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___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina COURSE #P477 — 4 CE HOURS Release Date: 04/01/15 Expiration Date: 03/31/18 HIV/AIDS: Epidemic Update for North Carolina HOW TO RECEIVE CREDIT • Read the enclosed course. • Complete the questions at the end of the course. • Return your completed Answer Sheet/Evaluation to Paragon CET by mail or fax, or complete online at www.ParagonCET.com. Your postmark or facsimile date will be used as your completion date. • Receive your Certificate(s) of Completion by mail, fax, or email. Faculty Jane C. Norman, RN, MSN, CNE, PhD, received her undergraduate education at the University of Tennessee, Knoxville campus. There she completed a double major in Sociology and English. She completed an Associate of Science in Nursing at the University of Tennessee, Nashville campus and began her nursing career at Vanderbilt University Medical Center. Jane received her Masters in Medical-Surgical Nursing from Vanderbilt University. In 1978, she took her first faculty position and served as program director for an associate degree program. In 1982, she received her PhD in Higher Education Administration from Peabody College of Vanderbilt University. In 1998, Dr. Norman took a position at Tennessee State University. There she has achieved tenure and full professor status. She is a member of Sigma Theta Tau National Nursing Honors Society. In 2005, she began her current position as Director of the Masters of Science in Nursing Program. John M. Leonard, MD, Emeritus Professor of Medicine, Vanderbilt University School of Medicine. Dr. Leonard completed his post-graduate clinical training at the Yale and Vanderbilt University Medical Centers, and then joined the Vanderbilt faculty in 1974. He has served as director of educational programs for the Department of Medicine and was the Residency Program Director from 1981 to 2003. Dr. Leonard’s clinical experience includes an active practice of general internal medicine and an inpatient consulting practice of infectious diseases. Division Planner Leah Pineschi Alberto, licensed cosmetologist and instructor of cosmetology, has been educating students in Northern California since 1975. In addition, she has been responsible for training educators in cosmetology, esthetics, and manicuring for more than 30 years. Mrs. Alberto began her career with Don’s Beauty School in San Mateo, California. She held a 30-year position at Sacramento City College and is currently the State Board Specialty Learning Leader and is involved in tutoring and consulting. She is a salon owner, a former Department of Consumer Affairs examiner, and a speaker at the Esthetics Enforcement Conference. The health and safety of the community of stylists, salon owners, and school owners has been the focus of Mrs. Alberto’s career. She served on the State Board Task Force on Pedicure Disinfection commissioned by Governor Schwarzenegger to investigate the cleanliness of the pedicure industry. The Task Force was responsible for developing foot spa safety regulations in response to illnesses and deaths resulting from unsafe pedicure practices. Mrs. Alberto is currently a member of the California Cosmetology Instructors Association. Audience This course is designed for all salon and spa professionals in North Carolina. Accreditation Paragon CET courses meet the requirement for continuing education as set forth by the North Carolina Board of Cosmetic Art Examiners. Copyright © 2015 Paragon CET A complete Works Cited list appears on page 18. Paragon CET • Sacramento, California Mention of commercial products does not indicate endorsement. Phone: 800 / 707-5644 • FAX: 916 / 878-5497 1 #P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________ Designation of Credit Paragon CET designates this continuing education activity for 4 CE hours. About the Sponsor The purpose of Paragon CET is to provide challenging curricula to assist professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of service to their clients. Course Objective In view of the already existing HIV/AIDS crisis in the United States, the issues associated with employing or providing services for persons with HIV infection or AIDS are significant. The purpose of this course is to provide salon owners and employees information regarding the transmission, symptoms, and management of HIV infection and to address workplace concerns. 2 Paragon CET • May 1, 2015 Learning Objectives Upon completion of this course, you should be able to: 1. Discuss the background and significance of the AIDS epidemic. 2. Describe the transmission of HIV infection, including risk behaviors and routes of contagion. 3. Review proper precautions for employees and clients. 4. Discuss the impact of the virus on special populations living with HIV infection, including women, children, and the elderly. 5. List ethical and legal issues related to HIV infection. www.ParagonCET.com ___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina INTRODUCTION WHAT IS HIV? The amount that has been learned and written about human immunodeficiency virus (HIV) infection and disease and its influence on individuals and society is staggering. Researchers in America and England have traced the ancestry of the HIV virus to two strains found in African red-capped mangabeys and greater spot-nosed monkeys. The strains most likely combined in chimpanzees that ate the monkeys, resulting in the chimpanzees developing simian immunodeficiency virus (SIV). Chimpanzees then transmitted the virus to humans, as early as 1930. Genetic studies suggest that the lower monkeys first became infected with SIV 100,000 years ago [29]. According to the Centers for Disease Control and Prevention (CDC), there are two types of HIV: HIV-1 and HIV-2. In the United States, unless otherwise noted, the term “HIV” primarily refers to HIV-1 [47]. Both types of HIV damage a person’s body by destroying specific blood cells, called CD4+ T cells, which are crucial to helping the body fight diseases. The CDC provides the following description of HIV and AIDS [47]: The first reported case of HIV occurred more than 30 years ago, in 1981. Since then, researchers have made major inroads in understanding the disease. Knowledge about the characteristics and behavior of this human retrovirus has helped to develop targeted therapeutic interventions and vaccine strategies. The availability of antiretroviral drug therapy has been a benefit to many who are HIV-infected, with a delay in the development of opportunistic infections and acquired immune deficiency syndrome (AIDS). However, HIV does eventually lead to AIDS in many people despite these advances. Paragon CET • Sacramento, California Within a few weeks of being infected with HIV, some people