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AIDS/HIV Four Hour, Current Evidence Based Practice

4.00 Contact Hours:
  • 0% complete
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Authors:    Donna Thomas (RN, MSN, BSHEd) , David Tilton (RN, BSN)

Purpose/Goals

The purpose of this course is to update healthcare professionals about the most current information along with best practice related to the treatment of HIV/AIDS infected individuals.

Objectives

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

  1. Relate the overall social impact of the HIV/AIDS pandemic in terms of incidence, diagnoses and deaths

  2. Identify the civil rights of the HIV/AIDS infected individual and their family/friends

  3. Differentiate between high risk groups in terms of behavior and race/ethnicity

  4. Discuss Human Immunodeficiency Virus (HIV) and the pathophysiologic changes in the human body following HIV infection

  5. Relate the three stages of an HIV infection encompassing signs and symptoms and changes in laboratory values

  6. Describe the modes of transmission of HIV and various strategies to prevent the spread of HIV

  7. Discuss informed consent relating to HIV along with pre and post-test counselling

  8. Discuss HIV test results and their implication to the individual

  9. Compare and contrast current medications regimens prescribed for the HIV infected individual and those medications used to prevent the transmission of the virus in high risk individuals

Introduction

The “Scourge of Our Time”, Human Immunodeficiency Virus (HIV), and its fatal end-stage Acquired Immunodeficiency Syndrome (AIDS) has brought dread to those with knowledge of its effects and impacts. New treatments have extended by decades the lifespan of those infected and 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 concerning the effects of HIV, transmission, treatment and the care of HIV victims who progress into the final stage of AIDS as we help those infected live healthier, more satisfying lives.

Historic Perspective

HIV as an infectious virus was first spotlighted in the United States in 1981 when attention was drawn to deaths among homosexual men experiencing unusual and life threatening multi-organism syndromes. 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 certain scientific organizations and media outlets alike.  (Discovery Science, 2015), (AIDS.GOV HIV/AIDS Basics, April 29, 2014).

Many healthcare professionals have followed the proposed theories and discussions of where HIV originated and why it had not been identified until 1981, the beginning of the AIDS epidemic. With the suffering and death that accompanied the recognition of AIDS, the many notions of extraterrestrial experiments or hidden government bioweapons gone rogue seem somewhat extreme as an epidemiological working model. (Sparkster, Nov. 11, 2013) (Avert, Aug. 14, 2014).

Information that researchers uncovered have related to the history and origins of HIV including a 1959 plasma sample from an adult African male living in what is now the Democratic Republic of Congo and genetic markers from the four known HIV-1 human viral groups 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 of the ape bound virus. (Avert, Aug. 14, 2014)

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. 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 which 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. However, 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. (University of Pennsylvania School of Med., March 6, 2015).

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. 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 from the mid-1980’s, 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.  (Chong, J., Oct. 30, 2007).

Table 1
  Timeline of the HIV/AIDS Epidemic in the United States

1981

First report on unusual infection clusters by the CDC.

1982

The CDC first used the term AIDS.

First AIDS treatment clinic opened in San Francisco.

1983

The CDC reported the first female cases of AIDS.

Identification of the HIV cytopathic retrovirus occurred.

AIDS reported in injection drug users and hemophiliacs.
1985

Serologic diagnostic test for HIV became available.

Blood banks began screening blood supplies for HIV.
1987

Antiretroviral drugs were introduced.

United States Department of Immigration added HIV to its immigrant exclusion list.
1988 First needle exchange program launched in Tacoma, WA.
1989 The CDC released “Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Healthcare and Public-Safety Workers”.
1990

The CDC reported on a possible transmission of HIV via a dental procedure from an infected dentist.

The CDC adopted client centered prevention counseling.
1991 The United States Congress enacted a law restricting HIV positive healthcare workers.
1992

AIDS became the number one cause of death for American men ages 25 - 44.

1994

AIDS became the leading cause of death for all Americans ages 25 - 44.

