Download HIV / AIDS - University of Florida

HIV/AIDS: Update for Health Care
Workers
Prepared by Infection Control
Department
Shands at University of Florida
1998 - 1999
Copyright 1998 Shands Hospital at the University of
Florida
Updated December 2000
HIV / AIDS
Pathogenesis and Clinical
Course
What is HIV ?
Human Immunodeficiency Virus
 HTLV I and HLTV II
 RNA virus (Ribonucleic Acid)
 Retrovirus (Oncovirus vs. Lentivirus)
 Target cell T4 cell and
Lymphocyte/Monocyte
What is AIDS ?
Acquired immune deficiency
syndrome
 Caused by HIV (Human
Immunodeficiency Virus)

Schematic of HIV
Schematic of T cell
being attacked by HIV virus
Clinical Stages of HIV
Infection
Primary - Acute
 Asymptomatic
 Symptomatic
 AIDS

Primary - Acute Stage
Asymptomatic Stage
AIDS Related Complex Stage
AIDS Stage
The course of HIV/AIDS
HIV/AIDS
Factors affecting progression
Accelerated Progression
Extremes of age
 Syncytium inducing virus
 Poor immune response

Slowed Progression
Viral mutants
 Chemokine receptor mutations
 Anti-HIV therapy

Opportunistic Infections

Bacterial




Strep pneumonia
TB
MAI
Viral





Herpes
Varicella Zoster
CMV / EBV
Influenza
Parasites




Pneumocystis carinii
Toxoplasmosis
Cryptosporidum
Fungus



Candida
Aspergillus
Cryptococcus
CMV retinitis
White area
Pneumocystis pneumonia
Grey area
lower lobe
MALIGNANCIES IN AIDS

AIDS defining





Kaposi’s sarcoma
Primary brain lymphoma
High grade non-Hodgkin’s lymphoma
Invasive carcinoma of the cervix
Other


Anorectal squamous carcinoma
Hodgkin’s disease
Kaposi’s sarcoma
Primary brain lymphoma
White
area
Wasting Syndrome
Tuberculosis in HIV and AIDS
Patients
HIV and AIDS Infection in Women
Sixth leading cause of death
 women of childbearing age
 Usual exposure is unprotected sex
 HIV and AIDS increasing more rapidly in
women than any other group of people

HIV / AIDS Infection in Children
Florida - 2nd highest rate
in U.S.
 > 90% of cases transmission from mother
 Diagnosis made by DNA
testing
 Treatment of HIV positive
mothers - to decrease
transmission

Neurological Abnormalities in
AIDS Dementia
ANTIRETROVIRAL DRUGS
AND THERAPY
2000 - 2001
Antiviral Therapy Objectives
Maximize suppression of virus
 Preserve immune function
 Prolong efficacy, delay resistance
 Patient compliance, tolerable regimens
 Preserve future treatment options

ANTIRETROVIRAL THERAPY
The moving target
Criteria for starting therapy.
 Criteria for changing therapy.
 Which and how many drugs.
 Should the most potent drugs be
used early or reserved for failing
patients.

Drug Treatment of HIV/AIDS

Purpose
Halt viral replication
 Prevent opportunistic infections
 Treat infections as the occur
 Maintain physical and mental well being

Treatment of HIV / AIDS in
Pregnant Women
ANTIRETROVIRAL DRUGS
Nucleoside analogs
Drugs and year introduced






Zidovudine
Didanosine
Zalcitabine
Stavudine
Lamivudine
Abacavir






1987
1990
1992
1994
1995
1999
ANTIRETROVIRAL DRUGS
Protease inhibitors
Drugs and year introduced





Saquinavir
Indinavir
Ritonavir
Nelfinavir
Amprenavir





1995
1996
1996
1998
1999
HIV therapy
The changing paradigm

Aim for cure vs chronic suppression.


Cure not feasible now
Aggressive therapy vs judicious
weighing of toxicities vs benefits of
therapy.
Treating primary HIV
Often unrecognized and untreated
 If recognized, the consensus is to treat

to prevent viral mutants
 perhaps lower the “set point”
 preserve immune function


However, the long term benefit is unknown
How to define failure
 Stringent
Inability to keep viral load <50 copies/ml.
 Inability to attain an undetectable viral load.

