HIV / AIDS: Essentials
Online Course #9015-V2 or #2015-V2 - 1 Contact Hour


Author: Shelda L. Shank, RN, BSN, PHN
©2010 National Center of Continuing Education, Inc.


This course meets Florida's mandatory HIV / AIDS instruction requirements.

You may print this course or save it to your hard drive if desired. You can return later to take your Independent Analysis and submit it for fast processing. Once you have submitted your Independent Analysis, you will see your results immediately. Your certificate will be mailed First Class after we receive your completed Independent Analysis Evaluation.
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Purpose and Goals

The purpose of this course is to provide basic information concerning HIV and AIDS, including modes of transmission, clinical management, infection control procedures, and prevention.

Instructional Objectives

Upon completion of this course, the motivated learner will be able to:

1.   Define HIV and AIDS, and identify the various signs and symptoms associated with AIDS.

2.   List the recommended strategies for the control of HIV in the environment.

3.   Name the various classes of pharmaceuticals used in the treatment of HIV/AIDS.

4.   Identify objectives for the treatment of hospital inpatients diagnosed with AIDS.

5.   Relate ways that HIV is transmitted.

About the Author

Shelda L. Shank, RN, BSN, PHN, completed her baccalaureate degree in nursing and public health certificate at Azusa Pacific University. She is a member of the International Association of Forensic Nurses (IAFN) and an academic member of the American Botanical Council. She is the Nurse Supervisor of the Instructional Systems Development section of the National Center of Continuing Education. In this capacity, she is responsible for directing the activities of the department and selecting qualified, credentialed authors for the courses offered by the National Center, as well as advising staff of required course design and criteria. Ms. Shank has over 15 years of experience in publishing courses in continuing education for health care professionals with the National Center.

Introduction

Over two decades ago, whispers of an unusual form of pneumonia was noted in a few cases of homosexual men. It told of the beginnings of a worldwide epidemic of several conditions we now call AIDS. Today, the HIV/AIDS epidemic still affects people globally and nationally. However, treatment, prevention strategies and powerful drug regimens have advanced dramatically, improving survival rates and quality of life.

HIV: More than Just a Virus

Acquired Immune Deficiency Syndrome, better known by its acronym AIDS, results from and is the most severe manifestation of infection with the Human Immunodeficiency Virus (HIV). Researchers more often agree on what AIDS is not rather than what AIDS is, exactly. One thing for certain: AIDS is not a single disease. It manifests itself in a combination of different diseases, after killing or disabling cells in the body’s immune system, making its victims more susceptible to diseases that a healthy person would have no trouble fighting off. By overwhelming the immune system, AIDS permits a variety of infections - most of which can be fatal - to develop throughout the body. An HIV-infected person receives a diagnosis of AIDS after developing one of the Centers for Disease Control (CDC)-defined AIDS indicator illnesses. An HIV-positive person who has not had any serious illnesses also can receive an AIDS diagnosis on the basis of certain blood tests (CD4+ counts). Scientists have estimated that about half the people with HIV develop AIDS within 10 years after becoming infected. This time varies greatly from person to person and can depend on many factors, including a person’s health status and their health-related behaviors. There are medical treatments that can slow down the rate at which HIV weakens the immune system. There are other treatments that can prevent or treat some of the illnesses associated with AIDS, though the treatments do not cure AIDS itself. As with other diseases, early detection offers more options for treatment and preventive health care.

The CDC considers certain “opportunistic infections” and cancers to be hallmarks of the presence of AIDS. The most prevalent conditions are Pneumocystis carinii ¬pneumonia (PCP); Kaposi’s sarcoma (KS); candidiasis, a fungal infection of the mouth and esophagus; Mycobacterium tuberculosis; cytomegalovirus (CMV), a viral infection that can cause blindness, pneumonia and death in AIDS clients; diarrhea caused by the protozoan crypto¬sporidium; and a few others. Pneumocystis carinii pneumonia is the most frequent life-threatening opportunistic infection in patients with HIV, but the incidence has fallen with the use of advanced treatment regimens. Kaposi’s sarcoma, a malignant multifocal neoplasm that can metastasize to the lymph nodes and viscera, has become a visible hallmark of the AIDS patient.

None of the symptoms listed below is said to be specific to AIDS when considered alone, but each is a reason for serious concern. If any of the symptoms persist, a physician should be consulted.

