Download Preview the material

1
HIV/AIDS Overview
Introduction
Human immunodeficiency virus has affected individuals worldwide
since it first caused rare illnesses in a select group of individuals in
1980.1 First identified in 1983, human immunodeficiency virus (HIV)
quickly spread, eventually becoming a worldwide pandemic. It has
been estimated that approximately forty million people worldwide live
with HIV,4 and one million of those with HIV reside in the United
States. The disease had a significant impact on Africa, with the
numbers peaking at 2.3 million in 2010. By 1983, HIV was discovered
as the cause of a number of rare cases of Kaposi’s sarcoma and
pneumocystis pneumonia in otherwise healthy individuals.2 In the first
decade, the disease spread rapidly, destroying the immune systems of
those infected. Health clinicians must understand the signs and
symptoms of infection, as well as the various stages of HIV infection.
Overview Of Human Immunodeficiency Virus
Since it was first discovered, HIV has become a worldwide pandemic.3
Initially, HIV was considered a homosexual disease, but it was soon
discovered to be a virus that infected anyone, regardless of race,
sexual orientation, or socioeconomic status.5 HIV attacks, and
eventually destroys, the immune system. During the early stages of
infection, individuals can live symptom free.6 Progression of the
disease varies by patient and can be impacted by a variety of factors.
In the stage of the infection known as HIV, patients often exhibit few
symptoms. When the disease transitions to acquired immune
deficiency syndrome (AIDS) the patient often experiences an increase
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
2
in symptoms and severity of the disease and presents with one or
more opportunistic infections.7,8
Origin of HIV
When HIV emerged in the early 1980s scientists began trying to
determine its origins. After years of research, scientists traced the
virus to chimpanzees in Africa.9 These chimpanzees were infected with
simian immunodeficiency virus (SIV), which is a retrovirus similar to
HIV.9 While HIV did not spread significantly into the human population
until the 1980s, evidence shows that SIV may have infected humans
as early as 1884.10 While there are no documented cases of HIV from
that time period, scientists did discover a documented case of HIV
posthumously in a fifteen-year-old black male who died in 1968.11
There are various theories as to why the virus did not spread in earlier
populations, but there is no definitive answer as to why. Regardless,
something caused the virus to spread in the 1980’s, resulting in the
pandemic that has affected society for the past decades.
Although there is evidence that HIV may have infected humans as
early as 1884, the subtype of the virus that currently infects
individuals has been traced to a more recent time period. Research
shows that HIV most likely spread to humans at three different points
in history, one for each subtype of HIV-1 (M, N, and O).12 The most
common strain of HIV-1, the type that infects most patients today, is
believed to have been transmitted by the Cameroon chimps to humans
in the period shortly before 1931.10 This conclusion was made after
extensive research, which examined the virus in samples of infected
tissue that was collected over the past three decades. Upon
examination of these samples, it was determined that an ancestral
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
3
form of HIV started to spread in the human population approximately
75 years prior.13 Therefore, it is assumed that the transmission from
chimpanzees to humans occurred shortly before that.
History of HIV Development
In June of 1981, the Centers for Disease Control and Prevention (CDC)
reported on five individual cases of a rare lung infection, Pneumocystis
carinii pneumonia (PCP).14 All five individuals were homosexual men
living in Los Angeles, and each patient had been healthy prior to the
onset of infection. Upon further examination, it was determined that all
five men were experiencing other illnesses as well.14 When the CDC
report was released, other medical clinicians submitted reports of
similar cases nationwide. In all cases, patients had been previously
healthy and were presenting with similar infections.2 Among the
infections were reports of a rare form of cancer, Kaposi’s sarcoma.1,5 A
task force was formed to study the incidence of infections and to
determine common causes among the patients.3 In 1981, there were
270 cases reported with 121 deaths.15 By 1982, there were a total of
452 reported cases from 23 states.15
In the two years following the first reported cases, various initiatives
were established to assist with the identification, management and
care of the unknown disease. Initially, the disease was thought to be
specific to homosexual men.5 In fact, in the beginning, many
individuals referred to the disease as GRID (Homosexual-Related
Immune Deficiency).16 While the virus was originally thought to be a
disease only affecting homosexual men, it was soon discovered in
other individuals, especially those who had received blood
transfusions.17,18 In 1982, the term Acquired Immune Deficiency
Syndrome (AIDS) was used to define the syndrome that was affecting
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
4
individuals throughout the country.19 Care centers were established to
help the tens of thousands of patients who were infected with the
disease.16
By 1983, the CDC was able to identify the specific transmission modes
of the disease as through sexual contact and exposure to blood and
blood-borne pathogens.20 The CDC also discovered that the disease
had infected homosexual men, women with male partners, infants and
injection drug users.15 As a result, a public statement was released
warning individuals to refrain from activities that would put them in
contact with the disease.20 Scientists in France identified the specific
virus strain suspected to be causing AIDS as Lymphadenopathy
Associated Virus (LAV),21 while scientists in the United States identified
the virus as the retrovirus HTLV-III.22 After comparing the findings, it
was determined that the two strains were almost identical. It was also
determined that they were most likely the cause of AIDS.10
In 1985, the viral strain became known as Human Immunodeficiency
Virus and was identified as the cause of AIDS.10 As a result, the CDC
redefined the AIDS clinical definition to include HIV as the cause of the
infection. Acquired Immune Deficiency Syndrome was determined to
be an end result of HIV infection.3 While the disease is considered to
have started in 1980, it is now understood that it must have originated
years earlier as an individual can live for many years with HIV before
progressing to the stage of AIDS.13
In the years following the discovery of HIV, significant research
focused on identifying the origin and causes of the virus, developing
treatment, and attempting to find a cure.23 In the late 1980s and
throughout the 1990s, when the virus reached its peak, numerous
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
5
organizations were founded to address the needs of those living with
HIV and to help prevent the spread of the infection.3 During this time,
the stigma associated with the virus impacted how people viewed and
interacted with HIV positive individuals and educational campaigns
aimed at eliminating the stigma were introduced.16 Social service and
case management programs were developed to address non-HIV
issues in patients and training for healthcare clinicians focused on the
effective treatment and management of the virus.16
Since the first reported case of AIDS the disease spread and grew to
significant numbers.10 Human immunodeficiency virus has impacted
individuals throughout the world and has resulted in a worldwide
pandemic which required myriad initiatives to help infected individuals
live with the disease and also to minimize the spread of the infection.
However, by the early 2000s, public knowledge of the virus had
increased. Due to educational programming and patient treatment
strategies, the number of new cases began to decrease.24 In addition,
HIV positive individuals began to live longer and remained relatively
symptom-free for extended periods of time.6 Human immunodeficiency
virus treatment strategies evolved and a multifaceted approach to
disease management became standard protocol for working with HIV
positive patients.25
Epidemiology Of HIV
Over the past decades, HIV has become a worldwide pandemic. Since
the epidemic began, approximately sixty million people worldwide
have contracted the disease.26 Currently, there are approximately forty
million people living with HIV. Of those, one million reside in the
United States.4 Approximately 3 million of the current HIV cases are in
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
6
individuals under the age of fifteen.27 Since 1995, HIV has been one of
the leading causes of death in persons age 25 to 44.28 The total
number of deaths since the virus was first reported total approximately
thirty million worldwide.26
Global Impact
While the epidemic has had a significant impact on the United States,
its impact has been even greater worldwide, with the most significant
numbers occurring in Sub-Saharan Africa.26 More than two-thirds of
the reported cases of HIV are in individuals living in Sub-Saharan
Africa.29 Since the disease began spreading, it has utterly devastated
the country, with the number of reported cases peaking at 2.3
million.30 Due to the lack of adequate care and prevention measures,
the transmission rate of HIV in Sub-Saharan Africa is greater than in
other areas.26
The World Health Organization (WHO) monitors the disease on a global
scale, and reports are issued annually which provide detailed statistics
on the number of reported cases globally and by nation. According to
the WHO, 34.0 million (31.4–35.9 million) people globally were living
with HIV at the end of 2011. An estimated 0.8% of adults aged 15 to
49 years worldwide are living with HIV, although the burden of the
epidemic continues to vary considerably between countries and
regions. Sub-Saharan Africa remains most severely affected, with
nearly 1 in every 20 adults (4.9%) living with HIV and accounting for
69% of the people living with HIV worldwide.29
While HIV has affected individuals on a global scale, the disease has
been reported as most prevalent in Sub-Saharan Africa, where 69% of
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
7
the population is currently HIV positive.26 HIV was reported to also be
the leading cause of death in Africa. This region had the highest
percentage of children who are HIV positive, which is 94%. In nine
countries in this region, at least 10% or more of the population is HIV
positive, and all the nations in the region have generalized HIV
epidemics.31 The highest numbers of people worldwide who are HIV
positive reside in South Africa, and Swaziland had the highest overall
prevalence rate, reported as 26%. The remaining HIV cases were
spread throughout the world, with a high concentration of cases in low
and middle-income countries.32 International and national
organizations responding to the HIV epidemic supported health team
efforts to provide education and health aid to high-risk areas, such as
the U.S. Peace Corps as well as other Africa and interurban initiatives.
HIV Prevalence & Incidence by Region
Region
Total No. (%)
Living with
HIV in 2011
Newly Infected
in 2011
Adult
Prevalence Rate
2011
Global Total
34.0 million
(100%)
2.5 million
0.8%
Sub-Saharan Africa
23.5 million
(69%)
1.8 million
4.9%
South/South-East
Asia
4.0 million
(12%)
280,000
0.3%
Eastern
Europe/Central
Asia
1.4 million
(4%)
140,000
1.0%
Latin America
1.4 million
(4%)
86,000
0.4%
North America
1.4 million
(4%)
51,000
0.6%
Western/Central
Europe
900,000 (3%)
30,000
0.2%
East Asia
830,000 (2%)
89,000
0.1%
Middle East/North
Africa
300,000 (1%)
37,000
0.2%
230,000
(0.7%)
13,000
1.0%
Caribbean
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
8
Oceania
53,000
(0.2%)
2,900
0.3%
Since 2001, the number of new HIV infections has decreased by more
than 20%.26 In low and middle-income countries, the rate of infection
has declined by more than 50%.30 However, even with a decline, there
are still new cases reported each year, and the risk of infection in low
and middle-income countries is still high. In 2011, there were 2.5
million new infections reported, and 1.8 million of the infections were
in Sub-Saharan Africa.32
Between the years 2010 to 2014, the rate of HIV infection diagnosed
for persons aged 25–29 years reportedly increased. The rates for
children (aged less than 13 years) and persons aged 13–14, 15–19,
35–39, 40–44, 45– 49, 50–54, 55–59, and 60–64 years were reported
decreased. The rates of HIV infection for persons aged 20–24, 30–34,
and 65 years and older remained stable. In 2014, the highest rate of
diagnosed HIV infection was for persons aged 25–29 years, followed
by the rate for persons aged 20– 24 years.32 Young women are two
times more likely to test positive for HIV than men of the same age.26
The virus also significantly impacts children under the age of fifteen. In
2011, there were 3.3 million children worldwide who tested positive for
HIV.33 There are many international health organizations, such as
UNICEF, World Camp for Kids, Save the Children, and others
supporting volunteer efforts for children with HIV infections and AIDS.
National Impact
To properly track the HIV epidemic in the United States, reporting of
the virus has been required throughout the country since shortly after
the virus was discovered.24 From 1981 through 1995, the virus spread
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
9
rapidly, and although antiretroviral treatment helped reduce the
number of cases, the virus peaked in the United States in the period
from 1993 to 1995.28 By 1989, the number of reported cases in the
United States reached 100,000, and by 1995 the numbers had
exceeded half a million.28
To accurately measure the impact of the virus in the United States, the
CDC collects information about each reported HIV case. This
information is compiled into surveillance reports that explain how and
where the virus has spread. The reports examine factors such as risk
group, age, gender, status, and geographic location to analyze trends
in viral spread and progression.
The most recent HIV Surveillance Report, released in 2014 by the
CDC, provided information on the period from 2010 to 2014. While the
report itself is very detailed and includes extensive information on the
epidemiology of the virus, the CDC also releases brief reports that
summarize the information and provide basic trend information based
on risk group. The following is the CDC’s most recent summary of HIV
trends from 2010 through 2014.32
HIV Incidence (New Infections)
The estimated incidence of HIV has remained stable overall in recent
years. During the years 2010–2014, the CDC reported the annual
estimated number and rate of HIV diagnoses in the U.S. as increased
in some subgroups while decreased in others. Such variations in trends
among groups were anticipated as a result of public education and
testing outcomes in certain subgroups.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
10
Some groups are affected more than others by HIV infection. Men who
have sex with men (MSM) continued to bear the greatest burden of
HIV infection; and, among races/ethnicities, while African Americans
had been disproportionately affected, from 2010 through 2014, the
rates for American Indians/Alaska Natives and Asians increased while
the rates for blacks/African Americans, Native Hawaiians/other Pacific
Islanders, and persons of multiple races decreased. The rates for
Hispanics/Latinos and whites remained stable. In 2014, the rates were
49.4 for blacks/African Americans, 18.4 for Hispanics/Latinos, 15.4 for
persons of multiple races, 10.6 for Native Hawaiians/other Pacific
Islanders, 9.5 for American Indians/Alaska Natives, 6.2 for Asians, and
6.1 for whites.32
HIV Diagnoses
In 2011, an estimated 49,273 people were diagnosed with HIV
infection in the United States. In that same year, an estimated 32,052
people were diagnosed with AIDS. Since the epidemic began, an
estimated 1,155,792 people in the United States have been diagnosed
with AIDS.4 At the end of 2013, an estimated 516,401 persons in the
United States were living with infection ever classified as stage 3
(AIDS).32
Deaths
An estimated 15,529 people with an AIDS diagnosis died in 2010, and
nearly 636,000 people in the United States with an AIDS diagnosis
have died since the epidemic began.3 The deaths of persons with an
AIDS diagnosis can be due to any cause — that is, the death may or
may not be related to AIDS.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
11
Risk Group
Homosexual, bisexual, and other men who have sex with men (MSM)
of all races and ethnicities remain the population most profoundly
affected by HIV.

In 2010, the estimated number of new HIV infections in MSM
cohorts was 29,800, a significant 12% increase from the 26,700
new infections with MSM in 2008.

