Overview

As we begin the 21st century, the amount that has been learned and written about HIV infection and disease and its influence on individuals and society is staggering. Since the discovery of HIV, scientists have made major inroads in understanding modes of transmission, infectivity, and pathogenicity. Therapeutic alternatives, especially antiretroviral drugs, have been tested and approved and are providing benefit to many who are HIV-infected. Much has been learned about the complexities of caring for HIV-infected persons, how to keep them disease-free longer, and how to manage their symptoms more effectively. In addition, the development of new knowledge from HIV-related research also has helped to clarify aspects of the human immune response, behavioral interventions, public health strategies, and social and ethical approaches that contribute to the understanding and management of other diseases and health conditions. Behavioral health professionals will continue to play a major and significant role in preventing the spread of HIV infection and in caring for those who are infected or affected by HIV. As the demographics of HIV infection evolve, both in the United States and around the world, it is clear that all healthcare professionals in all practice settings will be involved to some extent with HIV infection. To be effective and provide compassionate care, adequate and up-to-date information about transmission, prevention, and care of HIV-infected individuals must be obtained by all behavioral health professionals. They must feel comfortable with this knowledge in order to provide care, educate patients and others, and fulfill their professional obligations without undue fear or anxiety.

Education Category: Infection Control / Internal Medicine
Release Date: 03/01/2014
Expiration Date: 02/28/2017

Audience

This course is designed for all behavioral health professionals, including social workers, counselors, and marriage and family therapists, who may be involved with the care of persons with HIV or AIDS.

Accreditations & Approvals

NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. NetCE, #1092, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org through the Approved Continuing Education (ACE) Program. NetCE maintains responsibility for the program. ASWB Approval Period: 03/13/2016 to 03/13/2019. Social workers should contact their regulatory board to determine course approval for continuing education credits. NetCE is accredited by the International Association for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE SW CPE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #0033. This course is considered self-study, as defined by the New York State Board for Social Work. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

NetCE designates this continuing education activity for 3 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 7 Clinical continuing education clock hours, in accordance with the Association of Social Work Boards. NetCE is authorized by IACET to offer 0.7 CEU(s) for this program.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190; Texas State Board of Social Worker Examiners, Approval #3011; Texas State Board of Examiners of Professional Counselors, Approval #1121; Texas State Board of Examiners of Marriage and Family Therapists, Approval #425.

Special Approvals

This course meets the qualifications for 7 hours of continuing education credit for mental health professionals in the area of HIV/AIDS as required by the California Board of Behavioral Sciences.

Course Objective

In view of the already existing crisis in healthcare in the United States, the problems associated with providing the necessary care for persons with HIV infection or AIDS are significant. The purpose of this course is to address those problems in the discussion of epidemiology, pathophysiology, transmission, complications, treatment advancements, prevention, ethical and legal aspects of care, and workplace concerns.

Learning Objectives

Upon completion of this course, you should be able to:

  1. Discuss the background and significance of the AIDS epidemic, including geographic patterns of transmission.
  2. Describe the transmission of HIV infection, including risk behaviors and routes of contagion.
  3. Discuss the impact of the virus on women living with HIV infection.
  4. Review the transmission of HIV to the infant and child, and discuss care of these infected children.
  5. Summarize issues unique to older persons with HIV infection.
  6. Discuss challenges of HIV as it impacts the workplace.
  7. Review ethical and legal implications of HIV infection.

Faculty

Jane C. Norman, RN, MSN, CNE, PhD, received her undergraduate education at the University of Tennessee, Knoxville campus. There she completed a double major in Sociology and English. She completed an Associate of Science in Nursing at the University of Tennessee, Nashville campus and began her nursing career at Vanderbilt University Medical Center. Jane received her Masters in Medical-Surgical Nursing from Vanderbilt University. In 1978, she took her first faculty position and served as program director for an associate degree program. In 1982, she received her PhD in Higher Education Administration from Peabody College of Vanderbilt University. In 1998, Dr. Norman took a position at Tennessee State University. There she has achieved tenure and full professor status. She is a member of Sigma Theta Tau National Nursing Honors Society. In 2005, she began her current position as Director of the Masters of Science in Nursing Program.

John M. Leonard, MD, Professor of Medicine Emeritus, Vanderbilt University School of Medicine, completed his post-graduate clinical training at the Yale and Vanderbilt University Medical Centers before joining the Vanderbilt faculty in 1974. He is a clinician-educator and for many years served as director of residency training and student educational programs for the Vanderbilt University Department of Medicine. Over a career span of 40 years, Dr. Leonard conducted an active practice of general internal medicine and an inpatient consulting practice of infectious diseases.

Faculty Disclosure

Contributing faculty, Jane C. Norman, RN, MSN, CNE, PhD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Contributing faculty, John M. Leonard, MD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Alice Yick Flanagan, PhD, MSW

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Table of Contents

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#74711: HIV/AIDS: Epidemic Update for Behavioral Health Professionals

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INTRODUCTION

The amount that has been learned and written about human immunodeficiency virus (HIV) infection and disease and its influence on individuals and society is staggering. Since the first reported case of HIV more than 30 years ago, researchers have made major inroads in understanding modes of transmission, infectivity, and pathogenicity. Knowledge about the characteristics and behavior of this human retrovirus and its complex mechanisms of immunopathogenesis has helped to develop targeted therapeutic interventions and vaccine strategies. Sophisticated techniques have been and are being developed to diagnose infection, monitor immune decline, monitor response to therapy and disease progression, and accurately detect and diagnose opportunistic diseases.

Therapeutic alternatives, especially the nucleoside analogue antiretroviral drugs, have been tested, approved, and are providing benefit to many who are HIV-infected. Much has been learned about the complexities of caring for HIV-infected persons, how to keep them disease-free longer, and how to manage their symptoms more effectively. In addition, the development of new knowledge from HIV-related research has also helped to clarify aspects of the human immune response, behavioral interventions, public health strategies, and social and ethical approaches that contribute to the understanding and management of other diseases and health conditions.

EPIDEMIOLOGY

The epidemiology of HIV infections is presented as it appears in Africa, Asia, Europe, and the United States. Analysis reveals that the HIV pandemic continues to escalate throughout developing countries compared to a notable stabilization in new cases and fatalities in some developed countries. The established healthcare community became aware of the illness that has since become known as acquired immune deficiency syndrome (AIDS) in 1981. The tasks of slowing the HIV pandemic and decreasing the mortality rate are being accomplished by efforts such as diligent treatment of sexually transmitted infections (STIs), increased condom distribution, and utilization of needle exchange programs. In order to further decrease HIV transmission, there are increased efforts to strengthen public health infrastructures, support HIV/STI prevention programs, introduce microbicide, use inexpensive antiretroviral drug therapy for treatment and prevention of transmission, and improve educational campaigns [1].

Two human immunodeficiency viruses, HIV-1 and HIV-2, have been identified and both cause AIDS. Researchers in America and England have traced the ancestry of the HIV-1 virus to two strains found in African red-capped mangabeys and greater spot-nosed monkeys. The strains most likely combined in chimpanzees that ate the monkeys, resulting in the chimpanzees developing simian immunodeficiency virus (SIV). Chimpanzees then transmitted the virus to humans, as early as 1930. Genetic studies suggest that the lower monkeys first became infected with SIV 100,000 years ago [2]. HIV-2 is believed to be endemic in West Africa. Several well-documented cases of HIV-2 infection have been reported in Europeans and among West Africans residing abroad. Between 1988 and 2010, there were a total of 166 verified cases of HIV-2 in the United States, the majority of which were associated with immigration from, travel to, or a sexual partner from West Africa [3]. Differences in the global spread are attributed to differences in transmissibility and duration of infectiousness [4]. In the United States, HIV-2 infection is concentrated in the Northeast [3].

Many countries owe acquisition of HIV infection in their population to sexual transmission or contact with American blood products that were exported before the 1985 HIV screening procedures.

TRANSMISSION PATTERNS

In 1988, the World Health Organization (WHO) established three broad, but distinct, geographic patterns of AIDS transmission, based on worldwide epidemiological studies [5]. It is important to note that, due to a number of factors, these transmission patterns are evolving.

Pattern I

According to these definitions, in pattern I, typical of industrialized countries with large numbers of reported cases, most cases occurred among men who have sex with men (MSM) and among urban injecting drug users (IDUs). A smaller percentage of cases are attributed to heterosexual transmission, but this percentage is increasing significantly. Transmission from exposure to HIV-contaminated blood or blood products occurred between the late 1970s and 1985, but this has since been largely controlled through routine blood screening procedures [4].

Pattern II

Pattern II, which was mainly found in areas of central, eastern, and southern Africa and in some Caribbean countries, is comprised of cases occurring mostly among heterosexuals. MSM and IDU transmission either does not occur or occurs at a very low rate. Transmission through contaminated blood and blood products remains a significant problem [4].

Pattern III

Pattern III was observed in areas of eastern Europe, the Middle East, Asia, and most of the Pacific basin. HIV appeared to have been introduced to these areas since the mid-1980s. When the WHO originally described this pattern, only small numbers of cases had been reported. Generally, cases had occurred among those who have traveled to endemic areas or who had sexual contact with individuals from endemic areas. Only a small number of cases had been reported due to receipt of imported HIV-contaminated blood [4]. However, the percentage of HIV/AIDS infected population in Asia, particularly in the south and east areas, is increasing. Although transmission patterns vary geographically, the highest risk groups appear to be MSM, IDUs, and female sex workers and their clients [6]. Several areas within this pattern group, such as Russia, China, and India, have been identified as "second wave countries" and are considered at risk for a future pandemic [7].

According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), an estimated 35.3 million individuals worldwide were living with HIV/AIDS in 2012, approximately half of which were women [8]. Eastern Europe (particularly the Russian Federation), Central Asia, the Middle East, and Northern Africa have the fastest growing epidemic [8]. It is important to note that despite increases in certain geographic areas and demographic groups, overall, the rate of new infections is declining. This is due, in part, to lower prices for anti-AIDS drugs and implementation of prevention programs [8]. Africa is still the hardest hit area, with 71% of all HIV-infected persons living in sub-Saharan Africa in 2012 [8]. In 2003, the U.S. government approved the purchase of generic drugs to fight the disease in Africa. In that same year, the President's Emergency Plan for AIDS Relief (PEPFAR) was introduced and implemented [11]. PEPFAR was reauthorized in 2008 and 2013, with more than $50 billion in funds to address HIV/AIDS and additional health issues, including malaria, tuberculosis, maternal health, and clean water [12].

