AIDS- acquired
immunodeficiency syndrome- was first reported in the
HIV belongs to a
class of viruses called retroviruses.
Retroviruses are ribonucleic acid (RNA) viruses, and in order to
replicate they must make a deoxyribonucleic acid (DNA) copy of their RNA. It is the DNA genes that allow the virus to
replicate.
Like all viruses,
HIV can replicate only inside cells, commandeering the cells
machinery to
reproduce. However, only HIV and other
retroviruses, once inside a cell, use an enzyme called reverse transcriptase to
convert their RNA into DNA, which can be incorporated into the host cells’
genes.
HIV belongs to a
subgroup of retroviruses known as lentiviruses, or “slow” viruses. The course of infection with these viruses is
characterized by a long interval between initial infection and the onset of
serious symptoms.
More than 830,000
cases of AIDS have been reported in the
On the national
level, figures released as of July 6,2004 from the U.N. Report state that, “The
numbers are staggering: Five million
people became infected with HIV last year, more people than any previous year. Nearly 38 million adults and children are
living with HIV worldwide. While Africa
continues to be hit hard,
The report further
states that, “Some $12 billion will be needed by 2005 to effectively fight AIDS
in developing countries—but current annual spending is less than half
that”. “By 2007, an estimated $20
billion will be needed.”
Facts that came
out of the U.N. Report are:
·
The
fastest-growing epidemic is in Asia, with 1.1 million new infections in 2003
alone – the most in a single year to date in
·
70% of
the HIV-infected world population lives in Africa, yet
·
An
estimated 15 million children under age 18 worldwide have lost one or both
parents to AIDS, 12 million of them in sub-Saharan
·
Of the
10 million young people living with HIV worldwide; 6 million live in
sub-Saharan
The term AIDS
applies to the most advanced stages of HIV infection. CDC developed official criteria for the
definition of AIDS and is responsible for tracking the spread of AIDS in the
CDC’s definition
of AIDS includes all HIV-infected people who have fewer than 200 CD4 positive T
cells (abbreviated CD4+ T cells) per cubic millimeter of blood (healthy adults
usually have CD4 positive T-cell counts of 1,000 or more.). In addition, the definition includes 26
clinical conditions that affect people with advanced HIV disease. Most of these conditions are opportunistic
infections that generally do not affect healthy people. In people with AIDS, these infections are
often severe and sometimes fatal because the immune system is so ravaged by HIV
that the body cannot fight off certain bacteria, viruses, fungi, parasites, and
other microbes.
Symptoms of
opportunistic infections common in people with AIDS include
* Coughing and shortness of breath
* Seizures and lack of coordination
* Difficult or painful swallowing
* Mental symptoms such as confusion and
forgetfulness
* Severe and persistent diarrhea
* Fever
* Vision loss
* Nausea, abdominal cramps, and vomiting
* Weight loss and extreme fatigue
* Severe headaches
* Coma
A small number of
people first infected with HIV ten (10) or more years ago have not developed
symptoms of AIDS. Scientists are trying
to determine what factors may account for their lack of progression to AIDS, such
as particular characteristics of their immune systems or whether they were
infected with a less aggressive strain of virus, or if their genes may protect
them from the effects of HIV. Scientist
hope that understanding the body’s natural method of control may lead to ideas
for protective HIV vaccines and use of vaccines to prevent the disease from
progressing.
Infection with HIV
has been the only common factor shared by persons with AIDS throughout the
world, including homosexual men, transfusion recipients, persons with
hemophilia, sex partners of infected persons, children born to infected women,
and health care workers who were infected with HIV while on the job, mainly by
being stuck with a needle used on an HIV-infected patient.
HIV destroys a certain
kind of blood cells—CD4+T cells (helper cells)—which are crucial to the normal
function of the human immune system. In
fact, loss
of these cells in
people with HIV is an extremely powerful predictor of the development of
AIDS. Studies of thousands of people
have revealed that most people infected with HIV carry the virus for years
before enough damage is done to the immune system for AIDS to develop. However, recently developed sensitive tests
have shown a strong connection between the amount of HIV in the blood and the
decline in CD4+T cell numbers and the development of AIDS. Reducing the amount of virus in the body with
anti- HIV drugs can slow this immune destruction.
Scientists are
constantly discovering more information about HIV and AIDS. These discoveries help people learn how to
stop transmission of the virus and help people infected with HIV to live
longer, healthier lives. One important
question to answer is why some people exposed to HIV become infected and others
do not. Scientists believe it is most
likely because of how infectious the other person is and how they are
exposed. For example, more that 90
percent of persons who were exposed through an HIV-infected unit of blood
became infected. So we know that
blood-to-blood contact is a very efficient way that HIV is spread. On the other hand, many health care workers
are splashed with blood or bloody body fluids and this type or exposure has
caused very few occurrences of HIV infection.
Researchers know how HIV is spread and the ways that people can help
protect themselves from being exposed to HIV.
AIDS
STATISTICS
At the end of the
December 2002, the Center for Disease Control and Prevention (CDC) reported
approximately 384,906 persons in the
Of these,
·
46%
were in whites,
·
34% in
blacks,
·
18% in
Hispanics,
·
< 1% in Asians and Pacific Islanders,
·
and
<1% in American Indians and
Of the 298,248 men
(of 13 years or older) who were living with AIDS,
·
57%
were men who had sex with men (MSM),
·
23%
were injecting drug users (IDU),
·
10%
were exposed through heterosexual contact,
·
8%
were both MSM and IDU;
Of the 82,764
adult and adolescent women with AIDS,
·
61%
were exposed through heterosexual contact,
·
36%
were exposed through injecting drug use;
3893 children were
living with AIDS.
In June 1981, the
first cases of what is now known as AIDS were reported in the
Through December
2002 there were 517,414 persons reported to the CDC as living with HIV
infection or AIDS. These reports only
include persons diagnosed with HIV/AIDS infection in States with integrated
HIV/AIDS surveillance systems (30 out of 50 states). In 1999, CDC estimated that 800,000 to
900,000 persons in the
·
reporting
of persons diagnosed with HIV has not yet been implemented in all States and
Territories
·
anonymous
tests are excluded from case reports
·
and
many people are unaware of their HIV status.
