CDC AIDS HIV UPDATE

 Define

HIV and AIDS  Demonstrate knowledge of Epidemiology, Immunology, Transmission, and Universal Precautions  Describe the most common HIV test  Assess attitudes and behaviors when confronted with HIV positive patients and respond appropriately

History
 

Human Immunodeficiency Virus (HIV) is the virus that causes AIDS Earliest known case of HIV 1959 from a man in Kinshasha, Democratic Republic of Congo
genetic analysis of this blood sample suggests HIV-1 HIVmay have stemmed from a single virus in the late 1940s or early 1950

 

Existed in the United States since at least the midmid-to late 1970s 1982 public health officials began to use the term "acquired immunodeficiency syndrome," or AIDS
formal tracking (surveillance) of AIDS cases began in the United States

History


Cause of AIDS is a virus isolated in 1983

first named HTLV-III/LAV (human T-cell lymphotropic HTLVTvirusvirus-type III/lymphadenopathy- associated virus) III/lymphadenopathychanged to HIV

How long does it take for HIV to cause AIDS?

1992, estimated half the people with HIV develop AIDS within 10 years after becoming infected today medical treatments can slow down the rate at which HIV weakens the immune system so seroconversion is no longer estimated

History
 Body

fluids known to transmit the virus

blood semen vaginal fluid breast milk other body fluids containing blood

Healthcare Provider Concerns

 cerebrospinal

fluid surrounding the brain and the spinal cord  synovial fluid surrounding bone joints  amniotic fluid surrounding a fetus

What about symptoms?

way to determine infection is to be tested  Cannot rely on symptoms to know if infected with HIV
 Only

Many people infected are asymptomatic for many years

May be warning signs of HIV infection

rapid weight loss dry cough recurring fever or profuse night sweats profound and unexplained fatigue swollen lymph glands in the armpits, groin, or neck diarrhea that lasts for more than a week white spots or unusual blemishes on the tongue, in the mouth, or in the throat  pneumonia  red, brown, pink, or purplish blotches on or under the skin or inside the mouth, nose, or eyelids  memory loss, depression, and other neurological disorders
      

AIDS is a medical diagnosis made by a doctor based on specific criteria established by the CDC

HIV tests


Rapid test
very quick, usually 5 to 30 minutes availability may differ from place to place considered to be just as accurate as the EIA Only detects HIV-1 HIVMore expensive but more cost-effective cost-

In comparison, traditional test - the EIA (enzyme immunoassay)

1-2 weeks (send to lab) widely used throughout the world testing required two visits positive results confirmed retesting then a supplemental HIV antibody test --Western blot or immunofluorescence assay (IFA) --Western less costly but not cost-effective cost 26% of those who tested positive for HIV and 33% of those who tested negative do not return for their test results

Additional HIV Tests



Limited, specific uses

Radioimmunoprecipitation assay (RIPA): confirmatory blood test used when antibody levels are very low or difficult to detect or when Western blot test results are uncertain. Expensive, requires time and expertise to perform Rapid latex agglutination assay: simplified, inexpensive blood test, may prove useful in medically disadvantaged areas where there is a high prevalence of HIV infection

DotDot-blot immunobinding assay: rapid-screening blood rapidtest, cost-effective, may become an alternative to costconventional EIA and Western blot testing  p24 antigen capture assay: Also known as the HIV-1 HIVantigen capture assay, blood test added as an interim measure by the Food and Drug Administration (FDA) in 1996 to protect the blood supply further until other tests become available to detect early HIV infection before antibodies are fully developed, some activity of p24 antigen is unpredictable, therefore determined not useful for helping people find out if they have HIV  Polymerase chain reaction (PCR): specialized blood test for HIV genetic information, expensive and laborlaborintensive, detect the virus even if recently infected. Developed to further protect the blood supply.


What s new and upcoming in testing?



Second-generation rapid HIV tests being developed, may be licensed by the FDA in the near future
Require little to no equipment Can be performed on serum, plasma, or whole blood, which can be collected by using the finger-stick method Sensitivity and specificity similar to those of EIA Results in 2 to 5 minutes Detect HIV-1, HIV-2, and HIV-1 group O Make possible the World Health Organization (WHO) strategy for combinations of two or more different rapid HIV tests to confirm a diagnosis of infection
 This strategy has not been approved by the FDA for use in the United States.

REMEMBER
 negative

antibody test result does not necessarily mean not infected

may have been tested too soon
 average time between infection and development of detectable antibodies is 25 days

 however

most clients at all U.S. publicly funded testing sites, including STD clinics, test negative for HIV (approximately 2.1 million)

How is HIV passed from one person to another?

 

blood, semen (including pre-seminal fluid), prevaginal fluid, or breast milk through a vein (e.g., injection drug use), the anus or rectum, the vagina, the penis, the mouth, other mucous membranes (e.g., eyes or inside of the nose), or cuts and sores transfusions of infected blood or blood clotting factors
since 1985, all donated blood in the US tested for HIV, risk is extremely low. The U.S. blood supply is considered to be among the safest in the world.