UNITED STATES STATISTICS

As of 2012, an estimated 1.3 million individuals were living with HIV/AIDS in North America [8]. The CDC estimates that approximately 20% of these individuals are unaware of their infection [13]. To compound the problem, only 51% of individuals aware of their infection receive ongoing care. Approximately 72% of all individuals infected with HIV remain untested, without treatment, or both [13]. Unfortunately, this poses a risk both for those who are infected and for others.

Many changes in the progression of the HIV/AIDS epidemic should be considered. Since the first reported cases of HIV in 1981 in the United States, the epidemic continues to vary a great deal between regions, states, and even communities. Populations that are affected by HIV are also shifting. In addition to individuals traditionally considered to be high-risk (e.g., MSM or IDUs), new groups have been identified as being at greater risk. For example, in the beginning stages of the HIV/AIDS epidemic in the United States, white people were chiefly impacted. However, the epidemic now greatly affects racial and ethnic minorities, particularly black Americans, who represent nearly half of all new diagnoses in the United States [15]. Women also have a higher risk of infection. More than half of HIV infections that result from heterosexual contact occur in women.

One should keep in mind when reviewing HIV/AIDS trends that the widespread use of antiretroviral therapy (ART) has resulted in fewer deaths and longer survival [13]. As of 2013, the Centers for Disease Control and Prevention (CDC) report several trends in the HIV/AIDS epidemic [15]:

  • By region, 40% of persons living with AIDS reside in the South, 30% in the Northeast, 20% in the West, and 10% in the Midwest.

  • By race/ethnicity, 42% are black, 37.9% white, 17.4% Hispanic, 1.5% are multiple race, and less than 1% are American Indian/Alaska Native or Asian/Pacific Islander.

  • By gender, 80% of adults and adolescents living with AIDS are male.

The CDC has published guidelines for medical professionals to integrate HIV prevention into the regular medical care of those living with HIV. The three major components of the recommendation are [16]:

  • Screening for HIV transmission risk behaviors and STIs

  • Providing brief, behavioral risk-reduction interventions in the office setting and referring selected patients for additional prevention interventions and other related services

  • Facilitating notification and counseling for sex and needle-sharing partners of infected persons

The CDC, in partnership with other U.S. Department of Health and Human Services agencies and other government and non-government agencies, also launched the initiative Advancing HIV Prevention: New Strategies for a Changing Epidemic [17]. This initiative was a response to increases in HIV infections.

The CDC has also developed a method to better measure the rate of HIV infections in the United States. The Serologic Testing Algorithm for Recent HIV Seroconversion (STARHS) has allowed the CDC to more accurately monitor the number of new HIV infections in the United States, which in turn should facilitate targeted prevention in those populations most in need [18,19]. STARHS consists of two tests to determine both seropositivity and how recently the infection was contracted.

HIV TESTING

Several tests are available to screen for HIV. There are various ways by which these tests function: detection of the antibody, identification of antigens, detection/monitoring of viral nucleic acids, or rendering an estimate of T-lymphocytes (cell phenotyping). Tests used to detect antibodies are the most common and effective way of identifying HIV infection and can be further broken down into two categories [21]:

  • Screening Tests: Intended to determine all individuals infected with HIV; produces few false-negative results

  • Supplemental/Confirmatory Tests: Intended to determine all individuals who have positive screening tests, but are not infected (i.e., negates a false-positive), produces few false-positive results

Both types of tests are highly sensitive. Together, they can accurately assess the existence of HIV in blood supply and supplement clinical diagnosis.

Screening for the antibody is helpful only to the extent that individuals who have been exposed to HIV can be identified. However, not all of these individuals actually carry the virus, nor will all of them show signs of illness. Therefore, several situations are possible:

  • Exposure: An individual may be exposed to the virus but neither carry it nor contract the disease.

  • Carrier: The individual may carry the virus with the capability of infecting others without accompanying signs and symptoms.

  • Terminal Disease: The individual may be infectious, symptomatic, and terminal. HIV disease becomes AIDS when the immune system is so damaged that the number of CD4+ T-lymphocyte cells is less than 200 per mm3 or an opportunistic infection occurs.

It is thought that carriers of the virus who test positive for the antibody can remain as carriers for years with the virus in a dormant state. Although approximately one-third of those who now test positive for the disease eventually will begin to show clinical manifestations, it is thought by some investigators that the percentage of those who go on to develop the disease will eventually approach 100% [20].

TRANSMISSION OF HIV

Transmission of HIV results from intimate contact with blood and body secretions, excluding saliva and tears. The most common modes of transmission are sexual contact, administration of contaminated blood and blood products, contaminated needles, and mother-to-fetus. Blood transfusions of whole blood, packed cells, and fresh frozen plasma are most unlikely to be the cause of transmission with the more sophisticated crossmatching and antibody screening measures; individuals needing specific blood components (such as factor VIII and frequent plasma replacement) are more at risk [20].

On the basis of newly reported cases, the transmission categories are [15]:

  • Male-to-male sexual contact

  • IDUs

  • MSM who inject drugs

  • High-risk heterosexual contact

  • Blood transfusion

  • Hemophilia/coagulation disorder

  • Perinatal transmission

  • No reported risk category

SEXUAL TRANSMISSION OF HIV

HIV has been isolated from blood, seminal fluid, pre-ejaculate, vaginal secretions, urine, cerebrospinal fluid, saliva, tears, and breast milk of infected individuals. Whether HIV infects spermatozoa is controversial. Reports of the removal of infected cells from semen, allowing artificial insemination without seroconversion, support the idea that spermatozoa are not infected. No cases of HIV infection have been traced to saliva or tears [32].

The virus is found in greater concentration in semen than in vaginal fluids, leading to a hypothesis that male-to-female transmission could occur more easily than female-to-male. Sexual behavior that involves exposure to blood is likely to increase transmission risks. Transmission could occur through contact with infected bowel epithelial cells in anal intercourse in addition to access to the bloodstream through breaks in the rectal mucosa.

Although all HIV-seropositive people are potentially infectious, there is widespread variation in the seropositivity and seroconversion of their sexual partners. Factors that could explain this variability include differences in sexual practices and numbers of sexual contacts, susceptibility of the partner, differences in viral strains, changing degrees of infectiousness of the HIV-infected person over time, co-factors that enhance or limit transmission, genetic resistance, or a combination of these factors.

Posing the highest risk of infection is unprotected anal receptive intercourse, followed by unprotected vaginal intercourse. Risk is reduced through the use of latex condoms. For the wearer, latex condoms provide a mechanical barrier limiting penile exposure to infectious cervical, vaginal, vulvar, or rectal secretions or lesions. Likewise, the partner is protected from infectious pre-ejaculate, semen, and penile lesions. Oil-based lubricants may make latex condoms ineffective and should not be used. Water-soluble lubricants are considered safe. Natural membrane condoms (made from lamb cecum) contain small pores and do not block HIV passage.

Latex condoms are considered highly effective at preventing HIV transmission, resulting in an 85% reduction compared to never users [71]. Although abstinence from sexual contact is the sole way to absolutely prevent transmission, using a latex condom to prevent transmission of HIV is more than 10,000 times safer than engaging in unprotected sex [70]. Sexual activity in a mutually monogamous relationship in which neither partner is HIV-infected and no other risk factors are present is considered safe [4].

The phenomenon of men who identify publicly as heterosexual and generally have committed relationships with women, but who also engage in sexual activity with other men, termed being on the "down low" or DL, may be a transmission bridge to heterosexual women. In a 2005 study, researchers surveyed 328 MSM in 12 cities and found that 43% of black men, 26% of Hispanic men, and 7% of white men reported being on the down low [25]. However, it is important to note that men on the "down low" are not the only MSM who report having sexual contact with women. In a larger study of 5,000 HIV-positive MSM, 22% of gay-identified black MSM and 61% of bisexual-identified black MSM reported having had sex with a woman in the past five years [49]. Also, a 2009 study of 1,151 black MSM found that men who identified as "down low" were not more likely to engage in unprotected vaginal or anal sex with women or men [9]. To better understand the actual extent of this behavior and its impact on HIV transmission, more research and studies must be undertaken.

Oral Sex

Numerous studies have demonstrated that oral sex can result in the transmission of HIV and other STIs. While the risk of HIV transmission through oral sex is much smaller than the risk from anal or vaginal sex, there are several co-factors that can increase this risk, including oral ulcers, bleeding gums, genital sores, and the presence of other STIs. The highest oral sex risk is to individuals performing oral sex on an HIV-infected man, with ejaculation. Prevention includes the use of a latex or plastic condom on the penis and a cut-open condom or a dental dam used between the mouth and the vagina or anus [26].

BLOOD DONOR PRODUCTS

It has been estimated that an HIV-infected drop of human blood contains 1 to 100 live virus particles. In comparison, a drop infected with hepatitis B virus has 100 million to 1 billion organisms. Even so, HIV is transmitted via blood, primarily through sharing of contaminated needles among IDUs and, rarely, through blood transfusion. Transmission of HIV-1 has occurred after transfusion of the following components: whole blood, packed red blood cells (including washed and buffy coat poor), fresh frozen plasma, cryoprecipitate, platelets, and plasma-derived products, depending on the production process.

With the implementation of a donor screening program of the nation's blood supply in 1985 and advances in the treatment of donated blood products, blood transfusion is now even safer; the current risk of transmission of AIDS through this route is estimated to be 1 in 225,000. A somewhat higher estimate of 1 in 40,000 to 1 in 60,000 is reported from areas that have a high prevalence of HIV-1 infection. It is possible that before blood screening implementation, more than 12,000 people were infected. A large percentage of hemophiliacs acquired HIV in this manner. Donor screening, HIV testing, and heat treatment of the clotting factor have greatly reduced the risks. To further decrease the possibility of HIV transmission through transfusion of blood and blood products, patients scheduled to undergo elective surgery are increasingly advised to make predeposited blood donations for intraoperative autotransfusion.

To date, screening tests cannot detect either recently HIV-1-infected people who have not yet developed antibody (the "window period") or HIV antibody-negative patients who have AIDS. Donating procedures include an interview for risk factors and the ability of the potential donor to exclude their blood from being used. No transfusion-related cases of HIV-2 infection have been reported in the United States since 1992, when all U.S. blood centers began to test donations for antibodies to both HIV-1 and HIV-2. Clinicians should recommend HIV antibody testing for all people transfused between January 1978 and March 1985 [4].