The first oral HIV test was approved.
1995 The first protease inhibitor, beginning of highly active antiretroviral therapy (HAART) became available.
1996

Combination antiretroviral therapy (ART) pioneered.

The number of new AIDS cases declined for the first time since the beginning of the epidemic.

AIDS no longer the leading cause of death for ages 25 - 44.

The first HIV home collection and testing kit approved.

The first HIV urine test approved.
1998 The CDC issued the first national treatment guidelines for the use of antiretroviral therapy.
1999

The World Health Organization (WHO) announced that HIV/AIDS had become the fourth biggest killer worldwide and the number one killer in Africa.

The first HIV vaccine trial preformed in Thailand but pronounced a failure in 2003.
2002 The FDA approved the first rapid HIV diagnostic test kit which provided results with 99.6% accuracy in as little as 20 minutes.
2008 The CDC announced HIV and AIDS cases had been drastically underreported in previous years yet, despite higher estimates, rates of new cases had remained relatively stable.
2010 The United States HIV immigration ban was lifted.
2011 A CDC study provided evidence that daily oral antiretroviral drugs used to treat HIV infection can reduce HIV among uninfected individuals exposed to the virus.
(AIDS.GOV HIV/AIDS Basics, April 29, 2014) (Bartlett, J.G., Jan. 23, 2015)

Overall Impact of HIV/AIDS

The CDC estimates that 1,218,400 individuals ages 13 years and older are living with HIV infection (Table 2), including 156,300 (12.8%) who are unaware of their infection. Over the past decade, the number of individuals living with HIV has increased, while the annual number of new HIV infections has remained relatively stable. Still, the pace of new infections continues at far too high a level, particularly among certain groups.

HIV Incidence (New Infections)

The estimated overall incidence of HIV has remained stable in recent years, at about 50,000 new HIV infections per year. This is an important achievement as there is currently no cure for HIV infection and despite intensive research there remains no safe, reliable vaccine to prevent HIV infection. For this reason, the focus remains on prevention.

The fact that the number of new cases discovered annually has stabilized still results in a 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.

HIV Diagnoses

HIV diagnoses is defined as a new diagnoses regardless of when the HIV infection occurred or stage of disease at diagnosis. In 2013, an estimated 47,352 individuals were diagnosed with HIV infection in the United States. In that same year, an estimated 26,688 individuals were diagnosed with AIDS. Overall, an estimated 1,194,039 individuals in the United States have been diagnosed with AIDS.

Deaths

deaths of individuals with an AIDS diagnosis can be due to any cause, that is, the death may or may not be related to AIDS.

Table 2
HIV Prevalence United States Worldwide
HIV annual new cases 50,000 2,100,000

Total estimated living with HIV/AIDS

1,218,400 35,000,000
Annual AIDS deaths 13,700 1,500,000
(AIDS.GOV HIV/AIDS Basics, April 29, 2014)

HIV and Civil 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 1980’s and 1990’s. 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.

High Risk Groups

By Behavior

  1. Gay, bisexual and other men who have sex with men (MSM*) of all races and ethnicities remain the population most profoundly affected by HIV.

  2. In 2010, the estimated number of new HIV infections among MSM was 29,800, a significant 12% increase from the 26,700 new infections among MSM in 2008.

  3. Although MSM represents about 4% of the male population in the United States, in 2010, MSM accounted for 78% of new HIV infections among males and 63% of all new HIV infections. MSM accounted for 54% of all individuals living with HIV infection in 2011, the most recent year these data are available.

  4. In 2010, white MSM continued to account for the largest number of new HIV infections (11,200), by transmission category, followed closely by Black/African American MSM (10,600).

  5. The estimated number of new HIV infections was greatest among MSM in the youngest age group. In 2010, the greatest number of new HIV infections (4,800) among MSM occurred in young Black/African American MSM ages 13 - 24. Young Black/African American MSM accounted for 45% of new HIV infections among Black/African American MSM and 55% of new HIV infections among young MSM overall.