During the 1990’s,
the epidemic shifted steadily toward a growing proportion of AIDS cases in
blacks and Hispanics and in women, and toward a decreasing proportion in MSM,
although this group remains the largest single exposure group. Blacks and Hispanics, among whom AIDS rates
have been markedly higher than among whites, have been disproportionately
affected since the early years of epidemic.
In absolute numbers, blacks have outnumbered whites in new AIDS
diagnoses and deaths since 1996, and in the number of people living with AIDS
since 1998.
The proportion of
women with AIDS has increased steadily, and the proportion infected
heterosexually has also increased, surpassing (in 1994) the proportion infected
through injecting drug use. Midway
through the 1990’s, effective therapies became available, and as early as 1996
their effect on decreases in AIDS incidence and on deaths were detected through
surveillance at the population level. As
deaths have decreased, AIDS prevalence has steadily increased, a trend that
will continue as long as the number of people with a new AIDS diagnosis exceeds
the number of people dying each year.
During 2002, 162
pediatric AIDS cases were reported; of these, 88% were acquired
perinatally. The number of estimated
pediatric AIDS cases diagnosed each year has declined since 1992. The decline in pediatric AIDS incidence is
associated with the implementation of Public Health Service guidelines. The guidelines include universal counseling
and voluntary HIV testing of pregnant women and use of zidovudine by HIV-infected
pregnant women and their newborn infants.
Pediatric HIV surveillance will play an important role, helping to gauge
the extent to which intensified prevention efforts contribute to reduced
transmission.
NOTE: (For
more statistical information regarding Race/Ethnicity see the attached HIV/AIDS
Surveillance supplemental Report that is published by the Dept of Health and
Human Services.)
BEHAVIORS
Twenty years after
the first report on human immunodeficiency virus (HIV) infection in the
In this report,
males were studied from
Another source for
the spread of HIV infection is when the infection spreads easily when people
share equipment to use drugs. Sharing
equipment also spreads hepatitis B, Hepatitis C and other serious diseases.
Even small amounts
of blood on cookers, filters, tourniquets, or in rinse water can be enough to
infect another user. Blood on your hands
– even small amounts – can also be dangerous when you help someone else find a
vein, steady their arm, or when you pass equipment.
For a lot of
people, drugs and sex go together. Drug
users might trade sex for drugs. Some
people think that sexual activity is more enjoyable when they are using drugs. Drug use, including alcohol, increases the
chance that people will not protect themselves during sexual activity. Someone who is trading sex for drugs, might
find it difficult to set limits on what they are willing to do. Anyone using drugs is less likely to remember
to use protection, or to even care about it.
In some
communities, needle exchange programs provide free, new syringes. These programs reduce the rate of new HIV
infections.
Also drug use can
lead to missed doses of anti-HIV medications.
This increases the chance of treatment failure and resistance to
medications.
Mixing
recreational drugs and anti-HIV medications can be dangerous. Drug interactions can cause serious side
effects or dangerous overdoses.
OPPORTUNISTIC DISEASES
People with HIV
infection, particularly those with AIDS, are more susceptible to certain
microbes. The resulting infections can
cause severe illnesses or even death in people with severely impaired immune
systems. Some infections can be
prevented with immunizations, others with specific medications prescribed by
HIV care providers. There are many
infections, however, that only the patient can guard against. Specific methods for avoiding or thwarting
these illnesses are listed below.
·
In all
cases of life, strict hand washing should be adhered to with everything that
the HIV positive patient does.
·
Take
special precautions with handling pets and pet wastes. Avoid pet scratches and bites. Avoid all contact with reptiles and with
exotic pets.
·
Food
should be prepared properly. Hot food
should be kept hot and cold food should
be kept cold until ready to consume.
·
Correct
and consistent condom use during all sexual acts should be used.
·
When
traveling pay special attention to vaccinations that are needed and make sure
that those needed are not something that will interfere with treatment. Most vaccines for HIV patients will need to
be killed vaccines.
Symptoms of
opportunistic infections common in people with AIDS include:
·
Coughing
and shortness of breath.
·
Seizures
and lack of coordination.
·
Difficult
or painful swallowing.
·
Mental
symptoms such as confusion and forgetfulness.
·
Severe
and persistent diarrhea.
·
Fever.
·
Vision
loss.
·
Nausea,
abdominal cramps, and vomiting.
·
Weight
loss and extreme fatigue.
·
Severe
headache.
·
Coma
Examples of
opportunistic infections include:
Tuberculosis
Salmonellosis
Candidiasis
Cryptococcus
Histoplasmosis
Cytomegalovirus
Herpes
Hepatitis
Epstein Barr
Genital wart
Molluscum
Bacterial
Pneumocystis
carinii pneumonia
Toxoplasmosis
Cryptosporidium
Isoporiasis
TESTING
From MMWR Weekly,
On June 27, 2004, there would be National HIV Testing Day. This annual event is sponsored by the
National Association of People with AIDS to encourage persons at risk for human
immunodeficiency virus (HIV) infection to get tested and learn their
status. This year’s theme, “It’s Better
to Know,” underscores the importance of being tested for HIV. An estimated 850,000 – 950,000 persons in the
United States are HIV positive, and an estimated one in four are not aware of
their infection. Persons who know they
are infected can benefit from advances in medical care that can prolong their
lives, and they can take action to prevent transmission to others.
HIV testing has
become easier, more accessible, and less invasive in 2004. One antibody test can provide preliminary
results in as little as 20 minutes and can be used in both medical and
nonclinical settings. A new oral version
of that test approved by the Food and Drug Administration (FDA) in April, will
make getting tested even easier by eliminating the need for a finger-stick
blood sample.
Questions and
Answers about testing:
·
What
is an HIV antibody test?
A.
