Download HIV/AIDS: Epidemic Update for Florida Initial Licensure

________________________________
#CMHIV1RHIV/AIDS:
Epidemic Update
for Florida Initial Licensure
COURSE #CMHIV1 — 4 CE HOURS
elease Date: 05/01/11
Expiration Date: 04/30/13
HIV/AIDS:
Epidemic Update for Florida
Initial Licensure
HOW TO RECEIVE CREDIT
• Read the enclosed course.
• Complete the questions at the end of the course.
• Return your completed Answer Sheet/Evaluation to
Paragon CET by mail or fax, or complete online at
www.ParagonCET.com. Your postmark or facsimile
date will be used as your completion date.
• Receive your Certificate(s) of Completion by mail,
fax, or email.
Faculty
Jane C. Norman, RN, MSN, CNE, PhD
John Leonard, MD
Division Planner
Leah Pineschi Alberto
Audience
This course is designed for cosmetologists and nail
technicians as they begin or continue their practice
in Florida.
Accreditation
Paragon CET is approved by the Florida Department
of Business and Professional Regulation to provide
continuing education for Cosmetologists.
Designation of Credit
This course has been approved by the Florida Board of
Cosmetology for 4 CE hours.
Special Approval
This course fulfills the Florida requirement for 4 hours of
continuing education on HIV/AIDS for initial licensure
and/or license reactivation.
About the Sponsor
The purpose of Paragon CET is to provide challenging
curricula to assist professionals to raise their levels of
expertise while fulfilling their continuing education
requirements, thereby improving the quality of service
to their clients.
Course Objective
In view of the already existing HIV/AIDS crisis in the
United States, the issues associated with employing
or providing services for persons with HIV infection
or AIDS are significant. The purpose of this course is
to provide salon owners and employees information
regarding the transmission, symptoms, and management
of HIV infection and to address workplace concerns.
Learning Objectives
Upon completion of this course, you should be able to:
1. Discuss the background and significance
of the AIDS epidemic.
2. Describe the transmission of HIV infection,
including risk behaviors and routes of contagion.
3. Review proper precautions for employees
and clients.
4. Discuss the impact of the virus on special
populations living with HIV infection,
including women, children, and the elderly.
5. Outline ethical and legal implications of HIV
infection.
Copyright © 2011 Paragon CET
A complete Works Cited list begins on page 15. Paragon CET • Sacramento, California
Mention of commercial products does not indicate endorsement.
Phone: 800 / 707-5644 • FAX: 916 / 878-5497
1
#CMHIV1 HIV/AIDS: Epidemic Update for Florida Initial Licensure_________________________________ INTRODUCTION
The amount that has been learned and written
about human immuno­deficiency virus (HIV) infection and disease and its influence on indi­viduals
and society is staggering. Researchers in America
and England have traced the ancestry of the HIV
virus to two strains found in African red-capped
mangabeys and greater spot-nosed monkeys. The
strains most likely combined in chimpanzees
that ate the monkeys, resulting in the chimpanzees developing simian immuno­deficiency virus
(SIV). Chimpanzees then trans­mitted the virus to
humans, as early as 1930. Genetic studies suggest
that the lower monkeys first became infected with
SIV 100,000 years ago [29].
The first reported case of HIV occurred about
30 years ago, in 1981. Since then, researchers
have made major inroads in under­standing the
disease. Knowledge about the characteristics and
behavior of this human retrovirus has helped to
develop targeted therapeutic in­terventions and
vaccine strategies. The availability of antiretroviral
drug therapy has been a benefit to many who are
HIV-infected, with a delay in the development
of opportunistic infections and acquired immune
deficiency syndrome (AIDS). However, HIV does
eventually lead to AIDS in many people despite
these advances.
Within a few weeks of being infected with HIV,
some people develop flu-like symptoms that last
for a week or two, but others have no symptoms
at all. People living with HIV may appear and feel
healthy for several years. However, even if they
feel healthy, HIV is still affecting their bodies. All
people with HIV should be seen on a regular basis
by a health care provider experienced with treating
HIV infection. Many people with HIV, including
those who feel healthy, can benefit greatly from
current medications used to treat HIV infection.
These medications can limit or slow down the
destruction of the immune system, improve the
health of people living with HIV, and may reduce
their ability to transmit HIV. Untreated early HIV
infection is also associated with many diseases
including cardiovascular disease, kidney disease,
liver disease, and cancer. Support services are also
available to many people with HIV. These services
can help people cope with their diagnosis, reduce
risk behavior, and find needed services.
AIDS is the late stage of HIV infection, when a
person’s immune system is severely damaged and
has difficulty fighting diseases and certain cancers.
Before the development of certain medications,
people with HIV could progress to AIDS in just
a few years. Currently, people can live much
longer—even decades—with HIV before they
develop AIDS. This is because of “highly active”
combinations of medications that were introduced
in the mid 1990s.
WHAT IS HIV?
According to the Centers for Disease Control and
Prevention, there are two types of HIV: HIV-1
and HIV-2. In the United States, unless otherwise
noted, the term “HIV” primarily refers to HIV-1
[47]. Both types of HIV damage a person’s body
by destroying specific blood cells, called CD4+ T
cells, which are crucial to helping the body fight
diseases. The CDC provides the following description of HIV and AIDS [47]:
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Paragon CET • October 2, 2012
IMPACT OF HIV
According to the Joint United Nations Programme
on HIV/AIDS (UNAIDS), an estimated 33 million individuals worldwide were living with HIV
or AIDS in 2007, approximately half of which
were women [30]. Eastern Europe (particularly the
Russian Federation) and Southeast Asia have the
fastest growing epidemic [30]. It is important to
note that despite increases in certain geographic
areas and demo­graphic groups, overall, the rate of
new infections is declining. This is due, in part,
to lower prices for anti-AIDS drugs [22]. Africa is
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________________________________ #CMHIV1 HIV/AIDS: Epidemic Update for Florida Initial Licensure
still the hardest-hit area, with two-thirds (67%)
of all HIV-infected persons living in sub-Saharan
Africa in 2007 [30]. In 2003, the U.S. government
approved the purchase of generic drugs to fight the
disease in Africa. In that same year, the President’s
Emergency Plan for AIDS Relief (PEPFAR) was
introduced and implemented [37]. PEPFAR was
re­authorized in July 2008, with a total of $48 billion in funds over the following 5 years and expansion to address addi­tional health issues, including
malaria, tuberculosis, maternal health, and clean
water [31].