 Less
stringent
Lack of maintenance/or elevation of CD4
count
 Clinical progression

Assisting adherence
simplify drug regimens



decrease number of drugs
fewer doses-e.g. ddI given once a day
time doses as conveniently as possible
review medications each visit
provide medication boxes
emphasize the importance of
adherence
Drug toxicities
 Anemia-
ZDV
 Hypersensitivity- abacavir
 hepatotoxicity- ritonavir
 kidney stones- indinavir
 pancreatitis- ddI,d4T
 peripheral neuropathy- ddI ,d4T,ddC
 metabolic disorders- protease inhibitors
Prophylaxis of opportunistic
infections
An important aspect of
treatment
Living with HIV / AIDS

Treatment requires close coordination
between patient and healthcare
provider.

Successful treatment
more people are living longer with AIDS /
HIV.
 more people are able to maintain “normal”
activities - quality of life.

Epidemiology of HIV / AIDS
HIV: The 4th Decade

Pre - 1970
Silent

1971 - 1980
Sporadic Cases

1981 - 1990
Epidemic

1991 -
Current Pandemic
AIDS is Present in Virtually
Every Country in the World
Worldwide Summary of the HIV/AIDS
Epidemic,
December 2000
People newly infected with
HIV in 2000

Total = 5.3 million
Number of people living
with HIV/AIDS

Total = 36.1 million

Total = 3 million

Total = 21.8 million
AIDS deaths in year 2000
Total number of AIDS
deaths since the
beginning of the
epidemic
States Reporting Highest Number AIDS Cases in
USA
Data as of October 2000
New York
California
Florida
Texas
140,416
119,229
79,633
53,709
In Florida 1 out of 156 people are HIV +
1: 286 Whites (HIV +)
1:127 Hispanics (HIV +)
1:50 Blacks (HIV+)
AIDS Cases Reported in Florida through 1999
in Seniors ( > 50 years old)
 9,
722 cases in the state of Florida
83% = Males
17% = Females
Older persons with HIV/AIDS are at increased
risk for mortality
In 1995 Total AIDS Deaths Declined
for the First Time
You Are Never Too Old for
Sex, But You May Be Too
Young To Start
Every Year 3 Million Teens
Acquire a Sexually
Transmitted Disease
53% of All Sexually Active
High School Students Used a
Condom the Last
Time They Had Sex
In Choosing
Your Actions
You Accept
the Consequences
STD = sexually transmitted disease
40% of Men and 58% of Women
have had an STD diagnosis at
some point in their lives
Florida is SECOND in the
US in reported cases of
AIDS in women and
children.
64% of all HIV positive
women have had at least 1
pregnancy
95% of the U.S. pediatric
AIDS cases are from perinatal
transmission
Perinatal transmission
decreased 2/3 with the AZT
protocol

In the U.S., African American and
Hispanic women are 21% of the
population, but 77% of the female
AIDS cases

In the U.S., the rate of infection
for African American women is 17
times higher than for Caucasian
females
Karon, Roswnburg et. al. 1996 “Prevalence of HIV Infection in the United States”,
JAMA 276, 126-131, 1984-1992
In 1999 23% of Florida TB
Cases were HIV Positive
60% of Florida TB Cases
Miami
West Palm
Orlando
Jacksonville
Ft. Lauderdale
HIV Testing
HIV TESTING
 Culture
(using cells in a laboratory)
 Antibody Detection (ELISA / IFA / WB)
 Antigen Detection (P24)
 RNA and DNA Detection(Viral load/ PCR)
HIV Culture
 Only
performed by research or special
laboratories
 Not
used for routine diagnosis of HIV
HIV Antibody Testing
 What

is an antibody?
A protein your body produces in response to a
foreign substance. For example, this virus.
 Types

EIA/ELISA:


IFA:


Enzyme Linked Immunosorbent Antibody
Immunofluorescent Antibody
Western Blot:

Immunoblot that combines EIA with
electrophoresis
EIA/ELISA:
Used as a Screening Test Since 1985
 Advantages
Easy to perform
 Easy to automate
 Accurate
 Less costly than
other tests

 Disadvantages

All positives must
have a
confirmatory test
performed.
HIV IFA Testing:
Used as a confirmatory test
 Advantages
Accurate
 Short turn around
time

 Disadvantages
Requires special
equipment
 Requires Skilled
Technologist for
accurate results
 Low volume

