Consent to Share Confidential InformationThe Community Integration Collaborative is an effort to link HIV-infected persons to medical care in order to optimize their health and avoid further infections. Through this collaboration, services will be provided to you based on your needs. However, to give you the best possible care, information will be needed from other doctors or agencies that are providing or have provided you medical care or any type of assistance. Please complete this form to assist us in serving your needs. Refusal to complete the form does not prevent you from accessing s
Thursday, November 1, 2007
Prevention and Infection Control
What is most important in HIV/AIDS prevention is that people not limit themselves to one approach over the other. They may take from several approaches, as indicated by the needs of the individuals and communities that are targeted by preventive measures:
Abstinence: Abstinence is the only 100% effective method of preventing sexually transmitted HIV infection. Also, effectively discouraging young people from becoming sexually active prevents unwanted pregnancy and other sexually-transmitted diseases. However, studies have shown that up to 60% of young people who vow to remain abstinent do not actually do so.
Condoms: In the current conservative climate, condom use is often considered the last line of defense, rather than the first. According to research by UNAIDS, condom use is 90% effective in preventing HIV transmission. Education about how, when, and why to use condoms is an important component of any HIV prevention programs. Since condoms can break or slip, people should not rely on them as their only defense against HIV but should use a spermicide, such as nonoxynol-9 for added protection. Transmission of HIV is more likely where the skin is broken, for example due to anal sex, rough or violent sex, or the presence of sexually transmitted infections. Using a condom is very important under these circumstances
Needle exchange/safe needle programs: Needle exchange programs are not without controversy, as the use of illicit IV drugs is illegal in the United States. Therefore, some people argue that the program is rewarding and abetting illegal activity. Most states, including Florida, continue to restrict access to syringes by enforcing “drug paraphernalia” laws, and regulating the purchase and sale of syringes in pharmacies. However, a needle-exchange program, coupled with methadone substitution for injecting drug use, and condom distribution and instruction, can be an effective means of reducing HIV infection. If needle exchange programs are not available, education efforts need to be made to advise people not to share needles, cotton, syringe, or cookers - all which may be contaminated with blood. People need to be taught to use new needles or to clean needles with full strength bleach and rinse thoroughly with water before each use.
Substance abuse programs: The United States has approximately 1.5 million injection drug users and many additional people who use other drugs, such as cocaine, crack, or alcohol. However, there are only about one-half million drug treatment slots available. Therefore, meeting the needs of HIV positive people who suffer from substance abuse presents a particular challenge.
Education/counseling programs: There is a continuing need for community outreach programs to educate high risk populations about HIV/AIDS. However, money necessary to fund such programs is sometimes inadequate. The present administration has emphasized volunteer and faith-based programs, and there are a number of such programs in place.
Universal/Standard precautions: Universal precautions are mandated by OSHA for health care workers, as a way to reduce risk from bloodborne pathogens, e.g. HIV, Hepatitis A, B, C, Staph, Strep, Syphillis, TB, etc.
Standard precautions have since been promoted by the CDC to reduce the transmission of all infectious diseases. Workers are to treat all bodily fluids, except perspiration, as though they are infectious and use appropriate care to avoid contact. The use of Universal/Standard precautions protects not only the workers but patients as well. The following precautions should be taken:
Gloves: Should be used for any treatment or procedures that involve contact with mucous membranes, contaminated or non-intact skin, or body fluids or items soiled with body fluids. Gloves should be used only once and should be discarded in a special container separate from other trash.
Hand washing: Should be done immediately after removing gloves. Obviously, handwashing should be done if any blood or body fluid gets on the hand or other body surface. It should be done immediately after each contact with a patient, since ANY patient may be HIV positive.
Protective clothing (masks, goggles, gowns): Surgical mask and eyewear should be worn during any task that may cause exposure of mouth, nose, and eyes to blood or body fluids. Disposable gowns or aprons should be used when blood or body fluids may splash on clothes. Cloth gowns or aprons should be washed according to instructions for washing linens soiled with blood.
Safety precautions with needles: Should always use disposable needles; Should not recap or purposely bend needles; Should discard needles in the way recommended by health care agency; Should be placed in puncture-proof container, specifically marked, and not overfilled; Needlesticks should be immediately reported to health care agency.
Disposal of waste products and washing of soiled linens; Waste products should be disposed of in red plastic bags, double-bagged; Linens or clothing soiled with blood must be washed separately from other laundry, using detergent and germicide.Guidelines for sterilization or disinfection: Should use chemical germicides registered with the EPA for sterilization or disinfection and chemicals should be used only in recommended concentrations and only with proper ventilation.
Abstinence: Abstinence is the only 100% effective method of preventing sexually transmitted HIV infection. Also, effectively discouraging young people from becoming sexually active prevents unwanted pregnancy and other sexually-transmitted diseases. However, studies have shown that up to 60% of young people who vow to remain abstinent do not actually do so.
Condoms: In the current conservative climate, condom use is often considered the last line of defense, rather than the first. According to research by UNAIDS, condom use is 90% effective in preventing HIV transmission. Education about how, when, and why to use condoms is an important component of any HIV prevention programs. Since condoms can break or slip, people should not rely on them as their only defense against HIV but should use a spermicide, such as nonoxynol-9 for added protection. Transmission of HIV is more likely where the skin is broken, for example due to anal sex, rough or violent sex, or the presence of sexually transmitted infections. Using a condom is very important under these circumstances
Needle exchange/safe needle programs: Needle exchange programs are not without controversy, as the use of illicit IV drugs is illegal in the United States. Therefore, some people argue that the program is rewarding and abetting illegal activity. Most states, including Florida, continue to restrict access to syringes by enforcing “drug paraphernalia” laws, and regulating the purchase and sale of syringes in pharmacies. However, a needle-exchange program, coupled with methadone substitution for injecting drug use, and condom distribution and instruction, can be an effective means of reducing HIV infection. If needle exchange programs are not available, education efforts need to be made to advise people not to share needles, cotton, syringe, or cookers - all which may be contaminated with blood. People need to be taught to use new needles or to clean needles with full strength bleach and rinse thoroughly with water before each use.