NEEDLE SHARING

Transmission of HIV among injecting drug users occurs primarily through contamination of injection paraphernalia with infected blood. The risk of sustaining HIV infection from a needle stick with infected blood is approximately 1 in 300. Behavior such as needle sharing, "booting" the injection with blood, and performing frequent injections increases the risk. Cocaine use (by injection or smoking) is associated with a higher prevalence of HIV infection. This may in part be attributed to the exchange of cocaine for sex. Sharing of equipment is common due to legal and financial restrictions and cultural norms. Geographically, the rate of infection varies; 80% of New York City addict needle sharers are infected, as opposed to lower rates in other metropolitan area clusters. Secondary transmission occurs to children and sexual partners. Preventative strategies include drug treatment, onsite medical care in a drug treatment program, recruitment of "street" outreach workers for intensive drug and sex "risk reduction" educational campaigns, teaching addicts to sterilize their equipment between use, the free provision or exchange of sterile injection equipment (as allowed by law), distribution of condoms and bleach to clean drug use equipment, or a combination of these interventions [4].

Health professionals should stress the following messages when they counsel IDUs [85]:

  • The best way for you to prevent HIV and hepatitis B and C virus transmission is to NOT inject drugs.

  • Entering substance abuse treatment can help you reduce or stop injecting. This will lower your chances of infection.

  • Get vaccinated against hepatitis A and hepatitis B. You can prevent these kinds of viral hepatitis if you get vaccinated.

  • If you cannot or will not stop injecting, you should:

    • Use a new, sterile syringe obtained from a reliable source to prepare and divide drugs for each injection.

    • Never reuse or share syringes, water, cookers, or cottons.

    • Use sterile water to prepare drugs each time, or at least clean water from a reliable source.

    • Keep everything as clean as possible when injecting.

  • If you cannot use a new, sterile syringe and clean equipment each time, then disinfecting with bleach may be better than doing nothing at all:

    1. Fill the syringe with clean water and shake or tap. Squirt out the water and throw it away. Repeat until you do not see any blood in the syringe.

    2. Completely fill the syringe with fresh, full-strength household bleach. Keep it in the syringe for 30 seconds or more. Squirt it out and throw the bleach away.

    3. Fill the syringe with clean water and shake or tap. Squirt out the water and throw it away.

  • If you do not have any bleach, use clean water to vigorously flush out the syringe. Fill the syringe with water and shake or tap it. Squirt out the water and throw it away. Repeat several times.

It is important to note that a disinfected syringe is not a sterile syringe. The best option is always to use a new, sterile syringe with every injection.

PERINATAL TRANSMISSION

In the absence of prophylactic treatment, approximately 30% to 50% of children born to HIV-infected mothers will contract HIV infection. HIV is transmitted to infants by transplacental spread from mother to fetus in utero, during parturition, or through breastfeeding after birth. Because infants have underdeveloped natural resistance systems, they are highly susceptible to many infections, including HIV. Both uninfected and infected infants have been born to mothers who have previously borne an infected infant. Studies have dramatically shown the beneficial effect of treating pregnant women and newborns with zidovudine (ZDV) to prevent transmission to the child, resulting in dramatic declines in the incidence of perinatally acquired AIDS [75]. Standard screening of all pregnant women is necessary to reduce transmission of HIV to infants.

Worldwide, perinatal transmission accounts for most HIV infections among children. In the United States in 2010, 143 infants were born with HIV infection, down from more than 1,700 in the mid-1990s. In all, perinatal transmission has been markedly decreased, by more than 80%, since 1991 [75]. This dramatic decrease is mainly attributed to the use of ART [28]. Other strategies for reducing perinatally acquired HIV infection have included preventing HIV infection among women and, for HIV-infected women, avoiding pregnancy or refraining from breastfeeding. On February 21, 1994, the National Institutes of Health's National Institute of Allergy and Infectious Diseases (NIAID) and National Institute of Child Health and Human Development (NICHD) announced preliminary results from a randomized, multicenter, double-blind clinical trial of ZDV to prevent HIV transmission from mothers to their infants. This report summarizes the interim results of that trial, which indicate effectiveness of ZDV for prevention of perinatal transmission. Based on these interim findings, NIAID accepted the recommendation of an independent data and safety monitoring board to terminate enrollment into the trial and to offer ZDV to women in the group who had received the placebo but had not yet delivered and to their infants younger than 6 weeks of age [29].

OCCUPATIONAL EXPOSURES

Transmission due to occupational exposure of healthcare workers has occurred in needlestick accidents and blood splashes to the mucous membranes. Needlestick is the most common route. Thousands of healthcare personnel who were so exposed have been studied, and only 57 cases of well-documented infection have been reported in the United States (24 of which were nurses) [34]. The risk of infection through this route is low, and every effort should be made to decrease the exposure rate. Educational efforts, implementation of engineering controls in needled and sharp-edged medical devices, the use of hard plastic needle disposal units where these devices are most frequently used, and the development of procedural details to avoid blood and body fluid contact have greatly reduced the exposure rate. Healthcare personnel must apply universal precautions, as discussed in the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens standard regulations, to all activities to avoid contact with human fluids [4].

All body fluids should be considered potentially infectious. Contaminated needles or other sharps should not be bent, recapped or removed, unless specifically required by a particular medical or dental procedure. All healthcare professionals should have access to and use personal protective equipment, such as gloves, gowns, face shields, masks, eye protection, and ventilation devices, to limit exposure to potentially infectious fluids. OSHA standards require that single-use gloves be worn when contact with blood or other potentially infectious substance, including mucous membranes, can be reasonably anticipated [35].

ORGAN TRANSPLANTATION

Because these procedures are less common than other transmission-related activities, there have been very few case reports of HIV acquisition by this route. HIV has been transmitted via transplanted kidneys, liver, heart, pancreas, bone, and, possibly, skin grafts and through artificial insemination. HIV testing is used in these circumstances to rule out infection. Most cases of transmission through transplants of organs, bone, or tissue occurred before HIV screening was available. However, in 2007, four organ transplant recipients contracted HIV and hepatitis C from a single deceased organ donor [79]. This was the first case of HIV infection resulting from transplantation since 1985. Since then, a living kidney donor who tested negative for HIV 12 days prior to donation was found to have transmitted HIV to the donor recipient, the first case of transmission from a living donor since 1989 [81]. As with blood transfusions, donors testing antibody seronegative may pass HIV infection on to recipients [4]. The use of nucleic acid testing and reconsideration of the use of high-risk donors have both been recommended to ensure the safety of donor recipients [79].

In 2013, Congress passed a bill overturning the ban on HIV-positive organ donation for HIV-positive recipients [44]. As patients with HIV live increasingly longer lives, organ donation has become more common, although only organs from HIV-negative donors were accepted in the past. As such, the HIV Organ Policy Equity (HOPE) Act has the potential of increasing the donation pool for those with and without HIV and saving thousands of lives.

MANAGEMENT OF HIV INFECTION

Primary physicians in consultation with specialists are playing an increasing role in the care of HIV-infected individuals. It is not possible for all care to be delivered by infectious disease and oncology specialists. Moreover, with early ART and prophylaxis for opportunistic infections, HIV disease shares features of other multisystem, chronic diseases characterized by acute exacerbations and end-stage manifestations.

Primary care physicians should provide risk factor assessment of their patients and, when appropriate, screening for HIV infection with pretest and post-test counseling [41]. Pretest counseling should include review of risk factors for HIV infection, discussion of safer sex, and the meaning of a positive test. Post-test counseling should include information on steps to lower HIV risk. Post-test counseling for the patient who has a positive test result should include [40,41]:

  • Addressing emotional response and concerns associated with being HIV positive

  • Treatment options

  • A referral for HIV and mental health care

  • Emphasis on the importance of notifying the patient's sex or drug use partner(s)

  • Information about how to avoid transmitting HIV to others

Patients with HIV infection should be seen at regular intervals by a primary care provider to perform periodic physical examinations, monitor prognostic markers (e.g., CD4 count, viral load), initiate and monitor antiviral and prophylactic therapy, provide supportive counseling, and offer assistance with terminal care. Specialists should be consulted for patients intolerant of standard drugs, those in need of systemic chemotherapy, and those with complicated opportunistic infections. In some cases, a single specialist consultation with follow-up to the primary care physician will provide the needed expertise while ensuring continuity of care.

ANTIRETROVIRAL THERAPY (ART)

Strategies for the treatment of HIV infection are based on an understanding of the molecular biology of HIV and the life cycle of the virus within the host cell. Antiviral agents have been developed that act predominately on processes specific to the virus particle in order to preserve the integrity of the host cell. Several potential strategies specifically aimed at interruption of the viral life cycle have been defined, including:

  • Preventing the virus from attaching to the CD4 receptor of the T4 lymphocyte

  • Interfering with uncoating of the virus within the cell, the first essential step in proviral integration into cellular DNA

  • Inhibiting reverse transcriptase (RT), a viral enzyme specific to retroviruses, which enables the virus to make a DNA copy from single-stranded viral RNA prior to integration into cellular DNA

  • Blocking viral regulatory and transactivating proteins, which are involved in the transcription and translation of viral RNA proteins from proviral DNA as the virus goes from the quiet, integrated state to active replication

  • Inhibiting protease, a viral enzyme responsible for the cleaving of viral proteins both before proviral integration and as the viral particles recombine into functional proteins needed for viral maturation

  • Preventing viral assembly and budding out of the cell

  • Blocking the viruses' ability to enter CD4 cells

ART combines 6 classes of agents: nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), fusion inhibitors, integrase inhibitors, and chemokine (C-C motif) receptor 5 (CCR5) antagonists. Initiated in 1995 in the U.S., ART regimens have been effective in dramatically decreasing HIV-related morbidity and mortality and should be considered for all HIV-infected persons who qualify for such therapy. In addition to combination therapy, the sequencing of drugs and the preservation of future treatment options are also important. Three types of combination regimens may be employed as initial therapy. These include: NNRTI-based regimens, PI-based regimens, and rarely, triple-NRTI regimens. The goal of these regimens is to "save" one or more classes of drugs for later use [42]. The U.S. Department of Health and Human Services, in their revised guidelines for the use of antiretroviral agents in HIV-infected adults and individuals, have made the distinction between NNRTI-based regimens and PI-based regimens. Treatment is also classified as "recommended" or "alternative." These changes may simplify therapeutic decisions for clinicians [42,43].

The decision to initiate ART is one that requires careful discussion with the patient, usually in consultation with an infectious disease specialist or other physician well-versed in the use of ART. Physicians and patients alike should be aware of the advantages, potential toxicities, and complexity of monitoring therapy. At the present time, the most active triple-drug regimen (for example, two nucleoside analogs and a PI) in a previously untreated patient can be expected to reduce the viral load below detectable levels, increase CD4 counts by an average of 100–150/mm3, reduce the risk of HIV-associated complications, and prolong survival. However, the ability to achieve this advantage depends on the patient's willingness to accept a complex medical regimen that requires rigorous compliance, frequent follow-up, and moderate risk for drug toxicity.

