Download HIV/AIDS: Epidemic Update for North Carolina

___________________________________________
#P477 HIV/AIDS: Epidemic
Update for North Carolina
COURSE #P477 — 4 CE HOURS
Release Date: 04/01/15
Expiration Date: 03/31/18
HIV/AIDS: Epidemic
Update for North Carolina
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, received
her undergraduate education at the University of
Tennessee, Knoxville campus. There she completed a
double major in Sociology and English. She completed
an Associate of Science in Nursing at the University
of Tennessee, Nashville campus and began her nursing career at Vanderbilt University Medical Center.
Jane received her Masters in Medical-Surgical Nursing
from Vanderbilt University. In 1978, she took her first
faculty position and served as program director for an
associate degree program. In 1982, she received her
PhD in Higher Education Administration from Peabody
College of Vanderbilt University. In 1998, Dr. Norman
took a position at Tennessee State University. There
she has achieved tenure and full professor status. She is
a member of Sigma Theta Tau National Nursing Honors Society. In 2005, she began her current position as
Director of the Masters of Science in Nursing Program.
John M. Leonard, MD, Emeritus Professor of Medicine,
Vanderbilt University School of Medicine. Dr. Leonard
completed his post-graduate clinical training at the Yale
and Vanderbilt University Medical Centers, and then
joined the Vanderbilt faculty in 1974. He has served as
director of educational programs for the Department of
Medicine and was the Residency Program Director from
1981 to 2003. Dr. Leonard’s clinical experience includes
an active practice of general internal medicine and an
inpatient consulting practice of infectious diseases.
Division Planner
Leah Pineschi Alberto, licensed cosmetologist and
instructor of cosmetology, has been educating students
in Northern California since 1975. In addition, she has
been responsible for training educators in cosmetology,
esthetics, and manicuring for more than 30 years.
Mrs. Alberto began her career with Don’s Beauty School
in San Mateo, California. She held a 30-year position
at Sacramento City College and is currently the State
Board Specialty Learning Leader and is involved in
tutoring and consulting. She is a salon owner, a former Department of Consumer Affairs examiner, and
a speaker at the Esthetics Enforcement Conference.
The health and safety of the community of stylists,
salon owners, and school owners has been the focus of
Mrs. Alberto’s career. She served on the State Board
Task Force on Pedicure Disinfection commissioned by
Governor Schwarzenegger to investigate the cleanliness
of the pedicure industry. The Task Force was responsible
for developing foot spa safety regulations in response
to illnesses and deaths resulting from unsafe pedicure
practices.
Mrs. Alberto is currently a member of the California
Cosmetology Instructors Association.
Audience
This course is designed for all salon and spa professionals
in North Carolina.
Accreditation
Paragon CET courses meet the requirement for continuing education as set forth by the North Carolina Board
of Cosmetic Art Examiners.
Copyright © 2015 Paragon CET
A complete Works Cited list appears on page 18. Paragon CET • Sacramento, California
Mention of commercial products does not indicate endorsement.
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#P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________
Designation of Credit
Paragon CET designates this continuing education
activity for 4 CE hours.
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.
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Paragon CET • May 1, 2015
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. List ethical and legal issues related to
HIV infection.
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___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina
INTRODUCTION
WHAT IS HIV?
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].
According to the Centers for Disease Control and
Prevention (CDC), 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]:
The first reported case of HIV occurred more than
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.
Paragon CET • Sacramento, California
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.
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#P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________
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 longereven decades-with HIV before they develop AIDS.
This is because of “highly active” combinations
of medications that were introduced in the mid1990s.
IMPACT OF HIV
According to the Joint United Nations Programme
on HIV/AIDS (UNAIDS), an estimated 35 million individuals worldwide were living with HIV or
AIDS in 2013, approximately half of which were
women [48; 50]. Eastern Europe (particularly the
Russian Federation) and the Middle East/North
Africa 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 still the hardest-hit area, with more than
two-thirds (71%) of all HIV-infected persons living
in sub-Saharan Africa in 2013 [49]. 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].
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Paragon CET • May 1, 2015
As of 2013, an estimated 1.4 million individuals
were living with HIV/AIDS in the United States
[52]. The CDC estimates that approximately 20%
of these individuals are unaware of their infection
[51]. 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.
Many changes in the progression of the HIV/
AIDS epidemic should be considered. Since the
first reported cases of HIV in 1981 in the United
States, 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., men who have sex with
men [MSM] or injection drug users [IDUs]), new
groups have been identified as being at greater risk.
