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HIV/Aids Update For Florida Health Care Providers

 

 

 

 

What are HIV and AIDS  images-4

 

 

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:

 

*Certain infections, such as repetitive pneumonia

 

*Certain cancers, such as cervical cancer, Kaposi sarcoma and central  

   nervous system lymphoma

 

*CD4+ count less than 200 or 14% of lymphocytes

 

 

imgresSymptoms of HIV Infection

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)
  •         pneumonia
  •         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

 

 

Prevalence

 

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. According to the Center for Disease Control (CDC) as of June 2016, 17 million people living with HIV were receiving medicines to treat HIV, called antiretroviral therapy (ART). 

 

Advances in HIV have led to dramatic declines in AIDS deaths and hiv1slowed 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. 

 

 

 

 


The Infection    

 

imgres-2While there are treatments that help people survive some of the diseases they get as a result of losing their immunity, there is no cure for AIDS.  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.  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.

 

Medical tests detect antibodies to HIV.  These antibodies are in the bloodstream and are an attempt of the immune system to eliminate the virus.  Antibodies are generally detectable 6 to 12 weeks after infection with HIV.  When antibodies are present in someone’s blood, that person is said to be HIV-positive.  Generally, in an untreated HIV-infected person, symptoms serious enough to constitute an AIDS diagnosis begin to appear eight to ten years after infection.

 

Before highly active antiretroviral therapy became available, most people who contracted HIV eventually progressed to AIDS and had some AIDS-related complication such as deterioration of the immune system functioning and an increased risk of infection and cancers.  Presently, most HIV-positive people live normal, active lives for several years after infection.

 

A number of factors can affect how rapidly HIV progresses, some that can be controlled, and some that cant.  An individual who takes better care of himself or herself, which improves the immune system, and following the doctors’ advice slows the progression of HIV disease to AIDS.  An infection by a virulent strain of HIV, having a higher viral load, older age, and the abuse of alcohol and other drugs may cause the HIV progression to AIDS to be more rapid.

 

 

 

Transmission

 

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. 

imgresimgres-1

 

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 transfusions 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 have been infected after being

    stuck 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).

 

 

 

Preventionimgres-2

  

The first step in controlling HIV is to prevent new infections. 

 

There are three key things that can be done to help prevent all forms of HIV transmission. 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.

 

Out of these three key components, we will look at specific protocols and recommendations based on the route of transmission.

 

 images-2

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. 

 

 

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.

 

 

The last of these can be achieved by the use of antiretroviral drugs, safer feeding practices, and other interventions.

 

 

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.

 

 

Educationimgres-3

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 a 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.

 

HIV Testingimages-1

 

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. The following summarizes the HIV testing recommendations from the CDC.

 

 

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.

 

Pregnant Women  

  • 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.

 

There are 3 primary tests for HIV.

 

  • Elisa
  • Western Blot
  • PCR (Viral Load)

 
The tests to determine if a person has been infected with HIV really do not test for the actual HIV virus. Instead, these tests detect proteins that circulate in the body when a person has been infected with HIV. Two of these antibody blood tests are used to detect HIV antibodies in the bloodstream while the third detects HIV proteins.

 

Elisa
This is the first portion of the HIV test. This test detects the presence of HIV antibodies in the blood. If the test is negative then the person is determined not to be HIV infected. If the test is positive the second portion of the test is run to confirm the results.

 

Western Blot
This test is used to confirm a positive Elisa test. The Western Blot test detects specific protein bands that are present in an HIV infected individual.

In combination with a positive Elisa, a positive Western Blot is 99.9% accurate in detecting HIV infection.

 

PCR
PCR detects specific DNA and RNA sequences that indicate the presence of HIV in the genetic structure of anyone HIV infected. After one is infected with HIV, RNA, and DNA from the HIV virus circulating in the blood. The presence of this DNA and RNA “pieces” indicates the presence of the HIV virus.

