HIV/AIDS One Hour Update for the Healthcare Professional | Copyright © 2009 CEUFast.com

Course Contents

	Purpose/Goals    Objectives    Prevalence        HIV Incidence Estimate    International Statistics        Healthcare Workers    Understanding the Virus        HIV Infection Cycle:        AIDS Lifecycle (NLM, nd)           Stage 1           Stage 2           Stage 3           Stage 4           Stage 5           Stage 6           Stage 7           Stage 8           Stage 9    Screen Testing    HIV Transmission    Prevention    Treatments    Legal Information for the Healthcare Provider    Conclusion    References    Click any section in the index above to browse to the corresponding course section

Purpose/Goals

The purpose of this course is to update healthcare professionals on current trends and treatments of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS).

Objectives

This course is designed so that the healthcare professional will be able to:

HIV kills and damages cells of the body's immune system by destroying the body's ability to fight infections and certain cancers. You cannot get AIDS without first having HIV. AIDS is the end stage of HIV infection.

Prevalence

Prevalence is the number of people living with HIV/AIDS in a given year.

AIDS is the most catastrophic disease in modern history. It has become the world's deadliest infectious disease and is threatening to eliminate up to a sixth of the world's population. An estimated 33.2 million people worldwide are infected with HIV and 2.1 million died of AIDS in 2007, of which 1.7 Million were Adults, and 330,000 were children less than 15 years old (UNAIDS, 2007). UNAIDS and the World Health Organization (WHO) estimate there are 30.8 million adults living with HIV, 15.4 million Women, and 2.5 million children less than 15 years of age.

Since the 1990s two significant changes have occurred in the course of HIV/AIDs: antiretroviral medications were developed and deaths from the disease decreased (Trynka, & Erlen, 2004). The annual number of deaths from AIDS peaked between 1991 and 1996. Deaths declined 14% between 1998 and 2002 (Trynka, & Erlen, 2004). This trend is directly attributed to the widespread use of antiretroviral medication (Trynka, & Erlen, 2004).

HIV Incidence Estimate

Incidence is the number of new HIV infections that occur during a given year.

The Center for Disease Control (CDC) estimated that approximately 56,300 people were newly infected with HIV in 2006. 53% of these new infections occurred in gay and bisexual men. African American men and women were also strongly affected and were estimated to have an incidence rate than was 7 times greater than among whites, (Hall HI, Ruiguang S, Rhodes P, et al., 2008).

Table above is the estimated numbers of cases of HIV/AIDS, by year of diagnosis and selected characteristics, 2004-2007-34 states And 5 U.S., dependent areas with confidential name-based HIV infection reporting

Note. These numbers of HIV infections (CDC, 2008) do not represent reported case counts. Rather, these numbers are point estimates, which result from adjustments of reported case counts. The reported case counts have been adjusted for reporting delays and missing risk-factor. Specifics on the above numbers: information, but not for incomplete reporting.

International Statistics

In the most recent CDC data over 6,800 persons become infected with HIV every day and over 5,700 persons die daily from AIDS. This is mostly due to inadequate access to HIV prevention and treatment services. The HIV pandemic remains the most serious of infectious diseases and is a major challenge world wide.

Currently the 2007 epidemiologic assessment suggests the following:

	the global prevalence of HIV infection or percentage of persons infected with HIV remains at the same level and the global number to persons living with HIV is increasing because of ongoing accumulation of new infections with longer survival times, measured over a continuously growing general population;
	specific countries demonstrate a localized reduction in prevalence;
	with a scaling up of treatment access there has been a reduction of HIV-associated deaths;
	globally, there has been a reduction of new HIV infections.

Globally, the survival of those with HIV without treatment has increased from 9 to 11 years.

Regional and global trends in 2007 suggest the pandemic has formed two broad patterns:

In 2007 33.2 million people were estimated to be living with HIV, 2.5 million people became newly infected and 2.1 million dies of AIDS.