For example, in the beginning stages of the HIV/
AIDS epidemic in the United States, 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 United States [33]. Women
also have a higher risk of infection. More than half
of HIV infections that result from heterosexual
contact occur in women.
As of 2013, the CDC reported several trends in
the HIV/AIDS epidemic [52]:
• By region, 42% reside in the South,
25% in the Northeast, 19% in the West,
and 12% in the Midwest.
• By race/ethnicity, 43% are black, 32% white,
20% Hispanic, 3% are multi-racial, 1% are
Asian or Pacific Islander, and less than 1%
are American Indian/Alaska Native.
• By gender, 76% of adults and adolescents
living with HIV are male.
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___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina
North Carolina ranks thirteenth in the United
States in terms of number of reported cases of HIV
[1]. As of December 31, 2013, an estimated 28,101
persons were living with HIV in North Carolina,
with 1,525 new diagnoses in 2013 alone [55]. As is
true in the country, the disease has disproportionately affected minorities in North Carolina. Black
persons have the highest rate of HIV in the state,
accounting for 64% of cases.
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 toxoplasmosis, 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, burning sensation in the hands or feet),
extreme weight loss, and chronic diarrhea [39].
Paragon CET • Sacramento, California
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.
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.
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.
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#P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________
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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Paragon CET • May 1, 2015
RISK CATEGORIES
On the basis of newly reported cases, the transmission risk 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, cerebrospinal 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].
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.
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.
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___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina
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% [53]. 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].
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
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.
Paragon CET • Sacramento, California
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,
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 needle sharing, “booting” the injection with
blood, and performing frequent injections increases
the risk. Sharing of equipment is common due to
legal and financial restrictions and cultural norms.
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#P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________
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].
IDUs should be advised [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:
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Paragon CET • May 1, 2015
– 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.
Perinatal Transmission
In the absence of preventive treatment, approximately 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
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.
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___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina
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].
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, haircutting
shears or cuticle scissors) 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. In
2014, there was a documented case of a woman in
Brazil who is believed to have contracted HIV from
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sharing manicure utensils with an older cousin,
later known to be HIV infected [58]. However,
it is important to note that this was the result of
sharing equipment at home, not a salon, where
sanitation procedures should prevent this type of
transmission.
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
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.
In 2010, the CDC started the Hairstylist/Barber
HIV Prevention Initiative, a program to promote
HIV testing and educations in salons, hair shows,
and barber shops [56]. Through this initiative,
hair stylists, barbers, and salon professionals are
encouraged to engage in conversations with their
clients about basic HIV facts, getting tested, and
seeking treatment, if needed. The CDC had provided several tips to salon professionals and barbers
wishing to incorporate HIV education into their
services [57]:
• Share what you have been doing lately and
mention that you are increasing awareness
about HIV and AIDS prevention in your
community.
• Try placing a flyer or other printed material
on your station mirror or around the shop
to spark a discussion about getting the facts,
getting tested, and getting involved.
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#P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________
• Lead the conversation with a fact. You don’t
have to be an expert, just know some simple
facts (for example, more than 1 million
Americans are living with HIV, but nearly
1 in 5 are unaware of their infection).
• During your conversation, allow your clients
to share their thoughts about HIV and AIDS
and help correct any misunderstandings.
• Let your clients know that this will be an
ongoing conversation and that you will be
available to talk privately with them.
• Have a list of resources available to provide
useful phone numbers and web sites.
Several salons in North Carolina participate in the
Hairstylist/Barber HIV Prevention Initiative and
may present Shop Talk Workshops and Special
Events, including [57]:
•
•
•
•
•
•
•
33 Fingers Salon (Charlotte)
Christian Styles Studios Salon (Raleigh)
Ebony and Ivory Hair Designers II (Shelby)
Kreative Image (Lumberton)
Mane Emotions (Durham)
Salon Hair Forte (Dunn)
Unique Touch Salon (Kannapolis)
MANAGEMENT OF
HIV INFECTION
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 three 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.
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Paragon CET • May 1, 2015
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
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.
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 vac-
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___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina
cinated 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://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf.
HIV INFECTION IN
SPECIAL POPULATIONS
WOMEN LIVING WITH HIV INFECTION
Women now make up nearly half of all AIDS cases
worldwide and 23% in the United States [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 tripled from 8% in 1985 to
23% in 2011. 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].
