HIV/Aids Update For Florida Health Care Providers
WHAT ARE HIV AND AIDS
Effective HIV prevention and treatment occurs across a continuum of care. This comprehensive approach spanning from HIV screening to treatment can help reduce new HIV infections and improve health outcomes among people with HIV.
The Human Immunodeficiency Virus, which is commonly referred to as HIV, is a virus that directly attacks certain human organs, such as the heart or kidneys, as well as the human immune system. The immune system is made up of cells, which work to protect the body from infections and some cancers. HIV attacks the cells, which are required for a proper immune system function. When HIV destroys enough of these cells, there is a failure of the immune system to protect the individual from certain opportunistic infections.
Acquired Immunodeficiency Syndrome or AIDS refers to an individual who has very advanced HIV disease, and their immune system has incurred significant damage.
According to The Centers for Disease Control, the conditions that mark a progression from HIV disease to AIDS are:
As many as 90% of people will recall experiencing symptoms during the acute phase of HIV infection. Acute HIV infection can present as an infectious mononucleosis-like or influenza-like syndrome, but the clinical features are highly variable. Symptoms typically begin a median of 10 days after infection and can include fever, maculopapular rash, arthralgia, myalgia, malaise, lymphadenopathy, oral ulcers, pharyngitis, and weight loss. The presence of fever and rash has the best positive predictive value.
The only way to determine for sure whether someone has HIV/AIDS is to be tested for the HIV infection. Someone cannot rely on symptoms to know whether or not they are infected with HIV. Many people who are infected with HIV do not have any symptoms at all for many years. The potential symptoms include:
- rapid weight loss
- dry cough
- recurring fever or profuse night sweats
- profound and unexplained fatigue
- swollen lymph glands in the armpits, groin, or neck (lymphadenopathy)
- diarrhea that lasts for more than a week
- white spots or unusual blemishes on the tongue, in the mouth, or in the throat (thrush)
- red, brown, pink, or purplish blotches on or under the skin or inside the mouth, nose, or eyelids (Kaposi Sarcoma)
- memory loss, depression, and other neurological disorders.
HIV and AIDS remain a persistent problem for the United States and countries around the world. While great progress has been made in preventing and treating HIV, there is still much to do. There are 37.9 million people globally, living with HIV. There are 1.1 million people in the United States about 14% of those don’t know they are infected.
Advances in HIV have led to dramatic declines in AIDS deaths and slowed the progression from HIV to AIDS. Better treatments have led to a rise in the number of people in the United States who are living with AIDS. This growing population represents an increasing need for better understanding, empathy, support, continued HIV prevention services, and treatment.
HIV can be diagnosed with laboratory-based or point-of-care assays that detect anti-HIV antibodies, HIV p24 antigen, or HIV-1 RNA. In the United States, the recommended laboratory-based screening test for HIV is a combination of antigen/antibody assay that detects antibodies against HIV, as well as p24 antigen. The combination antigen/antibody assay becomes reactive approximately 2–3 weeks after HIV infection. It is estimated that 99% of people will develop a reactive combination antigen/antibody result within six weeks of infection, but in rare cases, it can take up to 6 months to develop a reactive test result. Point-of-care HIV antibody tests performed on oral fluid (instead of blood) have been associated with a lower sensitivity during early HIV infection. The earliest time after exposure that HIV infection can be diagnosed is approximately nine days when HIV-1 RNA becomes detectable in blood.
The first step in controlling HIV is to prevent new infections.
Although scientists have yet to find a cure or an effective vaccine, AIDS, unlike many other life-threatening illnesses, is completely preventable. We have the knowledge, technology, and resources to halt the spread of the epidemic.
Promoting widespread awareness of HIV and how it can be spread, counseling and testing, and providing antiretroviral treatment. This treatment enables people living with HIV to enjoy longer, healthier lives, and as such, it acts as an incentive for people to volunteer for HIV testing. It also brings people into contact with health care workers who can deliver prevention messages and interventions.
Preexposure prophylaxis (or PrEP) with tenofovir-emtricitabine is highly effective in preventing HIV infection and is recommended as a prevention option for adults at substantial risk of HIV acquisition.
Postexposure prophylaxis (or PEP) with antiretroviral medications is another method to prevent HIV infection. PEP is recommended as a prevention option after a single high-risk exposure to HIV during sex, through sharing needles or syringes, or from a sexual assault. PEP must be started within 72 hours of possible exposure.
Prevention of Occupational Exposure
There are many strategies that can be used to reduce the risk of occupational exposure.
