HIV/AIDS: AN UPDATE

AN UPDATE
A Self-instructional Program
Approved for 2 Contact Hour*
(*This equals .2 CEU Credits for Iowa Nurses)
This study was prepared by Linda S. Greenfield, RN, Ph.D. for

Consultants for the Future

Continuing Education for Healthcare Professionals

www.consultantsforthefuture.com
Telephone: 800-654-CEUS (2387)
*This course and Consultants for the Future have been approved by:
The Florida Boards (Provider No. 50-435)

Nursing,
Clinical Social Work, Marriage & Family Therapy, and Mental Health Counseling,
Occupational Therapy,
Acupuncture
Respiratory Therapy
Nursing Home Administrators

It is accepted through complementary board approval by the Florida Boards of

Midwifery
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Athletic Training
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Electrolysis

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Behavioral Science Examiners for Mental Health Counselors and Marital & Family Therapists, Sponsor No. 1-05,
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The Course meets the requirements of the Minnesota, Ohio, Nevada, District of Columbia and Kentucky
Boards of Nursing, and other states by reciprocity.
No portion of this study may be reproduced without permission of the author and Consultants for the Future.
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HIV/AIDS: AN UPDATE

This course serves as an update to help you live and work in a world
containing the Human Immune Virus (HIV). It is a valid course for all of the
states in which our courses are approved, but it has been designed to meet the
specific requirements for the Florida for healthcare professionals who are
required to receive 2 contact hours.

Please read these IMPORTANT INSTRUCTIONS as they contain answers

to many of the questions we are often asked regarding home study.
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Initial printing: September 2002

Current revision: May 2011

HIV/AIDS: AN UPDATE

As healthcare workers, blood-borne pathogens carry some common realities for us. We must
learn about the virus, and develop appropriate cautionary and preventative measures so that our patients
and we are safe. You are one of our worlds health teachers. Because of your experience and learning,
you have knowledge about HIV that other people dont have. You have a responsibility to utilize and
share that knowledge. You can make a difference. But we all have to keep learning, and keep teaching.
This course has been designed to empower you to do that.

Objective No. 1: Describe how HIV/AIDS has increased and in what populations.
Objective No. 2: Understand how the virus attacks, the incubation period and the modes
of transmission of the virus.
Objective No. 3: Identify infection control practices and precautions for health care
workers.
Objective No. 4: List steps that can be taken to prevent the spread of HIV.
Worldwide, it is estimated that roughly 40 million are infected with HIV, at a rate of approximately
10 new cases every minute. In the United States we now have more than a million reported HIV cases.
The incidence of new cases averages about 50,000-80,000 per year. (Bowers, 110) The CDC estimates
that half of new infections are occurring in persons under age 25. (ibid)
The statistics closer to home can be overwhelming. Florida, for example, hosts the third highest
number of cumulative AIDS in our country and around 11% of the countrys reported cases. (Jones, 41) It
ranks high in heterosexually acquired cases of HIV in women (over 40%) and is second in the nation of
the number of AIDS cases among children. In the population of heterosexually transmitted HIV between
ages 13 and 19 (our teenagers), 91% have been female. Women represent the largest number of
people with new diagnoses of AIDS. Cases in women are increasing faster than in men.
Globally, HIV has always been a heterosexual problem. In some African countries, as many as
70% of women of reproductive age are HIV infected and 80% of people between 20 and 49 years of age
are infected. (Bowers 100) Worldwide, five youths between ages 10 and 24 are infected with HIV every
minute. (Sowell, 180) The global ramifications of this disease are impossible to imagine.
The majority of women tend to be unemployed and live in low-income housing. In the US, fifty
percent of these women have a child under the age of 15 and only 14% are married. (Norman, 23) Why
are women, particularly those with traditionally low societal support and recognition so affected? Women
are more vulnerable to HIV because infected semen has far higher concentrations of the virus than does
infected vaginal secretions. Plus, womens sexual partners have often had multiple other sexual
contacts, increasing the likelihood that they are infected. Women with little societal power tend to take a
more passive role in sexual relationships with men, so they are more apt to agree to sex without knowing
their partners HIV status. For many of these women, the sexual relationship with their male partner is an
aspect of survivalthe politics of the bedroom. The majority of women with HIV live in poverty and are
single heads of households. Most of the worlds women are poor and most of the worlds poor are
women. In some countries the rate of infection for teenage girls is 5 times higher than that for teenage
boys. The limits of power, control and social status make it difficult for these women to inquire about
condom use or be able to leave risky relationships.
Of those infected women, many have been misdiagnosed, not diagnosed at all, or diagnosed in the
late stages of HIV disease when AIDS is developing. Access to healthcare may be limited. Denial and
fear of the diagnosis is a problem. Many foresee only danger should the diagnosis become known, and
so dont seek testing or alter high-risk behaviors. Most who have been tested have been pushed into or
at least drifted into HIV testing, often with little forethought of the risks or concerns for the benefits of
diagnosis. The life expectancy of women after HIV diagnosis is less than that of men, although this may
be due to inadequate access to appropriate healthcare. As many as two-thirds of HIV cases in women
are diagnosed during pregnancy. Women are more likely than men to have sole responsibility for
children and to be terrified of losing custody of their children if they become sick. Women with AIDS are
sometimes forced to move when the diagnosis becomes known, because of discrimination.
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HIV/AIDS: AN UPDATE

It follows then, that the percentage AIDS cases acquired during birth would increase. Perinatal
transmission of HIV now accounts for 90% of all pediatric AIDS cases in the US and almost all new HIV
infections in children. It is important that pregnant women have access to medical care something
often denied to uninsured women. Transmission of HIV from a mother to her child may occur during the
prenatal, birthing process or postpartum periods. Prenatally, HIV can travel through the placenta.
Intrapartum transfer can occur when maternal blood is contacted by fetal passage through the birth
canal, and postpartum transfer can occur with breast-feeding. HIV has been recovered from fetal tissue
as early as eight weeks gestation. Preventable risk factors are breast-feeding and duration of ruptured
membranes over 4 hours. Higher viral loads are associated with an increased risk of transmission. But
even women with undetectable viral loads due to effective anti-viral therapy have transmitted the virus to
their infants.
The CDC has revised their recommendations for HIV testing of adults, adolescents, and pregnant
women in order to address these concerns. HIV screening is recommended for patients in all healthcare settings after the patient is notified that testing will be performed, unless the patient declines (optout screening.) Persons at risk for HIV infections should be screened annually. ALL Pregnant women
should be screened as part of prenatal screening and again in the third trimester if there is increased
risk. Opt-out screening is a significantly different approach than was used in the past. With opt-out
screening, assent is inferred unless the patient declines. Thus, HIV screening is handled much like other
tests for serious illnesses. Separate written consent should not be required, and instead, general
consent for medical care should be considered sufficient to encompass consent for HIV testing.
Screening is a basic public health tool used to identify unrecognized health conditions so treatment can
be offered before symptoms develop and, for communicable diseases, so interventions can be
implemented to reduce the likelihood of continued transmission. HIV infection is consistent with all
generally accepted criteria that justify screening:
HIV infection is a serious health disorder that can be diagnosed before symptoms develop;
HIV can be detected by reliable, inexpensive, and noninvasive screening tests;
Infected patients have years of life to gain if treatment is initiated early, before symptoms
develops; and
The costs of screening are reasonable in relation to the anticipated benefits.
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
In 1994, twenty to thirty percent of infants born to HIV infected mothers were infected with HIV,
however, it was discovered that the rate of transmission can be reduced to 1% if maternal anti-retroviral
therapy is used, and zidovudine is given to the infant for 6 weeks after delivery. Zidovudine (AZT) is able
to concentrate in the fetal spaces, and is effective in reducing HIV transmission regardless of the
maternal fetal load. This finding emerged from a joint French-US study called the Pediatric AIDS Clinical
trials Group Protocol 076, and is since referred to as the 076 protocol. The CDC is recommending
universal counseling and testing with informed consent to every pregnant woman, making HIV testing a
part of routine prenatal care. In our country, various drug availability programs could cover the cost of
testing and preventative treatment. Treatment of the mother with HAART (Highly Active AntiRetroviral
Therapy) should be offered at whatever stage she enters the healthcare system. Intrapartum treatment
and newborn treatment still reduces the transmission rate. For details, refer to.
http://www.aidsinfo.nih.gov/contentfiles/Perinatal_FS_en.pdf
AIDS is growing in numbers among American adolescents, more rapidly among females than
among males. In the United States, STDs (sexually transmitted diseases) are epidemic among young
people. About 18.9 million new cases of STDs were reported in 2000; approximately half of those
occurred in 15-24-year-olds, although that age-group represented only one-quarter of the sexually
experienced population. (Yarbor, 2005) One report indicates that more than half of females and almost
3/4 of males have had intercourse before their eighteenth birthday. Eighty six percent of males and 75%
of females have sexual intercourse by the age of 20. "Two thirds of high school seniors say they have
had intercourse." (Coates, 97) It is documented that adolescents and young adults are inconsistent users
of latex or polyurethane male condoms. Adolescents have the highest rate of STD. One out of six
sexually active teens is affected.
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HIV/AIDS: AN UPDATE