• Periods of severe fatigue
• Sudden unexplained weight loss
• Night sweats and/or fever
• Persistent diarrhea
• Unusual bruising and/or bleeding
• Coughing and shortness of breath
• Skin rashes and spots
• Persistent generalized lymphadenopathy
• Neurologic problems

Transmission of HIV

HIV is readily transmitted through sexual contact, as well as exposure to blood and/or blood products and certain body fluids. Studies indicate the highest percentage of HIV transmissions occur during sex acts where body fluids are exchanged. Body fluids include blood, blood products, saliva, tears, urine, semen, vaginal secretions, breast milk, and perspiration. The use of contaminated needles by injecting drug users is the second most frequent route of transmission of HIV.

Current perspectives on the transmission and prevention of HIV are based on two distinct findings. First, it is accepted that HIV can be transmitted through infected blood or semen. However, the production of overt disease by the transmitted virus seems to demand additional conditions such as a significant level of infection or repeated exposure. Thus, HIV spreads primarily through persons who engage in risky behaviors where these conditions are most likely to be met.

HIV can also be transmitted perinatally from pregnant women to their babies during the birthing process.

Can I get HIV from getting a tattoo or through body piercing?

A risk of HIV transmission does exist if instruments contaminated with blood are either not sterilized or disinfected or are used inappropriately between clients. CDC recommends that instruments that are intended to penetrate the skin be used once, then disposed of or thoroughly cleaned and sterilized.

Personal service workers who do tattooing or body piercing should be educated about how HIV is transmitted and take precautions to prevent transmission of HIV and other blood-borne infections in their settings.

If you are considering getting a tattoo or having your body pierced, ask staff at the establishment what procedures they use to prevent the spread of HIV and other blood-borne infections, such as hepatitis B virus. You also may call the local health department to find out what sterilization procedures are in place in the local area for these types of establishments.

Preventing the Spread of HIV

Concern regarding this life-threatening and incurable disease is often out of proportion to the actual risks revealed by scientific studies. The known facts continue to be presented by advocacy groups, counseling centers, neighborhood education programs, mass communication media and other concerned individuals in an intense effort to educate the general public concerning the facts about AIDS and HIV. Facts that are emphasized to reduce misinformation about AIDS include the following:

1. HIV is not spread by shaking hands or otherwise touching someone who is HIV positive.
2. HIV is not spread by insect bites such as those inflicted by mosquitoes.
3. HIV is not spread by sharing eating utensils with someone who is HIV positive.
4. HIV is not spread by sharing drinking glasses or cups.
5. HIV is not spread by kissing, although some sources recommend against “deep kissing” of an infected person.

To prevent HIV infection, the CDC offers the following suggestions:

• Do not have sex with an infected person.
• Do not share needles with an infected person.
• Avoid any behavior that might result in contact with blood, semen, vaginal secretions, or body fluids with visible blood. Specifically, avoid sex with anyone who might be infected with HIV, and do not share “injecting drug works.”

Reducing high-risk behaviors through educational efforts is still the best way to prevent HIV infections.

Caregiver Concern

Despite the myths and half-truths that exist concerning HIV and AIDS, if recommended precautions are taken and the caregiver doesn’t succumb to unrealistic fears, adequate protection from the virus will be achieved. The best approach to avoid contracting AIDS or the transmission of HIV is to heed the CDC’s recommendation to treat every client as though they are HIV positive. Occupational Health and Safety Administration (OSHA) regulations, which protect healthcare workers, require the practice of Universal Precautions. CDC has broadened these requirements to include taking precautions with ALL body fluids and substances. These expanded recommendations are known as Standard Precautions.

Standard Precautions

The experience of treating a client with AIDS often presents the health professional with a dilemma. The question often arises of how to protect others and ourselves in the daily requirements of our responsibility to clients, without contributing to perceptions of discrimination. Using the Standard Precautions suggested by the CDC, you can protect yourself and others as you provide care by treating all clients equally.

The Standard Precautions requirement is, of course, applicable in emergency care situations or in those areas where there is a risk of exposure to blood or body fluids. It is in those situations that the risk of being exposed to contaminated blood or body fluids is greatest.