Substance abuse programs: The United States has approximately 1.5 million injection drug users and many additional people who use other drugs, such as cocaine, crack, or alcohol. However, there are only about one-half million drug treatment slots available. Therefore, meeting the needs of HIV positive people who suffer from substance abuse presents a particular challenge.
Education/counseling programs: There is a continuing need for community outreach programs to educate high risk populations about HIV/AIDS. However, money necessary to fund such programs is sometimes inadequate. The present administration has emphasized volunteer and faith-based programs, and there are a number of such programs in place.
Universal/Standard precautions: Universal precautions are mandated by OSHA for health care workers, as a way to reduce risk from bloodborne pathogens, e.g. HIV, Hepatitis A, B, C, Staph, Strep, Syphillis, TB, etc.
Standard precautions have since been promoted by the CDC to reduce the transmission of all infectious diseases. Workers are to treat all bodily fluids, except perspiration, as though they are infectious and use appropriate care to avoid contact. The use of Universal/Standard precautions protects not only the workers but patients as well. The following precautions should be taken:
Gloves: Should be used for any treatment or procedures that involve contact with mucous membranes, contaminated or non-intact skin, or body fluids or items soiled with body fluids. Gloves should be used only once and should be discarded in a special container separate from other trash.
Hand washing: Should be done immediately after removing gloves. Obviously, handwashing should be done if any blood or body fluid gets on the hand or other body surface. It should be done immediately after each contact with a patient, since ANY patient may be HIV positive.
Protective clothing (masks, goggles, gowns): Surgical mask and eyewear should be worn during any task that may cause exposure of mouth, nose, and eyes to blood or body fluids. Disposable gowns or aprons should be used when blood or body fluids may splash on clothes. Cloth gowns or aprons should be washed according to instructions for washing linens soiled with blood.
Safety precautions with needles: Should always use disposable needles; Should not recap or purposely bend needles; Should discard needles in the way recommended by health care agency; Should be placed in puncture-proof container, specifically marked, and not overfilled; Needlesticks should be immediately reported to health care agency.
Disposal of waste products and washing of soiled linens; Waste products should be disposed of in red plastic bags, double-bagged; Linens or clothing soiled with blood must be washed separately from other laundry, using detergent and germicide.Guidelines for sterilization or disinfection: Should use chemical germicides registered with the EPA for sterilization or disinfection and chemicals should be used only in recommended concentrations and only with proper ventilation.
Side effects of HIV treatment
Numerous anti-viral drugs, some in combined form, have been approved by the FDA for treatment of HIV, to reduce the viral load and prevent destruction of the immune system. These drugs must be given in combination. However, they are all associated with side effects. The primary method of treating the side effects is to make a change in the antiviral medications. Major side effects may include the following:
· Hepatotoxicity: Women, especially those who are pregnant; those with existing liver diseases, such as Hepatitis B or C; and those who use alcohol may be at higher risk for developing hepatotoxicity.
· Hyperglycemia: An increase in blood glucose levels by itself, or as part of diabetes mellitus, is a side effect of all protease inhibitors (PIs).
· Hyperlipidemia: An increase in the lipids in the blood, such as cholesterol and triglycerides, is a side effect of some protease inhibitors (PIs).
· Lactic Acidosis: Too much lactate in the blood and a low blood Ph (acidic) are side effects of mitochondrial toxicity, caused by of all nucleoside reverse transcriptase inhibitors (NRTIs).
· Lipodystrophy: Fat redistribution, a disturbance in the way the body produces, uses and stores fat, is a side effect of the concurrent use of nucleoside reverse transcriptase inhibitors (NRTIs) and protease inhibitors (PIs).
· Osteonecrosis, osteoporosis, osteopenia: Damage to the bones is a side effect of HIV and some of the damage is related to protease inhibitors (PIs).
· Skin rash: NNRTIs cause most skin rashes, with Viramune causing the most severe rashes. NRTIs can also cause skin rashes.
Risk Factors
Currently, people of color are being disproportionately affected by HIV. For example, African American women are only 12% of all of the women in the United States, but they represent 68.8% of all women infected with HIV. Although African American women are currently bearing the greatest effect of the disease, in 1985 white homosexual males were most at risk. Therefore, race neither predisposes nor does it protect an individual from HIV infection. We must look to factors, other than race, that predispose individuals to engage in "high risk behaviors" which increase the probability of HIV infection.
There are many risk factors associated with HIV infection. Some factors pose a higher risk of infection than others. There are also differences in rates of infection, related to age.
Estimated per-act risk for acquisition of HIV
Exposure route
Risk per 10,000 exposures to infected source
Blood transfusion 9,000
Needle-sharing injection-drug use 67
Receptive anal intercourse 50
Percutaneous needle stick 30
Receptive penile-vaginal intercourse 10
Insertive anal intercourse 6.5
Insertive penile-vaginal intercourse 5
Receptive oral intercourse 1
Insertive oral intercourse 0.5
Risk factors are related to the following:
Poverty/socioeconomic factors: Studies have shown that there is a direct correlation between poverty and rates of HIV. Because nearly 1 in 4 African American and 1 in 5 Hispanics live in poverty, this impacts the rate at which they become HIV infected. Additionally, people living in poverty often don't have direct access to adequate health care.
Youth: Young people continue to be at risk for HIV infection and are becoming HIV infected in increasing numbers. This risk is more pronounced for minority and ethnic youth in the US.
Heterosexual transmission: Heterosexual contact poses a significant risk for women, especially those of minority races or ethnicities.
Men having sex with other men (MSM): The risk factors and barriers to preventing HIV for young MSMs are different from heterosexual men. Factors include the stigma attached to homosexuality, and young mens' frequent reluctance to disclose their sexual orientation.
Sexually transmitted diseases: Individuals who are infected with STDs are three to five times more likely than non-infected individuals to acquire HIV, if exposed to the virus through sexual contact. In addition, if an HIV-infected individual is also infected with another STD, that person is 3 to 5 times more likely than other HIV-infected persons, to transmit HIV through sexual contact. In the United States, over 12 million people develop STDs each year, and most of these people are under age 25.