Sex education is helping. Most sex and HIV prevention education programs offered to teens
presents information about contraceptives, pregnancy, abstinence, and sexually transmitted diseases,
including HIV. Studies show that sexual activity is not increased as a result of this teaching, and in fact,
the teen is often empowered to behave more safely, and to have sex less frequently. Sex education
efforts need to be ongoing, as a one-time exposure to information is less successful than repeated
reinforcement. And it needs to consider the importance of being able to obtain information,
latex/polyurethane condoms, or testing in a confidential manner. Knowledge remains our greatest hope.
Safe practice and precautions continue to be primary concerns. Prevention is still the key.
Answer the following questions on the answer sheet provided at the end of the study:

Question No. 1: True or False? The CDC now recommends that ALL pregnant women should be
tested for HIV prenatally, and again in the 3rd trimester if there is increased risk.
True.
b. False.
Question No. 2: Which description of the majority of heterosexual women with HIV is NOT
accurate?
a. For those with low societal support, the sexual relationship with their male partner may
be an aspect of survival.
b. Fourteen percent are married.
c. Of the worlds poor, women are a minority.
d. Women are more vulnerable because infected semen has a higher concentration of the
virus.
Question No. 3: According to statistics:
a. More than of females and almost of males have had intercourse by the age of 20.
b. One-half of new infections with HIV are occurring in persons under 25.
c. Sexual activity is not increased as a result of sex education, and in fact, the teen is often
empowered to behave more safely, and to have sex less frequently.
d. All of these are correct.
Question No. 4: True or False? According to CDC recommendations, general consent for medical
care should be sufficient for consent for HIV testing.
a. True.
b. False.
THE NATURE OF THE VIRUS: In two decades of HIV history we have learned a great deal about
it. The virus that causes AIDS, the human Immunodeficiency virus (HIV), does not itself kill the patient.
It creates the possibility for the opportunistic infections and certain forms of cancer to cause death.
Opportunistic infections are from organisms most of us already have in our bodies, or are readily
available in the environment. They are certain bacteria, viruses, protozoa and fungi that are allowed to
increase and create disease because the hampered immune system cannot keep them in check. The
death comes indirectly from a defenseless, viral-destroyed immune system.
Understand the nature of any virus. It is a genome, composed of RNA, (or sometimes DNA in
other viral types) covered by an antigenic coat -- the capsid. Any virus does not have the cytoplasmic
machinery to replicate like other cells such as bacteria or our own body cells have. A virus must invade
a host cell and insert its own DNA/RNA into that cell's nucleus to create a hostage situation in which the
host cell becomes a viral factory.
HIV has only RNA, and is a retrovirus. It has an outer protein (gp120) that seeks out and binds to a
very specific receptor called the CD-4 receptor. These receptors are primarily on the helper T
lymphocytic cells, the "general in command" of the whole immune response. Lymphocytes are a type of
white blood cell, and there are two types of lymphocytes. The B-lymphocytes make antibody, a function
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HIV/AIDS: AN UPDATE

also very important to immunity. But the T lymphocytes tell all of the other white cells what to do. The
helper T cell is the "kingpin", and also the target of HIV. HIV-specific helper CD4 cells are some of the
first cells to be destroyed in the first few weeks of infection. This leaves the rest of the immune system
without these cells that are needed to coordinate the immune system and control the virus.
There are some other cells with CD4 receptors, but these exist in lesser quantities: mononuclear
cells (monocytes, also called macrophages) (another white blood cell), cells in the bone marrow which
produce the white blood cells, and on some Epstein-Barr virus-infected B lymphocytes. It is harder for
HIV to attach to some of these cells, than to a helper T cell. Another key cell that contains CD4
receptors is called the follicular dendritic cell (FDC). (Ill explain its function later).
Once the virus fuses with the host cell membrane, it can enter the cell through the CD4 doorway. In
that cells cytoplasm, it uses an enzyme it produces, called reverse transcriptase, to transcribe its RNA
message into viral DNA. The viral DNA then becomes spliced into the nucleus of the host cell. Another
enzyme called integrase helps splice the viral DNA into the host cell's DNA. The viral DNA is then
transcribed into messenger RNA, which leaves the nucleus of the cell and goes into the cytoplasm. The
messenger RNA communicates to the cytoplasm the arrangement of proteins necessary to produce the
viral protein core and the envelope. As a provirus, the proteins are large, immature and noninfectious.
Another enzyme called protease converts the proviral proteins into active protein forms of a fully mature,
infectious virus. The cell begins to create thousands of viruses as it functions as a viral factory. As the
cell fills with viruses, they bud from the infected host cell, leaving that cell in search for another host,
taking pieces of cell membrane with it. In time the cell membrane becomes so weakened, it cannot
function, which kills the cell. Up to 5000 viral particles can explode from each replicating cell. (Moran 830)
Early infection shows a high level of free viruses in the blood. The battle has begun, as uninfected
T cells try to fight the infection. The period between infection with HIV and symptoms is about 14 days
(with a range of 5 to 30 days). The lymph nodes swell, but this early response may be transient. Often a
rash occurs, and mucous ulcers sometimes appear. Within 3 weeks, antibody if formed and most people
seroconvert (show positive antibody to HIV on testing) by 6 months. The average is 22 to 27 days. As
the antibody increases, the primary infection winds down, the free viremia clears in the serum, and any
symptoms that might have appeared, disappear. However, the virus has only receded into the cells to
hide from the antibody and the white blood cells. The infection becomes chronic, and persistent.
The lymph node is a very important site for viral spread. The lymph node is a grand central station
for lymphocytes. The nodes are laden with cells called "follicular dendritic cells" (FDCs). FDCs are very
large cells with numerous CD4 receptors. They have a very large cellular membrane with many pleats
and folds. The purpose of the folds is to trap antigens and infectious agents, so the phagocytic white
blood cells can destroy them. Immune complexes (antigen / antibody clumps) also attach to the FDCs.
When the infectious agent is HIV, it loves to become trapped by the FDCs. One FDC can contain high
levels of virus. The contaminated FDCs create a node that easily supports a spreading infection as
lymphocytes pass through. In response to the infection, FDCs increase in number, creating persistent
generalized lymphadenopathy (enlarged and abnormal lymph nodes that persist more than 3 months).
When the FDCs themselves become infected and die, the impact is wide spread with global collapse of
the lymph node. With the lymph node collapse, the FDC is not there to soak up the virus, and huge
loads of virus can now enter the general circulation. The CD4 counts are rapidly declining, and with the
chronic immune failure, AIDS sets in.
Many CD4 cells become latently infected, i.e., they don't begin producing viruses until later, and the
T-cells continue to live with a resting virus inside. It is estimated that for every virus-producing cell, there
are probably 1 to 4000 latently infected cells in the lymph node. Certain immune chemicals that stimulate
T-cells to fight other organisms can activate a latent cell and make it start producing virus.
Understand that the virus doesn't stop replicating in other cells at any time. It just sets up a vast
storehouse of viral laden, infected, but latent cells, as it is working.
For example, during treatment and with active antibody ability in the beginning of the disease, the
circulating serum level of virus can drop by 99.99 percent. Most of the virus is hiding inside cells. With
the offenders off the street, the CD4 cells can be regenerated, at this point. Ten billion viral particles
may exist in the body at any given time, and the virions have a plasma half-life of just 6 hours. The
turnover in CD4 cells may be as high as 10 million cells a day. (Wolfe, 128) That's an amazing recovery
6

