Download Chapter 1 - HIV/AIDS in Florida

Chapter 1 - HIV/AIDS in Florida
Florida has the third highest incidence of HIV/AIDS in the United States, exceeded only by
California and New York. The Florida Department of Health (2009a) estimates that
approximately 125,000 persons in the state are living with HIV infection (including AIDS). In
2009, Florida reported 5,508 new HIV diagnoses, and 4,369 cases of AIDS. Although the
HIV/AIDS epidemic is prevalent throughout Florida, the majority of cases (76%) were reported in
nine counties: Broward, Duval, Hillsborough, Lee, Miami-Dade, Orange, Palm Beach, Pinellas,
and Polk.
HIV/AIDS is more prevalent among women in Florida than in women nationally and also more
prevalent among blacks. However, the prevalence among men who have sex with men (MSM)
in Florida is lower than among MSM nationally. The prevalence of AIDS among heterosexual
populations in Florida is much higher than among heterosexuals nationally (38% vs. 24%)
(Florida Department of Health, 2009a).
Blacks account for nearly half of Florida’s HIV-positive population and nearly half of the AIDS
cases, even though they comprise only 14 percent of the state’s population. HIV is the leading
cause of death for black women between the ages of 25 and 44 and the third leading cause of
death for black men in this age group (Florida Department of Health, 2009b). HIV is the third
leading cause of death among Hispanic women in this age group and the ninth leading cause of
death among white women in this age group (Florida Department of Health, 2009c).
Seniors represent 27% of the HIV-infected population in Florida and in the United States. Males
account for three-fourths of cases and females accounted for a fourth. Half of HIV-infected
seniors are black, a third are white, and the remainder are Hispanic. Nearly two-thirds of all
Florida senior HIV/AIDS cases reported through April 2010 came from four counties: MiamiDade, Broward, Palm Beach, and Orange. Of the nearly 2,500 HIV-related deaths in 2008,
almost half were among people age 50 or older (Florida Department of Health, 2009d).
Chapter 2 - Transmission of HIV
Contrary to myths and misinformation, HIV is not transmitted by casual contact such as
hugging, other nonsexual touching, and the shared handling of objects. Insects do not carry
HIV, nor is the virus transmitted through air or water. HIV is a relatively fragile virus. Once
outside the human body, HIV has a very short lifespan, which makes most medical procedures
and caregiving activities safe if standard infection control procedures are followed.
Three conditions are necessary for HIV to be transmitted:
1. An HIV source
2. A sufficient dose (viral load) of virus
3. Access to the bloodstream of another person
Varying levels and concentrations of HIV have been found in most bodily fluids of infected
persons, including blood, semen, saliva, tears, breast milk, and vaginal and cervical secretions.
However, only blood, semen, breast milk, and vaginal and cervical secretions have been
proven to transmit HIV infection.
SEXUAL CONTACT
Transmission of HIV occurs primarily through sexual contact with an infected person. This
includes anal, oral, and vaginal contact. The risk of transmission depends on sexual practices.
Receptive anal contact without a latex condom carries the greatest risk, probably because of the
larger surface area of mucous membranes involved. (Receptive partners are at greater risk for
transmission of any sexually transmitted disease, including HIV.)
INJECTION DRUG USE
Sharing injection needles, syringes, and other paraphernalia with an HIV-infected person can
send HIV directly into the user’s bloodstream. Paraphernalia with the potential for transmission
include the syringe, needle, “cooker,” cotton, and/or rinse water (sometimes called works).
Transmission also occurs through indirect sharing of contaminated paraphernalia and/or
dividing a shared or jointly purchased drug while preparing and injecting it. “Indirect sharing”
includes squirting the drug back from a dirty syringe into the drug cooker and/or someone else’s
syringe, or sharing a common filter or rinse water.
NEEDLESTICKS
Healthcare workers may be infected with HIV through needlesticks or direct contact with HIVinfected blood—for example, through a break in the skin or through the eyes or the mucosal
lining of the nose. The risk of developing HIV infection from a needlestick with infected blood is
about 1:300 without prompt antiretroviral treatment, and the risk increases with deep punctures,
hollow bore needles, visible blood on the needle, and high viral load in the source.