Sub- Saharan Africa still remains the most seriously affected area, with AIDS the leading cause of death. There were an estimated 1.7 million new HIV infections in sub-Saharan Africa in 2007, a significant reduction since 2001.

There is an estimated 22.5 million living with HIV. 68% of the global total of those living with HIV are in sub-Saharan Africa.

In Sub-Saharan Africa, continued treatment scale-up and HIV prevention efforts are bringing results in some countries, but mortality from AIDS remains high in Africa due to the extensive unmet treatment needs. Cote d'Ivoire, Kenya and Zimbabwe have all seen downward trends in their national prevalence. Beyond Sub-Saharan Africa, declines in new HIV infections have occurred in South and South-East Asia, notably in Cambodia, Myanmar and Thailand.

There is a need to adapt and revive HIV prevention efforts as some countries are seeing a reversal of declining trends. Burundi’s declining trend from the late 1990’s did not continue beyond 2005. HIV prevalence started to increase again at most surveillance sites. Despite achievements in reversing the epidemic in Thailand, HIV prevalence is rising among men who have sex with men and has remained high among injecting drug users over the past 15 years, ranging from 30% to 50%.

UNAIDS and WHO officials point out that the new estimates do not change the need for immediate action and increased funding to scale up towards universal access to HIV prevention, treatment, care and support services is vitally needed.

Global Factsheet 2008

Adult Prevalence (15-49) [%] in 2008 [Source: AIDS Epidemic Update, UNAIDS, December 2008]

Sub-Saharan Africa	5.0%
Middle East and North Africa	0.3%
South and South-East Asia	0.3%
East Asia	0.1%
Oceania	0.4%
Latin America	0.5%
Caribbean	1.1%
Eastern Europe and Central Asia	0.8%
Western and Central Europe	0.3%
North America	0.6%

Adults and Children Estimated to be Living with HIV during 2008 [Source: AIDS Epidemic Update, UNAIDS, December 2008]

Estimated Adult and Child Deaths due to AIDS during 2008 [Source: AIDS Epidemic Update, UNAIDS, December 2008]

Adults and Children Estimated to be Newly Infected with HIV during 2008 [Source: AIDS Epidemic Update, UNAIDS, December 2008]

Healthcare Workers

The main cause of infection in healthcare work settings is exposure to HIV-infected blood via a percutaneous injury (i.e. from needles, instruments, bites which break the skin, etc. The average risk for HIV transmission after such exposure to infected blood is low; about 3 per 1,000 injuries (CDC, 2007). Certain specific factors may mean a percutaneous injury carries a higher risk, for example:

	A deep injury
	Late-stage HIV disease in the source patient
	Visible blood on the device that caused the injury
	Injury with a needle that had been placed in a source patient's artery or vein

 If Percutaneous exposure occurs then the site of exposure should be washed liberally with soap and water but, without scrubbing. Bleeding should be encouraged by pressing gently around the site of the injury. It is important not to press immediately on the injury site and to cleanse wound under running water. Although infection through needle-stick injury does not often occur, it can be devastating for the person.

HIV has been acquired through contact with non-intact skin or mucous membranes (i.e. splashes of infected blood in the eye) in a small number of situations. Research suggests that the risk of HIV infection after mucous membrane exposure is less than 1 in 1000. If mucocutaneous exposure occurs then the affected area should be washed thoroughly with soap and water. If the eye is affected, it should be irrigated thoroughly.

If intact skin is exposed to HIV infected blood then there is no risk of HIV transmission.

Understanding the Virus

The immune system is a network of cells and organs that work together to defend the body against infection by germs such as HIV.

Antibodies attach themselves to the enemy to slow them down so that the phagocytes can engulf them. When all the enemy cells are engulfed and the battle is won, T suppressor cells send out the recall signal. Phagocytes come in to clean up and eat the dead cells. After the battle, most of the cells die off. Some T cells survive and become T memory cells. These memory cells remember the battle and are able to fight again should the same invader strike. Thus, the body is said to be immune to that infection. HIV disguises itself by mutating the outer cell coating. This mutation helps the virus evade antibody detection because the T memory cells only recognize previously encountered invaders (Staff, 2004c).