HIV/AIDS: AN UPDATE

ability of the immune system. The virus must replicate furiously and at a greater rate than the CD4 cells,
to hold the line against the immune system. Early treatment, which may cripple the virus early in infection
before the virus becomes too varied to contain, is a must.
This variation of viruses is a formidable aspect of the battle. As the cauldron of chronic infection
begins to simmer, this variation scenario unfolds. Transcribing RNA into double stranded DNA, quickly,
is risky business for the virus, and as a result, many mutational errors easily occur. HIV does not have
the "proof-reading" capacity that other cells have to assure a correct copy. This allows the creation of
variants or errors. "an average of one mutation is introduced in every one to three HIV genomes
copied." ("Report of the NIH Panel..", 1072) When a variant is made that escapes recognition by the
roaming B-lymphocytes (those with the pattern for the previous virus type), a new infection is created.
As before, high titers of free virus are released, and stay in the blood, until new antibodies can be formed
to the new variant, in the following weeks. Some variants allow more complete binding at the CD4 site,
so that now, maybe, monocytes can also be invaded in addition to T cells, and the new virus can spread
through these cells. It is the monocyte that is capable of carrying the HIV into the brain, and probably
through the placenta. Monocytes (macrophages) live much longer than do T-cells, and help create a
chronic, resistant infectious pattern.
Other variant forms develop resistance to the antiviral drugs used to fight the infection.
Sidestepping resistance is a constant part of the battle. Eventually variants will form that attack
progenitor CD4 cells in the bone marrow. These are the cells that replenish the immune system as the T
cells are killed. When these cells come under attack, the CD4 counts drop even lower.
The opportunistic infections further contribute to the cascade. Many T cells are infected with virus,
but latent. When that T cell is called upon to fight a specific infection, because it's particular pattern
matches that of the antigenic opportunistic organism, this stimulation also activates the HIV and the cell
begins production of virus. This leads to death of that T cell, a reduced ability to respond to the
opportunistic infection, and a further depletion of the CD4 count. Research is also being done on the
effect of other co-factors involved with viral activation. Alcohol, drugs, and especially Amyl Nitrates
(Poppers) destroy white cells, and affect the immune system. Poppers are used as an aphrodisiac.
If untreated, less than 5% of HIV infected people will develop AIDS within two years; twenty to
twenty-five percent will develop AIDS within 6 years; and fifty percent will develop AIDS within 10 years.

Question No. 5: True or False? Once the antibody are produced by uninfected lymphocytic cells
following early infection, the presence of the virus in the serum clears, and there is no more
infection of the body.
a. True.
b. False.
Question No. 6: If the virus creates enough errors during its process of transcribing RNA into
DNA, so that the antibody cant recognize this new form:
a. A new infection is formed, probably with greater ability to spread.
b. The virus becomes weaker and is usually able to infect even less cells than before.
c. The virus dies from the errors and the disease is cured.
d. The virus is not able to enter the bloodstream.
Question No. 7: Which is NOT an accurate description?
a. Helper T lymphocytic cells have CD4 receptors.
b. HIV cannot enter a host cell just anywhere. It must use special receptor doorways such
as the CD4 receptor.
c. HIV has only RNA, not DNA, and it must insert its RNA into the host cells nucleus in
order to make that host cell produce HIV.
d. If a CD4 cell is latently infected, that means the virus is actively reproducing inside the
cell.

HIV/AIDS: AN UPDATE

MODES OF TRANSMISSION AND INFECTION CONTROL

We have been taught to treat everyone as if they might have HIV or hepatitis, and take appropriate
precautions. This emphasis on infection control benefits everyone even when HIV is not involved. Not
only are blood-borne pathogens a concern, but also the rate of spread of resistant bacteria in our
healthcare environments mandates that we use every precaution to prevent infection of any organism.
Universal precautions should be universal. Knowledge of how HIV is transmitted will help you
understand the importance of using safe practice in your work, and of teaching safe practice to others.
One thing that has not significantly changed with thousands of cases studied, is the basic
understanding of HIV transmission. These are the facts you can teach to others.
Ways a person can become infected with HIV:
1. Having sex (vaginal, anal, or oral) with a person who is infected with HIV and not using barrier
protection. It is passed through blood, semen, vaginal secretions, or blood contaminated other bodily
fluids (e.g. saliva.) Other body fluids with a possible risk include: cerebrospinal fluid, synovial fluid,
pleural fluid, peritoneal fluid, pericardial fluid or amniotic fluid.
2. Sharing needles and other drug paraphernalia with someone who is infected with HIV. There are
small amounts of blood on the contaminated needles.
3. Receiving blood transfusions or blood products, donor tissue, or sperm for artificial insemination from
someone infected with HIV. The blood and tissue banks adopted strict screening guidelines for HIV
in 1985. This route of transmission is no longer a major route.
4. A baby being born to a woman infected with HIV can contract the disease during pregnancy, during
birth and through breast-feeding. Perinatal and antenatal treatment has markedly lowered the rate of
infant infections.
5. Among health care workers, HIV can be transmitted when injury with sharp objects contaminated
with HIV occurs, or if splattered in mucous membranes or non intact skin dermatitis, chapped or
abraded skin) by HIV contaminated blood, through improper handling of cultures of HIV virus.
Transmission can also occur with contact of the virus with intact skin when the duration is several
minutes or more, or if contact involves an extensive area in contact with blood tissue or other body
fluids.
6. HIV can be transmitted as a free virus in secretions, or as a virus hidden inside a cell, during
infusions of fresh infected blood products, via seminal fluid, vaginal secretions, or breast-milk. Other
body fluids with an undetermined risk include: cerebrospinal fluid, synovial fluid, pleural fluid,
pericardial fluid or amniotic fluid.
Exposure to saliva, tears, sweat, urine or feces with no visible blood is not a route of transmission.
There are NO documented cases of anyone ever contracting it from sweat, tears, or saliva. Since the
virus does not live outside the body for much more than an hour, it is highly unlikely, and NEVER
documented, that it is transmitted through public facilities such as restrooms, pools, spas, water
fountains, etc. The virus is not airborne, and NO transmission has ever been traced to contact with
clothing, food, dishes, utensils, toilet seats or even chewed pencils. You can't contact HIV by standing
close to someone who has it. Breathing, sneezing, touching, coughing, wrestling has NEVER been
known to spread HIV.
Those most at risk are people who engage in high risk sexual behaviors, injectable drug users who
share paraphernalia, sexual partners of members of high-risk groups, any who think it can't happen to
them or their loved ones, and those who refuse to be educated. Basically, No Sex, No Drugs, No
Blood, No Risk.
Ease of infection depends on the numbers of viruses (the viral titer) and the numbers of CD4
receptors. The more of each, the easier infection will be.
HIV is very much a sexually transmitted disease. Therefore, education to ensure prevention needs
to involve the word and concepts of sex. Sexual expression is highly individual. What one person
considers normal, another would consider unacceptable. In order to teach prevention principles, the total
range of sexual activity needs to be considered. I'll list for you activities considered safer, risk reducing,
and high risk, without judging any of these activities as normal or abnormal, appropriate or inappropriate.
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HIV/AIDS: AN UPDATE

The principles of sexual risk apply to any risk situation: male / male; male / female; female / female; or
whatever combination can be conceived.

No Risk
Most of the really safe activities involve only skin-to-skin contact where transfer of the virus is
unlikely from one person to another.
1. Abstinence.
2. Mutual masturbation (male or female) (without semen or vaginal fluids)
3. Social kissing (dry)
4. Body massage, hugging
5. Body-to body rubbing
6. Nipple stimulation.
7. Erotic bathing or showering..
8. Using one's own inserted sexual devices.
9. Contact with feces or urine on intact skin.
While abstinence would be the desired or ideal behavior to prevent HIV transmission, it would be
blind to consider it the only choice people will make. In studies of sexual behaviors of HIV positive
persons, "Abstinence from sexual relationships occurs in a minority." (Stein, 265) It is important to
provide people with the spectrum of information about sexual risk.
Theoretical Risk
1. Wet kissing.
2. Cunnilingus (oral-vaginal stimulation) with barrier protection.
3. Digital-anal and digital-vaginal intercourse, with or without a glove and with intact skin.
4. Using shared, but disinfected inserted sexual devices.
Risk Reducing Sex
In these activities, small amounts of certain body fluids may be exchanged, causing some risk.
This risk is increased in proportion to the number of contacts.
1. Intercourse with a condom. This is safe if the condom does not break, causing spillage of
semen into the vagina or rectum. The risk is also reduced if withdrawal occurs before climax. Latex
condoms may breakdown from heat, and have concerns, but this type is recommended. Those from
natural membranes (e.g. lamb cecum) do not block HIV. Oil based lubricants, including petroleum jelly,
vegetable shortening, butter, etc. should not be used because they increase the risk of condom
breakage. Water-soluble lubricants such as K-Y jelly or diaphragm jelly can be used.
Latex condoms are highly effective in preventing the spread of HIV. Studies show, however, that
many who engage in high-risk sexual behaviors, don't use them. "[M]ost women at sexual risk of HIV
do not consistently use condoms with their partners, and particularly when there is one main, risky
partner...Although all couples received safe sex counseling according to state HIV testing center
guidelines, one fourth of the couples resumed or continued to engage in unprotected sex." (Skurnick, 503)
Fewer than 10% of teenagers who have sex use condoms consistently. The ABCs of HIV protection are
(A)bstain, (B)e faithful to one partner and use a (C)ondom.
2. Fellatio. This is the term used to describe oral sex, or sucking on the penis.. Since preejaculatory fluid may have virus in it, there is some risk in this practice. Also the risk is increased if there
are mouth sores. A condom (or dental dam) is recommended for any fellatio activity. If a condom is not
available, nonporous (nonmicrowaveable) plastic wrap may be used. Fellatio with ejaculation and
ingestion of semen carries more risk than fellatio with a condom.
3. Cunnilingus. This is the term used to describe oral stimulation of the female perineum. Since
both saliva and vaginal secretions are known to contain the virus, there would be some risk. If
menstruation is occurring, risk is increased. Dental dams or nonporous plastic wrap is advised.