(Comparatively, the risk after a mucous membrane exposure is about 1:9,000, and the risk of
HIV transmission after nonintact skin exposure is estimated to be less than the risk for mucous
membrane exposure.)
UNCOMMON MODES OF TRANSMISSION
Transmission of HIV through transfusion has been uncommon in the United States since 1985
and in other countries where blood is screened for HIV antibodies. In 1999, about 1% of U.S.
AIDS cases were caused by transfusions or use of contaminated blood products. The majority
of those cases were in people who received blood or blood products before 1985.
An infected pregnant woman can transmit HIV to her fetus, and an infected mother can infect
her breastfeeding infant. However, the incidence of perinatally acquired HIV peaked in 1992
and has decreased to 2% nationally in recent years. Implementation of Public Health Service
guidelines for universal counseling and voluntary HIV testing of pregnant women, scheduled
cesarean delivery, avoidance of breastfeeding, and the use of antiretroviral therapy by pregnant
women and administered to newborn infants primarily account for the decline.
Chapter 3 - HIV Testing
Most HIV infections are transmitted by people who do not know they are infected. Therefore,
HIV testing is the first step in halting spread of the virus. Research shows that people who are
unaware of their HIV infection have a transmission rate of almost 11 percent compared with a
rate of less than 2 percent in those who know they are HIV-positive. When counseling services
are available and effective, that rate falls to near zero.
WHO SHOULD BE TESTED?
Testing is essential for anyone who has had a potential exposure to HIV. This includes anyone
who has had unprotected anal, vaginal, or oral sex; who has shared needles or other injection
drug preparation equipment; or who has had an occupational exposure. People with partners
who have such risk factors should also consider testing.
In addition to the primary high-risk groups, Florida law provides for testing special populations.
PREGNANT WOMEN
In Florida, the Targeted Outreach for Pregnant Women Act (TOPWA), established in 1999 by
Florida statute 381.0045, requires that healthcare providers counsel and offer HIV testing to all
pregnant women on their initial prenatal visit and again at 28 to 32 weeks’ gestation. TOPWA
outreach workers go into the community and seek out pregnant women in housing projects,
laundromats, bars, or other public places. The TOPWA program has increased poor women’s
access to prenatal care, including HIV testing and antiviral therapy, reducing the number of
babies born with HIV infection. Through July 2009, more than 32,000 pregnant high-risk or HIVinfected women have been enrolled in TOPWA.
CORRECTIONAL POPULATIONS
Florida Statute 495.355 mandates that prisons test inmates for HIV within 60 days before they
are released back into the community. (Unlike prisons, jails are not required to test inmates
unless they have been convicted of a sex-related crime.) Those who test positive must be
provided with transitional assistance, which includes:
• Education on preventing transmission of the virus to others and on the importance of
follow-up care and treatment
• A written, individualized discharge plan that includes referrals to and contacts with the
county health department and local HIV primary care services in the area where the
inmate plans to reside
• A 30-day supply of all HIV-related medications that the inmate is taking prior to release
under the protocols of the Department of Corrections and the treatment guidelines of the
United States Department of Health and Human Services
TYPES OF HIV TESTS
HIV testing is a two-step process that includes a screening test and, when the screening test is
reactive (positive), a confirmatory test. Until 2002, testing for HIV antibodies relied on an
enzyme-linked immunosorbent assay (ELISA) of blood. Since then, six rapid HIV tests have
been approved by the FDA, all of which are interpreted visually. Four of the tests have been
approved for use outside of a clinical laboratory. The FDA and the Centers for Medicare and
Medicaid Services have also issued guidelines for a rapid HIV test quality-assurance program
(Greenwald et al., 2006). All positive (reactive) rapid HIV tests require repeat testing for
confirmation.
RAPID HIV TESTS
1. OraQuick ADVANCE Rapid HIV-1/HIV-2 Antibody Test detects HIV-antibodies in oral
fluid as well as in blood.