When
HIV enters the body, it begins to attack certain white blood cells called T4
lymphocyte cells (helper cells). Your
doctor may also call them CD4 cells. The
immune system then produces antibodies to fight off the infection. Although these antibodies are ineffective in
destroying HIV, their presence is used to confirm HIV infection. Therefore, the presence of antibodies to HIV
result from HIV infection. HIV tests
look for the presence of HIV antibodies; they do not test for the virus itself.
·
What
blood tests detect the presence of HIV?
A.
HIV
testing consists of an initial screening with two types of tests commonly used
to detect HIV infection. The most
commonly used initial test is an enzyme immune assay (EIA) or the enzyme linked
immunosorbent assay (ELISA). If EIA test
results show a reaction, the test is repeated on the same blood sample. If the sample is repeatedly the same result
or either duplicate test is reactive the results are “confirmed” using a second test such as the Western Blot. This more specific (and more expensive) test
can tell the difference between HIV antibodies and other antibodies that can
react to the EIA and cause false positive results. False positive EIA results are uncommon, but
can occur. A person is considered infected
following a repeatedly reactive result from the EIA, confirmed by the Western
Blot test.
·
What
about home test kits?
A.
Home
test kits can be purchased in most pharmacies and via the Internet and involve
no actual testing of the blood by the person using the kit. The only “at-home” components of the testing
process involve the collection of a small sample of blood using a finger stick
and the receipt of the results over the phone.
First, the blood sample is mailed to the manufacturer for a standard EPA
test. The consumer must call a phone
number several days later to receive the results and be offered the choice of
speaking to a trained counselor. A
positive result must be confirmed with a blood-based Western Blot (which cannot
be done with a home-based test kit).
WHO Should Get
Tested?
·
Have
you injected drugs or steroids or shared equipment (such as needles, syringes,
cotton, water) with others?
·
Have
you had unprotected vaginal, anal, or oral sex with men who have sex with men,
multiple partners, or anonymous partners?
·
Have
you exchanged sex for drugs or money?
·
Have
you been diagnosed with or treated for hepatitis, tuberculosis (TB), or a
sexually transmitted disease (STD), like syphilis?
·
Have
you received a blood transfusion or clotting factor between 1978 and 1985?
·
Have
you had unprotected sex with someone who would answer yes to any of the above
questions?
WHERE Can a Person
Get Tested?
·
Local
health departments.
·
Private
doctor’s offices.
·
Hospitals
·
Clinics
Information:
1-800-342-AIDS
1-800-AIDS-TTY
(TTY)
1-800-344-SIDA
(Spanish)
If you test
positive: SEE A PHYSICIAN! Immediate treatment and a healthy lifestyle
can help you stay well.
If your test is
negative: It does not mean that the
person or people that you have engaged in risky behavior with are also
negative. HIV is not necessarily
transmitted every time there is an exposure.
The HIV antibody
test has limitations. Antibodies usually appear within 3 to 6 months after
exposure to and subsequent infection with HIV.
Because an infected person does not develop antibodies immediately, a
negative result cannot rule out recent HIV infection. If recent exposure is suspected, the test
must be repeated in 6 months.
TRANSMISSION
Some means of
transmission have been previously discussed.
In addition to this scientists and medical authorities agree that HIV
does not survive well in the environment, making the possibility of
environmental transmission remote. HIV
is found in varying concentrations or amounts in blood, semen, vaginal fluid,
breast milk, saliva and tears. To obtain
data on survival of HIV, laboratory studies have required the use of
artificially high concentrations of laboratory-grown virus. Although these unnatural concentrations of
HIV can be kept alive for days or even weeks under precisely controlled and
limited laboratory conditions, CDC studies have shown that drying of even these
high concentrations of HIV reduces the amount of infectious virus by 90 to 99
percent within several hours. Since the
HIV concentrations used in laboratory studies are much higher than those
actually found in blood or other specimens, drying of HIV-infected human blood
or other body fluids reduces the theoretical risk of environmental transmission
to that which has been observed—essentially unnecessarily alarmed some people.
Among adults, HIV
is spread most commonly during sexual intercourse with an infected
partner. During sex, the virus can enter
the body through the mucosal linings of the vagina, vulva, penis, or rectum
after intercourse or, rarely, via the mouth and possibly the upper
gastrointestinal tract after oral sex.
The likelihood of transmission is increased by factors that may damage
these linings, especially other sexually transmitted diseases that cause ulcers
or inflammation.
Research suggests
that immune system cells of the dendrite cell type, which reside in the mucosa,
may begin the infection process after sexual exposure by binding to and
carrying the virus from the site of infection to the lymph nodes where other
immune system cells become infected.
HIV can also be
transmitted by contact with infected blood, most often by sharing of needles or
syringes contaminated with minute quantities of blood containing the
virus. The risk of acquiring HIV from
blood transfusion is now extremely small in the
Kissing: Casual contact through closed-mouth or
“social” kissing is not a risk for transmission of HIV. Because of the potential for contact with
blood during “French” or open-mouth kissing, CDC recommends against engaging in
this activity with a person known to be infected. However, the risk of acquiring HIV during
open-mouth kissing is believed to be very low.
CDC has investigated only one case of HIV infection that may be
attributed to contact with blood during open-mouth kissing.
Biting: In 1997, CDC published findings from a
state health department investigation of an incident that suggested
blood-to-blood transmission of HIV by a human bite. There have been other reports in the medical
literature in which HIV appeared to have been transmitted by a bite. Severe trauma with extensive tissue tearing
and damage and presence of blood were reported in each of these instances. Biting is not a common way of transmitting
HIV. In fact, there are numerous reports
of bites that did not result in HIV infection.
Insects: From the onset of the HIV epidemic, there
has been concern about transmission of the virus by biting and blood sucking
insects. However, studies conducted by
researchers at CDC and elsewhere have shown no evidence of HIV transmission
through insects—even in areas where there are many cases of AIDS and large
populations of insects such as mosquitoes.
Lack of such outbreaks, despite intense efforts to detect them, supports
the conclusion that HIV is not transmitted by insects.