Homelessness/runaways: Young people who are homeless or runaways, often engage in substance abuse, which can increase the risk for HIV infection. They may exchange sex for drugs or money, believing this is their only chance of survival on the streets. Homelessness is not just a problem of young people. Studies indicate that between 3-20% of homeless people are infected with HIV, with some subgroups having much higher rates. Also, surveys have indicated that homeless rates for those with HIV/AIDS are increasing. Because people with HIV/AIDS often lose their jobs or are unable to work, many will become homeless at some point.
Substance abuse: Young people (18-24) who use alcohol, tobacco, or other drugs are more likely to engage in high-risk behaviors, such as unprotected sex, when they are under the influence of drugs or alcohol. Substance abuse is also a risk factor for other age groups.
Unsafe medical practices/Needlestick injuries: Unsafe medical practices that can lead to HIV infection include:
· using improperly sterilized instruments,
· using HIV-contaminated blood in transfusions,
· using HIV contaminated organs in transplants,
· exposing open wounds to HIV infected blood,
· needlestick injuries, and
· exposure of mucous membranes, and even supposedly "intact" skin to HIV-contaminated blood.
Needlestick injuries are a major concern for people in the healthcare industry. While the risk for HIV transmission from needlestick is low, it is still a significant danger. A study of syringes used to administer medications to people with HIV showed 3.8% had detectable HIV RNA. Moreover, in a study of the viability of the virus in needles, viable HIV was found in 8% at 21 days, when the needles had been stored at room temperature.
HIV positive children becoming adults: Many children who were infected through perinatal transmission are now becoming young adults, and making decisions about sexual behavior.
Perinatal Transmission: The number of new perinatal infections each year has steadily declined since 1994. At that time, a zidovudine regimen given prenatally, intrapartum, and to the newborn, was shown to reduce the risk of mother-to-child transmission by two thirds. However, the CDC estimates that between 280-370 neonates continue to be infected every year. Of those infected, 40% were born to mothers whose HIV status at delivery was unknown. CDC recommends universal HIV testing of pregnant women and routine rapid HIV testing using the opt-out approach for all women in labor whose HIV status is unknown.
Severe mental illness: Adults with severe mental illness have been disproportionately affected by the HIV/AIDS epidemic. Studies have shown that the majority of adults with severe mental disorders are sexually active and many engage in high-risk behaviors, such as unprotected sex, multiple sexual partners, and IV drug use.
Older adults engaging in unsafe sex: With improvement in health care, and the availability of drugs like Viagra, many older adults are remaining sexually active. Some older males have contact with prostitutes, as well as multiple sexual partners. About 10% of those with AIDS are over age 55 and 1 in 25 cases of AIDS in the U.S. are people 65 years old and older.
· Hepatotoxicity: Women, especially those who are pregnant; those with existing liver diseases, such as Hepatitis B or C; and those who use alcohol may be at higher risk for developing hepatotoxicity.
· Hyperglycemia: An increase in blood glucose levels by itself, or as part of diabetes mellitus, is a side effect of all protease inhibitors (PIs).
· Hyperlipidemia: An increase in the lipids in the blood, such as cholesterol and triglycerides, is a side effect of some protease inhibitors (PIs).
· Lactic Acidosis: Too much lactate in the blood and a low blood Ph (acidic) are side effects of mitochondrial toxicity, caused by of all nucleoside reverse transcriptase inhibitors (NRTIs).
· Lipodystrophy: Fat redistribution, a disturbance in the way the body produces, uses and stores fat, is a side effect of the concurrent use of nucleoside reverse transcriptase inhibitors (NRTIs) and protease inhibitors (PIs).
· Osteonecrosis, osteoporosis, osteopenia: Damage to the bones is a side effect of HIV and some of the damage is related to protease inhibitors (PIs).
· Skin rash: NNRTIs cause most skin rashes, with Viramune causing the most severe rashes. NRTIs can also cause skin rashes.
Risk Factors
Currently, people of color are being disproportionately affected by HIV. For example, African American women are only 12% of all of the women in the United States, but they represent 68.8% of all women infected with HIV. Although African American women are currently bearing the greatest effect of the disease, in 1985 white homosexual males were most at risk. Therefore, race neither predisposes nor does it protect an individual from HIV infection. We must look to factors, other than race, that predispose individuals to engage in "high risk behaviors" which increase the probability of HIV infection.
There are many risk factors associated with HIV infection. Some factors pose a higher risk of infection than others. There are also differences in rates of infection, related to age.
Estimated per-act risk for acquisition of HIV
Exposure route
Risk per 10,000 exposures to infected source
Blood transfusion 9,000
Needle-sharing injection-drug use 67
Receptive anal intercourse 50
Percutaneous needle stick 30
Receptive penile-vaginal intercourse 10
Insertive anal intercourse 6.5
Insertive penile-vaginal intercourse 5
Receptive oral intercourse 1
Insertive oral intercourse 0.5
Risk factors are related to the following:
Poverty/socioeconomic factors: Studies have shown that there is a direct correlation between poverty and rates of HIV. Because nearly 1 in 4 African American and 1 in 5 Hispanics live in poverty, this impacts the rate at which they become HIV infected. Additionally, people living in poverty often don't have direct access to adequate health care.
Youth: Young people continue to be at risk for HIV infection and are becoming HIV infected in increasing numbers. This risk is more pronounced for minority and ethnic youth in the US.
Heterosexual transmission: Heterosexual contact poses a significant risk for women, especially those of minority races or ethnicities.
Men having sex with other men (MSM): The risk factors and barriers to preventing HIV for young MSMs are different from heterosexual men. Factors include the stigma attached to homosexuality, and young mens' frequent reluctance to disclose their sexual orientation.
Sexually transmitted diseases: Individuals who are infected with STDs are three to five times more likely than non-infected individuals to acquire HIV, if exposed to the virus through sexual contact. In addition, if an HIV-infected individual is also infected with another STD, that person is 3 to 5 times more likely than other HIV-infected persons, to transmit HIV through sexual contact. In the United States, over 12 million people develop STDs each year, and most of these people are under age 25.