2. Uni-Gold Recombigen HIV Test detects HIV-1 antibodies in whole blood, serum, and
plasma; results take from 10 to 12 minutes.
3. Reveal G3 Rapid HIV-1 Antibody Test detects HIV antibodies in serum or plasma;
although the test takes only 3 minutes to run, it is categorized as a moderately complex
test and is usually done in a clinical laboratory.
4. Multispot HIV-1/HIV-2 Rapid Test uses fresh or frozen serum and plasma to detect
HIV-1 and HIV-2 and distinguish one from the other; results are available in 20 minutes.
Also a moderately complex test, it is usually done in a clinical laboratory (FDA, 2008).
5. Clearview HIV-1/HIV-2 STAT-PAK uses whole blood or serum and plasma; results are
available in 15 minutes; requires no training to use.
6. Clearview HIV-1/HIV-2 Complete is a single-use, self-contained closed system for the
collection, processing, and analysis of a whole blood, serum, or plasma sample; results
are available in 15 minutes.
HOME TESTING KITS
Tests are now available for self-testing of HIV serostatus. Home Access Express HIV-1 Test
System is the only FDA-approved home test kit currently on the market, but several unapproved
kits are marketed on the Internet. This Home Access Express product is really an in-home
sample collection system rather than a test with readily visible results. The person who wants to
test at home pricks a finger and collects blood spots on special paper. The paper is mailed to a
certified clinical laboratory with a confidential and anonymous personal identification number
(PIN) and then tested using a standard ELISA process.
If the initial test result is positive, the results are confirmed by a Western blot test. The person
tested obtains the results by calling a toll-free telephone and using the assigned PIN. Post-test
counseling is available by telephone for everyone tested, whether the results are positive or
negative.
Home testing is a controversial issue, primarily because of the need for counseling. The FDA
has expressed concern that people who have not been appropriately counseled by experienced
staff in a culturally competent way before they receive the news that they are HIV-positive may
commit suicide. Counseling needs to help reduce anxiety and risk-taking behavior as well as
link individuals to services. However, at least one survey showed that nearly 1/4 of clients at
public testing services would choose a home self-test.
TESTING AND INFORMED CONSENT IN FLORIDA
Florida’s Omnibus AIDS Act of 1988 and its 1998 update are essential for doctors, nurses,
and other healthcare providers to understand. This legislation corresponds closely with federal
guidelines and accepted medical practice. Violations are heavily penalized, and good-faith
efforts at compliance do not ensure anyone against legal difficulties.
The principal methods for dealing with the HIV/AIDS epidemic as stipulated in the Florida
Omnibus Aids Act are education and testing that is informed, voluntary, and confidential. Florida
legislation stipulates four reasons for deviation from traditional educational and testing methods:
• It is assumed that involuntary and nonconfidential testing may drive HIV-infected
individuals underground.
• The government cannot constitutionally investigate or regulate much of the private
behavior that permits the transmission of HIV.
• Because there is no effective cure for AIDS, there is less incentive to enforce
mandatory testing and notification of individuals who have been exposed.
• “The excessively anxious and sometimes intensely hostile public reaction” to people
with this illness requires the protection afforded by anonymity.
OBTAINING CONSENT
Before anyone can be tested for HIV in Florida, they must explicitly consent to be tested.
Testing without informed consent can result in disciplinary action by a healthcare provider’s
licensing board, fines, suspension or revocation of license, and civil liability for negligence and
invasion of privacy.
A general consent to draw a patient’s blood and run unspecified tests does not meet the Florida
criteria of informed consent for HIV testing. The healthcare provider must explain the HIV test in
a manner appropriate to the age, mental capacity, and language skill of the subject. The
explanation should include the following information (Department of Health Rule 64D-2.004,
F.A.C):
• That an HIV test is a test to determine if an individual is infected with the virus that
causes AIDS
• The potential uses and limitations of the test
• The procedures to be followed
• That HIV testing is voluntary and consent to be tested can be withdrawn at any time
prior to testing
• That if the test results are positive, that is, if the results show that the person is infected
with HIV, the provider is required to report the test subject’s name to the local county
health department
A separate statute, designed to eliminate “unnecessary diagnostic testing,” may make an HIV
test illegal even when informed consent is granted. The law forbids diagnostic tests “which are
not reasonably calculated to assist the healthcare provider in arriving at a diagnosis and
treatment of a patient’s condition.” It is also forbidden to test for evidence of HIV infection “solely
for the purpose of protecting healthcare workers.”