PREVENTION
The Centers for
Disease Control and Prevention’s new initiative, Advancing HIV Prevention:
New Strategies for a Changing Epidemic, is aimed at reducing barriers to
early diagnosis of HIV infection and, if positive, increasing access to quality
medical care, treatment, and ongoing prevention services. The initiative emphasizes the use of proven
public health approaches to reduce the incidence and spread of disease. As with other sexually transmitted diseases
(STD’s) or any other public health concern, principles applied to prevent
disease and its spread will be used, including appropriate routine screening,
identification of new cases, partner counseling and referral services, and
increased availability of sustained treatment and prevention services for those
infected.
CDC’s HIV
prevention activities over the past two decades have focused on helping
uninfected persons at high risk for HIV change and maintain behaviors to keep
them uninfected. Despite these efforts,
the number of new HIV infections is estimated to have remained stable and the
number of persons living with HIV continues to increase.
The new initiative
capitalizes on new rapid test technologies, interventions that bring persons
unaware of their HIV status to HIV testing, and behavioral interventions that
provide preventions skills to persons living with HIV.
The next decade
promises new hope as three primary areas of HIV prevention are emphasized:
·
Early
detection of persons who are HIV positive and referral to care services.
·
Prevention
interventions with persons living with HIV.
·
Prevention
with person who are at high risk for HIV infection.
The initiative
consists of four key strategies:
·
Make
HIV testing a routine part of medical care.
·
Implement
new models for diagnosing HIV infections outside medical settings.
·
Prevent
new infections by working with persons diagnosed with HIV and their partners.
·
Further
decrease perinatal HIV transmission.
This initiative,
which was started in FY 2003 comes with a $35 million allocation to help fund
the project.
The initiative
allows for consultations with constituents, grantees, and community
groups. It allows for more training for
those doing testing and for reduced rates on kits to do the testing.
To prevent
exposures to the blood of persons who are HIV infected, at risk for HIV
infection, or whose infections and risk status are unknown, the following
should be considered:
·
Gloves
should be worn during contact with blood or other body fluids that could possibly
contain visible blood, such as urine, feces or vomit.
·
Cuts,
sores, or breaks on both the care givers’ and patients’ exposed skin should be
covered with bandages.
·
Hands
and other parts of the body should be washed immediately after contact with
blood or other body fluids, and surfaces soiled with blood should be
disinfected appropriately.
·
Practices
that increase the likelihood of blood contact, such as sharing of razors and
toothbrushes should be avoided.
·
Needles
and other sharp instruments should be used only when medically necessary and
handled accordingly to recommendations for health-care settings. (Do not put
caps back on needles by hand or remove from syringes. Dispose of needles in puncture-proof containers).
Condoms are
classified as medical devices and are regulated by the Food and Drug
Administration (FDA). Condom
manufacturers in the
There are many
different types and brands of condoms available—however, only latex or
polyurethane condoms provide a highly effective mechanical barrier to HIV. In laboratories viruses occasionally have
been shown to pass through natural membrane (“skin” or lambskin) condoms, which
may contain natural pores and are therefore not recommended for disease
prevention (they are documented to be effective for contraception). Women may wish to consider using the female
condom when a male condom cannot be used.
For condoms to
provide maximum protection, they must be used consistently (every time) and
correctly. Several studies of correct
and consistent condom use clearly show that latex condom breakage rates in this
country are less than 2 percent.
When condoms are
used reliably, they have been shown to prevent pregnancy up to 98 percent of
the time among couples using them as their method of contraception. Similarly, numerous studies among sexually
active people have demonstrated that a properly used latex condom provides a
high degree of protection against a variety of sexually transmitted diseases,
including HIV infection.
The CDC recommends
that people who inject drugs should be regularly counseled to:
·
Stop
using and injecting drugs.
·
Enter
and complete substance abuse treatment, including relapse prevention.
For injecting drug
users who cannot or will not stop injecting drugs, the following steps may be
taken to reduce personal and public health risks:
·
Never
reuse or “share” syringes, water or drug preparation equipment.
·
Only
use syringes obtained from a reliable source (such as pharmacies or needle
exchange programs).
·
Use a
new, sterile syringe each time to prepare and inject drugs.
·
If
possible, use sterile water to prepare drugs; otherwise, use clean water from a
reliable source (such as fresh tap water).
·
Use a
new or disinfected container (“cooker”) and a new filter (“cotton”) to prepare
drugs.
·
Clean
the injection site with a new alcohol swab prior to injection.
·
Safely
dispose of syringes after one use.
If new, sterile
syringes and other drug preparation and injection equipment are not available,
then previously used equipment should be boiled in water or disinfected with
bleach before reuse.
PERINATAL TRANSMISSION
The chance that
HIV infection is transmitted from a mother who is HIV infected to her child during
pregnancy can be reduced to 2 percent or less (fewer) than 2 out of every
100). This is possible because of better
medicines available to treat HIV. But
first, the pregnant woman and her doctor must know if she is infected with HIV.
OFFERING RAPID
TESTING AT DELIVERY TO LATE PRESENTING WOMEN:
One of the groups
at high risk for transmitting HIV-1 to their infants are those women who have
not received antenatal care and were not offered HIV-1 counseling and
testing. The feasibility of offering
counseling and rapid HIV-1 testing to women of unknown HIV-1 status who present
while in labor requires further study.
Additionally, the efficacy and acceptability of intrapartum/postpartum
or postpartum infant interventions to reduce the risk of intrapartum transmission
by women first identified as infected with HIV-1 during delivery needs to be
assessed.
Many pregnant
women with HIV-1 infection in the
To prevent P.
carinii, all infants born to women with HIV-1 infection should begin
prophylaxis at age 6 weeks, after completion of the ZDV prophylaxis
regimen. Monitoring and diagnostic
evaluation of HIV-1 exposed infants should follow current standards of
care. Data do not indicated any delay
inHIV-1 diagnosis in infants who have received the ZDV regimen. However, the effect of combination
antiretroviral therapy in the mother or newborn on the sensitivity of infant
virologic diagnostic testing is unknown.
Infants with negative virologic test results during the first 6 weeks of
like should have diagnostic evaluation repeated after completion of the neonatal
antiretroviral prophylaxis regimen.
