resistance assays are used: genotypic and phenotypic assays. Genotypic assays detect drug resistance mutations in the viral genes, while phenotypic assays measure a virus’s ability to grow in different concentrations of antiretroviral drugs. Genotypic assays take 1 to 2 weeks and phenotypic assays, 2 to 3 weeks. A genotypic assay is generally recommended for patients who have never had antiretroviral therapy. Genotypic resistance testing also is recommended for all pregnant women prior to initiation of therapy and for those entering pregnancy with detectable HIV RNA levels while on therapy.

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 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.

COEXISTING INFECTIONS

Infections that are commonly found in HIV-positive patients include a number of other sexually transmitted diseases, TB, and hepatitis. Coexisting infections may increase the risk of transmission of HIV and make its treatment more complex.

Tuberculosis

Mycobacterium tuberculosis (M. tuberculosis, or TB) is the most common and most deadly coexisting infection for HIV-positive individuals. Likewise, the spread of HIV/AIDS has helped fuel the TB epidemic. The CDC estimates that TB is the cause of death for a third of people with HIV worldwide. Any HIV-infected person with a diagnosis of TB should be reported as having TB and AIDS.

In 2008, reported cases of TB in the United States fell to 12,904, the lowest rate (4.2 cases per 100,000) since 1953 (CDC, 2009b). However, the rate of decline in TB incidence has slowed, which experts see as cause for concern. Left untreated, active TB disease will develop in 5% to 10% of infected individuals. In 2008 in King County, 7% of TB cases were coinfected with HIV.

Coinfection with TB and HIV also declined in 2008. However, coinfection rates were much higher among such subgroups as injection drug users, non-injection drug users, homeless persons, non-Hispanic blacks, and correctional facility inmates (CDC, 2009c).

As the decline in TB rates has slowed, the number of multidrug-resistant TB cases has increased, and disparities in TB rates between whites and racial/ethnic minorities have persisted. In 2008 more cases of TB were reported among Asians nationally than in any other racial/ethnic population. In Washington State and in King County, blacks/African Americans had the highest incidence of TB, followed by Hispanics, Asians, Native Americans/Alaska Natives, and whites.

According to the CDC (2009d):

• A person with HIV and untreated latent TB infection is much more likely to develop active TB disease during his or her lifetime than someone without HIV infection.
• Among people with latent TB infection, HIV infection is the strongest known risk factor for progressing to active TB disease.
• Any HIV-infected person with a diagnosis of TB should be reported as having both TB and AIDS.

Current recommendations for care of the person with TB can be found in the Washington State Department of Health’s Guidelines for the Prevention, Treatment and Control of TB. A copy may be obtained by calling the Washington State Department of Health TB Program at 360-236-3447. Treatment of multidrug-resistant TB (MDR-TB) is much more difficult and must be individualized. Treatment takes two years or more.

TB TRANSMISSION

TB is transmitted by airborne droplets from people with active pulmonary or laryngeal TB during coughing, sneezing, or talking. When these infected droplets are inhaled, the bacteria enter the bloodstream and lymphatic system, and circulate throughout the body.

Most of the bacteria settle in the lungs, where they multiply and may cause pneumonia-like symptoms. This process is called primary infection and in most cases resolves by itself within 4 to 12 weeks, after which a latent state of TB develops. Nine out of 10 people with latent TB never experience subsequent disease and are not infectious to others. The only evidence of TB infection is a positive tuberculin skin test.

In 10% of infected individuals, the TB infection undergoes reactivation at some point, causing active TB disease. Progression to active disease and obvious symptoms (cough, weight loss, and fever) usually occurs within the first 2 years after infection but may occur at any time.

TB TESTING AND TREATMENT

All people infected with HIV should be tested for TB and, if infected, begin complete therapy as soon as possible to prevent active TB disease. HIV-infected persons with either latent TB infection or active TB disease can be effectively treated. The first step is to ensure that HIV-infected persons are tested for TB. The second step is to help those infected with TB to get proper treatment and prevent rapid progression from latent TB infection to active TB disease.