MINORS
Children under 18 are considered adults for the purpose of consenting to, or refusing, an HIV
test. Parental permission is not required for a child judged by the healthcare provider to be
sufficiently mature to consent or refuse an HIV test. Florida law forbids informing parents of a
minor’s HIV test results either directly or indirectly (such as sending a bill for testing or treatment
without the minor’s consent). It is up to the healthcare provider to decide whether the minor is
capable of understanding the risks and benefits of the test or treatment.
DURING PREGNANCY
A 1998 amendment to the Florida Omnibus AIDS Act requires the physician or midwife
attending a woman for a condition related to pregnancy to offer HIV testing in conjunction with
her required blood tests at the initial prenatal care visit and again at 28 to 32 weeks’ gestation,
regardless of risk behaviors.
In 2005, the statute was amended to establish the current system of opt-out testing for all
pregnant women. Under this system, all pregnant women are advised that their healthcare
provider will conduct an HIV test but that they have the right to refuse testing. Any pregnant
woman who refuses testing must do so in writing, and her refusal must be placed in her medical
record (§384.31, F.S.).
Any pregnant woman who has positive test results should be referred to medical and support
services related to HIV/AIDS as well as the Healthy Start Care Coordination System. Any
pregnant woman who presents at delivery without a record of a blood test for HIV during
pregnancy must be counseled and offered an HIV test.
TESTING WITHOUT INFORMED CONSENT
HIV testing without informed consent may occur in the following circumstances:
• Bona fide medical emergencies in which treatment is indicated by HIV status
• When there has been significant exposure by medical personnel to a person’s blood,
the source will not voluntarily submit to HIV testing, and a blood sample is not available
(court order required)
• In the event of a significant exposure to medical or nonmedical personnel providing
help in an emergency and the victim has expired during treatment for the emergency
• When a person is charged with sexual offenses (court order required)
• When donating blood, sperm, or tissue to specialty banks
• For infants whose parents cannot be located after reasonable attempts (court order
required, and attempts to locate the parents documented)
• Of prison inmates before they are released into the community
• When performing HIV testing to monitor the clinical progress of a patient previously
diagnosed as HIV-positive or repeated HIV testing conducted to monitor possible
conversion from a significant exposure
• Certain medical examiner cases, including court-ordered autopsies
• When a child is deemed too young to make an informed decision (however, parental
consent is required; the law does not specify what age is too young to make an informed
decision)
• Established epidemiologic research methods that ensure test subject anonymity
• Of convicted prostitutes
CONFIDENTIALITY
Anonymous and confidential HIV tests are available at Florida county health departments and
other registered testing sites. County health departments and registered testing sites are
required to provide private pre-test and post-test counseling for all persons tested. Confidential
HIV tests are also increasingly available in private-sector doctors’ offices and hospitals.
The legal requirements for counseling and testing are different for public- and private-sector
facilities. County health departments must obtain written informed consent from the test subject.
Registered testing sites and private-sector facilities are not required to obtain written consent,
provided that the medical record includes documentation that the test was explained and
consent was obtained. Written consent is preferable, nonetheless, because it provides practical
advantages to the testing agency or facility and the healthcare worker in the event of litigation.
SUPERCONFIDENTIALITY
Medical records are, by law, confidential. The Florida Omnibus Aids Act designates information
about HIV testing as superconfidential if the tests can be traced to an identifiable individual. All
test results, positive or negative, are superconfidential, which means that the information is only
made available to healthcare personnel on a need-to-know basis. Providers, in turn, must sign a
legal document not to divulge this information except on a need-to-know basis.
