The HIV/AIDS Hour

Perhaps you are reading this program on the HIV/AIDS (human immunodeficiency virus / acquired immune deficiency syndrome) because you, or somebody you love, has been affected by the HIV/AIDS virus. HIV is a personal disease affecting us all--as a species confronted with a global epidemic.

HIV/AIDS presents such a serious, unique danger to the public health and welfare that President Clinton set a national goal in 1997 to develop an HIV vaccine within ten years. Remarkable scientific research is currently in progress, with exciting advances toward developing an immunization against the retrovirus responsible for this virus. However, to date, there is still no approved vaccination to control HIV. Advanced medical treatments are able to slow the growth of HIV and to cure some illnesses associated with AIDS, but there is no medicinal cure for HIV. More treatment and preventive health care options are available with early detection of the disease, but a person may be HIV positive and in the communicative state for years prior to showing any obvious signs or symptoms. Public fears and state medical costs have both been raised, secondary to the unique methods of transmission of HIV and its inevitably fatal course.

History

AIDS was first mistakenly assumed to be an illness related to the gay lifestyle in the early 1980's, when groups of homosexual men exhibited similar symptoms of immune disorders. For this reason, the disease was first named GRIDS, Gay-Related Immune Deficiency Syndrome. The Center for Disease Control and Prevention (CDC) gathered increasing amounts of information, and discovered the same disease was being reported in other populations, including Haitians, injectable drug abusers, blood products/transfusion recipients, prostitutes and children. Shortly thereafter, the disease was named AIDS, or Acquired Immune Deficiency Syndrome.

Coincidentally, two men, Robert Gallo of the United States and Luc Montagnier of France, unbeknownst to each other, both identified the AIDS virus in 1984. Montagnier named the virus HTLV-III, and Gallo named the virus LAV. After a short scientific shuffle, the virus was named HIV, or human immunodeficiency virus, to provide standardization.

Modes of Transmission

For transmission of the ever-evolving HIV, there must be a certain quantity of the virus and a portal of entry. The most common method of transmission is sexual contact that includes the blood-tainted semen or vaginal secretions of an infected partner. HIV may also be transmitted with blood to blood contact, such as with transfused contaminated blood products, sharing injectable drug supplies, or occupational exposure. Another mode of transmission is from mother to child in utero, during labor and delivery, or during breast-feeding.

HIV may be present in these human body fluids: blood, semen, saliva, tears, breast milk, vaginal secretions, urine, and cerebrospinal, amniotic, pericardial, pleural, synovial and peritoneal fluids. Unfixed human tissues and organs are potentially infectious, as well as HIV-containing cells or tissue cultures.

Susceptibility to contacting HIV depends on the dosage of virus, the route the virus enters, and the individual's immune status and genetic predisposition. Certain body fluids, such as blood, contain higher concentrations of the virus, while others, including vaginal secretions and semen, contain lesser quantities. All are potentially infectious. Blood-free saliva, sweat, and tears do not have adequate amounts of the virus to be infectious. In contrast, the blood of a person with end stage AIDS contains high concentrations of HIV, or elevated viral loads.

Contagion from casual contact is not supported by any scientific evidence. One may hug, hold hands with, or simply provide care for the person with HIV/AIDS without fear of contracting HIV.

Statistics

An estimated 50 million people, worldwide, have been infected with HIV as of the year 2000. As many as 16,000 people are infected daily. Greater than 90% of these infected people live in developing countries, especially Asia and Africa. Scientists estimate that 50% of the people infected with HIV will develop AIDS within 10 years; though this time period varies, depending on a multitude of factors, such as the person's health-related behaviors and health status.

The total number of AIDS cases reported to the Center of Disease Control (CDC) by the end of the last millennium in the United States was 733,374 persons, which includes 604,843 males and 119,813 females in the adult and adolescent category of HIV cases, and 8718 cases in children under age 13. Health Care Workers (HCW) comprise 22,218 of the total reported AIDS cases (the largest proportion is nurses, and the smallest, surgeons). The HCW category has 56 documented occupational exposures, and 23 of these are nurses. Coincidentally, the majority of AIDS deaths among HCW are nurses. (www.cdc.gov/hiv/pubs/facts/hewsurv.htm)

From 1985 to 1998, AIDS cases among adolescent and adult women more than tripled. Though African American and Hispanic women represent only one fourth of all American women, together they account for more than three fourths of the AIDS cases. Ethnically, the African American community has been the most devastated by HIV and AIDS. Though HIV/AIDS is the fifth leading cause of death for the general population of North Americans, ages 25 - 44, it is the leading cause of death for the African-American community in this age group. Researchers estimate that 1 in 50 African American men, and 1 in 160 African American women are HIV positive (www.cdc.gov/hiv/pubs/facts/afam.htm). For the total United States population, it is estimated that fully one half of all new HIV infections occur among people under 25, and the majority of these young people are infected sexually.