Homelessness/runaways: Young people who are homeless or runaways, often engage in substance abuse, which can increase the risk for HIV infection. They may exchange sex for drugs or money, believing this is their only chance of survival on the streets. Homelessness is not just a problem of young people. Studies indicate that between 3-20% of homeless people are infected with HIV, with some subgroups having much higher rates. Also, surveys have indicated that homeless rates for those with HIV/AIDS are increasing. Because people with HIV/AIDS often lose their jobs or are unable to work, many will become homeless at some point.
Substance abuse: Young people (18-24) who use alcohol, tobacco, or other drugs are more likely to engage in high-risk behaviors, such as unprotected sex, when they are under the influence of drugs or alcohol. Substance abuse is also a risk factor for other age groups.
Unsafe medical practices/Needlestick injuries: Unsafe medical practices that can lead to HIV infection include:
· using improperly sterilized instruments,
· using HIV-contaminated blood in transfusions,
· using HIV contaminated organs in transplants,
· exposing open wounds to HIV infected blood,
· needlestick injuries, and
· exposure of mucous membranes, and even supposedly "intact" skin to HIV-contaminated blood.
Needlestick injuries are a major concern for people in the healthcare industry. While the risk for HIV transmission from needlestick is low, it is still a significant danger. A study of syringes used to administer medications to people with HIV showed 3.8% had detectable HIV RNA. Moreover, in a study of the viability of the virus in needles, viable HIV was found in 8% at 21 days, when the needles had been stored at room temperature.
HIV positive children becoming adults: Many children who were infected through perinatal transmission are now becoming young adults, and making decisions about sexual behavior.
Perinatal Transmission: The number of new perinatal infections each year has steadily declined since 1994. At that time, a zidovudine regimen given prenatally, intrapartum, and to the newborn, was shown to reduce the risk of mother-to-child transmission by two thirds. However, the CDC estimates that between 280-370 neonates continue to be infected every year. Of those infected, 40% were born to mothers whose HIV status at delivery was unknown. CDC recommends universal HIV testing of pregnant women and routine rapid HIV testing using the opt-out approach for all women in labor whose HIV status is unknown.
Severe mental illness: Adults with severe mental illness have been disproportionately affected by the HIV/AIDS epidemic. Studies have shown that the majority of adults with severe mental disorders are sexually active and many engage in high-risk behaviors, such as unprotected sex, multiple sexual partners, and IV drug use.
Older adults engaging in unsafe sex: With improvement in health care, and the availability of drugs like Viagra, many older adults are remaining sexually active. Some older males have contact with prostitutes, as well as multiple sexual partners. About 10% of those with AIDS are over age 55 and 1 in 25 cases of AIDS in the U.S. are people 65 years old and older.
Treatment during pregnancy
The U.S. Public Health Service has recommended that HIV-infected pregnant women should receive treatment with antiretroviral drugs as though they were not pregnant. If a woman is diagnosed in her first trimester, she should be evaluated and treated. Depending on lab test results, she may be able to postpone treatment until the second trimester when drug-related risks to the fetus are lower. If an HIV-infected woman is already on medications prior to pregnancy, she should continue the drugs. While the risk that the drugs pose to the fetus are not completely clear, they appear to be low. However, efavirenz is known to cause birth defects and should be avoided. Drug treatment during pregnancy greatly reduces the risk that HIV will be transmitted to the fetus or newborn. With new treatments that are available, the risk of a treated mother passing on the infection to her baby has been reduced to 2%.
Both the fetus and the newborn of a mother who is HIV positive are vulnerable to infection. Infection can occur in utero, during labor and delivery, or from breast feeding. To avoid transmitting the infection from mother-to-child, a woman who knows she is HIV positive should be carefully monitored and ideally should receive 500 to 600 mg Zidovudine (ZDV), divided into 2 to 5 doses daily, starting at 14 to 34 weeks of pregnancy, Together the physician and mother will determine whether vaginal delivery or C-section should be performed. Vaginal delivery of HIV infected mothers may be advised if viral load is <1000 copies. The mother-to-child transmission may be higher in vaginal delivery, but the caesarean delivery carries an increased risk of infection for the mother, as well as other surgery-related complications.
In order to minimize the danger of transmission of HIV to the infant, the mother should receive IV ZDV during labor. For a Caesarean delivery, the ZDV should be started 3 hours before delivery and continue until delivery. For a vaginal delivery, IV ZDV should be given throughout labor and delivery. With either type of delivery, the infant should receive anti-HIV drug treatment, usually 6 weeks of ZDV, for prevention of mother-to-child transmission. Mothers with HIV should not breast feed their infants because HIV can be transmitted through breast milk.
Both the fetus and the newborn of a mother who is HIV positive are vulnerable to infection. Infection can occur in utero, during labor and delivery, or from breast feeding. To avoid transmitting the infection from mother-to-child, a woman who knows she is HIV positive should be carefully monitored and ideally should receive 500 to 600 mg Zidovudine (ZDV), divided into 2 to 5 doses daily, starting at 14 to 34 weeks of pregnancy, Together the physician and mother will determine whether vaginal delivery or C-section should be performed. Vaginal delivery of HIV infected mothers may be advised if viral load is <1000 copies. The mother-to-child transmission may be higher in vaginal delivery, but the caesarean delivery carries an increased risk of infection for the mother, as well as other surgery-related complications.
In order to minimize the danger of transmission of HIV to the infant, the mother should receive IV ZDV during labor. For a Caesarean delivery, the ZDV should be started 3 hours before delivery and continue until delivery. For a vaginal delivery, IV ZDV should be given throughout labor and delivery. With either type of delivery, the infant should receive anti-HIV drug treatment, usually 6 weeks of ZDV, for prevention of mother-to-child transmission. Mothers with HIV should not breast feed their infants because HIV can be transmitted through breast milk.
Adjustments to Treatment
People who are receiving antiretroviral medications should have a baseline viral load and CD4 count done and regular evaluations during treatments. If the viral load increases and CD4 count decreases, the treatment regimen may need to be adjusted. In that case, the physician will evaluate 3 factors to determine what adjustments need to be made:
· Adherence: Refers to how closely a person follows the medication regimen. If someone is unable to follow the regimen, treatment may need to be adjusted to give medication in fewer doses or fewer pills.
