Nursing Assistants from California, only. You must read the material on this page before you can take the test. The California Department of Public Health, Training Program Review Unit has determined that is the only way to prove that you actually spent the time to read the course. Less
Referred to as the “Scourge of Our Time,” the Human Immunodeficiency Virus (HIV) and its fatal end-stage, Acquired Immunodeficiency Syndrome (AIDS), brings dread to those with knowledge of its effects and impacts.1,2 New treatments have extended, by decades, the lifespan of those infected which has shifted HIV from an acute terminal illness to a chronic condition requiring care and monitoring. As healthcare professionals, it is imperative that we keep current on new information regarding HIV, the effects seen with HIV, its transmission, treatment and the best care for HIV victims who progress into the final stage of AIDS as we help those infected live healthier, more satisfying lives.
HIV as an infectious virus came into focus in the United States in 1981 when an unusual number of deaths among homosexual men experiencing uncommon and life-threatening multi-organism syndromes was highlighted as a statistical anomaly. The Centers for Disease Control and Prevention (CDC) published a description of cases involving a rare lung infection, Pneumocystis carinii pneumonia, in its weekly Morbidity and Mortality Report and provoked a flood of stories from physicians who were currently encountering similar rare infections among the gay male population. This June 1981 publication marked the first reporting of what was soon to be known as the AIDS epidemic, currently referred to as the “Scourge of Our Time” by scientific organizations and media outlets alike.2,3
Over the past forty years, many healthcare professionals have followed the theories and discussions of where HIV originated and why it escaped identification until 1981 when it suddenly emerged as the AIDS epidemic. For the purpose of this discussion we will skip past the internet popular notions of extraterrestrial experiments or hidden government bioweapons gone rogue as sources of HIV and/or AIDS as they seem somewhat unworkable as theoretical epidemiological working models.4,5
Information uncovered by more mainstream researchers relate to the history and origins of HIV, and include a 1959 HIV positive plasma sample from an adult African male living in what is now the Democratic Republic of Congo.6 This sixty-year-old sample related well to genetic markers from the four known HIV type 1 human viral groups, all of which show viral sharing with apes located in Cameroon, Gabon, the Democratic Republic of Congo and Uganda. These shared markers, along with other trace information, supports the strong probability that HIV originated in Africa among humans who hunted local chimpanzees and apes infected by the Simian Immunosuppressant Virus (SIV). The likelihood of the SIV virus being transmitted to humans is not without reason, due to the quickly replicating, frequent alterations into new strains tendency found in the ape bound virus.7
Close-up of a HIV viral particle free floating in bloodstream
There have been at least four cross-species transmissions of SIV infected ape blood to local humans according to Microbiologist Beatrice Hahn in her 2015 article in Proceedings of the National Academy of Sciences.8 Dr. Hahn’s research demonstrated that the four subgroups of the HIV-1 strain found in humans, groups M, N, O and P, were from separate cross-species transmissions that each had a different impact on the human population. Group M is central to the current AIDS pandemic, which has infected more than 40,000,000 individuals by spreading across Africa and throughout the rest of the world. Group O, although not as widespread and prevalent as group M, has nonetheless infected about 100,000 individuals in west-central Africa. Groups N and P, at the other extreme, have only been found in a few individuals who lived in or visited Cameroon.
The leap from simian to human, researchers postulate, may have even occurred in less recent times, when the spread of the virus was isolated to single villages rather than the spread via modern vectors of mass transportation which can swiftly whisk an infected individual away from an isolated village and into the global population.
Politics, economics and propaganda so surround the topic of HIV and its origins that we may never recognize or have the opportunity to seriously discuss the actual roots of the AIDS epidemic, should it ever be fully known.9 Those who believe this a somewhat cynical view of how scientifically important endeavors can be derailed, need only look to the history of HIV vector studies with careers put in jeopardy and efforts to suppress or spin findings.
Haitian HIV studies, for example, faced extreme pressures to suppress serious investigation or findings made in the mid-1980s, until UCLA’s Dr. Michel Worobey’s meticulous and hard gained data was finally presented to the March 2007, Fourteenth Conference on Retroviruses and Opportunistic Infections (CROI) among his hometown crowd in Los Angeles. Dr. Worobey’s complex genetic analysis of a single HIV subtype demonstrated strong evidence that HIV had been brought to Haiti by a single individual around 1966. This Haitian strain of HIV then slowly began to circulate from individual to individual among the closed population of the island before being brought to the United States. The research published by Dr. Worobey and colleagues gave a 99.7% certainty of the travels of that one particular subtype and strain and, thus, immediately came under the weight of political, commercial and tourism opposition of the type which had crushed findings of previous researchers examining the Africa - Haiti - United States transmission link.10
Brief Timeline of the HIV AIDS Epidemic 11,12,13
Probable time of transmission of SIV in African apes to African humans.
First known laboratory positive HIV specimen in deceased human.
Haiti shows spreading HIV cases likely from traveler(s) from Africa.
HIV travels to New York from Haiti, the spread boosted by an upsurge of gay male activities in New York.
HIV spreads from New York to San Francisco gay clubs and participants.
First report on unusual infection clusters by the CDC.
CDC first uses the term AIDS.
First AIDS clinic opens in San Francisco.
CDC reports first female cases of AIDS.
Identification of the HIV cytopathic retrovirus.
AIDS reported in injection drug users and hemophiliacs.
Serologic diagnostic test for HIV.
Blood banks begin screening supplies.
Antiretroviral drugs introduced.
US dept. of immigration adds HIV to its immigrant exclusion list.