Opt-in:
·
Pregnant
women are given pre-HIV test counseling.
·
They
must agree to get an HIV test, usually in writing.
Opt-out:
·
Pregnant
women are told that an HIV test will be included in the standard group of
prenatal tests (that is to say, tests given to all pregnant women), and that
they may decline the test.
·
Unless
they decline, they will receive an HIV test.
WHAT DOES THE CDC
RECOMMENT?
CDC recommends the
opt-out approach, which would make the HIV test a part of the group of tests
that all pregnant women receive routinely .
Studies show that the opt-out approach can
·
Increase
testing rates among pregnant women,
·
Increase
the number of HIV-infected women who are offered treatment, and
·
Reduce
HIV transmission to their babies during birth.
Several lessons
have been learned from the evaluation of the study that was completed in 1995
by PHS. Many women, especially those who
used illicit drugs, were not tested for HIV during pregnancy because of lack of
prenatal care. In additions, many women
refused testing because their health-care providers did not strongly recommend
it. Some women declined testing because
of perceived low risk, and some providers failed to offer testing because of
perceived low risk, perceived difficulties and complexity of required counseling,
and misunderstanding of counseling requirements. The logistics of testing, if too complex,
also were considered a potential barrier to testing.
Maximum reduction
of perinatal transmission depends on preventing HIV infection in women or
identifying HIV infection before pregnancy or as early as possible during
pregnancy. Diagnosis allows a woman to
receive effective antiretroviral therapies for her own health and preventive
drugs (e.g., ZDV) to improve the chances that her infant will be born free of
infection. Early knowledge of maternal
HIV status is also important for decisions regarding obstetrical
management. Achieving these goals
requires increased access to and use of prenatal care.
TREATMENT
Class /Generic Name
/ Brand and Other
Names
Nonnucleoside
Reverse Transcriptase Inhibitors (NNRTIs)
Delavirdine Rescriptor,DLV Pfizer
Efavirenz Sustiva, EFV
Nevirapine Viramune, NVP
Necleoside Reverse
Transcriptase Inhibitors (NRTIs)
Abacavir Ziagen, ABC
Abacair,
Lamivudine, Zidovudine Trizivir
Didanosine Videx, ddl
Videx
EC
Emtricitabine Emtriva, FTC
Coviracil
Lamivudine Epivir, 3TC
Lamivudine,Zidovudine Combivir
Stavudine Zerit, d4T
Tenofovir DF Viread, TDF
Zalcitabine Hivid, ddC
Zidovudine Retrovir, AZT, ZDV
Protease
Inhibitors (PIs)
Amprenavir Agenerase, APV
Atazanavir Reyataz, ATV
Fosamprenavir Lexiva, FPV
Indinavir Crixivan, IDV
Lopinavir, Ritonavir Kaletra, LPV/r
Nelfinavir Viracept, NFV
Ritonavir Norvir, RTV
Saquinavir Fortovase, SQV, Invirase
Fusion Inhibitors
Enfuvirtide Fuzeon, T-20
OSHA BLOODBORNE PATHOGENS STANDARDS
1910.1030(c)(1)(i)
Each employer
having an employee(s) with occupational exposure as defined by paragraph (b) of
this section shall establish a written Exposure Control Plan designed to
eliminate or minimize employee exposure.
1910.1030(c)(1)(iii)
Each employer
shall ensure that a copy of the Exposure Control Plan is accessible to
employees in accordance with 29 CFR 1910.1020(e).
1910.1030
(c)(1)(iv)
The Exposure
Control Plan shall be reviewed and updated at least annually and whenever
necessary to reflect new or modified tasks and procedures which affect occupational
exposure and to reflect new or revised employee positions with occupational
exposure. The review and update of such
plans shall also:
1910.1030.(d)(1)
General. Universal precautions shall be observed to
prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation
between body fluid types is difficult or impossible, all body fluids shall be
considered potentially infectious materials.
1910.1030(d)(2)(iv)
When provision of
hand washing facilities is not feasible, the employer shall provide either an
appropriate antiseptic hand cleanser in conjunction with clean cloth/paper
towels or antiseptic towelettes. When
antiseptic hand cleansers or towelettes are used, hands shall be washed with soap
and running water as soon as feasible.
1910.1030(d)(2)(vi)
Employers shall
ensure that employees wash hands and any other skin with soap and water and
flush mucous membranes with water immediately or as soon as feasible following
contact of such body areas with blood or other potentially infectious
materials.
1910.1030(d)(2)(vii)
Contaminated
needles and other contaminated sharps shall not be bent, recapped, or removed
except as noted in paragraphs (d)(2)(vii)(A) and (d)(2)(vii)(B) below. Shearing or breaking of contaminated needles
is prohibited.
1910.1030(d) (3)
(i)
Provision.
When there is occupational exposure, the employer shall provide, at no
cost to the employee, appropriate personal protective equipment such as, but
not limited to, gloves, gowns, laboratory coats, face shields or masks and eye
protection, and mouthpieces, resuscitation bags, pocket masks, or other
ventilation devices. Personal protective
equipment will be considered “appropriate” only if it does not permit blood or
other potentially infectious materials to pass through to or reach the
employee’s work clothes, street clothes, undergarments, skin, eyes, mouth, or
other mucous membranes under normal conditions of use and for the duration of
time which the protective equipment will be used.
1910.1030(d) (3)
(ii)
USE. The
employee shall ensure that the employee uses appropriate personal protective
equipment unless the employer shows that the employee temporarily and briefly
declined to use personal protective equipment when, under rare extraordinary
circumstances, it was the employee’s professional judgment that in the specific
instance its use would have prevented the delivery of health care or public
safety services or would have posed an increased hazard to the safety of the
worker or co-worker. When the employee
makes this judgment, the circumstances shall be investigated and documented in
order to determine whether changes can be instituted to prevent such
occurrences in the future.