develop flu-like symptoms that last for a week or two, but others have no symptoms at all. People living with HIV may appear and feel healthy for several years. However, even if they feel healthy, HIV is still affecting their bodies. All people with HIV should be seen on a regular basis by a health care provider experienced with treating HIV infection. Many people with HIV, including those who feel healthy, can benefit greatly from current medications used to treat HIV infection. These medications can limit or slow down the destruction of the immune system, improve the health of people living with HIV, and may reduce their ability to transmit HIV. Untreated early HIV infection is also associated with many diseases including cardiovascular disease, kidney disease, liver disease, and cancer. Support services are also available to many people with HIV. These services can help people cope with their diagnosis, reduce risk behavior, and find needed services. Phone: 800 / 707-5644 • FAX: 916 / 878-5497 3 #P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________ AIDS is the late stage of HIV infection, when a person’s immune system is severely damaged and has difficulty fighting diseases and certain cancers. Before the development of certain medications, people with HIV could progress to AIDS in just a few years. Currently, people can live much longereven decades-with HIV before they develop AIDS. This is because of “highly active” combinations of medications that were introduced in the mid1990s. IMPACT OF HIV According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), an estimated 35 million individuals worldwide were living with HIV or AIDS in 2013, approximately half of which were women [48; 50]. Eastern Europe (particularly the Russian Federation) and the Middle East/North Africa have the fastest growing epidemic [30]. It is important to note that despite increases in certain geographic areas and demographic groups, overall, the rate of new infections is declining. This is due, in part, to lower prices for anti-AIDS drugs [22]. Africa is still the hardest-hit area, with more than two-thirds (71%) of all HIV-infected persons living in sub-Saharan Africa in 2013 [49]. In 2003, the U.S. government approved the purchase of generic drugs to fight the disease in Africa. In that same year, the President’s Emergency Plan for AIDS Relief (PEPFAR) was introduced and implemented [37]. PEPFAR was reauthorized in July 2008, with a total of $48 billion in funds over the following 5 years and expansion to address additional health issues, including malaria, tuberculosis, maternal health, and clean water [31]. 4 Paragon CET • May 1, 2015 As of 2013, an estimated 1.4 million individuals were living with HIV/AIDS in the United States [52]. The CDC estimates that approximately 20% of these individuals are unaware of their infection [51]. To compound the problem, up to one-third of individuals aware of their infection do not receive ongoing care. Approximately 50% of all individuals infected with HIV remain untested, without treatment, or both [35]. Unfortunately, this poses a risk both for those who are infected and for others. Many changes in the progression of the HIV/ AIDS epidemic should be considered. Since the first reported cases of HIV in 1981 in the United States, the epidemic continues to vary a great deal between regions, states, and even communities. Populations that are affected by HIV are also shifting. In addition to individuals traditionally considered to be high-risk (e.g., men who have sex with men [MSM] or injection drug users [IDUs]), new groups have been identified as being at greater risk. For example, in the beginning stages of the HIV/ AIDS epidemic in the United States, white people were chiefly impacted. However, the epidemic now greatly affects racial and ethnic minorities, particularly black Americans, who represent almost half of all cases in the United States [33]. Women also have a higher risk of infection. More than half of HIV infections that result from heterosexual contact occur in women. As of 2013, the CDC reported several trends in the HIV/AIDS epidemic [52]: • By region, 42% reside in the South, 25% in the Northeast, 19% in the West, and 12% in the Midwest. • By race/ethnicity, 43% are black, 32% white, 20% Hispanic, 3% are multi-racial, 1% are Asian or Pacific Islander, and less than 1% are American Indian/Alaska Native. • By gender, 76% of adults and adolescents living with HIV are male. www.ParagonCET.com ___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina North Carolina ranks thirteenth in the United States in terms of number of reported cases of HIV [1]. As of December 31, 2013, an estimated 28,101 persons were living with HIV in North Carolina, with 1,525 new diagnoses in 2013 alone [55]. As is true in the country, the disease has disproportionately affected minorities in North Carolina. Black persons have the highest rate of HIV in the state, accounting for 64% of cases. SIGNS AND SYMPTOMS HIV infection passes through several stages and, if untreated, carries an 80% mortality rate at 10 years. The initial event, reported in 50% to 90% of infected individuals, is an acute mononucleosislike illness. Symptoms include fever, sore throat, malaise, rash, diarrhea, enlarged lymph nodes, ulcerations (broken, inflamed skin or mucous membranes), and weight loss averaging 10 pounds. A variety of neurologic syndromes including swelling of the brain (encephalitis) may occur. The illness begins 1 to 3 weeks after viral transmission and lasts about 2 to 3 weeks. This is followed by a prolonged asymptomatic period in most individuals. Symptomatic infection can be expected after the CD4 T-cell count has decreased to less than 200/ mm3 as this represents the stage of severe immunodeficiency. The CDC defines late-stage HIV infection as AIDS on the basis of two criteria: CD4 count less than 200/mm3 and the presence of a characteristic AIDS-defining illness such as pneumonia, parasitic infections (such as toxoplasmosis, which affects the nervous system), or other opportunistic infections or tumors. A variety of syndromes may develop at this point, including dementia, nerve damage (numbness, tingling, burning sensation in the hands or feet), extreme weight loss, and chronic diarrhea [39]. Paragon CET • Sacramento, California Signs and symptoms of HIV generally are related to opportunistic infections preying on an impaired immune system. These diseases include pneumonia, tuberculosis, and others. Individuals with HIV commonly succumb to uncontrollable infection, becoming increasingly debilitated, feverishly ill, malnourished, and often in pain. To date, there is no predictable cure [14]. In the absence of medication therapy, the average survival is approximately 3.5 years after the