  6. Since the epidemic began, an estimated 311,087 MSM with an AIDS diagnosis have died, including an estimated 5,380 in 2012.

*For assessing disease risk, the term MSM 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.

  1. Heterosexuals and injection drug users (IDUs) also continue to be affected by HIV.

  2. Since the epidemic began, almost 92,613 individuals with AIDS that were infected through heterosexual sex have died, including an estimated 4,550 in 2012.

  3. New HIV infections among women are primarily attributed to heterosexual contact (84% in 2010) or injection drug use (16% in 2010). Women accounted for 20% of the estimated new HIV infections in 2010 and 23% of those living with HIV infection in 2011. The 9,500 new infections among women in 2010 reflect a significant 21% decrease from the 12,000 new infections that occurred among this group in 2008.

  4. IDUs represented 8% of new HIV infections in 2010 and 15% of those living with HIV in 2011.

  5. Since the epidemic began, nearly 186,728 individuals with AIDS who injected drugs have died, including an estimated 3,514 in 2012.

By Race/Ethnicity

  1. Black/African Americans continue to experience the most severe burden of HIV, compared with other races and ethnicities.

  2. Black/African Americans represent approximately 12% of the United States population but accounted for an estimated 44% of new HIV infections in 2010. They also accounted for 41% of individuals living with HIV infection in 2011.

  3. Since the epidemic began, an estimated 270,726 Black/African Americans with AIDS have died including an estimated 6,540 in 2012.

  4. THispanics/Latinos represent approximately 16% of the United States population but accounted for 21% of new HIV infections in 2010. Hispanics/Latinos accounted for 20% of individuals living with HIV infection in 2011.

  5. Disparities persist in the estimated rate of new HIV infections in Hispanics/Latinos. In 2010, the rate of new HIV infections for Hispanic/Latino males was 2.9 times that for white males, and the rate of new infections for Hispanic/Latinas was 4.2 times that for white females.

  6. Since the epidemic began, more than 100,888 Hispanics/Latinos with an AIDS diagnosis have died including 2,155 in 2012

Table 3

US Subpopulations Estimated New HIV Infections

CDC. Estimated HIV Incidence Among Adults and Adolescents in the United States, 2007–2010. HIV Surveillance Supplemental Report 2012: 17(4).

The Virus HIV

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 HIV ready to continue the spread and conquest throughout more of the human victim’s body.

HIV Virus

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 way with viruses, a small percentage of these trillions of copies will have miniscule differences from the original. These miniscule differences make HIV more resistant to medications or treatments that would have successfully controlled the original virus.

Two significant varieties of HIV virus have been identified: type 1 (HIV-1) and type 2 (HIV-2). HIV-1 is more virulent 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 individuals from West Africa or are from that region themselves. 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. The HIV virus changes and mutates readily, and a single infected individual may have several differing strains of HIV. Thus, the future will bring more significant, recognized subtypes of HIV. (Bartlett, J.G., Jan. 23, 2015).

HIV Infection

HIV is a viral infection which progresses through three stages terminating in AIDS. HIV enters the bloodstream and attaches to T-helper lymphocytes (Helper-T cells) which are one type of white blood cell called lymphocytes 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.

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 amounts of the virus. Many newly infected individuals report having flu-like symptoms such as generalized aches, headache, fever and perhaps even a rash. During this stage, the virus begins taking possession of CD4 Helper-T cells destroying them in the process of multiplying itself.

Seroconversion (Table 4) denotes the time period from initial infection to when the body begins to create antibodies in sufficient amounts to fight the HIV infection and these antibodies can be detected by HIV antibody testing. 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. (AIDSinfo, June 8, 2015).

Acute Retroviral Syndrome - Seroconversion Syndrome - Seroconversion Illness (Cichocki, M., June 19, 2014)

Seroconversion is often accompanied by a series of symptoms referred to as seroconversion syndrome or illness, although the more technical term is Acute Retroviral Syndrome.