1910.1030(d) (3)
(iii)
Accessibility. The
employer shall ensure that appropriate personal protective equipment in the
appropriate sizes is readily accessible at the worksite or is issued to
employees. Hypoallergenic gloves, glove
liners, powderless gloves, or other similar alternatives shall be readily
accessible to those employees who are allergic to gloves normally provided.
HIV POSTEXPOSURE PROPHYLAXIS
Antiretroviral
agents from three classes of drugs are available for the treatment of HIV
infection. These agents include the
nucleoside reverse transcriptase inhibitors (NRTIs), nonnucleioside reverse
transcriptase inhibitors (NNRTIs), and protease inhibitors (PIs). Only antiretroviral agents that have been
approved by FDA for treatment of HIV infections are discussed in these
guidelines.
Determining which
agents and how many to use or when to alter a PEP regimen is largely
empiric. Guidelines for the treatment of
HIV infection, a condition usually involving a high total body burden of HIV,
include recommendations for the use of three drugs; however, the applicability
of these recommendations to PEP remains unknown. In HIV-infected patients, combination
regimens have proved superior to monotherapy regimens in reducing HIV viral
load, reducing the incidence of opportunistic infections and death, and
delaying onset of drug resistance. A
combination of drugs with activity at different stages in the viral replication
cycle (e.g., nucleoside analogues with a PI) theoretically could offer an
additional preventative effect in PEP, particularly for occupational exposures
that pose an increased risk of transmission.
Although the use of a three-drug regimen might be justified for
exposures that pose an increased risk of transmission, whether the potential
added toxicity of a third drug is justified for lower-risk exposures is
uncertain. Therefore, the
recommendations at the end of this document provide guidance for two- and
three-drug PEP regimens that are based on the level of risk for HIV
transmission represented by the exposure.
BASIC AND EXPANDED
HIV POSTEXPOSURE PROPHYLAXIS REGIMENS
Basic Regimen
·
Zidovudine
(RETROVIR™; ZDV; AZT) + Lamivudine (EPIVIR™; 3TC); available as COMBIVIR™
--ZDV:
600 mg per day, in two or three divided doses, and
--3TC:
150 mg twice daily.
Alternate Basic
Regimens
·
Lamivudine
(3TC) + Stavudine (ZERIT™; d4T)
--3TC: 150 mg twice daily, and
--d4T:
40 mg (if body weight is < 60 kg, 30 mg twice daily) twice daily.
·
Didanosine
(VIDEX™, chewable/dispersable buffered tablet; VIDEX™ EC, delayed-release
capsule: ddl) + Stavudine (d4T)
--ddl:
400 mg (if body weight is < 60kg, 125 mg twice daily) daily, on an empty
stomach.
--d4T:
40 mg (if body weight is < 60 kg, 30 mg twice daily) twice daily.
Expanded Regimen
·
Indinavir
(CRIXIVAN™; IDV)
--800
mg every 8 hours, on an empty stomach.
·
Nelfinavir
(VIRACEPT™; NFV)
--750
mg three times daily, with meals or snack, or
--1250
mg twice daily, with meals or snack.
·
Efavirenz
(SUSTIVA™; EFV)
--600
mg daily, at bedtime.
·
Abacavir
(ZIAGEN™; ABC); available as TRIZIVIR™, a combination of ZDV, 3TC, and ABC
--300
mg twice daily.
CONSENT TO TEST
214.625
Legislative
findings – Consent for medical procedures and tests including HIV infection –
Physician’s responsibility – Confidentiality of results – Exceptions –
Disclosure – Network of voluntary HIV testing programs.
(1) The General Assembly finds that the use of tests designed to reveal a condition indicative of human immunodeficiency virus (HIV) infection can be a valuable tool in protecting the public health. The General Assembly finds that despite current scientific knowledge that zidovudine (AZT) prolongs the lives of acquired immunodeficiency syndrome victims, and may also be effective when introduced in the early stages of human immunodeficiency virus infection, many members of the public are deterred from seeking testing because they misunderstand the nature of the test or fear that test results will be disclosed without consent. The General Assembly finds that the public health will be served by facilitating informed, voluntary, and confidential use of tests designated to detect human immunodeficiency virus infection.
(2) A person who has signed a general consent form for the performance of medical procedures and tests is not required to also sign or be presented with a specific consent form relating to medical procedures or tests to determine human immunodeficiency virus infection, antibodies to human immunodeficiency virus, or infection with any other causative agent of acquired immunodeficiency syndrome that will be performed on the person during the time in which the general consent form is in effect. However, a general consent form shall instruct the patient that, as part of the medical procedures or tests, the patient may be tested for human immunodeficiency virus infection, hepatitis or any other blood-borne infectious disease if a doctor orders the test for diagnostic purposes. Except as otherwise provided in subsection (5)(c) of this section, the results of a test or procedure to determine human immunodeficiency virus infection, antibodies to human immunodeficiency syndrome performed under the authorization of a general consent form shall be sued only for diagnostic or other purposes directly related to medical treatment.
(3) In an emergency situation where informed consent of the patient cannot reasonably be obtained before providing health-care services, there is no requirement that health-care provider obtain a previous informed consent.
(4) The physician who orders the test pursuant to subsections (1) and (2) of this section, or the attending physician, shall be responsible for informing the patient of the results of the test if the test results are positive for human immunodeficiency virus infection. If the tests are positive, the physician shall also be responsible for either:
(a) Providing information and counseling to the patient concerning his infection or diagnosis and the known medical implications of such status or condition; or
(b) Referring the patient to another appropriate professional or health-care facility for the information and counseling.
(5) (a) No person in this state shall perform a test designed to identify the human immunodeficiency virus, or its antigen or antibody, without first obtaining the informed consent of the person upon whom the test is being performed, except as specified in subsections (2) and (3) of this section.
(b) NO test result shall be determined as positive, and no positive test result shall be revealed to any person, without corroborating or confirmatory tests being conducted.