Treatment of HIV/TB coinfected patients involves a complex 6- or 9-month multidrug regimen. All these drugs have significant side effects, which can lead to nonadherence and development of MDR TB, which is much more difficult to treat successfully. Coinfected individuals are at increased risk of developing active TB disease, and their anti-HIV medications must be carefully orchestrated to coincide with the TB regimen. Ideally, this complex care involves experts in the management of both tuberculosis and HIV disease (CDC, 2007c).

EXPOSURE RISK FOR HEALTHCARE WORKERS

Healthcare workers should be screened and evaluated to identify those who are at risk for TB disease or exposure. In situations that pose a high risk of exposure to M. tuberculosis (such as rooms where cough-inducing or aerosol-generating procedures are performed), healthcare workers need to use respiratory protection equipment such as particulate filter respirators. Effectiveness of respiratory protection depends on how well the respirator fits the individual, the care in using the respirator, and the adequacy of the training and fit-testing program.

The CDC also recommends that visitors to airborne infection isolation (AII) rooms and other areas where there are patients who have suspected or confirmed infectious TB should be offered disposable respirators and should be instructed by a healthcare worker on use of the respirator before entering an AII room (CDC, 2005d).

Hepatitis

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.

Those who receive hepatitis B vaccine should be tested for antibodies to hepatitis B surface antigen (antiHBs) 1 to 2 months after completion of the primary series of hepatitis B vaccine. Those who fail to respond should be revaccinated with up to three additional doses.

COMPARISON CHART OF HIV, HBV, AND HCV

	HIV	HBV	HCV
Source: Washington State Department of Health, 2007.
Transmission by:
Blood	Yes	Yes	Yes
Semen	Yes	Yes	Rarely (more likely if blood present)
Vaginal fluid	Yes	Yes	Rarely (more likely if blood present)
Breast milk	Yes	No (but may be transmitted if blood is present)	No (but may be transmitted if blood is present)
Saliva	No	No	No
Target in the body	Immune System	Liver	Liver
Risk of infection after needlestick exposure to infected blood	0.5%	1–31%	2–3%
Vaccine available	No	Yes	No

HEPATITIS B

Hepatitis B (HBV) can cause chronic liver disease or liver cancer, which makes vaccination essential to prevention. HBV vaccine is relatively inexpensive for infants and children and commonly administered to most infants before their first birthday. It is critical that infants whose mothers are HBV positive receive the vaccine; otherwise, they have a 90% chance of developing the disease. Adult doses of HBV vaccine cost about $150 per person, which may explain why most adults are not vaccinated against HBV.

Each year, an estimated 43,000 people in the United States are infected with HBV. Each year, more than 11,000 people will be hospitalized and about 4,000 to 5,000 people will die from chronic liver disease or liver cancer caused by HBV (CDC, 2010d). Washington State Department of Health (2008) reported more than 15,000 cases of HBV from December 2000 through September 2008. HBV is diagnosed most often among people ages 25–54. Males have higher rates of infection in most age groups, although females ages 25–34 have a higher rate than males in that age group.

People with HBV should not donate blood, semen, or body organs.

Symptoms of HBV may vary. Some people may feel fine and look healthy; others may have only mild symptoms, such as loss of appetite, extreme fatigue, abdominal pain, jaundice (yellowing of the eyes and skin), joint pain, malaise, dark urine, nausea or vomiting, and skin rashes. Still others may experience more severe symptoms and may be incapacitated for weeks or months. Long-term complications may also occur, including chronic hepatitis, recurring liver disease, liver failure, or cirrhosis (chronic liver damage).

Risk factors for HBV include:

• Being born in areas with a high prevalence of HBV (China, Southeast Asia, Africa, the Pacific Islands, the Middle East, South America, and Alaska)
• Sharing injection paraphernalia
• Having sexual intercourse with an infected person or with multiple partners
• Men having sex with men
• Occupational exposures that involve contact with blood or body fluids, such as in a healthcare setting or prison
• Sharing personal care items such as razors or toothbrushes with an infected person
• Being on kidney dialysis
• Getting a tattoo or body piercing with equipment contaminated with the blood of someone infected with HBV

There are no medications available for recently acquired (acute) HBV infection. There are antiviral drugs available for the treatment of chronic HBV infection, but they are not always effective.