Symptomatic seroconversion has a flu-like presentation with fever and swollen glands in the neck, axillae 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.

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. These questions can identify up to 30 - 50% of newly infected individuals during seroconversion so that early treatment options can be 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 amount of virus 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.

HIV Chronic 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 last 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 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%. (NIH News., May 12, 2011).

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 allow symptomatic illness indicators of the HIV infection to once more surface as the beleaguered immune system grows too weak to counteract and control symptoms.

Progressing to AIDS

Transitioning from Stage 2 HIV infection (HIV Chronic or Asymptomatic Infection) to Stage 3 HIV infection (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 Conditions (AIDS.GOV Opportunistic Infections., Nov. 16, 2010):

  • Candidiasis of the bronchi, trachea, esophagus or lungs
  • Invasive cervical cancer with metastasis to other parts of the body, chronic intestinal diarrhea of greater than 1 month duration (particularly CMV retinitis)
  • Encephalopathy, HIV-related
  • Herpes simplex, chronic ulcer(s) (greater than 1 month's duration) or generalized bronchitis, pneumonitis or esophagitis
  • HIV Wasting Syndrome, involuntary loss of 10% baseline body weight, protozoa causing diarrhea, malnutrition, chronic intestinal inflammation (greater than 1 month duration)
  • Kaposi's sarcoma
  • Lymphoma, multiple forms
  • Mycobacterium avium complex, bacterial infection
  • Pneumocystis carinii
  • Pneumonia, recurrent
  • Progressive multifocal leukoencephalopathy
  • Salmonella septicemia
  • Toxoplasmosis of brain

HIV as AIDS: The Final Stage of Infection

AIDS is the final stage of HIV infection (Table 4). 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.

Table 4
Human Immunodeficiency Virus (HIV) Acquired Immunodeficiency Syndrome (AIDS)
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 syndrome 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.
(CDC HIV/AIDS Prevention, April 29, 2015), (AIDS.GOV HIV/AIDS Basics, April 29, 2014)

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, 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 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, (Table 5) 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.

Table 5
CDC Stages of HIV  
No Infection

CD4 count 500 to 1600 cells/mm3

No symptoms

Stage 1

Primary or Acute Infection

CD4 count at least 500 cells/mm3 or

CD4 cells at least 29% of all lymphocytes

Flu-like symptoms

Stage 2

Chronic or Asymptomatic Infection

CD4 count 200 to 499 cells/mm3 or

CD4 cells 14% to 28% of all lymphocytes

No symptoms until end of stage

Stage 3

HIV as AIDS

CD4 count lower than 200 cells/mm3 or

CD4 cells less than 14% of all lymphocytes or

An AIDS related condition is present
(Thompson, E.G., April 5, 2012)

Visible symptoms that the HIV stage of AIDS has been reached include: (AIDS.GOV HIV/AIDS Basics, April 29, 2014).

  • 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.

Transmission of HIV Infection

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). Sex does not need to occur for the HIV virus to be transmitted. The mode of transmission from an HIV infected individual to a non-infected individual’s bloodstream or to their blood rich mucous membranes include:

  • 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.

  • Bodily fluid

  • Pre-seminal fluid

  • Rectal fluids

  • Vaginal fluids

  • Breast milk

  • 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 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 the ease of viral spread have led the CDC to provide a list of ways HIV cannot be spread: (CDC HIV/AIDS Prevention, April 29, 2015).

  • 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 is most often spread through sexual activities or exposure to infectious blood. Male to male sexual contact, “men who have sex with men” (MSM), when combined with injection drug use, account for around half of all new HIV cases in the United States. In contrast, case numbers from developing countries and resource limited areas show almost 80% of new HIV infections arise from vaginal intercourse. (Bartlett, J.G., Jan. 23, 2015).