In reaching a decision, it is helpful to bear in mind that prognosis is determined by viral load and the CD4 count. Patients with a viral load in excess of 60,000 copies per milliliter have a relatively rapid course and average survival of a little more than 4 years. In contrast, those with less than 6,000 copies per milliliter have an average survival of more than 10 years. The CD4 count is also a prognostic factor, as counts less than 350 indicate severe damage to immune function and corresponding risk for opportunistic infection.

Patient compliance may be improved with a regimen of Combivir, Epzicom, Trizivir, Truvada, Atripla, or Stribild therapy. These therapies combine more than one drug into a single pill, making it easier for patients to comply with their medication regimen. In addition to those medications that have been FDA-approved for the treatment of HIV, there is a long list of investigational, or "pipeline," drugs being tested in clinical trials. For more information on those agents and the trials, please visit the U.S. Department of Health and Human Services AIDS information website at http://aidsinfo.nih.gov.

PREVENTION OF OPPORTUNISTIC INFECTIONS

Depending on the CD4 count and other risk factors, asymptomatic patients may benefit from treatment to prevent opportunistic infections. In many cases, ART is useful in the prevention and treatment of these infections. Recommendations for anti-microbial prophylaxis of opportunistic infections are summarized in Table 1 according to guidelines provided by the CDC, National Institutes of Health, and Infectious Diseases Society of America [53]. Prophylactic therapy for these conditions is strongly recommended because these infections are relatively common in HIV patients, preventive therapy is simple and cost effective, and efficacy has been established in clinical studies. In addition, all patients should be vaccinated with pneumococcal vaccine. Hepatitis B vaccination should be considered in patients whose serologic testing indicates susceptibility.

PROPHYLAXIS TO PREVENT FIRST EPISODE OF OPPORTUNISTIC DISEASE AMONG ADULTS AND ADOLESCENTS INFECTED WITH HIV

PathogenIndicationPreventive Regimen
Preferred*Alternative
Pneumocystis carinii pneumonia (PCP)CD4 count <200 cells/mm3 (AI), or oropharyngeal candidiasis (AII), or CD4 <14% (BII), or a history of AIDS-defining illness (BII), or CD4 count >200 but <250 cells/mm3 if monitoring CD4 cell count every 3 months is not possible (BII)Trimethoprim-sulfamethoxazole (TMP-SMZ) 1 double-strength (DS) daily (AI), or TMP-SMX 1 single-strength (SS) daily (AI)TMP-SMX 1 DS three times weekly (TIW) (BI); or dapsone 100 mg daily or 50 mg twice daily (BI); or dapsone 50 mg daily + pyrimethamine 50 mg + leucovorin 25 mg weekly (BI); or dapsone 200 mg + pyrimethamine 75 mg + leucovorin 25 mg weekly (BI); or aerosolized pentamidine 300 mg via Respirgard II nebulizer every month (BI); or atovaquone 1500 mg daily (BI); or atovaquone 1500 mg + pyrimethamine 25 mg + leucovorin 10 mg daily (CIII)
Toxoplasma gondii encephalitisToxoplasma immunoglobulin G (IgG)-positive patients with CD4 count <100 cells/mm3 (AII). Seronegative patients receiving PCP prophylaxis not active against toxoplasmosis should have toxoplasma serology retested if CD4 count decline to <100 cells/mm3 (CIII). Prophylaxis should be initiated if seroconversion occurred (AII).TMP-SMX 1 DS daily (AII)TMP-SMX 1 DS TIW (BIII); or TMP-SMX 1 SS daily (BIII); or dapsone 50 mg daily + pyrimethamine 50 mg + leucovorin 25 mg weekly (BI); or dapsone 200 mg + pyrimethamine 75 mg + leucovorin 25 mg weekly (BI); or atovaquone 1500 mg daily (CIII); or atovaquone 1500 mg + pyrimethamine 25 mg + leucovorin 10 mg daily (CIII)
Latent Mycobacterium tuberculosis infection (LTBI)A positive screening test for LTBI, with no evidence of active TB and no prior treatment for active TB or LTBI (AI); or close contact with a person with infectious TB, regardless of screening test results (AII)Isoniazid (INH) 300 mg + pyridoxine 25 mg daily for 9 months (AII); or INH 900 mg biweekly (by direct-observation therapy) + pyridoxine 25 mg daily for 9 months (BII).Rifampin 600 mg daily for 4 months (BIII); or rifabutin (dose adjusted based on concomitant ART) for 4 months (BIII). For drug-resistant TB, consult an expert or public health authorities.
Disseminated Mycobacterium avium complex (MAC) diseaseCD4 count <50 cells/mm3 after ruling out active disseminated MAC disease based on clinical assessment (AI)Azithromycin 1200 mg once weekly (AI); or clarithromycin 500 mg twice daily (AI); or azithromycin 600 mg twice weekly (BIII)Rifabutin 300 mg daily (dose adjusted based on concomitant ART) (BI); rule out active TB before starting
Streptococcus pneumoniae infectionIndividuals who have not received any pneumococcal vaccine, regardless of CD4 count13-valent pneumococcal conjugate vaccine (PCV13) 0.5 mL IM x 1 (AI), followed in 8 weeks by PPV23 if CD4 count ≥ 200 cells/mm323-valent pneumococcal polysaccharides vaccine (PPV23) 0.5 mL IM x 1 (BII)
Influenza A and B virus infectionAll HIV-infected patients (AIII)

Inactivated influenza vaccine annually (AIII)

Note: Live-attenuated influenza vaccine is contraindicated in HIV-infected patients (AIII).
SyphilisIndividuals exposed to a sex partner with a diagnosis of primary, secondary, or early latent syphilis within past 90 days (AII); or individuals exposed to a sex partner >90 days before syphilis diagnosis in the partner, if serologic test results are not available immediately and the opportunity for follow-up is uncertain (AIII)Benzathine penicillin G 2.4 million units IM for 1 dose (AII)For penicillin-allergic patients, doxycycline 100 mg twice daily for 14 days (BII); or ceftriaxone 1 g IM or IV daily for 10–14 days (BII), or azithromycin 2 g for 1 dose (BII) (not recommended for MSM or pregnant women [AII])
Histoplasma capsulatum infectionCD4 count <150 cells/mm3 and at high risk because of occupational exposure or living in a community with a hyperendemic rate of histoplasmosis (>10 cases/100 patient-years) (BI)Itraconazole 200 mg daily (BI)
CoccidioidomycosisA new positive IgM or IgG serologic test in patients who live in a disease-endemic area and with CD4 count <250 cells/mm3 (BIII)Fluconazole 400 mg daily (BIII)
Varicella-zoster virus (VZV) infection (pre-exposure)Patients with CD4 counts≥200 cells/µL who have not been vaccinated, have no history of varicella or herpes zoster, or who are seronegative for VZV (CIII)

Primary varicella vaccination (Varivax™), 2 doses (0.5 mL SQ each) administered 3 months apart (CIII).

If vaccination results in disease because of vaccine virus, treatment with acyclovir is recommended (AIII).

VZV-susceptible household contacts of susceptible HIV-infected persons should be vaccinated to prevent potential transmission of VZV to their HIV-infected contacts (BIII).
Varicella-zoster virus (VZV) infection (post-exposure)Close contact with a person with chickenpox or herpes zoster and is susceptible (i.e., no history of vaccination or of either condition or known to be VZV seronegative) (AIII)Varicella-zoster immune globulin (VariZIG™) 125 IU IM per 10 kg (maximum 625 IU), administered as soon as possible and within 10 days after exposure (AIII)Acyclovir 800 mg 5 times per day for 5–7 days (BIII); or valacyclovir 1 g three times per day for 5–7 days (BIII)
Human papillomavirus (HPV) infectionAge 13 to 26 years (BIII)HPV quadrivalent vaccine 0.5 mL IM at months 0,1–2, and 6 for men and women (BIII); or HPV bivalent vaccine 0.5 mL IM at months 0,1–2, and 6 for women (BIII)
Hepatitis B virus (HBV) infectionPatients without chronic HBV or without immunity to HBV (i.e., anti-HBs <10 IU/mL) (AII); or patients with isolated anti-HBc and negative HBV DNA (BII). Early vaccination is recommended before CD4 count falls below 350 cells/µL (AII). However, in patients with low CD4 cell counts, vaccination should not be deferred until CD4 count reaches >350 cells/mm3, because some patients with CD4 counts <200 cells/mm3 do respond to vaccination (AII).HBV vaccine IM (Engerix-B 20 µg/mL or Recombivax HB 10 µg/mL) at 0, 1, and 6 months (AII); or combined hepatitis A and B vaccine (Twinrix) 1 mL IM as a 3-dose (0, 1, and 6 months) or 4-dose series (days 0, 7, 21 to 30, and 12 months) (AII)
MalariaTravel to disease-endemic areaRecommendations are the same for HIV-infected and HIV-uninfected patients.
PenicilliosisPatients with CD4 cell counts <100 cells/mm3 who live or stay for a long period in rural areas in northern Thailand, Vietnam, or Southern China (BI)Itraconazole 200 mg once daily (BIFluconazole 400 mg once weekly (BII)
*All medications are taken orally unless otherwise indicated.

RECOMMENDATIONS RATING SCHEME

CategoryDefinition
Strength of Recommendation
AStrong
BModerate
COptional
Level of Evidence
IOne or more randomized trials with clinical outcomes and/or validated laboratory endpoints
IIOne or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes
IIIExpert opinion

The CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America have developed guidelines for the prevention of opportunistic infections among HIV-infected individuals. The report offers guidelines specific to each type of opportunistic infection and can be viewed online at http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf.

HUMAN SERVICES FOR THOSE INFECTED

All persons who are infected with HIV need information on the meaning of infection. Secondary health education should include the person's sexual partner and family whenever possible. Persons with HIV infection should not assume that they will or will not develop clinical disease and should take all precautions possible to extend life. However, they should be informed that they are infected for life and contagious for life. This information means that they should not engage in unsafe sexual practices, and they should be told that anything that may be contaminated by their blood, semen, or vaginal fluid may constitute a risk of infection.

A health maintenance program to involve symptom surveillance, therapy, hygiene, nutrition, stress reduction and involvement in supportive interpersonal relationships should be maintained. Through lifestyle changes, persons with HIV infection can also minimize or eliminate immunosuppressive factors and emphasize factors that promote immune function. First, regular medical and psychiatric evaluations and follow-up are advised for HIV-infected persons. Secondary health maintenance involves prophylaxis and treatments to prevent disease progression.