 

Getting tested earlier than 3 months may result in an unclear test result, as an infected person may not yet have developed antibodies to HIV. The time between infection and the development of antibodies is called the window period. Some test centers may recommend testing again at 6 months.

 

It is also important that an individual is not exposed to further risk of getting infected with HIV during the window period. The test is only accurate if there are no other exposures between the time of possible exposure to HIV and testing.

 

If an individual’s test is negative at six months and they have not had unprotected sex or shared needles again in the meantime, it means that they do not have HIV, and will not, therefore, go on to develop AIDS.

 

 

HIV Treatment  

 

imagesThe importance of testing and diagnosis is ever increasing with significant progress being made regarding the treatment of HIV.  Antiretroviral medications can slow and even stop the damage occurring to the body.  Medical compliance is crucial to slowing the progression of HIV to AIDS.

 

 

 

 

The Initiation of Treatment

 

  • Antiretroviral therapy is recommended for all patients with AIDS-defining illnesses or symptomatic HIV infection regardless of CD4 count or HIV Viral Load.
  • Antiretroviral therapy is recommended for asymptomatic patients with a CD4 count < 200.
  • Those asymptomatic patients with CD4 counts of 201 – 350 should be offered treatment.
  • Most experienced clinicians will defer treatment for those asymptomatic patients with CD4 counts > 350 and viral loads > 100,000.
  • HIV Treatment should be deferred for those patients with a CD4 count > 350 and a viral load of < 100,000.

 

Confidentiality

 

 

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 2 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 3 working days from the date of receipt of test results and physicians are required to report within 2 weeks of diagnosis. Only confidential positive tests which diagnose HIV infection are reportable. Examples of tests, previously noted, to diagnose HIV infection are anti-body-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 is 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 Positive Personnel

 

Twenty years ago, returning to work with HIV was not an issue. It was not an issue because people were too sick or died soon after their diagnosis. But today, with the advent of powerful HIV drugs, people are living long productive lives. People are feeling well and want to resume their normal lives…lives that include family, relationships, and employment. While going back to work is a positive thing, there are things you must know before returning to the workplace to avoid problems after taking the job.

 

Unless your HIV disease affects your ability to perform your job you are under no legal obligation to disclose your HIV status. And because HIV is not transmitted by casual contact, your HIV infection does not put any of your coworkers in danger of being infected.

 

Employers should proactively develop comprehensive personnel policies to address the broad-spectrum HIV-related issues that can arise at the worksite. The ever-expanding scope of the HIV epidemic essentially guarantees that all employers will be confronted with the human relations issues related to HIV infection.

The “hands-on” nature of health care creates specific challenges in drafting scientifically sound personnel policies. While employment and personnel policies frequently reflect societal attitudes on a number of issues, health care employers must base HIV policies on scientific facts rather than misinformation and/or in response to political/social pressures.

Personnel policies should create a maximally safe and healthful environment for all workers.

Legal topics discuss HIV infection reporting and the availability/location of anonymous test sites. A list of anonymous test sites in your area can be obtained from your local county health department. However, once a person meets the CDC defined AIDS criteria they are reportable, regardless of whether or not they tested anonymously. Furthermore, because AIDS is still a reportable disease a new report needs to be filed for all HIV reported persons who later meet the AIDS criteria.

 

HIV & AIDS Reporting Guidelines

HIV
Reportable in Florida if:


  • Patient tests positive for any test to diagnose and/or
    confirm HIV diagnosis on or after July 1997

    -Tests such as Western Blot
    PCR qualitative testing
    PCR quantitative*

* (ONLY if used for diagnostic purposes)

AIDS
Reportable in Florida if:


         Patient has a documented AIDS-defining Opportunistic Infection
at any time

AND/OR

         Patient has a documented
CD4 <200 or <14% at
any time

 

 

 

 

Legal Protection for the HIV-infected Person

 

 

The Americans with Disabilities Act (ADA) gives federal civil rights protection 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 the 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 individuals 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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