HIV/AIDS: AN UPDATE

High Risk Sex

1. Penal-vaginal intercourse, or penal-anal intercourse without a condom.
2. Intercourse with withdrawal before ejaculation
These activities involve tissue trauma and or exchange of body fluids that may transmit HIV or
other microbes. They carry high risk unless the sex partners have been monogamous and healthy for
five years or more. It is important to recognize how some people interpret the word "monogamous."
Some people, when describing their monogamy, are actually describing "serial monogamy", in which the
person may have had only one partner at a time, but had had multiple partners since becoming sexually
active. Without adequate protection, this would be high-risk behavior. "These women apparently had
assumed that if they had no knowledge that their partner was infected or engaged in high-risk behavior
then unprotected sex was not unsafe sex." (Siegel 118) There is need to encourage some people to
inquire deeply about a potential partner's risk status, and to recognize the potential for dishonesty.
Protection for Injecting Drug Users:
Teaching efforts are necessary to reach those in danger of transmitting HIV through contaminated
needles. This is one of the highest-risk groups and is a leading factor in spreading HIV. Although the
message to not share needles has been widely distributed, few injecting drug users will be stopped from
injecting just because only one used needle is available. Multiple efforts are necessary to reduce the
impact of this mode of transmission. Approaches to the problem include, but are not limited to:.
Needle and syringe exchange programs are available in many larger cities. This provides access to
sterile needles. Numerous studies in several countries have demonstrated that this practice can
reduce the incidence of blood-borne disease and it does not increase drug use.
Needles and syringes can be sterilized using a bleach solution of 1 part bleach to 9 parts water.
There are bleach kits available, usually given free of charge at treatment program centers.
Efforts are ongoing to increase access to health services and drug treatment programs, with a major
goal to decrease the spread of HIV.

Question No. 8: True or False? HIV is airborne and can be transmitted with sneezing.
a. True.
b. False.
Question No. 9: Which of these is true about condoms and their use?
a. Latex condoms are not effective in preventing the spread of HIV.
b. Many who engage in high-risk sexual behaviors dont use latex condoms.
c. The majority of teenagers use condoms consistently.
d. All of these are true.
Question No. 10: Having one partner at a time, but multiple partners since becoming sexually active
is called:
a. Monogamy, and it is low risk behavior.
b. Serial monogamy, and it is high-risk behavior.
Question No. 11: Of these four ways to become infected with HIV, which is the most common?
a. A baby being born to a woman infected with HIV.
b. Having unprotected vaginal, anal or oral sex with a person infected with HIV.
c. Receiving contaminated blood transfusions.
d. The virus contacts intact skin for several minutes.
Recommendations for Persons with A Positive HIV Antibody Test:

To avoid sexual activity or inform the partner of the positive HIV exposure, and then provide
protection from body fluids during sex. Condoms should be used, and any practice that may injure
10

HIV/AIDS: AN UPDATE

body tissues should be avoided. Oral-genital contact and open-mouthed, intimate kissing should be
avoided without protection.
Do not assume that HIV-positive people do not want to become involved in intimate relationships.
Studies show otherwise. Teaching needs to be constantly reinforced. Even if both partners are HIV
positive, it is important for them to practice safer sex or risk-reducing behaviors. They could infect one
another with different HIV strains or other sexually transmitted diseases, compromising the success of
their therapy. HIV-positive people following their drug therapy regime closely, who now have
"undetectable" viral loads, can still transmit HIV to other people. "Undetectable" merely means that
our laboratory equipment is not yet sophisticated enough to be able to measure HIV hidden in body
reservoirs. The HIV is still in the person's body, just not in the blood stream where it could be measured.
To have regular medical evaluations and follow-up.
To inform present and previous partners and any persons with whom needles may have been
shared, of the potential exposure to HIV and encourage these people to seek counseling and
antibody testing at appropriate care facilities.
It is also important for all people to know that many HIV-positive people DO NOT disclose their HIV
status to their partner. "In our study of urban hospital patients initiating primary care in Boston and
Rhode Island, 40% reported that they had not disclosed their HIV status to all sexual partners in the past
six months." (Stein, 266)
To not donate blood, plasma, organs, body tissue, or sperm.
If a drug user, to enroll in a drug treatment program. To never share needles and other equipment.
Not to share toothbrushes, razors, or items that could be contaminated with blood.
To clean blood or other body fluid spills on household surfaces with freshly diluted household bleach,
i.e. 1 part bleach to 9 parts water. Don't use bleach on wounds. Bleach is recommended, although,
many disinfectants are appropriate. Bleach maintains its potency for only 24 hours, so it must be
reconstituted daily.
To inform healthcare practitioners of the positive HIV status, so that proper precautions can be taken
to protect all. The fear here is that the health care practitioner may refuse to provide care. The
Americans With Disabilities Act (ADA), supported by the interpretation of Bragdon v Abbot, provides
some protection to the HIV-positive person. "The Court also ruled that health care professionals may
legally refuse to treat a patient because of concern that the patient poses a direct threat to safety only
if there is an objective, scientific basis for concluding that the threat to safety is significant. "A stateby state survey of those laws demonstrates that, consistent with Bragdon v Abbott, individuals with
asymptomatic HIV have a wide-spread protection on the state level." (Gostin, 745)
Women with positive antibody tests should avoid pregnancy.

Implications for Health care workers:

For several years now, surveys of health care workers who have intense exposure to patients with
AIDS have been under way. The data consistently shows that those who care for patients with AIDS or
process their specimens carry a low risk when appropriate precautions are taken. The risk is small, but
real. For example, human bites carry a potential risk, yet HIV transmission through bites has rarely been
reported. If blood is involved in the bite, the health care worker should be offered prophylactic therapy.
Of the documented cases, the greatest majority was from percutaneous (e.g. needle-stick) injury.
There are roughly 800,000 needle-stick injuries documented each year. Only a very small
proportion of occupational exposures result in HIV transmission. Much has been learned about needle
stick injuries. Five factors influencing the risk of HIV transmission from needle stick injury include:
1) Depth of injury.
2) Visible blood on the object.
3) Vascular access procedure.
4) Stage of HIV disease.
5) If the person stuck with the needle, or injured, uses antiviral therapy following the injury.
For treatment details, refer to http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf, Treatment should be started
within 1 to 2 hours of exposure, and continues for four weeks. Beginning these drugs more than 72
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HIV/AIDS: AN UPDATE

hours after exposure probably will not prevent infection, but may be beneficial to therapy. The doctor and
patient need to weigh the potential toxicity of these combined drugs against the potential benefit of
therapy. With appropriate antiretroviral therapy, the risk for HIV infection can be reduced by 79%-81%.
(Moran, 831) Significant side effects are reported from healthcare workers treated with post-exposure
prophylaxis (PEP.)
Other factors are important as well. Suture needles are less likely to transmit HIV than are hollow
bore needles, such as those used for IM injections. A small gauge needle carries less risk than a large
gauge needle. Use of gloves is quite important. . If the needle went through gloves before sticking into
the skin of the healthcare worker, approximately 50% of the blood is removed, which decreases the risk
of contamination. Use gloves for sub-q injections, IM injections, when using a needle and syringe to
irrigate a wound, and certainly for IV procedures.

