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AIDS/HIV One Hour, Current Evidence Based Practice

1 Contact Hour - 1 Pharmacology Hour
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Athletic Trainer (AT/AL), Certified Nursing Assistant (CNA), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Dietetic Technicians, Registered (DTR), Dietitian/Nutritionalist (RDN), Electrologist (EO), Licensed Nursing Assistant (LNA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Pedorthist (PED), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Respiratory Therapist (RT)
This course will be updated or discontinued on or before Wednesday, November 10, 2021
Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.

AOTA Classification Code: CAT 3: Contemporary Issues & Trends.
Education Level: Intermediate
AOTA does not endorse specific course content, products, or clinical procedures. AOTA provider number 9575.

Course Description
This 1-hour course will inform healthcare professionals about the latest information and treatment for human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS). After taking the course, you will be able to explain HIV/AIDS, how it’s transmitted and how it impacts the immune system. You will also be able to discuss preventing transmission of the virus, prevention and treatment among children, and the most current treatments available.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    David Tilton (RN, BSN)

Outcomes

This 1-hour course will inform healthcare professionals about the latest information and treatment for human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS). After taking the course, you will be able to explain HIV/AIDS, how it’s transmitted and how it impacts the immune system. You will also be able to discuss preventing transmission of the virus, prevention and treatment among children, and the most current treatments available.

Objectives

After completing this course, the learner will be able to:

  • Identify the civil rights of the HIV/AIDS infected individual and their family/friends
  • Relate the mechanism of action of HIV as an infectious agent
  • Describe the pathophysiologic changes in the human body following HIV infection
  • Describe the modes of transmission of HIV and various strategies to prevent the spread of HIV
  • Discuss informed consent relating to HIV
  • Compare and contrast current medications modalities prescribed for the HIV infected individual

Introduction

The infection known as Human Immunodeficiency Virus (HIV) has brought devastation and debilitation to individuals and nations since its world debut in the 1980s. HIV is a fatal infection whose final terminal stage is referred to as Acquired Immunodeficiency Syndrome (AIDS). Individuals, countries and cultures, particularly in central and southern Africa, have suffered tremendously due to the devastation that accompanies HIV, rightly referred to as the “Scourge of Our Time.”1,2 In the past few years, new treatments have been developed which have extended by decades the lifespan of those infected, effectively shifting HIV from an acute terminal illness to a chronic debilitating condition requiring a different perspective on care and monitoring. As healthcare professionals, it is imperative that we keep current on new information regarding HIV as it is continuously being discovered. Information concerning the spread (i.e., modes of transmission), treatment and care of the HIV infected individual, as well as those individuals who progress into the final stage of AIDS is crucial as we strive to help those infected live healthier more satisfying lives.

The HIV Infected Have Rights

The prospect of having HIV can provoke fear and dread. This anxiety is reasonable given the history surrounding HIV and AIDS both in the United States and globally. HIV infection is a very serious medical condition, though not quite the sentence of an agonizing wasting death that it was during the 1980s and 1990s. There are now medications that can slow the progression of the disease, by decades in many cases, giving a new quality of life to those diagnosed rather than the specter of a wasting, suffering death.

The question remains as to why so many in the United States avoid HIV testing when it is so important to become aware of infection early, in order to begin treatment and slow or avoid the fate they see portrayed by the news media visiting impoverished AIDS-stricken countries in Africa’s west, central and southern regions. Perhaps it is the fear of receiving a diagnosis with a fatal infectious disease or the fear of living with the responsibility of keeping a demanding disease such as HIV/AIDS under control. Keeping HIV under control is a time and resource-consuming task. However, the option of letting the disease run its course unchecked would be a very poor choice, as well.

Whatever factor(s) bring hesitation to those needing HIV prevention counseling, screening or treatment, we know that one commonly held fear is that of the stigma attached to having HIV or AIDS. Having HIV brings with it a “scarlet letter” fear of repercussions due to possessing an unwanted health status. When questioned, many of those newly diagnosed with HIV seem unaware that federal laws exist to protect them from discrimination and ensure that benefits such as any social or medical services they would qualify for will not be withheld. As healthcare professionals, it is important to share with those in high-risk groups that key pieces of legislation exist which offer protection from discrimination. Interestingly, some of the mandates and pieces of legislation protecting those with current needs predate the HIV/AIDS epidemic, e.g., Section 504 of the Rehabilitation Act of 1973 and pieces of the 1990 Americans with Disabilities Act (ADA). These well-established laws mean services that apply to an otherwise qualified individual will also be available to HIV infected individuals.