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 group is White MSM followed by Black/African American MSM followed by Hispanic/Latino MSM. (Table 3 previous)

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 fully heal before engaging in intercourse. (Johns Hopkins Medicine, April 2015).

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. IDUs constitute a growing population of new HIV cases. 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)

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. The pill (brand name Truvada) contains two medicines (tenofovir and emtricitabine) that are used in combination with other medicines to treat 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 ongoing substantial 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-up. 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.

On May 14, 2014, the United States Public Health Service released the first comprehensive clinical practice guidelines for PrEP  . 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 guidelines:

  • Provide clear criteria for determining an individuals 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 a providers’ supplement  with additional materials and 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 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 as one of several options to protect the partner who is HIV-negative.

In all PrEP Clinical Trials HIV transmission risk was lowest for participants who took the pill consistently. Specifically:

  • Among gay and bisexual men, those who were given PrEP were 44% less likely overall to get HIV than those who were given a placebo. Among the men with detectable levels of medicine in their blood (confirming that they had taken the medication consistently), PrEP reduced the risk of infection by as much as 92%.
  • Among heterosexually active men and women, PrEP reduced the risk of getting HIV by 62%. Participants who became infected had far less medication in their blood, compared with matched participants who remained uninfected.
  • Among injection drug users, a once-daily tablet containing tenofovir (one of the two drugs prescribed) reduced the risk of getting HIV by 49%. For participants who had detectable tenofovir in their blood, PrEP reduced the risk of infection by 74%.
  • Among men and women in HIV discordant couples, those who received PrEP were 75% less likely to become infected than those on a placebo. Among those with detectable levels of medication in their blood, PrEP reduced the risk of HIV infection by up to 90%.

None of the studies found any significant safety concerns with the daily use of oral PrEP. Some trial participants reported side effects such as an upset stomach or loss of appetite but these were mild and usually resolved in the first month.

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 an 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.

HIV Testing Informed Consent

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. (CDC State HIV Testing Laws, June 4, 2015)

As of 2015, all states but Nebraska have enacted laws that are consistent with the following CDC recommendations:

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:

  • Is an interactive process for assessing the risk of HIV infection, recognizing specific behaviors that increase infection risk and developing a plan to reduce the risk(s).

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 states 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.

The CDC recommends at least one HIV test for all individuals between ages 13 and 64. 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 the 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

  • Meaning the potential results have for the individual should the HIV test return positive

Early HIV Testing

Early HIV detection heralds the beginning of early medical treatment. New drug therapies have significantly lengthened the lifespan 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 still others to infection.

HIV Test Counseling

Pre-test HIV counseling is 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 individuals 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.

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 which occurred in 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. 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 public health responses focused on the vector responsible, in this case, the lack of information and no questions asked needle exchange stations.  (Johns Hopkins University Bloomberg School, June 25, 2015).

HIV Screening Tests

Almost one in five HIV infected individuals in the United States are unaware of their infection and the possibility that they are infecting others. 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, as well as, 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 to begin at age 13. Consensus among these organizations persists that healthcare professionals need to be much more assertive conducting HIV screenings. (Bartlett, J.G., Aug. 28, 2014).

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., MSM, IDUs, 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 judgement, 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 with a repeat screening around the third trimester. (USPSTF Final Recommendation Statement, April 2013), (Bartlett, J.G., Aug. 28, 2014).

Diagnostic Tests for HIV

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. 

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 (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. (CDC HIV Testing, June 27, 2014).

  • Blood-based HIV screening:

  • Finger stick testing detects antibodies.

  • 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.

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 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 antibody’s hiding the antigen evidence become reactive to the test allowing accurate detection efforts to continue.

The ELISA (enzyme-linked immune assay) and Western blot (protein immunoblotting IgM IgG) tests for HIV are no longer recommended by the CDC as confirmation of HIV tests. The fourth generation Ag/Ab assays have taken on the role as the preferred method of confirming initial positive/reactive screening results due to their ability to accurately diagnose during the critical “window period” of acute infection. RNA testing is recommended if serologic assays are indeterminate. (Bartlett, J.G., Aug. 28, 2014).