OSHA Bloodborne Pathogens Standards

Standard Precautions or universal precautions or Bloodborne Pathogens Standards are not a
synonym for "infection control". Blood borne Pathogens Standards means taking routines to protect staff
and patients from infection by blood and bodily fluids, such as Hepatitis B, HIV, and multiple other blood
borne diseases. There are many infectious risks, however, in which the blood is not the mechanism of
transmission, so other infection controls procedures (respiratory isolation, wound and enteric
precautions, etc.) are necessary if the organism is other than HIV.
CDC recommendations for health care workers precautions:
Avoid accidental wounds from sharp instruments such as scalpels and needles, which might be
contaminated with material from any patients.
Avoid contact of open skin lesions with material from any patient.
Wear gloves when handling blood specimens, blood-soiled items, body fluids, excretions and
secretions, or when handling any objects that have been exposed.
Wear gowns when clothing may be soiled by any body fluids.
Wash hands after removing gown and gloves, and especially if hands have been contaminated
with blood.
Label specimens with "Standard / Universal Precautions" and transport them in impervious
containers.
Clean blood spills with disinfectant solutions.
Place articles soiled with blood in an impervious container labeled "Standard / Universal
Precautions" before sending for reprocessing or disposal.
Place needles in a puncture resistant container after use without bending the needle. Needles
should not be replaced in their sheaths after use, as this is a common cause of needle injury.
The old practice of replacing the cap is too risky. Actually, this procedure accounted for 30% of
all needle sticks according to one study. Don't recap needles!
Use disposable needles whenever possible. There is growing support for safer devices for
needle disposal and needle-less systems. The American Red Cross has adopted some of the
newer safety devices. Place patients in private rooms if they are too ill to practice good hygiene
with regard to body secretions.
Masks are necessary only when the patient has a lung infection with an organism that is airborne
and is actively coughing. If you have a cold, wear a mask to protect the patient. Linen precautions are
necessary only when there are draining wounds or the patient is unable to control excretions. Then,
linen should be placed in specially marked bags and disposed of appropriately in accordance with facility
procedure. Dietary precautions are not part of standard precautions, since there is no evidence that HIV,
etc. can be spread through food, dishes or utensils. However, dietary precautions are necessary in other
types of infections, which do spread in this manner. Many patients with AIDS excrete cytomegalovirus
(CMV). Since this virus may cause birth defects, it may be advisable for pregnant women to be excused
from the direct care of any known CMV excretor.
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HIV/AIDS: AN UPDATE

If an invasive procedure is required (operating room, delivery room, emergency department or

outpatient, dental procedures in which bleeding may occur), additional precautions are recommended by
the CDC. All health care workers participating in the invasive procedure should wear gloves, surgical
masks, protective eyewear, and gowns or aprons which are made of materials known to be an effective
barrier, especially if splashing of blood or body fluids could result. These items are collectively referred
to as "personal protective equipment". Hand care and glove use will be considered in detail.
Wearing gloves is an important aspect to infection control, and one that needs to be emphasized.
Wearing gloves does not eliminate the need to wash your hands between patients and before invasive
procedures, etc. Keep reminding yourself that when you have worn gloves, your moisture level of your
hands has increased, and your microbial count increased. Organisms can penetrate through
microscopic tears.
As the risk for bloodborne pathogens rose, people wisely became concerned with the quality of
gloves used. There are two types of materials commonly available. The most frequently used are the
latex gloves, which are made from natural rubber latex. These mold easier to your hand, allowing more
fine motor movements. Plus, latex reseals easily if tiny punctures occur. Also available are synthetically
manufactured materials, including vinyl. Wear vinyl gloves if you or your patient is allergic to latex. There
are extreme variables in different glove manufacturers. Generally speaking, vinyl gloves are considered
less protective, and many advocate double gloving if you are using vinyl gloves. Whether or not double
gloving helps with any type of glove is still being argued, although if you are involved in a high risk
procedure, you may choose to double glove and frequently change gloves if the procedure takes longer
than 10 minutes.
Don't store latex gloves longer than 6 months, and keep them away from ultraviolet and fluorescent
lights. These weaken the integrity of the gloves. Check the expiration date on sterile-glove packages
and keep them current. Gloves are single use items. Use them and toss them. Do not wash the gloves
and continue to the next patient. This weakens the glove and organisms are not always removed from
gloves, despite friction, the cleansing agent and drying.
OSHA mandates gloves when there is "a reasonable likelihood of hand contact" with blood or other
potentially infectious material, mucus membranes, or non-intact skin, and when performing invasive
procedures and handling contaminated items or surfaces. From a cost-containment perspective, it is
important to know when gloves are not necessary. You do not need to wear gloves to bathe a patient,
unless you will bathe the genitalia, or contact body fluids. You also dont need to wear gloves: to wash
hair, assist a patient to the bathroom or in transfer and ambulation, ambulate a patient with a catheter,
take vital signs, change IV bags, routinely change bed linen, feed patients, provide enteral feedings, or
care for a stage 1 ulcer (intact skin).
Aside from hand washing and gloves, there are other decisions your facility or you will make in
regard to protection and infection control. When do you want to wear a gown or a mask or eye protective
equipment? In making your choices beyond those mandated by facility policy, you'll need to think in
terms of possible risk. For example, if you are changing the dressing on a wound or a pressure sore,
probably gloves with hand washing will be enough protection. But, if you are going to irrigate that
wound, there might be backsplash in some combative patient situations. If so, you may need a moisture
proof apron or gown, goggles, a mask or a face protector as well as gloves. It really doesn't matter if I
you know there is an infection or not. You treat all patients alike -- as if they are HIV or Hepatitis positive.
If all these precautions are followed, health care workers' risk of contracting blood borne pathogens
must be considered almost zero, in the health-care setting. There is absolutely no need to put on full
isolation gear when providing routine care to a patient with HIV. Greater precautions than necessary
makes it harder for patients to cope with their illness physically and emotionally.
Many of the procedures described above had their emphasis in protecting the healthcare worker.
Sometimes, measures are taken to protect the person with AIDS. Remember, by the time symptoms
appear, the persons CD4 count is falling quite drastically. He is an immunocompromised patient.
Organisms in the environment that a non-infected person can easily handle can cause serious illness for
the AIDS patient. Some concerns include:
Prevent the growth of molds, fungus and bacteria in the refrigerator, on the kitchen and bathroom
floor, tub and shower with the daily use of a good disinfectant (e.g. 1 part bleach to nine parts water.)
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HIV/AIDS: AN UPDATE

Rooms should be well ventilated.

Flush body wastes down the toilet. Double bag tissue and dressings (biohazardous waste).
When cleaning birdcages, fish tanks, or cat litter boxes, people with HIV should wear disposable
gloves and masks, or have someone else do it, because these are sources of serious infections.
Relatives and friends with any infections should stay away.
Items which should not be shared by patients include:
Glass oral and rectal thermometers, and disposable protective sheathes for automated thermometers
Electric and safety razors. These can exchange blood between patients. Used safety razors should
be disposed of in the needle disposal boxes. The patient can bring his own electric razor, but throw it
away if he dies.
Toothbrushes, tweezers and nail clippers.

Question No. 12: In light of the research of healthcare workers who care for HIV positive patients,
which of these precautions seem necessary?
a. Always wear gowns when caring for these patients.
b. Bend and break needles before putting the sheath over the hub of the needle.
c. Wear gloves when handling blood specimens.
d. Put these patients in complete isolation.
Question N. 13: Which is NOT true about the risk of caring for a patient with AIDS?
a. If the needle went through a glove before sticking a healthcare worker, approximately
50% of the blood was removed, which lowered the risk of HIV transmission.
b. Only a small proportion of needle-stick injuries result in infection.
c. Post exposure prophylaxis with anti-retroviral therapy should be started after needle
stick injury any time within the first week after the injury.
d. Suture needles are less likely to transmit HIV than are those used to give an IM injection.
Question No. 14: What is true about the Bragdon vs Abbott case?
a. A health care worker can only refuse to treat a patient with HIV if there is an objective,
scientific basis for concluding that the threat to safety is significant.
b. HIV-infected individuals without symptoms have a wide-spread protection on the state
level.
c. This case supports the American with Disabilities Act (ADA).
d. All of these are true.

Objective NO. 5: Summarize the clinical progression, testing, and treatment

objectives of the patient with HIV.
Clinical Progression from HIV infection to AIDS
HIV creates the possibility for the opportunistic infections and certain forms of cancer to occur.
When these diseases appear, the person has AIDS. The list of opportunistic infections does not include
the common cold; but flu, colds and stress should be avoided as much as possible. AIDS (Acquired
ImmunoDeficiency Syndrome) comes indirectly from a defenseless, viral-destroyed immune system.
There is no cure, as we have nothing that will completely eliminate the virus from the body. There is no
preventative vaccine, and it appears unlikely that we will have one in the foreseeable future. Prevention
of HIV transmission remains our primary objective.
The development and diagnosis of HIV disease, which may progress to AIDS, occurs in stages, but
the stages vary widely. Following infection without treatment, 7 to 10 years pass during which many
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HIV/AIDS: AN UPDATE

