IMPORTANT: The following course is ONLY available to those who have already purchased it. The information has been updated in the current HIV/AIDS courses #392 by mail, 992 or 992P online, and #395 by mail.

HIV / AIDS:
Traditional & Complementary Therapies

Online Course #990 V2- 4 Contact Hours
Author: Shelda L. Shank, RN, BSN, PHN
Editor: Ila Pound, RN, MA
©2009 National Center of Continuing Education, Inc.

This course meets and exceeds Florida's mandatory HIV/AIDS instruction requirement.

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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Instructional Objectives:

Introduction

Knowledge is POWER. Accurate and timely information is a basic ingredient of knowledge and is essential to people who are working to end the HIV/AIDS epidemic. AIDS has created more literature, published and ephemeral, than any disease in history. Keeping up with this information is extremely challenging. It is the goal of this course that this knowledge will assist you in educating and caring for these special clients and their families.
In an effort to combat the threat of AIDS, health care facilities have mounted an intensive education and training effort to ensure people are knowledgeable, and take the recommended measures to prevent the transmission of HIV; and are given the tools to pass on this vital information to others.
Acquired Immune Deficiency Syndrome, better known by its acronym AIDS, is a direct result of infection with the Human Immunodeficiency Virus (HIV). It manifests itself in a combination of different diseases, by 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. Today the numbers of persons diagnosed with either the HIV or AIDS continue to increase. In the United States, for the 665,357 total cases of AIDS there have been 401,028 deaths. This is an approximate mortality rate of 60 percent.
However, according to the most recent international conference on HIV which took place in Geneva, Switzerland, AIDS incidence and deaths dropped for the first time in 1996. This drop is largely due to the impact of treatment advances in delaying progression of HIV infection to AIDS and from AIDS to death. Consequently, from 1996 on, cases of AIDS and deaths will provide a valuable measure of the continuing impact of treatment, as well as describe populations for whom treatment is either not accessible or not effective. In the first two quarters of 1997, the declining trend in both AIDS cases and deaths accelerated, with AIDS cases declining 15% and AIDS deaths declining 45%, compared to the first two quarters 1996.
A major goal of this course is to provide each caregiver with information necessary to allay apprehensions concerning treatment of the HIV positive client and dispel persistent myths and half-truths.
The CDC advises that caregivers use Standard Precautions which treats ALL blood and body fluids of any patient as if they were infected. Indeed, any blood may contain pathogens such as Hepatitis B, Hepatitis C, and/or HIV. Other body fluids may carry visible or invisible blood particles.
The emphasis is on practicing the same procedures routinely with each of your clients in order to assure the transmission of HIV does not occur and to change our attitudes toward HIV-positive individuals and treat them as you would any other client.
The CDC estimates there are over one million people infected with HIV in the United States, with 40,000-80,000 new infections occurring each year. Since January 1, 1993 the AIDS case definition applies to adults/adolescents (>13 yrs.) who are HIV-infected with a CD4+ T-lymphocyte counts of less than 200/ml or a CD4+ percentage of less than 14. This count is one-fifth the typical level of a healthy adult. The new definition also added three new illnesses to the list of 23 opportunistic infections afflicting persons with AIDS. Those new illnesses are pulmonary tuberculosis, recurrent pneumonia, and invasive cervical cancer. These three illnesses are especially prevalent among women and injecting drug users who are HIV positive. This definition adopted by the CDC has temporarily resulted in a disproportionate number of new cases of AIDS among women and injecting drug users, however the majority of cases remain among men who have sex with men. (See Table 1).

....317,862

Females...45,075

...168,008

Men who have sex with men
& inject drugs

.....42,093

Females...222

.......4,781

.....62,599

.......8,311

Total:

.....53,423

Epidemiology/Trends

There has been a striking increase in the number of Americans in their teens and early 20s infected heterosexually with HIV, even as rates of infection are declining among those in their late 20s and older. Women ages 18-27 are far more likely to be infected with the virus than their older counterparts. This is particularly true for black women.
The majority of the cases reported among heterosexuals has shown to be pregnant women who are presenting for treatment of HIV. The FDA's Antiviral Drugs Advisory committee unanimously recommended amending Retrovir's labeling to include perinatal use. Retrovir (zidovudine, commonly called AZT) is approved for preventing the transmission of the HIV from infected pregnant women to their babies.
Trends in AIDS incidence among children continued to demonstrate the dramatic success of efforts to reduce perinatal (mother-to-child) transmission. Clinical trials showed that HIV-infected women could reduce the risk of transmitting the virus to their babies by as much as two-thirds through administration of zidovudine during pregnancy, labor, and delivery, and by giving their babies AZT for the first 6 weeks after birth. (See Tables 3 and 4).