First needle exchange program launched in Tacoma, WA.
CDC releases “Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers.”
CDC report on possible transmission of HIV via a dental procedure from an infected dentist.
CDC adopts client-centered prevention counseling.
US Congress enacts law restricting HIV positive healthcare workers.
AIDS becomes the number one cause of death for US men ages 25-44.
AIDS becomes leading cause of death for all Americans age 25-44.
First oral HIV test approved.
First protease inhibitor, highly active antiretroviral therapy HAART.
Number of new AIDS cases declines for first time since beginning of epidemic.
AIDS no longer leading cause of death for ages 25-44.
First HIV home collection and testing kit approved.
First HIV urine test approved.
CDC issues the first national treatment guidelines for the use of antiretroviral therapy.
The World Health Organization (WHO) announces that HIV/AIDS has become the fourth biggest killer worldwide and the number one killer in Africa.
First HIV vaccine trial performed in Thailand, pronounced failure in 2003.
FDA approves the first rapid HIV diagnostic test kit that provides results with 99.6 percent accuracy in as little as 20 minutes.
A bone marrow transplant for cancer treatment from a genetically resistant to HIV donor to a recipient with HIV, “the Berlin patient” produces a negative test for HIV. The first recorded “cure” of HIV.
CDC announces HIV and AIDS cases had been drastically underreported in previous years, yet despite higher estimates have remained relatively stable.
US HIV immigration ban lifted.
CDC study provides evidence that daily oral antiretroviral drugs used to treat HIV infection can reduce HIV among uninfected individuals exposed to the virus, PrEP.
FDA approves the use of Truvada® for pre-exposure prophylaxis (PrEP), and the first at-home HIV test that will let users learn their HIV status right away.
First well-documented case of an HIV-infected child functionally “cured” of HIV infection (i.e., no detectable levels of virus or signs of disease, even without antiretroviral therapy), and two HIV-positive adults in Boston who had bone-marrow transplants for blood cancers show as virus-free.
The two Boston HIV post bone-marrow transplant adults’ relapse into active HIV. Sadly, so does the HIV infected child announced “cured” in 2013.
FDA approves the first diagnostic test that differentiates between different types of HIV infections (HIV-1 and HIV-2). The test can also differentiate between acute and established HIV infections.
International study indicates that HIV resistance to some medications is becoming increasingly common.
International research team finds early antiretroviral therapy (ART) is key to reducing brain atrophy for people living with HIV. A global analysis finds that people living with HIV are twice as likely as their HIV-negative counterparts to suffer from heart disease.
Researchers announce the second cure of a person with HIV. Like the 2007 case of the “Berlin Patient” (the first person to be cured of HIV), the “London Patient” has no detectable HIV infection three years after he received a bone marrow transplant from a donor who is genetically immune to HIV. Both patients received bone marrow transplants to treat cancer. While the treatment is too dangerous and costly for widespread use, researchers hail the news as proof that HIV can be cured.
The CDC estimates that at the end of 2015, the most recent year for which United States prevalence statistics are currently available, there were approximately 990,000 adults and adolescents living with HIV infection nationally, over 520,000 of whom had infection classified as HIV stage 3 (AIDS).14
In 2016, the rate of HIV stage 3, a.k.a. AIDS diagnosed in the United States was 5.6 per 100,000 population. Or, to put it another way, from 1981-2016, 1,232,346 persons were diagnosed with AIDS in the United States, with 692,789 people going on to die from the direct effects of AIDS.
These numbers from over the past decade are a mix of good news/ mixed news. The good news is that from 2011 to 2016, the annual number of new HIV infection diagnoses decreased by 5.3%.14 The mixed news is that there remains a slow progressive annual increase in the total number of HIV infections as HIV sufferers are living longer with the advent of new treatments, resulting in an ever-expanding number of active HIV cases both in the United States and worldwide. Still, reduction in new cases is an important achievement as there is currently no cure for HIV infection. For this reason, the primary research focus remains on prevention.
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 which 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 questions remain 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 and southern regions. Perhaps it also is the fear of the possibility of a diagnosis of 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. But then the option of letting the disease run its course unchecked would be a very poor choice to make as well.
Whatever factor(s) that brings hesitation to those needing HIV prevention counseling, screening or treatment, is that of the stigma attached to having HIV or AIDS. Having HIV brings with it a “scarlet letter,” fear of repercussions due to having 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 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 Title II of the Americans with Disabilities Act (ADA). These well-established laws mean services which 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.
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 preventative 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 epidemic with its slowly widening reach into our culture and homes, remember that what we are really dealing with are the frightened and wounded, each one faced with the sudden overwhelming burden that comes with managing the chronic terminal condition of HIV/AIDS.
Gay, bisexual and other men who have sex with men (MSM*) of all races and ethnicities remain the population most profoundly affected by HIV. In 2017, the estimated number of new HIV infections among MSM was 25,748, a number identified as relatively stable from 2012 through 2017.15
Injection drug users of all sex and ages show around 2,389 known new HIV diagnosis in 2017.
MSM sexual activities simultaneous with injection drug use shows a large enough presentation of new HIV diagnosis to be categorized by the CDC separately, at 1,252 cases in 2017.
Heterosexual contact at all ages in 2017 revealed a 9,170 new HIV diagnosis rate.