HIV is classified as a retrovirus that has a long latency period. HIV invades the body through the bloodstream and uses the immune system against itself. As the macrophages recognize the invader, they attack just as they would for any other foreign substance. Some of the HIV are destroyed when the helper T cells join the battle; however, the HIV attach themselves to the T cells and the T cells accept the foreign HIV cells as their own. The outer coverings of the two cells fuse.

Once inside the T-4 cell, HIV uses a reverse transcriptase enzyme to translate its own genetic program ribonucleic acid (RNA) into the T-4 cells' genetic material deoxyribonucleic acid (DNA). Instead of fighting against the infection the T cell is reprogrammed to either produce more HIV cells or to remain dormant.

People infected with HIV eventually develop symptoms that usually last a long time and are often severe. These symptoms include enlarged lymph glands, fever, tiredness, loss of appetite and weight loss, diarrhea, yeast infections of the mouth and vagina, and night sweats.

As the immune system becomes weaker, the infected person becomes more susceptible to illnesses that normally do not occur in healthy people. These illnesses are called Opportunistic infections. The most common opportunistic infections are Pneumocystis Carinii Pneumonia (PCP), yeast infections of the mouth and esophagus, and Kaposi's sarcoma, a cancer of certain blood vessels.

HIV Infection Cycle:

AIDS Lifecycle (NLM, nd)

Stage 1

HIV virus is passed from one person to another. The virus travels through the bloodstream to many different places in the body.

Stage 2

The immune system, which helps the body fight off illness, fights back in three ways:

1. Custom-made antibodies

2. These antibodies have macrophages that eats up all foreign invaders

3. Killer T-cells that seek out and destroy cells that are already infected with the virus

Stage 3

This defense is coordinated by the helper T cells. But HIV has an ingenious battle strategy; it attacks the T cells themselves, crippling the body's defenses.

Infected helper T-cells (foreground)

Stage 4

HIV has a special shape on its surface which, like a piece of a jigsaw puzzle, fits perfectly into a shape on the T cell. This shape is a protein called CD4. HIV uses CD4 to enter the cells it infects. This is why the T helper cell is referred to as a CD4 lymphocyte.

AIDS virus attaching to a CD4 receptor on a helper T-cell

Stage 5

Once inside a T helper cell, HIV takes over the cell and the virus then replicates. The virus's genetic information (RNA) is transcribed into a form that is identical to the cell's genetic information (DNA). The virus, now in the form of DNA, hides out inside the nucleus of the cell, escaping from the body's defenses.

HIV RNA being transcribed to DNA

Stage 6

After a while, HIV comes out of hiding and begins to reproduce.

The DNA is transcribed into many copies of RNA that produces proteins for the new viruses.

Stage 7

The proteins are cut into usable pieces and packaged with the RNA.

Stage 8

The new viruses then bud from the cell. Each new virus may then go on to infect and destroy other T cells, weakening the immune system's defense.

Infected T-cell budding new viruses

Stage 9

After a lot of T cells are destroyed, the person is said to have AIDS. A person with AIDS will probably develop one or many opportunistic infections. A person with AIDS will usually die of an opportunistic infection.

Opportunistic infections in the bloodstream of a person with AIDS

Screen Testing

Enzyme immunoassay (EIA) is a screening test for HIV. A blood sample is drawn, sent to a lab, and the results are available within several days to several weeks. A negative screening test means a person is not infected with HIV, and does not require further testing. If a person has risky behaviors they could be in the window period and a repeat test is suggested in six months. A positive screening test means the person needs further testing. A Western Blot, or immunofluorescence assay (IFA), is performed to confirm the diagnosis of HIV.

A rapid test licensed by the Food and Drug Administration (FDA), known as the Single Use Diagnostic System for HIV-1 (SUDS) can give HIV-1 test results in 5 to 30 minutes. Another rapid test is Ora Quick Rapid HIV Test.