HEPATITIS C

Hepatitis C (HCV) is the most common chronic bloodborne infection in the United States and a leading cause of chronic liver disease. HCV was discovered in the late 1980s, although it was probably being spread for decades prior to that. The CDC (2009e) estimates that 3.2 million Americans have been infected with HCV, many of them from blood transfusions, and half of them do not know they are HCV-positive. (Since 1992, all blood donations in the United States have been tested for HCV.) People infected with HCV may have no symptoms for decades. When symptoms do appear, they are similar to those of HBV (see above).

Each year another 17,000 people in the United States are infected with HCV, and more than 8,000 people die from HCV-associated liver disease. In Washington State, approximately 5,300 cases of HCV were diagnosed annually from 2003 to 2007. Two-thirds of cases were among males. During this same time period, there were 590 HCV deaths annually among males and 306 deaths annually among females (Washington State DOH, 2009d).

Complications and costs associated with chronic HCV infection are expected to increase during 2010–2019 because the incidence of new infections peaked from the late 1960s to early 1980s (Klevens et al., 2009). About 4 of every 100 infants born to mothers with hepatitis C become infected with the virus. However, the risk increases if the mother is coinfected with both HIV and 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 (IDUs) (50%–90%). Coinfection with HIV and HCV is associated with higher titers of HCV, more rapid progression to HCV-related liver disease, and increased risk for cirrhosis of the liver.

Liver disease from chronic HCV is now one of the leading causes of death among people living with HIV. Individuals coinfected with HIV and HCV should restrict alcohol consumption and if possible avoid alcohol altogether because of potential liver damage.

The U.S. Public Health Service/Infectious Disease Society of America guidelines recommend that all HIV-infected persons be screened for HCV infection. People who should consider testing for HCV include:

• Current or former injection drug users
• Those who received blood transfusions or an organ transplant prior to 1992
• People with hemophilia who received clotting factor concentrates produced before 1987
• Those who received chronic hemodialysis
• Infants born to infected mothers
• Healthcare workers who have been occupationally exposed to blood or who have had accidental needlesticks
• Sex partners of people with HCV
• People with type 2 diabetes

An FDA-approved home test for HCV, the Hepatitis C Check, is available from the Home Access Health Company. The test is accurate if it has been at least six months since possible exposure to HCV.

Coinfected patients also need to consult their health professional before taking any new medications, including over-the-counter (OTC), 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.

In coinfected patients with lower CD4 counts (<200 cell/mm³), it may be preferable to initiate antiretroviral therapy and delay HCV therapy until CD4 counts increase. Patients receiving or considering therapy with ribavirin should avoid didanosine, stavudine, and zidovudine. Antiretroviral agents with the greatest risk of DILI should be used with caution (Public Health Service Task Force, 2009).

HIV/AIDS in Women

Both CDC and the American College of Obstetrics and Gynecology (ACOG) recommend offering all women of childbearing age preconception counseling and care as part of routine primary medical care. The goals are to identify risk factors that could lead to adverse maternal or fetal outcome, provide education and counseling appropriate to her individual needs, and treat or stabilize medical conditions to optimize maternal and fetal outcomes.

All HIV-infected women of childbearing age should be screened for pregnancy at initial and subsequent visits and asked about interest in future pregnancy and use of contraceptives. Providers should be aware of potential interactions of antiretroviral drugs with hormonal contraceptives that could reduce the efficacy of oral contraceptives.

Counseling about safer sexual practices can help protect women from acquiring other STDs or more virulent or drug resistant HIV strains. Women should also be counseled to eliminate alcohol, illicit drug use, and cigarette smoking.

TREATMENT RECOMMENDATIONS

Current recommendations for pregnant women 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.

Therapy should be individualized for each woman based on her history of HIV antiretroviral therapy (past or current use or never used) as well as possible coinfection with HBV and/or HCV. Choice of therapy regimen also should consider not only the effectiveness of drug treatment for maternal disease but also possible teratogenic effects of the drugs on the infant. For example, efavirenz (EFV) should be avoided during the first trimester of pregnancy, and no pregnant woman should be offered regimens containing nelfinavir (NFV).

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. Clinical trial results indicate that antiretroviral prophylaxis to prevent perinatal transmission of HIV should be offered to all HIV-infected women, regardless of CD4 cell count (Panel on Treatment of HIV-Infected Pregnant Women, 2010).