(c) No person who has obtained or has knowledge of a test result pursuant to this section shall disclose or be compelled to disclose the identity of any person upon whom a test is performed, or the results of the test in a manner which permits identification of the subject of the test, except to the following persons:
1. The subject of the test or the subject’s legally authorized representative;
2. Any person designated in a legally effective release of the test results executed prior to or after the test by the subject of the test of the subject’s legally authorized representative;
3. A physician, nurse, or other health-care personnel who has a legitimate need to know the test result in order to provide for his protection and to provide for the patient’s health and welfare:
4. Health-care providers consulting between themselves or with health-care facilities to determine diagnosis and treatment;
5. The cabinet, in accordance with rules for reporting and controlling the spread of disease, as otherwise provided by state law;
6. A health facility or health-care provider which procures, processes, distributes or uses:
a. A human body part from a deceased person, with respect to medical information regarding that person; or
b. Semen provided prior to July 13, 1990, for the purpose of artificial insemination;
7. Health facility staff committees, for the purposes of conducting program monitoring, program evaluation, or service reviews;
8. Authorized medical or epidemiological researchers who shall not further disclose any identifying characteristics or information;
9. A parent, foster parent, or legal guardian of a minor; a crime victim; or a person specified in KRS 438.250;
10. A person allowed access by a court order which is issued in compliance with the following provisions:
a. No court of this state shall issue an order to permit access to a test for human immunodeficiency virus performed in a medical or public health setting to any person not authorized by this section or by KRS 214.420. A court may order an individual to be tested for human immunodeficiency virus only if the person seeking the test results has demonstrated a compelling need for the test results which cannot be accommodated by other means. In assessing compelling need, the court shall weight the need for testing and disclosure against the privacy interest of the test subject and the public interest which may be disserved by disclosure which deters blood, organ and semen donation and future human immunodeficiency virus-related testing or which may lead to discrimination. This paragraph shall not apply to blood bank donor records;
b. Pleadings pertaining to disclosure of tests results shall substitute a pseudonym for the true name of the subject of the test. The disclosure to the parties of the subject’s true name shall be communicated confidentially, in documents not filed with the court;
c. Before granting any order, the court shall provide the individual whose test result is in question with notice and a reasonable opportunity to participate in the proceedings if he is not already a party;
d. Court proceedings as to disclosure of test results shall be conducted in camera, unless the subject of the test agrees to a hearing in open court or unless the court determines that a public hearing is necessary to the public interest and the proper administration of justice; and
e. Upon the issuance of an order to disclose test results, the court shall impose appropriate safeguards against unauthorized disclosure, which shall specify the persons who may have access to the information, the purposes for which the information shall be used, and appropriate prohibitions on future disclosure.
No person to whom the results of a test have been disclosed shall disclose the test results to another person except as authorized by this subsection. When disclosure is made pursuant to this subsection, it shall be accompanied by a statement in writing which includes the following or substantially similar language: “This information has been disclosed to you from records whose confidentiality is protected by state law. State law prohibits you from making any further disclosure of such information without the specific written consent of the person to whom such information pertains, or is otherwise permitted by state law. A general authorization for the release of medical or other information is NOT sufficient for this purpose.” An oral disclosure shall be accompanied by oral notice and followed by a written notice within ten (10) days.
CONFIDENTIALITY ISSUES
214.645
Reporting
system of HIV-positive persons – Confidentiality and reporting requirements –
Reporting system surveillance, assessment and restrictions.
(1) The Cabinet for Health Services shall establish a system for reporting, by the use of a unique code, of all persons who test positive for the human immunodeficiency virus (HIV) infection. The reporting shall include the date including, but not limited to, CD4 count and viral load, and other information that are necessary to comply with the confidentiality and reporting requirements of the most recent edition of the Centers for Disease Control and Prevention’s (CDC) Guidelines for National Human Immunodeficiency Virus Case Surveillance. As recommended by the CDC, anonymous testing shall remain as an alternative. If less restrictive date identifying requirement are identified by the CDC, the cabinet shall evaluate the new requirements for implementation.
(2) The reporting system established under subsection (1) of this section shall:
(a.) Use a unique code that consists of any combination of initials, the last four (4) numbers of the Social Security number, birth date, or other information to be determined by the cabinet;
(b.) Attempt to identify all modes of HIV transmission, unusual clinical or virologic manifestations, and other cases of public health importance;
(c.) Require collection of the unique code and date from all private and public sources of HIV-related testing and care services: and
(d.) Use reporting methods that match the CDC’s standards for completeness, timeliness, and accuracy, and follow up, as necessary, with the health care provider making the report to verify completeness, timeliness and accuracy.
(3) Authorized surveillance staff designated by the cabinet shall:
(b.)
Match
the information from the reporting system
to other public health databases, wherever possible, to limit
duplication and to better quantify the extent of HIV infection in the
Commonwealth;
(c.)
Conduct
a biennial assessment of the HIV and AIDS reporting systems, insure that the
assessment is available for review by the public and any state or federal
agency, and forward a copy of the assessment to the Legislative Research
Commission and the Interim Joint Committee of Health and Welfare;
(d.)
Document
the security policies and procedures and insure their availability for review
by the public or any state or federal agency;
(e.)
Minimize
storage and retention of unnecessary paper or electronic reports and insure
that related policies are consistent with CDC technical guidelines;
(f.)
Assure
that electronic transfer of data is protected by encryption during transfer;
(g.)
Provide
that records be stored in a physically secluded area and protected by coded
passwords and computer encryption;
(h.)
Restrict
access to data a minimum number of authorized surveillance staff who are
designated by a responsible authorizing official, who have been trained in
confidentiality procedures, and who are aware of penalties for unauthorized
disclosure of surveillance information;
(i.)
Require
that any other public health program that receives data has appropriate
security and confidentiality protections and penalties;
(j.)
Restrict
use of data, from which identifying information has been removed, to
cabinet-approved research, and require all persons with this use to sign
confidentiality statements;
(k.)
Prohibit
release of any unique codes or any other identifying information that may have
been received in a report to any person or organization, whether public or
private, except in compliance with federal law or consultations with other
state surveillance programs and reporting sources. Under no circumstances shall a unique code or
any identifying information be reported to the CDC; and
(l.)