*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 a behavior.18
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.19
Hispanics/Latinos represent approximately 18% of the United States population but 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%.20
White men having sex with men runs in third place of new HIV diagnosis, with around 6,982 reported new cases in 2017.21
Heterosexual African American/black women, young people and transgender women of all ethnicities are also disproportionately affected.20
HIV belongs to a viral family known as retroviruses. Some viruses are known as retro, or backward, due to their ability to transcribe, or copy, their genetic code from RNA to DNA in 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 themselves, a process known as replication. This process ultimately destroys the host cell. For most viruses the body’s immune system responds and quickly destroys the invader. Unfortunately, it is the immune system itself that the HIV virus desires to invade and then replicate in. This progressively leads to the destruction of the body’s immune defenses and the proliferation of masses of new viral particles.
Becoming infected with HIV means the virus has entered the human host’s bloodstream and HIV viral particles have begun to invade CD4 T-cells, macrophages and dendritic cells. HIV viral particles then lock onto the invaded cells and quickly regurgitate their core into the inside of the doomed cell thus allowing the HIV viral RNA to begin the process of transcribing itself 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 relatively silent in the genome of its human host cell for some time, or it may immediately exert itself forcing the human genome to make more copies of viral particles. The human genome becomes a mass producer of new viral particles ready to continue the spread and conquest throughout more of the human victim’s body.
Human Immunodeficiency Virus (HIV)22
Diagram of HIV structure.
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 one million copies of the virus. As is the way with viruses, a small percentage of these trillions of copies will have minuscule differences from the original. These minuscule differences make HIV more resistant to medications or treatments that would have successfully controlled the original virus.
Taxonomic Terminology – Clades
The term clade, more technically known as a monophyletic group, is all the linear descendants of one organism, excluding any other descendants that may be similar yet not exactly the same.
So, think back to the days of boring biology/ taxonomy training. A clade is the twig of a branch, off a larger branch, off a main branch connected to the trunk of an organism family tree.
Or, for those of us who scratch their heads when confronted by taxonomy terminology, a clade is a subgroup with features unique from other subgroups.
Two significant varieties of HIV virus have been recognized: type 1 (HIV-1) and type 2 (HIV-2). Both have propagated into multiple subtypes, known as clades.14 HIV-1 is the more virulent variety and the primary cause of infections worldwide. In general, HIV-1 is being discussed when HIV is being referred to without a clarification. HIV-2 is less easily transmitted and less commonly occurring, appearing mostly in West Africa or in individuals who have had contact with those infected with HIV-2 from West Africa. Both HIV-1 and HIV-2 progress to the terminal stage of AIDS and both are transmitted through blood, sexual contact and virus harboring body fluids. Current tests are available to detect both HIV-1 and HIV-2.23 Since the HIV virus changes and mutates readily, a single infected individual may have several differing clades of HIV. It is therefore essential to realize that the future will bring more significant, recognized subtypes of HIV.
What Type? Why There? 14,23
So, here’s a line of questioning to ponder as a thought exercise.
In the Western world and developed countries, the type HIV-1, clade B, is by far the most prominent variety of HIV/AIDS. In western Africa, where the bulk of HIV vaccine field trials are being currently conducted, HIV-2 finds its home. Virtually all in-development vaccines are targeted towards HIV-1 clade B.
Why then the geographic location of the trials, which gives the appearance of ignoring prevalent needs of a large third world population plagued by HIV-2?
HIV is a viral infection which progresses through three distinct stages terminating in the condition known as AIDS. HIV enters the bloodstream and attaches to T-helper lymphocytes (Helper-T cells) which are one type of the white blood cells, called by the general name of lymphocyte, which are necessary to the proper functioning of the immune system. Helper-T cells are also referred to as T4 or CD4 cells.
Helper-T cells coordinate the body’s immune response by communicating with other white blood cells, such as B cells which produce antibodies, phagocytes which are cells which engulf microbes to protect the body’s immune system and cytotoxic T lymphocytes (CTLs) (also known as Killer T cells) which use chemical weapons to directly attack foreign cells and even the body’s own cells which have been altered or are carrying foreign or abnormal molecules such as viral shells on their surface. All of the immune cells summoned and directed by CD4 Helper-T cells work together to fight invasion and ward off infection.
Antibodies target specific complex molecules produced by B cells in the body’s immune system at the behest of CD4 Helper-T cells. Normally, antibodies work by attaching to and attacking microorganisms that have not yet infected the body’s cells but are lurking in blood or the spaces between cells. Microorganisms swarmed by antibodies cannot function and are swept up by macrophages and other defensive immune cells to be destroyed and disposed of.
HIV infection does a hostile takeover of our CD4 Helper-T cells and prevents the chemical commands needed by the B cells in the immune system to make antibodies to a new infectious agent. This leaves the body vulnerable to opportunistic bacteria, fungal infections, parasites or other viruses as the production of antibodies is blocked.
HIV infection has three stages as defined by the CDC: HIV Primary or Acute infection, HIV Chronic or Asymptomatic infection and HIV as AIDS.
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 amounts of the virus, e.g., a high enough viral load.24 Many newly infected individuals report having flu-like symptoms such as generalized aches, headache, fever and perhaps even a rash.14 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.24 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.
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, swollen 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, stomachache, 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 particles 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 the body’s immune response rallies and fights to bring the number of virus particles 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.
CDC Stages of HIV26
CD4 count 500 to 1600 cells/mm3,
Stage 1 HIV Infection
CD4 count at least 500 cells/mm3, or,
CD4 cells at least 29% of all lymphocytes,
Flu-like symptoms within 2 to 4 weeks post-exposure.
Stage 2 HIV Infection
CD4 count 200 to 499 cells/mm3, or
CD4 cells 14% to 28% of all lymphocytes,
No symptoms until end of stage which may last from one to several decades.