Specific detailed guidelines for the antepartum, intrapartum, and postpartum treatment of HIV-infected women of childbearing age and treatment of their infants evolve rapidly. Practitioners are advised to consult the most recent information on the CDC’s AIDSinfo website (Panel on Treatment of HIV-Infected Pregnant Women, 2010).

Smoking cessation is important for all women receiving ART because it interferes with the therapy’s effectiveness. A large, 8-year study of women showed that those who smoked were more likely than nonsmokers to die during the study period. Smokers also had higher viral loads and lower CD4 counts. They also were more likely to be diagnosed with an AIDS-related illness such as wasting syndrome or non-Hodgkin’s lymphoma (Feldman, 2006).

According to the Office of Women’s Health (2009), women taking antiviral drugs may have different side effects than men on the same drugs. This may be because women are generally smaller than men and have a higher body-fat content and different hormones. For example, ritonavir (Norvir, RTV) causes more nausea and vomiting in women but less diarrhea than in men.

Some women with HIV, especially those with a low CD4 count, experience irregular or long menstrual periods. Others may also experience early menopause and are more likely to have rashes, fat buildup, and problems with their pancreas and liver. However, more research is needed before treatment doses can change, and more clinical trials need to be done that include higher numbers of women.

Women with HIV may suffer discrimination by prescribing physicians. A study of HIV-infected patients in 10 U.S. cities showed that women were less likely than men to receive prescriptions for the most effective treatments for HIV infection (McNaghten et al., 2004).

GYNECOLOGICAL PROBLEMS

Women infected with HIV/AIDS face an increased risk of gynecologic problems, including pelvic inflammatory disease (PID), abscesses of the fallopian tubes and ovaries, and recurrent yeast infection (candidiasis). HIV-infected women also have a higher prevalence of infection with the human papillomavirus (HPV), certain strains of which cause cervical cancer, which is an AIDS-indicator condition.

Women with HIV need to have Pap tests twice a year and more frequently if the results are abnormal.

Part 5: Legal and Ethical Issues

LEGAL REPORTING REQUIREMENTS

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

Reporting of HIV and AIDS cases assists local and state health officials in tracking the epidemic. The statistics also allow for more effective planning and intervention services to prevent further transmission of HIV and reduce the burden of this disease.

Providers who diagnose an individual with AIDS must submit a confidential case report to the local health jurisdiction within 3 days. Providers who receive notice of an individual’s positive HIV test must report this information, including the individual’s name, to the local health jurisdiction within 3 days. In some local health jurisdictions, the state department of health fulfills this function for local authorities.

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

CONFIDENTIALITY

Confidentiality is a paramount concern for people with HIV/AIDS. This infection not only carries the stigma of a sexually transmitted disease but also the association with homosexuality and/or injection drug use. Workplace, housing, and insurance discrimination have been (and, in some areas, continue to be) barriers to disclosure of HIV status and seeking treatment. Children with AIDS have sometimes been barred from attending classes and, in at least one instance, a family home was burned after one member of the family developed AIDS.

All medical records are confidential and must be maintained in a manner that protects that confidentiality, using an approach consistent with Washington law (RCW 70.02 and RCW 70.24) and, if applicable, the Privacy and Security Requirements promulgated by the federal government in the Health Insurance Portability and Accountability Act (HIPAA). Client information must be kept strictly confidential, and records should be managed and stored in a secure manner. Special requirements for HIV and AIDS are found in WAC 246-100 and RCW 70.24.105.

Confidential information includes any material, whether oral or recorded in any form or medium that identifies (or can readily be associated with the identity of) a person and is directly related to their health and care. All information related to an individual’s HIV/AIDS status is protected under medical confidentiality guidelines and legal regulations. Recognizing the sensitive nature of these conditions, medical record protection for HIV and AIDS, like those for substance abuse and mental health, are protected more rigorously than other medical information.

Confidentiality of medical information means that any information that can be related to a specific patient may not be disclosed to anyone except under specific circumstances. This usually means that the individual signs a release-of-information form, but there are exceptions. The most common circumstances permitting disclosure of confidential patient information are:

• Existence of a separate, signed release-of-information form
• Release to another healthcare provider for related ongoing medical care
• A life-or-death emergency
• Release to a third-party payer (insurance provider)
• Reporting notifiable conditions to the local health jurisdiction or the department of health

Anyone who violates the confidentiality laws may be found guilty of a misdemeanor and be subject to civil liability actions for reckless or intentional disclosure, up to a fine of $10,000 for each infraction, or actual damages, whichever is greater (RCW 70.24.080, RCW 9A.20.021, RCW 70.24.084) (Washington State Department of Health, 2005).