The Precautions are designed to prevent the transmission of pathogens from all body substances such as:

• blood
• all body fluids, secretions, and excretions (except perspiration) regardless of whether or not they contain visible blood
• non-intact skin
• mucous membranes
• saliva - Although it has not been specifically implicated in the transmission of HIV, saliva has not been removed from the list of body fluids that require the caregiver to exercise Standard Precautions. The CDC suggests that in instances of resuscitation, mouthpieces, resuscitation bags or other ventilation devices should be readily available. In all clinical settings the CDC and the American Dental Association’s Council on Dental Therapeutics suggest assuming that saliva contaminated with blood can potentially carry HIV.

Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals. Use Standard Precautions, or the equivalent, for the care of all patients.

• Handwashing — Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. Use a plain (nonantimicrobial) soap for routine handwashing. Use an antimicrobial agent or a waterless antiseptic agent for specific circumstances (e.g., control of outbreaks or hyperendemic infections), as defined by the infection control program.

HANDWASHING IS THE SINGLE MOST
IMPORTANT FACTOR
IN PREVENTING HIV AND OTHER DISEASES.

• Barrier Precautions — Healthcare professionals should always use barrier precautions to prevent skin or mucous membrane exposure to blood or body fluids.

• Gloves — Clean, nonsterile gloves are adequate when touching blood, body fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments. They should also be worn when performing venipuncture or other vascular access procedures. Always examine gloves closely before wearing.

• Protective Equipment — Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions.

• Gowns — Wearing a clean, non-sterile gown can protect the caregiver from soiling of clothing during patient procedures where body fluids may contaminate. Select a gown that is appropriate for the activity and amount of fluid likely to be encountered. Remove a soiled gown as promptly as possible, and wash hands to avoid transfer of microorganisms to other patients or environments.

• Patient/Resident Equipment — Use Standard Precautions when handling, discarding, or cleaning any medical equipment. Although HIV is considered fragile, (it has been shown to be easily destroyed by exposure to common cleaning agents, and by all routine methods of sterilization presently used in hospitals and clinics) Hepatitis B Virus (HBV) may live for several weeks on equipment, furniture, and linens.

• Environment — Facility policy should dictate routine and proper cleaning and disinfecting of walls, floors, bed and bedside furniture, and any other frequently used items. Standard procedures currently recommended for disinfection and sterilization are adequate to control HIV. These include the procedures and requirements of hospitals, clinics (medical and dental), offices, hemodialysis centers, and long-term care facilities. HIV has not posed any special requirements or procedures for the caregiver in order to achieve proper sterilization or disinfection within the professional environment.

• Sharps and Needle Stick Protection — While HIV infection is rare among caregivers, there is the potential for exposure any time a puncture wound occurs from a contaminated needle, lancet, or surgical instrument. Special care should be taken when using, caring for, disinfecting, or cleaning these items. Needles should NEVER be recapped with both hands, purposely bent, broken, manipulated, or removed from disposable syringes by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers, which are located as close as practical to the area in which the items were used, and place reusable syringes and needles in a puncture-resistant container for transport to the reprocessing area. Housekeepers and other environmental workers must adhere to the same precautions when disposing of contaminated rubbish.

Specimens should be placed in leak-proof containers or bags with a biohazard warning label. Appropriate procedures must be followed for cleaning and sterilizing instruments. Never re-use disposable equipment.

About one out of every four needle stick injuries involves IV therapy equipment. Many injuries result during disassembly, but they may also occur during any of the steps of the assembly/use/discard process, including insertion into drip chambers, injection ports and IV bags.

Invasive Procedures

Some procedures you perform will pose a greater threat of contracting HIV than others. Along with OSHA, the CDC has supplied specific information concerning invasive procedures. “Characteristics of exposure-prone procedures include digital palpation of needle tip in a body cavity or the simultaneous presence of the healthcare worker’s fingers and needle or other sharp instrument or object in a poorly visualized or confined anatomic site. The performance of exposure-prone procedures presents a recognized risk of percutaneous injury. If such an injury occurs, blood is likely to contact the client’s body cavity, subcutaneous tissues, and/or mucous membranes.”

An invasive procedure is defined as a surgical entry into tissues, cavities, or organs, or repair of major traumatic injuries:

1. In the operating room, delivery room, emergency department, or outpatient setting to include both physician and/or dental offices;
2. Cardiac catheterization and angiographic procedures;
3. A vaginal or cesarean delivery, or other obstetric procedures where bleeding may occur;
4. Manipulation, cutting or removal of any oral or perioral tissues, including tooth structure, where bleeding occurs or the potential for bleeding exists.