The primary means of preventing the health care worker’s occupational exposure to HIV and other blood-borne pathogens is to follow infection control precautions with the assumption that the blood and other body fluids from all patients are potentially infectious. These precautions include:
Routinely using barriers (such as gloves and/or goggles) when anticipating contact with blood or body fluids
Immediately wash hands and other skin surfaces after contact with blood or body fluids.
Carefully handling and disposing of sharp instruments during and after use.
Safety devices also have been developed to help prevent needle-stick injuries.
If used properly, these types of devices may reduce occupational HIV exposure risk. Furthermore, because many percutaneous injuries are related to sharps disposal, strategies for safer disposal, including safer design of disposal containers and placement of containers, are being developed.
Although the most important strategy for reducing the risk of occupational HIV transmission is to prevent occupational exposures, plans for post-exposure management of health care workers should be in place. The administration of antiretroviral drugs as post-exposure prophylaxis (PEP) should be considered. Using zidovudine as PEP has been shown to be safe and associated with decreased risk for occupationally related HIV infection. Newer antiretrovirals also may be effective, although there is less experience with their use as PEP. CDC recently issued guidelines for the management of HCW exposures to HIV and recommendations for PEP. These guidelines outline a number of considerations in determining whether or not an HCW should receive PEP and in choosing the type of PEP regimen. The recommendations will be updated if ongoing data collection and analysis show increased the effectiveness of newer drug treatments.
As mentioned, all health care workers should use universal precautions. These precautions should include the routine use of gloves and or goggles when contact with blood or body fluids is possible, washing hands and other skin surfaces immediately after contact with blood or body fluids and using extra care when handling or disposing of sharp instruments.
Precautions Regarding Sex
To reduce the transmission of HIV, the CDC recommends abstinence, monogamy with a safe, tested the significant person, or, at a minimum, the use of latex or polyurethane condoms.
Injectable Drug Use
Abstinence from IV drug use is also a necessary component of the reduction in the transmission of HIV. If drug use is an issue, the user should only use clean needles and syringes and seek the aid of a substance abuse rehabilitation program.
The strongest weapon against HIV is education. As a society and each individual must conquer the fear through knowledge and education rather than allowing the fear to postpone testing and take part in unsafe practices such as unprotected sex.
The CDC provides the following to dispel popular misconceptions:
* There is no known transmission of HIV by contact with an environmental surface. (Public accommodations, transportation, etc.)
* There is no evidence of HIV transmission through mosquitoes or other insects.
* There is no known risk of HIV transmission to co-workers, clients, or consumers from contact in industries such as food-service establishments.
* Casual contact through closed-mouth kissing is not a risk for transmission of HIV. The CDC recommends engaging in French or open-mouth kissing, although the risk of acquiring HIV during this practice is believed to be very low.
* Contact with saliva, tears, or sweat has never been shown to result in the transmission of HIV.
* Natural membrane condoms have been shown to allow viruses to pass through them. For condoms to provide maximum protection, they must be latex or polyurethane, be used every time and correctly.
SCREENING AND DIAGNOSTIC TESTS
HIV screening is recommended for all adolescents and adults 13-64 years of age. Testing can reduce HIV transmission, and early diagnosis can improve medical outcomes.
The Centers for Disease Control and Prevention has recommended that HIV testing and HIV screening be part of routine clinical care in all health care settings. The CDC also has stated it suggests that the patient’s right to refuse be preserved in order to facilitate a good working relationship between patient and doctor.
Diagnosing HIV quickly and linking people to treatment immediately are crucial to achieving a further reduction in new HIV infections.
The Centers for Disease Control and Prevention (CDC) recommends:
Routine HIV screening at least once for everyone.
Frequent screenings for patients at greater risk for HIV
All patients who test positive for HIV should be linked to medical treatment, care, and prevention services
Benefits of Early HIV Diagnosis
People with HIV who are aware of their status should be prescribed Antiretroviral therapy (ART). By achieving and maintaining an undetectable (<200 copies/mL) viral load, patients can remain healthy for many years. ART is now recommended for all people with HIV, regardless of CD4 count. Studies show that the sooner people start treatment after diagnosis, the more they benefit from ART. Early diagnosis followed by prompt ART initiation:
Reduces HIV-associated morbidity and mortality
Greatly decreases HIV transmission to others
May reduce the risk of serious non-AIDS‒related diseases
Patients in all Health-Care Settings
HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening).
Persons at high risk for HIV infection should be screened for HIV at least annually.
Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient and imply consent for HIV testing.
Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings.
HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women.
HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines (opt-out screening).
Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient for HIV testing.
Repeat screening in the third trimester is recommended in certain areas with elevated rates of HIV infection among pregnant women.
HIV tests have improved substantially over the years, and are now easier and less expensive, with a more rapid turnaround time for results.
Three types of HIV tests are available:
Nucleic acid tests (NATs) — detects HIV ribonucleic acid (RNA)
Antigen/antibody combination tests — detects HIV p24 antigen as well as HIV immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies
Antibody tests — detects HIV IgM and/or IgG antibodies
Following an exposure that leads to HIV infection, the amount of time during which no existing diagnostic test is capable of detecting HIV is called the eclipse period.
The time between potential HIV exposure and an accurate test result is referred to as the window period. Improvements in testing technology continue to reduce the detection window period, and, therefore, the time to diagnosis and treatment of early HIV infection. As seen in the figure, each type of HIV test has its own testing window, with the NAT capable of detecting HIV the earliest, followed by the antigen/antibody combination test, and lastly, the antibody test.
We know how HIV is and is not spread. Educating everyone about how to protect him or herself is the only way we can halt the spread of this disease. Prevent HIV infection, and you will prevent AIDS.
Prompt medical care and effective treatment with antiretrovirals can partially reverse HIV-induced damage to the immune system, and prolong life. Effective treatment also substantially reduces the risk of HIV transmission to others.
Keeping patients in regular care improves their health and reduces their risk of HIV transmission to others. The benefits of ongoing care can include addressing and supporting ART adherence, maintaining decreased viral load and increased CD4 count, lowering rates of progression to AIDS, decreasing rates of hospitalization, and improving overall health.
Poor retention in HIV care is more common in people who have substance use disorders, serious mental health problems, unmet socioeconomic needs such as housing, food, or transportation, limited financial resources or health insurance, or schedules that complicate adherence to HIV medication.
Patients with HIV are at an increased risk of acquiring STDs, viral hepatitis, and opportunistic infections such as tuberculosis (TB). Coinfections can have a negative impact on their health and HIV treatment. Viral suppression can reduce a patient’s risk of coinfection, but providers should discuss regular screening and prevention measures with their patients.
STD preventive services are an essential component of HIV prevention and care. Providers should engage patients in regular conversations about STDs, including a review of sexual history and STD symptoms, at every visit. Patients with HIV should be screened for STDs at least annually and more frequently if they or their sexual partners have multiple or anonymous sex partners. Certain STDs can increase HIV viral load and genital HIV shedding, which may increase the risk of sexual and perinatal HIV transmission. Correct and consistent condom use should be advised to prevent STDs and can reduce HIV transmission risk in those with an STD or unsuppressed viral load. Learn more about STD treatment and care with the STD Treatment Guidelines and Updates.
Because of shared modes of transmission, a high proportion of adults with HIV are also at risk for coinfection with the hepatitis B virus, or, more commonly, the hepatitis C virus. People who have these coinfections are at increased risk for serious, life-threatening complications. Anyone with HIV should be tested for hepatitis B and hepatitis C and treatment or vaccinations, when appropriate, should be considered.
People with HIV are also at risk for a variety of opportunistic infections such as TB. These risks can be reduced by viral suppression and a number of other prevention behaviors.
As we continue to research how to control and eventually eradicate this disease, our efforts have focused on the identification of the ways in which HIV can be transmitted.
According to The Centers for Disease Control and Prevention:
HIV is transmitted by:
- Sexual contact with an infected person sharing needles and/or syringes with someone who is infected
- Less commonly (and now very rare in countries where blood is screened for HIV antibodies), through transfusion of infected blood or blood clotting factors
- Babies born to HIV-positive women may become infected before or during birth or through breastfeeding after birth
- In health care settings, workers may become infected after being struck with needles containing HIV-infected blood
- Less frequently, workers have been infected after HIV-positive blood gets into a worker’s open cut, eyes or inside of the nose
- Sexual contact with an infected person
- Sharing needles and/or syringes with someone who is infected
- Less commonly (and now very rare in countries where blood is screened for HIV antibodies), through transfusion of infected blood or blood clotting factors
- Babies born to HIV-positive women may become infected before or during birth or through breastfeeding after birth
- In health care settings, workers may become infected after being struck with needles containing HIV-infected blood.