Western Blot:
Confirmatory Test
 Advantages

Very specific for
HIV-low false
positive rate
 Disadvantages





Long turn around
time
Skilled technologist
Must be interpreted
by specially trained
MD/PhD
Costly
Equivocal Results
HIV Antigen Testing
 What
is an antigen? A substance (such
as a virus) that is capable of causing the
body to produce antibodies.
 Types

p24 ( core protein)
HIV Antigen p24 Testing:
Diagnostic Test used in Blood Banks since
1995
 Advantage



Detectable 2-3
weeks after initial
infection in most
people
Detected before
antibody testing
Used to screen
blood units
 Disadvantages



Not measurable in
all patients
Short window for
identification
Only performed in
specialized labs
and blood banks
HIV RNA and DNA by PCR
Diagnostic test
 Advantages



Tests for viral
presence
Can be used in
diagnosing
children < 18
months
Used to monitor
treatment efficacy
 Disadvantages



Costly
Only done in
reference labs
Long turn around
time
Interpretation of HIV Results

EIA =Screening Test
 Negative = No
antibody detected

Positive
 Repeat test x 2


If Positive,
Perform
confirmatory
test
If negative,
report as
negative

Western Blot =
Confirmatory Test



Negative =
Reported as
negative
Positive = Reported
as positive
Indeterminate or
equivocal = Advise
repeating test in 34 weeks
Blood Bank Screening for HIV
 1985
- Began screening for HIV-1
 1992
- Started screening for HIV-1+ HIV-2
 1995
- Started screening for p24 Antigen
Risk of HIV associated with Blood
Transfusions
2
in 1 million
chance of getting
an HIV + unit
Incidence of AIDS associated with
blood transfusion in USA since
1985

As of 6/30/97, there have
been 40 AIDS cases from
transfusions since April
1985 when the screening
test was initiated.
RAPID TESTS
 Rapid

Tests
Serum/ Plasma

SUDS-HIV-1 test
Since 1999, this test has been used
at Shands UF in healthcare
workers exposures
New tests using saliva are being
developed
Legal Requirements
associated with HIV in
Florida
Informed Consent



Patients must give informed
consent to be tested for HIV.
Written informed consent is best
Place on chart
Minors may give informed consent for
testing without parental consent (The
child must be old enough to make an
informed decision).
Exceptions to Informed Consent




A bona fide medical emergency that requires
knowledge of the HIV status of a patient for
medical management.
If knowledge of testing would be detrimental to
patient and is necessary for medical diagnostic
purposes to provide appropriate care.
If consent is obtained for an autopsy, specific HIV
consent is not required.
Consent is not required to test for tissue or blood
donation.
Exceptions to Informed Consent
Post Exposure Testing


A patient involved in a significant exposure to blood
or body fluids may be tested without informed
consent only when:
 There has been a significant exposure
 There is existing blood available
 The exposed employee consents to be tested or
has a documented HIV test within 6 months
 The patient has been told and refused testing. The
patient must be then told that testing will be done
under Florida Law
 Results are not entered into patient’s chart
The source of a significant exposure dies during
emergency treatment
Significant Exposure



Exposure to blood or body fluids through
needle stick, instruments, or sharps
Exposure of mucous membranes to
visible blood or body fluids, to which
Standard Universal Precautions apply
according to CDC
Exposure of skin which is chapped,
abraded or afflicted with dermatitis or
contact is prolonged or involving an
extensive area
Pre-test Counseling








Transmission
Prevention
Risk Factors
Explanation of Procedure
Testing is Voluntary
 Right to withdraw consent
Confidentiality of test result
Reportability of Positive Test Result
Need for pre-test counseling eliminated in private
sector but INFORMED CONSENT remains intact.
Post Test Counseling:
Opportunity for Face to Face Counseling
The rule leaves specific post-test counseling procedures to the
individual medical practice.





Meaning of test results
Need for additional
testing
Measures to prevent
HIV transmission
Health care support in
area


Benefit of contact
tracing
Public Health’s
assistance with contact
tracing
Positive results are
reported to health
department
Release of Results

Elisa tests must be confirmed with a
confirmatory test such as a Western Blot
before a positive result can be released.