Although MSM represent about 4% of the male population in the
United States, in 2010, MSM accounted for 78% of new HIV
infections among males and 63% of all new infections.2 MSM
accounted for 52% of all people living with HIV infection in 2009,
the most recent year these data are available.

In 2010, white MSM continued to account for the largest number
of new HIV infections (11,200), by transmission category,
followed closely by black MSM (10,600).

The estimated number of new HIV infections was greatest with
MSM in the youngest age group. In 2010, the greatest number
of new HIV infections (4,800) with MSM occurred in young
black/African American MSM aged 13–24. Young black MSM
accounted for 45% of new HIV infections among black MSM and
55% of new HIV infections among young MSM overall.

Since the epidemic began, almost 300,000 MSM with an AIDS
diagnosis have died, including an estimated 6,863 in 2009.
Heterosexuals and injection drug users also continued to be affected
by HIV.

Heterosexuals accounted for 25% of estimated new HIV
infections in 2010 and 27% of people living with HIV infection in
2009.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
12

Since the epidemic began, more than 85,000 persons with an
AIDS diagnosis, infected through heterosexual sex, have died,
including an estimated 4,003 in 2010.

New HIV infections among women are primarily attributed to
heterosexual contact (84% in 2010) or injection drug use (16%
in 2010). Women accounted for 20% of estimated new HIV
infections in 2010 and 24% of those living with HIV infection in
2009. The 9,500 new infections among women in 2010 reflect a
significant 21% decrease from the 12,000 new infections that
occurred among this group in 2008.

Injection drug users represented 8% of new HIV infections in
2010 and 16% of those living with HIV in 2009.

Since the epidemic began, more than 182,000 injection drug
users with an AIDS diagnosis have died, including an estimated
4,218 in 2010.
The CDC 2014 surveillance report indicated that between the years
2010 - 2013, the rates of deaths for male and female adults and
adolescents diagnosed with HIV infection decreased. The number of
deaths among males with diagnosed HIV infection attributed to
perinatal transmission increased. The number of deaths among males
with infection attributed to injection drug use, male-to-male sexual
contact and injection drug use, or heterosexual contact decreased. The
number of deaths among males with diagnosed HIV infection
attributed to male-to-male sexual contact remained stable. The
number of deaths among females with infection attributed to injection
drug use or heterosexual contact decreased. The number of deaths
among female adults and adolescents with infection attributed to
perinatal transmission remained stable.32
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
13
Race/Ethnicity
Blacks/African Americans were reported to experience the most severe
burden of HIV, compared with other races and ethnicities.

Blacks represent approximately 12% of the U.S., population, but
accounted for an estimated 44% of new HIV infections in 2010.
They also accounted for 44% of people living with HIV infection
in 2009.

Since the epidemic began, more than 260,800 blacks with an
AIDS diagnosis have died, including 7,678 in 2010.

Unless the course of the epidemic changes, at some point in
their lifetime, an estimated 1 in 16 black men and 1 in 32 black
women will be diagnosed with HIV infection.
HIV had also disproportionately affects Hispanics/Latinos. Data
extracted from literature showed:

Hispanics/Latinos represented 16% of the population but
accounted for 21% of new HIV infections in 2010.2
Hispanics/Latinos accounted for 19% of people living with HIV
infection in 2009.

Disparities persist in the estimated rate of new HIV infections in
Hispanics/Latinos. In 2010, the rate of new HIV infections for
Latino males was 2.9 times that for white males, and the rate of
new infections for Latinas was 4.2 times that for white females.

Since the epidemic began, more than an estimated 96,200
Hispanics/Latinos with an AIDS diagnosis have died, including
2,370 in 2010.27
As mentioned previously, those diagnosed with AIDS in the 2014 CDC
surveillance report indicated that from 2010 through 2014, rates for all
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
14
race/ethnicity groups decreased. In 2014, the rates were 25.4 for
blacks/African Americans, 12.6 for persons of multiple races, 7.7 for
Hispanics/Latinos, 4.0 for American Indians/ Alaska Natives, 3.5 for
Native Hawaiians/other Pacific Islanders, 2.7 for whites, and 2.1 for
Asians.32
HIV Retrovirus And Types
Human Immunodeficiency Virus (HIV) is a retrovirus that attacks the
immune system. Retroviruses are viruses that contain DNA as part of
their genetic material.34 When the virus enters the body, it attacks the
CD4+ T cells (lymphocytes with a central role in cell-mediated
immunity), thereby causing the production of antibodies. Once this
process is initiated, HIV subsequently destroys the immune system by
taking over the helper cells and reducing their ability to protect the
body from other diseases.35 Over time, the body becomes unable to
fight off infection and succumbs to a variety of secondary infections.36
Human Immunodeficiency Virus is often slow to progress, and
individuals who test positive for HIV often exhibit no symptoms for
long periods of time.34 Some individuals will go a number of years
without seeing progression of the virus. In a select few, the virus
never progresses.37
Human Immunodeficiency Virus has been categorized into two distinct
subtypes: HIV-1 and HIV-2. Both types of HIV are transmitted the
same way, but the impact of HIV-2 is less severe than that of HIV-1.
In addition, HIV-2 is not transmitted as easily as HIV-1.35
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
15
HIV Type 1
Human Immunodeficiency Virus Type 1 (HIV-1) is the most common
form of HIV and it makes up the majority of HIV cases worldwide.
When people refer to HIV, they are often referring to HIV-1.38
HIV Type 2
Human Immunodeficiency Virus Type 2 (HIV-2) is a newer
classification of HIV. It is predominately found in West Africa and is not
common amongst HIV cases.39
Subtypes
Human Immunodeficiency Virus mutates rapidly, and there are a
number of subtypes found in both HIV-1 and HIV-2.35 As the disease
continues to evolve, more subtypes found are to be expected. Current
testing methods are able to identify all types and subtypes of HIV.40
Human Immunodeficiency Virus Type 1 can be separated into four
distinct groups, with nine or more subtypes occurring among the four
groups. Group M (“major”) is by far the most common group,
accounting for over 90% of all HIV/AIDS infections. Group N (“non-M,
non-O”), has only been seen in Cameroon. Group O (“Outlier”) is
usually only seen in West-central Africa. Group P (“Pending”) is a new
identified HIV sequence only seen in one women, and is pending
additional discovery in other human cases. While various subtypes are
present, over ninety percent of the infections belong to one group and
subtype. The other subtypes are less prevalent and make up only a
small percentage of HIV infections.35
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
16
Acquired Immune Deficiency Syndrome
Acquired Immune Deficiency Syndrome (AIDS) is the end stage of HIV
infection. AIDS occurs when the immune system has been destroyed
and the individual is unable to fight off other infections.7 Acquired
Immune Deficiency Syndrome is diagnosed when the patient presents
one or more AIDS indicator illnesses or when the patient’s CD4+ T cell
count drops below 200, where normal CD4+ counts range from 500 to
1600.41 Acquired Immune Deficiency Syndrome indicator illnesses,
also known as opportunistic infections, are conditions that a healthy
immune system is typically able to fight off. However, once the virus
has destroyed the immune system, HIV positive patients are more
susceptible to these infections.36 The CDC has identified more than
twenty opportunistic infections that are considered AIDS Indicator
Conditions.42 These are listed below, as:

Candidiasis of bronchi, trachea, esophagus, or lungs

Invasive cervical cancer

Coccidioidomycosis

Cryptococcosis

Cryptosporidiosis, chronic intestinal (greater than 1 month's
duration)

Cytomegalovirus disease (particularly CMV retinitis)

Encephalopathy, HIV-related

Herpes simplex: chronic ulcer(s) (greater than 1 month's
duration); or bronchitis, pneumonitis, or esophagitis

Histoplasmosis

Isosporiasis, chronic intestinal (greater than 1 month's duration)

Kaposi's sarcoma

Lymphoma, multiple forms

Mycobacterium avium complex
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
17

Tuberculosis

Pneumocystis carinii pneumonia

Pneumonia, recurrent

Progressive multifocal leukoencephalopathy

Salmonella septicemia, recurrent

Toxoplasmosis of brain

Wasting syndrome due to HIV
Once an individual develops AIDS, HIV infection has progressed to a
stage that is difficult to manage. Individuals with AIDS are at risk of
life-threatening complications and death related to AIDS acquired
infections.43
Transmission Of HIV
Human immunodeficiency virus is transmitted when an individual
comes in contact with certain body fluids or tissue of an infected
person. For transmission to occur, the infected fluid must come into
contact with a mucous membrane or open wound.44 Individuals who
get infected fluid on their skin are not at risk, unless there is a break
in the skin.
Another method of transmission is through direct injection of the virus
into the bloodstream, which occurs when individuals share needles.
Three conditions must be present for HIV to be transmitted:45
1. There must be an HIV source.
2. There must be a sufficient dose of virus.
3. There must be access to the bloodstream of another person.
If all three conditions are not present, HIV transmission will not occur.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
18
Human immunodeficiency virus is found in the following body fluids:46

Blood

Vaginal secretions

Semen

Other body fluids containing blood

Breast milk
Human immunodeficiency virus is transmitted through the following
methods:46