As of 2009, the CDC reported several trends in
the HIV/AIDS epidemic [33]:
As of 2008, an estimated 1.2 million individuals
were living with HIV/AIDS in the United States
[30]. The CDC estimates that approximately 25%
of these individuals are unaware of their infection
[35]. To compound the problem, up to one-third of
individuals aware of their infection do not receive
ongoing care. Approximately 50% of all individuals
infected with HIV remain untested, without treatment, or both [35]. Unfortunately, this poses a risk
both for those who are infected and for others.
Florida ranks third in the U.S. in terms of number
of reported cases of HIV and second in terms of
pediatric cases [1]. As is true in the country, the
disease has disproportionately affected minorities
in Florida.
Many changes in the progression of the HIV/
AIDS epidemic should be considered. Since the
first reported cases of HIV in 1981 in the U.S., the
epidemic continues to vary a great deal between
regions, states, and even communities. Populations that are affected by HIV are also shifting. In
addition to individuals traditionally considered
to be high-risk (e.g., MSM or IDUs), new groups
have been identified as being at greater risk. For
example, in the beginning stages of the HIV/AIDS
epidemic in the U.S., white people were chiefly
impacted. However, the epidemic now greatly
affects racial and ethnic minorities, particularly
black Americans, who represent almost half of all
cases in the U.S. [33]. Women also have a higher
risk of infection. More than half of HIV infections that result from heterosexual contact occur
in women.
Paragon CET • Sacramento, California
• By region, 40% reside in the South,
29% in the Northeast, 20% in the
West, and 11% in the Midwest.
• By race/ethnicity, 48% are black,
33% white, 17% Hispanic, and less
than 1% are American Indian/Alaska
Native or Asian/Pacific Islander.
• By gender, 73% of adults and
adolescents living with AIDS are male.
SIGNS AND SYMPTOMS
HIV infection passes through several stages and,
if untreated, carries an 80% mortality rate at 10
years. The initial event, reported in 50% to 90%
of infected individuals, is an acute mono­nucleosislike illness. Symptoms include fever, sore throat,
malaise, rash, diarrhea, enlarged lymph nodes,
ulcerations (broken, inflamed skin or mucous membranes), and weight loss averaging 10 pounds. A
variety of neurologic syndromes including swelling
of the brain (encephalitis) may occur. The illness
begins 1 to 3 weeks after viral transmission and lasts
about 2 to 3 weeks. This is followed by a prolonged
asymptomatic period in most individuals.
Symptomatic infection can be expected after the
CD4 T-cell count has decreased to less than 200/
mm3 as this represents the stage of severe immunodeficiency. The CDC defines late-stage HIV
infection as AIDS on the basis of two criteria:
CD4 count less than 200/mm3 and the presence
of a characteristic AIDS-defining illness such as
pneumonia, parasitic infections (such as toxoplas­
mosis, which affects the nervous system), or other
opportunistic infections or tumors. A variety of
syndromes may develop at this point, including
dementia, nerve damage (numbness, tingling,
Phone: 800 / 707-5644 • FAX: 916 / 878-5497
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#CMHIV1 HIV/AIDS: Epidemic Update for Florida Initial Licensure_________________________________ burning sensation in the hands or feet), extreme
weight loss, and chronic diarrhea [39]. Signs
and symptoms of HIV generally are related to
opportunistic infections preying on an impaired
immune system. These diseases include pneumonia, tuberculosis, and others. Individuals with HIV
commonly succumb to uncontrollable infection,
becoming increasingly de­bilitated, feverishly ill,
malnourished, and often in pain. Enlarged lymph
nodes, lung disease, extreme weight loss, and brain/
nervous system abnormalities (such as dementia,
tremors, and inflammation) con­tribute to the
debilitated state.
To date, there is no predictable cure [14]. In the
absence of medication therapy, the average survival
is approximately 3.5 years after the individual’s
CD4 count has reached 200/mm3 and 1.5 years for
the person who has developed an AIDS-defining
diagnosis.
HIV TESTING
According to the CDC, [47]:
It can take some time for the immune
system to produce enough antibodies
for the antibody test to detect, and this
“window period” between infection with
HIV and the ability to detect it with
antibody tests can vary from person to
person. During this time, HIV viral load
and the likelihood of transmitting the
virus to sex or needle-sharing partners
may be very high. Most people will
develop detectable antibodies that can be
detected by the most commonly used tests
in the United States within 2 to 8 weeks
(the average is 25 days) of their infection.
Ninety-seven percent (97%) of persons
will develop detectable antibodies in the
first 3 months. Even so, there is a small
chance that some individuals will take
longer to develop detectable antibodies.
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Paragon CET • October 2, 2012
Therefore, a person should consider a
follow-up test more than three months
after their last potential exposure to HIV.
In extremely rare cases, it can take up to 6
months to develop antibodies to HIV.