TABLE 4. Estimated pediatric AIDS incidence by year of diagnosis, 1992 through 1997, United States, CDC, HIV/AIDS Surveillance Report, June 1998

These numbers do not represent actual cases of children diagnosed with AIDS.  Rather, these numbers are point estimates based using the 1987 definition, adjusted reporting delays. The 1993 AIDS surveillance case definition affected only the adult/adolescent cases, not pediatric cases.

In 1994 the Public Health Service (PHS) issued guidelines (AIDS Clinical Trials Group (ACTG) Protocol 076) for using AZT during pregnancy. In 1995, the guidelines for routinely counseling all pregnant women about HIV and offering them an HIV test was put into practice. As health care providers across the country incorporated these guidelines into clinical practice, assessed risk factors, offered confidential testing, and drug treatment, perinatal AIDS incidence dropped dramatically.
According to a study released early November 1998, even if only given after birth, AZT appears to substantially reduce the chances of newborns from vertical transmission of the AIDS virus. Doctors typically give the AZT drug to HIV-infected mothers during their last 14 weeks of pregnancy, and then to their babies for six weeks after birth. Infected mothers do not always seek prenatal care, so its not always possible to provide the full course of treatment. The study revealed that even the shorter treatment cuts the risk, and adds weight to the argument that HIV infection can be prevented after exposure. Similar to others, this one found a 27% risk that HIV-infected mothers would pass the virus to their babies if no AZT was given. Additional result showed risk to be:
= 6 % if treatment was started before birth.
= 9 % when started within the first two days of life.
= 18% if started after three days of life.
Even with these encouraging results, the full course of AZT is still recommended when possible. Between 1992 and 1996, the number of children with perinatally acquired AIDS dropped 43%. But despite declines in all racial/ethnic groups, the majority of perinatally acquired AIDS cases continue to occur among African-American and Hispanic children. This indicated the need for intensified efforts to prevent infection among minority women and to reach infected women with early prenatal care and preventive treatment. Though the overall rate of HIV infections among men and women aged 16 and 21 is dropping, women in that age group are now being infected at a rate 50 percent higher than men the CDC reported recently.
A recent study of 350,000 youths in the federal Job Corps program showed the overall rate of infection among these youths declined from 1990 to 1996. However, the study revealed that women aged 16 to 18 were being infected at a dramatically higher rate, while infection rates for men and women aged 19 to 21 were roughly equal.
Researchers suggested the difference between the sexes was because young women are more likely to have sex with older partners who are more likely to have HIV than younger men. Research shows that only a few caregivers have contracted the HIV in the hospital environment. They attribute this low rate of transmission to the established Standard Precautions rule that recommends caregivers regard all clients as being positively infected with the HIV and treat them accordingly.
Julian Bond, Board Chairman of the NAACP, recently told this group that AIDS has become a "black epidemic". He said the disease is the leading cause of death for blacks age 25 to 44 and the blacks, who are 13 % of the population, account for 50 % of new HIV infections in the United States. (See Table #5).

Table 5

AIDS Cases and Deaths and Change from First Half of 1996 to First Half of 1997 by Gender and Race
Table from Geneva '98 Conference

The following data are from the CDC semiannual HIV/AIDS Surveillance Report. Numbers based on AIDS cases reported to CDC through June 1998. Of the total AIDS cases, patient's ages were distributed as follows:

What is AIDS?