individual’s CD4 count has reached 200/mm3 and 1.5 years for the person who has developed an AIDS-defining diagnosis. HIV TESTING According to the CDC, [47]: It can take some time for the immune system to produce enough antibodies for the antibody test to detect, and this “window period” between infection with HIV and the ability to detect it with antibody tests can vary from person to person. During this time, HIV viral load and the likelihood of transmitting the virus to sex or needle-sharing partners may be very high. Most people will develop detectable antibodies that can be detected by the most commonly used tests in the United States within 2 to 8 weeks (the average is 25 days) of their infection. Ninety-seven percent (97%) of persons will develop detectable antibodies in the first 3 months. Even so, there is a small chance that some individuals will take longer to develop detectable antibodies. Therefore, a person should consider a follow-up test more than three months after their last potential exposure to HIV. In extremely rare cases, it can take up to 6 months to develop antibodies to HIV. Phone: 800 / 707-5644 • FAX: 916 / 878-5497 5 #P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________ Several tests are available to screen for HIV. There are various ways by which these tests function: detection of the antibody, identification of antigens, detection/monitoring of viral nucleic acids, or rendering an estimate of T-lymphocytes (cell phenotyping). Tests used to detect antibodies are the most common and effective way of identifying HIV infection and can be further broken down into two categories [42]: • Screening Tests: Intended to determine all individuals infected with HIV; produces few false-negative results • Supplemental/Confirmatory Tests: Intended to determine all individuals who have positive screening tests, but are not infected (i.e., negates a false-positive), produces few false-positive results Both types of tests are highly sensitive. Together, they can accurately assess the existence of HIV in blood supply and supplement clinical diagnosis. TRANSMISSION OF HIV Transmission of HIV results from intimate contact with blood and body secretions, excluding saliva and tears. The most common modes of transmission are sexual contact, administration of contaminated blood and blood products, contaminated needles, and mother-to-fetus [14]. It is important to note that HIV cannot be spread by air or water; insects, including mosquitoes; saliva, tears, or sweat; casual contact like shaking hands or sharing dishes; or closed-mouth or “social” kissing [47]. Tattooing or body piercing present a potential risk of HIV transmission, but no cases of HIV transmission from these activities have been documented. Only sterile equipment should be used for tattooing or body piercing. 6 Paragon CET • May 1, 2015 RISK CATEGORIES On the basis of newly reported cases, the transmission risk categories are [33]: • Male-to-male sexual contact • Injecting drug users • Men who have sex with men who inject drugs • High-risk heterosexual contact • Blood transfusion • Perinatal transmission (i.e., from an infected pregnant woman to her fetus or infant) MODES OF TRANSMISSION Sexual Transmission of HIV HIV has been isolated from blood, seminal fluid, pre-ejaculate, vaginal secretions, urine, cerebrospinal fluid, saliva, tears, and breast milk of infected individuals. Whether HIV infects spermatozoa is controversial. Reports of the removal of infected cells from semen, allowing artificial insemination without seroconversion, support the idea that spermatozoa are not infected. No cases of HIV infection have been traced to saliva or tears [40]. Sexual behavior that involves exposure to blood is likely to increase transmission risks. Transmission could occur through contact with infected bowel epithelial cells in anal intercourse in addition to access to the bloodstream through breaks in the rectal mucosa. Posing the highest risk of infection is unprotected anal receptive intercourse, followed by unprotected vaginal intercourse. Risk is reduced through the use of latex condoms. For the wearer, latex condoms provide a mechanical barrier limiting penile exposure to infectious cervical, vaginal, vulvar, or rectal secretions or lesions. Likewise, the partner is protected from infectious pre-ejaculate, semen, and penile lesions. Oil-based lubricants may make latex condoms ineffective and should not be used. www.ParagonCET.com ___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina Water-soluble lubricants are considered safe. Natural membrane condoms (made from lamb cecum) contain small pores and do not block HIV passage. It is estimated that latex condom efficacy in the prevention of HIV transmission is approximately 85% [53]. Although abstinence from sexual contact is the sole way to absolutely prevent transmission, using a latex condom to prevent transmission of HIV is more than 10,000 times safer than engaging in unprotected sex [38]. Sexual activity in a mutually monogamous relationship in which neither partner is HIV-infected and no other risk factors are present is considered safe [7]. Oral Sex Numerous studies have demonstrated that oral sex can result in the transmission of HIV and other sexually transmitted infections (STIs). While the risk of HIV transmission through oral sex is much smaller than the risk from anal or vaginal sex, there are several co-factors that can increase this risk, including oral ulcers, bleeding gums, genital sores, and the presence of other STIs. Prevention includes the use of latex condoms, a natural rubber latex sheet, plastic food wrap, a cut open condom, or a dental dam, all of which serve as a physical barrier to transmission [9]. Blood Donor Products HIV is transmitted via blood, primarily through sharing of contaminated needles among IDUs and, rarely, through blood transfusion. Transmission of HIV-1 has occurred after transfusion of the following components: whole blood, packed red blood cells, fresh frozen plasma, cryoprecipitate, platelets, and plasma-derived products, depending on the production process. Paragon CET • Sacramento, California With the implementation of a donor screening program of the nation’s blood supply in 1985 and advances in the treatment of donated blood products, blood transfusion is now even safer; the current risk of transmission of AIDS through this route is estimated to be 1 in 225,000. A somewhat higher estimate of 1 in 40,000 to 1 in 60,000 is reported from areas that have a high prevalence of HIV-1 infection. It is possible that before blood screening implementation, more than 12,000 people were infected. A large percentage of hemophiliacs acquired HIV in this manner. Donor screening, HIV testing, and heat treatment of the clotting factor have