Sexual Intercourse

Injecting Drugs

Mother to Child

Blood Transfusions, blood products and organ/tissue donation
The most common methods of transmission are through sexual
intercourse (anal or vaginal) and sharing needles with an infected
person.47 While other methods of transmission are also a risk, the rate
of transmission is lower. Human immunodeficiency virus is not
transmitted through feces, saliva, sweat, urine, or other bodily fluids.
In addition, HIV is not spread through the air.48 Each method of
transmission must be understood so that proper preventative
measures can be taken.
Sexual Intercourse
Human immunodeficiency virus transmission rates are extremely high
during sexual intercourse. Primary modes of transmission are through
anal or vaginal intercourse.46 While there is a small risk of
transmission during oral intercourse, it is not as common as through
vaginal or anal intercourse.49
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
19
Human immunodeficiency virus is transmitted during sexual contact as
vaginal fluid, pre-semen and semen all contain HIV. Both partners are
at risk of becoming infected with HIV during sexual intercourse.46
During anal sex, the skin lining of the rectum can tear easily, providing
an opening for the infection to enter.50 The inside of the vagina is lined
with mucous membranes that allow the virus to enter the body.46
During penetration, the lining of the vagina can tear, providing
additional locations for the virus to enter the body.44 In the penis, the
urethra provides another route for the infection to enter. Additionally,
the penis may have small cuts or tears in the skin that provide a place
for the virus to enter.44
Intravenous Drugs and Needle Sharing
Along with sexual intercourse, sharing needles is the most common
method of HIV transmission.46 When an individual injects drugs, blood
enters the syringe. If another person uses the syringe after an infected
individual, the infected blood enters the bloodstream of the noninfected individual.51
Human immunodeficiency virus can also be transmitted through
sharing other drug paraphernalia that has come into contact with an
HIV positive person’s blood. This includes the tools used to cook or
dissolve drugs, the water that is used to clean paraphernalia and other
objects used during the drug preparation and injection process.46
Mother to Child
Human immunodeficiency virus can be transmitted from a positive
mother to her child during pregnancy, delivery, and breastfeeding.
Transmission occurs when the infant is exposed to the mother’s
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
20
vaginal secretions or blood that is present in the amniotic fluid.46
Additionally, the virus can be transmitted to the child during
breastfeeding as breast milk also contains trace amounts of HIV.
The risk of transmission depends on the viral load of the infected
mother. The HIV viral load is ordered in conjunction with the CD4 cell
count; high viral load can be anywhere from 5,000 to 10,000
copies/mL. Mothers with a high viral load have a higher chance of
transmitting the virus to their infants during pregnancy, delivery or
breastfeeding.
In the early 1990s, the use of antiretroviral agents to interrupt HIV
transmission were initiated and studied in the U.S. and other wealthy
countries. The avoidance of breastfeeding and improved
comprehensive pregnancy health services led to significantly reduced
perinatal transmission of HIV, and it was estimated that only 69 HIVinfected infants were born in 2013.52
Efforts in less wealthier countries to introduce antiretroviral agents for
perinatal prevention also led to a decrease in perinatal (mother to
child) HIV transmission from over 570,000 in 2003 to an estimated
110,000 in 2015 within the sub-Saharan Africa.52 Transmission from
mother to child is less common than transmission during sexual
intercourse or from sharing needles.46 However, the risk is still
present. With no medical interventions, the risk of transmission from
mother to child is significant.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
21
Blood Transfusions, Blood Products and Organ/Tissue Donation
Human immunodeficiency virus is highly concentrated in blood.
Therefore, blood transfusions and receipt of blood products and
organ/tissue donation can directly transmit HIV from an infected
individual to a non-infected person.53
While HIV is transmitted most easily through direct entrance into the
bloodstream, there is minimal risk of acquiring the virus through blood
transfusions, blood products and organ/tissue donation. An extensive
screening and testing process ensures that these products are HIV free
prior to being given to an individual.46
Probability of Infection
Although HIV has become a worldwide pandemic over the last thirty
years, it is actually more difficult to acquire HIV than it is other
diseases, such as Hepatitis.54 Most cases of HIV are transmitted
through direct sexual intercourse or sharing needles.47 An increase in
the use of preventative measures has had an impact on the probability
of infection after contact with an HIV positive individual.55
The following table from the CDC shows the probability of infection
based on different activities.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
22
Estimated Per-Act Probability of Acquiring HIV from an Infected Source, by
Exposure Act
Type of Exposure
Risk per 10,000
Exposures
Parenteral
Blood Transfusion
9,000
Needle-sharing during injection drug use
67
Percutaneous (needle-stick)
30
Sexual
Receptive anal intercourse
50
Receptive penile-vaginal intercourse
10
Insertive anal intercourse
6.5
Insertive penile-vaginal intercourse
5
Receptive oral intercourse
Low
Insertive oral intercourse
Low
Other
Biting
Negligible
Spitting
Negligible
Throwing body fluids (including semen or saliva)
Negligible
Sharing sex toys
Negligible
Vulnerable Populations
While HIV can infect anyone who comes into contact with the virus,
there are certain populations that have a higher risk of acquiring the
disease than others. These are defined as vulnerable populations.
Populations most vulnerable to HIV infection are sex workers, drug
users, men who have sex with men, partners and those living with an
HIV infected individual, and prisoners.46 Additional education and
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
23
prevention measures are necessary to help these populations avoid
becoming infected with HIV.
Co-Infection with Other Sexually Transmitted Disease’s
Individuals who engage in the type of risky behaviors that can
transmit HIV are often co-infected with other sexually transmitted
diseases (STDs) and infections.57 Individuals who are already infected
with other STDs are at an increased risk of developing HIV because
their immune systems are already compromised.58 Some STDs cause
lesions or other breaks in the skin that make it easier for HIV to enter
the bloodstream. Others cause an increase in pus and bleeding at the
site, which provides a source for infection.57 In addition, these
individuals are more at risk because they are engaging in the type of
behaviors that regularly transmit STDs and other infections, such as
Hepatitis C.57,59
Approximately one-third of HIV positive individuals in the United
States are also infected with Hepatitis C.60 Co-infection poses problems
in the management and treatment of HIV, as the disease tends to
progress rapidly and cause more complications.60 Since the liver is
already damaged from Hepatitis C, antiretroviral treatment for HIV
poses a greater risk of permanently destroying the liver.61
Workplace Exposure
Individuals who work in occupations that put them at risk of coming in
contact with the body fluids of infected individuals are considered to
have an occupational risk of acquiring the disease. The occupations
that pose the greatest risk for exposure to HIV include: healthcare
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
24
workers, emergency personnel, law enforcement officials, mental
health workers and correctional employees.46 Ultimately, anyone who
has the potential to come in contact with the bodily fluids of an
infected individual is at risk. Healthcare workers are at greatest risk of
acquiring HIV as they often work directly with the body fluids of
infected individuals.
The most common cause of transmission in healthcare workers is by
needle stick.62 While individuals are at risk of acquiring HIV,
occupational transmission rates are very low. The chance of getting
HIV from a needle stick is less than 1%.46 However, individuals who
work in occupations that put them in contact with the bodily fluids of
infected individuals should still take the necessary precautions to
prevent the spread of infection.
Prevention Of HIV
Proper prevention strategies help to reduce the spread of HIV. Since
HIV is transmitted through sexual intercourse, sharing needles,
contact with infected blood and blood products, and from mother to
child, a variety of methods should be employed to prevent the spread
of infection. An important step in preventing transmission of HIV is to
properly identify active cases. Therefore, regular testing and diagnosis
of new HIV infections is crucial.63 In the United States alone,
approximately twenty percent of people who are infected with HIV do
not know that they have the virus.64
Individuals who do not know that they are HIV positive do not take the
same precautions as those who do know their status, thereby
increasing the chances of transmitting the virus to someone else.48
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
25
Specific prevention measures should be utilized for each method of
transmission, which will ensure universal precaution.
Sexual Intercourse
Abstinence
The most reliable way to prevent HIV transmission is to abstain
completely from sexual activities. This method of prevention is 100%
effective. However, few individuals are receptive to this form of
prevention, so other prevention strategies must be introduced and
encouraged.65
Monogamy
Monogamy is the practice of having only one sexual partner. This
strategy only works if each person has a confirmed negative status
prior to committing to a monogamous relationship.66 Individuals who
practice complete monogamy can engage in all forms of sexual activity
with each other because the risk of transmitting HIV is non-existent.
The exception to this is if one partner is an intravenous drug user, as
he or she is at risk of acquiring the disease through needle sharing and
then passing it to his or her sexual partner.65 Another strategy
involves limiting sexual partners to minimize the potential of
transmission. However, this strategy does not reduce the risk as
greatly as abstinence or monogamy.66
Individuals who choose to engage in sexual intercourse with a variety
of partners can take precautions to prevent the transmission of HIV.
These strategies are discussed further below.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
26
Condoms
Latex and polyurethane condoms are an effective means of preventing
the transmission of HIV when used correctly. In recent studies, female
condoms have also been proven to prevent the transmission of HIV.65
Condoms can be used during penetration and also to prevent
transmission of HIV during oral sex on a man.49 To work properly, all
condoms must be stored and used properly. Condoms should be kept
in a cool dry place. Condoms should not be stored in a wallet or other
place that could cause the material to break down, thereby resulting in
tears that could allow the virus to get through the barrier.67
Non-Penetrative Sexual Activity
Minimizing penetration during sexual activities is one method that
helps reduce transmission of HIV. With this method, individuals refrain
from anal or vaginal penetration during intercourse, engaging in other
sexual activities instead. Through this prevention strategy, individuals
are less likely to transmit bodily fluids that may contain HIV.65
Dental Dams
Dental dams are thin pieces of latex that can be used as a barrier
during oral sex on a woman. Dental dams cover the surface of the
vagina and reduce contact with vaginal secretions.49
Injection Drug Use
Individuals who inject drugs can prevent transmission of HIV by
reducing the amount they come into contact with the blood of other
users. Other than refraining completely from using injection drugs, the
best way to prevent HIV transmission during injection drug use is to
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
27
never share needles or other drug paraphernalia.51 For injection drug
users who cannot ensure a clean, new needle during each injection,
there are two strategies that will help prevent the spread of infection.
Needle Sterilization
Injection users who share needles with others should clean needles
and all syringe parts between uses. Syringes and needles should be
cleaned using water and bleach. The syringe should first be rinsed with
water to remove any traces of blood, followed by full strength bleach.
The bleach should remain in the syringe for thirty seconds or longer
and should be followed by a rinse with clean water.51 While cleaning
needles and paraphernalia with bleach can be effective in preventing
the spread of HIV, success is dependent on the individual properly
following the guidelines. Therefore, there is a large margin of error and
many individuals still become infected with HIV even after sterilizing
paraphernalia.68
Needle Exchange
The most effective method of preventing the spread of HIV among
injection drug users is through needle exchange programs.68 Injection
drug users can exchange their dirty needles and syringes for new,
clean paraphernalia at registered needle exchange centers.
Individuals can be assured that the sites are safe and secure and they
will not be penalized for using illegal substances. These programs are
meant as a way to help prevent the spread of HIV, not as a means of
catching illicit drug users.68
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
28
Mother to Child
A mother infected with HIV is at risk of passing the infection on to her
child during pregnancy, delivery and through breastfeeding if
appropriate preventative measures are not taken.46,52 With proper
prevention strategies, the risk of transmission from mother to child is
lower than five percent.52
Mothers who are treated with antiretrovirals during pregnancy
significantly reduce the risk of transmitting HIV to the child.
Antiretroviral therapy has been shown to reduce the rate of
transmission during pregnancy and delivery from approximately 25%
to 5%.52,69 A woman who is HIV positive and pregnant should start
antiretroviral therapy immediately and should be monitored closely
throughout her pregnancy.69 Special precautions should be taken
during delivery to minimize the infant’s contact with the mother’s
blood and vaginal secretions. A cesarean may be recommended, but
should be done so only after careful consideration by the attending
physician.52 Human immunodeficiency virus is present in breast milk.
Therefore, a mother who is HIV positive should not breastfeed her
child. During treatment, an HIV positive mother should be given
information regarding breastfeeding and HIV transmission and she
should be encouraged to refrain completely from breastfeeding.52
Blood Transfusions, Blood Products and Organ/Tissue Donation
Blood transfusions, blood product donation and organ/tissue donation
pose a great risk for HIV transmission if not monitored closely. In
1985, new requirements were instituted for screening blood and blood
products in the United States. All blood and blood products are tested
for HIV prior to use and infected blood is discarded immediately.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
29
Human immunodeficiency virus testing is also done on all organ and
tissue donations to ensure that HIV is not transmitted during the
donation process.70
Healthcare Workers
Proper prevention strategies ensure that healthcare workers who
regularly come into contact with bodily fluids do not acquire HIV from
infected patients. The rate of transmission of HIV in healthcare
workers is extremely low. Since 2001, there have been no reported
cases of HIV transmission in healthcare workers.62 Healthcare workers
have been expected to follow standard precautions to ensure that they
do not acquire HIV from infected patients, which has resulted in
relatively low rates of transmission. Healthcare workers are expected
to adhere to the following standards when working with all patients,
whether or not they are confirmed HIV positive.
Universal/Standard Precaution
Healthcare workers are required to treat all patients as potentially
infected, and to take all preventative measures. The CDC has issued
the following recommendations for healthcare workers to practice
universal precaution:71

routinely use barriers (such as gloves and/or goggles)
when anticipating contact with blood or body fluids

immediately wash hands and other skin surfaces after
contact with blood or body fluids

carefully handle and dispose of sharp instruments during
and after use
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
30
Universal precaution was standard protocol until 1996, when the
terminology changed to standard precaution.62 When healthcare
providers practiced universal precaution, the main goal was to utilize
protective measures to prevent themselves from coming into contact
with blood borne pathogens and other disease that could result in
infection.71 Universal precaution focused on infectious agents present
in blood. Standard precaution expanded the definition to include
protecting other patients and individuals in the clinical setting.
Standard precaution also treats all bodily fluids, with the exception of
sweat, as potential disease carriers.71
Personal Protective Equipment
Healthcare workers are required to use personal protective equipment
when working with patients to minimize the spread of infection.
Personal protective equipment should be worn whenever there is a
chance that the provider will come in contact with a patient’s blood or
other bodily fluids. Standard protective equipment includes gloves and
masks, as well as face shields and protective eyewear when
appropriate.72
Sharps Disposal
Sharps needles, scalpel blades and any other sharp objects must be
disposed of properly to prevent the possibility of accidental needle
sticks or punctures. Proper disposal requires that the items be
immediately removed from the utensils and placed directly in properly
labeled sharps containers. Needles and other sharp tools must not be
left on counters or disposed of in standard trash containers as this
increases the risk of accidental sticks and cuts.71,72
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
31
Post-Exposure Precautions
When an individual has been exposed to HIV, either occupationally or
through sexual activity or needle sharing, immediate precautions can
help reduce the likelihood that the individual will become HIV
positive.73 When an individual comes into contact with the bodily fluids
of an HIV positive individual, a standard set of procedures is initiated.
These procedures are known as post-exposure prophylaxis. Postexposure prophylaxis is specific to the individual exposure, but often
include immediate first aid, counseling and testing services.74 In some
cases, a 28-day course of antiretrovirals is prescribed to prevent HIV
from spreading throughout the body.75 Post-exposure prophylaxis is
standard protocol for healthcare workers who have come into contact
with blood or other bodily fluids.71 However, the use of post-exposure
prophylaxis is expanding to other individuals who have been exposed
to the virus, including victims of sexual assault and those who have
engaged in high risk activities with HIV positive individuals.76
Vaccine
Since HIV was first discovered, researchers have attempted to develop
a vaccine to prevent the spread of the infection. However, due to the
unique nature of the virus and the way it attacks the immune system,
this has been difficult.16 Over the years, numerous vaccine trials have
been performed using animal subjects. While these trials have helped
scientists identify potential vaccine options, they have not resulted in
the successful development of an effective vaccine.24
Currently, no vaccine exists for HIV. However, scientists continue to
conduct trials and are much closer to developing a vaccine than they
were in the past. In 2009, a trial in Thailand showed a protection rate
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
32
of thirty one percent with a trial vaccine study.77 This has been the
most significant result thus far. Since 2009, research has focused on
improving the results and determining exactly how the vaccine
worked.78 In 2011, after further research and development, a vaccine
was approved to begin trials on humans.79 While no vaccine currently
exists, there is the potential that one will be developed in the near
future.
Diagnosis Of HIV
Early diagnosis of HIV is imperative to ensure that the illness does not
progress beyond the early stages. If HIV is diagnosed while it is still in
the early stages, the potential for the patient to remain symptom and
complication free is increased significantly.80 Once the disease
progresses, treatment is less successful and further complications can
develop.81
Signs and Symptoms
In the early stages of HIV infection, an individual may present very
few symptoms. However, there are some signs that may indicate
infection. Within the first two months of infection, individuals might
experience flu like symptoms such as fever, fatigue, headache, muscle
soreness, rash and other typical flu symptoms.82 Once the virus
progresses, an individual can remain symptom free for ten or more
years, which can make it difficult to diagnose the disease.82 Providers
must rely on information obtained from the patient regarding sexual
activity, drug use, and high risk behaviors and encourage patients to
undergo testing to determine if they are HIV positive.55
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
33
Once HIV progresses to a more severe stage, it will produce more
symptoms and will make it easier for healthcare providers to identify
and diagnose the disease.82 HIV itself does not produce symptoms, but
in the later stages of infection, individuals are more susceptible to
other infections because of their compromised immune systems.82 As
individuals present these symptoms, healthcare providers can screen
for HIV and begin treatment.
Some of the symptoms that patients my present as the illness
progresses include:36

diarrhea

unexplained weight loss

persistent fever

persistent cough

persistent vaginal candidiasis (women)