In March 2004, the Ora Quick Rapid HIV Test was approved, by the FDA, for use on Oral Fluid. A reactive HIV test result from either of these tests needs to be confirmed by an additional, more specific test (CDC, n.d.a).

The patient having a rapid test can be advised immediately of their screening test results, and counseled on HIV prevention and transmission. A negative rapid test result is always negative, unless the patient has been tested before the antibodies have formed (window period).

HIV Transmission

The blood, semen, vaginal fluid, and breast milk of people infected with HIV has enough of the virus in it to infect other people. It has not been documented as fact that HIV can be transmitted through tears and saliva, but CDC has kept saliva on the list of body fluids that require the healthcare professional to exercise standard precautions. CDC and the American Dental Association's Council on Dental Therapeutics suggest assuming that saliva containing a lot of blood could potentially carry HIV and other harmful pathogens).

An HIV infected person who has no signs of an infection or illness can still infect others.

There are four known common ways HIV is transmitted:

HIV can enter the body through certain types of tissues that line the anus, vagina, or penis. It also can enter through cuts or tears in the vagina, rectum, penis, or mouth. HIV can be spread through unprotected sexual intercourse from male-to-male, male-to-female, or female-to-female. Unprotected sexual intercourse means sexual intercourse without correct and consistent use of a latex condom or any other physical barrier to HIV. It is possible to catch HIV through oral sex if there are open sores in a person's mouth or bleeding gums.

Insects such as mosquitoes, bugs or animals do not spread HIV. HIV is also not spread through casual contact of any kind such as:

Prevention

Reducing high risk behaviors through educational efforts can prevent HIV infections. To prevent HIV infections, the Center of Disease Control (CDC) (n.d.b) offers the Following suggestions:

	do not have sex with an HIV infected person,
	do not share needles with an HIV infected person, and
	avoid any risky behaviors that might result in contact with blood, semen, vaginal secretions, or other body fluids

The best way for a healthcare worker to avoid contracting HIV and developing AIDS is to follow CDC's recommendations to treat every patient as though they are HIV positive. The Occupational Health and Safety Administration (OSHA) and CDC recommend the use of standard precautions whenever there is a risk of a person being exposed to contaminated blood or body fluids. It is recommended that all individuals be treated as if they could be infected. Hand washing is the single most important factor in preventing HIV and other diseases. Keeping hands away from ones face and not eating or drinking in any environment that may be contaminated is recommended.

Barrier precautions should always be used to prevent exposure to blood and other body fluids. Vinyl or latex gloves must be worn before touching any blood, body fluids, non-intact skin, mucous membranes, or excretions. Wearing a clean waterproof, non-sterile gown will protect the healthcare worker from exposure to contaminated body fluids. Both OSHA and CDC recommend the use of blood and body fluid precautions for all invasive procedures. An invasive procedure is a procedure requiring surgical entry into tissues, organs, cavities, or repair of traumatic injury. These precautions prevent the transmission of pathogens from all body substances. When doing CPR, masks, ventilation bags, and other intubation equipment should be used to prevent exposure to saliva.

The most direct way of spreading HIV is through a puncture wound from a contaminated needle or other object that causes a break in the skin. Needles should NEVER be recapped, bent, broken, or removed from contaminated syringes. Sharps should be disposed into a puncture-proof container and then transported to a reprocessing area. One out of every four needle stick injuries involves IV therapy equipment.

Specimens should be placed in leak-proof bags or containers with an identifiable Biohazard Warning label. Used equipment and instruments need to be systematically cleansed and sterilized. The HIV virus can easily be destroyed on surfaces by exposure to common cleansing agents and by all routine methods of sterilization.