greatly reduced the risks. To further decrease the possibility of HIV transmission through transfusion of blood and blood products, patients scheduled to undergo elective surgery are increasingly advised to make predeposited blood donations for intraoperative autotransfusion. To date, screening tests cannot detect either recently HIV-1-infected people who have not yet developed antibody (the “window period”) or HIV antibody-negative patients who have AIDS. Donating procedures include an interview for risk factors and the ability of the potential donor to exclude their blood from being used. No transfusion-related cases of HIV-2 infection have been reported in the United States since 1992, when all U.S. blood centers began to test donations for antibodies to both HIV-1 and HIV-2. Needle Sharing Transmission of HIV among injecting drug users occurs primarily through contamination of injection paraphernalia with infected blood. The risk of sustaining HIV infection from a needle stick with infected blood is approximately 1 in 300. Behavior such as needle sharing, “booting” the injection with blood, and performing frequent injections increases the risk. Sharing of equipment is common due to legal and financial restrictions and cultural norms. Phone: 800 / 707-5644 • FAX: 916 / 878-5497 7 #P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________ Geographically, the rate of infection varies; 80% of New York City addict needle sharers are infected, as opposed to lower rates in other metropolitan area clusters. Secondary transmission occurs to children and sexual partners. Preventative strategies include drug treatment, onsite medical care in a drug treatment program, recruitment of “street” outreach workers for intensive drug and sex “risk reduction” educational campaigns, teaching addicts to sterilize their equipment between use, the free provision or exchange of sterile injection equipment (as allowed by law), distribution of condoms and bleach to clean drug use equipment, or a combination of these interventions [7]. IDUs should be advised [44]: • The best way for you to prevent HIV and hepatitis B and C virus transmission is to NOT inject drugs. • Entering substance abuse treatment can help you reduce or stop injecting. This will lower your chances of infection. • Get vaccinated against hepatitis A and hepatitis B. You can prevent these kinds of viral hepatitis if you get vaccinated. If you cannot or will not stop injecting, you should: – Use a new, sterile syringe obtained from a reliable source to prepare and divide drugs for each injection. – Never reuse or share syringes, water, cookers, or cottons. – Use sterile water to prepare drugs each time, or at least clean water from a reliable source. • Keep everything as clean as possible when injecting. • If you cannot use a new, sterile syringe and clean equipment each time, then disinfecting with bleach may be better than doing nothing at all: 8 Paragon CET • May 1, 2015 – Fill the syringe with clean water and shake or tap. Squirt out the water and throw it away. Repeat until you do not see any blood in the syringe. – Completely fill the syringe with fresh, full-strength household bleach. Keep it in the syringe for 30 seconds or more. Squirt it out and throw the bleach away. – Fill the syringe with clean water and shake or tap. Squirt out the water and throw it away. – If you do not have any bleach, use clean water to vigorously flush out the syringe. Fill the syringe with water and shake or tap it. Squirt out the water and throw it away. Repeat several times. Perinatal Transmission In the absence of preventive treatment, approximately 30% to 50% of children born to HIVinfected mothers will contract HIV infection. HIV is transmitted to infants through the placenta from mother to fetus in utero, during childbirth, or through breastfeeding after birth. Because infants have underdeveloped natural resistance systems, they are highly susceptible to many infections, including HIV. Transmission in utero is the most common route [45]. Both uninfected and infected infants have been born to mothers who have previously borne an infected infant. Studies have shown the beneficial effect of treating pregnant women and newborns with antiviral medications to prevent transmission to the child, resulting in dramatic declines in the incidence of perinatally acquired AIDS [46]. Standard screening of all pregnant women is necessary to reduce transmission of HIV to infants. www.ParagonCET.com ___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina Worldwide, perinatal transmission accounts for most HIV infections among children. In the United States, perinatal transmission has been markedly decreased, by more than 80%, since 1991 [46]. This dramatic decrease is mainly attributed to the use of antiviral medications. Other strategies for reducing perinatally acquired HIV infection have included preventing HIV infection among women and, for HIV-infected women, avoiding pregnancy or refraining from breastfeeding. Occupational Exposure The risk of infection through occupational exposure for salon professionals is low. Educational efforts and universal precautions, as discussed in the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens standard regulations, should be recognized [7]. CONSIDERATIONS FOR SALON AND SPA PROFESSIONALS The activities generally performed by cosmetologists, massage therapists, and nail technicians are not considered to be a transmission threat to clients or coworkers. In 1985, the CDC issued routine precautions that all personal-service workers (such as barbers, cosmetologists, and nail technicians) should follow, even though there is no evidence of transmission from a personal-service worker to a client or vice versa [40]. Instruments that are intended to penetrate the skin (such as tattooing and acupuncture needles or ear piercing devices) should be used once and disposed of or thoroughly cleaned and sterilized. Instruments not intended to penetrate the skin but that may become contaminated with blood (for example, haircutting shears or cuticle scissors) should be used for only one client and disposed of or thoroughly cleaned and disinfected after each use. Personal-service workers can use the same cleaning procedures that are recommended for healthcare institutions. In 2014, there was a documented case of a woman in Brazil who is believed to have contracted HIV from Paragon CET • Sacramento, California sharing manicure utensils with an older cousin, later known to be HIV infected [58]. However, it is important to note that this was the result of sharing equipment at home, not a salon, where sanitation procedures should prevent this type of transmission. The CDC recommends that precautions should be taken in all settings (including the home) to