thrush/oral candidiasis

enlarged lymph nodes or other swollen glands
Since many of the symptoms present in HIV positive individuals mirror
symptoms of other illnesses, it is difficult to identify and diagnose HIV.
Healthcare providers should discuss these symptoms with their
patients and inquire about past and current risky behavior as part of
the diagnosis process.63 HIV testing should be recommended as part of
this process.
Once an individual has transitioned from HIV to AIDS status, more
symptoms will be present. AIDS is characterized by an increase in
opportunistic infections, most of which cause specific symptoms. The
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
34
immune system of an AIDS patient has been destroyed by HIV, which
results in more pronounced illness.83
Diagnostic Testing
Since HIV does not produce concrete signs and symptoms in the early
stages of infection, it is imperative to counsel all patients to undergo
regular testing any time they engage in high-risk behavior.84 Early
diagnosis and treatment can minimize the impact of HIV on the
immune system and can enable a patient to live with the illness for a
long time without progressing to later stages of infection, such as
AIDS.83 Any individual who engages in behaviors that can transmit the
infection should regularly be tested for HIV. There are two different
testing options:
Confidential
With confidential testing, patients provide their full name and medical
information and consent to having the testing information recorded in
their medical records. Even though their information is provided, the
results of the test are kept confidential and are only given to the
patient. All confidential testing results are reported to the Department
of Public Health for tracking purposes, but the patient’s name is not
attached to the report.85
Anonymous
Anonymous testing is completely anonymous. Patients do not provide
their names or medical information. Results are not linked to a
patient’s name or medical record.85
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
35
Informed Consent
In both confidential and anonymous testing, the patient is required to
give informed consent. Testing cannot occur if the patient does not
consent to the procedure.85
Counseling
Pre- and post-test counseling is recommended for all patients.
Counseling can be administered by the testing provider or through
direct referral to a provider. While counseling is recommended, it is
not mandatory. Patients have the option to opt out of pre- and posttest counseling without being denied the right to test.84
Pre-Test Counseling
Counseling prior to testing should focus on behavior expectations and
change. Patients should be encouraged to consider risky behaviors and
identify strategies for reducing future risks. Patients should also be
encouraged to discuss the potential effects a positive result will have
and identify strategies for coping with the result.86
Post-Test Counseling
Individuals who are negative may opt not to have any post-test
counseling. If they do consent to post-test counseling, the discussion
should focus on how to change future behaviors to minimize the
potential of acquiring the virus.84 Individuals who test positive will
require more in-depth counseling. In most instances, the testing
provider will provide the post-test counseling.85 However, there are
occasions when the patient will need to be referred to someone else
for counseling. Post-test counseling for HIV positive individuals must
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
36
include information on reporting requirements and partner notification
services.86
Post-test counseling for positive individuals must also include referrals
to appropriate services, including mental health counselors, medical
providers, drug and alcohol counselors and other appropriate
personnel.84 Counseling should also include discussions of prevention
and treatment strategies, as well as strategies for notifying friends and
family members.86
Types of Testing
HIV is diagnosed using either screening or confirmatory tests. In all
cases, tests screen for HIV antibodies, not the virus itself.40
Screening Tests
Initial HIV testing is done through the use of a screening test. This is
the first option for testing because it is less expensive than
confirmatory testing and easier to perform.87 However, screening tests
are also less reliable than confirmatory tests, so a positive test result
should always be verified using a confirmatory test.40 The primary
form of screening test is the ELISA (enzyme-linked immunosorbent
assay) test. The ELISA test is done to screen for HIV antibodies in a
serum specimen taken from the individual.40 ELISA tests can detect
HIV antibodies in the following specimens:
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
37
Blood
The majority of ELISA tests screen for HIV antibodies using a patient’s
blood sample. Blood can be extracted using venipuncture or a
fingerstick.87
Oral Fluid
Some test kits allow patients to use samples collected from the oral
mucosal transudate (mucous membrane of the mouth). A common
misconception is that these tests detect antibodies in the saliva of the
patient, however the antibodies are actually detected in the lining of
the mucous membrane. These tests use a special collection instrument
to gather cells from the lining of the mouth. The sample is then sent to
a lab for testing.87
Urine
Human Immunodeficiency Virus antibodies are present in the urine of
infected patients. New screening tests are now available that can
detect these antibodies using standard sample of urine from the
patient. These tests are typically conducted in a doctor’s office.
However, while screening tests can detect antibodies in the urine,
there is currently no confirmatory test that can test urine. Therefore, a
confirmatory test will still need to be done using a blood sample.40
Confirmatory Tests
Once a patient has had an initial positive result from a screening test,
a confirmatory test must be conducted to verify the positive result.87
Confirmatory tests are more expensive than screening tests, so they
should only be used to confirm a positive result, not as an initial
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
38
screening for a patient who suspects he or she may be infected with
the virus.40 Most screening tests are conducted in a laboratory. The
sample is collected and sent to the laboratory for testing. When a
sample is positive, a confirmatory test is conducted on the same
sample. Although screening tests are highly accurate, some screening
tests can produce a false positive because the enzyme reacts to
specific proteins present in the sample.87 These proteins are often a
result of other autoimmune diseases.40
The use of a confirmatory test following a positive result on a
screening test will ensure proper diagnosis of HIV infection. The most
common confirmatory test is the Western Blot;87 sometimes called the
protein immunoblot, it is a widely approved method to detect specific
proteins. It uses gel electrophoresis to isolate specific proteins by their
length. These proteins are then transferred to a membrane and are
attached to antibodies that react to the protein being tested.
Rapid Testing
Although most samples are sent to laboratories for testing, there is the
option to have patients screened using a rapid serologic test. These
tests provide results in approximately thirty minutes and do not
require the sample to be sent to a laboratory. Rapid tests differ from
ELISA tests in that they measure antibodies using different
mechanisms. Rapid test kits are less sensitive than ELISA tests, but
they are easier to use and are quite accurate. Test results from a rapid
test kit still require validation from a confirmatory test as rapid tests
are only screening tests.88
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
39
Home Test Kits
Some patients choose to conduct their own HIV testing using a Federal
Drug Administration (FDA) approved home test kit. Home test kits
provide patients with the option of testing without having to utilize the
services of a health clinic or testing center. Home test kits require the
patient to provide a small blood sample, which is sent to the testing
company via mail. The sample is mailed in packaging that is provided
with the test kit and which adheres to appropriate mailing standards
for the transfer of bodily fluids. The testing company conducts the test
and positive results are confirmed using an on-site Western Blot
confirmatory test.89 Home test kits provide another option for
individuals, but they do not ensure appropriate pre- and post-test
counseling.40
Additional HIV Tests
Traditional screening and confirmatory tests are recommended for
individuals to determine their HIV status. However, additional testing
methods do exist and can be used to determine HIV infection levels in
specific populations, such as healthcare workers who are exposed to
the infection occupationally.76 These tests are expensive and are not
recommended as initial screening tests.
p24 Antigen Test
The p24 Antigen Test detects core protein of HIV, which is present in
the early stages of HIV infection. Core protein levels drop and
eventually disappear once the body produces antibodies to the virus.
Therefore, the p24 antigen test should only be used immediately
following exposure to an infected individual.90
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
40
Plasma HIV rNA Test
Viral load can be determined through the Plasma HIV RNA test, which
can detect levels of the virus in a person’s blood approximately nine
days after infection occurs. Since this tests levels of the virus, there is
no chance of a false positive.91 Plasma RNA HIV tests are not used as
screening tests in the general population, but can be used to
determine infection in individuals who know they have had direct
exposure to the virus. This test is often used on healthcare workers
who receive a needle stick from an infected patient.76
The p24 Antigen Test and the Plasma HIV RNA Test listed above are
not used as primary screening tests for individuals because most
people who request testing have passed the window phase of infection.
The window phase of infection is the stage when no antibodies have
been produced in response to the infection. Therefore, traditional
screening tests will easily diagnose an HIV positive status.40 The above
tests are best used in patients who have been exposed to the bodily
fluids of an infected individual through sexual intercourse, needle
sharing or accidental needle stick and need to determine status
immediately following the exposure so that appropriate treatment can
begin.90
Test Results
During the screening process, test results can be negative, positive,
and indeterminate. Depending on time that has elapsed since
infection, negative results may not be accurate.82
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
41
Window Period
When an individual is infected with HIV, there is a window period
during which no antibodies are present.40 Since screening tests
measure the antibodies present in the individual, test results may
come back negative even though the individual is infected.82 Some
people may produce enough antibodies within a few weeks of
becoming infected, but others can take up to twelve weeks.38
Therefore, the window period is defined as three months to ensure
antibodies have time to develop.36 If an individual receives a negative
test result while in the window period, it is recommended that another
test be conducted once the window period has ended to ensure
accuracy.40
Negative Results
Negative test results verify that there are no antibodies present in the
specimen. Unless an individual is still in the window period, these
results can be considered accurate.82 There are no false-negative
results once an individual has passed the window period.92
Positive Results
A positive screening result confirms that the screening test has reacted
positively to antibodies in the specimen.40 Positive results are quite
accurate. However, the test occasionally reacts positively to antibodies
produced by other autoimmune disorders.93 Therefore, a confirmatory
test is required to ensure accuracy. A positive confirmatory result
verifies that a person is HIV positive.87
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
42
Indeterminate Results
Although rare, a confirmatory test will sometimes provide an
indeterminate result, meaning there is not enough evidence to
conclude that an individual is HIV positive or negative.92 Indeterminate
results can occur when a patient is newly infected and has not
produced enough antibodies. Indeterminate results can also be caused
by other factors, including recent vaccination, pregnancy and the
presence of other autoimmune disorders.93
If an individual is considered high risk, further testing can be done,
including p24 antigen testing or HIV RNA testing. However, these tests
should only be used if an individual is thought to be in the window
period. For individuals whose risk is low, no additional testing is
recommended.87
Reporting Test Results
Once an individual is determined to be HIV positive, the information
should be disseminated to the appropriate parties. It minimum, this
includes basic reporting to the CDC. However, infected individuals are
encouraged to notify those they might have exposed to the virus as
well.94
Reporting Requirements
As of 2008, confidential, name based reporting of HIV cases is
conducted in the United States. This information is used to compile
surveillance data for the Centers for Disease Control.95 Prior to 2008,
various methods were used for data collection and reporting, which
negatively impacted the effectiveness of surveillance reports.87
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
43
Partner Notification
To prevent the transmission of HIV through early testing and
diagnosis, individuals are encouraged to notify their past and current
sexual partner and/or those they have shared needles with during
drug use.96 Post-test counseling provides information regarding
partner notification. Patients can notify their partners themselves, or
they can use a partner notification service.86 This is a free service that
is provided by testing and healthcare centers. When partner
notification occurs, the individual receives notification that he or she
may have been exposed to HIV through an individual who has been
confirmed as HIV positive.96 The name and identifying information of
the infected individual is not revealed. The recipient of the information
is given instructions regarding testing options and counseling services
available.86
Early diagnosis and treatment is imperative in helping prevent the
spread of the infection to other individuals.83 Partner notification
services allow individuals to inform past and current partners of the
potential risk without having to identify themselves as HIV positive.
The Clinical Stages of HIV Infection
To truly understand how HIV progresses, an understanding of the
biology of the virus and the functions of the immune system is
necessary. HIV uses the immune system to replicate itself and
increase the viral load in the body.96 Therefore, it is essential to
understand both systems and how they function together.
Human immunodeficiency virus belongs to a group of viruses known as
retroviruses. Retroviruses are unique because they store their genetic
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
44
material on long strands of Ribonucleic Acid (RNA). Almost all
organisms, including most viruses, store their genetic material on long
strands of DNA. While the structures of DNA and RNA are similar, the
two molecules do have some differences that make it more
complicated for HIV to replicate than those viruses that store their
genetic material on strands of DNA. HIV cannot live outside of a
human host and it relies on CD4 cells to replicate.
Once HIV enters the body, it immediately begins to attack the immune
system as it seeks a host for the replication process.97 Any virus that
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
45
cannot enter a human body dies within hours.98 Since HIV cannot
replicate in the absence of a human host, there is no increase of
infectiousness. However, as soon as HIV enters the body, it begins the
process of replicating and taking over the host’s immune system.100
The virus is able to quickly and efficiently replicate using the attributes
of its own genetic makeup combined with those of the host cell.101 The
human immune system is the ideal breeding ground for HIV and the
viral load rapidly increases within the first few weeks of infection.97
Meanwhile, the healthy immune system becomes depleted as CD4 cells
are destroyed during the replication process.99
The Biology of HIV
Human immunodeficiency virus is a spherical shaped virus, comprised
of an outer coat, known as a viral envelope. The viral envelope is
made up of two layers of lipids that are hijacked from the membrane
of a human cell after the formation of a new virus particle, known as a
virion.99 There are proteins embedded within the viral envelope that
came from the host cell, along with approximately 72 copies of a
complex HIV protein.102 The HIV protein, which is called Env, protrudes
from the surface of the virus. Env is comprised of molecules called
glycoprotein 120 (gp120) and glycoprotein 41 (gp41), which secure
the molecule in the viral envelope.99 The inside of the nucleoid
contains Viral Genomic RNA and the associate enzyme called reverse
transcriptase (RT).98 Two proteins known as Transmembrane
Glycoprotein and Envelope Glycoprotein surround the outer layer, or
envelope. These proteins enable HIV to bind and fuse with another
target cell.99
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
46
The core of the virus is bullet-shaped and contains approximately
2,000 copies of the viral protein, p24.99 Within the core are two
strands of HIV RNA, both of which contain complete copies of the viral
genes.102 The information needed to make the structural proteins for
new virus particles exist within the virus’s structural genes: gag, pol,
and env. The core also contains the HIV nucleocapsid protein p7.
Between the viral core and the viral envelope is the HIV matrix protein
called p17.98,99
HIV uses regulatory genes to aid in infecting a cell.100 There are six
genes total (tat, rev, nef, vif, vpr, and vpu), and they all contain the
necessary information that will enable the virus to produce the
proteins that will control the ability of HIV to infect a cell, produce new
copies of virus, or cause disease.102 The virus also contains three
enzymes that it uses to take over a cell and complete the replication
process, thereby increasing the amount of virus in the body. The
three enzymes are: reverse transcriptase, integrase, and protease.100
At the end of the strand of HIV RNA is the long terminal repeat (LTR),
which is able to control the production of new viruses by acting as a
switch.99 Proteins from HIV or the host cell activate the LTR.98
The Immune System
The immune system is complex and has myriad ways of fighting off
foreign agents. When a virus enters the body, the immune system
responds by initiating specific processes that work together to defend
the body from the invader. The first stage of defense involves
recognition of the foreign agent and delivery of the agent to the lymph
system. Once in the lymph system, a macrophage acts quickly to
ingest and eliminate the agent.103
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
47
Once the macrophage ingests the agent, it processes it and displays
the antigens for the virus on its exterior. The antigen acts as a signal
for the helper T-cells.104 Once a helper T-cell recognizes and deciphers
the signal, it sounds an alarm for the rest of the immune system to
respond.103 The first responder is the B-cell, which reads the antigen
from the surface of the macrophage and is activated to produce
antibodies that are antigen specific.103 The released antigens then
spread throughout the body and attach to the virus particles.104 The
antibodies assist the immune system during the invasion as the virus
attempts to outnumber the immune cells. The antibodies attach to the
antigens and send signals to the macrophages and immune cells to
destroy the antibody and whatever it has captured.104 Once the level
of agents has decreased significantly, and the infection has been
eliminated, the suppressor T-cell sends a signal to other cells so that
they can stop acting against the agent.103
HIV Replication
Human immunodeficiency virus cannot replicate without an
appropriate host. It relies on cells within the human body to complete
its lifecycle and will die if it does not locate a host within a short period
of time.99 Once HIV enters the body, it immediately begins its
replication process.101 HIV relies on CD4+ T cells for the replication
process. When HIV enters a body, it seeks out CD4 cells and attaches
to them.97 The spiky surface enables the virus to attach to the CD4
cell, after which the viral envelope fuses with the cell membrane.100
Once fusion occurs, the HIV particle releases its contents into the cell
and leaves the empty envelope behind.99
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
48
After the virus releases its particles into the cell, the reverse
transcriptase enzyme begins its conversion process. During this
process, the enzyme converts viral RNA into DNA, which is recognized
and accepted by the human genetic material.101 The converted DNA is
transported to the cell’s nucleus. From there, it is converted to human
DNA by the HIV enzyme integrase.97 Once the integration is complete,
the converted DNA becomes a provirus.99
Once the virus becomes a provirus, it can lie dormant for an extended
period of time. It will not begin the next phase of the replication
process until the cell is activated.99 Once the cell is activated, it treats
the HIV genes as if they are human genes.97 The first stage of
replication involves using human enzymes to convert the HIV genes
into messenger RNA, which are removed from the nucleus.98 The
messenger RNA is then used as a blueprint for the production of HIV
proteins and enzymes.99
The strands of messenger RNA contain complete copies of HIV genetic
material.99 When these copies come together with the newly formed
HIV proteins and enzymes, they produce new viral particles. The new
particles are released from the cell as part of a process called
“budding”.105 At this point in the HIV lifecycle, the enzyme protease
takes on a crucial role. Protease works by chopping the long strands of
protein into smaller pieces. These smaller pieces of protein are then
used to construct mature viral cores.99
The mature viral cores are the result of a complete HIV lifecycle and
are ready to begin the process with new CD4 cells.101 These new cells
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
49
seek out CD4 cells and begin to replicate. This process enables HIV to
spread very quickly and eventually destroy the immune system.97
Stages of HIV Infection
Human immunodeficiency virus is a progressive illness. Once HIV
enters an individual’s body, it goes through seven stages of infection.97
Healthcare providers should be familiar with the various stages of
infection so that they can best treat and manage the illness in their
patients. The first three stages of infection are all part of the window
period, during which an individual might not test positive for HIV.40
Once a person passes through the first three stages, he or she will
have enough antibodies present to cause a positive reaction on a
screening test.92
Viral Transmission
Viral transmission is the first stage of HIV infection and refers to the
period during which the virus enters the body from an infected source.
Viral transmission occurs immediately, and the disease quickly
transitions to the next stage of infection.98
Primary HIV Infection
The first few weeks after viral transmission are known as the period of
primary HIV infection. During this time, individuals may experience
flu-like symptoms such as a sore throat, fever, rash, swollen lymph
nodes, and fatigue.82 However, many patients will experience no
symptoms at all. During this stage, patients have a high viral load and
can already transmit the virus to others.107 However, since the body is
still responding to the virus, antibodies might not yet be present.40
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
50
Seroconversion
Seroconversion is the technical term for the primary stage of the
window period. Seroconversion is the period of time between initial
infection and the development of adequate antibodies. During this
stage, individuals will often test negative for HIV because there are not
enough antibodies present in their system. Patients rarely experience
symptoms during this stage, but they are still contagious to others.
Asymptomatic HIV Infection
The asymptomatic stage of infection is the period that follows the
window period. During this stage of infection, an individual has enough
antibodies present and will produce a positive test result.82 However,
at this stage, the patient does not present any symptoms. Individuals
can remain in the asymptomatic stage of infection for ten years or
more.108 Individuals who have not been tested for HIV will not be
aware of their positive status while they are in this stage of infection.40
This poses a great risk, as individuals will continue to engage in risky
behavior during this time while being unaware that they are potentially
transmitting the virus to others.55
Symptomatic HIV Infection
This is the period during which a patient begins to exhibit symptoms
associated with HIV. Symptomatic HIV infection occurs prior to the
disease transition to AIDS.108 At this point in the illness, HIV has
destroyed the immune system to a point that it is unable to fight off
other infections.40 Patients in the symptomatic stage of infection will
often present the following symptoms:36
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
51