Vaccine Research

Over the last decade, 34 potential HIV vaccines have been tested on small groups of healthy, low-risk, uninfected volunteers (each group consisting of 20-80 people) to determine the potential vaccines' safety, optimal dosage and best immunization schedule. Of these 34 potential vaccines, 3 were considered successful enough to continue their experimentation on larger groups (each consisting of several hundred people). The researchers found these potential vaccines to be safe and well tolerated; nearly all have produced varying degrees of HIV-specific immune responses. The knowledge gained from these experiments led to the first large-scale vaccine trial in the United States in June 1998. There are a variety of social concerns related to the HIV vaccine research. As an example, the subjects who receive the HIV immunization may develop vaccine-induced HIV antibodies, and because HIV antibody testing is sometimes a requirement for accessing insurance, medical care, and employment, these research participants may be exposed to discrimination based on antibody test results. Though the HIV vaccine research has made advances, these first HIV vaccines do not always produce the intended result. Simply stated, the HIV vaccinations on trial do not always prevent HIV contagion.

Prevention

At present, education is our single best prevention of HIV transmission. The public must be informed how HIV is transmitted and the methods of prevention. Courses must be designed to reach all ethnic groups, especially targeting the African American and non-English speaking populations. Community programs must reach people who lack educational and economic opportunity in settings such as homeless shelters and detention centers. Educational programs to target prostitutes must be implemented; though it may take place in jail since prostitution is illegal in the United States. Some women have sexual partners who are unwilling to use condoms--in which case, instruction on the usage of the internal female condom and better microbicides may reduce her risk of contracting the virus. The CDC is investigating prevention effectiveness of the female condom and researching better microbicides to kill HIV. In many cultures, the woman has low social status and is unable to protect herself. Promote sexual equality to reduce women's risk of contracting HIV.

Adolescents are at very high risk of sexual contagion, and though we may hope and/or demand of the adolescent population to remain sexually celibate, celibacy is not always realistic. Did your parents tell you to remain celibate until marriage? And did you follow these orders? Do you think your teenagers will be able to control their sexuality? Unfortunately, in these times, a teenager's sexuality is a life-threatening issue. Many studies have been done to learn of the adolescent's perception of the AIDS epidemic, and research reveals that sex education programs teaching the adolescents abstinence and usage of condoms has curbed risky behavior that could lead to AIDS. In 1993, the World Health Organization (WHO) conducted an extensive review of the scientific literature on sex and AIDS, and reported conclusively that sex education does not lead to sexual behavior. Sex education delays or decreases sexual activity; and safer sex is practiced among those who were already sexually active. In September 1995, the Office of Technology Assessment (OTA) conducted research on the effectiveness of prevention programs and came to the same conclusion as the WHO: Sex education delays or decreases sexual activity; and safer sex is practiced among those who were already sexually active. Both reports indicate that adolescents who have already experienced sex before receiving HIV/AIDS education are more likely to use condoms after the HIV/AIDS education than to abstain from any future sexual activity. Possession of a condom does not provoke sexual activity, but it will prevent HIV if used correctly. Instructions on proper usage of the condom, and how to be assertive about demanding their use will promote condom compliance, thereby reducing HIV transmission. Of utmost importance are the early, clear communications between parents and young people about sexual relations, and the continued reinforcement of HIV/AIDS knowledge--reminding the importance of avoiding unsafe sex at all costs. A single message does not work! Just as a parent may have to remind a teenager to pick up their wet towels in the bathroom, or their clothes in the bedroom, or to do their homework, the knowledge of HIV/AIDS must be reinforced on a regular basis. "Unsafe sex may cause a painfully lingering, premature death," is a fairly accurate message that a parent may occasionally remind a teenager. Display magazine and newspaper articles, indicating the occurrence of AIDS in the adolescent group, in a place where the teenager at risk will frequently view them--such as on the refrigerator.