Several tests are available to screen for HIV. There
are various ways by which these tests function:
detection of the antibody, identification of antigens, detection/monitoring of viral nucleic acids,
or rendering an estimate of T-lymphocytes (cell
phenotyping). Tests used to detect antibodies are
the most common and effective way of identifying
HIV infection and can be further broken down into
two categories [42]:
• Screening Tests: Intended to determine
all individuals infected with HIV; produces
few false-negative results
• Supplemental/Confirmatory Tests: Intended
to determine all individuals who have
positive screening tests, but are not infected
(i.e., negates a false-positive), produces few
false-positive results
Both types of tests are highly sensitive. Together,
they can accurately assess the existence of HIV in
blood supply and supplement clinical diagnosis.
TRANSMISSION OF HIV
Transmission of HIV results from intimate contact
with blood and body secretions, excluding saliva
and tears. The most common modes of transmission
are sexual contact, administration of contaminated
blood and blood products, contaminated needles,
and mother-to-fetus [14]. It is important to note
that HIV cannot be spread by air or water; insects,
including mosquitoes; saliva, tears, or sweat; casual
contact like shaking hands or sharing dishes; or
closed-mouth or “social” kissing [47]. Tattooing
or body piercing present a potential risk of HIV
transmission, but no cases of HIV transmission
from these activities have been documented. Only
sterile equipment should be used for tattooing or
body piercing.
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________________________________ #CMHIV1 HIV/AIDS: Epidemic Update for Florida Initial Licensure
RISK CATEGORIES
On the basis of newly reported cases, the transmission categories are [33]:
• Male-to-male sexual contact
• Injecting drug users
• Men who have sex with men who
inject drugs
• High-risk heterosexual contact
• Blood transfusion
• Perinatal transmission (i.e., from an infected
pregnant woman to her fetus or infant)
MODES OF TRANSMISSION
Sexual Transmission of HIV
HIV has been isolated from blood, seminal fluid,
pre-­ejaculate, vaginal secretions, urine, cerebro­
spinal fluid, saliva, tears, and breast milk of infected
individuals. Whether HIV infects spermatozoa is
controversial. Reports of the removal of infected
cells from se­men, allowing artificial in­semination
without sero­conversion, support the idea that
spermatozoa are not infected. No cases of HIV
infection have been traced to saliva or tears [40].
The virus is found in greater concentra­tion
in semen than in vaginal fluids, leading to a
hy­pothesis that male-to-female transmission could
occur more easily than female-to-male. Sexual
behavior that involves exposure to blood is likely
to increase trans­mission risks. Transmission could
occur through contact with infected bowel epithelial cells in anal in­tercourse in addition to access
to the bloodstream through breaks in the rectal
mucosa.
Although all HIV-seropositive people are potentially infectious, there is widespread variation
in the seropositivity and sero­conversion of their
sexual partners. Factors that could explain this
variability include differences in sexual practices
and numbers of sexual contacts, susceptibil­ity of
the partner, differences in viral strains, changing degrees of infectiousness of the HIV-infected
person over time, co-factors that enhance or limit
trans­mission, genetic resistance, or a combination
of these factors.
Paragon CET • Sacramento, California
Posing the highest risk of infection is unprotected
anal receptive intercourse, followed by unprotected
vaginal intercourse. Risk is reduced through the
use of latex condoms. For the wearer, latex condoms provide a mechanical barrier limiting penile
exposure to infectious cervical, vaginal, vulvar, or
rectal secretions or lesions. Likewise, the partner
is protected from infectious pre-ejaculate, semen,
and penile lesions. Oil-based lubricants may make
latex condoms ineffective and should not be used.
Water-soluble lubricants are con­sidered safe.
Natural membrane condoms (made from lamb
cecum) contain small pores and do not block HIV
passage.
It is estimated that latex condom efficacy in the
prevention of HIV transmission is approximately
85%. Although abstinence from sexual contact is
the sole way to absolutely prevent trans­mission,
using a latex condom to prevent trans­mission of
HIV is more than 10,000 times safer than engaging
in unprotected sex [38]. Sexual activity in a mutually monogamous relationship in which neither
partner is HIV-infected and no other risk factors
are present is considered safe [7].
The phenomenon of men who identify publicly
as heterosexual and generally have committed
relationships with women, but who also engage
in sexual activity with other men, termed being
on the “down low” or DL, may be a transmission
bridge to heterosexual women. In a 2005 study,
researchers surveyed 328 MSM in 12 cities and
found that 43% of black men, 26% of Hispanic
men, and 7% of white men reported being on the
down low [36]. However, it is important to note
that men on the “down low” are not the only MSM
who report having sexual contact with women. In
a larger study of 5,000 HIV-positive MSM, 22% of
gay-identified black MSM and 61% of bisexualidentified black MSM reported having had sex
with a woman in the past five years [43]. To better
understand the actual extent of this behavior and
its impact on HIV transmission, more research and
studies must be undertaken.
Phone: 800 / 707-5644 • FAX: 916 / 878-5497
5
#CMHIV1 HIV/AIDS: Epidemic Update for Florida Initial Licensure_________________________________ Oral Sex
Numerous studies have demonstrated that oral sex
can result in the transmission of HIV and other
sexually transmitted infections (STIs). While the
risk of HIV transmission through oral sex is much
smaller than the risk from anal or vaginal sex,
there are several co-factors that can increase this
risk, including oral ulcers, bleeding gums, genital
sores, and the presence of other STIs. Prevention
includes the use of latex condoms, a natural rubber
latex sheet, plastic food wrap, a cut open condom,
or a dental dam, all of which serve as a physical
barrier to transmission [9].
Blood Donor Products
It has been estimated that an HIV-infected drop of
hu­man blood contains 1 to 100 live virus particles.