AIDS is the fourth leading cause of death in women
35 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 [28]. Women of color have
been disproportionately affected by AIDS; the
prevalence 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.
Paragon CET • Sacramento, California
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. More than 45% of HIV-infected
women also test positive for some type of human
papillomavirus (HPV) [54]. 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
2013, the U.S. 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].
Phone: 800 / 707-5644 • FAX: 916 / 878-5497
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#P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________
OLDER PEOPLE WITH HIV
Approximately 19% of all persons living with
HIV/AIDS are 55 years of age or older, and 24%
of persons with 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
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.
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].
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___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina
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 pose 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].
Paragon CET • Sacramento, California
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]:
• 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.
Phone: 800 / 707-5644 • FAX: 916 / 878-5497
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#P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________
In 2014, a man was fired from his job as an assistant
manager at a hair salon in Maryland after testing
positive for HIV. Originally, the company used
state regulations to justify its discrimination. However, after investigation, the hairstylist was reinstated and the company issued policy guidance to
reinforce the company’s policy to terminate those
who are living with HIV or another disability [8].
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.
• 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.
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NORTH CAROLINA STATUTES
The state of North Carolina has specific laws and
statutes governing HIV testing, including sections
devoted to informed consent, confidentiality, and
counseling. Knowledge of these statutes may be
useful in ensuring that public health is served and
rights are protected. Portions of the following
statutes are presented as they may apply to salon
professionals and/or the general public [59; 60].
130A-148. LABORATORY TESTS
FOR AIDS VIRUS INFECTION
(g) Persons tested for AIDS virus infection shall be
notified of test results and counseled appropriately.
This subsection shall not apply to tests performed
by or for entities governed by Article 39 of Chapter
58 of the General Statutes, the Insurance Information and Privacy Protection Act, provided that
said entities comply with the notice requirements
thereof.
(h) The Commission may authorize or require
laboratory tests for AIDS virus infection when
necessary to protect the public health.
A test for AIDS virus infection may also be
performed upon any person solely by order of a
physician licensed to practice medicine in North
Carolina who is rendering medical services to that
person when, in the reasonable medical judgment
of the physician, the test is necessary for the appropriate treatment of the person; however, the person
shall be informed that a test for AIDS virus infection is to be conducted, and shall be given clear
opportunity to refuse to submit to the test prior to
it being conducted, and further if informed consent
is not obtained, the test may not be performed. A
physician may order a test for AIDS virus infection
without the informed consent of the person tested
if the person is incapable of providing or incompetent to provide such consent, others authorized
to give consent for the person are not available,
and testing is necessary for appropriate diagnosis
or care of the person.
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___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina
An unemancipated minor may be tested for AIDS
virus infection without the consent of the parent
or legal guardian of the minor when the parent
or guardian has refused to consent to such testing
and there is reasonable suspicion that the minor
has AIDS virus or HIV infection or that the child
has been sexually abused.
(i) Except as provided in this section, no test for
AIDS virus infection shall be required, performed
or used to determine suitability for continued
employment, housing or public services, or for the
use of places of public accommodation or public
transportation.
Further it shall be unlawful to discriminate against
any person having AIDS virus or HIV infection
on account of that infection in determining suitability for continued employment, housing, or
public services, or for the use of places of public
accommodation or public transportation.
Any person aggrieved by an act or discriminatory
practice prohibited by this subsection relating to
housing shall be entitled to institute a civil action
pursuant to G.S. 41A-7 of the State Fair Housing
Act. Any person aggrieved by an act or discriminatory practice prohibited by this subsection other
than one relating to housing may bring a civil
action to enforce rights granted or protected by
this subsection.
The action shall be commenced in superior court
in the county where the alleged discriminatory
practice or prohibited conduct occurred or where
the plaintiff or defendant resides. Such action shall
be tried to the court without a jury. Any relief
granted by the court shall be limited to declaratory
and injunctive relief, including orders to hire or
reinstate an aggrieved person or admit such person
to a labor organization.
Paragon CET • Sacramento, California
In a civil action brought to enforce provisions of
this subsection relating to employment, the court
may award back pay. Any such back pay liability
shall not accrue from a date more than two years
prior to the filing of an action under this subsection. Interim earnings or amounts earnable with
reasonable diligence by the aggrieved person shall
operate to reduce the back pay otherwise allowable.
In any civil action brought under this subsection,
the court, in its discretion, may award reasonable
attorney’s fees to the substantially prevailing party
as a part of costs.