However, the law uses a narrow definition of “HIV test result.” The superconfidentiality standard
applies only to the part of a person’s medical record that documents an HIV test and the results,
negative or positive, of that test. If the documented HIV status was based on a health
department anonymous test or a home testing kit, that does not constitute “HIV test results” and
is not covered by the superconfidentiality standard.
Providers’ clinical assessments of any medical conditions associated with AIDS are also exempt
from the superconfidentiality standard because they do not constitute “HIV test results” unless
they include laboratory reports or medical-record notes of an HIV test. For example, a patient’s
chart documenting symptoms of AIDS and including the word AIDS throughout the chart, but
without an HIV test result or report, is not considered superconfidential.
DISCLOSURE
Disclosure of HIV test results is limited to the following:
• The test subject and his or her representative
• Healthcare providers consulting among themselves regarding diagnosis and treatment
of AIDS
• The Department of Health
• Healthcare providers exposed to the subject’s body fluids
• Authorized medical or epidemiologic researchers; repeated tests may be given to
monitor clinical progress without seeking renewed consent
• Hospital staff, administrators, and healthcare workers who provide aid and care to the
subject, on a need-to-know basis; this is especially important in cases of significant
exposure to body fluids by healthcare workers
• Appropriate authorities in the course of reporting child abuse
• Adults responsible for a child who is placed in foster care or for adoption
• An exposed healthcare worker who exercised the right to subpoena the medical
records of the patient and demand that HIV status be determined
BREACHES OF CONFIDENTIALITY
The 1998 amendment to Florida’s Omnibus AIDS Act increased the penalty for breaches of
confidentiality. Anyone who maliciously, or for monetary gain, breaches the confidentiality of
sexually transmitted disease information commits a third-degree felony.
NOTIFICATION RESPONSIBILITIES
The healthcare provider ordering an HIV test must make all reasonable efforts to notify the
person tested of the results. If the HIV-negative person fails to obtain the results, either by
missing a scheduled visit or not calling in, the provider has met the “all reasonable efforts”
standard.
However, if the test results show the person to be HIV-positive, the provider must exhaust all
available means to contact the patient. If all efforts fail, the responsibility for notification can be
transferred to the county health department through HIV infection–reporting requirements.
POST-TEST COUNSELING
If test results are HIV-negative, notification should include appropriate information on preventing
transmission of HIV. Information for high-risk test subjects may not be appropriate for low-risk
test subjects and vice versa.
If test results are HIV-positive, counseling the test subject must include information on the
following:
• Availability of appropriate medical and support services
• Importance of notifying partners who may have been exposed
• Prevention of the transmission of HIV
Counseling someone who has just learned of his or her HIV-positive status requires not only
that the healthcare provider be familiar with local HIV health and social services but also that the
provider have the ability to communicate with clarity, sensitivity, and compassion.
The Florida Department of Health has developed “Model Protocols on Counseling and Testing”
that may be obtained through the website at http://www.floridaaids.org.
Chapter 4 - Infection Control Procedures
To prevent HIV transmission in healthcare settings, CDC instituted universal precautions
(blood and body fluid precautions). Under universal precautions, healthcare personnel should
assume that the blood and other body fluids from all patients are potentially infectious and
therefore follow infection-control precautions at all times and in all settings.
Standard precautions is a newer term that hospitals and other agencies are moving toward. It
includes all recommendations for universal precautions plus body substance isolation (BSI)
when other potentially infectious materials (OPIM) are present.
These precautions include:
• Routine use of barriers (such as gloves and/or goggles) when anticipating contact with
blood or body fluids
• Washing hands and other skin surfaces immediately after contact with blood or body
fluids, and
• Careful handling and disposing of sharp instruments during and after use
PROTOCOLS FOR HEALTHCARE WORKERS EXPOSED TO BLOOD
Any healthcare worker who receives a needlestick or other significant exposure to potential HIV
infection should follow the employer’s protocol, which is based on guidelines issued by the CDC
(2005). Prompt reporting of the incident is essential because in some cases postexposure
prophylaxis (PEP) may be recommended and started as soon as possible. Discuss with a
healthcare professional the extent of the exposure, treatment, follow-up care, personal
prevention measures, the need for a tetanus shot, and other care.