Prevention of HIV transmission for injectable drug abusers includes substitution strategies, such as methadone drug replacement, and access to clean needles. Providing syringes without a prescription does not increase the use of illegal drugs, but it does reduce the risk of needle sharing and of street purchases of contaminated needles. For those unable to obtain clean syringes, or who insist on sharing needles, teach the necessity to clean their "works" with household bleach before and after each usage with this method: Fill the syringe with clean water and empty; next fill the syringe with bleach (leave in syringe for at least 30 seconds) and empty, then twice fill with water and empty. Also important in this population, safe-sex education must be provided for the women who may be trading sex for drugs. Until our government implements better strategies for integrating these groups into mainstream healthcare, it will remain difficult to care for and educate them.

Though all donated blood is screened for HIV since 1985, there remains a small risk of obtaining HIV from a blood transfusion. In the United States, this risk is approximately two cases of HIV per one million units transfused. The risk of contacting hepatitis from a blood transfusion is much greater (8X) than HIV. Encouraging persons to donate autologous blood prior to elective surgery, or returning the patient's blood with cell salvage processing are two options to reduce the necessity of injecting foreign blood products.

Infection Control Procedures

Statistics blatantly indicate that nurses have the highest incidence of occupational exposure to HIV among the Health Care Workers (HCW). The majority of transmissions occur with percutaneous injuries, such as from a needle stick. There are fewer cases of mucocutaneous exposure, or being exposed to the virus through the mucous membranes or skin. Important factors that increase the risk of seroconversion after exposure are the concentration of HIV in the blood or body fluid, the amount of blood or body fluid exposed to, and the status of the exposed person's underlying health. As an example, an overworked nurse, who sticks herself with a syringe of blood immediately removed from a patient with end stage AIDS, would be at very high risk of contagion. This nurse must report the incident to her supervisor/employer as a "significant exposure," and then follow the necessary steps to protect herself.

UNIVERSAL PRECAUTIONS REMAINS THE PRIMARY MEANS OF PREVENTING OCCUPATIONAL EXPOSURE TO HIV. Universal Precaution is the assumption that the blood and body fluids from all patients are potentially infectious. Gloves must be worn whenever anticipating contact with blood and body fluids (with the exception of blood-free perspiration). Though it may be easier to perform venipuncture, ABGs or IV starts without gloves, don't take chances. Palpate the vein or artery; mark it for easy locating, then glove up. Restrain the proposed extremity if there is a risk of jerking or thrashing during the procedure to prevent the bloody needle from accidentally returning in your direction. Hand washing must occur before and after removing the gloves. Discard the used gloves into the designated contaminated items container. Cover any cuts or abrasions on your hands with an effective viral and bacterial barrier dressing that is waterproof and breathes. Water resistant gowns, masks and eye protection must be worn if there exists potential for blood splashes or flying body fluids, such as may occur during the following instances: amniotic fluid during childbirth; pulmonary secretions from an endotrachial tube during intubation, extubation or suctioning; or the vomitus and bloody secretions during the insertion of a nasogastric tube. You are responsible for protecting yourself.

Extreme caution must be taken with sharps--both during usage and disposal. Beware of sharps containers that may be full or improperly used. Never resheath needles; if you are obsessed to resheath for whatever compulsive reason, use the one hand method of picking up the sheath with the needle, and don't ever place your other hand near the resheathed needle. However, the bottom line is "Never resheath needles!" Be cautious when cleaning used procedure trays--inconsiderate healthcare professionals may leave contaminated sharps jutting outward or hidden within gauze. When collecting blood samples for the lab, bring along a tray with the small, sharps container for immediate disposal of the bloody sharp. Many health care facilities are now using the "resheathable needles" (the sheath snaps back over the needle after use) to reduce their employees' risk of being stuck with a contaminated needle. Be sure to be thoroughly oriented to all new equipment before using.