Immediately
investigate any report of breach of reporting, surveillance, or confidentiality
policy, report the breach to the CDC, develop recommendations for improvements
in security measure, and take appropriate disciplinary action for any
documented breach.
RYAN WHITE CARE ACT
The Ryan White
CARE (Comprehensive AIDS Resource Emergency) Act was originally signed August
18, 1990, as a federal program designed to improve the quality and availability
of care for persons with HIV/AIDS and their families. The Act was amended and reauthorized in May
1996 with four years of funding at levels determined annually as part of the
federal budget process. The Program is
administered by the Health Resources and Services Administration (HRSA) which
is within the U.S. Department of Health and Human Services (DHHS).
There are four
Titles and Part F of the Ryan White Care Act.
The titles are administered by the HIV/AIDS Bureau of HRSA. Care funds cannot offset state and local
expenditures including Medicaid.
CULTURAL SENSITIVITY
There is a report
compiled by The Horizons Program from
In this report the
writer addresses the Silence and denial that may be the most pervasive
reactions to the stigma. This is
signified by the title of the last year’s International AIDS Conference: Breaking the Silence. Through research the writer finds that not
knowing one’s HIV serostatus is far preferable to being tested. The fear is that the lack of confidentiality,
which is highly likely in many settings, forces disclosure and that individuals
can then face prejudice, discrimination, the loss of a job, strains on or the
breakup of relationships, social ostracism, or violence. In underdeveloped countries there is a doom
of, “Why should I go and get tested
when I know for a fact I won’t be able to get the necessary treatment?”
In this study
first, while it may be unrealistic to think that we can eliminate stigma
altogether, the studies reviewed here show that we can do something about
stigma and that it can be reduced through a variety of intervention strategies
(including information, counseling, coping skills acquisition, and contact). Among studies with a control or comparison
group that received information alone (basic intervention), adding another
intervention strategy such as counseling or coping skill acquisition was
effective in changing attitudes and behaviors.
In sub-Saharan
Africa, where many of the people in the community are at risk, interventions
were aimed at the total population, where in the
Flaws with this
study are in the fact that there was only a short term study of the after
effects, showing not much change in attitudes.
Future recommendations point to continued interventions with more long
term goals, involving a larger population instead of the short term effect.
One of the most
significant problems in dealing with the stigma of HIV/AIDS is that the
population of people that are being dealt with for the most part are a
population that are looked down upon anyway.
A large population of people infected with HIV/AIDS are “MSM’s”,
prostitutes and drug abusers, therefore they are shunned by the public before
you get to the topic of disease.
OTHER
529.90
Person
convicted required to submit to screening for HIV infection- Prostitution or
procuring prostitution with knowledge of sexually transmitted disease or HIV.
(2)
Any
person convicted of prostitution or procuring another to commit prostitution
under the provisions of KRS 529.020 shall be required to undergo screening for
human immunodeficiency virus infection under direction of the Cabinet for
Health Services and, if infected, shall submit to treatment and counseling as a
condition of release from probation, community control, or incarceration. Notwithstanding the provisions of KRS
214.420, the results of any test conducted pursuant to this subsection shall be
available by the Cabinet for Health Services to medical personnel, appropriate
state agencies, or courts of appropriate jurisdiction to enforce the provisions
of this chapter.
207.250 Disclosure
of HIV information in real estate transaction prohibited.
(1) The fact that an occupant of real property is infected or has been infected with human immunodeficiency virus or diagnosed with acquired immunodeficiency syndrome is not a material fact that shall be disclosed in a real estate transaction.
(2)
No
cause of action shall arise against an owner of real property or his agent, or
any agent of a transferee of real property for the failure to disclose to the
transferee that an occupant of that property was infected with human
immunodeficiency virus or diagnosed with acquired immunodeficiency syndrome.
207.135 Protections
available to persons with HIV-Employment discrimination prohibited.
(1)
Any
person with acquired immunodeficiency syndrome, acquired immunodeficiency syndrome
related complex, or human immunodeficiency virus shall have every protection
made available to individuals with disabilities under KRS 207.130 to 207.240
and Section 504, Public Law No. 93-112, the Rehabilitation Act of 1973.
Americans
with Disabilities Act (
The
To be protected by the
214.610
Educational
course to be completed by health-care workers
and
social workers- Approval by licensing board or certifying entity-Publication of
courses.
(1) (a) The
Cabinet for Health Services or the licensing board or
certifying
entity, subject to the board’s or entity’s discretion, shall approve
appropriate educational courses on the transmission, control, treatment, and
prevention of the human immunodeficiency virus and acquired immunodeficiency
syndrome, that may address appropriate behavior and attitude change, to be
completed as specified in the respective chapters by each person licensed or
certified under KRS Chapters 311, 311A, 312, 313, 314, 315, 320, 327, 333, and
335. Each licensing board or certifying
entity shall have the authority to determine whether it shall approve courses
or use courses approved by the cabinet.
Completion of the courses shall be required at the time of initial
licensure or certification in the Commonwealth, as required under KRS 214.615
and 214.620 and shall not be required under this section or any other section
more frequently than one (1) time every ten (10) years thereafter, unless the
licensing board or certifying entity specifically requires more frequent
completion under administrative regulations promulgated in accordance with KRS
Chapter 13A.
PRACTICAL
EXERCISES TO BE USED WITH HIV TRAINING
1.) Assemble the appropriate attire to wear when
treating someone that is bleeding and have someone don the attire in the proper
fashion and then remove the attire correctly so as not to expose themselves to
blood.
2.) Ask attendees to write items on the board
that are most precious to them and then one item at a time take them away as an
HIV/AIDS victim would lose these items, such as their job and their health,
insurance, family etc.
3.)
Ask attendees to talk to each other as patients/care giver in a
demeaning way that would unacceptable when we are taking care
of our patients.
Relate the emotions that are going on with this conversation as to
how patients feel if you treat them like this when you are the care-
giver.
4.)
If you have phone access in the classroom or near the room, ask an
attendee to use the phone book to find resources for testing and
treatment and attempt to call them to see how quickly information
can be obtained.