The CDC recommends that postexposure prophylaxis (PEP) begin as soon as possible, ideally
within 24 hours after the exposure and no later than 7 days. Animal studies indicate that cellular
HIV infection occurs within 2 days of exposure to HIV. Virus in blood is detectable within 5 days.
For exposure to HIV-positive blood, recommendation is for a four-week course combining either
two antiretroviral drugs for most HIV exposures, or three antiretroviral drugs for exposures that
may pose a greater risk for transmitting HIV (e.g., those involving a larger volume of blood with
a larger amount of HIV or a concern about drug-resistant HIV). The antiviral drugs used in PEP
are potentially toxic and should not be used for exposures that pose a negligible risk. CDC
recommends consultation with an infectious disease consultant or another physician
experienced with antiretroviral drugs; however, consultation “should not delay timely initiation of
PEP.”
Chapter 5 - Clinical Management
Antiretroviral therapy (ART) has become the gold standard for treatment of HIV/AIDS.
Antiretroviral drugs are administered in “cocktails” of three or more. The primary goal of ART is
to reduce HIV-associated morbidity and mortality by suppressing the individual’s viral load to
below detectable levels. People with HIV may also receive medications to treat or prevent
opportunistic infections, boost the immune system, and prevent anemia.
Antiretroviral treatment of people with HIV continues to prove complex, controversial, dynamic,
and expensive. These drugs do not constitute a “cure” for HIV/AIDS. If therapy is discontinued,
viral load will increase. Even during treatment, the virus is replicating and the person remains
infectious to others.
HIV/AIDS DRUGS
Five major classes of drugs are used to treat HIV/AIDS:
• Nucleoside/nucleotide reverse transcriptase inhibitors (NRTI)
• Non-nucleoside reverse transcriptase inhibitors (NNRTI)
• Protease inhibitors (PI)
• Entry inhibitors, including fusion inhibitors and CCR5 antagonists*
• Integrase inhibitors**
*CCR5 stands for chemokine (C-C motif) receptor 5, one of the two known points of entry used
by the HIV virus to penetrate the CD4 T-cells. CCR5 antagonists are designed to block this
receptor. The first of these drugs was approved by the FDA in August 2007 for use in treatmentexperienced patients who have detectable HIV RNA and multidrug resistance to antiretrovirals.
**The first of these newest drugs, raltegravir (Isentress), was approved by the FDA on October
12, 2007. This class of drugs is designed to slow the progression of HIV by blocking the HIV
integrase enzyme that the virus needs in order to multiply.
ART COMPLICATIONS
Discontinuing or interrupting ART may become necessary due to factors such as serious drug
toxicity, intervening illness, surgery, or unavailability of medications. Although unplanned shortterm interruption of therapy may be unavoidable, planned interruption is no longer
recommended. Interrupting therapy increases the risk of AIDS-related complications, declining
CD4 counts, and other non–AIDS-related complications such as heart attack and liver failure.
While extending and improving lives of people with HIV, long-term use of some of these drugs
increases the risk of liver problems, high cholesterol, stroke, heart disease, osteoporosis,
diabetes, pancreatitis, neuropathy, and skin rashes. Some of the skin rashes can be lifethreatening, such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
which are two different forms of the same kind of skin rash. TEN may involve as much as 30%
of the total body skin area. Both these severe rashes must be treated by a physician.
Antiretroviral drugs may also interact with other drugs used to treat opportunistic infections. For
example, researchers reported that using oral erythromycin while taking protease inhibitors
increased the risk of sudden death from cardiac causes (Ray et al., 2004). As patients live
longer with HIV/AIDS, many develop drug-resistant strains of the virus, which further
complicates treatment.