In comparison, a drop infected with hepatitis B
virus has 100 million to 1 billion organisms. Even
so, HIV is transmitted via blood, primarily through
sharing of contaminated needles among IDUs and,
rarely, through blood transfusion. Transmis­sion
of HIV-1 has occurred after trans­fusion of the
fol­lowing components: whole blood, packed red
blood cells, fresh fro­zen plasma, cryoprecipitate,
platelets, and plasma-de­rived products, depending
on the production process.
With the imple­mentation of a donor screening
program of the nation’s blood supply in 1985
and advances in the treatment of donated blood
products, blood transfusion is now even safer; the
current risk of trans­mission of AIDS through this
route is estimated to be 1 in 225,000. A somewhat
higher estimate of 1 in 40,000 to 1 in 60,000 is
reported from areas that have a high prevalence
of HIV-1 infection. It is possible that before blood
screening imple­mentation, more than 12,000
people were infected. A large percentage of
hemophili­acs acquired HIV in this manner. Donor
screening, HIV testing, and heat treatment of the
clotting factor have greatly reduced the risks. To
further decrease the possibility of HIV transmission
through transfusion of blood and blood products,
6
Paragon CET • October 2, 2012
patients scheduled to undergo elective surgery are
in­creasingly advised to make predeposited blood
donations for intraopera­tive autotransfusion.
To date, screening tests cannot detect either
recently HIV-1-infected people who have not
yet developed an­tibody (the “window period”) or
HIV antibody-nega­tive patients who have AIDS.
Donating procedures in­clude an interview for risk
factors and the ability of the potential donor to
exclude their blood from being used. No transfusion-related cases of HIV-2 infec­tion have been
reported in the United States since 1992, when
all U.S. blood centers began to test donations for
antibod­ies to both HIV-1 and HIV-2.
Needle Sharing
Transmission of HIV among injecting drug users
occurs pri­marily through contamination of injection parapher­nalia with infected blood. The risk of
sustaining HIV infection from a needle stick with
infected blood is approximately 1 in 300. Behavior
such as needle­sharing, “booting” the injection
with blood, and performing frequent injections
increases the risk. Cocaine use (by injection or
smoking) is associated with a higher prevalence
of HIV infection. This may in part be attributed
to the exchange of cocaine for sex. Sharing of
equipment is common due to legal and financial
restrictions and cultural norms. Geo­graphically,
the rate of infection varies; 80% of New York City
addict needle sharers are infected, as op­posed to
lower rates in other metro­politan area clusters.
Secondary transmission occurs to children and
sexual partners. Pre­ventative strategies include
drug treatment, onsite medical care in a drug treatment program, recruit­ment of “street” outreach
workers for intensive drug and sex “risk reduction”
educational cam­paigns, teaching addicts to sterilize
their equipment between use, the free provision or
exchange of sterile injection equipment (as allowed
by law), distribution of con­doms and bleach to
clean drug use equipment, or a combination of
these inter­ventions [7].
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________________________________ #CMHIV1 HIV/AIDS: Epidemic Update for Florida Initial Licensure
Health professionals should stress the following
messages when they counsel IDUs [44]:
• The best way for you to prevent HIV
and hepatitis B and C virus transmission
is to NOT inject drugs.
• Entering substance abuse treatment
can help you reduce or stop injecting.
This will lower your chances of infection.
• Get vaccinated against hepatitis A and
hepatitis B. You can prevent these kinds
of viral hepatitis if you get vaccinated.
• If you cannot or will not stop injecting,
you should:
– Use a new, sterile syringe obtained
from a reliable source to prepare
and divide drugs for each injection.
– Never reuse or share syringes, water,
cookers, or cottons.
– Use sterile water to prepare drugs
each time, or at least clean water
from a reliable source.
– Keep everything as clean as possible
when injecting.
• If you cannot use a new, sterile syringe
and clean equipment each time, then
disinfecting with bleach may be better
than doing nothing at all:
• Fill the syringe with clean water and
shake or tap. Squirt out the water and
throw it away. Repeat until you do not
see any blood in the syringe.
• Completely fill the syringe with fresh,
full-strength household bleach. Keep
it in the syringe for 30 seconds or more.
Squirt it out and throw the bleach away.
• Fill the syringe with clean water and
shake or tap. Squirt out the water and
throw it away.
• If you do not have any bleach, use clean
water to vigorously flush out the syringe.
Fill the syringe with water and shake or tap
it. Squirt out the water and throw it away.
Repeat several times.
Paragon CET • Sacramento, California
It is important to note that a disinfected syringe is
not a sterile syringe. The best option is always to
use a new, sterile syringe with every injection.
Perinatal Transmission
In the absence of preventive treatment, approxi­
mately 30% to 50% of children born to HIVinfected mothers will contract HIV infection.
HIV is transmitted to infants through the placenta
from mother to fetus in utero, during childbirth, or
through breastfeeding after birth. Because infants
have underdeveloped natural resis­tance systems,
they are highly susceptible to many in­fections,
including HIV. Transmission in utero is the most
common route [45]. Both uninfected and infected
infants have been born to mothers who have
previously borne an infected infant. Studies have
dramatically shown the beneficial effect of treating pregnant women and newborns with antiviral
medications to prevent transmis­sion to the child,
resulting in dramatic declines in the incidence of
perinatally acquired AIDS [46]. Standard screening of all pregnant women is necessary to reduce
transmission of HIV to infants.
Worldwide, perinatal transmission accounts for
most HIV infections among children. In the
United States, perinatal transmission has been
markedly decreased, by more than 80%, since 1991
[46]. This dramatic decrease is mainly attributed to
the use of antiviral medications. Other strategies
for reducing perinatally acquired HIV infection
have included preventing HIV infection among
women and, for HIV-infected women, avoiding
pregnancy or refraining from breastfeeding.