Title II of the ADA prohibits discrimination by state and local government organizations even those not dependent on federal funding. For those nervous or fearful concerning how those close to them might be treated should they acquire HIV, Title II of the ADA also protects an HIV positive individual’s friends and family against discrimination or denial of services that might come from being related to someone with HIV.3

Information privacy regarding an individual’s HIV status is guaranteed by the 1996 Health Insurance Portability and Accountability Act (HIPAA), whose Privacy Rule is enforced by the Office for Civil Rights (OCR). HIPAA protects the privacy of health information while allowing each individual access to their records so that they can see what is written about them and even ask to make corrections to what is documented.

Awareness of their individual rights and the value that each life inherently possesses are crucial foundational steps leading to the inclusion of those suffering from HIV into society and into better health. By emphasizing the importance of each individual’s life, we, as healthcare professionals, can increase participation of the HIV infected individual in his/her own care by educating them to:

  • Keep informed of any changes in HIV knowledge and care
  • Use measures to stop the transmission of HIV
  • Avoid high-risk behaviors
  • Have routine screening for HIV infection, if necessary
  • Actively participate in treatment should the individual become infected

Therefore, as we progress to viewing the magnitude of the current HIV pandemic with its slowly widening reach into our culture and homes, remember that what we are really dealing with are the frightened and wounded. Each is one faced with the sudden overwhelming burden that comes with managing the chronic terminal condition of HIV/AIDS.

Impact of HIV and AIDS

The CDC estimates the total number of Americans living with HIV as of 2016, the last year with good public health statistics, at 1,008,929.5 Of those, 156,300 (12.8%) are unaware of their infection.6

Latest Statistics 5,6,7

United States 2016

Worldwide 2018

HIV annual new cases

38,700

1,800,000

Total estimated living with HIV/AIDS

1,008,929

37,900,000

Annual AIDS deaths

15,807

770,000

CDC reports indicate that during recent years, the estimated incidence of new HIV infections has stabilized at about 39,000 per year.5 The fact that the number of new cases discovered annually has achieved relative stability still results in a progressive annual increase in the total number of HIV infections. Theories behind this center around HIV sufferers living longer due to the advent of new treatments, resulting in an ever-expanding number of active HIV cases both in the United States and worldwide.4

Gay, bisexual and other men who have sex with men (MSM)* of all races and ethnicities, particularly young to middle-aged Black/African American MSM, remain the population most profoundly affected by HIV.5 In 2017, the estimated number of new HIV infections among MSM was 25,748, a number identified as relatively stable from 2012 through 2017.5

Terminology Time8:

*For assessing disease risk, the term MSM (men who have sex with men) is often used instead of gay, homosexual or bisexual because it refers to a risk behavior, rather than an identity that may or may not be tied to the behavior.

Other behaviors warranting following by public health include2,5,6:

  • Injection drug use in all sex and age groups, which show around 2,389 known new HIV diagnosis during the year 2017.
  • MSM sexual activities simultaneous with injection drug use show a large enough presentation of new HIV diagnoses to be categorized by the CDC separately, at 1,252 cases in 2017.
  • Heterosexual contact of all ages in 2017 revealed a 9,170 new HIV diagnosis rate.

Black/African Americans continue to experience the most severe burden of HIV compared with other races and ethnicities. Black/African Americans represent approximately 13% of the United States population but accounted for an estimated 43% of new HIV infections in 2017. They also accounted for 42% of individuals living with HIV infection.9

new_hiv_diagnoses

New HIV Diagnoses in the US and Dependent Areas for the Most-Affected Subpopulations, 20175

Hispanics/Latinos represent approximately 18% of the United States population and accounted for 26% of new HIV infections in 2016. Among Latino and Hispanic MSM, new infections rose by around 30%, from 6,400 to 8,300 in 2016. The greatest rise was among 25 to 34-year-olds, where new infections increased by 68%.10

White men having sex with men runs in third place of new HIV diagnosis, with around 6,982 reported new cases in 2017.5

Heterosexual African American/black women, young people and transgender women of all ethnicities are also disproportionately affected.10

Transmission and Prevention of HIV Infection

How HIV viral particles enter the bloodstream for an individual to become infected relates directly to the prevention of HIV. HIV, once having invaded the body, is tough and resilient and impossible for the infected individuals’ body defenses to destroy. Outside the body, however, HIV is fragile and does not survive for long. Misleading rumors about ease of viral spread have led the CDC to provide a list of ways HIV cannot be spread11:

  • HIV cannot be spread in air or water.
  • HIV cannot be spread by insects, including bed bugs, ticks or mosquitoes.
  • HIV cannot be spread in saliva, sweat or tears and no documented case exists of HIV being transmitted by spitting.
  • HIV cannot be spread by casual contact, such as sharing dishes or shaking hands.
  • HIV cannot be spread by closed mouth or social kissing.
  • HIV cannot be spread from toilet seats.