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 look and feel healthy. The length of this asymptomatic stage differs from individual to individual and may last as long as ten years without treatment.26 During this chronic stage, HIV copying is still active, although replication levels are much slower than the enormous reproduction surges of the acute and final stages. 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 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 appropriate antiviral medication may potentially reduce the chance of transmitting the infection to new sexual partners.
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.
Transitioning from Stage 2 HIV infection (HIV Chronic or Asymptomatic Infection) to Stage 3 HIV infection (terminal HIV, aka., AIDS) is accompanied by evidence of a severely weakened and declining immune system. The immune system is no longer able to put limits on unregulated cell growth resulting in unwanted or abnormal cells spreading unchecked. Diseases such as cancers or opportunistic infections (OIs) develop. Most life-threatening OIs occur when the individuals CD4 count is below 200 cells/mm3. OIs are the most common cause of death for individuals with HIV/AIDS.
The CDC has developed a list of more than twenty opportunistic infections and disease conditions considered “AIDS-defining.” A diagnosis of HIV and the presence of one or more of these infections is sufficient for a diagnosis of AIDS regardless of the CD4 count.
AIDS Defining Conditions14,27
Bacterial infections, multiple or recurrent
Candidiasis of bronchi, trachea, esophagus, or lungs
Invasive cervical cancer with cancerous cells spread to other parts of the body
AIDS is the final stage of HIV infection. AIDS occurs when the body’s immune system has been badly damaged, making the individual 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.
Stage 3 HIV = AIDS 26,28
Human Immunodeficiency Virus
Acquired Immunodeficiency Syndrome
HIV is a viral infection that must enter an individual’s bloodstream in order to infect them.
AIDS is an acquired syndrome. It is not hereditary nor does the syndrome pass from one individual to another. AIDS only develops after an individual has had HIV enter their bloodstream and progressed through the stages of an HIV infection.
HIV infection may cause a number of symptoms as the virus impairs or kills cells of the body’s immune system. Groups of symptoms commonly found together are known as syndromes.
AIDS is a complex condition, not an actual disease itself; it is acquired from severe HIV infection of the immune system.
HIV infection progresses in stages. Medical treatment can slow the progression of HIV.
AIDS is the final, most severe stage of the HIV infection.
An AIDS diagnosis can only be made by a licensed healthcare professional 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 reverse 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. They do, however, 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 a decade, 10 to 12 years. Current medication therapies and lifestyle changes have been able to lengthen the lifespan by decades.
200 CD4 cells per cubic millimeter of blood, 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 3 of AIDS has been reached include26:
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 two to three years.29 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.
HIV viral particles must enter the bloodstream for an individual to become infected. Various carrier fluids can provide the vehicle for this blood exposure, including the fluids encountered during sexual contact resulting in HIV being listed among sexually transmitted diseases (STDs), aka, sexually transmitted infections (STIs). Sex does not need to occur for the HIV virus to be transmitted. The true mode of HIV transmission from an infected person to a non-infected person is from blood to blood, or from virus plentiful secretions to vascular rich thin mucous membranes.2
Direct blood exposure from:
Sharing of needles, e.g., intravenous drug users (IDUs)
Use of equipment exposed to blood from multiple individuals without proper sterilization, i.e., tattoo needles, body piercing tools, medical equipment, etc.
Less common exposures include:
Being born to an HIV infected mother
Receiving infected medical blood products, organ or tissue transplants
Eating food pre-chewed by an infected individual
Bites or other penetrating wounds from an infected individual
Deep open-mouthed kissing in the presence of sores or bleeding gums (Transmission through kissing alone is rare.)
HIV, once having invaded the body, is tough, 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 the ease of viral spread have led the CDC to provide a list of ways HIV cannot be spread29:
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 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.30 Male to male sexual contact, “men who have sex with men” (MSM), have 28 times the rate of infection than dedicated heterosexuals.14
New Cases of MSM HIV Diagnosis in 201731
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
HIV is found in every population and group, with the highest rate of new HIV infections in MSM. Overall, when viewed by ethnicity, the most heavily affected ethnic groups are Black/African American MSM, followed by Hispanic/Latino MSM, and then Caucasian MSM.
New HIV Diagnoses in the US and Dependent Areas for the Most-Affected Subpopulations, 201715:
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.14 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 reducing 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.32
Transmission of HIV particles into blood can occur through such things as needle exchange, blood sharing rituals or inadequately sterilized equipment exposed to blood. Cosmetic instrumentation exposed to blood and body fluids may be as great or greater a risk than improperly sterilized 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 individuals to avoid the spread of life-threatening disease.
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 infection.
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. Individuals who use PrEP must commit to taking the medication every day and follow-up with their healthcare professional every three months for a repeat HIV test and other follow-ups. At this time, the healthcare professional should write a prescription refill, offer counseling about medication adherence and risk reduction, test for STDs if necessary and assess side effects.33
On May 14, 2014 (updated in 2017), the United States Public Health Service released the first comprehensive clinical practice guidelines for PrEP.34 The guidelines were developed by a federal inter-agency working group led by the CDC and reflect input from healthcare professionals, individuals with HIV and their partners and affected communities. These new CDC guidelines include:
Provide clear criteria for determining an individual’s HIV risk and indications for PrEP use.
Require that individuals be HIV tested to confirm negative status before starting PrEP.
Underscore the importance of counseling about adherence and HIV risk reduction, including encouraging condom use for additional protection.
Recommend regular monitoring of HIV infection status, side effects, adherence and sexual or injection risk behaviors.