- Less frequently, workers have been infected after HIV-positive blood gets into a worker’s open cut or a mucous membrane (eyes or inside of the nose)
Perinatal Transmission of HIV
The perinatal transmission of HIV each year in the United States by approximately 6,000 to 7,000 HIV-infected women giving birth, results in 280 to 370 new perinatal infections. Approximately 40% of the HIV infected women who pass their HIV to their child never knew they were HIV infected or were never tested for HIV during their pregnancy.
Effective prevention of mother-to-child transmission (PMTCT) requires a three-fold strategy.
Preventing HIV infection among prospective parents
Avoiding unwanted pregnancies among HIV positive women
Preventing the transmission of HIV from HIV positive mothers to their infants during pregnancy, labor, delivery, and breastfeeding.
For HIV-positive women in well-resourced countries, the advice from national health agencies is straightforward: they should avoid breastfeeding altogether because the risk of HIV transmission far outweighs the risks associated with replacement feeding.
Many women do not know that perinatal transmission of HIV is preventable. Only about 33% of all hospitals offer rapid HIV testing to women in labor, and only 50% of them have policies to test women whose HIV status is unknown.
Under most circumstances, HIV testing is voluntary. Unless there are special circumstances, most states require a person to give informed consent before he or she can be tested for HIV. Many options are available for anonymous testing at clinics and at home. Most states have laws that protect the confidentiality of HIV testing and diagnosis.
Confidentiality is a complex issue. The need for confidentiality is paramount to further the efforts of testing and treatment. However, most, if not all, states carry the requirement of disclosing HIV status to a prospective sexual or needle-sharing partner. In some states, failure to do so is a misdemeanor; in others, it is a felony. The challenge lies in defining an identifiable sexual or needle-sharing partner while respecting the rights of the HIV-infected individual to confidentiality.
REPORTING HIV AND AIDS IN FLORIDA
As part of informed consent, it is important to verbalize and put in writing your responsibilities as a professional prior to beginning assessments and treatment. Also, should a situation arise where you are unsure, it is always best to seek supervision through a supervisor and mentor in your field.
HIV/AIDS cases should be reported to the local county health department within two weeks of diagnosis, per FL Statutes. Cases may be reported ONLY by MAIL or by TELEPHONE.
The Centers for Disease Control and Prevention (CDC) published its first surveillance case definition for Acquired Immune Deficiency Syndrome (AIDS) in September of 1982. Starting in 1983, Florida designated AIDS as a reportable disease, and an AIDS surveillance program was instituted. Reporting at that time, however, was voluntary, and it was not until 1986 that the mandatory reporting of AIDS became incorporated into Florida Statues (s.384, F.S.). Currently, an HIV positive patient age 13 or older meets the CDC surveillance case definition of AIDS if they have a CD4 T-lymphocyte count less than 200/ul or 14%. They also meet the criteria if they have any one of 26 opportunistic infections. Florida Administrative Code 64D directs that all AIDS cases, as defined by CDC, be reported to the local county health department by physicians who diagnose or treat AIDS.
AIDS surveillance data has provided critical information necessary for tracking this disease and targeting both prevention and treatment resources. In recent years, however, AIDS surveillance data has been less reflective of the epidemic due to the success of antiretroviral therapy. Individuals infected with HIV are doing better, and the progression from HIV to AIDS is much longer. People are living longer, healthier lives. Consequently, the number of AIDS cases has dropped. With fewer cases and longer progression from HIV to AIDS, it is difficult to know where new infections are occurring and where to target resources.
In 1996 legislation was passed, amending s.384, F.S., and 64D, F.A.C., authorizing the Department of Health to establish rules to require both laboratory and physician reporting of positive HIV infections. Effective July 1, 1997, HIV infection became reportable by name in the State of Florida. Laboratories are required to report within three working days from the date of receipt of test results, and physicians are required to report within two weeks of diagnosis. Only confidential positive tests that diagnose HIV infection are reportable. Examples of tests, previously noted, to diagnose HIV infection are antibody-based testing systems such as repeat ELISAs followed by a Western Blot, and antigen tests such as p24 antigen or polymerase chain reaction (PCR), when these are used for confirmatory purposes. Tests to determine viral load are not reportable unless done to diagnose HIV infection. Under Florida Law, there is no retroactive reporting; only positive results obtained from specimens collected on or after July 1, 1997, are reportable.
HIV reporting in the state of Florida was implemented, not only to have a more accurate picture of the epidemic but also to link patients to services. Under Florida Law, a health department representative will contact the reporting physician for permission to contact the patient. This contract is for the purpose of offering and initiating follow-up services. Examples of follow-up services are post-test counseling for persons who did not return for test results, referral for medical evaluation, case management services, and voluntary partner notification. This linking of seropositive patients to services is one reason that patient names are necessary on the reports. Another reason names are needed to prevent duplication. Eliminating duplicates prevents the inflation of statistics and ensures that the data are as accurate as possible.
