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________________________________ #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]: 2 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 www.ParagonCET.com ________________________________ #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 3 #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. 4 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. www.ParagonCET.com ________________________________ #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]. www.ParagonCET.com ________________________________ #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]. Phone: 800 / 707-5644 • FAX: 916 / 878-5497 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 8 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 www.ParagonCET.com ________________________________ #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. www.ParagonCET.com ________________________________ #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 Paragon CET • Sacramento, California 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]: 12 Paragon CET • October 2, 2012 • 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. www.ParagonCET.com ________________________________ #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. Paragon CET • Sacramento, California (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. 14 Paragon CET • October 2, 2012 (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. www.ParagonCET.com ________________________________ #CMHIV1 HIV/AIDS: Epidemic Update for Florida Initial Licensure Works Cited 1. Florida HIV/AIDS Hotline. HIV/AIDS Statistics. Available at http://www.211bigbend.org/hotlines/hiv/statistics.htm. Last accessed March 2, 2011. 2. International Partnership for Microbicides. What Are Microbicides? Available at http://www.ipmglobal.org/why-microbicides/ arv-based-microbicides-and-how-they-work/what-are-microbicides. Last accessed March 2, 2011. 3. Boland M. Overview of perinatally transmitted HIV infection. Nurs Clin North Am. 1996;31:155-163. 4. 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Effectiveness of latex condoms as a barrier to human immunodeficiency virus-sized particles under the conditions of simulated use. Sex Transm Dis. 1992;19(4):230-234. 39. UNAIDS. HIV-Related Opportunistic Diseases: UNAIDS Technical Update. Available at http://data.unaids.org/Publications/ IRC-pub05/opportu_en.pdf. Last accessed March 2, 2011. 40. Centers for Disease Control and Prevention. HIV and Its Transmission. Available at http://www.cdc.gov/hiv/resources/factsheets/ PDF/transmission.pdf. Last accessed December 22, 2009. 41. Haile B. The forgotten tenth: AIDS in the older generation. RITA Newsletter. 1998;4(3):15-16. 42. Constantine N. HIV Antibody Assays. HIV InSite Knowledge Base Chapter. May 2006. Available at http://hivinsite.ucsf.edu/ InSite?page=kb-02-02-01. Last accessed March 2, 2011. 43. Montgomery JP, Mokotoff ED, Gentry AC, et al. The extent of bisexual behaviour in HIV-infected men and implications for transmission to their female sex partners. 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