Finally, health maintenance efforts include proper nutrition, elimination of recreational drug and alcohol use, stress management, and prevention of pregnancy, all of which may be influential in slowing the rate of disease progression. Secondary health maintenance should be directed at lifestyle changes in these areas. Persons in the asymptomatic stage of HIV disease should focus on maintaining their weight and increasing calorie and protein intake as necessary. High-calorie, high-protein foods are from the protein, dairy, starch and grain, and fat food groups. Using food supplements and eating between meals are strategies for increasing intake. Evidence that nutrition plays a role in enhancing immunocompetence in persons with HIV comes from a prospective study of dietary intake in HIV-seropositive men who have sex with men.

Assisting persons with HIV to limit or give up the use of alcohol, recreational drugs, and tobacco is also part of secondary health maintenance. These substances reduce immunocompetence. Limiting or removing their use may slow or prevent disease progression in HIV-infected individuals. Self-help programs may be indicated. Women who are infected with HIV must be informed of the effects of pregnancy on the progression of disease. Pregnancy itself has an immunosuppressant effect; it is possible that pregnancy accelerates the pace of disease expression. Women must also realize that AIDS is maternally transmitted. They do not need to be sick to pass HIV to the fetus, and the virus may be contracted through breast milk. In the United States, about three in ten fetuses become infected if the mother is HIV-positive and has not received ART. Women also need information on the use of ZDV during pregnancy. Counseling on birth control, pregnancy, enrolling in clinical trials, abortion, and breastfeeding should be part of any health maintenance program for women.

Stress reduction programs may also be useful in secondary health maintenance. They contribute to quality of life and may also contribute to immunocompetence. Information on stress reduction, in addition to regular exercise, rest, sleep, and personal use of relaxation techniques may be of help to some persons. It is also important to provide avenues for expression of emotion, such as friends and family, social support groups, and professional counseling. Treatment of depression is recommended both to enhance quality of life and perhaps to enhance immunocompetence.

There are several special issues that often arise in the HIV/AIDS patient population. Because HIV occurs with greater frequency in gay and ethnic minority (particularly black) communities, cultural competency and sensitivity are core elements of care. The guidelines recommend that providers demonstrate respect and provide excellent care to patients with various cultural backgrounds, beliefs, and sexual orientations [58]. Other socioeconomic issues, including poverty, professional and personal stigma, lack of insurance, and illegal immigration status, occur more frequently among these groups and can impact the ability to provide care.

WOMEN LIVING WITH HIV INFECTION

Women now make up nearly half of all AIDS cases worldwide and 24% in the United States [28]. The rate of HIV infection in women is rising rapidly. The proportion of AIDS cases in women has nearly quadrupled between 1985 and 2006, in part due to the CDC's expanded case definition of AIDS in 1993. More women were found to meet the AIDS case definition when the CD4+ T-lymphocyte count of <200 was added to the criteria. This may be evidence that the previous case definitions based on the clinical characteristics of men did not accurately reflect the clinical manifestations of HIV in women [28,54]. As of 2010, women accounted for 20% of new HIV infections, a 21% decrease since 2008 and the first significant decrease after more than a decade of relatively steady HIV incidence among women [28].

The 2014 case definition for HIV infection includes tests and multi-test algorithms that were not available when the AIDS case definition was previously revised. The revised case definition for HIV infection also permits states to report cases to the CDC based on the result of any test licensed for diagnosing HIV infection in the United States [36].

AIDS is the eighth leading cause of death in women 25 to 44 years of age in the United States. It is the fourth leading cause of death in African American women in the same age group [28]. Women of color have been disproportionately affected by AIDS; the prevalence rate of AIDS cases among black women is 21 times that of white women. When compared with adults, a greater percentage of AIDS cases in adolescents are young women. They are more likely to be African American or Latina, and they are more likely to be infected through heterosexual intercourse.

Although AIDS cases have been identified throughout the United States, most are concentrated in large urban areas. The majority of AIDS-infected women live below the poverty line, and most have children younger than 18 years of age in their household. The most rapidly increasing incidence of AIDS is among women who have had heterosexual contact with an HIV-infected man. Cases of woman-to-woman sexual transmission have been reported and are accounted for in the CDC reporting category "other." Other possible modes of transmission that may occur among women include infection through artificial insemination (especially before the availability of HIV testing), sexual abuse or assault, contaminated instruments used for body piercing or tattooing, and healthcare-related occupational exposure. Certain female reproductive tract conditions (e.g., bacterial vaginosis, pelvic inflammatory disease, chlamydia) make HIV more serious.

The risk for acquisition of HIV and the factors that may affect seroconversion in heterosexual women are areas of research. In Europe and the United States, heterosexual monogamous couples with one HIV-infected partner and no other risk factors were followed over time. It was found that female partners of HIV-infected men were 17.5 times more likely to become infected than male partners of infected women. It was also found that the risk for infection increased in couples who did not consistently use latex condoms, were symptomatic, or had low CD4 counts. In other words, women are much more likely to become infected with HIV through heterosexual sex than men, and latex condoms, when used consistently, are an effective means of preventing transmission [55].

TOPICAL MICROBICIDES

Because HIV is spread predominantly through sexual transmission, the development of chemical and physical barriers that can be used intravaginally or intrarectally to inactivate HIV and other STI pathogens is critically important for controlling HIV infection.

Researchers are developing and testing new chemical compounds that women could apply before intercourse to protect themselves against HIV and other sexually transmitted organisms. These include creams or gels, known as topical microbicides, which ideally would be non-irritating and inexpensive. In addition, microbicides should be available in both spermicidal and non-spermicidal formulations so women do not have to put themselves at risk for acquiring HIV and other STIs in order to conceive a child. The research effort for developing topical microbicides includes basic research, preclinical product development, and clinical evaluation.

First-Generation Microbicides

The first microbicides developed to lessen the risk of HIV infection were non-specific entry inhibitors and surfactants [37,57]. These products formed physical barriers in the vagina (surfactants) or changed the vaginal chemistry (pH-modifiers, polyanions), essentially making an environment that is less conducive to the transmission of HIV. First-generation microbicides are gel products that must be applied within a few hours prior to sexual intercourse. Given the complexity of HIV transmission, it is possible that these early microbicides would only be at best 30% to 50% effective [56].

Next-Generation Microbicides

Today, topical microbicide research is focused primarily on new technologies for preventing HIV infection, predominantly the use of antiretroviral agents in the products' formulations. The newer microbicides include NRTIs, NNRTIs, or entry inhibitors to suppress the virus before it begins replication [37,57]. In contrast to the less specific first-generation microbicides, these products are formulated to specifically target HIV.

Because next-generation products may be formulated in sustained-release formulations (e.g., the dapivirine ring), application is not dependent upon planned sexual contact [57]. However, resistance to the antiretroviral agents is a serious concern.

CLINICAL MANIFESTATIONS

Research is being conducted to determine whether the clinical manifestations of HIV, other than those related to the reproductive tract, are different for women than for men. It appears that many symptoms and signs of acute HIV infection and non-specific manifestations, such as fevers, weight loss, and fatigue, are the same. Because past research has either excluded women altogether or included only small cohorts of women, it has been difficult to determine gender differences in the clinical course of HIV disease.

In a large, multicenter cohort study comparing mortality and disease progression between women and men, women were more likely than men to develop bacterial pneumonia, especially if they were injection drug users. In addition, women were more likely to have mycobacterial infections, whereas men had higher rates of oral hairy leukoplakia and Kaposi's sarcoma [55,56].

It is noteworthy that many healthcare providers fail to recognize recurrent vaginal candidiasis as a potential indicator of HIV [56]. This failure to diagnose results in delays in treatment. As many as 60% of HIV-infected women also test positive for some type of human papillomavirus (HPV). HIV infection is a risk factor for higher prevalence of HPV in the cervix and increased likelihood of infection by multiple HPV types. HIV infection is associated with a high rate of cervical cancer and cervical intra-epithelial neoplasia (CIN) or squamous intra-epithelial lesions (SIL). Menstrual irregularities are also frequently reported by women with HIV [56].

PROGNOSIS

Studies have shown that women with AIDS have a poorer prognosis than men, although this is mainly attributed to socioeconomic factors. In a large sample of women and men with HIV, it was found that women had poorer survival rates, although the rates of progression of disease were the same over a 15-month observational period. According to the National Institutes of Health, HIV-positive women whose diagnosis is timely and who receive appropriate treatment have the same survival rate as HIV-infected men [56]. Researchers have speculated that poorer access to or use of healthcare resources (later diagnosis), domestic violence, homelessness, and lack of community support may contribute to the seemingly higher mortality rate for HIV-infected women [56].

ART IN THE HIV-INFECTED PREGNANT WOMAN

HIV counseling and the offer of HIV testing to pregnant women have been universally recommended in the United States and are now mandatory in some states. Care of the HIV-infected pregnant woman should involve a collaboration between the HIV specialist caring for the woman when she is not pregnant, her obstetrician, and the woman herself. Treatment recommendations for HIV-infected pregnant women are based on the belief that therapies of known benefit to women should not be withheld during pregnancy unless there are known adverse effects on the mother, fetus, or infant that outweigh the potential benefit to the woman [30,31]. Regardless of the stage of pregnancy or childbirth, if a woman is found to be HIV-positive, there are treatment options that should be explored.

Patients should be registered with the Antiretroviral Pregnancy Registry, which collects observational, nonexperimental data. The registry is sponsored by GlaxoSmithKline, in affiliation with the CDC and Kendle International Inc. Women who have been treated with ART at any time during their pregnancies are eligible for registry enrollment. The telephone number for registration is (800) 258-4263, and the website is http://www.apregistry.com.

UTILIZATION OF HEALTHCARE SERVICES

There is evidence that the utilization of healthcare services is different for women with HIV disease than for men. Women are less likely than men to receive combination ART and generally have poorer access to services than men [28]. Overall, women received fewer services even after they had been diagnosed and had accessed healthcare services. Women with HIV are more likely to utilize emergency services and to be hospitalized than men with HIV [23,28].

There are several factors that affect HIV-positive women's ability to utilize available services. Studies have shown that women are almost twice as likely as men to postpone necessary care due to lack of available transportation or being too sick to visit their physician [28]. Other factors identified as barriers to equal access to care for women with HIV are stigma and isolation, lack of empowerment, competing concerns (e.g., food, housing, care for other family members), child care, insurance, and domestic or partner violence [23]. Predictors for poor access to care include racial or ethnic minority status and lack of insurance [23].

PSYCHOSOCIAL FACTORS RESULTING FROM HIV

Many women experience stigmatization and isolation after being diagnosed with HIV. Because of women's position in society, HIV-positive women confront many problems not confronted by men with HIV. For instance, the social expectation is that women are the caregivers for those who are ill in the family. As a result, women with HIV often care for their partner or children when they are ill themselves. Domestic violence has been increasingly identified among women living with HIV. In some instances, this violence has led to death [55].