Diarrhea

Fever or night sweats

Enlarged glands

Oral infections

Skin problems
Many patients do not discover their HIV positive status until they enter
the symptomatic stage of infection.109 Patients can live for ten or more
years with the virus without experiencing any symptoms.108 If a
patient is not tested for HIV during the asymptomatic stage of
infection, he or she will have no indication of the illness.40 However,
when a patient begins experiencing symptoms during this later stage
of infection, presence of the virus is suspected and the patient is often
tested and diagnosed.109 This presents a problem for caregivers as
patients who are unaware of their HIV status until they reach the
symptomatic stage of infection often experience more complications
than those who know their status early on.109 HIV is managed well
with antiretroviral treatment and patient care.37 This is difficult in
patients that are unaware of their status.
Acquired Immune Deficiency Syndrome (AIDS)
Acquired Immune Deficiency Syndrome is the final stage of HIV
infection and eventually results in death.110 In this stage, the immune
system of the patient is almost completely destroyed, leaving the
patient susceptible to a range of infections.7 AIDS is diagnosed using
two separate criteria:36

CD4 levels <200 cells/µL

Presence of one or more AIDS defining conditions
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
52
During clinical management of HIV, patient CD4 counts are regularly
monitored.107 Once a patient’s CD4 count drops below 200, he or she
is considered to have moved into the final stage of infection. A CD4
count below 200 indicates that the virus has destroyed the immune
system and the patient will have difficulty fighting off infection.36
Patients are considered to have AIDS when they present with one or
more of the AIDS defining conditions, also known as opportunistic
infections, listed below:111

Bacterial infections, multiple or recurrent

Candidiasis of bronchi, trachea, or lungs

Candidiasis of esophagus

Cervical cancer, invasive

Coccidioidomycosis, disseminated or extrapulmonary

Cryptococcosis, extrapulmonary

Cryptosporidiosis, chronic intestinal (>1 month's duration)

Cytomegalovirus disease (other than liver, spleen, or nodes),
onset at age >1 month

Cytomegalovirus retinitis (with loss of vision)

Encephalopathy, HIV related

Herpes simplex: chronic ulcers (>1 month's duration) or
bronchitis, pneumonitis, or esophagitis (onset at age >1 month)

Histoplasmosis, disseminated or extrapulmonary

Isosporiasis, chronic intestinal (>1 month's duration)

Kaposi sarcoma

Lymphoid interstitial pneumonia or pulmonary lymphoid
hyperplasia complex

Lymphoma, Burkitt (or equivalent term)

Lymphoma, immunoblastic (or equivalent term)
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
53

Lymphoma, primary, of brain

Mycobacterium avium complex or Mycobacterium kansasii,
disseminated or extrapulmonary

Mycobacterium tuberculosis of any site, pulmonary,
disseminated, or extrapulmonary

Mycobacterium, other species or unidentified species,
disseminated or extrapulmonary

Pneumocystis jirovecii pneumonia

Pneumonia, recurrent

Progressive multifocal leukoencephalopathy

Salmonella septicemia, recurrent

Toxoplasmosis of brain, onset at age >1 month

Wasting syndrome attributed to HIV
Patients often experience a variety of symptoms once they progress to
AIDS. These symptoms are not caused by HIV, but rather by the
opportunistic infections that the individual is susceptible to as the
result of a suppressed immune system.36
Proper management of AIDS is necessary for patient comfort and
longevity. With appropriate treatment, the affects of AIDS can be
minimized. Patients who receive regular care are able to reduce the
number and severity of opportunistic infections, thereby ensuring
fewer symptoms and illness-related complications.112
While a patient may reduce the impact of AIDS through proper care,
the patient’s status does not change. Once a patient is diagnosed with
AIDS, he or she maintains that diagnosis, even if the patient begins to
feel better and experiences less symptoms.36
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
54
Patients who receive adequate care during this stage have an
increased likelihood of living longer than those that do not receive
adequate care.113 The typical life expectancy of an individual with AIDS
is 10 – 12 months.112 However, some patients can live four or more
years with AIDS if the disease is managed properly.113 Patient
morbidity is not a direct result of HIV. It is the result of complications
from HIV, typically as the result of opportunistic infections.111
Classification Systems
There are currently two classification systems in place to track and
monitor HIV worldwide. These classification systems define stages of
infection and are used to monitor patient progress and provide
information for surveillance purposes. The two official classifications
are the U.S. Centers for Disease Control and Prevention (CDC)
classification system and the World Health Organization (WHO) Clinical
Staging and Disease Classification System. The CDC classification
system determines stages based primarily on CD4+ T-cell counts,
which requires regular laboratory testing and frequent monitoring to
assess. In later stages of infection, the CDC does incorporate
documentation of AIDS-defining conditions as additional criteria.7,37
However, primary classification is based on CD4+ T-cell counts. The
WHO classification system determines stages based on clinical
manifestations that can be assessed and evaluated without the use of
laboratory testing. The WHO classification system is used primarily to
assess and classify patients who do not have access to appropriate
diagnostic testing methods. 7,37
CDC Classification System
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
55
The CDC Classification system has three clinical stages that are
defined by CD4+ T-cell count. The follow are the clinical stages of HIV
as defined by the CDC:
HIV infection, stage 1:
No AIDS-defining condition and either CD4+ T-lymphocyte count of
≥500 cells/μL or CD4+T-lymphocyte percentage of total lymphocytes
of ≥29.
HIV infection, stage 2:
No AIDS-defining condition and either CD4+ T-lymphocyte count of
200–499 cells/μL or CD4+ T-lymphocyte percentage of total
lymphocytes of 14-28.
HIV infection, stage 3 (AIDS):
CD4+ T-lymphocyte count of <200 cells/μL or CD4+ T-lymphocyte
percentage of total lymphocytes of <14, or documentation of an AIDSdefining condition. Documentation of an AIDS-defining condition
supersedes a CD4+ T-lymphocyte count of ≥200 cells/μL and a CD4+
T-lymphocyte percentage of total lymphocytes of ≥14.
HIV infection, stage unknown:
No information available on CD4+ T-lymphocyte count or percentage
and no information available on AIDS-defining conditions.
World Health Organization Classification System
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
56
The World Health Organization uses the following stages for HIV
infection.
Clinical stage 1 (Asymptomatic):

Asymptomatic

Persistent generalized lymphadenopathy
Clinical stage 2 (Mild disease):

Moderate unexplained weight loss (<10% of presumed or
measured body weight)

Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis
media, pharyngitis)

Herpes zoster

Angular chelitis

Recurrent oral ulceration

Papular pruritic eruptions

Seborrhoeic dermatitis

Fungal nail infections
Clinical stage 3 (Moderate disease):

Unexplained severe weight loss (>10% of presumed or
measured body weight)

Unexplained chronic diarrhea for longer than one month

Unexplained persistent fever (intermittent or constant for longer
than one month)

Persistent oral candidiasis

Oral hairy leukoplakia

Pulmonary tuberculosis
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
57

Severe bacterial infections (i.e., pneumonia, empyema,
pyomyositis, bone or joint infection,

meningitis, bacteremia)

Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis

Unexplained anemia (<8 g/dl), neutropenia (<0.5 x 109 /L) and
or chronic thrombocytopenia

(<50 X 109 /L3)
Clinical stage 4 (Severe disease):

HIV wasting syndrome

Pneumocystis pneumonia

Recurrent severe bacterial pneumonia

Chronic herpes simplex infection

Esophageal candidiasis (or candidiasis of trachea, bronchi or
lungs)

Extrapulmonary tuberculosis

Kaposi's sarcoma

Cytomegalovirus infection (retinitis or infection of other organs)

Central nervous system toxoplasmosis

HIV encephalopathy

Extrapulmonary cryptococcosis including meningitis

Disseminated non-tuberculous mycobacteria infection

Progressive multifocal leukoencephalopathy

Penicilliosis

Chronic cryptosporidiosis

Chronic isosporiasis

Disseminated mycosis (extrapulmonary histoplasmosis,
coccidiomycosis)

Recurrent septicemia (including non-typhoidal Salmonella)
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
58

Lymphoma (cerebral or B cell non-Hodgkin)