prevent exposures to the blood of persons who are HIV infected, at risk for HIV infection, or whose infection and risk status are unknown [40]. Gloves should be worn during contact with blood or other body fluids that could possibly contain visible blood, such as urine, feces, or vomit. Cuts, sores, or breaks on both the cosmetologist’s and client’s exposed skin should be covered with bandages. Hands and other parts of the body should be washed immediately after contact with blood or other body fluids, and surfaces soiled with blood should be disinfected appropriately. Practices that increase the likelihood of blood contact, such as sharing of razors, should be avoided. In 2010, the CDC started the Hairstylist/Barber HIV Prevention Initiative, a program to promote HIV testing and educations in salons, hair shows, and barber shops [56]. Through this initiative, hair stylists, barbers, and salon professionals are encouraged to engage in conversations with their clients about basic HIV facts, getting tested, and seeking treatment, if needed. The CDC had provided several tips to salon professionals and barbers wishing to incorporate HIV education into their services [57]: • Share what you have been doing lately and mention that you are increasing awareness about HIV and AIDS prevention in your community. • Try placing a flyer or other printed material on your station mirror or around the shop to spark a discussion about getting the facts, getting tested, and getting involved. Phone: 800 / 707-5644 • FAX: 916 / 878-5497 9 #P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________ • Lead the conversation with a fact. You don’t have to be an expert, just know some simple facts (for example, more than 1 million Americans are living with HIV, but nearly 1 in 5 are unaware of their infection). • During your conversation, allow your clients to share their thoughts about HIV and AIDS and help correct any misunderstandings. • Let your clients know that this will be an ongoing conversation and that you will be available to talk privately with them. • Have a list of resources available to provide useful phone numbers and web sites. Several salons in North Carolina participate in the Hairstylist/Barber HIV Prevention Initiative and may present Shop Talk Workshops and Special Events, including [57]: • • • • • • • 33 Fingers Salon (Charlotte) Christian Styles Studios Salon (Raleigh) Ebony and Ivory Hair Designers II (Shelby) Kreative Image (Lumberton) Mane Emotions (Durham) Salon Hair Forte (Dunn) Unique Touch Salon (Kannapolis) MANAGEMENT OF HIV INFECTION ANTIRETROVIRAL THERAPY The introduction of antiretroviral drugs for the treatment of HIV has resulted in longer lives and fewer symptoms in HIV-positive individuals. Most people take a combination of at least three different medications. HIV has been shown to develop resistance to the medications, particularly when only one drug is used. Therefore, in addition to combination therapy, the sequencing of drugs and the preservation of future treatment options are also important [25; 37]. Treatment continues for an individual’s entire life. 10 Paragon CET • May 1, 2015 There are 6 major classes of antiretroviral drugs: nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), fusion inhibitors (FIs), CCR5 antagonists, and integrase inhibitors. Antiretroviral therapy should be initiated in individuals with a history of an AIDS-defining illness or with a CD4 T-cell count less than 350/mm3 [25]. Persons with a CD4 T-cell count greater than 350/mm3 may consider treatment with medications. Therapy should also be initiated in the following groups regardless of CD4 T-cell count [25]: • Pregnant women • Those with HIV-associated kidney disease (nephropathy) • Those also infected with hepatitis B when treatment for the hepatitis infection is indicated Individuals who have never received antiretroviral treatment are usually started on a regimen of two NRTIs plus a PI. This combination results in the best reduction of HIV in the blood for the longest period of time and will achieve the goal of no detectable virus in approximately 60% to 80% of individuals. PREVENTION OF OPPORTUNISTIC INFECTIONS Opportunistic infections are infections that cause disease in persons with weakened immune systems but would probably not cause disease in healthy people. Depending on the CD4 count and other risk factors, asymptomatic people may benefit from treatment to prevent opportunistic infections. In many cases, antiretroviral therapy is useful in the prevention and treatment of these infections [27]. Prophylactic therapy for these conditions is strongly recommended because these infections are relatively common in HIV-positive individuals, preventive therapy is simple and cost effective, and efficacy has been established in clinical studies. In addition, all of these individuals should be vac- www.ParagonCET.com ___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina cinated with pneumococcal vaccine. Hepatitis B vaccination should be considered in patients who have not already been vaccinated. The CDC has developed guidelines for the prevention of opportunistic infections among HIVinfected individuals. The report offers guidelines specific to each type of opportunistic infection and can be viewed at http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf. HIV INFECTION IN SPECIAL POPULATIONS WOMEN LIVING WITH HIV INFECTION Women now make up nearly half of all AIDS cases worldwide and 23% in the United States [21]. The rate of HIV infection in women is rising rapidly. In the last twenty years, the proportion of AIDS cases in women has nearly tripled from 8% in 1985 to 23% in 2011. In 1993, when the CDC expanded the case definition of AIDS, there was a 151% increase in the number of AIDS cases in women and a 105% increase in cases in men. More women were found to meet the AIDS case definition when the CD4+ T-lymphocyte count of <200 was added to the criteria. This may be evidence that the previous case definitions based on the clinical characteristics of men did not accurately reflect the symptoms of HIV in women [21]. AIDS is the fourth leading cause of death in women 35 to 44 years of age in the United States. It is the third leading cause of death in black women in the same age group [28]. Women of color have been disproportionately affected by AIDS; the prevalence of AIDS cases among black women is 21 times that of white women. When compared with adults, a greater percentage of AIDS cases in adolescents are young women. They are more likely to be black or Hispanic/Latino, and they are more likely to be infected through heterosexual intercourse. Paragon CET • Sacramento, California It is noteworthy that recurrent vaginal candidiasis (yeast infection) is a potential indicator of HIV, but is