Other common psychological issues that arise for women with HIV include chronic low self esteem, feelings of powerlessness, substance abuse, continuing high-risk behaviors, and psychiatric comorbidities [23]. The prevalence of anxiety and mood disorders, illicit drug use, significant alcohol use, and use of psychotropic medications among individuals with HIV is significantly higher than in the general population [23]. These issues must be addressed in order to ensure compliance with prescribed treatments and adherence to scheduled follow-up.

IMPLICATIONS FOR BEHAVIORAL HEALTH AND HEALTHCARE PROFESSIONALS

Healthcare professionals must assume a greater role in advocating for women with HIV, shaping public policy and increasing knowledge about HIV infection through research. Behavioral health professionals are in an ideal position to participate in the early identification of women with HIV and to facilitate their entry into the healthcare system. Clinicians with a holistic perspective are ideally suited to provide a comprehensive family-oriented approach to healthcare that incorporates multiple services in one setting for women with HIV.

Lending their experience and expertise, healthcare professionals can influence the development of appropriate institutional and public policies that affect HIV-infected women. For example, in substance abuse programs, behavioral health professionals can advocate for policies that support gender-appropriate, as well as culturally sensitive services and incorporate the use of the harm reduction model into the program. On a local government level, professionals can be active in the support of community-based efforts established to meet the needs of women with HIV. On a national level, it is imperative that the protection of women's reproductive rights, confidentiality regarding HIV status, and other critical issues that women with HIV face are advocated [55].

The epidemiology, clinical manifestations, and social factors that affect women with HIV have been reviewed. Many of these issues have been only briefly touched on because they are too lengthy to cover in this course. Readers are encouraged to seek more information about these issues from the recently growing body of literature on women and HIV. Finally, it is important for healthcare professionals to respond to the need for quality healthcare for the growing number of women infected with HIV and their families, to serve as advocates by influencing public policy, and to pursue research that increases our understanding of the problems faced by women living with HIV [55].

INFANTS AND CHILDREN WITH HIV

The initial case reports of pediatric AIDS in infants published in 1983 took much of the world by surprise. Initially, these reports were the subject of much discussion and controversy because many people refused to believe that children could suffer from AIDS. Over the ensuing years, there have been many advances in the recognition, diagnosis, and treatment of pediatric AIDS as well as the unfolding of a pandemic that is a worldwide concern. In the United States, effective screening of blood and improved manufacturing techniques for coagulation factors have eliminated these products as a cause of transmission. In 2010, an estimated 217 children younger than 13 years of age were diagnosed with HIV; 162 (75%) of those children were perinatally infected [59]. Thus, the epidemic in children is closely linked to the epidemic in women [59]. Mother-to-child transmission (MTCT) can occur during pregnancy, labor and delivery, or breastfeeding in both symptomatic and asymptomatic women.

PREVENTION OF PEDIATRIC HIV

The tragedy of MTCT is that women may be unaware of their risk. The CDC has adapted recommendations that advocate universal counseling and testing with informed consent for every pregnant woman regardless of geography, identified risk behavior, or self-identified risk. In its 2013 guideline, the U.S. Preventative Services Task Force (USPSTF) recommended screening all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. The benefits supporting this statement included a potential for decreased perinatal transmission of HIV resulting from maternal and neonatal ART treatment and the increased opportunity to provide counseling regarding risks associated with breastfeeding and elective cesarean delivery [60].

Many women do not have an identified care provider, lack insurance coverage, seek care only for acute illness, or lack access to ongoing care. Nonetheless, by making counseling and testing a component of routine prenatal care, these recommendations will improve the care given to HIV-infected pregnant women and identify infants at risk for HIV prior to their birth. The American Academy of Pediatrics recommends HIV testing of newborn infants if testing was not offered or accepted by the mother during the prenatal period or if the mother did not receive prenatal care [47]. Testing should be offered confidentially, with counseling and informed consent provided and available healthcare services that are readily accessible.

DIAGNOSIS AND TREATMENT

The major advances in diagnosis and treatment are profoundly influencing the care of women and children with HIV infection. The documented ability of ZDV to interrupt MTCT has had a tremendous impact on the field of maternal and pediatric HIV. A second major advance is in the diagnosis of HIV infection in infants, which may be completed by 1 month in nonbreastfed infants with the use of virologic assays [84].

In settings throughout the United States, healthcare professionals encounter women and children in their daily practice. Knowledge about and understanding of the nationwide spread of HIV and its implications are crucial. Every pregnant woman must be offered an opportunity to know her HIV status in order to receive the best prenatal care and to assure prompt assessment of her newborn. Although surveys provide a statistical picture, each woman is an individual. HIV testing should always be offered after information and counseling has been provided to the pregnant woman.

More critical than pretest counseling is post-test support. Negative results provide opportunity to reinforce risk. Positive results should always be given in person, never over the phone. If the site is unable to provide continuing services, arrangements must be made for uninterrupted prenatal care that is acceptable to the woman. The diagnosis of HIV is devastating to a pregnant woman, and intense support through an identified friend or family member may be helpful. Depending on the length of gestation, the woman will have many questions regarding the pregnancy as well as her own health.

The full spectrum of HIV disease in children has become evident as children survive longer. Early in the epidemic, only the most symptomatic and ill children were diagnosed, and so death appeared to occur in infancy and early childhood for most children. It is now recognized that to understand the natural history (disease progression), the progress of infected children must be followed from birth. Several prospective studies in the United States and Europe are following the progress of infants born to HIV-infected women; these cohorts serve as the basis for our description and understanding of the disease in children. Recent reports from these groups show that the median survival for infected children is 8 years, with children with PCP and encephalopathy having the poorest prognosis and the highest mortality in the first year of life. The period from infection to onset of AIDS-defining symptoms is often referred to as the clinical latency period. However, ongoing, complex interaction occurs between the virus and the immune system. The absence of clinical symptoms does not mean that the child is truly "well." Except for age at diagnosis and type of clinical presentation, no demographic or clinical indicators have been related to prognosis. Low CD4 counts for age are the best indicators of immunodeficiency and indicators of the risk of developing opportunistic infections. Early identification of the infected infant, specific prophylactic regimens to prevent infections, and ongoing supportive care are important in improving survival.

Antiretroviral therapy is believed to play a major role in slowing progression of the disease process. Many of the antiretroviral medications approved for use in the treatment of HIV/AIDS are produced in a pediatric formulation [84]. The pharmacologic recommendations for infants and children are based on the same regimens that have been established for adults.

Children receiving ART should be monitored for side effects, adherence, efficacy and toxicity. The U.S. Department of Health and Human Services recommends evaluating all pediatric patients within 1 to 2 weeks and again within 1 to 2 months to monitor compliance, side effects, and response to treatment. Subsequently, a visit should be scheduled every 3 to 4 months [84]. Strategies to improve adherence should focus on selecting an appropriate regimen, educating the family/caregiver, and consistent follow-up.

CARING FOR THE CHILD WITH HIV

HIV infection is a chronic health condition meeting the classic definition as "a condition with a protracted course which can be progressive and fatal, or associated with a normal life span despite impaired physical and mental functioning" [62]. It is helpful to view HIV infection as developing along a continuum that begins with little direct impact on the child and ends with profound impact on the child and family. This continuum occurs within a framework of family illness and loss that must be acknowledged by nurses, physicians, and other healthcare and service providers. Continuum of family illness is one of the most significant differences between HIV and other chronic health conditions of childhood. Experience gained while working with other chronic childhood conditions can be used when dealing with healthcare concerns of the child with HIV. Healthcare providers have played a central role in building and staffing networks for HIV-infected children and continue to be key care providers in an era of changing healthcare delivery models.

When planning care for a child with HIV infection, the complete spectrum of disease must be considered. Because their practice is dictated by the requirements of the setting or the position, there is a temptation for many healthcare providers to narrow the focus to the immediate needs of a child in a particular setting. However, the scope of needs for the child is broad and changes with symptoms, disease progression, and treatment. Healthcare providers who combine excellent clinical and interpersonal skills with sensitivity and respect for children and a willingness to educate and support the child and caretakers can make a tremendous difference in the quality of life for the child and family. Such practitioners are aware of their place within a team that may encompass other healthcare professionals and several settings and evidence a willingness to work cooperatively. Communication and consultation with case managers, clinical specialists, nurse practitioners, and mental health practitioners can benefit the child and family.

ADVANCED HIV DISEASE IN CHILDREN

The advanced stage of HIV disease in children is manifested by multiple complications. Usually, several organ systems are affected, producing many symptoms, and the progression of disease can be slow or rapid. The course of the disease is not easily predictable. Children who appear to be near death can rally and live for months or years, whereas other children die suddenly and unexpectedly. This uncertainty makes planning and decision making difficult for patients, families, and providers. Quality of life issues come into conflict with treatment decisions. Symptoms that are caused either by the disease itself or its treatment are extremely complicated to manage. Multiple services are required in the community to allow a child to remain at home for as long as possible.

In 2008, the CDC published a revised case definition for pediatric HIV. Advanced disease is characterized as severe immune dysfunction accompanied by severe clinical symptoms. Immune dysfunction is evaluated by CD4 count at a specific age. Children with CD4 counts in these ranges are considered severely immunologically depressed and are at high risk for the complications associated with advanced HIV disease. Clinical symptoms are divided into four categories, ranging from no symptoms to severe symptoms. Children with advanced HIV disease frequently have more than one symptom occurring simultaneously [64].

MAINTAINING THE CHILD IN THE HOME AND COMMUNITY

As HIV disease progresses and the child becomes increasingly ill, it is still in the child's best interest to remain at home and to engage in as many normal activities as possible. In order for this to happen, a great deal of coordination and planning is required by various healthcare providers, including nurses, social workers, physicians, psychologists, nutritionists, and community outreach workers. A system such as case management can assure good planning and implementation of services and avoid duplication. Using community-based home care services including visiting nurses, home health aides, pharmacies, infusion therapy, and respiratory therapy services can assist the family in caring for a child at home for a long period of time. Good communication with these agencies is essential. Social workers play a critical role in assisting families to find resources and entitlement programs that provide payment for these services. Developing a relationship with the child's school can result in a child continuing to attend school for a few hours a day.

For children to remain in their homes, their families must be able to care for them safely and comfortably. This care can present a big challenge to the family and healthcare providers. Children with HIV live in many kinds of family situations. Many live with biologic parents who also may be sick with HIV. Drug and alcohol abuse may be present in the home. Many children live in homes with low incomes in high-crime areas. Others live with extended family members, often grandparents, who may be elderly with health problems of their own. Some live in foster homes in which there are more than one sick child who needs care. All of these situations can make the provision of safe home care a challenge.