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

INFORMED CONSENT

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

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

Minors

Washington law (RCW 70.24.110) specifies that children 14 years of age or older who may have come in contact with any sexually transmitted disease or suspected sexually transmitted disease may give consent to the furnishing of hospital, medical, and surgical care related to the diagnosis or treatment of such disease.

Parental or legal guardian consent is not necessary, and parent(s) or legal guardians are not liable for payment for any care rendered. Washington State law forbids informing the subject’s parents of the test, or of the results, without the subject’s permission.

Testing Without Informed Consent

HIV testing without informed consent may occur in the following circumstances:

• When the person is incompetent to give consent (RCW 7.70.065)
• In seroprevalence studies, where neither the persons whose blood is being tested know the test results nor the persons conducting the tests know who is undergoing testing
• If the Department of Labor and Industries determines that it is relevant, in which case payments made under Title 51 RCW may be conditioned on the taking of an HIV antibody test.

Under Washington State law (WAC 246-100-205), someone who has experienced a substantial exposure to another person’s bodily fluids in a manner that creates a possible risk of HIV transmission, and that exposure occurred while on the job in certain categories of employment deemed at substantial risk for HIV exposure, may ask a state or local health officer to order pretest counseling, HIV testing, and post-test counseling of the source person, in accordance with RCW 70.24.340.

Source persons who may be tested for HIV without informed consent include those convicted of a sexual offense (RCW 9A.44), prostitution (RCW 9A.88), or drug offenses involving hypodermic needles (RCW 69.50). This law does not apply to the department of corrections or to inmates in its custody or subject to its jurisdiction.

Substantial exposure that presents a possible risk of transmission is limited to:

• Physical assault upon the exposed person involving blood or semen
• Intentional, unauthorized, nonconsensual use of needles or sharp implements to inject or mutilate the exposed person
• An accidental parenteral or mucous membrane or non-intact skin exposure to blood, semen, or vaginal fluids

Categories of employment at substantial risk for HIV exposure include:

• Healthcare provider
• Staff of healthcare facilities
• Law enforcement officer
• Firefighter
• Funeral director
• Embalmer

If the health officer refuses to order counseling and testing, the exposed person may petition the superior court for a hearing to determine whether an order shall be issued.

CIVIL RIGHTS

RCW 49.60, the Washington Law Against Discrimination, prohibits discrimination based on age, creed, religion, race, color, national origin, sex, sexual orientation and gender identity, HIV and hepatitis C status, whistleblower retaliation, marital status (housing and employment), families with children (housing), or the presence of any sensory, mental, or physical disability or the use of a trained dog guide or service.

Exceptions to this law are applicants for the U.S. Military, the Peace Corps, and the Job Corps, under federal law, which supersedes state law.

Effective January 4, 2010, foreign visitors with HIV/AIDS can legally enter the United States without their infection being considered, and testing is no longer required for immigration. CDC removed HIV/AIDS from the inadmissible diseases list in 2009.

Disability and Discrimination

People with HIV/AIDS are protected by federal law under the Americans with Disability Act (1990) and Section 504 of the Federal Rehabilitation Act of 1973, as amended. The Washington Law Against Discrimination (WLAD-RCW 49.60.174) regulates “disabled” status. These laws make it illegal to discriminate against someone with AIDS or who has HIV or Hepatitis C infection. It is also illegal to discriminate against someone “believed” to have HIV/AIDS, even though that person is not infected. The areas encompassed in the laws include:

• Employment (see below for details)
• Rental, purchase, or sale of apartment, house, or other real estate
• Public places (restaurants, theaters)
• Healthcare, legal services, home repairs, and other personal services available to the general public
• Applying for a loan or credit card, or other credit transaction
• Certain insurance transactions

(Note: Federal and state jurisdictions differ.)