In the event you are stuck with a contaminated sharp, you will no doubt feel very light-headed from the stress of wondering if you may die from this error. First provide care to the puncture site by washing well with antimicrobial soap and running water; some suggest bleeding the wound well. Don't pour bleach over puncture site. If mucous membrane is splashed with infected fluids, run water over affected site until clear of contaminants. Follow your institution's procedure for reporting, then follow through with the incident, which may mean HIV blood testing at various intervals and/or following the medication post-exposure prophylaxis (PEP). CDC has issued guidelines for the management of the health care worker's exposure to HIV; their recommendations for PEP includes the following statement: “Theoretically, initiation of antiretroviral PEP soon after exposure may prevent or inhibit systemic infection by limiting the proliferation of virus in the initial target cells or lymph nodes.” The CDC's recommended PEP is a four week program packed with side effects and contraindications. Prepare yourself in advance by reading current literature on PEP, so you won't have to comprehend difficult literature in the dazed rush of post sharp stick. The following link leads to an informative PEP article: http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/00052722.htm. Of particular interest are the algorhythms at the end of the linked article, which attempt to simplify the PEP decision-making process.

Signs and Symptoms of AIDS

The signs and symptoms of AIDS are varied and similar to a lot of other illnesses. Many people do not demonstrate any symptoms for quite a few years. The following is a list of possible warning signs of HIV infection: dry cough, profound and unexplained fatigue, rapid weight loss, swollen lymph glands in the armpits, groin, or neck, recurring fever or profuse night sweats, pneumonia, diarrhea that lasts for more than a week, memory loss, depression, and other neurological disorders, white spots or unusual blemishes on the tongue, in the mouth, or in the throat, and/or red, brown, pink, or purplish blotches on or under the skin or inside the mouth, nose, or eyelids. Once again, these symptoms may be caused by other infections. No one should assume HIV infection based only on these signs and symptoms. In order to determine if HIV is present, one must be screen tested for HIV.

Screen Testing for HIV

The enzyme immunoassay (EIA) is the standard screening test for HIV in the USA, and world wide. To perform the EIA, a blood sample is drawn, sent to a lab, and the results are available within several days to several weeks (depending on the efficiency of the lab). A negative screening test means a person is not infected with HIV, and does not require further testing. A positive screening test means the person needs further testing. A positive EIA is repeated, and when the results are again positive, another test known as the Western blot or immunofluorescence assay (IFA) is performed to confirm the diagnosis of HIV.

A rapid test known as the Single Use Diagnostic System for HIV-1 (SUDS) has been licensed by the Food and Drug Administration. This system produces HIV-1 test results in 5 to 30 minutes. The rapid HIV test is easier to use, produces results more quickly than the EIA, and the sensitivity and specificity of the rapid HIV test are just as good as those of the EIA. The SUDS is a more efficient system for several reasons. When using the EIA method, two patient visits are required--the CDC found that 61% of those tested never returned for the second visit after the EIA to learn of their test results (1996, Dr. Paul Farnham). Because a single visit is required with the SUDS system, more people learn of their HIV results. In addition, the expensive field visits made to search for the subject are no longer necessary. Just as with the EIA, a reactive (positive) SUDS test result must be confirmed. The persons tested can be advised immediately of their screening test result, and counseled on HIV prevention and transmission. When appropriate, an appointment is made for the return visit for a confirmatory test result. A negative SUDS result is always negative, unless the subject has been tested before the antibodies have formed. The average time between infection and the development of detectable antibodies is 25 days, so the individual may choose to repeat the test at a later time for confirmation. There has been one genetically confirmed case of HIV antibodies making their appearance a full year after initial contagion, according to a CDC report.

All HIV antibody tests performed on an infant less than 15 months of age may merely reflect the mother's HIV status, secondary to the antibodies being transferred from the mother to the baby. Until the maternal antibodies disappear, only specific virus detection tests can determine the infant's infection status.

Clinical Management

Until a vaccine is developed to prevent AIDS, the many people who contract the virus will need care. Before 1995, treating persons with AIDS was largely centered around controlling the opportunistic infections that ravaged the unfortunate individual. Several current advances have improved the prospects for most patients receiving care today, including the development of new, potent drugs, and the ability to test viral levels. Not only have the death rates from AIDS declined in 1996 and 1997, but the frequency of HIV-related hospitalization and major HIV-related complications have declined as well. Many scientists are optimistic that AIDS may now be managed as a chronic disease, such as diabetes or hypertension. Less optimistically, the treatment is costly, therefore not available to all members of our human race.