A civil action brought pursuant to this subsection
shall be commenced within 180 days after the date
on which the aggrieved person became aware or,
with reasonable diligence, should have become
aware of the alleged discriminatory practice or
prohibited conduct.
Nothing in this section shall be construed so as to
prohibit an employer from:
(1) Requiring a test for AIDS virus infection
for job applicants in pre-employment
medical examinations required by the
employer
(2) Denying employment to a job applicant
based solely on a confirmed positive test
for AIDS virus infection
(3) Including a test for AIDS virus infection
performed in the course of an annual
medical examination routinely required
of all employees by the employer
(4) Taking the appropriate employment
action, including reassignment or
termination of employment, if the
continuation by the employee who has
AIDS virus or HIV infection of his work
tasks would pose a significant risk to the
health of the employee, coworkers, or
the public, or if the employee is unable
to perform the normally assigned duties
of the job
Phone: 800 / 707-5644 • FAX: 916 / 878-5497
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#P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________
(j) It shall not be unlawful for a licensed healthcare
provider or facility to:
(1) Treat a person who has AIDS virus or
HIV infection differently from persons
who do not have that infection when
such treatment is appropriate to protect
the health care provider or employees of
the provider or employees of the facility
while providing appropriate care for the
person who has the AIDS virus or HIV
infection; or
(2) Refer a person who has AIDS virus
or HIV infection to another licensed
healthcare provider or facility when
such referral is for the purpose of
providing more appropriate treatment
for the person with AIDS virus or HIV
infection.
10A NCAC 41A .0202
CONTROL MEASURES: HIV
The following are the control measures for the
Acquired Immune Deficiency Syndrome (AIDS)
and Human Immunodeficiency Virus (HIV) infection:
(1) Infected persons shall:
(a)refrain from sexual intercourse unless
condoms are used; exercise caution
when using condoms due to possible
condom failure;
(b)not share needles or syringes, or
any other drug-related equipment,
paraphernalia, or works that may be
contaminated with blood through
previous use;
(c)not donate or sell blood, plasma,
platelets, other blood products,
semen, ova, tissues, organs, or breast
milk;
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Paragon CET • May 1, 2015
(d)have a skin test for tuberculosis;
(e)notify future sexual intercourse
partners of the infection;
(f) if the time of initial infection is
known, notify persons who have
been sexual intercourse and needle
partners since the date of infection;
and,
(g)if the date of initial infection is
unknown, notify persons who have
been sexual intercourse and needle
partners for the previous year.
(9) Local health departments shall provide
counseling and testing for HIV infection
at no charge to the patient. Third-party
payors may be billed for HIV counseling
and testing when such services are provided
and the patient provides written consent.
(10)HIV pre-test counseling is not required.
Post-test counseling for persons infected
with HIV is required, must be individualized, and shall include referrals for medical
and psychosocial services and control
measures.
(14)Every pregnant woman shall be offered
HIV testing by her attending physician
at her first prenatal visit and in the third
trimester. The attending physician shall
test the pregnant woman for HIV infection, unless the pregnant woman refuses
to provide informed consent. If there is no
record at labor and delivery of an HIV test
result during the current pregnancy for the
pregnant woman, the attending physician
shall inform the pregnant woman that an
HIV test will be performed, explain the
reasons for testing, and the woman shall
be tested for HIV without consent using a
rapid HIV test unless it reasonably appears
that the test cannot be performed without
endangering the safety of the pregnant
woman or the person administering the test.
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___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina
If the pregnant woman cannot be tested,
an existing specimen, if one exists that was
collected within the last 24 hours, shall be
tested using a rapid HIV test. The attending
physician must provide the woman with
the test results as soon as possible.
(15)If an infant is delivered by a woman with
no record of the result of an HIV test
conducted during the pregnancy and if the
woman was not tested for HIV during labor
and delivery, the fact that the mother has
not been tested creates a reasonable suspicion that the newborn has HIV infection
and the infant shall be tested for HIV. An
infant born in the previous 12 hours shall
be tested using a rapid HIV test.
(16)Testing for HIV may be offered as part of
routine laboratory testing panels using a
general consent which is obtained from the
patient for treatment and routine laboratory
testing, so long as the patient is notified
that they are being tested for HIV and
given the opportunity to refuse.
Paragon CET • Sacramento, California
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 North
Carolina salon professionals have the information
necessary to work with and provide services to
persons with HIV.
Phone: 800 / 707-5644 • FAX: 916 / 878-5497
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#P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________
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#P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________
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