often undiagnosed by healthcare providers [21]. This failure to diagnose results in delays in treatment. More than 45% of HIV-infected women also test positive for some type of human papillomavirus (HPV) [54]. HIV infection is a risk factor for higher prevalence of HPV in the cervix and increased likelihood of infection by multiple HPV types. HIV infection is associated with a high rate of cervical cancer and cervical intra-epithelial neoplasia or squamous intra-epithelial lesions. Menstrual irregularities are also frequently reported by women with HIV [21]. INFANTS AND CHILDREN WITH HIV In the United States today, the predominant route of infection with HIV in children is from an infected pregnant woman to her fetus or infant [32]. Thus, the epidemic in children is closely linked to the epidemic in women [3]. Prevention remains the only cure for HIV, yet no intervention aimed at changing behavior to promote health has been or will be 100% successful. The tragedy of perinatal transmission of HIV is that few women are aware of their risk, many are not offered HIV counseling and testing by healthcare providers, and most learn their diagnosis when their child becomes ill. The CDC has adapted recommendations that advocate universal counseling and testing for every pregnant woman regardless of geography, identified risk behavior, or self-identified risk, unless it is declined [23]. In 2013, the U.S. Preventative Services Task Force (USPSTF) published guidelines recommending the screening of all pregnant women for HIV. The benefits supporting this statement included a potential for decreased perinatal transmission of HIV resulting from maternal and neonatal antiretroviral therapy and the increased opportunity to provide counseling regarding risks associated with breastfeeding and elective cesarean delivery [20]. Phone: 800 / 707-5644 • FAX: 916 / 878-5497 11 #P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________ OLDER PEOPLE WITH HIV Approximately 19% of all persons living with HIV/AIDS are 55 years of age or older, and 24% of persons with AIDS are 50 years of age or older [11; 12]. However, until recently, there had been little attention given to this group [11]. HIV/AIDS has traditionally been thought to be the disease of the young; therefore, in the past, prevention and education campaigns had not been targeted toward older adults. However, evidence points to the increasing number of infected older people and a need for change in prevention and education campaigns. Some older persons may have less knowledge about HIV and risk reduction strategies. Due to divorce or being widowed and the availability of medications to treat erectile dysfunction, increasing numbers of older people are becoming sexually active with multiple partners [11; 41]. For postmenopausal women, contraception is no longer a concern, and they are less likely to use a condom. Furthermore, vaginal drying and thinning associated with aging can result in small tears or cuts during sexual activity, which also raises the risk for infection with HIV/AIDS [18]. Studies indicate that at-risk individuals in this age group are one-sixth as likely as younger at-risk adults to use condoms during sex [19]. The combination of these factors increases the risk for unprotected sex with new or multiple partners in this age group, thereby increasing their risk for AIDS. ETHICAL AND LEGAL CONSIDERATIONS The ethics and law around AIDS and infection with HIV give rise to many issues. In the United States, HIV infections have historically occurred overwhelmingly in two populations: men who have sex with men and injecting drug users. But the number of new infections is growing in many groups, including women. Furthermore, ethnic minority groups (particularly African Americans and Hispanics) are disproportionally affected by the disease. Therefore, sociocultural issues are an important aspect of care [10]. FINANCIAL ISSUES Employment can pose a problem for individuals with HIV/AIDS. Possible issues that may be raised include difficulty maintaining employment or resuming employment after health has been restored or stabilized, stigma associated with the disease, future disability risk, confidentiality concerns, and the resulting financial burden for the employer. Although individuals diagnosed with HIV/AIDS are living much longer as a result of available treatments, they may be forced into extended “HIV retirement,” whereby employment is no longer possible due to the effects of the disease. It has also increased the number of persons living with HIV/ AIDS returning to the workforce [13]. At the beginning of the AIDS epidemic, insurance companies would generally approve AIDSrelated disability claims quickly, as the prognosis for infected individuals was so poor. As prognosis for HIV-infected individuals has improved, it has become more difficult to obtain insurance approval for treatments and/or disability services [15]. 12 Paragon CET • May 1, 2015 www.ParagonCET.com ___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina DISCRIMINATION According to the Americans with Disabilities Act (ADA), an individual is considered to have a disability if he or she has a physical or mental impairment that substantially limits one or more major life activities, has a record of such impairment, or is regarded as having such impairment [16]. Persons with HIV disease, both symptomatic and asymptomatic, have physical impairments that substantially limit one or more major life activities and are protected by the law. Persons who are discriminated against because they are regarded as being HIV-positive are also protected. For example, a person who was fired on the basis of a rumor that he had AIDS, even if he did not, would be protected by the law. Moreover, the ADA protects persons who are discriminated against because they have a known association or relationship with an individual who is HIV-positive. For example, the ADA would protect an HIV-negative woman who was denied a job because her roommate had AIDS [16]. Under the ADA, an employer must make a reasonable accommodation to the known physical or mental limitations of a qualified applicant or employee with a disability. However, an employer is not required to provide an accommodation if it would pose an undue hardship on the operation of its business. Undue hardship is defined as “an action requiring significant difficulty or expense” [16]. The Federal Rehabilitation Act of 1973 also prohibits discrimination on the basis of a handicap. All stages of HIV disease, including asymptomatic HIV infection, have been found by the courts to be handicapping conditions under Section 504 of this Act [17]. Paragon CET • Sacramento, California The ADA also prohibits state licensing agencies and public trade schools for barbering