HIV Sexual Transmission

HIV infection, both worldwide and in the United States, is most often spread through anal or vaginal sexual activities, followed by exposure to infectious blood, most commonly from sharing equipment used taking illicit drugs. Male to male sexual contact, “men who have sex with men” (MSM), have 28 times the rate of infection than dedicated heterosexuals.2

New Cases of MSM HIV Diagnosis in 201712

MSM Accounts for:

  • 57 percent of all new cases of HIV in North America, Central Europe, and Western Europe
  • 41 percent of all new cases of HIV in Latin America
  • 25 percent of all new cases of HIV in Asia, the Pacific, and the Caribbean
  • 20 percent of all new cases of HIV in eastern Europe, central Asia, the Middle East, and North Africa
  • 12 percent of all new cases of HIV in Western and Central Africa

The transmission of HIV is significantly affected by the type of sexual exposure. Receptive anal intercourse has a much greater risk of viral transmission as compared to receptive vaginal intercourse. The use of condoms does not preclude transmission due to many factors affecting condoms such as holes, tears, improper fitting, etc. However, condom use does lower the chance of transmission as compared to intercourse without protection. The presence of other sexually transmitted diseases, such as the ulcerations of genital herpes, can increase the risk of transmission as much as four times. Circumcision has been shown to decrease the chance of HIV acquisition by the circumcised male, as well as decreasing the probability of transmitting HIV from the one circumcised to their partner in several randomized trials, although it is important to wait for a new circumcision to heal completely before engaging in intercourse.13

HIV Blood Transmission

Transmission of HIV particles into blood can occur through such things as needle exchange, blood sharing rituals or unsterilized equipment exposed to blood. Injection drug users (IDUs) constitute a growing population of new HIV cases. Cosmetic instrumentation exposed to blood and certain body fluids may be as great or greater a risk than improperly sanitized medical instrumentation due to the lack of awareness held by some practitioners of the tenacity held by HIV, hepatitis and other pathogens. Body piercing, tattooing and even manicure/pedicure tools must all be rigorously and methodically cleaned and disinfected between clients to avoid the spread of life-threatening disease.

Pre-Exposure Prophylaxis (PrEP)

Pre-exposure prophylaxis (PrEP) is a way for individuals who do not have HIV but who are at substantial risk of contracting it to prevent HIV infection by taking a pill every day. One PrEP option currently recommended is TDF-FTC (tenofovir disoproxil fumarate- emtricitabine), component drugs that are used in combination with other medicines to treat existing HIV. When an individual is exposed to HIV through sex and/or injection drug use, these medicines can help to keep the virus from establishing a permanent infection. PrEP is much less effective if it is not taken consistently. PrEP is only for individuals who are at substantial ongoing risk of HIV infection2:

  • Anyone who is in an ongoing relationship with an HIV-positive partner
  • Anyone who is not in a mutually monogamous relationship (i.e., an individual and their partner only have sex with each other and do not have sex outside of the relationship) who recently tested HIV-negative
  • A gay or bisexual man who has had anal sex without a condom or been diagnosed with an STD in the past 6 months
  • A heterosexual man or woman who does not regularly use condoms during sex with partners of unknown HIV status and are at substantial risk of HIV infection (e.g., individuals who inject drugs or have bisexual male partners).

PrEP is a powerful HIV prevention tool and can be combined with condoms and other prevention methods to provide even greater protection than when used alone. In all PrEP Clinical Trials, HIV transmission risk was lowest for participants who took the pill consistently. At times it reduced the risk of getting HIV from sexual intercourse by as much as 90%.14 Among those who inject drugs, PrEP showed a reduction of approximately 74% of contracting AIDS when taken daily.15

Clients receiving PrEP should have regular appointments with a medical provider. The recommendation is a follow-up one to three months after initiating PrEP treatment, with a visit every three months thereafter.14 Checkups are encouraged whenever exposure to, or symptoms from a sexually transmitted infection (STI) occurs, or if signs of kidney function issues appear. Should kidney markers appear during the three-month visits, (e.g., elevated creatinine, glycosuria, new proteinuria) consider halting the PrEP.14

Post-Exposure Prophylaxis (PEP)

For individuals who need to prevent HIV after a single high-risk event of potential HIV exposure such as unprotected sex, needle-sharing injection drug use or sexual assault, there is another option called post-exposure prophylaxis (PEP). It involves taking antiretroviral medications as soon as possible, but no more than 72 hours (3 days) after exposure to HIV to try to reduce the chance of becoming HIV positive. These medications keep HIV from making copies of itself and spreading throughout the body. Two to three medications are usually prescribed and must be taken for 28 days. PEP is not always effective. It does not guarantee that an individual exposed to HIV will not become infected with HIV.