· Tolerability: Refers to side effects caused by the medications. If a particular drug is causing a very difficult side effect, a different medication may be prescribed.
· Medication interactions: Refers to drug reactions to other medicines a person may be taking. Since some drug reactions can have a negative effect on the efficacy of antiretroviral treatment, these reactions need to be identified, so treatment can be adjusted.
Non-occupational Post-exposure prophylaxis (nPEP)
In January 2005, the CDC issued guidelines for non-occupational post-exposure prophylaxis (nPEP). The recommendations cover those exposed to HIV from rapes, accidents or isolated episodes of drug use or unsafe sex. The previous recommendation (1996) had recommended prophylactic treatment only for health care workers accidentally exposed on the job.
The nPEP regimen is intended for people seeking care within 72 hours of exposure to blood, genital secretions (semen and vaginal fluids), or other potentially infectious body fluids of a person of unknown HIV status, if a positive HIV status would pose a substantial risk of transmission. In many cases, the HIV status may be known, but, for example, a condom may break, exposing someone to infected semen. The recommended drug regimen is a 28-day course of highly active antiretroviral therapy (HAART).
No recommendation is made if the exposure was more than 72 hours prior to seeking treatment. People who receive nPEP should receive counseling and be scheduled for followup testing at 4-6 weeks, 3 months, and 6 months after exposure, to determine if HIV infection has occurred. Additional testing for sexually transmitted diseases, hepatitis B and C, and pregnancy should also be offered. Patients need instruction about the signs and symptoms of HIV infection.
Health care workers who incur accidental needle pricks will also be treated with this regimen of drugs. A case control study of health care workers who had needlestick injuries showed that prompt initiation of treatment with zidovudine was associated with an 81% decrease in the risk of acquiring HIV. A number of international studies have shown that nPEP results in almost 100% protection from HIV.
This protocol is not recommended for people who continually or repeatedly engage in high-risk behavior, because they would essentially have to be on the drug regimen fulltime. Because people seeking treatment may not know their own HIV status, it is recommended that all who are candidates for nPEP be tested for HIV, preferably with an FDA-approved rapid test kit that provides results within an hour prior to initiating therapy.
· Adherence: Refers to how closely a person follows the medication regimen. If someone is unable to follow the regimen, treatment may need to be adjusted to give medication in fewer doses or fewer pills.
· Tolerability: Refers to side effects caused by the medications. If a particular drug is causing a very difficult side effect, a different medication may be prescribed.
· Medication interactions: Refers to drug reactions to other medicines a person may be taking. Since some drug reactions can have a negative effect on the efficacy of antiretroviral treatment, these reactions need to be identified, so treatment can be adjusted.
Non-occupational Post-exposure prophylaxis (nPEP)
In January 2005, the CDC issued guidelines for non-occupational post-exposure prophylaxis (nPEP). The recommendations cover those exposed to HIV from rapes, accidents or isolated episodes of drug use or unsafe sex. The previous recommendation (1996) had recommended prophylactic treatment only for health care workers accidentally exposed on the job.
The nPEP regimen is intended for people seeking care within 72 hours of exposure to blood, genital secretions (semen and vaginal fluids), or other potentially infectious body fluids of a person of unknown HIV status, if a positive HIV status would pose a substantial risk of transmission. In many cases, the HIV status may be known, but, for example, a condom may break, exposing someone to infected semen. The recommended drug regimen is a 28-day course of highly active antiretroviral therapy (HAART).
No recommendation is made if the exposure was more than 72 hours prior to seeking treatment. People who receive nPEP should receive counseling and be scheduled for followup testing at 4-6 weeks, 3 months, and 6 months after exposure, to determine if HIV infection has occurred. Additional testing for sexually transmitted diseases, hepatitis B and C, and pregnancy should also be offered. Patients need instruction about the signs and symptoms of HIV infection.
Health care workers who incur accidental needle pricks will also be treated with this regimen of drugs. A case control study of health care workers who had needlestick injuries showed that prompt initiation of treatment with zidovudine was associated with an 81% decrease in the risk of acquiring HIV. A number of international studies have shown that nPEP results in almost 100% protection from HIV.
This protocol is not recommended for people who continually or repeatedly engage in high-risk behavior, because they would essentially have to be on the drug regimen fulltime. Because people seeking treatment may not know their own HIV status, it is recommended that all who are candidates for nPEP be tested for HIV, preferably with an FDA-approved rapid test kit that provides results within an hour prior to initiating therapy.
Routine HIV/AIDS testing
Dr Destiny
Testing is an essential component of HIV/AIDS diagnosis and treatment. Because people in the early stages of HIV/AIDS may be asymptomatic, they may be putting others at risk. While those with HIV/AIDS need multiple tests to accurately assess their physical condition, some tests are specific to HIV/AIDS:
HIV antibody CD4 t-cell Viral load
· HIV Antibody tests
The period between becoming infected and showing antibodies to HIV in the blood can range from 2 weeks to 6 months. During this period, a person can spread the disease even though the antibodies cannot be detected in the blood. The most common tests in recent years have been ELISA, Western Blot and IFA.
Enzyme-linked immunosorbent assay (ELISA).
· Usually the first test used to detect infection with HIV, but can cause false positive results
Western blot.
· More difficult than the ELISA to perform and interpret accurately, but less likely to give a false-positives; used to confirm ELISA results.
Indirect fluorescent antibody (IFA)
· Detects antibodies made to fight an HIV infection; used to confirm ELISA results.
New rapid HIV tests are now on the market, that are quick, easy to do, and allow for point-of-care testing. There are 4 rapid HIV tests that have been approved:
· OraQuick Advance HIV-1/2 - results in 20 minutes
· Uni-Gold Recombigen - results in 10 minutes
· Reveal G2 - results in 5 minutes
· Multispot HIV-1/HIV-2 - results in 15 minutes
Viral load
The viral load indicates the number of copies of HIV in the blood. A non-detectable result does not mean that there is no virus present; just that it was not detected. The newer versions of tests can now detect a load as low as 5 and as high as 1.5 million. A level of 55,000 requires antiretroviral treatment. Antiretroviral treatment is considered to be working if viral load drops by 90% within 8 weeks and continues to drop to less than 50 copies within 6 months. There are 2 different tests that give slightly different results. Therefore, when possible, people should be tested consistently with the same type of test.