and cosmetology from discriminating against individuals with disabilities. Consequently, a public or private entity cannot deny a person with HIV an occupational license or admission to a trade school because of his or her disability. According to the U.S. Department of Justice, examples of discrimination against persons with HIV/AIDS would include [5]: • A certificate program for health aides having a blanket policy denying admission to anyone with HIV • A cosmetology school denying admission to an HIV-positive individual because State cosmetology regulations require that cosmetologists be free from contagious, communicable, or infectious disease A man in Arkansas was expelled from a beauty college based on a state regulation banning those with infectious or communicable diseases from practicing cosmetology after he voluntarily disclosed his HIV infection to an instructor [6]. According to the ADA, for the purposes of occupational training and licensing requirements, the terms “infectious, communicable, or contagious disease” must exclude diseases, such as HIV, not transmitted through casual contact or through the usual practice of the occupation for which a license is required [5]. As a result, the Arkansas Board of Cosmetology explicitly recognized that cosmetologists with HIV pose no significant risk to clients and coworkers, and the statute has since been amended. It is important to note that the activities of cosmetology are not high-risk activities, and any indication that they are is unfounded. HIV-infected cosmetologists should not be prevented from doing their jobs as a result of their infection status. Phone: 800 / 707-5644 • FAX: 916 / 878-5497 13 #P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________ In 2014, a man was fired from his job as an assistant manager at a hair salon in Maryland after testing positive for HIV. Originally, the company used state regulations to justify its discrimination. However, after investigation, the hairstylist was reinstated and the company issued policy guidance to reinforce the company’s policy to terminate those who are living with HIV or another disability [8]. APPROPRIATE ATTITUDE AND BEHAVIOR OF THE SALON PROFESSIONAL • Be aware of your own attitudes toward HIV/ AIDS and toward the behavior risk factors that put people at risk for contracting HIV. Remember it is not appropriate for you to judge the behavior of a person infected with HIV. How a person became infected should not be an issue. • Treat others as you would like to be treated or you would like to have your family treated. Recognize that many family structures include same sex partners and extended family members. Avoid placing judgment on families that do not look or behave like yours. • Do not be afraid to touch a person with HIV. Holding a hand, giving a hug, or back rub may be comforting. However, also be sensitive to people who do not want physical closeness. • Remember that all people deserve to be treated respectfully. 14 Paragon CET • May 1, 2015 NORTH CAROLINA STATUTES The state of North Carolina has specific laws and statutes governing HIV testing, including sections devoted to informed consent, confidentiality, and counseling. Knowledge of these statutes may be useful in ensuring that public health is served and rights are protected. Portions of the following statutes are presented as they may apply to salon professionals and/or the general public [59; 60]. 130A-148. LABORATORY TESTS FOR AIDS VIRUS INFECTION (g) Persons tested for AIDS virus infection shall be notified of test results and counseled appropriately. This subsection shall not apply to tests performed by or for entities governed by Article 39 of Chapter 58 of the General Statutes, the Insurance Information and Privacy Protection Act, provided that said entities comply with the notice requirements thereof. (h) The Commission may authorize or require laboratory tests for AIDS virus infection when necessary to protect the public health. A test for AIDS virus infection may also be performed upon any person solely by order of a physician licensed to practice medicine in North Carolina who is rendering medical services to that person when, in the reasonable medical judgment of the physician, the test is necessary for the appropriate treatment of the person; however, the person shall be informed that a test for AIDS virus infection is to be conducted, and shall be given clear opportunity to refuse to submit to the test prior to it being conducted, and further if informed consent is not obtained, the test may not be performed. A physician may order a test for AIDS virus infection without the informed consent of the person tested if the person is incapable of providing or incompetent to provide such consent, others authorized to give consent for the person are not available, and testing is necessary for appropriate diagnosis or care of the person. www.ParagonCET.com ___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina An unemancipated minor may be tested for AIDS virus infection without the consent of the parent or legal guardian of the minor when the parent or guardian has refused to consent to such testing and there is reasonable suspicion that the minor has AIDS virus or HIV infection or that the child has been sexually abused. (i) Except as provided in this section, no test for AIDS virus infection shall be required, performed or used to determine suitability for continued employment, housing or public services, or for the use of places of public accommodation or public transportation. Further it shall be unlawful to discriminate against any person having AIDS virus or HIV infection on account of that infection in determining suitability for continued employment, housing, or public services, or for the use of places of public accommodation or public transportation. Any person aggrieved by an act or discriminatory practice prohibited by this subsection relating to housing shall be entitled to institute a civil action pursuant to G.S. 41A-7 of the State Fair Housing Act. Any person aggrieved by an act or discriminatory practice prohibited by this subsection other than one relating to housing may bring a civil action to enforce rights granted or protected by this subsection. The action shall be commenced in superior court in the county where the alleged discriminatory practice or prohibited conduct occurred or where the plaintiff or defendant resides. Such action shall be tried to the court without a jury. Any relief granted by the court shall be limited to declaratory and injunctive relief, including orders to hire or reinstate an aggrieved person or admit such person to a labor organization. Paragon CET • Sacramento, California In a civil action brought to enforce provisions of this subsection relating to