Employment Issues

Laws protect people diagnosed with HIV/AIDS from employment discrimination, including:

• Employment
• Recruitment
• Hiring
• Transfers
• Layoffs
• Termination
• Salary
• Job assignments
• Leaves of absence, sick leave, any other leave or fringe benefits available by virtue of employment

WORK ENVIRONMENT

Employers are required to provide and maintain a working environment free of discrimination. They must ensure that no harassment, intimidation, or personnel distinction is made in terms and conditions of employment. If a worksite situation poses the threat of discrimination, the employer is required to educate and supervise employees to end the harassment and any use of slurs and/or intimidation. An employer should promptly investigate allegations of discrimination, take appropriate action, and not retaliate against the person who complained.

Employers are responsible for providing reasonable worksite accommodations that will enable a qualified employee or job applicant with a disability to perform the essential tasks of a particular job. Reasonable accommodation means relatively inexpensive and minimal modifications in the context of the entire employer’s operation, such as:

• Providing special equipment
• Altering the work environment
• Allowing flex-time
• Providing frequent rest breaks
• Allowing the person to work at home (telecommute)
• Restructuring the job

An employee with a disability must self-identify and request a reasonable accommodation. The employer must engage in an interactive process with the requestor. The reasonable accommodation grant may not be exactly the same one as requested by the employee but can be equally effective. The employer does not have to change the essential nature of its work, or engage in undue hardship or heavy administrative burdens. The essential functions of the job must be accomplished, with or without reasonable accommodations.

EMPLOYEE GRIEVANCES

Employees who feel they are being discriminated against should first document the discrimination, speak with their supervisor, and follow the entity’s internal process to file a discrimination charge. However, it is not necessary to file an internal grievance process. If these remedies do not work, the employee should contact the federal Office for Civil Rights, U.S. Department of Health and Human Services, or the Washington State Human Rights Commission. An aggrieved person can also file directly in state court. A complaint must be filed within 180 days of the alleged discriminatory incident.

PROTECTING PUBLIC HEALTH

Washington State law (RCW 70.24) and rules (WAC 246-100 and 246-101) give state and local health officers the authority and responsibility to carry out certain measures to protect public health from the spread of sexually transmitted disease (STD), including HIV/AIDS.

The local health officer is the physician who directs the operations of the local county’s health department or health district. The responsibilities of the health officer include the authority to:

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

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

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

Knowingly transmitting HIV/AIDS is a Class A felony in Washington State (RCW 9A.36.011(1)(b).

Washington law requires that healthcare providers offer instruction on infection-control measures to any patient diagnosed with a communicable disease. Providers are also required to report to the local health officer any impediments or refusal to comply with prescribed infection-control measures.

For example, if a healthcare provider knows that a specific patient is failing to comply with infection-control measures (failing to disclose HIV status to sexual or needle-sharing partners or selling HIV-infected blood), the provider should contact the local health officer to discuss the case and determine if the name of the person should be reported for investigation and follow-up.

If credible evidence exists that an HIV-infected person is engaging in conduct that endangers public health, the health officer or other authorized representative will investigate the case.

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

Part 6: Psychosocial Issues

For 30 years, HIV/AIDS has proved to be a moving target, spreading beyond gay white men in cities to women, children, and seniors in small towns and rural areas. As people with HIV live longer, needs for healthcare services are changing. Depending on their personal support system and other resources, some people may require the assistance of a case manager to link them with various care services.

PERSONAL IMPACT OF HIV/AIDS

People with HIV/AIDS face a host of personal challenges: unpredictable cycles of illness and wellness; feelings of loss, grief, anger, and depression; expensive, complicated, sometimes disfiguring treatments; and, finally, deteriorating health and premature death. The fortunate ones have families and friends who share the experience and offer support as needed. For those without a support system, the challenges can seem insurmountable.

HIV-infected individuals may live for 10 or more years before symptoms develop. For those who know they are infected, a decade of uncertainty can be unsettling, even overwhelming. Despite more effective treatment, most people with HIV still die prematurely. Many are in the prime of life, which makes it more difficult to deal with the diagnosis of a fatal disease.