Allows for release of preliminary results when
decisions about medical care or treatment cannot
await the results of confirmatory testing
Patients must be given the opportunity for
face to face counseling when receiving
result.
Time to give results should be set at time of
pre-test counseling.
Mandatory Offering of Testing to
Pregnant Females





HCW providing care to pregnant
women must offer HIV testing to
them.
Benefits of AZT treatment in
decreasing transmission must
be explained.
Emphasize education for high 
risk patients
Refer to substance abuse
programs
Act as liaison with other
services
Allows healthcare
workers involved in
the delivery of a
newborn to note the
mother’s HIV test
results in the child’s
medical record
All HIV Positive Results are
Reportable as of July 1997

Exceptions



Anonymous Test
sites
Non consensual
Post exposure
testing
Certain Research
protocols
Partner Notification

MD may notify
sexual or needle
sharing partner if
patient will not,
BUT is not
required to report
or held liable if
reporting is done
HIV Education



Initial “Loading Dose”
On going
Licensure Requirements
 Individual
 Health care institution
 1998 revision calls for health
care providers course
requirements to include
education on new HIV/AIDS
protocols and procedures
Non-Discrimination
Can not discriminate for care,
employment, etc..
Personal Protection
HIV Transmission
 Sexual
Contact
 Mother to Infant
 Blood Contact
IV needle sharing
 Blood products including transfusion
 Healthcare worker exposure to blood and
body fluid

Risk Categories

From greatest to least risk are as
follows:







Males having sex with males
Injecting drug users
Males having sex with males that also inject
drugs
Heterosexual transmission
Blood transfusion
Perinatal transmission
no reported risk category
Options Available For Personal
Protection
 Abstinence
from sex
 Maintain a mutually monogamous
relationship with a person who is HIV
negative.
 Use safer sex methods.
Safer Sex Methods







Use condoms every time you have sex if you are not in a mutually
monogamous relationship
Always use latex or polyurethane condom (not a natural skin
condom)
Use only water based lubricants - oil based lubricants can
breakdown latex condoms
Avoid anal or rough vaginal intercourse
Abstain from sex with a HIV infected person
Discuss sexual history with partners
Reduce number of sexual partners
When Using A Condom Remember To:





Make sure the condom package is in date- not
expired
Make sure to check the condom package, see
that it is not damaged - that it still contains air
Don’t open the package with your teeth or
anything that is sharp this might tear or damage
the condom
Never use a condom more than once
Use a water based lubricant -excessive friction
from dryness can pull condoms off or tear them.
(Oil based lubricants such as baby oil or Vaseline
can damage the condom)
Steps To Follow When
Using a Male Condom
Female Condoms
Protection During Oral SEX
 Oral
sex is mouth to genital/anus contact
 Oral
sex is another method of potential
transmission of HIV(risk increases if there
are lesions/sores in the mouth)
 Always
use a latex barrier
Other Personal Protection Measures:
 Avoid
alcohol/illicit drugs = decrease thinking
- affect judgement
 Do
not share “the works”- needles, syringes
and/or cookers
 Do
 Do
not share personal hygiene items
not donate blood, plasma, sperm, organs
or tissues if HIV positive
HIV in Older People
Almost 10% of diagnosed cases of AIDS are
in people 50 years old and older
Because older people typically are not targeted
by HIV prevention and education campaigns,
the rise in sexually transmitted cases among
the “elderly” is expected to skyrocket
Steps to Reduce Risk of Vertical
Transmission
from Infected Mother to Infant
 Use AZT
and protease inhibitors
 Intrapartum
care
Steps to Reduce Postpartum
Transmission
From Mother to Infant
 No
breast feeding - the HIV virus has
been found in breast milk
 Avoid contact with open lesions
 Give anti-viral drug to newborn of HIV
infected mother
Transmission of HIV Through
Blood Products
Whole blood
 Packed cells
 Fresh frozen plasma
 Specific blood components

factor VIII
 frequent plasma replacement

HIV Transmission via Organ
Transplantation
Known transmission:
 Kidney
 liver
 heart
 pancreas
Possible transmission:
 bone
 skin grafts
 artificial
insemination
HIV and AIDS
Facts on the “transmission” of HIV
to family, household members,
casual contacts, etc.
OCCUPATIONAL
EXPOSURE
TO HIV
HIV Transmission
 Sexual
Contact
 Mother to Infant
 Blood
Contact
IV needle sharing
 Blood products including transfusion
 Healthcare worker’s occupational exposure
to blood and body fluid

Bloodborne Pathogens Exposure
Control Plan
Purpose: To provide a safe working
environment and reduce the risk of
exposure to bloodborne pathogens
 Location:
Infection Control Manual
(PM03-01, Appendix B)
Bloodborne Pathogen Exposure Control
Plan
Standard Universal Precautions