Occupational Exposure
The risk of infection through occupational exposure for salon professionals is low. Educational
ef­forts and universal pre­cautions, as discussed in
the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens standard
regulations, should be recognized [7].
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7
#CMHIV1 HIV/AIDS: Epidemic Update for Florida Initial Licensure_________________________________ Organ Transplantation
Because organ transplantation is less common than
other transmission-related activities, there have
been very few case reports of HIV acquisition by
this route. HIV has been transmitted via transplanted kidneys, liver, heart, pancreas, bone, and,
possibly, skin grafts and through artificial insemination. HIV testing is used in these circumstances to
rule out infection [7; 24].
be washed immediately after contact with blood
or other body fluids, and surfaces soiled with blood
should be disinfected appropriately. Practices that
increase the likelihood of blood contact, such as
sharing of razors, should be avoided.
CONSIDERATIONS FOR SALON
AND SPA PROFESSIONALS
The activities generally performed by cosmetologists, massage therapists, and nail technicians are
not considered to be a transmission threat to clients
or coworkers. In 1985, the CDC issued routine
precautions that all personal-service workers (such
as barbers, cosmetologists, and nail technicians)
should follow, even though there is no evidence
of transmission from a personal-service worker to
a client or vice versa [40]. Instruments that are
intended to penetrate the skin (such as tattooing
and acupuncture needles or ear piercing devices)
should be used once and disposed of or thoroughly
cleaned and sterilized. Instruments not intended
to penetrate the skin but that may become contaminated with blood (for example, razors) should
be used for only one client and disposed of or
thoroughly cleaned and disinfected after each use.
Personal-service workers can use the same cleaning
procedures that are recommended for healthcare
institutions.
ANTIRETROVIRAL THERAPY
The introduction of antiretroviral drugs for the
treatment of HIV has resulted in longer lives and
fewer symptoms in HIV-positive individuals. Most
people take a combination of at least 3 different
medications. HIV has been shown to develop
resistance to the medications, particularly when
only one drug is used. Therefore, in addition to
combination therapy, the sequencing of drugs and
the preservation of future treatment options are
also important [25; 37]. Treatment continues for
an individual’s entire life.
The CDC recommends that precautions should
be taken in all settings (including the home) to
prevent exposures to the blood of persons who
are HIV infected, at risk for HIV infection, or
whose infection and risk status are unknown [40].
Gloves should be worn during contact with blood
or other body fluids that could possibly contain
visible blood, such as urine, feces, or vomit. Cuts,
sores, or breaks on both the cosmetologist’s and
client’s exposed skin should be covered with bandages. Hands and other parts of the body should
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Paragon CET • October 2, 2012
MANAGEMENT
OF HIV INFECTION
There are 6 major classes of antiretroviral
drugs: nucleoside reverse transcriptase inhibitors
(NRTIs), non-nucleoside reverse transcriptase
inhibitors (NNRTIs), protease inhibitors (PIs),
fusion inhibitors (FIs), CCR5 antagonists, and
integrase inhibitors. Antiretroviral therapy should
be initiated in individuals with a history of an
AIDS-defining illness or with a CD4 T-cell count
less than 350/mm3 [25]. Persons with a CD4 T-cell
count greater than 350/mm3 may consider treatment with medications. Therapy should also be
initiated in the following groups regardless of CD4
T-cell count [25]:
• Pregnant women
• Those with HIV-associated kidney
disease (nephropathy)
• Those also infected with hepatitis B
when treatment for the hepatitis
infection is indicated
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________________________________ #CMHIV1 HIV/AIDS: Epidemic Update for Florida Initial Licensure
Individuals who have never received antiretroviral
treatment are usually started on a regimen of two
NRTIs plus a PI. This combination results in the
best reduction of HIV in the blood for the longest
period of time and will achieve the goal of no
detectable virus in approximately 60% to 80% of
individuals.
At the present time, the most active triple-drug
regimen (for example, two NRTIs and a PI) in
a previously untreated person can be expected
to reduce the viral load below detectable levels,
increase CD4 counts by an average of 100–150/
mm3, reduce the risk of HIV-associated compli­
cations, and prolong survival. However, the ability
to achieve this advantage depends on the individual’s willingness to accept a complex medical
regimen that requires many pills, rigorous compliance, frequent follow-up, and moderate risk for
drug toxicity.
PREVENTION OF
OPPORTUNISTIC INFECTIONS
Opportunistic infections are infections that cause
disease in persons with weakened immune systems
but would probably not cause disease in healthy
people. Depending on the CD4 count and other
risk factors, asymptomatic people may benefit from
treatment to prevent opportunistic infections.
In many cases, antiretroviral therapy is useful in
the prevention and treatment of these infections
[27]. Prophylactic therapy for these conditions is
strongly recommended because these infections
are relatively common in HIV-positive individuals,
preventive therapy is simple and cost effective, and
efficacy has been established in clinical studies. In
addition, all of these individuals should be vaccinated with pneumo­coccal vaccine. Hepatitis B
vaccination should be considered in patients who
have not already been vaccinated.
The CDC has developed guidelines for the prevention of opportunistic infections among HIVinfected individuals. The report offers guidelines
specific to each type of opportunistic infection
and can be viewed at http://www.cdc.gov/mmwr/
preview/mmwrhtml/rr5804a1.htm.
Paragon CET • Sacramento, California
HIV INFECTION IN
SPECIAL POPULATIONS
WOMEN LIVING WITH HIV INFECTION
Women now make up nearly half of all AIDS cases
worldwide and 27% in the U.S. [21]. The rate of
HIV infection in women is rising rapidly. In the
last twenty years, the proportion of AIDS cases in
women has nearly quadrupled from 8% in 1985 to
27% in 2006. In 1993, when the CDC expanded
the case definition of AIDS, there was a 151%
increase in the number of AIDS cases in women
and a 105% increase in cases in men. More women
were found to meet the AIDS case definition
when the CD4+ T-lymphocyte count of <200 was
added to the criteria. This may be evidence that
the previous case definitions based on the clinical
characteristics of men did not accurately re­flect the
symptoms of HIV in women [21; 28].
AIDS is the fifth leading cause of death in women
25 to 44 years of age in the United States. It is the
third leading cause of death in black women in the
same age group [21]. Women of color have been disproportionately affected by AIDS; the prevalence
rate of AIDS cases among black women is 21 times
that of white women. When compared with adults,
a greater percentage of AIDS cases in adolescents
are young women. They are more likely to be black
or Hispanic/Latino, and they are more likely to be
infected through heterosexual intercourse.
Research is being conducted to determine whether
the symptoms of HIV, other than those related to
the reproductive tract, are different for women
than for men. It appears that many symptoms and
signs of acute HIV infection and non-specific manifestations, such as fevers, weight loss, and fatigue,
are the same. However, other manifestations are
gender-specific. For example, It is noteworthy that
recurrent vaginal candidiasis (yeast infection) is
a potential indicator of HIV, but is often undiagnosed by healthcare providers [21]. This failure to
diagnose results in delays in treatment. As many
as 60% of HIV-infected women also test positive
for some type of human papillomavirus (HPV).
Phone: 800 / 707-5644 • FAX: 916 / 878-5497
9
#CMHIV1 HIV/AIDS: Epidemic Update for Florida Initial Licensure_________________________________ HIV infection is a risk factor for higher prevalence
of HPV in the cervix and increased likelihood of
infection by multiple HPV types. HIV infection is
associated with a high rate of cervical cancer and
cervical intra-epithelial neoplasia or squamous
intra-epithelial lesions. Menstrual irregularities
are also frequently reported by women with HIV
[21].
INFANTS AND CHILDREN WITH HIV
In the United States today, the predominant
route of infection with HIV in children is from an
infected pregnant woman to her fetus or infant [32].
Thus, the epidemic in chil­dren is closely linked to
the epidemic in women [3].
Prevention remains the only cure for HIV, yet
no intervention aimed at chang­ing behavior to
promote health has been or will be 100% successful. The tragedy of perinatal transmission of HIV
is that few women are aware of their risk, many
are not of­fered HIV counseling and testing by
healthcare providers, and most learn their diagnosis when their child becomes ill. The CDC has
adapted recom­mendations that advocate universal
counseling and testing for every pregnant woman
regardless of geography, identified risk behavior,
or self-identified risk, unless it is declined [23]. In
2005, the United States Preventative Services Task
Force (USPSTF) published guidelines recommending the screening of all pregnant women for HIV.
The benefits supporting this statement included a
potential for decreased perinatal trans­mission of
HIV resulting from maternal and neonatal antiretroviral therapy and the increased opportunity to
provide counseling regarding risks associated with
breastfeeding and elective cesarean delivery [20].
OLDER PEOPLE WITH HIV
Approximately 15% of newly diagnosed cases of
HIV/AIDS in 2005 occurred in individuals 50
years of age or older; 29% of all persons living
with HIV/AIDS are 50 years of age or older [11;
12]. However, until recently, there had been little
attention given to this group [11]. HIV/AIDS
has traditionally been thought to be the disease
of the young; therefore, in the past, prevention
10
Paragon CET • October 2, 2012
and education campaigns had not been targeted
toward older adults. However, evidence points to
the increasing number of infected older people
and a need for change in prevention and education campaigns. Some older persons may have less
knowledge about HIV and risk reduction strategies.
Due to divorce or being widowed and the availability of medications to treat erectile dysfunction,
increasing numbers of older people are becoming
sexually active with multiple partners [11; 41].
For post­menopausal women, contraception is no
longer a concern, and they are less likely to use a
condom. Furthermore, vaginal drying and thinning
associated with aging can result in small tears or
cuts during sexual activity, which also raises the
risk for infection with HIV/AIDS [18]. Studies
indicate that at-risk individuals in this age group
are one-sixth as likely as younger at-risk adults to
use condoms during sex [19]. The combination of
these factors increases the risk for unprotected sex
with new or multiple partners in this age group,
thereby increasing their risk for AIDS.
Early possible signs of HIV that are frequently overlooked or mistakenly attributed to aging include
yeast infections and skin problems, especially seborrheic dermatitis, shingles, and recurrent herpes
simplex virus type 2 in a person who does not have
a history of it. Early HIV symptoms in the elderly,
such as fatigue and weight loss, may appear to be a
normal part of aging, and AIDS-related dementia
is often mistaken for Alzheimer’s disease.
AIDS PREVENTION
AIDS VACCINE
Both preventive and therapeutic vaccines are being
studied for use in the fight against HIV. Preventive vaccines are developed to protect individuals
from contracting HIV [34]. The goal of therapeutic
vaccines is to boost immune response to and better
control existing HIV infection [26]. Of course, the
ultimate goal in vaccine research is a vaccine that
will prevent infection; however, despite several
trials, no vaccine effective in preventing HIV has
been discovered.
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________________________________ #CMHIV1 HIV/AIDS: Epidemic Update for Florida Initial Licensure
The Inter­national AIDS Vaccine Initiative (IAVI)
is working to speed the development and distribution of preventive AIDS vaccines, focusing on
four areas: mobilizing support through advocacy
and edu­cation; accelerating scientific progress;
encouraging industrial participation in AIDS vaccine devel­opment; and assuring global access.
TOPICAL MICROBICIDES
Because HIV is spread predominantly through
sexual transmission, the development of chemical
and physical barriers that can be used vaginally or
rectally to inactivate HIV and other STDs is critically important for controlling HIV infection.