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.

Negative HIV Results

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 be 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.

Positive HIV Results

A positive confirmatory test result indicates the presence of HIV antibodies or HIV RNA so the following conclusions can be drawn:

  • 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 inconclusive or indeterminate, 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.

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.

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 blood stream. 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.

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 loads are helpful every three to six months as they help indicate the continued effectiveness of treatment.

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.

Optimal treatment of HIV infection changes frequently as viral strains grow 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

  • CD4 count

  • Hepatitis screening and serology

  • Chemistry profile

  • Transaminase level

  • Serum urea nitrogen

  • Fasting blood glucose levels

  • Serum lipid levels

  • Urinalysis

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. Antiretroviral medications do not kill the HIV virus nor can they cure the disease. ART’s slow or prevent the growth and spread of the virus. (Panel on Antiretroviral Guidelines for Adults and Adolescents, May 1, 2014).

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 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 medications works by different mechanisms to combat HIV (Table 9). There are six classes of antiretroviral medications:

  • 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 need to mature into full function.

  • Fusion Inhibitors block HIV from entering the CD4 cells of the immune system.

  • Entry Inhibitors block proteins on the CD4 cells that HIV needs to enter the cells.

  • 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 included in Table 6 are Pharmacokinetic Enhancers and Combination HIV Medications commonly used in the ART and HAART regimens. Pharmacokinetic Enhancers used in HIV treatment to increase the effectiveness of an HIV medication included in an HIV regimen. Combination HIV Medicines are two or more HIV medications from one or more drug classes.

Table 6
Generic Name (Other Names and Acronyms) Brand Name
Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
abacavir (abacavir sulfate, ABC) Ziagen
didanosine (delayed-release didanosine, dideoxyinosine, enteric-coated didanosine, ddI, ddI EC) Videx
Videx EC
(enteric-coated)
emtricitabine (FTC) Emtriva
lamivudine (3TC) Epivir
stavudine (d4T) Zerit
tenofovir disoproxil fumarate (tenofovir DF, TDF) Viread
zidovudine(azidothymidine, AZT, ZDV) Retrovir
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
delavirdine (delavirdine mesylate, DLV) Rescriptor
efavirenz  (EFV) Sustiva
etravirine (ETR) Intelence
nevirapine (extended-release nevirapine, NVP) Viramune
Viramune XR (extended release)
rilpivirine (rilpivirine hydrochloride, RPV) Edurant
Protease Inhibitors (PIs)
atazanavir (atazanavir sulfate, ATV) Reyataz
darunavir (darunavir ethanolate, DRV) Prezista
fosamprenavir (fosamprenavir calcium, FOS-APV, FPV) Lexiva
indinavir (indinavir sulfate, IDV) Crixivan
nelfinavir (nelfinavir mesylate, NFV) Viracept
ritonavir (RTV) Norvir
saquinavir (saquinavir mesylate, SQV) Invirase
tipranavir (TPV) Aptivus
Fusion Inhibitors
enfuvirtide (T-20) Fuzeon
Entry Inhibitors
maraviroc (MVC) Selzentry
Integrase Strand Transfer Inhibitors (INSTI)
dolutegravir (DTG) Tivicay
elvitegravir (EVG) Vitekta
raltegravir (raltegravir potassium, RAL) Isentress
Pharmacokinetic Enhancers
cobicistat (COBI) Tybost
Combination HIV Medicines
abacavir and lamivudine (abacavir sulfate / lamivudine, ABC / 3TC) Epzicom
abacavir, dolutegravir, and lamivudine (abacavir sulfate / dolutegravir sodium / lamivudine, ABC / DTG / 3TC)  Triumeq 
abacavir, lamivudine, and zidovudine (abacavir sulfate / lamivudine / zidovudine, ABC / 3TC / ZDV) Trizivir
atazanavir and cobicistat (atazanavir sulfate / cobicistat, ATV / COBI) Evotaz
darunavir and cobicistat (darunavir ethanolate / cobicistat, DRV / COBI) Prezcobix
efavirenz, emtricitabine, and tenofovir disoproxil fumarate (efavirenz / emtricitabine / tenofovir, efavirenz / emtricitabine / tenofovir DF, EFV / FTC / TDF) Atripla
elvitegravir, cobicistat, emtricitabine, and tenofovir disoproxil fumarate (QUAD, EVG / COBI / FTC / TDF) Stribild
emtricitabine, rilpivirine, and tenofovir disoproxil fumarate (emtricitabine / rilpivirine hydrochloride / tenofovir disoproxil fumarate, emtricitabine / rilpivirine / tenofovir, FTC / RPV / TDF) Complera
emtricitabine and tenofovir disoproxil fumarate (emtricitabine / tenofovir, FTC / TDF) Truvada
lamivudine and zidovudine (3TC / ZDV) Combivir
lopinavir and ritonavir (ritonavir-boosted lopinavir, LPV/r, LPV / RTV) Kaletra