Caregiver education about the child's problems, treatments, and medications is essential. Frequently, this information must be repeated numerous times. Tools such as medication schedules, calendars, and diaries are helpful. Assessing the home before implementing a complex treatment such as oxygen or parenteral therapy is mandatory because the environment may need to be altered to accommodate the equipment. Some environments may be deemed unsafe, and alternate living arrangements may be required. Infrequently, the child's family, even with home care services, cannot carry out a treatment plan. The options are limited to forgoing the treatment or placing the child in another situation, possibly a foster home or group or nursing home. This should always be the last option considered, when all other means of maintaining the child at home have been exhausted. With the appropriate community-based services, most children with advanced HIV can remain at home throughout the course of the disease. This should always be the goal. Only when the child's safety is clearly at risk should other options be considered [22].

OLDER PEOPLE WITH HIV

Approximately 15% of newly diagnosed cases of HIV/AIDS in 2005 occurred in individuals 50 years of age or older; 29% of all persons living with HIV/AIDS are 50 years of age or older [46,65]. However, until recently, there had been little attention given to this group [65]. HIV/AIDS has traditionally been thought to be the disease of the young; therefore, in the past, prevention and education campaigns had not been targeted toward older adults. However, evidence points to the increasing number of infected older people and a need for change in prevention and education campaigns. Some older persons may have less knowledge about HIV and risk reduction strategies. Due to divorce or being widowed and the availability of medications to treat erectile dysfunction, increasing numbers of older people are becoming sexually active with multiple partners [65,66]. For postmenopausal women, contraception is no longer a concern, and they are less likely to use a condom. Furthermore, vaginal drying and thinning associated with aging can result in small tears or cuts during sexual activity, which also raises the risk for infection with HIV/AIDS [67]. Studies indicate that at-risk individuals in this age group are one-sixth as likely as younger at-risk adults to use condoms during sex [68]. The combination of these factors increases the risk for unprotected sex with new or multiple partners in this age group, thereby increasing their risk for AIDS.

This increase must be considered when evaluating older patients. Individuals in this age group are significantly less likely to be tested for HIV [68]. Elderly people presenting with confusion or altered mental status or having severe bouts of pneumonia may first be evaluated for other possibilities before HIV is considered. Many physicians do not suspect HIV in their older patients and miss the opportunity to suggest testing, which can result in delayed diagnosis and treatment.

Early possible signs of immunosuppression that are frequently overlooked or mistakenly attributed to aging include thrush and skin problems, especially seborrheic dermatitis, herpes zoster, and recurrent herpes simplex virus type 2 in a person who does not have a history of it. When HIV is not recognized or treated, the most typical opportunistic infections are PCP and recurrent bacterial pneumonia, CMV, and Mycobacterium tuberculosis or Mycobacterium avium complex. PCP can present as bacterial pneumonia, bronchitis, or congestive heart failure. Early HIV symptoms in the elderly, such as fatigue and weight loss, may appear to be a normal part of aging, and AIDS-related dementia is often mistaken for Alzheimer's disease.

CHALLENGES OF HIV CARE

Anyone caring for patients with HIV and AIDS faces significant challenges in their area of practice. Working with patients who are facing an illness with a long and unpredictable course and a fatal outcome, caregivers have the opportunity to help patients reach an optimal level of health, whatever their disease stage. They can facilitate the patient's role as active participants in their work, their families, their communities, and their health care. Caregivers find that caring for patients with HIV disease can be exceptionally rewarding but also can be stressful and frustrating. Stressors in HIV work arise both from specific issues related to HIV and from more generic concerns that stem from being a helping professional working with patients with a chronic illness in an environment of limited resources. By recognizing both the positive and difficult aspects of HIV care, members of the healthcare team can be more effective in caring for our patients and for ourselves.

As the lifespan for persons with HIV (both adults and children) has increased, the issues in HIV care share many commonalities with other chronic illnesses. Persons with HIV disease have periods of wellness interrupted by acute exacerbations and a gradual decline in health. Like other chronic illnesses, HIV forces patients to interact with the healthcare system on a regular basis when seeking subspecialty care and support services. Those caring for individuals with HIV in ambulatory and community settings often see them as vital, functioning members of the community, whereas in acute care settings, they may only see gravely-ill HIV patients [69].

However, HIV raises some particular issues that impact care providers as well as the patients. The stigma of HIV and AIDS leads many people to fear disclosure of diagnosis. As a result, patients may have little social support and may turn to healthcare providers as their sources of emotional support. Healthcare professionals in ambulatory settings, home care agencies, and hospital units find that their patients need more psychosocial support than those who have other sources of support.

The stigma of HIV also can affect healthcare professionals directly. Although public attitudes have improved over the years, many in the lay public are fearful of HIV and extend that fear to HIV healthcare providers. Most patients with HIV are young people in their most productive years; thus healthcare professionals, who are often in the same age group, must face the loss of patients whose lives may parallel their own. Providers must examine their own behavior and risk factors for HIV and confront their own fears of sexual transmission. Some have chosen to work in the HIV field because of their own personal experiences with family or loved ones with HIV, whereas others find themselves caring for HIV-infected patients while being unprepared for the issues that HIV raises.

HIV continues to be an illness for which the media and the public frequently blame the ill person who has acquired the disease. Because of its routes of transmission, HIV raises issues of sexuality and drug use that we must address if we are to be effective with patients. We must understand how our values about sexuality and drug use influence our attitudes toward patients and must increase our knowledge and comfort level about these issues so that we can work with patients about safer sex practices or dealing with past or current drug use. Similarly, we often have difficulty dealing with women who are HIV-positive and choose to have infants who are then at risk for acquiring HIV prenatally. Healthcare professionals who have not addressed their own beliefs and attitudes in these areas are likely to be ineffective with patients, frustrated in the practice and vulnerable to burnout.

Other HIV-specific issues add to the stress of HIV work. Providers caring for persons with HIV have a small, but real, risk of occupational transmission. Reactions range from extreme fear and avoidance of patients with HIV to an almost careless attitude. Care providers must decrease any perceived threat by increasing their understanding of their values and their comfort levels with difficult issues such as cultural differences, sexuality, and death. At the same time, they must be vigilant in practicing universal precautions so that the real risk of HIV occupational transmission is minimized [69].

Persons caring for children with HIV and their families confront issues of grief and death similar to those facing providers who care for children with other fatal childhood illnesses. Death occurs at a young age, out of the "natural order" of life, forcing providers and families to deal with grief and loss at an unanticipated point in their lives.

The spread of the AIDS epidemic forces health professionals to confront the modern myth of a cure. With the advent of antibiotics, infectious diseases became, for the most part, curable illnesses, and many health professionals entered the profession with that mindset. HIV has dislodged that confidence, and health professionals face an incurable illness with complications for which they have few interventions. Treatments that are available are complex and uncertain. The scientific knowledge on which management is based is emerging daily. This lack of effective treatment and rapidly changing science can lead to feelings of despair and helplessness [69].

In order to work effectively with HIV patients, professionals must develop strategies for coping with the demands of HIV work and maintaining a sense of professional integrity without despair. Burnout has been defined as "a syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment . . . as a result of chronic emotional strain of dealing extensively with other human beings, particularly when they are troubled" [69].

Personality factors also influence one's responses to stressful work. Research indicates that a factor such as personal hardiness can positively impact the ability to manage stress. Three personality characteristics make up personal hardiness [69]:

  • Commitment: a strong sense of dedication to self and others

  • Control: a sense that one can influence events in one's life and can distinguish those events from events that one cannot control

  • Challenge: a view of change as a positive experience rather than a threat

SUPPORT FOR HEALTHCARE PROFESSIONALS

Many causes of stress for caregivers in the HIV field lie not within the individual but within the system in which he or she practices. Management practices can accentuate or prevent these stresses. Some strategies require only openness and flexibility from those in administrative positions; other strategies require resources, both financial and time, that agencies may not have. By acknowledging that HIV work is stressful, management and leadership can establish administrative practices that help providers recognize stress and provide various strategies for stress reduction that respect both the nature of the practice and the variability in an individual's response. Policies should recognize the need for time to grieve. Some may wish to have time off to go to funerals, whereas others may reach closure in other ways. By establishing an equitable way to allot time for bereavement, administrators can support the staff in the grieving process. Others may need mental health time after a particularly difficult encounter such as discussing a "do not resuscitate" order with a family. Such policies demonstrate to the staff that the organization recognizes the stress of the work and values self-care.

Reviewing case loads provides an opportunity to readjust the volume of patients and to reassign difficult patients or families in order to provide a break and offer a fresh look at interacting and problem solving with the patient. Another important strategy for decreasing stress is for agencies to cultivate an environment of intellectual inquiry. Case conferences or team meetings can be a place in which new literature is discussed, new approaches are described, and a problem-solving approach is supported. Healthcare agencies have the potential to become learning organizations in which the goals of the organization are advanced by collective idea sharing and problem solving.

Agencies can lessen stress by helping personnel deal directly with issues that impact their care of patients with HIV and with which they may be uncomfortable. As the literature on burnout indicates, those who are less comfortable with issues such as sexuality, drug use, and death are more vulnerable to job stress. Through seminars, speakers, and in-service presentations, the staff can be offered the opportunity to increase their knowledge, examine their own values, and learn more about the culture and values of patients for whom they care. By increasing their knowledge level and examining their attitudes, they can be more effective with their patients [69].

END OF LIFE CARE

A study supported by the Agency for Healthcare Policy and Research has concluded that healthcare providers should periodically reassess patient preferences for life-sustaining care, especially for patients with a progressive disease such as AIDS. The study showed that about one-fourth of AIDS patients changed their minds about life-sustaining care over a 4-month period. Changes in physical functioning, pain, or thoughts of suicide were more apt to modify a patient's decision about resuscitation. Patients who lacked an advance directive, had not completed high school, or became more severely ill during the 4-month period were more likely to change their preferences about life-sustaining care [54].

ETHICAL AND LEGAL CONSIDERATIONS

The ethics and law around AIDS and infection with HIV give rise to many issues that cut across several values. There is often conflict between the autonomy of the patient to behave freely, the autonomy of the patient to have care when needed, and the autonomy of the care provider to exercise judgment in their practice.

In the United States, HIV infections have historically occurred overwhelmingly in two populations: MSM and IDUs. But the number of new infections is growing in many groups, including women. Furthermore, ethnic minority groups (particularly blacks and Hispanics) are disproportionally affected by the disease. Therefore, sociocultural issues are an important aspect of care [72].

FINANCIAL ISSUES

Employment can pose a problem for individuals with HIV/AIDS. Possible issues that may be raised include difficulty maintaining employment or resuming employment after health has been restored or stabilized, stigma associated with the disease, future disability risk, confidentiality concerns, and the resulting financial burden for the employer.