(50%) patients have no symptoms. With the use of medication, this period of time is being stretched.
There is hope that with the use of multiple combinations of antiretroviral drugs, the immune system can
remain intact, and the patient will not progress to AIDS. The long-term effects of life-long therapy with
antiretroviral drugs are not known. This requires a relatively early diagnosis of HIV infection, which is not
always possible.
Several experts have put HIV disease into stages. These stages would happen if antiviral therapy
was refused or not available, or the HIV became resistant and nonresponsive to the drug therapies. As
the combination of drugs offered to Americans become more effective, the course of the disease will
change radically. Already the attitude is changing from a life-threatening disease to a chronic disease
that hopefully can be controlled for many years.
No Illness:
This is the beginning asymptomatic stage, which can last for an indeterminate number of years
because of current therapies. Without therapies, this stage lasts from 7 to 10 years on average.
However, the medications required to keep HIV growth limited have concerns. Because there are no
physical symptoms, life continues its normal routines. Psychological symptoms of grief, regret,
depression, etc. often occur. Medical care may involve antiviral drugs, and monitoring of immune
functioning and side effects. The need for constant encouragement to be incredibly faithful to the drug
regime cannot be overlooked. Health care involves emotional support, educational support, education
concerning HIV transmission, and encouragement for life planning tasks such as durable powers of
attorney, decisions regarding child custody, etc.
Discrete Illness:
Diseases and symptoms that do appear, such as weight loss, or mild opportunistic infections, can
be treated and the person returns to a prediagnosis level of functioning. If antiviral drugs have not been
used to this point, now is when they are begun; however, the current approach is to offer treatment as
soon as the disease is diagnosed. In addition, prophylactic drugs for opportunistic infections are often
added to the regimen. The use of anti-viral medications is stretching the time in the first stage, and
delaying the onset of this discrete illness stage and the progression to the next stage.
During this stage, people experience one or more of these symptoms:
a. chronically swollen lymph glands, usually in the neck, armpits, or groin, lasting longer than two weeks,
b. drenching night sweats, unexplained fever or shaking chills lasting several weeks,
c. unexplained weight loss more than 10 pounds in 2 months, with loss of appetite,
d. severe or chronic persistent diarrhea,
e. unexplained persistent fatigue,
f. yeast infections in the mouth, unusual white spots like cottage cheese,
g. unexplained fever lasting more than a week,
h. leg weakness, difficulty climbing stairs,
i. hairy leukoplakia--a precancerous condition which shows white sores in the mouth and a thickening and
overgrowth of mucous membranes of the mouth, tongue or vagina,
j. shingles--a painful viral disease characterized by blisters which develop along a nerve path. It is rarely
seen in persons with healthy immune systems and under 50 years of age,
k. lymphoma--cancer of the lymphatic system. This can be the only clinical sign of altered immunity, and
the first warning sign of AIDS.
The presence of these symptoms warns that something is wrong, but does not indicate for certain
that a person has AIDS. Later symptoms include:
l. pink to purple flat or raised blotches or bumps occurring on or under the skin, the inside of the mouth, the
nose, eyelids, or rectum. Initially they may resemble bruises, but they do not disappear. They are
usually harder than the skin around them. Many of the first manifestations are seen in the skin.
m. persistent, dry cough which lasts too long to be caused by a common respiratory infection, especially if
accompanied by shortness of breath.
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HIV/AIDS: AN UPDATE

Opportunistic infections or Karposi's Sarcoma (defined later) cause symptoms that are specific to
the particular type of infection or cancer. The definition of AIDS involves twenty-six specific clinical
conditions, including pulmonary tuberculosis, recurrent pneumonia and invasive cervical cancer.
Cervical cancer is 8 to 11 times greater in women with HIV. The definition of AIDS also includes those
persons who test HIV positive and who have CD-4 (T-cell) counts below 200/mm3, but who do not have
an AIDS defining opportunistic infection or malignancy. Thus, it is possible (but unusual) to have AIDS
without having symptoms of disease.
Cascade of Illness:
As opportunistic infections begin to compound, the person begins to deal with numbers of chronic
conditions that may be controlled, but not cured. Few of the viral, parasitic or fungal opportunistic
infections complicating HIV can be cured with our current drugs. There will be multiple symptoms,
multiple drugs and drug side effects, multiple doctors visits and multiple bills.
The severity of symptoms, suddenness of onset, and response to treatment vary from person to
person. It is not known why one person develops an opportunistic infection and another Karposi's
Sarcoma; why one's infection is mild and another's severe; why one person has no warning signs and
another is ill for years before being diagnosed with AIDS; why one can go back to work and another is
too weak. One theory is that the disease syndrome varies due to the resistance each individual has.
End of Life:
This stage involves keeping the patient as comfortable as possible and providing the necessary
support. Some choose to face death in a hospice situation; some choose to stay in a home environment.
Many do not fear death as much as they fear the process of dying, the loss of bodily functioning, the loss
of control, and the anticipation of increasing discomfort and pain.

Diagnostic Testing
Tests can detect the antibody to HIV, and a positive test may mean that the person has been
exposed. It does not mean the person will necessarily develop AIDS. The general standard followed at
this time is that if a person remains seronegative for at least 6 months after exposure, their risk of
infection is very low. Typically, the time between initial contact with the virus and seroconversion (the
time when antibodies develop against HIV) may be from two weeks to six months, and rarely perhaps as
long as 3-4 years. The majorities will seroconvert within 6 to 12 weeks. It is important here to emphasize
that ONCE INFECTED, EVEN IF IT NEVER ACTIVATES, THE VIRUS CAN BE TRANSMITTED
THROUGH BODY FLUIDS AND INFECT OTHERS, FOR AS LONG AS LIFE. "Walking wounded" is the
name given to the people walking around with sero-positive antibodies, and infectious, many who don't
even know they are positive.
The screening test for positive antibody is the ELISA ("Enzyme-Linked Immuno Sorbent Assay") or
also called the EIA (Enzyme Immunoassay) test. The results are either reactive (positive) or nonreactive (negative), with reactive test results given by varying titer. The low titer has nothing to do with
how infectious a person is, nor does it lower the chances of developing into AIDS. The test does give
false positives, and negatives, even though it is sensitive and specific. Because of its sensitivity, half to
two-thirds of any given sample of blood donors testing positive, may be false. Over 60 factors can cause
false-positives, including many other infectious diseases and even the flu. (Klotter, 2006,) All samples that
test positive are retested with ELISA. If still positive, then a more expensive test, the "Western Blot",
known as the "gold standard" for final confirmation of HIV, is used.
The Western Blot uses a series of proteins that are believed to be unique to HIV, impregnated on a
strip. If the antibodies in the patients blood stick to these proteins, the person is considered positive for
HIV. But controversy surrounding the accuracy of the tests continues. For example, one protein used
most often (gp24) has been found in people with generalized warts, T-cell lymphoma and multiple
sclerosis. (ibid.) False-positives are not common, but they do become more common if the person is
seriously ill for other reasons. This brings into question the accuracy of the statistics. For 1997, among
the total of 60,000 cases diagnosed with AIDS, no fewer than 47,000 did not manifest the opportunistic
infections that had been the AIDS-defining conditions in the early 1980s; in particular, more than 36,000
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HIV/AIDS: AN UPDATE

had been diagnosed solely on the basis of a positive HIV test and low counts of immune-system cells
and in the absence of any symptoms of illness. (Bauer, 2008) (Serious illnesses other than HIV can drop
the CD4 count). This is the testing that we have available. The controversies only call our physicians to
carefully consider the impact of serious illness on the reliability of the tests.
The FDA has approved a few rapid tests for use in clinics, counseling centers and community
health centers. OraQuick rapid antibody test results are available in 20 minutes and are 99.6%
accurate. Single-use Diagnostic System for HIV-1 (SUDS) uses plasma instead of whole blood, and so
can be done with a finger stick. Uni-Gold Recombigen rapid test can be used with either whole blood or
plasma, with results in 10 minutes. The ability to get test results in the initial visit is important. The
Center for Disease Control and Prevention estimated that in 2002, some 2 million anonymous HIV tests
were processed, but an estimated 31% of patients didnt return 1 week after testing to obtain test results
and counseling. (Kenny, 2004) Immediate results mean immediate counseling, early treatment access
and prompt education about how to avoid transmitting HIV.
At home tests involve antibody formation as well. The OraSure HIV-1 Antibody Testing System
tests oral mucosa instead of blood. An over-the-counter test approved by the FDA is the Home Access
Express HIV-1 Test System. This test uses a finger stick for blood. Each test comes with a confidential
personal identification number. After the test is sent to the lab, a toll-free call will provide the results for
that numbers test. The tests are highly accurate. The concern is that if a positive test result is given
without sufficient pre and post-testing counseling, the patient might not receive the mental, emotional,
and physical resource assistance needed.
All persons who test positive, whether they are symptom free or ill, must be considered to be
potentially infectious to others, by sexual transmission, by sharing of drug injection equipment, by
childbearing, or by donation of blood, semen, or organs.
Courts can order HIV testing, but only in unusual or specific circumstances. Each state determines
what these circumstances are, so there are variations in rights from state to state. With a court order,
individual consent is not required. In Florida, an individual accused of rape must be tested. And
whenever a physician determines that a healthcare worker has had "significant exposure", the source's
blood sample can be tested for HIV without his permission. If no sample is available and the source
refuses to be tested, a court order for mandatory testing can be obtained. Before this is done, the worker
must consent for testing of the HIV. Specific criteria must be met throughout the process. In Florida,
pregnant women are strongly encouraged to be counseled and tested. If the woman refuses testing,
efforts must be made to obtain a written statement of that refusal, and the statement is included in her
permanent record.
Voluntary testing can be confidential or anonymous. Confidential testing keeps the results
available to only health care authorities with a "need to know". Mandatory reporting of positive status to
governmental health authorities is becoming more prevalent. Mandatory reporting of AIDS to the CDC
has been in existence since the disease became widespread. But, mandatory reporting of HIV infection
has not. Florida has had mandatory reporting of both positive HIV status and AIDS since 1997.
There are still Alternative Test Sites that can be used to protect a person's anonymity. Testing,
confidential counseling and partner notification services are all available. These designated places allow
a person to be tested without providing name, address, social security numbers or any other official
identification numbers. To obtain an anonymous test, call the AIDS hotline number for each state
All testing should provide pre-test counseling, post-test counseling, and follow-up counseling. Pretest information does not have to be extensive but may include: preventative teaching, the meaning of
the HIV test, the fact that positive results are confidentially reported to the health department, the
procedures, the modes of HIV transmission, the need for the test, and psychosocial support. Since
testing recommendations now are opt-out instead of opt-in as in the past, it is thought that less
extensive counseling may reduce anxiety. Post-test counseling includes test results, reinforced
preventative education, and appropriate referrals needed. Extensive efforts should be made to
encourage the HIV positive patient to disclose his HIV status to all sexual partners or those at risk due to
blood contact. Follow-up information includes reinforced education, and focusing of individual needs,
adjustments, and support of any changes in risky behaviors.
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HIV/AIDS: AN UPDATE