ART to HAART

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 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 individuals concurrent medications, over-the-counter medications/remedies and herbal supplements to lessen the chance that 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. 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. (Qureshi, S., April 17, 2015).

HIV Medication Combination Therapies

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. (Panel on Antiretroviral Guidelines for Adults and Adolescents, May 1, 2014).

In an antiretroviral naive individual, general guidelines (Table 7) suggest that the starting regimen should consist of:

two nucleoside/nucleotide reverse transcriptase agents (NRTIs) either tenofovir/emtricitabine (TDF/FTC) or abacavir/lamivudine (ABC/3TC) plus one active drug from one of the following classes: NNRTI, PI boosted with ritonavir (RTV) or INSTI.

Table 7 (Panel on Antiretroviral Guidelines for Adults and Adolescents, May 1, 2014), (Okulicz, J., Aug 12, 2014).

CDC Recommended Regimens Regardless of Pre-ART Viral Load or CD4 Cell Count
NNRTI-Based Regimens:
  • Efavirenz/tenofovir/emtricitabine (EFV/TDF/FTC)
  • 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)

INSTI-Based Regimens:

  • Dolutegravir (DTG) + abacavir/lamivudine (DTG+ABC/3TC) – (only for patients who are HLA-B5701 negative)
  • Dolutegravir/tenofovir/emtricitabine (DTG/TDF/FTC)
  • Elvitegravir/cobicistat/tenofovir/emtricitabine (EVG/COBI/TDF/FTC) (only for patients with pretreatment estimated creatinine clearance >70 mL/min)
  • Raltegravir (RAL) + TDF/FTC

PI-Based Regimens:

  • 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

INSTI-Based Regimen:

  • 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. The most current recommendations can be accessed from http://aidsinfo.nih.gov.guidelines.

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 pre-natal care, while others separate it as an opt-in additional 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 afterwards 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 mothers 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 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 less 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(AIDSinfo Factsheet, Feb. 2012).

HIV Treatment Adherence

Healthcare professionals who work closely with HIV positive individuals indicate that one of the greatest challenges is treatment adherence (Table 11). HIV is a life-long chronic medical condition requiring significant lifestyle alterations, intensive intrusive condition monitoring, harsh and, at times, expensive medications and which 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 wonder 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 dialog 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 inside their body. 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 the ART 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 and together 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 be reviewed. The individual’s daily activities should be reviewed to see if the individual 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, assuming the occasional, less than perfect, adherence and to discourage confabulations from the individual so as to look better to the healthcare professional than reality. The “white coat” is a phenomenon that occurs as individuals tell healthcare professionals what they think they should hear not the reality.