The standard blood and body fluid precautions are recommended by both the CDC and OSHA and should be the minimum for all invasive procedures.

Care of the AIDS Client

AIDS is a disease that presents a unique and challenging health- and life-threatening problem for the client, as well as challenges for the professional. Clients will require physical care, emotional support and counseling for a debilitating disease. They will not only be aware that the disease is fatal, but it also may have been transmitted to a loved one. In many cases, your clients are faced with the fact that AIDS is a stigmatized disease. You will find the emotional responses and requirements for help and support will vary with the inner coping and adjusting capabilities of each individual. These are directly related to the inner strengths, beliefs and mental health of each client. The importance of your sincere, dedicated emotional support to AIDS clients cannot be over-emphasized.

As the profile of AIDS clients continues to include more young people, women and minorities, healthcare professionals will need to develop awareness of new sets of cultural issues that may affect the client’s willingness to seek treatment, and the probability of compliance with the plan of care. Awareness of potential prejudices toward certain behavioral practices will remain important. The professional must remember that how a person became infected is not important; hope, compassion, and respect – not censure or condemnation – will be key aspects of your care.

The healthcare requirements for persons with AIDS will vary as the disease progresses. These needs are met in a variety of ways, circumstances and settings. During this time, the client’s personal needs for providers will also vary. Often a caregiver will be a nurse, a home health aide, a family member, a friend or maybe another person with AIDS.

During the course of the disease, your client may undergo multiple hospitalizations for treatment of acute opportunistic infections. You may be the primary provider during these episodes.

As the disease progresses to its terminal stages, your client’s family and friends may act as the primary care providers and perform the necessary care in the client’s home. During these periods your clients may also require the assistance of a home health aide.

Hospital Care of the AIDS Client. During early attempts to find treatment for, or at the very least control, the disease, numerous treatment and control techniques were suggested. However, the CDC now recommends special isolation for AIDS clients only if associated conditions such as infectious diarrhea, tuberculosis or other communicable diseases are present. With AIDS, these infections will often result in severe illness due to a compromised immune system.

Hospital care for AIDS is planned as with all other clients, on the basis of assessment. The plan will focus first on the most critical problems, which are usually opportunistic infections and malfunctioning organs or systems. Objectives of treatment are to:

1. Identify and treat infections
2. Maintain functioning organs 
3. Provide symptomatic relief  
4. Identify and/or prevent complications of treatment  
5. Provide compassionate emotional and physical support

Medical/Pharmaceutical Treatment

Medical management of HIV disease and AIDS has changed dramatically in recent years, primarily due to the use of powerful combination antiretroviral therapy, often referred to as highly active antiretroviral therapy or HAART. There are currently 20 approved antiretroviral agents belonging to the four classes of medications. The four classes include: NRTI, NNRTI, PI, and FI.

The combinations of three or four antiretroviral agents have usually included two nucleoside reverse transcriptase inhibitors (NRTIs) with either one or two protease inhibitors (PIs), or one of the nonnucleoside reverse transcriptase inhibitors (nNRTIs). According to data presented, efavirenz continues to be the drug of choice, in combination with lamivudine and another NRTI; such as zidovudine or tenofovir or stavudine. The NIH recommends reserving fusion inhibitor (FI) therapy for patients who have failed initial regimens. Another issue of concern is when to start antiretroviral treatment. There are multiple benefits and risks of early vs. delayed therapy.

Opportunistic infections (OIs) have decreased markedly since the introduction of HAART. Among patients with good immunologic and virologic responses to HAART, it has proven possible to stop primary prophylaxis and maintenance therapy in patients with previously active infections. Research revealed supports the most recent guidelines issued by the US Public Health Service and the Infectious Diseases Society of America, which currently recommend that primary and secondary prophylaxis for virtually all OIs can be discontinued following a rise in CD4+ cell count and control of viral replication. Research reported also suggests that, for patients coinfected with hepatitis C (HCV), HIV should be added to the list of factors known to accelerate progression to cirrhosis, such as male sex, older age, and alcohol use. Earlier and more aggressive treatment of HCV should be considered in these coinfected individuals.