Confidentiality is very important. The test results can only be given to the person being tested, his
legal representative, or foster or adoptive parents. Specific written permission has to be obtained for
release of information, and even then, only those with a clear "need to know" can have access to this
information, whether the test is positive or negative. Healthcare providers consulting together or with
health care facilities can have access to the information if it is necessary for the diagnosis or treatment of
the patient. The Department of Health and Rehabilitative Services has access to statistical AIDS/HIV
information. Those providers that receive, process and distribute donated blood, plasma, organs, semen,
etc. can assure those materials are HIV free. Authorized researchers of HIV/AIDS have access to limited
information. Medical records that contain HIV information can only be released when specifically
authorized by the patient in writing, or there is a court order to do so, (a stricter standard than required for
the release of general medical records.)
Once the patient is diagnosed as HIV positive, the activity of the infection and effectiveness of
therapy is monitored through the viral load assay tests. These antigen-based tests measure the
presence of HIV in the plasma. One common one measures the numbers of HIV RNA copies in the
plasma. Current treatment guidelines aim to maintain the viral load below 500 copies per ml. Keeping
the load as low as possible seems to provide more protection from drug resistance, but it is sometimes
difficult to keep a patient at this very low level. It is estimated that 40% of patients taking antiretroviral
treatment have viral loads less than 400 copies/ml. (Bowers, 110). Often the patient will have results that
read, Undetectable. This means the test is not able to find virus in the plasma. It does not mean that
there is no virus in the body. The test can read as high as 100,000,000 copies/ml.
The patients response to treatment and progression of disease is often monitored with a CD4
count and percentage. This is the number of helper T-cells in the circulating fluids. Normal is 600 to
1200 cells / mm3. The percentage is greater than 40%. A patient with 18% T4cells and only 172 cells
counted is very likely to develop opportunistic infections. The degree of risk for certain infections can be
estimated with the CD4 count. The CD4 cell count tells you roughly where the patient is at the moment;
the HIV RNA level indicates how rapidly the disease is progressing.
ANTIVIRAL DRUGS
Much has been learned about the battle against viruses, especially HIV. There is an increasing
arsenal of powerful antiretroviral drugs available that have stalled infectious growth for many. More than
30 individual antiretroviral agents plus fixed-dose drug combinations have been approved by the FDA.
Current antiretroviral therapy involves at least two, and usually three drugs that attack the virus at
different points in its life cycle. The guidelines issued by the International AIDS SocietyUSA Panel
recommend initial treatment with two NRTIs, plus either the NNRTI drug, efavirenz, or a ritonavir-boosted
PI. (Nguyen, 2009) The combination approach is called HAART: Highly active antiretroviral therapy.
Ttreatment should begin before the CD4 count falls below 350/mcL or for all patients with plasma HIV
RNA concentrations greater than 5000, to 10,000 copies/ml regardless of the CD4 count. Management
of HIV is a challenge, because of long-term toxicities, adverse drug effects, HAART failures, and the
nature of the infection. The drug categories are summarized below.
NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTIs)
An early step of the viral cycle is to synthesize proviral DNA from RNA. To accomplish this the viral
enzyme, reverse transcriptase, is needed. In 1985, the first drug that interferes with reverse
transcriptase was released: zidovudine (AZT, Retrovir). Examples of other drugs of this same family
soon followed -- didanosine (ddl) (Videx), dideoxycytodine (ddC) (Zalcitabine) (Hivid), (stavudine) (Zerit),
and 3TC, (Epivir) (lamivudine). Epivir is used in combination with AZT. With the advent of 3TC and AZT,
the value of combination therapy began to become obvious. The most popular of combination drugs
within the nucleoside analogues is AZT with 3TC. Combivir is lamivudine and zidovudine in one pill. A
newer drug from this same classification of drugs is abacavir (Ziagen). Ziagen is combined with
zidovudine and lamivudine in one pill called Trizivir. Ziagen is combined with lamivudine in a pill called
Epzicom. Another drug, Viread (tenofovir), has the advantage of only once per day dosing. One of the
newest of this family is emtricitabine (Emtriva, FTC). It is combined with tenofovir in Truvada, which is a
preferred combination for non-resistant patients with good renal status.
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HIV/AIDS: AN UPDATE

NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTIS)

These drugs block the same viral enzyme, reverse transcriptase, but with a different mechanism.
These are: Viramune (nevirapine), Rescriptor (delavirdine) (not widely recommended), and Sustiva
(efavirenz). The hope is that combination therapy with this class will allow the sparing of protease
inhibitors (next classification) for more serious cases. Etravirine is a new NNRTI recently approved to be
used against resistance strains of HIV. It is not used for initial therapy.
These drugs use the P450 isoenzyme system in the liver, so there are multiple important drug
interactions to monitor. It is thought that when two NRTIs are mixed with an NNRTI (instead of a
protease inhibitor) that there are fewer chronic side effects with an effective approach. However, just a
single mutation in the reverse transcriptase can produce viral resistance, and these drugs will fail to
work. When they do work, they use less pills, and are better tolerated.
PROTEASE INHIBITORS (PIs)
Protease is another enzyme HIV uses to survive. It interferes in the late stages of viral replication.
The function of protease is to split a larger viral precursor protein into three smaller proteins, which are
necessary for the replication of the virus. When protease is inhibited, a noninfectious virus results.
These drugs are able to reach infected lymphatic tissues, a place the virus has been able to hide before.
They use the P450 isoenzyme system for metabolism, so multiple important drug interactions require
careful monitoring. Regimens that contain PIs are difficult to adhere to because of dosing frequency, food
restrictions, and side effects. But they are very powerful drugs. The PIs are: Fortovase (saquinavir),
Norvir (ritonavir), Crixivan (indinavir), Viracept (nelfinavir), Agenerase (amprenavir), Reyataz
(atazanavir), Kaleta (a combination of lopinavir and ritonavir), fosamprenavir (Lexiva, 908), and Prezista
(darunavir). Ritonavir slows the breakdown of other PIs in the body, and increases the concentration of
the PIs. Giving Ritonavir with another PI is called Ritonavir-boosted therapy.
FUSION INHIBITOR:
Currently only one drug is in this family: enfuvirtide (Fuzeon, T-20). Fuzeon interferes with the entry
of HIV into cells by inhibiting the fusion the virus to the gp41 receptor site on the cellular membrane. It is
given only as an injectable twice daily.
The most recent drug advancement was the approval of Atripla in 2006. This is three widely used
antiretroviral drugs (Sustiva, Emtriva, and Viread) in a single tablet. One pill taken once a day makes
compliance much easier.
CHEMOKINE CORECEPTOR 5 (CCR5)
This new class of drugs acts by blocking HIV entry into body cells at the CCR5 coreceptor. It only
helps CCR5-tropic HIV strains, so testing should be done to determine the strain prior to the use of this
drug. The only drug of this class is maraviroc, which is used in combination with the other drug families.
INTEGRASE INHIBITOR
Integrase is a viral enzyme used to insert the viral DNA into the cells nucleus. Raltegravir, the first
drug of this new family, inhibits this enzyme. This drug does not use the P450 isoenzyme system for
metabolism, reducing drug interactions.
Side effects are troublesome with these drugs. With all antiretroviral drugs, strict schedules and
dietary restrictions must be followed. There are numerous drug interactions to consider, which makes
combined drug therapy very complex. For example, certain pills can't be taken with analgesics,
antidepressants, or certain drugs to help nausea. The patient MUST be encouraged to follow his total
drug regimen completely and totally. Missing doses is very dangerous, and even mistiming doses can
create problems. The proportion who maintain antiretroviral HIV therapy ranges from 25% to 85%. In
one national sample, 57% of subjects maintained antiretroviral treatment regimens at a 100% level over
the 7 days before the interview. (Noring, 692) "In one survey, the proportion of patients with undetectable
HIV RNA levels was twice as high among patients who reported 100% adherence compared to those
who reported taking less than 80% of prescribed doses in the previous 3 days. In another study, among
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HIV/AIDS: AN UPDATE