Invasive cervical carcinoma

Atypical disseminated leishmaniasis

Symptomatic HIV-associated nephropathy or HIV-associated
cardiomyopathy
Proper Diagnosis and Early Intervention
Proper care and management of HIV infected patients is of the utmost
importance in reducing the impact of the disease and preventing
patient morbidity. HIV can progress rapidly, especially in the absence
of treatment.112 Proper diagnosis and early intervention help prevent
the infection from progressing from the asymptomatic stage to the
symptomatic stage of infection.35 Patients who receive adequate care
early and regularly may not ever progress to AIDS.7 Treatment and
care of HIV infected patients is discussed in Part II of this course
series.
Summary
Human immunodeficiency virus is a disease that affects over forty
million people worldwide and one million people in the United States.
During the early stages of infection, individuals can live symptom free.
Progression of the disease varies by patient and can be impacted by a
variety of factors. Healthcare providers must understand the signs and
symptoms of infection, as well as the various stages of HIV infection.
Proper treatment can prevent the infection from progressing beyond
the asymptomatic stage. Therefore, providers must work closely with
patients to develop a treatment plan that minimizes progression.
Different therapies and strategies can have differing effects on patients
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
59
and an understanding of the adverse affects of antiretroviral drugs is
imperative in disease management. In the stage of the infection
known as HIV, patients often exhibit few symptoms. When the disease
transitions to Acquired Immune Deficiency Syndrome (AIDS) the
patient often experiences an increase in symptoms and severity of the
disease and presents with one or more opportunistic infections.
Appropriate treatment and management of HIV is imperative to
prevent the infection from causing irreversible effects on the patient.
Through the use of highly effective antiretroviral therapy, case
management services and prevention programs, the spread of the
disease in the U.S., has slowed in recent years. In low to middle
income countries, the number of individuals infected annually is still
significant. However, new initiatives aimed at reducing the spread of
HIV in these areas are starting to improve prevention rates. There is
no cure for HIV. HIV positive individuals require care from onset of
infection and through the remainder of the patient’s life. However,
through the use of antiretroviral therapy and a comprehensive
treatment plan, the disease can remain a manageable, chronic illness
for 10 – 20 years. Treatment for an HIV positive individual is a
complex process that requires the provider to work with the patient to
develop a treatment plan that is able to address the individual
patient’s needs and minimize the progression of the virus.
References Section
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
60
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Hymesa KB et al. Kaposi's sarcoma in homosexual men—a report
of eight cases. Lancet. 1981; (318) 8247: 598 – 600.
Gottlieb MS, Schroff R, Schanker HM, Weisman JD, Fan PT, Wolf
RA, Saxon A. Pneumocystis carinii pneumonia and mucosal
candidiasis in previously healthy homosexual men: evidence of a
new acquired cellular immunodeficiency. N Engl J Med. 1981 Dec
10;305(24):1425–1431.
Landesman SH, Ginzburg HM, Weiss SH. The AIDS epidemic. N
Engl J Med. 1985 Feb 21;312(8):521-5.
Centers for Disease Control and Prevention. HIV Surveillance
Report, 2011; vol. 23.
http://www.cdc.gov/hiv/topics/surveillance/resources/reports/.
Published February 2013.
Stahl RE et al. Immunologic abnormalities in homosexual men:
Relationship to Kaposi's sarcoma The Am J of Med. 1982; 73(2):
171 – 178.
van Sighem A, Gras L, Reiss P, Brinkman K, de Wolf F. Life
expectancy of recently diagnosed asymptomatic HIV-infected
patients approaches that of uninfected individuals. AIDS 2010;
24:1527–1535.
Bartlett, J.G. (2016). The natural history and clinical features of
HIV infection in adults and adolescents. Up To Date. Retrieved
online at https://www.uptodate.com/contents/the-naturalhistory-and-clinical-features-of-hiv-infection-in-adults-andadolescents?source=search_result&search=AIDS&selectedTitle=2
~150.
Lopez, F. and Sanders, C. (2016). Fever and rash in HIV-infected
patients. Up To Date. Retrieved online at
https://www.uptodate.com/contents/fever-and-rash-in-hivinfectedpatients?source=search_result&search=origin%20of%20HIV&sel
ectedTitle=10~150.
Gao F et al. Origin of HIV-1 in the chimpanzee Pan troglodytes.
Nature. 1999: 436-441.
Robbins, KE et al. U.S. Human Immunodeficiency Virus Type 1
Epidemic: Date of Origin, Population History, and
Characterization of Early Strains. J. Virol. 2003; 77: 6359-6366.
Garry RF, Witte MH, Gottlieb AA, Elvin-Lewis M, Gottlieb MS,
Witte CL, Alexander SS, Cole WR, Drake WL. Documentation
of an AIDS virus infection in the United States in 1968. JAMA.
1988 Oct;260(14):2085-7.
University of Illinois College of Agricultural, Consumer and
Environmental Sciences Tracking the origins of HIV. ScienceDaily.
2012. Retrieved from
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
61
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
http://www.sciencedaily.com-/releases/2012/12/121218143029.
htm
F. E. McCutchan, in The Evolution of HIV, K. A. Crandall, Ed.
(Johns Hopkins Univ. Press, Baltimore, 1999), pp. 41-101.
CDC. MMWR. Epidemiologic Notes and Reports: Pneumocystis
Pneumonia - Los Angeles. June 5, 1981;30(21):1-3.
Centers for Disease Control: Update: acquired immunodeficiency
syndrome (AIDS)-United States. MMWR 1984; 33:337-339.
Valdiserri RO. Thirty years of AIDS in America: A story of infinite
hope. AIDS Ed and Prev, 2011;23(6): 479–494.
Masur H, Michelis MA, Wormser GP, Lewin S, Gold J, Tapper ML,
Giron J, Lerner CW, Armstrong D, Setia U, et al. Opportunistic
infection in previously healthy women. Initial manifestations of a
community-acquired cellular immunodeficiency. Ann Intern Med.
1982 Oct;97(4):533–539.
Desforges JF. AIDS and preventive treatment in hemophilia. N
Engl J Med. 1983 Jan 13;308(2):94-5.
Dowdle WR. The epidemiology of AIDS. Pub Health Rep. 1983
Jul-Aug; 98(4): 308–312.
Landesman SH, Vieira J. Acquired Immune Deficiency Syndrome
(AIDS): A Review. Arch Intern Med. 1983;143(12):2307-2309.
Heeney JL, Dalgleish AG, Weiss RA. Origins of HIV and the
evolution of resistance to AIDS. Science. 2006 Jul
28;313(5786):462-6.
Broder S, Gallo RC. A pathogenic retrovirus (HTLV-III) linked to
AIDS. N Engl J Med. 1984 Nov 15;311(20):1292-7.
A Timeline of AIDS. Available at http://aids.gov/hiv-aidsbasics/hiv-aids-101/aids-timeline/. Last accessed April 6, 2013.
Karon JM, Fleming PL, Steketee RW and DeCock KM. HIV in the
United States at the Turn of the Century: An Epidemic in
Transition. American Journal of Public Health, July
2001;91(7):1060-1068.
Cheever LW. Engaging HIV-infected patients in care: their lives
depend on it. Clin Infect Dis. 2007;44:1500-1502.
Kilmarx PH. Global epidemiology of HIV. Curr Opin HIV AIDS.
2009 Jul;4(4):240-251.
CDC Fact Sheet. HIV in the United States: At a Glance. 2011.
Available at
http://www.cdc.gov/hiv/resources/factsheets/PDF/stats_basics_f
actsheet.pdf.
Epidemiology of HIV/AIDS --- United States, 1981—2005.
Centers for Disease Control and Prevention, MMWR
2006;55(21);589-592.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
62
29.
30.
31.
32.
33.
34.
35.
36.
37.
WHO HIV/AIDS Global Health Observatory. Available at
http://www.who.int/gho/hiv/en/.
Rehle TM, Hallett TB, Shisana O, et al. A decline in new HIV
infections in South Africa: estimating HIV incidence from three
national HIV surveys in 2002, 2005 and 2008. PLoS One
2010;5:e11094-e11094.
Hamouda O. Global Epidemiology of HIV. Sexually Transmitted
Infections and Sexually Transmitted Diseases 2011: 249-270.
CDC (2016). HIV Surveillance Reports. Retrieved online at
https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.
De Cock KM, Jaffe HW, Curran JW The evolving epidemiology of
HIV/AIDS. AIDS. 2012; (26)10:1205–1213.
HIV Types. Available at http://www.avert.org/hiv-types.htm.
Geretti AM. HIV-1 subtypes: epidemiology and significance for
HIV management. Curr Opin Infect Dis. 2006 Feb;19(1):1-7.
What are HIV and AIDS? Fact Sheet. National Institute of Allergy
and Infectious
Diseases.http://www.niaid.nih.gov/topics/HIVAIDS/Understandin
g/Pages/whatAreHIVAIDS.aspx.
Gottlieb, G. (2016). Epidemiology, transmission, natural history,
and pathogenesis of HIV-2 infection. Up To Date. Retrieved
online at https://www.uptodate.com/contents/epidemiologytransmission-natural-history-and-pathogenesis-of-hiv-2infection?source=search_result&search=hiv%201%20and%20hi
v%202&selectedTitle=1~150.
38.
39.
40.
Rychert, J. and Rosenberg, E. (2016). Immunology of HIV-1
Infection. Up To Date. Retrieved online at
https://www.uptodate.com/contents/immunology-of-hiv-1infection?source=search_result&search=hiv%20superinfection%2
0and%20viral%20diversity&selectedTitle=1~150.
Gottlieb, G. (2016). Clinical manifestations and diagnosis of HIV2 infection. Up To Date. Retrieved online at
https://www.uptodate.com/contents/clinical-manifestations-anddiagnosis-of-hiv-2infection?source=search_result&search=hiv%202&selectedTitle=
1~150.
Bartlett, J. and Sax, P. (2016). Screening and diagnostic testing
for HIV infection. Up To Date. Retrieved online at
https://www.uptodate.com/contents/screening-and-diagnostictesting-for-hivinfection?source=search_result&search=hiv%20%20testing&sele
ctedTitle=1~150.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
63
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
Baker JV, Peng G, Rapkin J, et al. CD4+ count and risk of nonAIDS diseases following initial treatment for HIV infection. AIDS.
2008;22:841-848.
Buchaz K, Baker R, Palella FJ, Chimiel J, Lichtenstein K, Novak R,
Wood K, Brooks JT. AIDS-defining opportunistic illnesses in US
patients, 1994-2007: a cohort study. AIDS. 2010;24(10):1549–
1559.
Bartlett, J. and Sax, P. (2016). Overview of prevention of
opportunistic infections in HIV-infected patients. Up To Date.
Retrieved online at
https://www.uptodate.com/contents/overview-of-prevention-ofopportunistic-infections-in-hiv-infectedpatients?source=search_result&search=HIV%20opportunistic%2
0infections&selectedTitle=1~150.
Cohen, M. (2016). HIV infection: Risk factors and prevention
strategies. Up To Date. Retrieved online at
https://www.uptodate.com/contents/hiv-infection-risk-factorsand-preventionstrategies?source=search_result&search=transmission%20of%20
HIV&selectedTitle=2~150.
International HIV/AIDS Alliance. Who are vulnerable and mostat-risk populations? Campaign policy briefing (July 2010).
Available at
http://www.aidsalliance.org/includes/Document/Prevention%20c
ampaign/Campaign-Policy-Briefing-1.pdf.
CDC HIV Transmission Information. Available at
http://www.cdc.gov/hiv/resources/qa/transmission.htm.
Lansky A, Brooks JT, DiNenno E, et al. Epidemiology of HIV in the
United States. J Acquir Immune Defic Syndr. 2010 Dec;55 Suppl
2:S64-8.
Hall HI, Holtgrave DR, Maulsby C. HIV transmission rates from
persons living with HIV who are aware and unaware of their
infection. AIDS. 2012;26:893-896.
Campo J, Perea M, Del Romero J, Cano J, Hernando V, Bascones
A. Oral transmission of HIV, reality or fiction? An update. Oral
Diseases. 2006; 12: 219–228.
Baggaley RF, White, RG, Boily MC. HIV transmission risk through
anal intercourse: Systematic review, meta-analysis and
implications for HIV prevention. Internat J Epid
2010;39(4):1048– 63.
Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin C,
Hickman M.Prevention of HIV infection for people who inject
drugs: why individual, structural, and combination approaches
are needed. Lancet. 2010; 376(9737): 285 – 301.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
64
52.
Flynn, P., et al. (2016). Prevention of mother-to-child HIV
transmission in resource-limited settings. Up To Date. Retrieved
online at https://www.uptodate.com/contents/prevention-ofmother-to-child-hiv-transmission-in-resource-limitedsettings?source=search_result&search=mother%20to%20child
%20transmission%20HIV&selectedTitle=1~150.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
Donegan E, Stuart M, Niland JC, et al. Infection with human
immunodeficiency virus type 1 (HIV-1) among recipients of
antibody-positive blood donations. Ann Intern Med
1990;113(10):733-739.
Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in
the United States, 2006-2009. PLoS ONE. 2011;6(8):e17502.
Gardner EM, McLees MP, Steiner JF, del Rio C, Burman WJ. The
spectrum of engagement in HIV care and its relevance to testand-treat strategies for prevention of HIV infection. Clin Infect
Dis. 2011;52:793-800.
CDC. HIV and the Law: HIV Transmission Risk. Available at
http://www.cdc.gov/hiv/law/transmission.htm.
Celum CL. Sexually transmitted infections and HIV: epidemiology
and interventions. Top HIV Med. 2010 Oct-Nov;18(4):138-42.
Fleming DT, Wasserheit JN. From epidemiological synergy to
public health policy and practice: the contribution of other
sexually transmitted diseases to sexual transmission of HIV
infection. Sex Transm Infect 1999;75:3-17.
Galvin SR, Cohen MS. The role of sexually transmitted diseases in
HIV transmission. Nature Reviews Microbiology. 2004: 33-42.
Soriano V, Vispo E, Labarga P, Medrano J, Barreiro P. Viral
hepatitis and HIV co-infection. Antiviral Res 2010 Jan;85(1):30315.
Seden K, Back D, Khoo S. New directly acting antivirals for
hepatitis C: potential for interaction with antiretrovirals. J