Prompt initiation of antiretroviral therapy soon after occupational exposure to HIV was found to substantially reduce the risk of HIV seroconversion (Pinkerton, et al., 2004). Therefore, the US Public Health Service recommends Post-exposure prophylaxis (PEP) with antiretroviral agents for persons with occupational HIV exposures if there is a recognized transmission risk. These medications are only available with a prescription. PEP should begin as soon as possible within 72 hours. Treatment is with 2 or 3 antiretroviral medications for 4 weeks if tolerated. PEP is not 100% effective and does not guarantee that exposure to HIV will not become a case of HIV infection (AIDS InfoNet, 2007).
The US Public Health Service does not recommend for or against antiretroviral agents for non-occupational situations because of the lack of efficacy data (Pinkerton, et al., 2004, AIDS InfoNet, 2007).

Treatments

Presently there is no cure for HIV. Vaccines are under development but are not yet available. Human testing has begun at the University of Massachusetts (Staff, 2004c).

Current treatment consists of medications to slow down the process of HIV duplication and weakening of the body's immune system. Highly Active Anti-Retroviral Therapy (HAART) is the combination of three or four antiretroviral agents (CDC, n.d.b). The following are a list of medications that may be used in HAART.

Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs)

	Zidovudine (AZT, ZDV) (Retrovir®)
	Didanosine (ddI) (Videx®)
	Lamivudine (3TC) (Epivir®)
	Stavudine (d4T) (Zerit®)
	Tenofovir (Viread™)
	Zalcitabine (ddC) (HIVID®)
	Abacavir (Ziagen™)
	Zidovudine + Lamivudine (Combivir™)
	Zidovudine + Lamivudine + Abacavir (Trizivir®)

Protease Inhibitors (PIs)

	Saquinavir (Invirase™ & Fortovase™)
	Ritonavir (Norvir™)
	Indinavir (Crixivan®)
	Nelfinavir (Viracept®)
	Amprenavir (Agenerase®)
	Ritonavir/Lopinavir (Kaletra™)
	Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
	Nevirapine (Viramune®)
	Delavirdine (Rescriptor®)
	Efavirenz (Sustiva™)

The success of this therapy is dependent not only on the HAART treatment plan, but also on the patient's ability to strictly adhere to the new medication regimen and tolerate the side effects of these powerful drugs. Side effects that may seem minor, such as fever, nausea, and fatigue, can mean there are serious problems. More serious side effects of HAART are (CDC, n.d.b):

	liver problems,
	diabetes,
	fat maldistribution (lipodystrophy syndrome),
	high cholesterol,
	increased bleeding in patients with hemophilia,
	decreased bone density, and
	skin rash.

It is important for the healthcare team to be aware of side effects (CDC, n.d.b).

AIDS is a stigmatized disease in most societies causing the AIDS patient to not seek treatment and not follow the treatment plan. The patient requires emotional, physical, and psychological support. It is not important to know the details. Censure and condemnation are not acceptable in providing care for the individual with this fatal disease. The caregiver must provide hope, compassion, and respect to the AIDS patient as his disease progresses. In the terminal stages of this disease, more and more physical and emotional support is required.

In the hospital setting, CDC does not recommend special isolation for HIV/AIDS patients. It is not acceptable to identify or flag a patient with HIV/AIDS in any way that is different from any other patient. Patients with HIV/AIDS may have other conditions that require isolation, such as tuberculosis, infectious diarrhea, or other communicable diseases. Isolation procedures in these cases should be applied as they would be done for any other patient.

Legal Information for the Healthcare Provider

Many states, as well as the Federal Government have enacted statutes and regulations related to the care of patients with HIV/AIDS. Addressed are topics dealing with the documentation of HIV/AIDS and related diagnosis, issues of informed consent, and the maintenance of patient confidentiality. The State of Florida developed legislation directed towards confidentiality and testing for HIV and AIDS.

The following is the Florida Senate Bill Number 1436: Section 381:609, (3), Human Immunodeficiency Virus Testing; Informed Consent; Results; Counseling; Confidentiality.