HIV invades certain cells in the immune system, including the T lymphocytes, where the virus replicates, then spreads to other cells. At the onset of the infection, there is a large amount of viral replication and the demise of the T lymphocytes, evidenced by a drop from the normal level of at least 800 cells per cubic millimeter of blood. At this stage, the infected person may experience fever, muscular and headaches, enlarged lymph nodes and rashes. The immune system attempts to eliminate the HIV, but it very rarely does. Viral replication continues, on an average of eight to ten years, during a prolonged, chronic stage in which the person may be unaware of communicability, secondary to adequate amounts of T cells to preserve defense responses. Once the level of T cells drops below 200 cells per cubic millimeter of blood, AIDS is diagnosed. Opportunistic infections such as Pneumocystis carinii pneumonia and toxoplasmosis start to proliferate as the levels of T cells drop below 100.

Scientists have discovered how the HIV destroys the T cells--a complicated process involving enzymes and strands of RNA. An enzyme known as reverse transcriptase copies the virus into a double strand DNA-- the property that qualifies HIV as a retrovirus. HIV utilizes the enzyme known as integrase to splice permanently into the chromosome of the host cell. When the host cell reproduces, the HIV is propagated as well. At this stage, a third enzyme, called protease, assists with the packaging of HIV's RNA into new viral particles within the host cell. When too many viral packets are formed, the host cell dies, and the packets of HIV continue on to infect other cells.

Because the amount of the virus in a person's system correlates directly with the prognosis, viral reproduction must be attacked in order to reduce viral levels. When the immune system is unable to protect itself, aggressive drug therapy offers one of the only hopes for the human life. All of the approved antiretroviral, or anti HIV drugs, attempt to stop the replication of HIV within the host cells by blocking either the HIV protease or the reverse transcriptase. Reverse transcriptase inhibitors block the HIV’s genetic integration and include the following drugs: Didanosine, Lamivudine, Stavudine, Delavirdine, Combivir, Abacavir, Efavirenz, and Nevirapine. The protease inhibitors halt the HIV from cleaving newly made proteins by blocking the active, catalytic site of the HIV protease and includes the following drugs: Indinavir, Ritonavir, Nelfinavir and Saquinavir. In order to be fully familiar with each medication, read the drug literature prior to administration--some of the drugs must be taken on an empty stomach, and others within defined hours following certain types of food, and each has a multitude of side effects and patient information. Provide the patient with literature, detailing the necessary drug information, at that patient's level of understanding and in the appropriate language. The following link is an excellent source of information on FDA approved HIV medications: http://www.hivatis.org/guidelines/adult/text/?list .

HIV is highly resistant to drug therapy because of its ability to mutate. The mutant virus adapts to the administered drug and proliferates, making the previous drug ineffective. This is one reason why post exposure prophylaxis (PEP) must be considered; a person who receives the PEP may develop resistant strains making the drug ineffective for the individual's future use. There is no single drug on the market able to individually suppress the virus; therefore combinations of drugs are used to maximize drug potency and to reduce the likelihood of resistance. When a person with HIV does not follow the drug regime exactly as prescribed, the chances of developing resistant strains are greatly increased, which reduces the patient's prognosis and places the community at greater risk for mutant strains.

A person infected with HIV will require close medical attention to assess for the presence of underlying infections, to determine the extent of immune deficiency and to monitor the progress of the medication regime. In addition to the nurse's role of caring for the patient's basic needs, including monitoring for infection and drug side effects, psychological and spiritual support, the nurse may be responsible to recognize and report pathological laboratory results to the primary care physician. The typical laboratory profile will include the following: T cell count, viral load baseline, screens for TB, toxoplasmosis, and syphilis, CBC with differential and a complete metabolic panel. Last, but certainly not least, patient teaching and counseling must be added to the care plan and clinical management of the HIV infected person.

AIDS Ethical Dilemmas

How can we provide equitable care within a capitalistic framework which provides for those able to buy healthcare, and does not always provide for those unable to buy? The current AIDS medication regime costs in excess of ten thousand dollars a year. The person who is not able to afford the best insurance plans, or who is unable to obtain government assistance, or who is not a member of a developed country may be unable to obtain the medication and treatment required to overcome HIV.