Starting PEP as soon as possible after a potential HIV exposure is important. Research has shown that PEP has little or no effect in preventing HIV infection if it is started more than 72 hours after HIV exposure. It takes about three days for HIV to make copies of itself once it enters the body and for it to spread throughout the body. When HIV is only in a few cells where it entered the body, it can sometimes be halted by PEP, but when it is in many cells in many places of the body, PEP will not work.

PEP should only be used right after an uncommon situation with potential HIV exposure. If the individual is often exposed to HIV, for example, because the individual often has sex without a condom with a partner who is HIV-positive, repeated uses of PEP are not the right choice. When medications are given only after exposure, more medications requiring higher dosages are needed to block infection than when they are started before the exposure and continued for a time thereafter. In this situation, pre-exposure prophylaxis (PrEP) is indicated.

The Virus HIV

The Human Immunodeficiency Virus belongs to a viral family known as retroviruses. Some viruses are known as retro, or backward, due to an ability to transcribe, or copy, their genetic code from RNA into the DNA of a host cell as opposed to the more common DNA to RNA method of transcription. Like other viruses, HIV can neither reproduce nor grow independently. HIV requires a living host, in this case, a human, in order to make copies of itself, a process known as replication, which, in the end, destroys the host cells commandeered to be production factories. For most viruses, human bodies respond by quickly destroying the invader by means of the human immune system. Unfortunately, it is the immune system itself that the HIV infection desires to invade and replicate in, leading to a progression where the very source of protection against viruses becomes a cellular killing ground destroying the body’s defenses and giving birth to masses of new viral particles.

The favorite prey of HIV viral particles is our CD4 T-cells, macrophages and dendritic cells. Once the favored cell has been found, the virus locks onto it and quickly regurgitates its core to the inside of the doomed host allowing viral RNA to begin the process of transcribing into the host cell’s DNA using an enzyme called reverse transcriptase. The resulting rewritten DNA integrates into the human genome of the body’s cell. HIV may remain a quiet passenger in the genome of its human host cell for some time, or it may immediately exert itself forcing the enslaved human genome into making more copies of viral particles, becoming a mass producer of new viruses ready to continue the spread and conquest throughout more of the infected human body.

HIV Virus Spreading through System

HIV Overwhelming Immune Cells

HIV Virus Spreading through System

HIV is a prolific breeder, able to create trillions of copies of itself within a short period of time. During periods of active viral replication, a single milliliter of blood may contain more than 1 million copies of the virus. As is the manner of viruses, a small percentage of these trillions of copies will have minuscule differences from the original, thus making them resistant to medications or treatments that would have successfully treated the original virus.

Two significant varieties of the HIV virus have been identified: type 1 (HIV-1) and type 2 (HIV-2).4 HIV-1 is more virulent, and the primary cause of infection worldwide. Generally speaking, when you hear HIV referred to without clarification as to type, HIV-1 is being discussed. HIV-2 is less easily transmitted and less common, appearing mostly in West Africa or in individuals who have had contact with a viral carrier from that region, or are themselves from that region. Both types of HIV have AIDS as their end stage and both are transmitted through blood, sexual contact and body fluids. Current tests are available to detect both HIV-1 and HIV-2. Be alert, as HIV changes and mutates readily, a single infected individual may have several different strains of HIV inside their body. The future will bring more significant, recognized subtypes of HIV.

Three Stages of HIV Infection

Currently, there is no cure for HIV infection. HIV infection has three distinct stages as defined by the CDC: HIV Primary or Acute infection, HIV Chronic or Asymptomatic infection and HIV as AIDS.

HIV Primary or Acute Infection

The earliest stage of HIV infection is known as the primary or acute stage. Acute HIV infection generally develops around two to four weeks after an individual has been infected by sufficient quantities of the virus, e.g., a high enough viral load. Many newly infected individuals report having flu-like symptoms such as generalized aches, headache, fever and perhaps even a rash.16 During this stage, the virus begins taking possession of CD4 Helper-T cells, destroying them in the process of multiplying itself.

Seroconversion denotes the time period from initial infection to when the body begins to create antibodies in sufficient amounts to be detected by HIV antibody testing.16 This brief, though variable, time period is also referred to as the “window period” of acute HIV infection. During this period an individual may have the infection, yet still not register as positive on current screening tests. Unfortunately, viral levels are generally high enough during this window period that newly infected individuals are themselves able to infect others and can easily transmit HIV by sexual acts, sharing drug paraphernalia and other modes of transmission specific to HIV. The length of this dangerous window period can be as little as 2 weeks or up to 6 months, making lifestyle screening an important tool during HIV pre-test counseling sessions.