For those patients not wishing to be reported if positive, Florida Law requires that anonymous testing be readily available in all counties of the state through the county health department. Persons who test positive for HIV through the anonymous testing system will not be reported. All persons being offered an HIV test are required by law to be informed about These locations are mandated by law to give equal opportunity to use or enjoy the public accommodation of goods, services, or facilities.
HIV/AIDS-related illnesses are also covered under the Family & Medical Leave Act. This allows eligible employees to take off up to 12 work weeks in any 12 month period to care for themselves or a family member with a serious health condition.
WORKING WITH PATIENTS WITH HIV/AIDS
The patient with HIV/AIDS is facing not only a life-threatening and often fatal illness but also with the social stigma, public fear, and concerns of transmitting the illness to loved ones. They often face isolation, discrimination, loss of career, and in many circumstances, abandonment by family and friends. They are financially threatened by medical expenses and fear for their benefits. In many situations, they also are faced with grief and loss from friends and loved ones who have died from AIDS. Medical professionals must address the psychological, biological, and social aspects of this illness.
With the advances made in treatment, HIV-positive clients should not be treated as hospice patients. Many HIV-infected clients live normal lives for years to come. For this reason, it is important to help the client to establish coping mechanisms for the long term well being.
The treatment plan should address medical compliance, and social services should develop a plan, including issues relating to prejudice, support issues, concerns about relationships, depression, anxiety, and suicide risk assessment, and education.
Universal precautions should be used with HIV positive clients, just as they should be used with all patients.
HIV & AIDS Reporting Guidelines
Patient tests positive for any test to diagnose and/or
* (ONLY if used for diagnostic purposes)
Patient has a documented AIDS-defining
Opportunistic Infection at any time
Patient has a documented CD4 <200 or <14% at any time
LEGAL PROTECTIONS FOR THE HIV-INFECTED PERSONS
The Americans with Disabilities Act (ADA) gives federal civil rights protections to individuals who are diagnosed with HIV/AIDS. Persons with HIV, both symptomatic and asymptomatic, are protected by law against discrimination and are entitled to equal opportunity in public accommodations, employment, and transportation. Additionally, individuals who are discriminated against because they associate with an HIV-infected person are also protected by the ADA.
This protection prohibits all private employers with 15 or more employees, as well as all public entities, regardless of their size from discriminating in employment against qualified individuals with disabilities. This includes hiring, firing, as well as job application procedures such as interviewing, job assignments, training, promotions, wages, benefits, leave, and all other employment-related activities. An example of this protection could include a hospital that discharged a mental health technician due to their HIV-positive status. Customer or co-worker attitudes do not constitute just cause for discharge.
The ADA mandates that an employer may not ask or require a job applicant to take a medical examination before making a job offer. It cannot make any pre-offer inquiry about a disability or the nature or severity of a disability. An employer may inquire as to whether a candidate is able to perform the duties of the job.
The ADA requires that medical information be kept confidential. Medical information must be kept in a separate file apart from an individual’s personnel file. All licensing boards have very strict guidelines for the maintenance of client files. Most require that client files be maintained in a locked file cabinet in a locked room. Only authorized staff is allowed to review charts. Again, it is stressed that the policy for confidentiality is best clearly defined in informed consent.
A public accommodation is also a legally protected issue. Public accommodation relates to a private entity that owns, operates, leases, or leases to a place of public accommodation. This would include places such as restaurants, shopping malls, medical practices, as well as others.
POST EXPOSURE TO BBP
Although not a primary means of HIV transmission, occupational exposure to HIV has resulted in documented cases of HIV seroconversion among health care workers in the United States.
Although, as discussed in the prevention section of this course, preventing exposures to blood and body fluids is the primary means of preventing occupationally acquired HIV infection, it is also appropriate to look at post-exposure management as an important element of workplace safety.
If you experienced a needlestick or sharps injury or were exposed to the blood or other body fluid of a patient during the course of your work, immediately follow these steps:
Wash needle sticks and cuts with soap and water
Flush splashes to the nose, mouth, or skin with water
Irrigate eyes with clean water, saline, or sterile irrigants
Report the incident to your supervisor
Immediately seek medical treatment
Any incident of exposure should be reported to your supervisor immediately.
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