patients taking less than 85% of prescribed doses, the probability of virologic failure was 83%. (Porche,
114) The reasons given for not taking their medication as prescribed include: side effects, conflicts with
daily routines, food scheduling difficulties, forgetting doses, numbers of pills, psychosocial factors such
as stress or feeling good or bad news, pharmacy refills, and needs for sleep or appetite, etc.
The most limiting problem is drug resistance, which is far more of a risk if the patient does not
follow the prescribed drug regime. In the case of lamivudine and the nonnucleoside RT inhibitors, it may
take only a short period of inadequate dosing for an entire useful class of drugs to be eliminated from
future consideration. The challenges include extensive patient education and support, as the patient
struggles with a highly complex drug regime. The patient must realize the limitations posed by
developing drug resistance. If the drug combinations can effectively suppress HIV, the drug resistance
can certainly be delayed, and maybe even prevented. This will allow the patient many more years of
productive life. Teaching can be enhanced with the following strategies:
Create a medication plan that is easy-to-read.
Discuss the plan with each visit to the doctor, constantly adding information and educating the
patient fully and completely.
Tailor the medication regime to the patient's lifestyle, and "connect" daily activities with medication
timing. Suggest timers, alarms, checklists and calendars to help.
Assign a surrogate to help maintain compliancy with medications, a form of supervised therapy to
act as reminders for the patient to take his pills.
Identify any issues to reasons that might interfere or impact the adherence to the planned medication
therapy. Privacy to take the pills might be a concern.
Keep follow-up communication open with telephone contact, reminder cards and doctor's visits.
The primary socio-economic limitation is cost. Most anti-retroviral regimes, although strong enough
to control the virus and return the patient to an active life, are expensive. For some, these costs are
prohibitive, and too few have the financial resources or insurance coverage to pay for this treatment.
Combination therapy may cost $20,000 per year. In response, congress has passed the AIDS Drug
Assistance Program to help people who would otherwise not be able to afford effective or treatment.
Most of the money to pay for these programs comes from the Ryan White Care Act. Each state's
process varies slightly, but generally, a person is able to receive financial help if he earns less than
$44,000 a year, and has less than $25,000 in assets not including his home or car. Sadly, there are still
long wait lists for these programs. For phone numbers to your states ADAP call the Access Project at
800-734-7104. Coordinating care for the HIV/AIDS patient involves knowledge of a wide variety of
federal, state and local programs to provide a variety of assistance. There are many other organizations
providing assistance besides the American with Disabilities Act and the AID Drug Assistance Program:
CDC National AIDS Hotline: 800-342-AIDS
HIV/AIDS Treatment Information Services: 800-448-0440
National AIDS Fund: 202-408-4848
National Association of People with AIDS: 202-898-0414
State hotline numbers include:
Alabama (in state) 800-478-2437
Southern California 800-922-2437 (TTY/TTD) 888-225-AIDS
Northern California 800-367-2437 (TTY/TTD) 415-864-6606
Florida (in state) 800-352-AIDS (English) or 800-545-SIDA (Spanish)
Iowa (in state) 800-445-2437
Kentucky (in state) 800-840-2865*(TTY/TTD) 502-564-6539

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HIV/AIDS: AN UPDATE

An excellent web site to help you find state by state resources is http://hivinsite.ucsf.edu/ Other
excellent
web
sites
are:
JAMA
HIV/AIDS
Information
Center
http://www.amsassn.org/special/hiv/hivhome.htm CDC National AIDS Clearinghouse http://www.cdcnac.org/ National
Library of Medicine Internet Grateful Med http://lgm.nlm.nih.gov/

Question No. 15: Which of these is NOT true of an AIDS diagnosis?

a. A combination fromf 26 specific conditions occurs.
b. It doesnt usually happen within the first 7 to 10 years of the infection.
c. Those who test positive for HIV and who have a CD4 count below 200 mm3 receive the
diagnosis.
d. When the person tests positive on the ELISA, this is diagnosed as AIDS.
Question No. 16: Which statement is true about the tests used to diagnose HIV?
a. Antibodies appear immediately, so the ELISA test will usually be positive within the first
week of becoming infected.
b. A positive reading means the person will definitely develop AIDS someday.
c. Both the ELISA and the Western Blot tests have significant false-positive reactions,
especially if the person is seriously ill for other reasons.
d. All of these are true.
Question No. 17: Why is taking the drugs as prescribed faithfully, every day, so important?
a. Because drug resistance can develop, which means the drugs lose their effectiveness.
b. Because missing doses means there is an increased risk of serious side effects.
c. Because the patient may develop a bad habit.
d. All of these are significant reasons.
Question No. 18: Because the goal is to prevent AIDS by controlling the damaged caused by HIV,
people are often started on anti-retroviral drugs as soon as the diagnosis is made. This
means:
a. That people are taking multiple drugs with significant side effects during the no illness
stage of the disease, in which they have no disease symptoms but lots of drug side effects..
b. That prophylactic drugs used to prevent opportunistic infection are often added to the
early regime as well.
c. That there is need for constant encouragement to stay with the drug regime.
d. All of these are true.
Question No. 19: Which is NOT true about drug therapy for HIV disease?
a. Management with drugs is a challenge because of long-term toxicities, drug side effects,
and drug failures.
b. The current approach involves at least two, and usually three anti-retroviral drugs from
different drug categories.
c. The drugs attack the virus at different points in the life cyclefor example, blocking the
enzyme the virus needs to synthesize proviral DNA from its RNA.
d. The International AIDS Society recommends using just one anti-retroviral drug initially.

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HIV/AIDS: AN UPDATE

Objective No. 6: Recognize the state's attempt to prevent discrimination and

provide confidentiality to all.
Obviously, discrimination against those with AIDS has happened in the past and even with legal
restrictions, is still happening. People who test HIV positive do not lose their constitutional rights. The
use of tests must be informed, voluntary and confidential. The person being tested must be informed in a
manner he can understand, and must include information about the test, about the prevention and
treatment of the disease, and about the confidential nature of the testing.
Would mandatory testing solve any of these problems? From a legal point of view, the failure to
warn those who may become infected with HIV from exposure to a HIV-positive persons blood is likely to
be considered negligent. Conversely, discrimination against those infected with HIV is unjust. The
balance under which we have labored for several years protects the privacy of individuals and prevents
discrimination. Self-protection is stressed rather than self-disclosure. This makes sense when you
consider that some at risk people do not even seek testing and some lie about their HIV status. Each
person needs to learn to be responsible for his or her own health.
Increased support for mandatory testing of pregnant women has appeared since it has become
known that perinatal transmission of HIV can be blocked by 2/3 with AZT therapy. How this can be
accomplished without discrimination to the woman is still an argument. The mandatory debate, pretty
much a closed issue for several years, is now gathering new steam. In February 1997, New York was
the first state to mandate the screening of all newborns for HIV, and to disclose the test results to the
mothers. Most states followed suit. The mothers are strongly encouraged to consent to testing so that
treatment can begin prenatally.

Question No. 20: True or False: Currently our laws stress self-disclosure (mandatory testing) over
self-protection (preventing discrimination.)
a. True.
b. False.

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HIV/AIDS: AN UPDATE

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Foley, Mary, Needlestick Safety and Prevention, Nevada RNformation, February 2005.
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Name _____________________________________________
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License No.
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__________

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1. (a) (b) )

11. (a) (b) (c) (d)

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12. (a) (b) (c) (d)

3. (a) (b) (c) (d)

13. (a) (b) (c) (d)

4. (a) (b) )

14. (a) (b) (c) (d)

5. (a) (b)

15. (a) (b) (c) (d)

6. (a) (b) (c) (d)

16. (a) (b) (c) (d)

7. (a) (b) (c) (d)

17. (a) (b) (c) (d)

8. (a) (b)

18. (a) (b) (c) (d)

9. (a) (b) (c) (d)

19. (a) (b) (c) (d)

10. (a) (b)

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