Researchers are developing and testing new chemical compounds that women could apply before
intercourse to protect themselves against HIV and
other sexually transmitted organisms [2]. These
include creams or gels, known as topical microbicides, which ideally would be non-irritating and
inexpensive. In addition, microbicides should be
available in both spermicidal and non-spermicidal
formulations so women do not have to put themselves at risk for acquiring HIV and other STDs
in order to conceive a child. The research effort
for developing topical microbicides includes basic
research, preclinical product development, and
clinical evaluation.
EDUCATION TO
PREVENT HIV INFECTION
Many adolescents engage in behaviors that put
them at risk for HIV infection. According to the
CDC, nearly 50% of high school students have
engaged in intercourse [8]. Approximately 39% of
sexually active high school students had not used
a condom at last sexual intercourse; 2% had ever
injected an illegal drug [8]. Although more than
90% of adolescents report having received education on HIV prevention in school, the content
of these discussions may not provide adequate
information on the subject. Furthermore, the
American Academy of Pediatrics determined that
school-based education and intervention programs
do not provide the necessary opportunities of
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confidential discussions or targeted counseling
[4]. Accurate and complete information on HIV
transmission and risk reduction is necessary for
school-aged children.
ETHICAL AND LEGAL
CONSIDERATIONS
The ethics and law around AIDS and infection
with HIV give rise to many issues. In the United
States, HIV infections have historically occurred
overwhelmingly in two populations: men who
have sex with men and injecting drug users. But
the number of new infections is growing in many
groups, including women. Furthermore, ethnic
minority groups (particularly African Americans
and Hispanics) are disproportionally affected by
the disease. Therefore, sociocultural issues are an
important aspect of care [10].
FINANCIAL ISSUES
Employment can pose a problem for individuals with HIV/AIDS. Possible issues that may be
raised include difficulty maintaining employment
or resuming employment after health has been
restored or stabilized, stigma associated with the
disease, future disability risk, confidentiality concerns, and the resulting financial burden for the
employer.
Although individuals diagnosed with HIV/AIDS
are living much longer as a result of available treatments, they may be forced into extended “HIV
retirement,” whereby employment is no longer
possible due to the effects of the disease. It has also
increased the number of persons living with HIV/
AIDS returning to the workforce [13].
At the beginning of the AIDS epidemic, insurance companies would generally approve AIDSrelated disability claims quickly, as the prognosis
for infected individuals was so poor. As prognosis
for HIV-infected individuals has improved, it has
become more difficult to obtain insurance approval
for treatments and/or disability services [15].
Phone: 800 / 707-5644 • FAX: 916 / 878-5497
11
#CMHIV1 HIV/AIDS: Epidemic Update for Florida Initial Licensure_________________________________ DISCRIMINATION
According to the Americans with Disabilities
Act (ADA), an individual is considered to have
a disability if he or she has a physical or mental
impairment that substantially limits one or more
major life activities, has a record of such impairment, or is regarded as having such impairment
[16]. Persons with HIV disease, both symptomatic
and asymptomatic, have physical impairments that
substantially limit one or more major life activities and are protected by the law. Persons who are
discriminated against because they are regarded as
being HIV-positive are also protected. For example,
a person who was fired on the basis of a rumor
that he had AIDS, even if he did not, would be
protected by the law. Moreover, the ADA protects
persons who are discriminated against because they
have a known association or relationship with
an individual who is HIV-positive. For example,
the ADA would protect an HIV-negative woman
who was denied a job because her roommate had
AIDS [16].
Under the ADA, an employer must make a reasonable accommodation to the known physical
or mental limitations of a qualified applicant or
employee with a disability. However, an employer
is not required to provide an accommodation if it
would post an undue hardship on the operation
of its business. Undue hardship is defined as “an
action requiring significant difficulty or expense”
[16]. The Federal Rehabilitation Act of 1973 also
prohibits discrimination on the basis of a handicap.
All stages of HIV disease, including asymptomatic
HIV infection, have been found by the courts to
be handicapping conditions under Section 504 of
this Act [17].
The ADA also prohibits state licensing agencies
and public trade schools for barbering and cosmetology from discriminating against individuals with
disabilities. Consequently, a public or private entity
cannot deny a person with HIV an occupational
license or admission to a trade school because of
his or her disability. According to the U.S. Department of Justice, examples of discrimination against
persons with HIV/AIDS would include [5]:
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• A certificate program for health aides
having a blanket policy denying
admission to anyone with HIV
• A cosmetology school denying admission
to an HIV-positive individual because
State cosmetology regulations require that
cosmetologists be free from contagious,
communicable, or infectious disease
A man in Arkansas was expelled from a beauty college based on a state regulation banning those with
infectious or communicable diseases from practicing cosmetology after he voluntarily disclosed his
HIV infection to an instructor [6]. According to
the ADA, for the purposes of occupational training
and licensing requirements, the terms “infectious,
communicable, or contagious disease” must exclude
diseases, such as HIV, not transmitted through
casual contact or through the usual practice of the
occupation for which a license is required [5]. As a
result, the Arkansas Board of Cosmetology explicitly recognized that cosmetologists with HIV pose
no significant risk to clients and coworkers, and
the statute has since been amended. It is important
to note that the activities of cosmetology are not
high-risk activities, and any indication that they
are is unfounded. HIV-infected cosmetologists
should not be prevented from doing their jobs as
a result of their infection status.
Appropriate Attitude and
Behavior of the Salon Professional
• Be aware of your own attitudes toward HIV/
AIDS and toward the behavior risk factors
that put people at risk for contracting HIV. Remember it is not appropriate for you to
judge the behavior of a person infected with
HIV. How a person became infected should
not be an issue.