Acute Retroviral Syndrome - Seroconversion Syndrome - Seroconversion Illness16
  • Seroconversion is often accompanied by a series of symptoms referred to as seroconversion illness, although a more technical term is Acute Retroviral Syndrome.
  • Symptomatic seroconversion has a flu-like presentation with fever and swollen lymph glands in neck, armpits, and/or groin. A rash, fatigue and sore throat are often present, as well as less common symptoms such as headache, diarrhea, stomach ache, or ulcerations of the esophagus.
  • Around 70% of those with acute HIV infection develop noticeable symptoms during the acute stage of infection.
  • Abnormalities in laboratory values during seroconversion include increased levels of inflammatory cytokines (indicating immune activation) and a short-term decrease in lymphocytes (white blood cells), followed by an increase in CD8+ cells and overall lymphocyte counts.
  • Seroconversion symptoms are non-specific, however, when viewed as a syndrome, or pattern of symptoms, they may serve to prompt the right type of diagnostic interview questions which can lead to up to 30-50% of newly infected individuals being identified during seroconversion and early treatment options instituted even before direct HIV testing can be employed.

Due to the window period and the initial high viral quantities in the bloodstream, it is generally considered that the acute stage of HIV infection holds the greatest risk of disease transmission to others, although HIV can be transmitted during any of its stages.

Our bodies are masterpieces of engineering and design, which, when given a chance, show incredible tenacity. This is demonstrated even during the massive invasion of new viral particles permeating the acute HIV infection stage as our immune response rallies and fights to bring the viral load down to a stable level. It is common toward the end of the acute stage for the infected individual to reproduce some of the CD4 T helper cells lost earlier, though CD4 counts rarely return to the levels they had pre-infection.

Chronic HIV or Asymptomatic Infection

Following the initial flu-like symptoms and the rapid surge of viral levels in the acute stage of HIV infection, comes a chronic or latency period during which infected individuals often feel and look healthy. The length of this asymptomatic stage differs from individual to individual and may linger as long as ten years. During this chronic stage, HIV is still active, although its replication levels are much slower than the enormous reproduction surge of the acute stage. Individuals who are infected and have started on antiretroviral therapy (ART) may be able to extend the symptom-free HIV period for up to several decades.

Individuals in the chronic HIV stage are still able to infect others. While the chronically infected individual may not themselves feel sick, any risky lifestyle habits such as those that brought them initially into contact with HIV must be addressed in order to limit the continued spread of this deadly infection. HIV carriers know they are infected. Lifestyle changes are important, and the initiation of antiviral medication can reduce the chance of transmitting the infection by as much as 90%.14

The chronic latency period of HIV infection will draw to a close, with or without supporting medications such as ART. The beginning of the end of the latency period is signaled by a progressive rise in viral levels, often referred to as the viral load, and a drop in the CD4 cell count. This combination of events allows symptomatic illness indicators of the HIV infection to once more surface as the beleaguered immune system grows too weak to counteract and control symptoms.

HIV as AIDS the Final Stage of Infection

Acquired Immunodeficiency Syndrome (AIDS) is the final stage of HIV infection. AIDS occurs when the body’s immune system has been so badly damaged that the individual is vulnerable to diseases, infections and even infection-related cancers. The general terms used for these entities are opportunistic illnesses or opportunistic infections as their presence occurs due to the absence of immune system defenses, allowing these opportunists to take advantage of the opening created by the HIV infection to spread without challenge or check.

aids_case_definition

An AIDS diagnosis can only be made by a licensed healthcare provider based on the results of HIV specific blood tests and/or the ill individual’s physical condition. Once diagnosed with AIDS, the current diagnostic protocols do not recognize backward travel through the HIV diagnostic criteria, even when symptoms are in remission, and the individual feels better. Therefore, it is diagnostically true that once identified as having AIDS the diagnosis will always be with that individual.

Some individuals with AIDS may appear healthy to the casual observer. However, they continue to be infectious and extremely vulnerable to opportunistic diseases, particularly when not receiving adequate supportive treatments. When untreated, the average lifespan from initial HIV infection to death in the United States is currently just over three years. Current medication therapies and lifestyle changes have been able to lengthen the lifespan by decades.

200 CD4 cells per cubic millimeter of blood or 200 cells/mm3 is the line below which AIDS is officially diagnosed, although the presence of one or more diagnostically recognized opportunistic illnesses is also considered adequate for the finding of the diagnosis of AIDS regardless of the CD4 count.

Visible symptoms that the HIV stage of AIDS has been reached include17:

  • Persistent low-grade fever
  • Extreme and unexplained fatigue
  • Difficulty recovering from colds or flu
  • Recurring fever or profuse night sweating
  • Diarrhea lasting more than one week
  • Rapid weight loss
  • Sores of the mouth, anus or genitals
  • Memory loss, depression or other neurologic disorders
  • Respiratory difficulties including pneumonia

Without treatment, the life expectancy of an individual diagnosed with AIDS is typically three years. The concurrent presence of a dangerous opportunistic illness lowers the life expectancy of an untreated AIDS individual to one year or less.