· PCR (polymerase chain reaction)
· bDNA
Testing is an essential component of HIV/AIDS diagnosis and treatment. Because people in the early stages of HIV/AIDS may be asymptomatic, they may be putting others at risk. While those with HIV/AIDS need multiple tests to accurately assess their physical condition, some tests are specific to HIV/AIDS:
HIV antibody CD4 t-cell Viral load
· HIV Antibody tests
The period between becoming infected and showing antibodies to HIV in the blood can range from 2 weeks to 6 months. During this period, a person can spread the disease even though the antibodies cannot be detected in the blood. The most common tests in recent years have been ELISA, Western Blot and IFA.
Enzyme-linked immunosorbent assay (ELISA).
· Usually the first test used to detect infection with HIV, but can cause false positive results
Western blot.
· More difficult than the ELISA to perform and interpret accurately, but less likely to give a false-positives; used to confirm ELISA results.
Indirect fluorescent antibody (IFA)
· Detects antibodies made to fight an HIV infection; used to confirm ELISA results.
New rapid HIV tests are now on the market, that are quick, easy to do, and allow for point-of-care testing. There are 4 rapid HIV tests that have been approved:
· OraQuick Advance HIV-1/2 - results in 20 minutes
· Uni-Gold Recombigen - results in 10 minutes
· Reveal G2 - results in 5 minutes
· Multispot HIV-1/HIV-2 - results in 15 minutes
Viral load
The viral load indicates the number of copies of HIV in the blood. A non-detectable result does not mean that there is no virus present; just that it was not detected. The newer versions of tests can now detect a load as low as 5 and as high as 1.5 million. A level of 55,000 requires antiretroviral treatment. Antiretroviral treatment is considered to be working if viral load drops by 90% within 8 weeks and continues to drop to less than 50 copies within 6 months. There are 2 different tests that give slightly different results. Therefore, when possible, people should be tested consistently with the same type of test.
· PCR (polymerase chain reaction)
· bDNA
Wednesday, October 31, 2007
Treatment and Clinical management
Antiretroviral medications are used to control the reproduction of the HIV virus and slow progression of HIV-related disease. Highly Active Antiretroviral Therapy (HAART) is the treatment protocol that is recommended for HIV infection. HAART combines 3 or more antiretroviral medications in a daily regimen. The exact medication regimen is highly individualized, depending upon many factors. Usually taking only 1 or 2 medications is not effective. Unless the individual is taking 3 or more medications, the decrease in viral load tends to be temporary. Treatment involves a number of considerations:
Antiretroviral medications Adjustments to treatment Non-occupational post-exposure prophylaxis (nPEP) Treatment during pregnancy Side effects of treatment
Antiretroviral medications
There are 4 classes of antiretroviral medication used in the treatment of HIV.
Class
Generic name
Brand name
Nonucleoside Reverse Transcriptase Inhibitors (NNRTIs) bind to and disable reverse transcriptase, a protein that HIV needs to replicate.
Delavirdine
Rescriptor, DLV
Efavirenz
Sustiva, EFV
Nevirapine
Viramune, NVP
Nuceleoside Reverse Transcriptase Inhibitors (NRTIs) are faulty versions of building blocks that HIV needs to replicate. When HIV uses an NRTI instead of a normal building block, reproduction of the virus is stalled.
Abacavir
Ziagen, ABC
Abacavir Lamivudine
Epzicom
Abacavir,Lamivudine,Zidovudine
Trizivir
Didanosine
Videx, ddI, Videx EC
Emtricitabine
Emtriva, FTC, Coviracil
Emtricitabine, Tenofovir DF
Truvada
Lamivudine
Epivir, 3TC
Lamivudine, Zidovudine
Combivir
Stavudine
Zerit, d4T
Tenofovir DF
Viread, TDF
Zalcitabine
Hivid, ddC
Zidovudine
Retrovir, AZT, ZDV
Protease Inhibitors (PIs) disable protease, a protein that HIV needs to replicate.
Amprenavir
Agenerase, APV
Atazanavir
Reyataz, ATV
Fosamprenavir
Lexiva, FPV
Indinavir
Crixivan, IDV
Lopinavir, Ritonavir
Kaletra,LPV/r
Nelfinavir
Viracept, NFV
Fusion Inhibitors function by blocking HIV entry into cells.
Enfuvirtide
Fuzeon, T-20
Instant Feedback:
One or two anti-retroviral medications are usually sufficient to decrease viral load.
TrueFalse
Adjustments to Treatment
People who are receiving antiretroviral medications should have a baseline viral load and CD4 count done and regular evaluations during treatments. If the viral load increases and CD4 count decreases, the treatment regimen may need to be adjusted. In that case, the physician will evaluate 3 factors to determine what adjustments need to be made:
· Adherence: Refers to how closely a person follows the medication regimen. If someone is unable to follow the regimen, treatment may need to be adjusted to give medication in fewer doses or fewer pills.
· Tolerability: Refers to side effects caused by the medications. If a particular drug is causing a very difficult side effect, a different medication may be prescribed. Medication interactions: Refers to drug reactions to other medicines a person may be taking. Since some drug reactions can have a negative effect on the efficacy of antiretroviral treatment, these reactions need to be identified, so treatment can be adjusted.
Antiretroviral medications Adjustments to treatment Non-occupational post-exposure prophylaxis (nPEP) Treatment during pregnancy Side effects of treatment
Antiretroviral medications
There are 4 classes of antiretroviral medication used in the treatment of HIV.
Class
Generic name
Brand name
Nonucleoside Reverse Transcriptase Inhibitors (NNRTIs) bind to and disable reverse transcriptase, a protein that HIV needs to replicate.
Delavirdine
Rescriptor, DLV
Efavirenz
Sustiva, EFV
Nevirapine
Viramune, NVP
Nuceleoside Reverse Transcriptase Inhibitors (NRTIs) are faulty versions of building blocks that HIV needs to replicate. When HIV uses an NRTI instead of a normal building block, reproduction of the virus is stalled.