Antimicrob Chemother. 2010;65(6):1079-1085.
Bartlett, J. and Weber, D. (2016). Management of healthcare
personnel exposed to HIV. Up To Date. Retrieved online at
https://www.uptodate.com/contents/management-of-healthcarepersonnel-exposed-tohiv?source=search_result&search=hiv%20risk%20in%20health%
20care%20workers&selectedTitle=5~150.
Granich RM, Gilks CF, Dye C, de Cock KM, Williams BG. Universal
voluntary HIV testing with immediate antiretroviral therapy as a
strategy for elimination of HIV transmission: a mathematical
model. Lancet 2009; 373:48-57.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
65
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
Richard D. Moore RD. Epidemiology of HIV Infection in the United
States: Implications for Linkage to Care Clin Infect Dis. (2011)
52(suppl 2): S208-S213.
U.S. National Library of Medicine. National Institutes of Health.
HIV Infection. Available at
http://www.nlm.nih.gov/medlineplus/ency/article/000602.htm.
Kalichman S, Cherry C, Schinazi R, et al. Sexual HIV transmission
and antiretroviral therapy: a prospective cohort study of
behavioral risk factors among men and women living with
HIV/AIDS. Annals Of Behavioral Medicine: A Publication Of The
Society Of Behavioral Medicine [serial online]. August
2011;42(1):111-119.
CDC. Condom Effectiveness. Available at
http://www.cdc.gov/condomeffectiveness/latex.htm.
Vlahov D, Robertson AM, Strathdee SA. Prevention of HIV
Infection among Injection Drug Users in Resource-Limited
Settings. Clin Infect Dis. 2010; 50 (Supplement 3): S114-S121.
Perinatal HIV Guidelines Working Group. Public Health Service
Task Force recommendations for use of antiretroviral drugs in
pregnant HIV-infected women for maternal health and
interventions to reduce perinatal HIV transmission in the United
States—April 29, 2009.
Donegan E. Transmission of HIV by Blood, Blood Products, Tissue
Transplantation, and Artificial Insemination. HIV InSite
Knowledge Base Chapter. October 2003. Available at
http://hivinsite.ucsf.edu/InSite?page=kb-07-02-09.
CDC Fact Sheet: Occupational HIV Transmission and Prevention
among Health Care Workers. Available at
http://www.cdc.gov/hiv/resources/factsheets/hcwprev.htm.
CDC. Updated U.S. Public Health Service Guidelines for the
Management of Occupational Exposures to HIV and
Recommendations for Postexposure Prophylaxis. MMWR
2005;54(RR09):1-17.
Grant RM. Antiretroviral agents used by HIV-uninfected persons
for prevention: pre- and postexposure prophylaxis. Clin Infect Dis
2010;50:Suppl 3:S96-S101.
Padian NS, McCoy SI, Karim SS, et al. HIV prevention
transformed: the new prevention research agenda. Lancet
2011;378:269-278.
Karim SS, Karim QA. Antiretroviral prophylaxis: a defining
moment in HIV control. Lancet 2011;378:e23-e25.
Smith DK et al. Antiretroviral Postexposure Prophylaxis After
Sexual, Injection-Drug Use, or Other Nonoccupational Exposure
to HIV in the United States. Recommendations from the U.S.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
66
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
Department of Health and Human Services. MMWR
Recommendations and Reports. January 21, 2005/54(RR02);120.
Robb ML et al. Risk behaviour and time as covariates for efficacy
of the HIV vaccine regimen ALVAC-HIV (vCP1521) and AIDSVAX
B/E: a post-hoc analysis of the Thai phase 3 efficacy trial RV 144.
Lancet. 2012; (12)7: 531-537.
Dolin R. HIV Vaccine Trial Results — An Opening for Further
Research. N Engl J Med 2009; 361:2279-2280.
Corey L et al. HIV-1 Vaccines and Adaptive Trial Designs. Sci
Transl. 2011: (3)79: 79ps13.
Wagner B, Kahn J, Blower S. Should we try to eliminate HIV
epidemics by using a ‘Test and Treat’ strategy? AIDS 2010; 24
(5):775–6.
Shrosbree J, Campbell L, Post F, et al. Late HIV diagnosis is a
major risk factor for intensive care unit admission in HIV-positive
patients: a single centre observational cohort study. BMC
Infectious Diseases [serial online]. January 19, 2013;13:23.
Mayo Clinic. HIV/AIDS Symptoms. Available at
http://www.mayoclinic.com/health/hivaids/DS00005/DSECTION=
symptoms.
Antinori A, Coenen T, Costagiola D, Dedes N, Ellefson M, Gatell J,
Girardi E,Johnson M, Kirk O, Lundgren J, et al: Late presentation
of HIV infection: a consensus definition. HIV Med 2011,
12(1):61–64.
Dieffenbach CW, Fauci, A. Universal voluntary testing and
treatment for prevention of HIV transmission. JAMA, 2009;301
(22):2380–2.
National HIV/AIDS Clinician’s Consultation Center. HIV Testing
State Laws and CDC Guideline Compatibility. Available at
http://www.nccc.ucsf.edu/docs/quickstatelawguidelines.pdf.
CDC. Technical Guidance on HIV Testing and Counseling.
Available at
http://www.cdc.gov/mmwr/preview/mmwrhtml/00020645.htm.
Bransom BM, Stekler JD. Detection of Acute HIV Infection: We
Can’t Close the Window. J Infect Dis. 2012; 205 (4): 521-524.
Delaney KP, Bernard BM, Uniyal A, Phillips S, Candal D, Owen M,
Kerndt PR. Evaluation of the Performance Characteristics of 6
Rapid HIV Antibody Tests. Clin Infect Dis. 2011; 52 (2): 257-263.
US FDA. Testing for HIV. Available at
http://www.fda.gov/biologicsbloodvaccines/safetyavailability/hivh
ometestkits/ucm126460.htm. Last accessed April 23, 2013.
Thies K, Anders C, Baldus M, Schleiffer T, Weber B, Rabenau H,
Hellstern P.Detection of Primary HIV Infection by a Second-
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
67
91.
92.
93.
94.
95.
96.
97.
98.
99.
100.
101.
102.
103.
104.
Generation HIV(p24) Antigen Test. Infusionsther
Transfusionsmed 1994;21:333–336.
Hecht FM et al. HIV RNA level in early infection is predicted by
viral load in the transmission source. AIDS. 2010 April 24; 24(7):
941–945.
Stekler JD, Wood RW, Swenson PD, Golden M (2007) Negative
rapid HIV antibody testing during early HIV infection. Ann Intern
Med 147: 147–148.
Branson BM. The Future of HIV Testing. JAIDS. 2010; 55:S102S105.
CDC. Data Security and Confidentiality Guidelines for HIV, Viral
Hepatitis, Sexually Transmitted Disease, and Tuberculosis
Programs: Standards to Facilitate Sharing and Use of Surveillance
Data for Public Health Action. Atlanta, Georgia: Centers for
Disease Control and prevention; 2011.
CDC. Diagnoses of HIV infection and AIDS in the United States
and Dependent Areas, 2008. Vol. 20. Atlanta: U.S. Department of
Health and Human Services, CDC; 2008:1–143.
Garland PM, Valverde EE, Fagan J, et al. HIV counseling, testing
and referral experiences of persons diagnosed with HIV who have
never entered HIV medical care. AIDS Educ Prev. 2011;23:117127.
Sax PE, Walker BD. Immunopathogenesis of human
immunodeficiency infection. In: Goldman L, Ausiello D, eds. Cecil
Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier;
2007:chap 408.
Hutchinson JF. The Biology and Evolution of HIV. Ann Rev of Ant.
2001; (30): 85 -108.
Turnera BG, Summersa MF. Structural biology of HIV. Journal of
Molecular Biology. 1999; (285) 1: 1 – 32.
Pinney JW, Dickerson JE, Fu W, Sanders-Beer BE, Ptak RG,
Robertson DL. HIV-host interactions: a map of viral perturbation
of the host system AIDS. 2009; (23) 5: 549-554.
Lewinski MK, Yamashita M, Emerman M, Ciuffi A, Marshall H,
Crawford G, Collins F, Shinn P, Leipzig J, Hannenhalli S, et al.:
Retroviral DNA integration: viral and cellular determinants of
target-site selection. PLoS Pathog 2006: 2:e60.
Kjems J, Askjaer P: Rev protein and its cellular partners. Adv
Pharmacol 2000; 48:251-298.
Kumar H, Kawai T, Akira S. Pathogen Recognition by the Innate
Immune System. Int Rev of Imm . 2011; 30(1):16-34.
Gabrilovich DI, Nagari S. Myeloid-derived suppressor cells as
regulators of the immune system. Nat Rev Imm. 2009;9:162174.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
68
105. Morita E, Sundquist WI: Retrovirus budding. Annu Rev Cell Dev
Biol 2004; 20:395-425.
106. Korenromp EL, Williams BG, Schmid GP, Dye C: Clinical
prognostic value of RNA viral load and CD4 cell counts during
untreated HIV-1 infection -- a quantitative review. PLoS One
2009, 4:e5950.
107. Cohen MS, Shaw GM, McMichael AJ, Haynes BF. Acute HIV-1
Infection. N Engl J Med 2011; 364:1943-1954.
108. May M, Gompels M, Delpech V, Porter K, Post F, Johnson M, Dunn
D, Palfreeman A, Gilson R, Gazzard B, et al: Impact of late
diagnosis and treatment on life expectancy in people with HIV-1:
UK Collaborative HIV Cohort (UK CHIC) Study. BMJ 2011,
343:d6016.
109. Achhra AC, Amin J, Law MG, Emery S, Gerstoft J, Gordin FM,
Vjecha MJ, Neaton JD, Cooper DA: Immunodeficiency and the
risk of serious clinical endpoints in a well studied cohort of
treated HIV-infected patients. AIDS. 2010; 24(12):1877–1886.
110. CDC AIDS Defining Conditions. Available at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5710a2.htm.
111. Zolopa A, Andersen J, Powderly W, Sanchez A, Sanne I, Suckow
C, Hogg E, Komarow L: Early antiretroviral therapy reduces AIDS
progression/death in individuals with acute opportunistic
infections: a multicenter randomized strategy trial. PLoS One
2009, 4:e5575.
112. Kitahata MM, Gange SJ, Abraham AG, et al; NA-ACCORD
Investigators. Effect of early versus deferred antiretroviral
therapy for HIV on survival. N Engl J Med. 2009;360(18):18151826
113. HIV Classification: CDC and WHO Staging Systems. Guide for
HIV/AIDS Clinical Care, HRSA HIV/AIDS Bureau. June 2012.
Available at http://www.aids-ed.org/aidsetc?page=cg205_hiv_classification
114. Centers for Disease Control and Prevention. 1993 revised
classification system for HIV infection and expanded surveillance
case definition for AIDS among adolescents and adults. MMWR
Recomm Rep. 1992 Dec 18;41(RR-17):1-19.
115. World Health Organization. WHO Case Definitions of HIV for
Surveillance and Revised Clinical Staging and Immunological
Classification of HIV-Related Disease in Adults and Children;
2007.
116. Metsch LR, Pereyra M, Messinger S, et al; Antiretroviral
Treatment and Access Study (ARTAS) Study Group. HIV
transmission risk behaviors among HIV-infected persons who are
successfully linked to care. Clin Infect Dis. 2008;47:577-584.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
69
117. MA Thompson, MJ Mugavero, KR Amico, et al. Guidelines for
Improving Entry Into and Retention in Care and Antiretroviral
Adherence for Persons With HIV: Evidence-Based
Recommendations From an International Association of
Physicians in AIDS Care Panel. Ann Intern Med. 2012 March 5.
118. World Health Organization. Antiretroviral therapy for HIV
infection in adults and adolescents: Recommendations for a
public health approach: 2010 revision. Available at
http://www.who.int/hiv/pub/arv/adult2010/en/ index.html.
Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient
adherence to treatment: three decades of research. A
comprehensive review. J Clin Pharm Ther. 2001;26:331-342.
119. Bozzette SA. The Care of HIV-Infected Adults in the United
States. N Engl J Med 1998; 339:1897-1904.
120. Centers for Disease Control and Prevention. Guidelines for
Prevention and Treatment of Opportunistic Infections in HIVInfected Adults and Adolescents: Recommendations from CDC,
the National Institutes of Health, and the HIV Medicine
Association of the Infectious Diseases Society of America. April
10, 2009.
121. Gonzalez JS, Batchelder AW, Psaros C, Safren SA. Depression
and HIV/AIDS treatment nonadherence: a review and metaanalysis. J Acquir Immune Defic Syndr. 2011;58:181-187.
122. Aberg JA et al. Primary Care Guidelines for the Management of
Persons Infected with Human Immunodeficiency Virus: 2009
Update by the HIV Medicine Association of the Infectious
Diseases Society of America. CID 2009:49
123. New York State Department of Health. Primary care approach to
the HIV-infected patient. New York (NY): New York State
Department of Health; 2011.
124. US Department of Health and Human Services. Clinical care
guidelines and resources. Health resources and services
administration. Available at https://hab.hrsa.gov/clinical-qualitymanagement/clinical-care-guidelines-and-resources.
125. WHO. Guidelines for the Clinical Management of HIV Infection in
Adults andAdolescents. Available at
http://www.who.int/mediacentre/news/releases/2016/worldaids-day/en/.
126. Volberding PA, Deeks SG. Antiretroviral therapy and
management of HIV infection. Lancet 2010; 376:49–62.
127. Bansi L, Sabin C, Delpech V, Hill T, Fisher M, Walsh J, et al.
Trends over calendar time in antiretroviral treatment success and
failure in HIV clinic populations. HIV Med 2010; 11:432–438.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
70
128. Johnson VA, Brun-Vézinet F, Clotet B, et al. Update of the drug
resistance mutations in HIV-1: December 2010. Top HIV Med.
2010;18:156-163.
129. Cambiano V, Lampe FC, Rodger AJ, Smith CJ, Geretti AM,
Lodwick RK, et al. Long-term trends in adherence to antiretroviral
therapy from start of HAART. AIDS 2010; 24:1153–1162.
130. Lima VD, Harrigan R, Bangsberg DR, Hogg RS, Gross R, Yip B, et
al. The combined effect of modern highly active antiretroviral
therapy regimens and adherence on mortality over time. J Acquir
Immune Defic Syndr 2009; 50:529–536.
131. Palella F, Armon C, Buchacz K, et al. CD4 at HAART initiation
predicts long-term CD4 responses and mortality from AIDS and
non-AIDS causes in the HIV outpatients study. In: 17th Annual
Canadian Conference on HIV/AIDS Research. San Francisco, CA:
CROI; 2010.
132. Wheeler W, Ziebell R, Zabina H, et al. Prevalence of transmitted
drug resistance associated mutations and HIV-1 subtypes in new
HIV-1 diagnoses, US— 2006. AIDS. 2010;24:1203-1212.
133. Raboud J, Li M, Walmsley S, et al. Once daily dosing improves
adherence to antiretroviral therapy. AIDS Behav. 2011;15:13971409.
134. Panel on Antiretroviral Guidelines for Adults and Adolescents.
Guidelines for the use of antiretroviral agents in HIV-1-infected