• Treat others as you would like to be treated
or you would like to have your family treated. Recognize that many family structures
include same sex partners and extended
family members. Avoid placing judgment
on families that do not look or behave like
yours.
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________________________________ #CMHIV1 HIV/AIDS: Epidemic Update for Florida Initial Licensure
• Do not be afraid to touch a person with
HIV. Holding a hand, giving a hug, or
back rub may be comforting. However,
also be sensitive to people who do not
want physical closeness.
• Remember that all people deserve to be
treated respectfully.
FLORIDA STATUTES
The state of Florida has specific laws and statutes
governing HIV testing, including sections devoted
to informed consent, confidentiality, and coun­
seling. Knowledge of these statutes may be useful in
ensuring that public health is served and rights are
protected. A portion of the statute has been reprinted
below, and the full Florida Statutes on HIV testing may be viewed online at http://www.leg.state.
fl.us/Statutes/index.cfm?App_mode=Display_
Statute&Search_String=&URL=03000399/0381/Sections/0381.004.html.
381.004 HIV testing.—
(1)LEGISLATIVE INTENT.—The Legislature
finds that the use of tests designed to reveal a
condition indicative of human immunodeficiency virus infection can be a valuable tool in
protecting the public health. The Legislature
finds that despite existing laws, regulations,
and professional standards which require or
promote the informed, voluntary, and confidential use of tests designed to reveal human
immunodeficiency virus infection, many
members of the public are deterred from seeking such testing because they misunderstand
the nature of the test or fear that test results
will be disclosed without their consent. The
Legislature finds that the public health will
be served by facilitating informed, voluntary,
and confidential use of tests designed to detect
human immunodeficiency virus infection.
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(2)DEFINITIONS.—As used in this section:
(a)“HIV test” means a test ordered after July
6, 1988, to determine the presence of the
antibody or antigen to human immunodeficiency virus or the presence of human
immunodeficiency virus infection.
(b)“HIV test result” means a laboratory report
of a human immunodeficiency virus test
result entered into a medical record on or
after July 6, 1988, or any report or notation
in a medical record of a laboratory report
of a human immunodeficiency virus test.
As used in this section, the term “HIV test
result” does not include test results reported
to a health care provider by a patient.
(c)“Significant exposure” means:
1. Exposure to blood or body fluids
through needlestick, instruments, or
sharps;
2. Exposure of mucous membranes to
visible blood or body fluids, to which
universal precautions apply according
to the National Centers for Disease
Control and Prevention, including,
without limitations, the following body
fluids:
a.
Blood.
b.
Semen.
c.
Vaginal secretions.
d. Cerebro-spinal fluid (CSF).
e.
Synovial fluid.
f.
Pleural fluid.
g.
Peritoneal fluid.
h.
Pericardial fluid.
i.
Amniotic fluid.
j. Laboratory specimens that contain
HIV (e.g., suspensions of concentrated virus); or
Phone: 800 / 707-5644 • FAX: 916 / 878-5497
13
#CMHIV1 HIV/AIDS: Epidemic Update for Florida Initial Licensure_________________________________ 3. Exposure of skin to visible blood or body
fluids, especially when the exposed skin
is chapped, abraded, or afflicted with
dermatitis or the contact is prolonged
or involving an extensive area.
(d)“Preliminary HIV test” means an antibody
screening test, such as the enzyme-linked
immunosorbent assays (ELISAs) or the
Single-Use Diagnostic System (SUDS).
(e)“Test subject” or “subject of the test”
means the person upon whom an HIV test
is performed, or the person who has legal
authority to make health care decisions for
the test subject.
(3)HUMAN IMMUNODEFICIENCY VIRUS
T E S T I N G ; I N F O R M E D C O N S E N T;
RESULTS; COUNSELING; CONFIDENTIALITY.—
(a)No person in this state shall order a test
designed to identify the human immunodeficiency virus, or its antigen or antibody,
without first obtaining the informed consent of the person upon whom the test is
being performed, except as specified in
paragraph (h). Informed consent shall be
preceded by an explanation of the right to
confidential treatment of information identifying the subject of the test and the results
of the test to the extent provided by law.
Information shall also be provided on the
fact that a positive HIV test result will be
reported to the county health department
with sufficient information to identify the
test subject and on the availability and
location of sites at which anonymous testing is performed. As required in paragraph
(4)(c), each county health department
shall maintain a list of sites at which
anonymous testing is performed, including
the locations, phone numbers, and hours
of operation of the sites. Consent need not
be in writing provided there is documentation in the medical record that the test has
been explained and the consent has been
obtained.
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(b)Except as provided in paragraph (h),
informed consent must be obtained from
a legal guardian or other person authorized
by law when the person:
1. Is not competent, is incapacitated, or is
otherwise unable to make an informed
judgment; or
2. Has not reached the age of majority,
except as provided in s. 384.30.
(c)The person ordering the test or that person’s designee shall ensure that all reasonable efforts are made to notify the test
subject of his or her test result. Notification
of a person with a positive test result shall
include information on the availability of
appropriate medical and support services,
on the importance of notifying partners
who may have been exposed, and on
preventing transmission of HIV. Notification of a person with a negative test result
shall include, as appropriate, information
on preventing the transmission of HIV.
When testing occurs in a hospital emergency department, detention facility, or
other facility and the test subject has been
released before being notified of positive
test results, informing the county health
department for that department to notify
the test subject fulfills this responsibility.
SUMMARY
Although prevention and new medical interventions may reduce the pace of the epidemic, HIV
will be a significant disease for many years both
in the United States and the world. Education
provides the opportunity to ensure that Florida
salon professionals have the information necessary to work with and provide services to persons
with HIV.
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________________________________ #CMHIV1 HIV/AIDS: Epidemic Update for Florida Initial Licensure
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