Should medications be provided to those persons who fail to follow the medication regime, encouraging the development of HIV mutant, resistant strains, which may then infect others? Physicians advise against providing drug therapy to noncompliant persons in order to reduce the risk of resistant strains. Medication compliance must be promoted.

Can a nurse refuse to care for an HIV infected person? According to the "Code for Nurses," the two instances allowing a nurse to refuse to provide care for a patient are during situations which violate the patient's rights or wishes, and situations in which the nurse is morally opposed to a specific intervention. Clearly, neither instance relates to the care of an HIV patient. From another perspective--though a nurse is duty bound, as part of licensure, to care for a patient with HIV, are we doing the patient justice by assigning a prejudicial health care worker to provide the care? Prejudice is largely born of fear and lack of knowledge; simply educating the prejudiced person about the transmission and prevention of HIV may assist in resolving this issue.

Florida Law on Aids and the impact on testing, confidentiality and treatment (appendix required by Florida State Board of Nurses)

The State of Florida requires all nurses to complete an educational program on the modes of transmission, infection control procedures, clinical management, prevention, and Florida Law on HIV/AIDS, including its impact on testing, confidentiality and treatment. Recent nurse graduates may submit verification of completion of an HIV/AIDS course on the form provided by the Board of Nursing. Nurses licensed before July 1, 1989 must complete a one-hour course biennially. Applicants for initial, reactivated, or reinstated licensure must complete a three hour course--unless the applicant has proof of completion of the HIV/AIDS course equivalent taken prior to the 1989 biennial renewal cycle, then a one hour course is required. Applicants for initial nurse licensure have six months to complete this AIDS course requirement. If you have any doubts or questions of your obligations for license renewal, please contact your Board of Nursing.

It is illegal in the State of Florida to perform any HIV screening test without first obtaining informed consent from the test subject (exceptions noted in next paragraph). At the time of testing, the subject shall be given information on prevention of, exposure to, and transmission of HIV; and a post test appointment shall be made to disclose the test results and to provide face-to-face counseling about the following: meaning of test results, possible need for additional testing, measures for preventing transmission of the virus, appropriate health services available for assistance, benefits of locating patient’s partner(s) who may have exposed or been exposed to HIV, and any public health authorities to locate and counsel the previous partner(s). A telephonic post test counseling may be given when reporting the HIV test results of certain Home Access HIV tests that have been approved by the government, and analyzed in certified labs.

Consent for HIV screening is not required when a person is a convicted prostitute, during documented medical emergencies, involving sexual battery, when mandated by court order, with certain approved research, when human tissue is lawfully collected, and when a HCW has had a significant exposure to a patient's body fluids within the scope of practice. Significant exposure means exposure to blood or body fluids (include lab specimens to those previously noted) through needle stick, instruments or sharps; and exposure of mucous membranes or skin (especially when skin's integrity is altered) to visible blood or body fluids. If the patient involved in the significant exposure refuses to be HIV tested, the HIV test will be performed, the patient will be informed, and post test counseling will be provided. It is required that a physician documents in the record of the HCW that a significant exposure has taken place and that the HIV screening test is medically necessary. The HCW must also be HIV tested at that time, or provide evidence of an HIV test within six months of the incident. An HIV screening test done on a patient during a medical emergency, in the course of treatment, does not require consent if a significant exposure has taken place (with same stipulations as previous HCW situation).

The test subject's name and HIV test results are confidential. The test results may be reported to the patient, the patient's legally authorized representative, third party payers designated by the subjects (includes insurance companies), and the health care facility or HCWs caring for subject. Test results may also be reported to health care facilities which procure, process, distribute and utilize body parts of the deceased; or to facilities which use semen for artificial insemination when the specimen is obtained prior to July 1988.

Facilities that perform HIV testing must meet government requirements including the provision of face-to-face pre and post testing counseling. Special training is provided to the counselors.

It is unlawful for any facility to require a person to have an HIV test as an admission prerequisite. However, a physician may refuse to perform a procedure, if the appropriateness of that procedure must be determined through the HIV status.

For further information on HIV/AIDS:

CDC National AIDS Hotline toll free number: 1-800-342-2437. Mailing address: CDC National Prevention Information Network, Post Office Box 6003, Rockville, Maryland, 20849-6003. Email: hivmail@cdc.gov