DRUG ACCESS CRISIS
The economic downturn since 2008 has affected both federal and state budgets, creating a drug
access crisis in many states. As of June 2010, the AIDS Drug Assistance Program (ADAP) in
Florida reported that nearly 1,800 HIV patients were waiting for access to lifesaving drug
treatment. In late summer, the program received a $6.9 million federal grant, enough for three
weeks’ worth of medications (Tasker, 2010). Meanwhile, the cost of HIV drugs almost tripled
between 1999 and 2009 (National ADAP Monitoring Project, 2010).
Chapter 6 - Conclusion
Thousands of people are living with HIV/AIDS in Florida, which has the third highest prevalence
of HIV/AIDS in the country. Despite this ongoing tragedy, the public no longer has a sense of
urgency or importance about AIDS. Research has produced drugs that slow but do not stop the
carnage, and the cost of these drugs has tripled during the past 10 years.
No vaccine has proved effective in preventing HIV. So the epidemic continues to spread,
primarily among disadvantaged and marginalized populations: the poor, people of color, people
in prison, injection drug users, and men who have sex with men. Many do not realize they are
infected and unknowingly transmit the virus to others.
Ignorance, prejudice, and lack of access to healthcare are fueling the epidemic. Therefore,
health professionals have a critical role in screening, testing, and educating patients, families,
and communities about prevention. Health professionals can also teach by example, through
offering nonjudgmental, compassionate care to those affected by this deadly virus.
Chapter 7 - References
Centers for Disease Control and Prevention (CDC). (2005). Updated U.S. Public Health Service
guidelines for the management of occupational exposures to HIV and recommendations for
postexposure prophylaxis. MMWR, 54(RR-9), 1–17. Retrieved May 12, 2006, from
http://www.cdc.gov/mmwr/PDF/rr/rr5409.pdf
Florida Department of Health, Bureau of HIV/AIDS. (2009a). Florida annual report 2009:
Acquired immune deficiency syndrome/human immunodeficiency virus. Retrieved September 3,
2010, from http://www.doh.state.fl.us/disease_ctrl/aids/trends/trends.html
Florida Department of Health, Bureau of HIV/AIDS. (2009b). Targeted outreach for pregnant
women — 10 years of TOPWA. Retrieved September 3, 2010, from
www.doh.state.fl.us/disease_ctrl/aids/updates/facts/BW04Women.pdf
Florida Department of Health, Bureau of HIV/AIDS. (2009c). HIV/AIDS among Blacks. Retrieved
September 3, 2010, from
http://www.doh.state.fl.us/disease_ctrl/aids/updates/facts/09Facts/2009_BlackFactSheet.pdf
Florida Department of Health, Bureau of HIV/AIDS. (2009d). HIV/AIDS among persons age 50+
in Florida. Retrieved September 3, 2010, from
http://www.doh.state.fl.us/Disease_ctrl/aids/updates/facts/09Facts/2009_50_plus_FactSheet.pdf
Food and Drug Administration (FDA). (2008). HIV testing. Retrieved September 15, 2010, from
http://www.fda.gov/oashi/aids/test.html
Greenwald J, Burstein G, Pincus J., & Branson B. (2006). A rapid review of rapid HIV antibody
tests. Current Infectious Disease Reports, 8, 125–31.
Hall HI, Song R, Rhodes P, et al. (2008). Estimation of HIV incidence in the United States.
Journal of the American Medical Association, 300(5), 520–529.
Holtgrave D & Anderson T. (2004). Utilizing HIV transmission rates to assist in prioritizing HIV
prevention services. Journal of Sexually Transmitted Diseases and AIDS, 15 ,789–92.
National ADAP Monitoring Project. (2010). Annual Report 1999–2010. Retrieved August 20,
2010, from http://www.kff.org/hivaids/ADAP.cfm
Ray W, Murray K, Meredith S, et al. (2004). Oral erythromycin and the risk of sudden death from
cardiac causes. New England Journal of Medicine, 351, 1089–96.
Tasker F. (2010). Florida: AIDS, HIV patients getting help from pharmaceutical companies.
Miami Herald, September 27, 2010.