Depression

Depression can be immobilizing and interfere with adherence to the treatment regimen, leading indirectly to drug resistance and poor management of the disease. Symptoms of depression include:

• Feeling sad, anxious, or “empty” most of the day, almost every day
• Lack of interest or pleasure in almost all activities, including sex
• Changes in appetite and/or weight
• Altered sleep patterns
• Changes in physical activity—ranging from slowing down to agitation or hyperactivity
• Feelings of worthlessness or excessive guilt
• Inability to concentrate or make decisions
• Recurrent thoughts of death or suicide, or suicide attempts

Depression can and should be treated, both with antidepressant medications and psychotherapy. Recognizing the symptoms of depression and referring patients for appropriate treatment may greatly improve their quality of life.

Rejection

In many areas of the United States, homosexuality and use of illegal drugs carry an indelible stigma and lead to social and employment discrimination. A diagnosis of HIV/AIDS adds another layer of social pressure and stress for MSM and injection drug users. Failure of family, friends, or coworkers to accept and support the person with HIV/AIDS can evoke painful guilt about the disease, about past behaviors, or about possibly having infected someone else. The need to practice safer sex can also affect self-esteem and self-image.

Altered Body Image

HIV/AIDS causes dramatic changes in a person’s appearance, including severe weight loss and a wasted appearance. Concurrent infections and malignancies, as well as some of the treatments, can cause major alterations in body image. For example, antiretroviral drugs can lead to lipodystrophy, the redistribution of body fat. There are two types of lipodystrophy: fat wasting and fat accumulation. A person with fat wasting (also called lipoatrophy) loses fat from particular areas of the body, especially the arms, legs, face, and buttocks. Someone with fat accumulation (also called hyperadiposity) experiences fat build-up, especially in the belly, breasts, and back of the neck.

Anger

People with HIV/AIDS may feel angry with themselves for contracting the disease, as well as anger at the person who transmitted it. Their once-normal lives are now organized around medication schedules, medical appointments, and dealing with side effects such as intractable diarrhea and nausea. Expensive medications can create financial hardship, even for those with health insurance.

Loss and Grief

Living with HIV/AIDS involves loss of many kinds, including:

• Loss of physical strength and abilities, sometimes even loss of vision
• Loss of mental acuity (confusion/dementia)
• Loss of income and savings
• Loss of health insurance
• Loss of employment
• Loss of housing and personal possessions (including pets)
• Loss of emotional support from family, friends, colleagues, and religious and social institutions
• Loss of self-sufficiency and privacy
• Loss of social contacts/roles
• Loss of self-esteem

Grief—the normal response to loss—is universal, individual, and unpredictable. Although Elizabeth Kübler-Ross and others have described stages of grief, each person experiences these stages in a different order and at a different pace, depending on their values, cultural norms, and circumstances.

In uncomplicated grief, an individual is able to move through the stages and emerge from the process ready to move on with life. In complicated grief (also called chronic grief), the normal process of grieving is prolonged. Complicated grief often results from multiple losses that leave too little time and emotional energy to reintegrate and move on, and can lead to feelings of guilt, helplessness, hopelessness, withdrawal, isolation, rage, and emotional numbness.

People who live or work with the HIV/AIDS community for several years may themselves experience chronic grief from the seemingly endless repetition of deaths, funerals, and lost friends.

ISSUES FOR CARE PROVIDERS AND FAMILIES

The psychological suffering and grief experienced by people with HIV/AIDS is also shared by family members, friends, caregivers, and partners. These feelings may manifest as physical symptoms, clinical depression, hypochondria, anxiety, insomnia, and the inability to derive pleasure from normal daily activities. Coping with these issues may lead to self-destructive behaviors such as alcohol or drug abuse.

Caregivers often mirror the feelings of their patient, such as a sense of vulnerability, helplessness, or isolation. Access to a support system, including a qualified counselor, can be as important for the caregiver as for the patient. Support from coworkers is also especially important.

DO’S AND DON’T’S FOR CAREGIVER SUPPORT

DO	DON’T
Do meet with a support person, group, or counselor on a regular basis to discuss your experiences and feelings.	Don’t isolate yourself.
Do set limits in caregiving time and responsibility and stick to those limits.	Don’t try to be all things to all people.
Do allow yourself to have questions. Let “not knowing” be OK.	Don’t expect to have all the answers.
Do get the information and support you deserve and need.	Don’t deny your own fears about AIDS or dying.
Do discuss with your employer some strategies for performing your job in ways that reduce stress and burnout.	Don’t continue to work in an area where you “can’t cope.”
Do remember that Universal and Standard Precautions are for the patient’s health and welfare as well as your own.	Don’t dismiss Universal and Standard Precautions because you “know” the patient.