Although individuals diagnosed with HIV/AIDS are living much longer as a result of available treatments, they may be forced into extended "HIV retirement," whereby employment is no longer possible due to the effects of the disease. It has also increased the number of persons living with HIV/AIDS returning to the workforce [45]. Data collected on the employment status of these individuals are scarce, but level of employment appears to be related to advanced disease, number of complications, and level of support/use of resources [39,74]. The National Working Positive Coalition has been established to study issues of employment among persons living with HIV/AIDS and provides several toolkits and resources for employees and employers [61].

At the beginning of the AIDS epidemic, insurance companies would generally approve AIDS-related disability claims quickly, as the prognosis for infected individuals was so poor. As prognosis for HIV-infected individuals has improved, it has become more difficult to obtain insurance approval for treatments and/or disability services [74].

CONFIDENTIALITY

Practitioners should take extreme care in not violating the patient's confidence and should obtain the patient's consent before sharing information about their health status. Ethical judgment may be enhanced by knowing the specific state law and regulations pertaining to persons with HIV and the release of confidential information [72].

FEAR OF HIV/AIDS PATIENTS

Some professionals, reluctant to care for HIV/AIDS patients, may find that the law enforces the duty to care for all patients [72]. Many states have passed laws requiring specific consent from the patient before an HIV test may be performed [76]. Nurses, for example, may refuse to compromise their own safety and ethical standards, but they have a professional responsibility to ensure that the nursing needs of patients are met on an emergency basis. Whether the nurse has a duty to care for all patients combines the nurse's ability, the requirements of the patient, and the degree of risk. Nurses may consider the risk of nursing some patients in the light of whether there is risk to themselves, their families, and their personal ethics.

Appropriate Attitude and Behavior of the Caregiver

  • Encourage the HIV positive patient to become involved in his/her own care and determine the schedule of care when possible. Allow them to make decisions regarding their care whenever possible. This will foster for them a sense of control and independence.

  • Be aware of your own attitudes toward HIV/AIDS and toward the behavior risk factors that put people at risk for contracting HIV. Remember it is not appropriate for you to judge the behavior of a person infected with HIV. How a person became infected should not be an issue.

  • Treat others as you would like to be treated or you would like to have your family treated. Recognize that many family structures include same sex partners and extended family members. Avoid placing judgment on families that do not look or behave like yours.

  • Do not be afraid to talk about the disease with the patient if he or she is willing to talk with you.

  • Do not be afraid to touch a person with HIV. Holding a hand, giving a hug or back rub may be comforting. However, also be sensitive to people who do not want physical closeness.

  • Be aware that universal/standard precautions are to be used with all patients, not just those who are HIV positive.

  • Be sensitive to the sense of isolation that may be felt by the HIV patient if they have an opportunistic infection that requires isolation precautions.

  • All information about a person who has HIV must be kept in the strictest confidence. Public health disclosures must be documented to meet HIPAA compliance.

  • Remember that all patients deserve respectful, competent care.

According to the Americans with Disabilities Act (ADA), an individual is considered to have a disability if he or she has a physical or mental impairment that substantially limits one or more major life activities, has a record of such impairment, or is regarded as having such impairment [87]. Persons with HIV disease, both symptomatic and asymptomatic, have physical impairments that substantially limit one or more major life activities and are, therefore, protected by the law. Persons who are discriminated against because they are regarded as being HIV-positive are also protected. For example, a person who was fired on the basis of a rumor that he had AIDS, even if he did not, would be protected by the law. Moreover, the ADA protects persons who are discriminated against because they have a known association or relationship with an individual who is HIV-positive. For example, the ADA would protect an HIV-negative woman who was denied a job because her roommate had AIDS [87].

Under the ADA, an employer must make a reasonable accommodation to the known physical or mental limitations of a qualified applicant or employee with a disability. However, an employer is not required to provide an accommodation if it would post an undue hardship on the operation of its business. Undue hardship is defined as "an action requiring significant difficulty or expense" [87].

Also, the Federal Rehabilitation Act of 1973 prohibits discrimination on the basis of a handicap. All stages of HIV disease, including asymptomatic HIV infection, have been found by the courts to be handicapping conditions under Section 504 of this Act [86].

CONSENT TO TEST

Informed consent should be obtained from each person being tested. Each individual should be fully aware of the limitations of the HIV-antibody test regarding HIV infection and the development of AIDS. The test and its meaning, the reason for ordering the test, and its potential adverse consequences should be understood. The consent also includes information about how the test information will be used.

Cultural Considerations in Informed Consent

An individual's ability and prerogative to make decisions about treatment is now seen as a vital expression of autonomy and is a prerequisite to participation in treatment or interventions. Autonomy, individualism, and self-determination are belief systems that are highly valued in Western societies, especially in the U.S. Autonomy may be categorized into two groups: first-order autonomy and second-order autonomy [51]. First-order autonomy is what Westerners espouse and value: self-determination and autonomy in decision making. Second-order autonomy, however, is prevalent in collectivistic societies where decision making is group-oriented and takes into account another decision-maker who is accorded authority and respect [51]. For example, in many Asian cultures, particularly if the family system is based on a patriarchal authority system, a male elder or leader who is regarded as the primary decision-maker is key in this process of informed consent.

The process of informed consent entails the explicit communication of information in order for the individual to make a decision. Again, Western cultures value explicit information, which is centered on American consumerism; believing in having choices and being able to exercise choices in purchases extends to healthcare. However, some cultures believe that language and information also shape reality [50]. In other words, explicit information, particularly if it is bad information, will affect the course of reality.

A signature is required on most Western informed consent forms to represent understanding and agreement on the part of the individual involved. Yet, this might be viewed as violation of social etiquette in some cultures. In some cultures (for example, Egypt), signatures are usually associated with major life events and legal matters. Therefore, requiring a signature outside these circumstances would imply a lack of trust, particularly when verbal consent has been given [48].

Furthermore, consent forms often contain technical and legal jargon that may be overwhelming to the native English speaking individual, but can be much more daunting for immigrants who may not be English proficient or familiar with various legal concepts. For some immigrants who have experienced political persecution in their homelands, asking for a signature on a consent form that contains foreign legal and technical terms can potentially place them at risk for secondary traumatization, as some were persecuted, tortured, and forced to sign documents in their homelands [52].

This cultural dissonance can be a challenge to many general healthcare and mental health practitioners. Cultural experts are highly recommended for consultations to assist in the interpretation and navigation of the complex web of cultural interactions.

AIDS PREVENTION

PRE-EXPOSURE PROPHYLAXIS

In 2012, the FDA approved the first medication for the prevention of sexually transmitted HIV infection, the combination drug Truvada (emtricitabine/tenofovir DF) [88]. In conjunction with safer sex practices, Truvada has been found to be partially effective as pre-exposure prophylaxis in high-risk patients [89]. In 2014, the CDC and the U.S. Department of Health and Human Services released clinical practice guidelines for pre-exposure prophylaxis for the prevention of HIV Infection [90]. This new guideline outlines indications for prophylaxis as one prevention option for HIV transmission, in particular for high-risk, IDUs, MSM, and heterosexually active men and women. The most important first step in determining if an individual is a candidate for pre-exposure prophylaxis is a thorough history, including sexual and injection drug activities.

All patients prescribed Truvada for pre-exposure prophylaxis must have a negative HIV test prior to initiating treatment and every 3 months thereafter. In addition, patients should be advised regarding possible side effects and the continued necessity for safe sex practices. Eligible patients should also be screened for hepatitis B and possible kidney problems [90].

AIDS VACCINE

Achieving an end to the AIDS epidemic will require the development of an effective vaccine. Both preventive and therapeutic vaccines are being studied for use in the fight against HIV. Preventive vaccines are developed to protect individuals from contracting HIV, while the goal of therapeutic vaccines is to boost immune response to and better control existing HIV infection [38]. Of course, the ultimate goal in vaccine research is a vaccine that will prevent infection; however, despite several trials, no vaccine effective in preventing HIV has been discovered. In 2014, a study of a new approach involving injection of known neutralizing antibodies (rather than an antigen to stimulate the body to produce antibodies) was initiated [27].

The International AIDS Vaccine Initiative (IAVI) is working to speed the development and distribution of preventive AIDS vaccines, focusing on four areas: mobilizing support through advocacy and education; accelerating scientific progress; encouraging industrial participation in AIDS vaccine development; and assuring global access.

EDUCATION AND INTERVENTION TO PREVENT HIV/AIDS INFECTION

Many adolescents engage in behaviors that put them at risk for HIV infection. According to the CDC, nearly 50% of high school students have engaged in intercourse [83]. Approximately 40% of sexually active high school students had not used a condom at last sexual intercourse; 2.3% had ever injected an illegal drug [83]. The CDC asserts that renewed educational efforts that reach all students before risk behaviors are initiated and that seek to delay the onset of sexual activity, increase condom use among students who are sexually active, and decrease injection drug use are warranted [83]. Education and interventions are considered vital to the reduction of high-risk behaviors in this population.

Although more than 90% of adolescents report having received education on HIV prevention in school, the content of these discussions may not provide adequate information on the subject. Furthermore, the American Academy of Pediatrics determined that school-based education and intervention programs do not provide the necessary opportunities of confidential discussions or targeted counseling [73]. Healthcare professionals have a unique opportunity to intervene in this population to provide accurate and complete information on HIV transmission and risk reduction.

The CDC HIV/AIDS Prevention Research Synthesis Project collects and analyzes systematic reviews and identifies evidence-based interventions that have been proven effective in eliminating or reducing sex- or drug-related risk behaviors, reducing the rate of new HIV infections, or increasing HIV-protective behaviors [78]. As of 2014, 82 best-evidence interventions had been identified, many of which target specific populations. Intervention packages and more information on these interventions are available at http://www.cdc.gov/hiv/dhap/prb/prs.

SUMMARY

Although prevention and new medical interventions may reduce the pace of the epidemic, HIV will be a significant disease for many years both in the United States and the world. Education provides the opportunity to ensure that healthcare professionals have the information necessary to provide the best possible care for persons with HIV. Healthcare administrators have the responsibility to recognize the special stresses, and the generic ones, associated with caring for HIV patients and to address those with meaningful changes in case load and staff support. Those who specialize in HIV care must identify ways to renew themselves through education, individual support, staff support, and variation of workload so that they can continue to contribute their valuable expertise to patients with HIV. With no easy cure in sight, healthcare professionals have the opportunity to work with patients to help them achieve and maintain their optimal level of health during the continuum of HIV disease.

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Evidence-Based Practice Recommendations Citations

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