Even with treatment, opportunistic infections will occur once AIDS is reached. Typically, antibiotic prophylaxis is prescribed to help the severely impaired immune system fight off infections.

Diagnostic Tests for HIV

Basically, there are three types of diagnostic tests for HIV: antibody tests, antigen (Ag)/ antibody (Ab) tests and nucleic acid (RNA) tests. Antibody tests detect antibodies, which are proteins that the body makes to fight against HIV. Antigen tests and RNA tests detect HIV directly.

HIV Antibody Tests

Antibody screening tests (immunoassays) are currently the most commonly used HIV tests. These are available as both laboratory and rapid testing versions using either blood or oral fluids. Antibodies are produced by the immune system in response to an infection and antibody screening tests performed on blood have the ability to detect the presence of HIV earlier in the infection process due to the available levels of antibody in the blood. Antibody screening immunoassays conducted at the point of care are capable of providing preliminary results in about 20 minutes.

Advances in laboratory-based enzyme immunoassays, as well as, chemiluminescent immunoassays are able to identify HIV as early as three weeks after infection. Not all antibody screening tests or testing services utilize the most current methods so variations in testing ability must be taken into consideration.

Antibody screening immunoassays have been designed to detect HIV-1 and/or HIV-2 antibodies in blood, oral fluid and even urine specimens. Reactive/positive screening test results are always considered preliminary, pending a confirmation test. When using a rapid screening tool, the confirmation test will be a laboratory follow-up test.18

  • Blood-based HIV screening:
    • Fingerstick testing detects antibodies
    • May be a rapid result test or a sent to the laboratory version
    • Most often used in medical offices, public health clinics and community outreach centers.
  • Oral fluid HIV screening:
    • Oral fluid containing antibodies in the oral mucosal transudate is gathered by swab from around the gums of the mouth.
    • Rapid test kits are available, or the swab can be placed in a special collection container for shipment to a licensed processing center.
    • Public health clinics and community outreach agencies are the primary users of this method.
  • Urine HIV screening:
    • Urine rapid test kits or collection devices are available to be sent to licensed processing centers but are not yet widely used.

HIV Antigen/Antibody Tests

Combination antigen/antibody (Ag/Ab) immunoassays are in their fourth generation for HIV detection and are capable of detecting antibodies against HIV and fragments of the virus itself called antigens. Ag/Ab tests require blood samples (serum, plasma or whole blood) and have the potential to detect a specific protein known as p24 viral core protein as soon as three weeks after the initial infection. The p24 particles, however, soon become undetectable once the body speeds up its antibody production and begins to “destroy the evidence” in its fight against HIV. At this point, the second part of the Ag/Ab test becomes valuable, as the antibodies hiding the antigen evidence become reactive to the test allowing accurate detection efforts to continue.

The Western blot (protein immunoblotting IgM/IgG) test for HIV is now the confirmatory test preferred by the CDC for double-checking the results of other HIV tests.18 Be aware that the Western Blot may be unreliable in new HIV infections, under two months since the time of infection.

HIV Nucleic Acid (RNA) Tests

Nucleic acid tests detect the genetic material of the HIV virus, ribonucleic acid (RNA). These tests are capable of identifying the presence of HIV in an individual’s blood as soon as ten days after they become infected. Only licensed laboratories are approved to perform this test. A blood plasma specimen is required for this test.

HIV Testing Informed Consent

The CDC has formulated specific recommendations balancing the rights of individuals with the need of the public regarding infectious disease. As of 2018, all states have enacted laws that are consistent with the following CDC recommendations19:

Consent:

  • A separate written consent for HIV testing is not recommended.
  • A general informed consent for medical care, which notifies an individual that an HIV test will be performed unless specifically declined (opt-out screening) should be sufficient to encompass informed consent for HIV testing.

Prevention Counseling:

  • Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in healthcare settings.
  • For specific information about each state's laws regarding HIV testing informed consent and prevention counseling rules go to the CDC state HIV law information page: CDC State HIV Law Information Page

Confidential HIV testing means that results go into the individual’s medical file and may be shared with other healthcare providers and insurance companies according to HIPAA regulations. Some states offer anonymous HIV testing where a unique identifier is attached to the results allowing only the individual to access the results.

Tests positive for HIV or other sexually transmitted infections (STI’s) will be reported to local or state health departments. This allows state tracking of new instances for the purpose of planning public health response. State health departments take the compiled information and forward them to the CDC after stripping all personal information from them.

Anonymous testing may delay or prevent a timely initiation of treatment and may lead to some individuals failing to receive care. Thus, anonymous testing is not an ideal option. Healthcare professionals should take the time to review whether anonymous HIV testing is in the best interest of the individual and if it is even an alternative in the area of practice.