	(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 paragraph (i). Informed consent shall be preceded by an explanation of the right of confidential treatment of information identifying the subject of the test and the results of the test to the extent provided by law. Consent need not be in writing providing there is documentation in the medical record that the test has been explained and the consent has been obtained.
	Section 75. Section 455.2224 Florida statute is created to Read: 455.2224 Hepatitis B or Human Immunodeficiency Carriers. "The Department of Professional Regulation and each appropriate board within the Division of Medical Quality Assurance shall have the authority to establish procedures to handle, counsel, and provide other services to healthcare professionals within their respective boards who are infected with Hepatitis B or the Human Immunodeficiency Virus.”

Conclusion

With the rapid changes taking place in HIV/AIDS treatment and the extension of life expectancy among people with HIV/AIDS, nurses have the opportunity to enhance quality of life among those who are afflicted with this disease (Goldrick, 2000). It is our responsibility as healthcare providers to be educated and to keep up to date with research being done nationally and worldwide. We must not be afraid to ask questions while maintaining the HIPAA rights of all our patients. Continued education nationally and worldwide is imperative.

Easy access to prevention and treatment sites without the fear of condemnation will enhance our ability as a society, to keep us all safe from this deadly disease.

References

AIDS Info Net fact sheet 2007: Number 156 Retrieved March 3, 2009 from www.aids.infonet.org

AIDS/Meds.com. Trizivir. Retrieved February 27, 2009 from http://www.aidsmed.com/drugs

AIDS/Meds.com. Combivir. Retrieved February 27, 2009 from http://www.aidsmed.com/drugs. Combivir.htm.

Centers for Disease Control (CDC). (2003a). Basic Statistics. Retrieved February 26, 2009 from http://www.cdc.gov/hiv/stats.htm#cumaids.

CDC. HIV Prevalence Estimates- United States, 2006. MMWR; 57:1073-1076.

CDC. (2003b). HIV/AIDS Among African Americans. Retrieved February 26, 2009 from http://www.cdc.gov/hiv/pubs/facts/afam.htm.

CDC. (2003c). Surveillance of healthcare personnel with HIV/AIDS, as of December 2002. Retrieved February 25, 2009 from http://www.cdc.gov/ncidod/hip/BLOOD/hivpersonnel.htm.

CDC. (n.d.a). OraQuick rapid HIV test for oral fluid-frequently asked questions. Retrieved February 24, 2009 from http://www.cdc.gov.

CDC. (n.d.b). HIV and its treatment: What you should know (2nd ed.). Center for Disease Control, National Center for HIV, STD and TB Prevention, Divisions of HIV? AIDS Prevention. Retrieved February 24, 2009 from http://aidsinfo.nih.gov/guidelines/adult/brochure/.

Goldrick, B., Baigia, J., Larsen, J., & Lemert, J. (2000). Nursing research and HIV infection: State-of –the-science. Journal of Nursing Scholarship. 32(3), 233-238. Retrieved February 24, 2009 from Proquest.

Hall HI, Ruiguang S, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA. 2008; 300:520-529.

Marks G, Crepaz N, Janssen R. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USAA. AIDS. 2006; 20:1447-1450. Retrieved March 1, 2009 from http://aidsonline.com/pt/re/aids/fulltext

Pinkerton, S., Martin, J., Roland, M., Katz, M. et al. (2004). Cost-effectiveness of post exposure prophylaxis after sexual or injection-drug exposure to human immunodeficiency virus. Archives of Internal Medicine. 164(1). P 46-56. Retrieved February 24, 2009 from Proquest.

Trynka, S., & Erlen, J. (2004). HIV disease susceptibility in women and the barriers to adherence. Medsurg Nursing, 13(2), p13 (2), p 97-105. Retrieved February 25, 2009 from Proquest 13(2), p 13(2), p 97-105. Retrieved February

UNAIDS Epidemic Update 2008 Retrieved February 26, 2009 from http://www.unaids.org

UNAIDS/WHO AIDS Epidemic Update: December 2007. ... AIDS epidemic update 2007: Report fact sheet: key facts by region ( en | fr | es | ru ) ...Retrieved February 24, 2009 from www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/default.asp