Include some form of providers’ supplement with sources for additional materials and health or compliance tools for use when prescribing PrEP.
PrEP is ordered in an attempt to prevent the sexual transmission of HIV. Individuals who are at high risk for contracting HIV via sex include:
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 also ordered in an attempt to prevent the transmission of HIV through the injection of drugs. Individuals who are at high risk for contracting HIV via this route include:
Individuals who have injected illicit drugs in the past 6 months and who have shared injection equipment or
Individuals who have been in drug treatment for injection drug use in the past 6 months
The use of PrEP should also be discussed with:
HIV discordant heterosexual couples (i.e., in which one partner is HIV-positive and the other HIV-negative) and during conception and pregnancy it is one of several options to protect an HIV-negative mother.35
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%.36 Among those who inject drugs, PrEP showed a reduction of around 74% of contracting AIDS when taken daily.35
A client receiving PrEP should have regular appointments with a medical provider. Recommended is a follow-up one to three months after initiating PrEP treatment, with a visit every three months thereafter.36 Checkups are encouraged whenever exposure to, or symptoms from, a sexually transmitted infection (STI) occurs, or should signs of kidney function issues appear. Should kidney function markers appear during the three-month visits, (e.g. elevated creatinine, glycosuria, new proteinuria) consider halting the PrEP.36
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.
In the United States, HIV testing is governed by a range of state and federal laws, common law principles, and various wide-flung codes of ethics. While state laws vary widely, the concept of informed consent, achieved through the process of physician-patient communication, is a legal and ethical obligation spelled out by statute and case law in every state. To help settle this confusion, the CDC has formulated specific recommendations balancing the rights of individuals with the need of the public regarding infectious disease. In 2006, the CDC published its Revised Recommendations for HIV Testing for Adults, Adolescents and Pregnant Women in Healthcare Settings, which addressed the issue of HIV testing and the need for test consent and pre-test counseling.
As of 2018, all states have enacted laws that are consistent with the following CDC recommendations37:
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.
Is an interactive process for assessing the risk of HIV infection, recognizing specific behaviors that increase infection risk and developing a plan to reduce that risk.
For specific information about each state’s laws regarding HIV testing informed consent and prevention counseling rules click this link to go to the CDC state HIV law information page: CDC State HIV Law Information Page.
Who should/must and how/when to receive testing has been a matter of vigorous debate and perhaps a few fistfights? The CDC recommends at least one HIV test for all individuals between ages 13 and 64.
Key points from CDC guidelines are as follows37:
For patients in all health-care settings:
HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening).
Persons at high risk for HIV infection should be screened for HIV at least annually.
Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing.
Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings.
For pregnant women:
HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women.
HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines (opt-out screening).
Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing.
Repeat screening in the third trimester is recommended in certain jurisdictions with elevated rates of HIV infection among pregnant women.
States’ laws are considered consistent with CDC’s recommendations on consent for HIV testing if:
Opt-out, part of the general medical consent form, and could be given orally.
States’ laws are considered consistent with CDC’s recommendations on HIV counseling if:
The law did not require prevention counseling prior to testing.
Frequent testing is recommended for any individuals who have placed themselves at risk for exposure through:
Unprotected anal, oral or vaginal sex
Having shared needles
Having been in contact with potentially unsterilized blood exposed instrumentation (e.g., tattoo needles, body piercing implements, etc.)
Occupational exposure to HIV (healthcare personnel, laboratory personnel, police, tattoo or body piercing artists, sex industry workers, etc.).
In addition to home HIV tests, screening is available through physician offices, at urgent care clinics, some public health departments, family planning and sexually transmitted disease clinics.
Confidential HIV testing is offered in all states. 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 infections for the purpose of planning public health response. State health departments take the compiled information and forward them to the CDC after stripping them of all personal information.
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 even if it is an alternative in the area of practice.
Comprehensive consent to medical treatment serves as consent for HIV testing as long as the individual is informed that it is included. Healthcare professionals need to take time with the individual, both before or after HIV testing occurs if possible, to discuss some key areas related to HIV testing such as the:
Benefits that come from learning their HIV status, as well as, benefits of early treatment if the HIV test returns positive
Potential dangers of HIV infection
Ways in which HIV is transmitted and how transmission can be prevented
Potential results for the individual should the HIV test return positive
Conservative estimates place the current number of HIV infected persons in the United States at around 1.1 million. Of these, around 15% (or 162,500) are unaware they have the disease and, as they are untreated, are highly contagious. Experts at the CDC recognize that around 40% of new HIV cases each year are transmitted by those who simply are unaware they are spreading a plague in the form of the HIV virus.38
Early HIV detection heralds the beginning of early medical treatment. New drug therapies have significantly lengthened the lifespan of and added quality of life to individuals with HIV infections. Early testing also allows early counseling to help the newly infected limit the risk of exposing others to infection.
Pre-test HIV counseling is generally not required. However, the healthcare professional should be able to offer the individual information or resources for further information. If the opportunity arises, the following should be provided:
Information on behavior that places the individual at risk and other individuals at heightened risk for contracting HIV.
Assistance setting realistic goals for behavioral change to reduce the individual’s risk for contracting or transmitting HIV.
Post-test HIV counseling should be offered to each individual even if they receive negative test results. Counseling can be performed by the healthcare professional providing the test results, or it can come in the form of a referral for the individual to the services of another healthcare professional. For those individuals who receive negative HIV test results, the information provided is much the same as in pre-test counseling, i.e., awareness of risk behaviors and assistance in reducing or eliminating the behaviors which have placed them and others at risk for contracting or transmitting HIV.