HIV Test Results

Negative HIV Results

The presence of a negative HIV result indicates one of two things:

  • No HIV infection is present or
  • The individual has been recently infected and has not yet produced enough antibodies to be detected by the test.

If the individual’s interview reveals a recent episode of high-risk behavior, it is recommended that a follow-up HIV test is performed three weeks to three months from the date of initial testing so as to work around the “window” effect that occurs during acute infection. Risk is particularly high if unprotected sex or needle-sharing behaviors have occurred. It is imperative that the individual is warned that a negative HIV test result does not mean that an individual is immune to HIV. Should risky behavior continue, HIV infection is likely to occur.

Positive HIV Results

Positive confirmatory test results indicate the presence of HIV antibodies or HIV RNA:

  • The individual has an HIV infection.
  • This individual is infected with HIV for life.
  • This individual can spread the HIV virus to others through behaviors such as unsafe sex, sharing contaminated injection devices and other high-risk behaviors.
  • Immediate assistance to obtain HIV treatment and medical care should be initiated so that the best possible outcome can be obtained.

Indeterminate HIV Results

Infrequently, an HIV test will return as inconclusive or indeterminate. Recent high-risk behaviors leading to the individual’s infection with HIV may indicate that they are still in the process of developing antibodies or “seroconverting.” Whenever seroconversion is suspected, RNA testing should be performed to determine whether or not the virus is present. If RNA testing is not available, a second HIV test using different antibody detection from the first indeterminate test should be performed. If the second test gives a positive result, HIV is present.

An indeterminate HIV test result does not automatically mean seroconversion is present as there is a potential for test cross-reactions with other proteins from sources such as an autoimmune disease, recent influenza vaccination or even pregnancy.

HIV Viral Load Testing

Laboratory testing is ongoing once a positive HIV test result occurs, as it is important to know both CD4 counts and viral loads when dealing with HIV infections. Viral load refers to the quantity of HIV viral particles present in an individual’s bloodstream. When the viral load is high, more HIV is present, indicating the immune system is not functioning well. Low viral loads reduce complications from the HIV infection and translate into an extended lifespan. Good laboratory results show a high CD4 count and low or absent viral load counts.

HIV Treatment

Currently, there is no cure for HIV infection. An individual’s lifespan can be extended and quality of life enhanced, yet every individual diagnosed with HIV infection will die from it as long as another life-ending event does not take them first. Consequently, prevention is the key, the goal and focus of early intervention. Once an HIV diagnosis does occur, early and aggressive therapy can add decades of life and enhance the quality of life.

A complete medical history, physical examination and general laboratory assay should be initiated as soon as possible after initial diagnosis. The results of these provide the foundational framework on which future results can be compared.

The current best practice for HIV treatment is early and continuing antiretroviral therapy (ART) for all HIV infected individuals, especially infected pregnant women, so as to reduce the risk of transmission to the fetus.20 Antiretroviral medications do not kill the HIV virus, nor can they cure the disease. ART’s are intended to slow or prevent the growth and spread of the virus.

There are several antiretroviral agents in use since the HIV virus has shown itself proficient at forming resistance to single-agent therapy. Highly active antiretroviral therapy (HAART) combines three or more antiretroviral agents that are given to prevent treatment resistance from forming within the infected individual.

Each drug class of antiretroviral medications work by a different mechanism to combat HIV. There are currently six classes of antiretroviral medications2,20:

  • Nucleoside Reverse Transcriptase Inhibitors (NRTIs) or “nukes” block reverse transcriptase, an enzyme HIV needs to create altered DNA from viral RNA to make copies of itself.
  • Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) or “non-nukes” bind to and later alter reverse transcriptase, in order to block the altered DNA creation from viral RNA though in a different fashion from the NRTIs.
  • Protease Inhibitors (PIs) interfere with the process of the newly formed HIV virus using the enzyme protease to gather components it needs to mature into full function.
  • Entry Inhibitors block proteins on the CD4 cells that HIV needs to enter the cells. This category includes the CCR5 antagonists, which block viral entry into CD4, and the lone-wolf Fusion Inhibitor enfuvirtide.
  • Post-Attachment Inhibitor, the monoclonal antibody Ibalizumab-uiyk, is the only PAI in current use. It does not block viral attachment to CD4 cells; however, it thwarts viral core entry into the cell core, thus preventing HIV replication.
  • Integrase Strand Transfer Inhibitors (INSTI) act to prevent the DNA from the virus from being inserted into the chromosome of the host cell by interfering with the HIV integrase enzyme, the tool the virus uses to unzip and then patch in its own genetics.