Healthcare Provider Concerns

 Seroconversion

infected after being stuck with needles containing HIV-infected blood HIVafter infected blood contacts HCP through open cut or through splashes into the providers eyes or inside their nose.
 only one instance of patients being infected by an HIVHIV-infected healthcare provider
an infected dentist to six patients.

follow universal precautions

ALWAYS!!

Risk of infection - percutaneous exposure to HIV-infected blood is 0.3% HIVmucous membrane exposure is 0.09% skin exposure seroconversions have been documented however no HCP seroconverted after an isolated skin exposure estimated median interval from exposure to seroconversion 46 days (mean: 65 days); estimated 95% seroconverted within 6 months after exposure 3 instances of delayed HIV seroconversion seropositive within 12 months after exposure
 2 with simultaneous exposure to hepatitis C virus (HCV)
1 of which was a rapidly fatal HCV disease course

Less than

1%
(but that is 1% too many if it is CCEMS)

You CANNOT get HIV/AIDS everyday close contact with an HIV-infected person HIV(even in the back of an ambulance)  from kissing on the cheek, unbroken skin is an excellent barrier


Open-mouth kissing is considered a very low-risk activity. July 11, 1997, Morbidity and Mortality Weekly Report - woman became infected with HIV from her sex partner through exposure to contaminated blood during open-mouth kissing, CDC recommends against open-mouth kissing with an infected partner.
 

getting a tattoo or body piercing

Instruments MUST be single use, sterilized or disinfected.

mosquitoes

Knowledge and Stigma

Knowledge is power and stigmatization is a barrier to testing

August--September August--September 2000 Research Triangle Institute

A module on HIV-related knowledge of transmission and stigma was included in a HIVlarger survey on health and aging. (conducted via the internet)

 Knowledge

2 questions asked

40.2% responded that HIV transmission could occur through sharing a glass 41.1% responded that it could occur from being coughed or sneezed on

Stigma 1 question asked

18.7% state persons who acquired AIDS through sex or drug use have gotten what they deserve.

Stigmatize Responses
- more common among men (78.5%) - aged >55 years (70.0%) - high school education (77.9%) - an income <$30,000 (76.6%) - poorer health compared with others (76.4%)

25% of those who were misinformed also gave stigmatizing responses vs 14% who were informed (p<0.05)

What does this mean?

 

Most U.S. adults do not hold stigmatizing views about persons with HIV infection or AIDS Significantly more of the respondents who were misinformed about HIV transmission gave a stigmatizing response, suggesting that increasing understanding about behaviors related to HIV transmission may result in lower levels of stigmatizing beliefs about infected persons. Overcoming stigma is an important step in persons seeking to know their HIV status.

Management Guidelines of Healthcare Providers

       

preventing blood exposures - primary means of preventing postexposure management includes considerations for zidovudine (ZDV) use for postexposure prophylaxis (PEP) written protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of exposures followexposureexposure-control plans (mandated Occupational Safety and Health Administration) access to clinicians who provide postexposure care available during all working hours antiretroviral agents for timely administration postexposure counseling educate to report exposures immediately

Rationale for Postexposure Prophylaxis (PEP)

 pathogenesis

of HIV infection  biologic plausibility that infection can be prevented or ameliorated by using antiretroviral drugs  evidence of the antiretrovirals  risk/benefit to the HCP

Recommendations for Postexposure

 Treatment

of an Exposure Site  Assessment of Infection Risk  Clinical Evaluation and Baseline Testing of Exposed HCPs  HIV PEP  Follow-up of HCPs Exposed to HIV Follow-

Considerations for Selection of Drugs For PEP

 balance

the risk for infection vs potential

toxicity  resistance of the Source Virus to antiretroviral drugs  known or suspected pregnancy in the HCP

PEP Regimens
Basic and expanded postexposure prophylaxis regimens ==================================================== Regimen category Application Drug regimen ------------------------------------------------------------------------------------------------------Basic Occupational HIV exposures for which there is a recognized transmission risk. 4 weeks (28 days) of both zidovudine 600 mg every day in divided doses (i.e 300 mg twice A day, 200mg three times a day, or 100 mg every 4 hours) and lamivudine 150 mg twice a day. Basic regimen plus either indinavir 800 mg every 8 hours or nelfinavir 750 mg three times a day.*

Expanded

Occupational HIV exposures that pose an increased risk for transmission (e.g. larger volume of blood and/or higher virus titer in blood)

POSTEXPOSURE REGISTRIES
HIV postexposure prophylaxis resources and registries =========================================================== ================== Resource or registry Contact Information ----------------------------------------------------------------------------National Clinicians' Telephone: (888) 448-4911 448Postexposure Hotline Telephone: (888) 737-4448 737Write: 1410 Commonwealth Drive Suite 215 Wilmington, NC 28405 Antiretroviral Pregnancy Registry Write: 1410 Commonwealth Drive Suite 215 Wilmington, NC 28405 Food and Drug Administration (for reporting unusual or severe toxicity to antiantiretroviral agents) CDC (for reporting HIV seroconversions in healthhealthcare workers who received PEP) Telephone: (800)258-4263 (800)258Fax: (800)800-1052 (800)800-

Telephone: (800)322-1088 (800)322-

Telephone: (404)639-6425 (404)639-