Individuals who test positive for HIV must be informed of the following, in addition to information relating to risk factors and high-risk behaviors. These individuals should be:
Informed that HIV is a reportable public health condition.
Offered assistance in the notification of past partners in terms of their need to be tested or referring past partners to public health services.
Offered assistance obtaining appropriate medical care.
Offered assistance with appropriate referrals for HIV prevention services (to limit any illness spread from their behaviors) and support services such as alcohol or drug counseling, TB screening and other condition applicable care.
When an HIV test is positive the testing site is required to report the positive results to the state health department. This allows public health services to monitor the ebb and surge of HIV cases in their city or state. All personal identifying information is stripped from the result (name, home address, etc.) before it is reported to the national database at the CDC.
Be aware that many states have statutes known as “partner notification laws,” which require either the positive testing person or the clinic where the testing was conducted to notify needle-sharing or sex partners that a physically intimate person has tested as HIV positive.39
HIV infection is a reportable condition allowing public health authorities to track its incidence and rate of spread. This is crucial in light of sudden outbreaks of HIV infection, such as the surge of cases that occurred on June 2015 in Scott County Indiana, a relatively rural area where the annual average of five new cases surged to 169 new diagnoses in a matter of months.40 In the Indiana case, mandatory reporting allowed the surge to be backtracked to an increase in the availability and use of intravenous drugs such as heroin accompanied by needle sharing. Early, usable information such as this allowed the quick placement of a public health response focused on the vector responsible, in this case, shared needles, resulting in placement of needle exchange stations.
Almost 15% of HIV infected individuals in the United States are unaware of their infection and the possibility that they are infecting others.38 Screening recommendations from the United States Preventive Services Task Force (USPSTF) strongly encourage healthcare professionals to routinely screen all adolescents and adults ages 15 - 65 for HIV infection. Screening should also include those younger or older who are considered at increased risk. The American College of Physicians (ACP) further recommends routine HIV screening extending out to age 75, and the CDC guidelines suggest screenings begin at age 13. The consensus among these organizations persists that healthcare professionals need to be much more assertive conducting HIV screenings.
Recommended intervals between routine HIV screenings vary as to risk levels and circumstances, with those showing positive for HIV needing placement into treatment rather than further follow-up screenings. Individuals actively engaged in risky behaviors (e.g., MSMs, IDU injection drug users, having sexually high-risk behaviors, etc.) or living in a high presence setting (e.g., homeless shelters, tuberculosis clinics, correctional facilities, etc.) should receive annual or more frequent screenings. For those with lesser degrees of risk, the amount of time between HIV screenings should be set according to circumstances and clinician judgment, with a suggestion of around every three to five years. The USPSTF acknowledges that routine HIV screening may not be necessary for individuals with a negative HIV initial screening who demonstrate the lack of an increased risk of exposure, although all newly pregnant women should be screened as early as possible in their pregnancy.41
Basically, there are three types of diagnostic tests for HIV infection: antibody tests, antigen/antibody (Ag/Ab) tests and nucleic acid (RNA) tests. Antibody tests detect antibodies, which are proteins that the body produces to fight against HIV, not HIV directly. Ag/Ab tests and RNA tests detect HIV directly.
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 (IAs) conducted at the point of care are capable of providing preliminary results in about 20 minutes.
Advances in laboratory-based enzyme immunoassays (EIAs), as well as, chemiluminescent immunoassays (CIAs) are able to identify infection 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 (IAs) 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.38
Blood-based HIV screening:
May be a finger stick that detects antibodies.
It can be a rapid result test or a send to 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.
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.38 Be aware that the Western Blot may be unreliable in new HIV infections, under two months since time of infection. Also, the Western Blot has difficulty reacting to/detecting the HIV clade “O,” which, though uncommon, is out there.38 Public health regions need awareness of both the type of infection, HIV-1 versus HIV-2 present in their watch areas, but knowledge of the subtypes or clades which are presenting, is important as well.
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.
The presence of a negative HIV test 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 be 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 an individual is immune to HIV. Should risky behavior continue, HIV infection is likely to occur.
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, also known as “seroconverting.” Whenever seroconversion is suspected, RNA testing should be performed to determine whether or not the virus is present. If RNA testing is inconclusive, indeterminate, or not available, a second HIV test using different antibody detection from the first test should be performed. If the second test gives a positive result HIV is present.38
An indeterminate HIV test result does not automatically mean seroconversion is present as there is a potential for test cross-reaction with other proteins from sources such as an autoimmune disease, recent influenza vaccination or even pregnancy.
When the interview with the individual reveals the level of risk for HIV exposure is low, retesting at a later time is suggested for indeterminate results. One to three months is suggested for return testing. Should sequential retests also return as indeterminate and risk factors remain low, then the individual is regarded as negative for HIV.
Laboratory testing will be ongoing once a positive HIV test result occurs, as it is important to monitor 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. A high viral load signifies that 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 may be seen in a high CD4 count and low or absent viral load counts.
Viral load testing is important at the time of diagnosis with HIV so that a baseline measurement can be established. Once treatment begins, it is common to measure viral loads every two to eight weeks or whenever there is a change in treatment as fluctuations in the viral load can indicate the effectiveness of medication. Once stabilized on a treatment regimen, viral load titers are helpful every three to six months as they help indicate the continued effectiveness of treatment.
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.