Abacavir
Ziagen, ABC
Abacavir Lamivudine
Epzicom
Abacavir,Lamivudine,Zidovudine
Trizivir
Didanosine
Videx, ddI, Videx EC
Emtricitabine
Emtriva, FTC, Coviracil
Emtricitabine, Tenofovir DF
Truvada
Lamivudine
Epivir, 3TC
Lamivudine, Zidovudine
Combivir
Stavudine
Zerit, d4T
Tenofovir DF
Viread, TDF
Zalcitabine
Hivid, ddC
Zidovudine
Retrovir, AZT, ZDV
Protease Inhibitors (PIs) disable protease, a protein that HIV needs to replicate.
Amprenavir
Agenerase, APV
Atazanavir
Reyataz, ATV
Fosamprenavir
Lexiva, FPV
Indinavir
Crixivan, IDV
Lopinavir, Ritonavir
Kaletra,LPV/r
Nelfinavir
Viracept, NFV
Fusion Inhibitors function by blocking HIV entry into cells.
Enfuvirtide
Fuzeon, T-20
Instant Feedback:
One or two anti-retroviral medications are usually sufficient to decrease viral load.
TrueFalse
Adjustments to Treatment
People who are receiving antiretroviral medications should have a baseline viral load and CD4 count done and regular evaluations during treatments. If the viral load increases and CD4 count decreases, the treatment regimen may need to be adjusted. In that case, the physician will evaluate 3 factors to determine what adjustments need to be made:
· Adherence: Refers to how closely a person follows the medication regimen. If someone is unable to follow the regimen, treatment may need to be adjusted to give medication in fewer doses or fewer pills.
· Tolerability: Refers to side effects caused by the medications. If a particular drug is causing a very difficult side effect, a different medication may be prescribed. Medication interactions: Refers to drug reactions to other medicines a person may be taking. Since some drug reactions can have a negative effect on the efficacy of antiretroviral treatment, these reactions need to be identified, so treatment can be adjusted.
Criteria for AIDS
There are criteria to determine when an infection advances from HIV positive to AIDS.
· Infection with HIV must be present,
· CD4 count falls below 200 cells/mmm3 (cubic milliliter), or
· Development of an "AIDS-defining" condition
o Candidiasis
o Cervical cancer (invasive)
o Coccidioidomycosis, Cryptococcosis, Cryptosporidiosis
o Cytomegalovirus disease
o Encephalopathy (HIV-related)
o Herpes simplex (severe)
o Histoplasmosis
o Isosporiasis
o Kaposi's sarcoma
o Lymphoma
o Mycobacterium avium complex
o Pneumocystis carinii pneumonia
o Pneumonia (recurrent)
o Progressive multifocal leukoencephalopathy
o Salmonella septicemia (recurrent)
o Toxoplasmosis of the brain
o Tuberculosis
o Wasting syndrome
Routine HIV/AIDS testing
Testing is an essential component of HIV/AIDS diagnosis and treatment. Because people in the early stages of HIV/AIDS may be asymptomatic, they may be putting others at risk. While those with HIV/AIDS need multiple tests to accurately assess their physical condition, some tests are specific to HIV/AIDS:
HIV antibody CD4 t-cell Viral load
· HIV Antibody tests
The period between becoming infected and showing antibodies to HIV in the blood can range from 2 weeks to 6 months. During this period, a person can spread the disease even though the antibodies cannot be detected in the blood. The most common tests in recent years have been ELISA, Western Blot and IFA.
Enzyme-linked immunosorbent assay (ELISA).
· Usually the first test used to detect infection with HIV, but can cause false positive results
Western blot.
· More difficult than the ELISA to perform and interpret accurately, but less likely to give a false-positives; used to confirm ELISA results.
Indirect fluorescent antibody (IFA)
· Detects antibodies made to fight an HIV infection; used to confirm ELISA results.
New rapid HIV tests are now on the market, that are quick, easy to do, and allow for point-of-care testing. There are 4 rapid HIV tests that have been approved:
· OraQuick Advance HIV-1/2 - results in 20 minutes
· Uni-Gold Recombigen - results in 10 minutes
· Reveal G2 - results in 5 minutes
· Multispot HIV-1/HIV-2 - results in 15 minutes
· Infection with HIV must be present,
· CD4 count falls below 200 cells/mmm3 (cubic milliliter), or
· Development of an "AIDS-defining" condition
o Candidiasis
o Cervical cancer (invasive)
o Coccidioidomycosis, Cryptococcosis, Cryptosporidiosis
o Cytomegalovirus disease
o Encephalopathy (HIV-related)
o Herpes simplex (severe)
o Histoplasmosis
o Isosporiasis
o Kaposi's sarcoma
o Lymphoma
o Mycobacterium avium complex
o Pneumocystis carinii pneumonia
o Pneumonia (recurrent)
o Progressive multifocal leukoencephalopathy
o Salmonella septicemia (recurrent)
o Toxoplasmosis of the brain
o Tuberculosis
o Wasting syndrome
Routine HIV/AIDS testing
Testing is an essential component of HIV/AIDS diagnosis and treatment. Because people in the early stages of HIV/AIDS may be asymptomatic, they may be putting others at risk. While those with HIV/AIDS need multiple tests to accurately assess their physical condition, some tests are specific to HIV/AIDS:
HIV antibody CD4 t-cell Viral load
· HIV Antibody tests
The period between becoming infected and showing antibodies to HIV in the blood can range from 2 weeks to 6 months. During this period, a person can spread the disease even though the antibodies cannot be detected in the blood. The most common tests in recent years have been ELISA, Western Blot and IFA.
Enzyme-linked immunosorbent assay (ELISA).
· Usually the first test used to detect infection with HIV, but can cause false positive results
Western blot.
· More difficult than the ELISA to perform and interpret accurately, but less likely to give a false-positives; used to confirm ELISA results.
Indirect fluorescent antibody (IFA)
· Detects antibodies made to fight an HIV infection; used to confirm ELISA results.
New rapid HIV tests are now on the market, that are quick, easy to do, and allow for point-of-care testing. There are 4 rapid HIV tests that have been approved:
· OraQuick Advance HIV-1/2 - results in 20 minutes
· Uni-Gold Recombigen - results in 10 minutes
· Reveal G2 - results in 5 minutes
· Multispot HIV-1/HIV-2 - results in 15 minutes
Symptoms of infection
A person who is HIV positive does not automatically have AIDS. AIDS, by definition, is a syndrome with multiple specific symptoms. However, there are certain symptoms that commonly occur along with an HIV infection. Sometimes HIV infected people who do not have AIDS, but are exhibiting certain symptoms, are said to have "acute retroviral syndrome."
All health care workers, and people who are HIV positive, should be aware of the following symptoms and their significance.
Signs/ symptoms
Percentage of occurrence
Fever 96%
Lymphadenopathy 74%
Pharyngitis 70%
Rash (Erythematous maculopapular with lesions on face, trunk, and sometimes extremities, including palms and soles; mucocutaneous ulceration of mouth, esophagus, or genitals) 70%
Myalgia or arthralgia 54%
Diarrhea 32%
Headache 32%
Nausea and vomiting 27%
Hepatosplenomegaly 14%
Weight loss 13%
Thrush 12%
Neurologic symptoms
o Meningoencephalitis or aseptic meningitiso Peripheral neuropathy or radiculopathyo Facial palsyo Guillain-Barré syndromeo Brachial neuritiso Cognitive impairment or psychoses 12%
All health care workers, and people who are HIV positive, should be aware of the following symptoms and their significance.
Signs/ symptoms
Percentage of occurrence
Fever 96%
Lymphadenopathy 74%
Pharyngitis 70%
Rash (Erythematous maculopapular with lesions on face, trunk, and sometimes extremities, including palms and soles; mucocutaneous ulceration of mouth, esophagus, or genitals) 70%
Myalgia or arthralgia 54%
Diarrhea 32%
Headache 32%
Nausea and vomiting 27%
Hepatosplenomegaly 14%
Weight loss 13%
Thrush 12%
Neurologic symptoms
o Meningoencephalitis or aseptic meningitiso Peripheral neuropathy or radiculopathyo Facial palsyo Guillain-Barré syndromeo Brachial neuritiso Cognitive impairment or psychoses 12%
Modes of Transmission
It's important to understand some basic information about how HIV gets into the cells of the body and replicates, and then is transmitted to other people.
There are a number of steps in the infection process:
Biological mechanism for infection Transmission Symptoms of infection Criteria for AIDS
There are a number of steps in the infection process:
Biological mechanism for infection Transmission Symptoms of infection Criteria for AIDS
Biological mechanism for infection
Infection takes place when the human immunodeficiency virus (HIV) enters the body and goes through a number of steps:
1. Binding and fusion: The virus binds with receptors (CD4 and one additional) on the surface of T-lymphocytes and then fuses with the host cell, releasing its RNA into the host cell.
2. Reverse transcription: An HIV enzyme (reverse transcriptase) uses the single-stranded HIV RNA to assemble a double-stranded HIV DNA molecule.
3. Integration: The HIV DNA enters the host cell's DNA, where an HIV enzyme (integrase) “hides” the HIV DNA within the host cell's own DNA. This now-integrated DNA is called a provirus and may remain inactive for several years, producing few or no new copies of HIV.
4. Transcription: When the host cells receives a signal to activate, the provirus uses an enzyme in the host called "RNA polymerase" to create copies of the HIV genomic material, as well as shorter strands of RNA called "messenger RNA (mRNA)." The mRNA is used as a blueprint to make long chains of HIV proteins.
5. Assembly: An HIV enzyme, called protease, cuts the long chains of HIV proteins into smaller individual proteins. These small proteins come together with copies of HIV's RNA genetic material, to create a new viral particle.
6. Budding: The new virus pushes out, or buds, from the host cell. During budding, the new viruses take part of the cell's outer envelope, which acts as a covering, and is studded with protein/sugar combinations, called HIV glycoproteins. These HIV glycoproteins are necessary for the virus to bind CD4 and co-receptors on other host cells. The new copies of HIV can then move on and infect other cells.
This process destroys the CD4T cells, making the CD4 count go down, and thus weakens the immune system of the body, while it increases the HIV viral load of the body.
This process destroys the CD4T cells, making the CD4 count go down, and thus weakens the immune system of the body, while it increases the HIV viral load of the body.
HIV/AIDS Update for Nurses
Wanda Lockwood
Introduction
In the early 1980's, a strange new disease seemed to come out of nowhere. It was initially called GRID (Gay-Related Immunodeficiency Disease) because it was thought to only affect gay men. Then, people with hemophilia started to die. The disease was eventually called Autoimmune Deficiency Syndrome or AIDS.
By 1982, the Centers for Disease Control (CDC) had linked the AIDS virus to the blood supply, and warned blood banks about the danger of blood being infected with the AIDS virus. In 1983, Luc Montagnier, at the Pasteur Institute in France, identified a virus he thought was implicated in AIDS. At that time, he couldn't prove it caused AIDS. Then, in 1984 Robert Gallo in the United States announced that he had identified the virus responsible for AIDS "human immunodeficiency virus (HIV)." Through an unusual agreement, Montagnier and Gallo share credit for identifying HIV. By 1985, dozens of Americans had been infected with HIV, which they received during blood transfusions. To protect the blood supply, the ELISA (enzyme-linked immunosorbent assay) test was universally adopted by blood banks and plasma centers in the US.
According to the CDC, at the end of 2003, an estimated 1,039,000 to 1,185,000 persons in the United States were living with HIV/AIDS, with 24-27% undiagnosed and unaware of their HIV infection. Approximately 40,000 new infections with HIV occur annually in the United States, including 300 infants who are infected by their mothers. Among all people in the United States, the annual number of new HIV infections has declined from a peak in the mid-1980s (of more than 150,000) and stabilized since the late 1990s. However, people of minority and ethnic groups are disproportionately represented and HIV/AIDS remains an ongoing challenge.
Subscribe to:
Posts (Atom)