SPECIAL POPULATIONS

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

Men Who Have Sex with Men (MSM)

America’s HIV/AIDS epidemic deepened the nation’s longstanding prejudice toward homosexuality. Some religious groups see the epidemic as divine retribution for “unacceptable” and “unnatural” behavior. Many men with HIV/AIDS report lack of support from their church families because of the stigma attached to homosexuality.

Societal attitudes toward MSM have made it more difficult to live and die with HIV/AIDS. Self-esteem and other psychological issues related to HIV infections complicate the lives of MSM. Grief and loss are not always validated when relationships are judged “unacceptable.”

Injection Drug Users

Injection drug users (IDUs) often are seen as “deserving” their infection, rather than deserving treatment for their addiction. Successful efforts to prevent the spread of HIV/AIDS, HBV, and HCV among IDUs, such as syringe exchange programs, can now receive federal funding even though some equate these programs with “approval” of drug use.

Many IDUs would like to stop using but do not have access to inpatient treatment facilities. Waiting lists for treatment programs are long, and by the time a space is available, the individual may be lost to follow-up. IDUs who do seek treatment for HIV may find the regimens too complex and financially prohibitive.

People with Hemophilia

During the 1980s, 90% of people with severe hemophilia were infected by HIV and/or HCV through use of clotting factor concentrates, which are made from pooled, donated blood. This created understandable anger among the affected community because evidence indicated that the companies manufacturing the concentrates knew the dangers of contamination but continued to distribute them anyhow.

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

Women

Women of color, particularly black/African American women, are disproportionately affected by HIV/AIDS. They represent the majority of new HIV infections and AIDS cases among women. Many women with HIV are low-income, and most have children under the age of 18.

According to the CDC, young women (ages 13–39) represent nearly two-thirds of new HIV infections among women. Having sex with multiple partners, engaging in risky behaviors such as alcohol and drug use, and/or being unable to negotiate safer sex practices with partners all contribute to this heightened risk of contracting HIV/AIDS.

Taking care of others’ needs—children or other family members—often prevents women with HIV/AIDS from taking care of themselves. Postponing medications or missing medical appointments may also be due to financial or transportation problems. Infection with HIV/AIDS may not seem to be a woman’s most serious problem. Income, housing, access to healthcare, possible abusive relationships, and concerns about her children seem more urgent and important, especially when HIV/AIDS symptoms are mild and manageable. Single mothers are especially vulnerable because they lack adequate financial and emotional support.

Older women with HIV/AIDS face complex challenges in addition to the common chronic health problems of this group—osteoporosis, high cholesterol, high blood pressure, obesity, and heart disease. Many of the antiretroviral drugs can exacerbate these conditions.

People of Color

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

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

Prevention messages need to be culturally appropriate and relevant and they must be delivered through channels appropriate to individual communities. These channels may include religious institutions and respected elders in the community. Ironically, some of these same institutions or elders may have contributed to the misinformation and stigma associated with HIV/AIDS.

CONCLUSION

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 56,000 Americans are infected with HIV.

Despite this ongoing tragedy, the public no longer has a sense of urgency or importance about AIDS. An editorial in the New England Journal of Medicine best describes the situation—“AIDS in America: Forgotten but Not Gone” (El-Sadr et al., 2009). Research has produced drugs that slow but do not stop the carnage, and the cost of these drugs has tripled during the past 10 years. No vaccine has proved effective in preventing HIV. So the epidemic continues to spread, primarily among disadvantaged and marginalized populations: the poor, people of color, people in prison, injection drug users, and men who have sex with men. Many do not realize they are infected and unknowingly transmit the virus to others.

Ignorance, prejudice, and lack of access to healthcare are fueling the epidemic. Therefore, health professionals have a critical role in screening 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:

• Reducing infection rates
• Increasing access to care for those infected
• Eliminating disparities in prevalence, diagnosis, and treatment

Health professionals can also teach by example, through offering nonjudgmental, compassionate care to those affected by this deadly virus.