Table 8 (Panel on Antiretroviral Guidelines for Adults and Adolescents, May 1, 2014)
Typical Types and Reasons for Lack of Adherence to HIV Treatment
  • Failure to fill prescriptions
  • Failure to understand dosing or timing instructions
  • Complexity of regimen (e.g., pill burden, pill size, dosing schedule, food requirements)
  • Pill aversion
  • Pill fatigue
  • Adverse medication effects
  • 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.

Case Study

Olaf, a 32 year old male with AIDS angrily tells you 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 has spread following a single, 2007 documented report of one unique instance where AIDS no longer tested positive after extreme and life endangering cancer treatments. 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 with 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.

Be aware that while fascinating and the subject of multiple research investigations that will continue for decades, this one instance is not 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 were provided.

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 (Liebert, M., Jan. 8, 2015).

Summary

HIV infection is a chronic medical condition that those infected will have until they succumbs to it in its final stage of AIDS or death ensues from another cause. 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 which 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 effecting 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 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.

References

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AIDSinfo Factsheet. (Feb. 2012). “HIV and Pregnancy”. U.S. Department of Health and Human Services. National Institute of Health. Retrieved July 15, 2015 from (Visit Source).

AIDSinfo. (June 8, 2015). “Window Period”. AIDSinfo, National Institute of Health. Retrieved June 9, 2015 from (Visit Source).

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Bartlett, J.G. (Aug. 28, 2014). “Screening and Diagnostic Testing for HIV Infection”. In: Hirsch MS (Ed.) UpToDate. Waltham, MA.\

Bartlett, J.G. (Jan. 23, 2015). “The Natural History and Clinical Features of HIV Infection in Adults and Adolescents”. In: Hirsch MS (Ed.) UpToDate. Waltham, MA.

CDC HIV Testing. (June 27, 2014). “Centers for Disease Control and Prevention and Association of Public Health Laboratories. Laboratory Testing for the Diagnosis of HIV Infection: Updated Recommendations”. Retrieved June 27, 2015 from (Visit Source).

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CDC HIV/AIDS Statistics Center. (May 11, 2015). “HIV in the United States Fast Facts”. Centers for Disease Control and Prevention, National Center for Health Statistics. Retrieved May 29, 2015 from (Visit Source).

CDC PrEP. (June 25, 2015). “Pre-Exposure Prophylaxis”. Centers for Disease Control and Prevention. HIV/AIDS Prevention Research. Retrieved July 5, 2015 from (Visit Source).

CDC State HIV Testing Laws. (June 4, 2015). “State HIV Testing Laws: Consent and Counseling Requirements”. Centers for Disease Control and Prevention. Policies and Programs. HIV Related Laws. Retrieved June 27, 2015 from (Visit Source).

Chong, Jia-Rui. (Oct. 30, 2007). “Analysis Clarifies Route of AIDS”. Los Angeles Times. Retrieved June 6, 2015 from (Visit Source).

Cichocki, M., (June 19, 2014). “Recognizing Acute HIV Syndrome: When Flu Symptoms May Not Be the Flu”, About Health. Retrieved June 27, 2015 from (Visit Source).

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Johns Hopkins Medicine. (April 28, 2015). “As Circumcision Wounds Heal HIV-positive Men May Spread Virus to Female Partners: Uganda Study”. Science Daily. Retrieved July 5, 2015 from (Visit Source).

Johns Hopkins University Bloomberg School. (June 25, 2015). "Needle Exchanges Can Prevent More HIV Outbreaks Like the One in Indiana".  Medical News Today. Retrieved July 1, 2015 from (Visit Source).

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This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Certified Nursing Assistant (CNA), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Dietetic Technicians, Registered (DTR), Dietitian/Nutritionalist (RDN), Electrologist (EO), Home Health Aid (HHA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Pedorthist (PED), Physical Therapist (PT/PTA), Podiatric Physician (PO), Registered Nurse (RN), Respiratory Therapist (RT)

Topics:

Advance Practice Nurse Pharmacology Credit, CPD: Practice Effectively, CPD: Preserve Safety, Infection Control/Disease, Medical Surgical


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