employment, the court may award back pay. Any such back pay liability shall not accrue from a date more than two years prior to the filing of an action under this subsection. Interim earnings or amounts earnable with reasonable diligence by the aggrieved person shall operate to reduce the back pay otherwise allowable. In any civil action brought under this subsection, the court, in its discretion, may award reasonable attorney’s fees to the substantially prevailing party as a part of costs. A civil action brought pursuant to this subsection shall be commenced within 180 days after the date on which the aggrieved person became aware or, with reasonable diligence, should have become aware of the alleged discriminatory practice or prohibited conduct. Nothing in this section shall be construed so as to prohibit an employer from: (1) Requiring a test for AIDS virus infection for job applicants in pre-employment medical examinations required by the employer (2) Denying employment to a job applicant based solely on a confirmed positive test for AIDS virus infection (3) Including a test for AIDS virus infection performed in the course of an annual medical examination routinely required of all employees by the employer (4) Taking the appropriate employment action, including reassignment or termination of employment, if the continuation by the employee who has AIDS virus or HIV infection of his work tasks would pose a significant risk to the health of the employee, coworkers, or the public, or if the employee is unable to perform the normally assigned duties of the job Phone: 800 / 707-5644 • FAX: 916 / 878-5497 15 #P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________ (j) It shall not be unlawful for a licensed healthcare provider or facility to: (1) Treat a person who has AIDS virus or HIV infection differently from persons who do not have that infection when such treatment is appropriate to protect the health care provider or employees of the provider or employees of the facility while providing appropriate care for the person who has the AIDS virus or HIV infection; or (2) Refer a person who has AIDS virus or HIV infection to another licensed healthcare provider or facility when such referral is for the purpose of providing more appropriate treatment for the person with AIDS virus or HIV infection. 10A NCAC 41A .0202 CONTROL MEASURES: HIV The following are the control measures for the Acquired Immune Deficiency Syndrome (AIDS) and Human Immunodeficiency Virus (HIV) infection: (1) Infected persons shall: (a)refrain from sexual intercourse unless condoms are used; exercise caution when using condoms due to possible condom failure; (b)not share needles or syringes, or any other drug-related equipment, paraphernalia, or works that may be contaminated with blood through previous use; (c)not donate or sell blood, plasma, platelets, other blood products, semen, ova, tissues, organs, or breast milk; 16 Paragon CET • May 1, 2015 (d)have a skin test for tuberculosis; (e)notify future sexual intercourse partners of the infection; (f) if the time of initial infection is known, notify persons who have been sexual intercourse and needle partners since the date of infection; and, (g)if the date of initial infection is unknown, notify persons who have been sexual intercourse and needle partners for the previous year. (9) Local health departments shall provide counseling and testing for HIV infection at no charge to the patient. Third-party payors may be billed for HIV counseling and testing when such services are provided and the patient provides written consent. (10)HIV pre-test counseling is not required. Post-test counseling for persons infected with HIV is required, must be individualized, and shall include referrals for medical and psychosocial services and control measures. (14)Every pregnant woman shall be offered HIV testing by her attending physician at her first prenatal visit and in the third trimester. The attending physician shall test the pregnant woman for HIV infection, unless the pregnant woman refuses to provide informed consent. If there is no record at labor and delivery of an HIV test result during the current pregnancy for the pregnant woman, the attending physician shall inform the pregnant woman that an HIV test will be performed, explain the reasons for testing, and the woman shall be tested for HIV without consent using a rapid HIV test unless it reasonably appears that the test cannot be performed without endangering the safety of the pregnant woman or the person administering the test. www.ParagonCET.com ___________________________________________ #P477 HIV/AIDS: Epidemic Update for North Carolina If the pregnant woman cannot be tested, an existing specimen, if one exists that was collected within the last 24 hours, shall be tested using a rapid HIV test. The attending physician must provide the woman with the test results as soon as possible. (15)If an infant is delivered by a woman with no record of the result of an HIV test conducted during the pregnancy and if the woman was not tested for HIV during labor and delivery, the fact that the mother has not been tested creates a reasonable suspicion that the newborn has HIV infection and the infant shall be tested for HIV. An infant born in the previous 12 hours shall be tested using a rapid HIV test. (16)Testing for HIV may be offered as part of routine laboratory testing panels using a general consent which is obtained from the patient for treatment and routine laboratory testing, so long as the patient is notified that they are being tested for HIV and given the opportunity to refuse. Paragon CET • Sacramento, California SUMMARY Although prevention and new medical interventions may reduce the pace of the epidemic, HIV will be a significant disease for many years both in the United States and the world. Education provides the opportunity to ensure that North Carolina salon professionals have the information necessary to work with and provide services to persons with HIV. Phone: 800 / 707-5644 • FAX: 916 / 878-5497 17 #P477 HIV/AIDS: Epidemic Update for North Carolina ____________________________________________ Works Cited 1. Centers for Disease Control and Prevention. HIV Surveillance Report: Diagnoses of HIV Infection in the United States and Dependent Areas, 2013. Available at http://www.cdc.gov/hiv/pdf/g-l/hiv_surveillance_report_vol_25.pdf. Last accessed March 17, 2015. 2. International Partnership for Microbicides. What Are Microbicides? Available at http://www.ipmglobal.org/why-microbicides/arvbased-microbicides-and-how-they-work/what-are-microbicides. Last accessed March 17, 2015. 3. Boland M. Overview of perinatally transmitted HIV infection. Nurs Clin North Am. 1996;31:155-163. 4. 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