The principal goal of therapy is to prevent or reverse the progression of clinical illness. HAART has been noted to improve the clinical status of persons living with HIV disease, decrease the incidence of opportunistic infections, and reduce mortality from AIDS. Achieving these ends can be very difficult, however, for the client and for the health professionals involved in his care.

The effectiveness of the therapy approach depends not only upon the selection of a potent medication regimen, but also on the patient’s ability to adhere to the regimen. Compliance of even the most dedicated patient may be challenged by the large pill burden with multiple daily doses, the discomforts and health risks related to drug side effects, and the necessity for a lifelong commitment to treatment. Strict adherence to the regimen is imperative: failure to adhere can result in the virus’ development of resistance to the entire class of drugs as well as to the specific drugs administered, thus seriously compromising long-term management.

The recent availability of potent antiretroviral therapy administered once daily is an additional consideration. However, there is no evidence to date of clinical or immunological advantages of once daily vs. multiple dose regimens.

Legal Information for Caregivers

Most jurisdictions in the United States have enacted statutes and governmental regulations regarding care of clients with HIV/AIDS. Topics generally addressed include documentation of HIV/AIDS and related diagnoses, maintenance of client confidentiality, and issues of informed consent. For example, the State of Florida has recently enacted the following legislation directed to confidentiality and testing for HIV and AIDS.

HIV/AIDS Laws and Requirements for Florida Caregivers

The State of Florida has recently enacted the following legislation directed to confidentiality and testing for HIV and AIDS.

Senate Bill Number 1436; SECTION 381:609, (3), HUMAN IMMUNODEFICIENCY VIRUS TESTING; INFORMED CONSENT; RESULTS; COUNSELING; CONFIDENTIALITY.

(A) “No person in this state shall perform a test designed to identify the Human Immunodeficiency Virus, or its antigen or antibody, without first obtaining the informed consent of the person upon whom the test is being performed, except as specified in paragraph (i). Informed consent shall be preceded by an explanation of the right of confidential treatment of information identifying the subject of the test and the results of the test to the extent provided by law. Consent need not be in writing providing there is documentation in the medical record that the test has been explained and the consent has been obtained.”

SECTION 75. Section 455.2224 Florida statute is created to read: 455.2224 Hepatitis B or Human Immunodeficiency carriers.

“The Department of Professional Regulation and each appropriate board within the Division of Medical Quality Assurance shall have the authority to establish procedures to handle, counsel and provide other services to healthcare professionals within their respective boards who are infected with Hepatitis B or the Human Immunodeficiency Virus.”

All caregivers are urged to familiarize themselves with the relevant legal requirements in their own State and local jurisdictions.

Healthcare professionals continue to play an important role as educators and advocates for this unique population. Keeping current with research, new and emerging treatment options and compassion are just a few ways to assist clients and families of this multifaceted disease. . . that is MORE THAN JUST A VIRUS.

(For a more expanded version of new and emerging trends and other issues please order course #392 or #395).

Resources

• The CDC maintains a Voice Information System that provides accurate and
up-to-date information concerning the HIV and the disease of AIDS.

• CDC National Prevention Information: 1-800-458-5231. Website: www.cdcnpin.org.

Included information and resources on HIV, STD, and TB prevention.

• Updated information about HIV PEP is available at www.cdc.gov;
CDC’s fax information service, (404) 332-4565.

• AIDS Information Service, telephone (800) 448-0440. M-F 8am-5pm EST

• The National Clinicians' Post-Exposure Prophylaxis Hotline (PEPline) offers treating clinicians up-to-the-minute advice on managing occupational exposures (i.e., needlesticks, splashes, etc.) to HIV, hepatitis and other blood-borne pathogens.

PEPline clinicians will respond to your call 24 hours a day, 7 days a week.
Phone: 1-888-448-4911

• National HIV/AIDS Information (800) 933-3413

• New Perinatal HIV HOTLINE-1-888-448-8765 www.ucsf.edu/hivcntr

• A-- Alternative approaches for AIDS/

Association of Nurses in AIDS Care HYPERLINK http://www.anacnet.org

AIDSinfo HYPERLINK http://www.aidsinfo.nih.gov

http://www.nlm.nih.gov/medlineplus/news/fullstory_22296.html

http://www.nlm.nih.gov/medlineplus/aidslivingwithaids.html

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