Optimal treatment of HIV infection frequently changes as viral strains become resistant to therapeutic agents and new pharmaceuticals come into use. Once a positive HIV diagnosis occurs, gaining the trust and cooperation of the individual is paramount. This has been demonstrated in the epidemiological history of HIV with cases of infected individuals denying the presence of the illness, refusing treatment and then infecting dozens of new victims in an exponentially expanding horror story of disease and death.
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, as well as, serving to preclude or discover current comorbid disease processes also requiring treatment.
The following laboratory tests should be ordered so that their values establish an individual’s baseline:
HIV serology testing
Hepatitis screening and serology
Serum urea nitrogen
Fasting blood glucose levels
Serum lipid levels
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.42 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 (or highly aggressive) antiretroviral therapy (HAART) combines three or more antiretroviral agents which are given to provide the continuing benefit of the agents, as well as, preventing treatment resistance from forming within the infected individual.
Each drug class of antiretroviral medication works by a different mechanism to combat HIV. There are currently six classes of antiretroviral medications14,42:
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 from creating any additional 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 cells. The Fusion Inhibitor enfuvirtide works by preventing viral contents from binding to CD4 components.
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 nucleic acid.
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 Medications are two or more HIV medications from one or more drug classes given together for greater impact.
The decision as to whether ART or HAART is the correct choice must be based on several factors. Viral drug resistance to HIV treatment agents is a huge concern as the current HIV virus being dealt with has traveled with many hosts and has had the opportunity to form resistance to many antiretroviral agents. Resistance testing is a growing factor that must be taken into consideration for the proper treatment of today’s HIV infected individual. The overall health of the individual is also important when viewed from the perspective of unwanted side effects/adverse effects from the available medications, particularly in terms of kidney and liver function, as antiretroviral medications have a well-earned reputation for making their recipients feel sicker than the HIV infection itself, particularly during the asymptomatic or Stage 2 period of HIV infection. This, of course, leads many individuals to stop their medications and subsequently shorten their lifespans while greatly increasing the chance of the virus developing medication resistance.
Drug-to-drug interactions are frequent and a very real treatment management concern. There are many potential interactions with ART medications, particularly when taken in HAART multi-drug combinations. One of the most prevalent offenders associated with unwanted drug interactions are pharmaceuticals that affect the manner in which medications are metabolized via the cytochrome P450 (CYP450) isoenzyme system. The pharmacy staff should be provided with a comprehensive list of the individual’s current medications, over-the-counter medications/remedies and herbal supplements to lessen the chance that any drug blocking or lowering of effect may occur.
Not all ART drug-to-drug interactions are bad. Some, in fact, are sought purposely such as giving the drug ritonavir (RTV) which inhibits the metabolizing isoenzyme CYP3A that subsequently leads, in conjunction with other protease inhibitors, to enhanced or boosted effects from the PIs.43 This combination, therefore, provides a substantially increased return by keeping the individual on a lower medication dosage which is an important factor when increased dosages may result in an increase of unwanted and undesirable side effects such as nausea, diarrhea, etc.
CDC guidelines recommend initiating prompt treatment following diagnosis with combination antiretroviral medications (ARTs). 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.44
In an antiretroviral-naive individual, general guideline suggestions include a starting regimen considering the following factors44:
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 an active drug (one with known aggressive traits) from one of the following classes: NNRTI, PI boosted with ritonavir (RTV) or INSTI.
CDC Recommended Regimens Regardless of Pre-ART Viral Load or CD4 Cell Count44
EFV + ABC/3TC (only for patients who are HLA-B5701* negative and who have a pre-ART plasma viral load of less than 100,000 copies/ml)
*HLA-B5701 is a genetic serotype linked to hypersensitivity reactions with abacavir)
Rilpivirine/tenofovir/emtricitabine (RPV/TDF/FTC) (only for patients with CD4 count > 200cells/uL and who have a pre-ART plasma viral load of less than 100,000 copies/ml)
Dolutegravir (DTG) + abacavir/lamivudine (DTG+ABC/3TC) – (only for patients who are HLA-B5701 negative)
Elvitegravir/cobicistat/tenofovir/emtricitabine (EVG/COBI/TDF/FTC) (only for patients with pretreatment estimated creatinine clearance >70 mL/min)
Raltegravir (RAL) + TDF/FTC
Darunavir/ritonavir (DRV/r) (once daily) plus TDF/FTC
Atazanavir/ritonavir (ATV/r) + TDF/FTC
ATV/r + ABC/3TC (only for patients who are HLA-B5701 negative and who have a pre-ART plasma viral load of less than 100,000 copies/ml)
DVR/r + ABC/3TC (only for patients who are HLA-B5701 negative)
Lopinavir/ritonavir (LPV/r) (once or twice daily) + ABC/3TC (only for patients who are HLA-B5701 negative)
Lopinavir/ritonavir (LPV/r) (once or twice daily) + TDF/FTC
RAL + ABC/3TC (only for patients who are HLA-B5701 negative)
The CDC recommendations on combination therapies for individuals who have previously been on antiretroviral medications or who have comorbid conditions requiring an increased need for individualization tend to change frequently as better information is gained regarding optimal response to treatment. Please check for the most current recommendations when creating an individualized medication regimen.
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, particularly when the viral load is greater than 1000 copies/ml at the pre-delivery check or the mother has not been taking antiretroviral medications. The preferred time for the C-section is around 38 weeks gestation 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.