adults and adolescents. Department of Health and Human
Services. 1-239. Available at https://aidsinfo.nih.gov/guidelines.
135. CDC Guidelines for the Use of Antiretroviral Agents in HIV-1Infected Adults and Adolescents. Available at
https://aidsinfo.nih.gov/guidelines.
136. Rathbun RC et al. Antiretroviral Therapy for HIV Infection.
Medscape Reference. 2012. Available at
http://emedicine.medscape.com/article/1533218-overview#a1.
137. WHO. Rapid advice: Antiretroviral therapy for HIV infection in
adults and adolescents. 2009. Available at
http://www.who.int/hiv/pub/arv/ rapid_advice_art.pdf.
138. Schambelan M, Benson CA, Andrew Carr A, et al. Management of
metabolic complications associated with antiretroviral therapy for
HIV-1 infection: Recommendations of an International AIDS
Society-USA Panel. J Acquir Immune defic Syndr. 2002.
139. Garnett GP, Baggaley R. Treating our way out of the HIV
pandemic: Could we, would we, should we? Lancet, 2009; 373
(9657):9–11.
140. Centers for Disease Control and Prevention. Vital Signs: HIV
Prevention Through Care and Treatment — United States. MMWR.
2011;60:1618-1623.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
71
141. Horstmann E, Brown J, Islam F, Buck J, Agins B. Retaining HIVInfected Patients in Care: Where Are We? Where Do We Go from
Here? Clin Infect Dis. 2010; 50 (5): 752-761.
142. Husbands W, Browne G, Caswell J, et al. Case management
community care for people living with HIV/AIDS (PLHAs). AIDS
Care. 2007 Sep;19(8):1065–72.
143. Pugh GL. Exploring HIV/AIDS case management and client
quality of life. Journal of HIV/AIDS and Social Services.
2009;8(2):202–18.
144. Soriano V, Vispo E, Labarga P, Medrano J, Barreiro P. Viral
hepatitis and HIV co-infection Antivir Res. 2010; 85(1):303–315.
145. Pawlowski A, Jansson M, Sköld M, Rottenberg ME, Källenius G
(2012) Tuberculosis and HIV Co-Infection. PLoS Pathog 8(2):
e1002464.
146. Dube MP, Sattler FR. Inflammation and Complications of HIV
Disease. J Infect Dis. 2010; 201 (12): 1783-1785.
147. Chu C, Selwyn PA .Complications of HIV infection: a systemsbased approach. Am Fam Phy. 2011; 83(4):395-406.
148. Shahmanesh M et al. Complications of HIV disease or treatment.
In: Second Joint Conference of the British HIV Association and
the British Association for Sexual Health and HIV, April 20-23
2010, Manchester, UK.
149. Luetkemeyer AF, Havlir DV, Currier JS. Complications of HIV
disease and antiretroviral therapy. Top Antivir Med. 2011 MayJun; 19(2):58-68.
150. Pineda JA, Macias J, Mira JA, Merchante N, del Valle J, Neukam
KI. HAART and the liver: friend or foe? Eur J Med Res. 2010;
15(3): 93–96.
151. Anis AH, Nosyk B, Sun H, et al; OPTIMA Team1. Quality of life
of patients with advanced HIV/AIDS: measuring the impact of
both AIDS-defining events and non-AIDS serious adverse events.
J Acquir Immune Defic Syndr. 2009;51(5):631-639.
152. May MT, Ingle SMLife expectancy of HIV-positive adults: a
review. Sexual Health. 2011; 8(4) 526-533.
153. Miller V, Horberg M. Getting to normal: are we there yet? AIDS:
2013; 27(6):1027–1028.
154. Masur H, Kaplan J, New Guidelines for the Management of HIVRelated Opportunistic Infections. JAMA. 2009;301(22):23782380.
155. Brooks JT et al. HIV-Associated Opportunistic Infections—Going,
Going, But Not Gone: The Continued Need for Prevention and
Treatment Guidelines. Clin Infect Dis. 2009; 48(5): 609-611.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
72
156. Rockstroh JK, Gatell J, Landman R, Antonori A. Management of
late-presenting patients with HIV infection. Antiviral Therapy
2010; 15 Suppl 1:25-30.
157. Mocroft A, Sterne JA, Egger M, May M, Grabar S, Furrer H, et al.
Variable impact on mortality of AIDS-defining events diagnosed
during combination antiretroviral therapy: not all AIDS-defining
conditions are created equal. Clin Infect Dis 2009; 48:1138–
1151.
158. Zolopa A, Andersen J, Powderly W, et al. Early antiretroviral
therapy reduces AIDS progression/death in individuals with acute
opportunistic infections: a multicenter randomized strategy trial.
PLoS One. 2009;4(5):e5575.
159. Waters L, Fisher M, Anderson J, Wood C, Delpech V, Hill T, Walsh
J, Orkin C, Bansi L, Gompels M, et al: Responses to highly active
antiretroviral therapy and clinical events in patients with a low
CD4 cell count: late presenters vs. late starters. HIV Med 2011,
12(5):289–298.
160. Crum-Cianflone NF, Huppler Hullisiek K, Marconi V. Trends in the
incidence of cancers among HIV-infected persons and the impact
of antiretroviral therapy: a 20-year cohort study. AIDS 2009;
23:41–50.
161. Volderberding PA, Deeks SG. Antiretroviral therapy and
management of HIV infection. The Lancet. 2010; 376(9734): 4962.
162. Neuhaus J, Angus B, Kowalska JD, et al; INSIGHT SMART and
ESPRIT study groups. Risk of all-cause mortality associated with
nonfatal AIDS and serious non-AIDS events among adults
infected with HIV. AIDS. 2010;24(5):697-706.
163. Simms V, Higginson IJ, Harding R, Simms V. Integration of
palliative care throughout HIV disease. Lancet. 2012; 12(7): 571575.
164. Blais C, Selwyn P, Tucker R, Hutton N, Merlin J. Palliative Care for
Patients With HIV: Challenges and Controversies (509). JPain
Symp Man. 2012; 43(2): 406 – 407.
165. Kelley AS, Meier DE. Palliative Care — A Shifting Paradigm. N
Engl J Med 2010; 363:781-782.
166. Fausto JA Jr, Selwyn PA. Palliative care in the management of
advanced HIV/AIDS. Prim Care. 2011 Jun;38(2):311-26.
167. Selwyn PA, Rivard M. Palliative care for AIDS: Challenges and
opportunities in the era of highly active anti-retroviral therapy.
Innovations in End-of-Life Care. 2002;4(3).
168. World Health Organization. Antiretroviral drugs for treating
pregnant women and preventing HIV infection in infants:
Recommendations for a public health approach (2010 version).
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
73
169.
170.
171.
172.
173.
174.
175.
176.
177.
178.
179.
180.
Available at
http://www.who.int/hiv/pub/mtct/antiretroviral2010/en/.
Damania KR, Tank PD, Lala MM. Recent trends in mother to child
transmission of HIV in pregnancy. J Ob Gyn of Ind. 2010; 60(5):
395-402.
HIV and Pregnancy Fact Sheet. Available at
http://aidsinfo.nih.gov/contentfiles/ Perinatal_FS_en.pdf.
Mayer KH. Pregnancy and Optimal Care of HIV-Infected Patients.
Clin Infect Dis. 2009; 48 (4): 449-455.
Matthews LT, Baeten JM, Celum C, Bangsberg DR. Periconception
pre-exposure prophylaxis to prevent HIV transmission: benefits,
risks, and challenges to implementation. AIDS 2010;24:19751982.
Vernazza PL, Graf I, Sonnenberg-Schwan U, Geit M, Meurer A.
Pre-exposure prophylaxis and timed intercourse for HIVdiscordant couples willing to conceive a child. AIDS
2011;25:2005-2008.
Lampe MA, Smith DK, Anderson GJ, Edwards AE, Nesheim SR.
Achieving safe conception in HIV-discordant couples: the
potential role of oral preexposure prophylaxis (PrEP) in the United
States. Am J Obstet Gynecol 2011;204(6):488.e1-488.e8.
Mugo NR, Heffron R, Donnell D, et al. Increased risk of HIV-1
transmission in pregnancy: a prospective study among African
HIV-1 serodiscordant couples. AIDS 2011;25:1887-1895.
Watts DH, Mofenson DM. Antiretrovirals in Pregnancy: A Note of
Caution. J Infect Dis. 2012; 206 (11): 1639-1641.
Haberer J, Mellins C. Pediatric adherence to HIV antiretroviral
therapy. Current HIV/AIDS Reports. 2009; 6(4): 194 – 200.
CDC. Diagnoses of HIV infection and AIDS in the United States
and Dependent Areas. 2008 Surveillance Report. Available at
http://www.cdc.gov/hiv/pdf/statistics_2008_HIV_Surveillance_Re
port_vol_20.pdf.
Merck Manual Home Health Handbook for Patients and
Caregivers. Human Immunodeficiency Virus (HIV) Infection in
Children. Available at
http://www.merckmanuals.com/home/childrens_health_issues/vi
ral_infections_in_infants_and_children/human_immunodeficiency
_virus_hiv_infection_in_children.html.
WHO recommendations on the diagnosis of HIV infection in
infants and children. 2010. Available at
http://www.who.int/hiv/pub/paediatric/diagnosis/ en/index.html.
National Institute of Health. Guidelines for the Use of
Antiretroviral Agents in Pediatric HIV Infection. 2012. Available at
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
74
181.
182.
183.
184.
185.
186.
187.
188.
189.
190.
191.
192.
http://www.aidsinfo.nih.gov/guidelines/html/2/pediatric-arvguidelines/0/.
Gray RH, Wawer MJ. Reassessing the hypothesis on STI control
for HIV prevention. Lancet 2008; 371:2064–2065.
Cabello-De la Garza AB. Bridging the gap: how to transform
taboos into opportunities for healthy change through
communication. HIV Clin. 2013 Winter;25(1):10-1.
Hunsmann M. Political determinants of variable aetiology
resonance: explaining the African AIDS epidemics. Int J STD
AIDS 2009; 20:834–838.
An Q, Prejean J, McDavid Harrison K, Fang X. Association
between community socioeconomic position and HIV diagnosis
rate among adults and adolescents in the United States, 2005 to
2009. American Journal Of Public Health [serial online]. January
2013;103(1):120-126.
Korthuis PT, Saha S, Fleishman JA, McGrath MM, Josephs JS,
Moore RD et al. Impact of patient race on patient experiences of
access and communication in HIV care. J Gen Intern Med.
2008;23:2046–2052.
Sayles JN, Wong MD, Kinsler JJ, Martins D, Cunningham WE. The
Association of Stigma with Self-Reported Access to Medical Care
and Antiretroviral Therapy Adherence in Persons Living with
HIV/AIDS. J Gen Int Med. 2009; 24(10):1101-1108.
Rotheram-Borus MJ, Swendeman D, Flannery D, Rice E, Adamson
DM, Ingram B. Common Factors in Effective HIV Prevention
Programs. AIDS and Behav. 2009; 13(3):399-408.
Thomas M. HIV/AIDS and Socioeconomic Status: A Texas Study.
Western Political Science Association 2011 Annual Meeting Paper
. Available at SSRN: http://ssrn.com/abstract=1767180
HIV/AIDS and Socioeconomic Status: Fact Sheet. American
Psychological Association. 2013. Available at
http://www.apa.org/pi/ses/resources/publications/factsheet-hivaids.aspx Accessed April 12, 2013.
Eshleman S, Hughes J, Hodder S, et al. Use of a multifaceted
approach to analyze HIV incidence in a cohort study of women in
the United States: HIV Prevention Trials Network 064 Study. The
Journal of Infectious Diseases. January 15, 2013;207(2):223231.
WHO: Addressing Violence Against Women and HIV/AIDS: What
Works? 2010. Available at http://whqlibdoc.who.int/publications/
2010/9789241599863_eng.pdf.
Jewkes R. Gender Inequities Must Be Addressed in HIV
Prevention. Science. 2010: 329 (5988), 145-147.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
75
193. Carr RL, Gramling LF. Stigma: a health barrier for women with
HIV/AIDS. J Assoc Nurses AIDS Care. 2004;15:30-39.
194. Land H, Linsk N. HIV Stigma and Discrimination: Enduring
Issues. J of HIV/AIDS & Soc Serv. 2013; 12(1):3-8.
195. Herek GM, Saha S, Burack J. Stigma and Psychological Distress in
People With HIV/AIDS. Basic App Soc Psy. 2013; 35(1): 41-54.
196. Fair CD, Ginsburg B. HIV-Related Stigma, Discrimination, and
Knowledge of Legal Rights among Infected Adults. Jof HIV/AIDS
& Soc Serv. 2010; 9(1):77-89.
APPENDIX A: HELPFUL HIV/AIDS RESOURCES
1. Aids.gov. Viral Load. http://aids.gov/hiv-aids-basics/justdiagnosed-with-hiv-aids/understand-your-test-results/viral-load/
2. Aids.org. CD4 (T-CELL) TESTS. http://www.aids.org/topics/aidsfactsheets/aids-background-information/what-is-aids/hivtesting/cd4-t-cell-tests/
3. Aids.org. Normal Laboratory Values.
http://www.aids.org/topics/normal-lab-values/
4. Clinical Guide. Clinical Guide Testing. CD4 and Viral Load
Monitoring
http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/cg206_cd4_monitoring.html
5. Lab Tests Online. CD4 and CD8.
http://labtestsonline.org/understanding/analytes/cd4/tab/test
6. Project Inform. HIV Diagnostic Tests.
http://cig.salk.edu/extra_html/etc_hiv_diagonstics.htm
7. University of California San Francisco. HIV Insight.
http://hivinsite.ucsf.edu/insite?page=pb-diag-02-00
8. U.S. Department of Veteran Affairs. Understanding Laboratory
Tests. http://www.hiv.va.gov/patient/diagnosis/labs-index.asp
9. U.S. Military HIV Research Program. HIV Diagnostics and
Reference Laboratory.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
76
http://www.hivresearch.org/research.php?ServiceID=12&SubServ
iceID=15.
10. http://www.seatec.emory.edu/documents/resources/brief_handou
ts/medical_care/common_labs_ordered_in_adult_HIV_care.pdf.
APPENDIX B: HIV/AIDS SUPPORT GROUPS & EDUCATION
The following websites provide the clinician with some helpful education tools
and referrals for individuals and families seeking support after being
diagnosed HIV positive and/or having AIDS in the U.S. and internationally.
1. AIDS Support Group. Aids Support Group Saba.
http://www.aidssupportgroupsaba.org/
2. AIDS Support Group. Welcome to aids support group.
http://aidssupport.aarogya.com/
3. AVERT. Introduction to HIV and AIDS Education.
http://www.avert.org/aids-hiv-education.htm.
4. Centers for Disease Control and Prevention. HIV / AIDS.
http://www.cdc.gov/hiv/.
5. Centers for Disease Control and Prevention. HIV / AIDS Among
Youth.http://www.cdc.gov/hiv/resources/factsheets/pdf/youth.pdf
6. National Aids Housing Coalition. AIDS Action.
http://nationalaidshousing.org/nahcresources/usorganizations/
7. National Information Prevention Network. HIV/AIDS Education and
Outreach. http://www.cdcnpin.org/scripts/hiv/outreach.asp.
8. National Institute of Health. AIDS INFO. http://www.aidsinfo.nih.gov/.
9. UNICEF. Join our Fight Against AIDS.
http://www.unicefusa.org/work/hivaids/
10. U.S. Department of Veteran Affairs. VA National HIV/AIDS
Website. http://www.hiv.va.gov/patient/diagnosis/steps-support.asp
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com