Study Points

HIV/AIDS: Epidemic Update for Behavioral Health Professionals

Course #74713 - $35 • 7 Hours/Credits

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  1. The established healthcare community became aware of the illness that has since become known as AIDS in

    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].

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  2. The HIV-1 virus was probably transmitted from chimpanzees to humans as early as

    EPIDEMIOLOGY

    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 1908. 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].

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  3. HIV-2 is believed to be endemic in

    EPIDEMIOLOGY

    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 1908. 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].

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  4. Approximately how many individuals were living with HIV/AIDS worldwide in 2018?

    EPIDEMIOLOGY

    According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), an estimated 37.9 million individuals worldwide were living with HIV/AIDS in 2018, 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 approximately 70% of all persons with HIV living in sub-Saharan Africa in 2015 [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, 2013, and 2018 with more than $50 billion in funds to address HIV/AIDS and additional health issues, including malaria, tuberculosis, maternal health, and clean water [12].

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  5. More than half of HIV infections that result from heterosexual contact occur in women.

    EPIDEMIOLOGY

    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., men who have sex with men [MSM] or injection drug users [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 approximately 40% of all new diagnoses in the United States [93]. Women also have a higher risk of infection. More than half of HIV infections that result from heterosexual contact occur in women.

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  6. Black Americans represent what percentage of all HIV/AIDS cases in the United States?

    EPIDEMIOLOGY

    One should keep in mind when reviewing HIV/AIDS trends that the widespread use of combination antiretroviral therapy (cART) has resulted in fewer deaths and longer survival [13]. As of 2018, the Centers for Disease Control and Prevention (CDC) report several trends in the HIV/AIDS epidemic [93]:

    • By region, 41% of persons living with AIDS reside in the South, 28% in the Northeast, 20% in the West, and 11% in the Midwest.

    • By race/ethnicity, approximately 41% are black, 35% white, 19% Hispanic, 3.5% are multiple race, and roughly 1% are American Indian/Alaska Native or Asian/Pacific Islander.

    • By gender, 78.6% of adults and adolescents living with AIDS are male.

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  7. HIV screening tests are intended to negate false-positive tests.

    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

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  8. Which of the following is NOT an established risk category for HIV transmission?

    TRANSMISSION OF HIV

    On the basis of newly reported cases, the transmission categories are [93]:

    • 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

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  9. There have been no cases of HIV transmission traced to

    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].

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  10. Of sexual transmission of HIV, the highest risk of infection is unprotected

    TRANSMISSION OF HIV

    Posing the highest risk of infection is unprotected receptive anal 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.

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  11. Latex condoms are considered highly effective at preventing HIV transmission, resulting in a 70% to 80% reduction compared to never users.

    TRANSMISSION OF HIV

    Latex condoms are considered highly effective at preventing HIV transmission, resulting in a 70% to 80% 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].

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  12. Which of the following co-factors increases the risk of HIV transmission through oral sex?

    TRANSMISSION OF HIV

    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 a man with HIV, 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].

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  13. In comparison with one milliliter of blood infected with hepatitis B virus, which has 100 million to 1 billion infective organisms, one milliliter of HIV-infected human blood contains

    TRANSMISSION OF HIV

    It has been estimated that a milliliter of HIV-infected human blood contains up to 10,000 copies of the virus. In comparison, a milliliter of blood infected with hepatitis B virus has 100 million to 1 billion infective 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 HIV through this route is conservatively estimated to be 1 in 1.5 million [10]. 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.

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  14. The United States implemented a donor screening program for its blood supply in

    TRANSMISSION OF HIV

    It has been estimated that a milliliter of HIV-infected human blood contains up to 10,000 copies of the virus. In comparison, a milliliter of blood infected with hepatitis B virus has 100 million to 1 billion infective 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 HIV through this route is conservatively estimated to be 1 in 1.5 million [10]. 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.

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  15. The risk of sustaining HIV infection from a needle stick with infected blood is approximately 1 in 3.

    TRANSMISSION OF HIV

    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. Preventive 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].

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  16. It is important to note that a disinfected syringe is not a sterile syringe.

    TRANSMISSION OF HIV

    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.

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  17. HIV is transmitted to infants by transplacental spread from mother to fetus in utero, during parturition, or through breastfeeding after birth.

    TRANSMISSION OF HIV

    In the absence of prophylactic treatment, approximately 30% to 50% of children born to mothers with HIV 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.

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  18. Since 1991, perinatal transmission in the United States has

    TRANSMISSION OF HIV

    Worldwide, perinatal transmission accounts for most HIV infections among children. In the United States in 2017, an estimated 73 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 95%, since 1991 [59,75]. This dramatic decrease is mainly attributed to the use of cART [28]. Other strategies for reducing perinatally acquired HIV infection have included preventing HIV infection among women and, for women with HIV, 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].

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  19. HIV has been transmitted via transplanted kidneys, liver, heart, pancreas, and bone.

    TRANSMISSION OF HIV

    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 [57]. 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].

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  20. Blood splashes to the mucous membranes are the most common route of occupational exposure to HIV.

    TRANSMISSION OF HIV

    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 should 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].

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  21. Patients with HIV infection should be seen at regular intervals by a primary care provider to perform periodic physical examinations, monitor prognostic markers, initiate and monitor antiviral and prophylactic therapy, provide supportive counseling, and offer assistance with terminal care.

    MANAGEMENT OF HIV INFECTION

    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.

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  22. All of the following are classes of antivirals used in combination therapy for HIV, EXCEPT:

    MANAGEMENT OF HIV INFECTION

    cART combines seven classes of agents: nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), fusion inhibitors, integrase inhibitors, chemokine (C-C motif) receptor 5 (CCR5) antagonists, and gp120 attachment inhibitors. Initiated in 1995 in the United States, cART regimens have been effective in dramatically decreasing HIV-related morbidity and mortality and should be considered for all persons with HIV who qualify for such therapy. In addition to combination therapy, the sequencing of drugs and the preservation of future treatment options are also important. Two types of combination regimens are recommended as initial therapy: INSTI-based regimens or a PI-based regimen. The goal of these regimens is to effectively reduce HIV-associated morbidity, prolong the duration and quality of survival, restore and preserve immunologic function, and prevent HIV transmission while also avoiding drug resistance [42]. A significant proportion of patients starting cART are infected with drug-resistant strains of HIV, which may lead to suboptimal virologic responses. Therefore, pretreatment genotypic resistance testing should be used to guide selection of the most optimal initial regimen [42].

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  23. Through lifestyle changes, persons with HIV infection can also minimize or eliminate immunosuppressive factors and emphasize factors that promote immune function.

    MANAGEMENT OF HIV 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 persons with HIV. Secondary health maintenance involves prophylaxis and treatments to prevent disease progression.

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  24. Between 2010 and 2016, cases of new diagnosis of HIV among women in the United States increased by 21%.

    WOMEN LIVING WITH HIV INFECTION

    Women now make up half of all AIDS cases worldwide and 23% in the United States [28,80]. The global rate of HIV infection in women is rising rapidly, although the rate in the United States has been decreasing. The proportion of AIDS cases in women 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 2017, women accounted for 19% of new HIV infections, a 21% decrease since 2008 [28,80]. Between 2010 and 2016, cases of new diagnoses of HIV among women in the United States decreased by 21% [80].

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  25. Among African American women 20 to 44 years of age in the United States, AIDS is

    WOMEN LIVING WITH HIV INFECTION

    As of 2017, AIDS is the ninth leading cause of death in African American women 20 to 44 years of age [43]. 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 [43]. While African American women continue to be disproportionately affected by AIDS, new HIV diagnoses among black women decreased 25% between 2010 and 2016 [80].

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  26. Certain female reproductive tract conditions make HIV more serious.

    WOMEN LIVING WITH HIV INFECTION

    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 a man with HIV. 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.

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  27. Women with HIV are more likely than men to develop

    WOMEN LIVING WITH HIV INFECTION

    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 sarcoma [55,56].

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  28. In women with HIV, there is an increased likelihood of

    WOMEN LIVING WITH HIV INFECTION

    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 women with HIV 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].

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  29. 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.

    WOMEN LIVING WITH HIV INFECTION

    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 pregnant woman with HIV 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 pregnant women with HIV 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.

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  30. All of the following are barriers to equal access to care for women with HIV, EXCEPT

    WOMEN LIVING WITH HIV INFECTION

    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 cART 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].

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  31. In substance abuse programs, the use of the harm reduction model would be inappropriate.

    WOMEN LIVING WITH HIV INFECTION

    Lending their experience and expertise, healthcare professionals can influence the development of appropriate institutional and public policies that affect women with HIV. For example, in substance abuse programs, behavioral health professionals can advocate for policies that support gender-appropriate and 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].

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  32. Mother-to-child transmission of HIV can occur during

    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 2017, an estimated 99 children younger than 13 years of age were diagnosed with HIV; 73 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.

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  33. The full spectrum of HIV disease in children is becoming evident because

    INFANTS AND CHILDREN WITH HIV

    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 should be followed from birth. Several prospective studies in the United States and Europe are following the progress of infants born to women with HIV; 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.

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  34. With the appropriate community-based services, most children with advanced HIV can remain at home throughout the course of the disease.

    INFANTS AND CHILDREN WITH HIV

    Caregiver education about the child's problems, treatments, and medications is essential. Frequently, this information should 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].

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  35. Which of the following has NOT been identified as a contributor to the increase in cases of AIDS in older people?

    OLDER PEOPLE WITH HIV

    Approximately 17% of newly diagnosed cases of HIV/AIDS in 2016 occurred in individuals 50 years of age or older; 45% 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.

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  36. Early HIV symptoms in the elderly, such as fatigue and weight loss, may appear to be a normal part of aging.

    OLDER PEOPLE WITH HIV

    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 may be mistaken for Alzheimer disease.

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  37. Which of the following is a possible employment issue that may be raised for an individual with HIV?

    ETHICAL AND LEGAL CONSIDERATIONS

    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.

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  38. Which of the following is NOT considered an appropriate attitude or behavior for HIV/AIDS caregivers?

    ETHICAL AND LEGAL CONSIDERATIONS

    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 patient with HIV.

    • 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.

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  39. Persons who are discriminated against because they are regarded as being HIV-positive are protected by the Americans with Disabilities Act.

    ETHICAL AND LEGAL CONSIDERATIONS

    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].

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  40. As of 2020, there are two vaccines that can be used to prevent HIV infection.

    AIDS PREVENTION

    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]. While much progress has been made in understanding the HIV pathogen, it has provided many challenges in vaccine development, and as of 2020, there is no vaccine to prevent HIV [15,37].

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