Healthcare professionals who work closely with HIV positive individuals indicate that one of the greatest challenges is treatment adherence. HIV is a life-long chronic medical condition requiring significant lifestyle alterations, intensive and intrusive condition monitoring, harsh and, at times, expensive medications. HIV also has a relatively symptom free middle stage that frequently leads individuals to question if the treatment is worth it. It is no wonder that even when an individual is agreeable to actively treating their condition, at times, they wander away from the necessities of the constant hassle.
Bolstering adherence to treatment should start early even before a diagnosis of HIV is made. Public service announcements targeting those who are engaging in high-risk behavior for contracting the disease can provide a foundation on which to build a therapeutic relationship between healthcare professionals and individuals if, or when, they present with symptoms or a positive HIV test. Question free needle exchange and easy access to community health clinics are important for the level of trust and rapport needed to limit the spread of HIV and help infected individuals return to the best health possible.
Early on, nonjudgmental, open dialogue about the benefits and unwanted effects of antiretroviral drug therapy is an important step toward an honest exchange of information. This allows those at higher risk of HIV an awareness that there are treatments that will help, though not cure, the disease if they become infected. New individuals should be made aware that HIV treatment is voluntary, and though they and those closest to them will benefit from treatment, they can decline treatment at any point without risk of being denied social service or medical benefits. If treatment, particularly ART therapy, is refused, follow-ups should be encouraged to monitor the progression of the illness and keep them informed of what is happening within their bodies. Periodically, ART should be reoffered and that they will be welcomed whenever they decide to initiate therapy.
The HIV infected individual should be involved in the selection of which ART is preferred when they are ready to begin medication for their HIV infection. Information should be shared about the therapeutic agents best suited for their strain of virus. Other factors such as potential adverse actions, dosing frequency, pill burden, nutritional requirements and any unwanted effects that would arise from skipping or stopping dosages should also be reviewed. The client’s daily activities should be reviewed to see if their life will be unduly altered by the limits placed on them by treatment needs and if the individual is willing to adapt to the needed changes. Share the cost or co-payment information for the medications with the individual to see if that will be a limiting factor that needs to be addressed. Involving the individual in important decisions at the beginning of treatment contributes to their continuation of treatment throughout the course of the illness.
Adherence to the medication regimen should be addressed in a calm, matter of fact manner every time the individual visits. Questions that normalize the human factor should be utilized, understanding that sometimes there will be less than perfect adherence. Clients should be encouraged to be “accurate” about their activities rather than “right or wrong,” with the focus on being nonjudgmental. The “white coat phenomenon” is a phenomenon that occurs as individuals tell healthcare professionals what they think they want to hear, not the reality.
Typical Types and Reasons for Lack of Adherence to HIV Treatment14,44
Failure to fill prescriptions
Failure to understand dosing or timing instructions
Inadequate understanding of drug resistance and its relationship to routine monitoring or medication changes
Costs of medication or treatment-related expenses
Depression, drug and alcohol use, homelessness, poverty
HIV AIDS stigma, perception of lack of civil rights
Non-disclosure of the negatives associated with HIV treatment
Other potential barriers
Positive reinforcement and celebration of successes, no matter how small, should be used in such situations as low or non-detectible viral loads, increases in CD4 cell counts, etc. Individuals should feel that the healthcare professional is glad to see them and encouraged that they kept the appointment no matter how they were feeling at the time.
The individual should be encouraged and helped to connect with community and family support systems such as visiting nurses, family counseling services, community workers, peer advocates, support groups and other available public services.
Olaf, a 32-year-old male with AIDS, angrily tells you that the cure for AIDS is known yet being withheld from him.
There are no current effective vaccines nor any other cures for AIDS.
Confusion and misinformation have spread following two unique medical occurrences. In 2007 a documented report of a unique instance where AIDS no longer tested positive after extreme and life-endangering cancer treatments popped up. Timothy Ray Brown, known in AIDS circles as “the Berlin patient,” in 2007 received treatment for his destroyed immune system following aggressive acute myeloid leukemia treatment. Mr. Brown who also suffered from HIV was treated with a stem cell transplant from a rare and possibly unique donor having a genetic mutation CCR5-Delta-32, which subsequently has shown resistance to the HIV virus. To everyone’s surprise, Mr. Brown has been able to stop all of his HIV medications and, as of 2014, continues to test HIV free.45 In a similar set of circumstances, a London man also began to test HIV free in 2017. While this second medical miracle recipient prefers to keep his story and identity secret, researchers are hard at work to find ways to replicate the forced remissions from the HIV virus.45
Be aware that while fascinating, and the subject of multiple research investigations that will continue for decades, these surprise instances are not regarded as a cure for HIV infection.
Olaf’s frustration and feelings of despair were listened to and his emotions validated. When he was ready for it, information about current available possibilities for treatment, along with local support groups and selections for counseling, will be offered to him.
Be aware that fear and anger, along with the entire spectrum of emotions accompany the devastation brought by HIV infection. Care does not stop with medication and referrals but continues on through support of the entire individual.
HIV infection is a chronic medical condition that those infected will have until they succumb to it in its final stage of AIDS, or death ensues from another cause first. Ironically, those carrying HIV are unlikely to die directly from the infection. Since HIV attacks the immune system of its host, damaging the body’s ability to fight off other infections and disease, often underlying illnesses, exposure to unwanted organisms, or opportunistic infections arise to deal the actual mortal blow.
There is no cure for HIV infection. This means that prevention is key to controlling its spread. Distributing knowledge of HIV along with information concerning an infected individuals’ rights and the value that their lives hold form key 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 15% of HIV infected individuals are unaware of their infection and, therefore 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 would without medication, and with a greater quality of life, though the medication regimen can be taxing. Support for adherence to the medication regime 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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