Also important are Pharmacokinetic Enhancers and Combination HIV Medications commonly used in the ART and HAART regimens. Pharmacokinetic Enhancers are used in HIV treatment to increase the effectiveness of an HIV medication included within an individualized HIV regimen. Combination HIV Medicines are two or more HIV medications from one or more drug classes given together for greater impact.

HIV Medication Combination Therapies

CDC guidelines recommend initiating prompt treatment following diagnosis with combination antiretroviral medications (ART’s). Each individual should have these medications personalized based on drug resistance testing, epidemiologic determination of susceptibilities of the local prevalent viral strains, comorbid conditions, possible drug to drug interactions and anticipated adverse effect profiles. The CDC provides recommendations for a general starting combination therapy.21

In an antiretroviral-naive individual, general guideline suggestions include a starting regimen considering the following factors20,21:

  • All new HIV positive clients should be offered ART.
  • While there are more than 25 medications from six major classes of antiretroviral medications used for HIV treatment, the most commonly used are NRTIs, NNRTIs, and PIs.
  • The general starting regimen should include two nucleoside/nucleotide reverse transcriptase agents (NRTIs) either tenofovir/emtricitabine (TDF/FTC) or abacavir/lamivudine (ABC/3TC), plus a drug from one of the following classes: NNRTI, PI boosted with ritonavir (RTV) or INSTI.

Case Study

Marissa, 28, comes to you after a public health worker contacted her as a reported contact of a newly diagnosed HIV client. Marissa is especially concerned because she recently found out she was pregnant and plans to carry her baby to term.

Confirmation tests indicate Marissa is indeed pregnant and, unfortunately, has also contracted the HIV virus.

The National Institute of Health (NIH) and the CDC both recommend HIV testing for all pregnant women. Some regions automatically include HIV testing as part of routine prenatal care, while others separate it as an additional opt-in test. The CDC recommends and requests that HIV tests be routine for all pregnant women.

Marissa was provided information about the means of protecting her unborn child, herself and potential contacts from the dangers of HIV infection. Nonjudgmental information that the unborn baby would be at heightened risk for mother-to-child transmission of HIV during pregnancy, labor and delivery, and afterward by breastfeeding was provided. Marissa was assured that with proper medication and treatment less than two babies in 100 with HIV positive mothers get the infection before or during birth.

Antiretroviral medications are strongly recommended:

  • Throughout the pregnancy – combinations of at least three different ART medications are generally used based on unwanted effect profiles.
  • During labor and delivery – additional intravenous AZT is recommended for the mother during labor and through the delivery process in addition to the oral ARTs.
  • After birth – liquid AZT is given to the newborn as a six-week preventative. Babies whose mothers were not on a pre-birth ART regimen may receive additional anti-HIV medications as well.
  • After delivery – the new mother's ART regimen will probably be amended to include medications whose adverse effects prevented their use during the pregnancy.

Marissa was informed that she would also be at risk for the progression of the HIV infection if medications are not started now to slow the infective processes. Potential sexual partners will also be at risk for infection unless deliberate steps to prevent the spread of HIV are implemented in a thoughtful methodical manner.

A cesarean delivery (C-section) may be preferred to regular vaginal delivery as a means of minimizing exposure of the newborn to infected blood and delivery fluids. The preferred time for the C-section is around 38 weeks gestation, or about two weeks prior to the normal due date.

Marissa was reassured that ongoing monitoring of her newborn would occur at two weeks, two months, and six months in order to make sure the baby remains HIV free.

Should the newborn have a positive HIV virologic test result, a combination of HIV medications with the addition of Bactrim to inhibit pneumonia will be started.

Summary

HIV infection is a chronic medical condition that those infected will have until an infected individual succumbs to it in its final stage of AIDS or death ensues from another cause. There is no cure for HIV infection, which means that prevention is key to controlling its spread. Distributing knowledge of HIV along with information concerning an infected individual's rights and the value that their lives hold form essential parts for positively affecting individuals/groups whose behaviors place them at a heightened risk for exposure and infection. It is important to share information concerning the transmission of HIV along with the risks of unprotected sex, sharing of needles and exposure to unsterilized blood-contaminated devices as methods by which the HIV retrovirus can be transmitted to still another victim.

It is estimated that approximately one in five HIV infected individuals are unaware of their infection and unable to begin life-extending treatment. HIV testing is available both from healthcare professionals and by means of home tests. Once a positive test is confirmed, early aggressive treatment with antiretroviral medications is highly encouraged. The state of HIV medications allows those infected to live decades longer than they otherwise would without medication, and with a greater quality of life, though the medication regimen can be taxing. Support for adherence to the medication regimen and behavioral changes that minimize the chance of spread of the virus by those infected are important objectives for healthcare professionals as they work toward helping the HIV infected live healthier, more satisfying lives.

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