Personal Protective
Equipment
Job Task List
Engineering Controls
Work Practice Controls




Post Exposure
Management
Biohazardous
Labeling
Waste Management
Bloodborne Pathogen
Training
Personal Protective Equipment





Gloves
Gown
Protective Eye and
Face Shield
Masks
Others


Boots, shoe covers
CPR shield
Engineering Controls
Sharps containers/self-sheathing needles/ needleless IV systems/ safety butterflies
Biosafety cabinets
Plastic sheet protectors
CPR face shields
Examples of some of the engineering controls to be used by health care workers
Be Careful with Sharps!





Do not recap by hand
Immediately dispose of sharps in Sharps container
Do not return used sharps to procedure tray
Sharps boxes should be replaced when 3/4 full
Always use available safety syringes, safety butterflies
and other IV safety devices
Work Practice Controls
 Handwashing
 Do
not recap needles by hand
 No food/drink in refrigerators with blood or
other infectious materials
 Do not drink, eat, apply cosmetics/lip balm,
or handle contact lenses in areas where
blood/body fluids may be present
 Keep work area clean and decontaminated
 Use proper
cleaning/disinfecting/sterilization practices
for equipment and patient care items
HANDWASHING
RECOMMENDATIONS
 Arriving
at and before leaving work
 Before and after patient contact
 Before and after eating
 After removing gloves
 After using restroom
 After coughing, sneezing, blowing nose
 Whenever hands are soiled or contaminated
HANDWASHING
FOR PATIENT CARE
 Friction/lather
10-15 seconds;
rinse and dry thoroughly
 “Waterless
agent” (alcohol based)apply to hands, rub together
Chlorhexidine gluconate - active
ingredient in hospital approved soap
“The consequences of
occupational exposure to
bloodborne pathogens are
not only infections. Each
year, thousands of health
care workers are affected by
psychological trauma during
months of waiting for
notification of [blood test]
results.
Bloodborne Pathogens
Exposure Facts



OSHA estimates 5.6 million workers
in healthcare and related
occupations are at risk for exposure
to bloodborne pathogens
NIOSH estimates that 600,000
needlestick injuries occur annually
in the hospital setting alone
As many as one-third of all sharps
injuries are related to the disposal
process.
Potential for Transmission of
Bloodborne Pathogens to Healthcare
Workers
Pathogen
Virus particles in
1cc serum
Rate of
transmission
Hepatitis B
1,000-1,000,000
6%-30%
Hepatitis C
10-100,000
2.7%-10%
HIV
10-1,000
0.31%
United States Healthcare Workers
with Documented Occupationally
Acquired HIV --1980- June, 2000
Documented
Cases
Possible
Cases*
Total
56
136
191
(25 have developed AIDS)
*These Health Care Workers have been investigated and are without identifiable
behavorial or transfusion risks; each reported percutaneous or mucocutaneous
occupational exposures to blood or body fluids, or laboratory solutions containing
HIV, but HIV seroconversion specifically resulting from an occupational exposure
was not documented.
Occupationally Acquired HIV
Infection in the US










23 Nurses
16 Clinical lab techs
6 Non-surgical physicians
3 Nonclinical lab techs
2 Surgical techs
1 Dialysis tech
1 Embalmer/morgue tech
1 Home health aids
2 Housekeeper/maintenance worker
1 Respiratory therapist
HIV Post-exposure Conversion
Factors







Hollow bore needle
Deep IM stick
HIV stage of source patient
Gloves not worn
Volume of exposure
Type of body fluid with blood
Lack of post-exposure prophylaxis
What should I do if an exposure
occurs?
Thoroughly wash exposed area
Contact supervisor/access
Occupational Health
“after hours” page Nursing Team
Coordinator
 Optimal
time for postexposure prophylaxis (PEP) is
1-2 hours post exposure

PEP for HIV = AZT + 3TC +
protease inhibitor
If it is wet and sticky and not yours,
DO NOT TOUCH IT- - - WITHOUT GLOVES !!!!!
HIV and AIDS Related
Organizations, Hot lines and
Resources
The Department of Infection Control thanks
Joseph W. Shands, Jr, MD and Jennifer
Janelle, MD for their medical guidance in
the development of this HIV educational
module.
References: