1. HIV and AIDS Update for Healthcare Providers Rebecca L. Dekker, PhD, APRN University of Kentucky College of Nursing

2. Learning Objectives • Discuss basic epidemiological and medical information about HIV • Describe transmission, prevention, and current medical treatment of HIV • Discuss management of HIV in the workplace

3. Learning Objectives • Discuss ethical and legal issues related to HIV infection • Describe appropriate attitudes and behaviors towards persons infected with HIV • List the resources available to persons with HIV infection

4. Basic Medical and Epidemiological Information

5. Definition of HIV/AIDS • HIV = Human Immunodeficiency Virus • A retrovirus that destroys CD4+ T cells • HIV-1 • HIV-2 • AIDS = Acquired Immune Deficiency Syndrome

6. Global Epidemic Data from the World Health Organization, 2010

7. History 1959: First retrospectively known human case 1981: Initial recognition in men having sex with men (US) 1985: HIV-1 antibody testing 1986: US Surgeon General Koop calls for sex education 1987: HIV-2 occurrence in the U.S., First anti-HIV drug 1988: First World AIDS Day

8. History 1993: CDC expands AIDS definition 1994: Perinatal prophylaxis 1995: First protease inhibitor 1996: Combination therapy becomes standard of care 1998: Vaccine human trials begin 2002: FDA approves rapid HIV tests 2006: CDC recommends expanded HIV testing

12. Risk Behaviors • Men having sex with men • Injection drug use (IDU) • Male-to-male sexual contact + IDU • Heterosexual contact • Mother-to-child (perinatal) transmission • Other (includes blood transfusions and unknown)

14. Reported Number of Kentucky AIDS Cases,All Ages, Cumulative through December 2009 Cumulative AIDS Diagnoses by ADD 0 - 100 101 - 200 201 - 500 Northern Kentucky 501 - 1,000 Buffalo Trace 441 38 1,000 - 2,500 FIVCO KIPDA 92 2,413 Gateway 57 Bluegrass 1,000 Big Sandy Lincoln Trail Green River 45 147 177 Kentucky River 48 Cumberland Lake Pennyrile Valley Cumberland Barren River 206 104 71 186 Purchase 195 Total = 5,227 7 cases missing ADD of residence

15. AIDS Cases in Kentucky Percentage of Cumulative AIDS Cases by Sex as of December 31, 2009 Female 16% Male 84% N = 5,227

16. AIDS Cases in Kentucky Percentage of Cumulative AIDS Cases by Race/Ethnicity as of December 31, 2009 Black, Not Hispanic 31% White, Not Hispanic 64% Hispanic 4% Other/Unknown 1% N = 5,227

17. AIDS Cases in Kentucky Percentage of Cumulative AIDS Cases by Transmission Category as of December 31, 2009 IDU 13% MSM 55% MSM/IDU 6% Hemophilia 2% Heterosexual 15% Transfusion <1% Undetermined 9% N = 5,192

18. Distribution of US HIV/AIDS population 950K 1000K 280K Undiagnosed 800K 600K 200K HIV+ but not in care 130K HIV+ 400K 200K 340K AIDS Delayed Testing in Kentucky Currently, another Kentuckian becomes infected every day. Between January 1, 2005 and December 31, 2009 there have been a total of 1,740 HIV infections reported in Kentucky. Of these infections, 23% were concurrently diagnosed with AIDS during the same calendar month as the initial HIV diagnosis. (Untested)

19. How does HIV work? • Retrovirus • HIV attracted to CD4 cells • Binds to receptor • Fuses with cell membrane • Core of the virus is injected • Inside the CD4 cell • Converts RNA into DNA • DNA inserts itself into host DNA

20. How does HIV work?

21. How does HIV work? • Decrease in CD4+ T helper cells • Necessary for immune function • HIV replicates prolifically • 10 billion HIV particles are produced each day • Completely overwhelms the body’s defenses

22. Clinical Course • Early infection • Rapid replication • Not detectable by lab tests • No symptoms • Infectious * Seroconversion • Antibodies are detectable • Flu-like symptoms for several weeks • Highly infectious

23. Clinical Course • Clinical latency • Virus levels have stabilized • Body is fighting infection • Last 3-12 years • Asymptomatic or mild symptoms • Rapid virus production • Persistent drop in CD4+ T cell count • Antiviral fight becomes less effective • Viral load increases • Chronic, symptomatic HIV infection

24. CDC HIV Classification System

25. AIDS-Defining Illnesses • Fungal • Candidiasis (Pulmonary, Esophageal) • Pneumocystis (carinii) jiroveci pneumonia • Coccidioidomycosis • Cryptococcosis • Histoplasmosis • Viral • Cytomegalovirus (CMV) • Herpes simplex (chronic ulcer >1 mo or pulmonary/esophageal) • Progressive multifocal leukoencephalopathy • Protozoal: • Toxoplasmosis • Isosporiasis • Cryptosporidiosis (intestinal)

26. AIDS-Defining Illnesses • Bacterial • Mycobacterium (tuberculosis, avium) • Pneumonia, recurrent • Salmonella septicemia, recurrent • Cancers • Kaposi’s sarcoma • Cervical cancer (invasive) • Lymphomas • Other • Wasting syndrome • Encephalopathy

27. Oral Manifestations • Common in HIV/AIDS • Seen with falling CD4+ counts • *Importance of oral assessment* • Higher risk of progression to AIDS • Types: • Fungal • Viral • Bacterial • Cancerous

28. Oral Manifestations • Herpes simplex • Oral candidiasis

29. Oral manifestations • Periodontal disease • Oral hairy leukoplakia

30. Oral manifestations • Lymphoma • Kaposi’s sarcoma

31. Diagnostic Tests

32. Rapid Testing • Four FDA-approved tests • Results ready in 5 - 20 min. • Benefit: more people receive their test results • Drawback: may get false positives (although rare) • Test must be confirmed with a Western Blot!

33. Testing Recommendations • Everyone after notification • Unless the person declines • High-risk: annual screening • Separate consent not required • Prevention counseling not required

34. Testing Recommendations

35. Testing Recommendations- Pregnancy • All pregnant women should be routinely screened • Unless the woman declines • Separate written consent is not required • Repeat screening in third trimester for women living in areas of high risk

36. Partner Counseling and Referral • Partner counseling and referral services (PCRS) • Assist in contacting past or current partners • Notifying partners of HIV exposure is voluntary and confidential • PCRS offers the partner counseling, testing, and referral services • Laws about notifying partners vary from state to state

37. Transmission, Prevention & Treatment

38. Why doesn’t everyone who is exposed develop active infection? • Conditions must be favorable • Viral load • Appropriate entry point

39. Transmission • Sexual • Parenteral • Mother to child

40. Sexual transmission • Unprotected sex with a person who has HIV • Increase of risk with: • Unprotected anal sex • Multiple partners • Sexually transmitted infections • Lack of circumcision • Alcohol and drug use

41. Parenteral transmission • Needle/syringe sharing between IDU’s • Blood or blood products • Health care exposure to blood, body fluids, or needles/sharp instruments

42. Mother to child transmission • Pregnancy • Labor and delivery • Breastfeeding • Increased risk with: • Lack of awareness of HIV status • Lack of prevention services

43. Prevention: Sexual transmission • Know your status • Abstain from sexual activity OR be in a long-term mutually monogamous relationship with an uninfected partner • Limit number of sex partners • Correct and consistent condom use • Testing and treatment for STI’s (+ partner) • Male circumcision

44. Safer Sex • Correct and consistent condom use: 80-97% effective • What is correct and consistent? • Male vs. Female condoms • What about oral sex? • Dental Dam • Condoms

45. Prevention: Parenteral Transmission • Best option: • Stop using injection drugs • Enter substance abuse treatment • If a person cannot or will not stop injecting: • Use a new, sterile syringe for each injection • Never reuse or share syringes, water, or other IDU products • Use sterile water to prepare drugs each time • If you cannot do this, then using bleach is better than nothing

46. Prevention: Mother to Child • Routine screening of all pregnant women • Anti-retroviral medications during pregnancy and labor and delivery • Scheduled C-section • Anti-retrovirals for baby x 6 weeks • Avoid breastfeeding in developed countries

47. Medical Treatment • HAART: Highly Active Antiretroviral Therapy • Goals of HAART • Delay or reverse loss of immune function • Decrease AIDS-related complications • Prolong life • Benefits vs. drawbacks of HAART

48. Types of Drugs

49. How do Anti-HIV drugs work? http://www.boehringer-ingelheim.com/hiv/art/art_videos.htm

50. Who should receive treatment? • Must weigh benefits vs. risk • All patients with acute or advanced HIV disease • HAART regimen with 3-4 drugs from 2 different classes • All pregnant women • People with low CD4+ cell counts (<350) • Some people with chronic asymptomatic disease