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 is the most severe manifestation of infection with the Human Immuno-deficiency Virus (HIV). The HIV has a diameter of 1/10,000 of a millimeter. It belongs to a class of viruses call retroviruses, which have genes composed of RNA molecules. Retroviruses, like all viruses, can only replicate within a living host cell because they contain only RNA and no DNA. In addition, retroviruses use RNA as a template to make DNA. Infection begins when an HIV particle encounters a cell with a surface molecule called CD4. The virus particle uses complex proteins in its outer envelope to attach itself to the cell membrane and then enter the host cell.
Within the cell the virus particle releases its RNA, and the enzyme reverse transcriptase then converts the viral RNA to DNA. This new HIV DNA then moves into the cell's nucleus, where with the help of enzymes, inserts itself into the host cells DNA. Once in the cell's genes, HIV DNA is called a provirus that can replicate and release new infectious viral particles.
The National Academy of Sciences has said that the points along the spectrum cannot be considered simply as stages of an orderly progression of the infection. Some will develop "end-stage" AIDS quickly and die, while others will remain asymptomatic for long periods of time. It is not known why there are these wide diversities in the clients' clinical history.

Signs and Symptoms

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), a severe lung infection; Kaposi's sarcoma (KS), a malignant tumor condition; Candidiasis, a fungal infection of the mouth and esophagus; Cryptococcosis, a fungal infection that can cause meningitis; Cytomegalovirus (CMV), a viral infection that can cause blindness, pneumonia and death in AIDS clients; and diarrhea caused by the protozoa Cryptosporidium, and a few others.
None of the symptoms listed below are said to be specific to AIDS when considered alone but each is a reason for serious concern. You should be aware that if any of the symptoms persist, a physician should be consulted.

Periods of Severe Fatigue
Your client will often report extended periods of extreme fatigue. Although it is not unusual for most persons to experience periods of tiredness resulting from a variety of stress factors, these periods should not be prolonged. Always tell your client that if profound fatigue persists for more than several weeks, it may be a sign of serious illness.

Sudden Weight Loss
The general rule of unexplained weight loss of 10 pounds or more in less than 60 days, or a loss of more than 10% of body weight is often a sign of serious illness. Should the loss of appetite and/or the loss of body weight persist, the person should promptly seek professional medical advice.

Night Sweats and/or Fever
Fevers and night sweats will often occur with AIDS as well as tuberculosis (TB) and other serious diseases. If these symptoms persist they should always be assessed by a physician.

Diarrhea
Diarrhea that persists for more than a week is common with AIDS sufferers and will result in severe dehydration and a loss of body salts. If your client relates such a condition, it should be assessed by a physician.

Bruising and/or Bleeding
Sometimes even minor injuries will result in severe bruising and mucous membranes will bleed in the absence of an injury. It has been found that HIV client's blood demonstrates an unusually delayed clotting time. You should advise clients who have any episodes of unusual bleeding or bruising to be assessed by a physician.

Coughing and Shortness of Breath
"Pneumocystis carinii" (PCP) is a major defining characteristic for AIDS diagnosis. Usually it will begin as a cough that can either be productive or be dry. If your client is HIV positive, the cough will often persist for weeks and lead to a severe shortness of breath which may indicate additional damage to the respiratory system. The persistent cough is often accompanied by chills, shortness of breath, fever, tightness in the chest, increased pulse and increased respirations. These can be early warning signs of pneumonia that warrant the attention of a physician. Additionally, because pneumonia often defines AIDS, there is an increased risk to the caregiver as well as others contracting it from the HIV/AIDS client. Pneumocystis carinii pneumonia is the most frequent life-threatening opportunistic infection in patients with the HIV. The incidence has fallen with the use of primary prophylaxis in persons with CD4+ T-lymphocyte counts below 200 /ml.

Neurologic Problems
HIV has been isolated and readily reproduces in the brain tissues of clients with HIV disease. Some clients with the HIV have exhibited subtle neurologic symptoms but do not show any signs of damage to the immune system. This is because the lymphocyte count did not trigger a positive response.
Clients who are infected with HIV often experience a variety of nervous system disorders. The approach to behavioral, emotional, and mental disorders in HIV-infected clients is the same as other medical problems. The availability of a consultant to help clarify difficult diagnostic issues is essential. Psychiatric symptoms such as depression, delusions, hallucinations and paranoia have been noted.

Transmission of the HIV

The HIV is shown to be readily transmitted through sexual contact, exposure to blood and/or blood products and certain body fluids. Studies indicate the highest percentage of the HIV transmissions occur during sex acts where body fluids are exchanged. Body fluids should be interpreted as blood, blood products, saliva, tears, urine, semen, vaginal secretions, breast milk, and perspiration. The use of contaminated needles by injecting drug use is the second most frequent route of transmission of the HIV. The accepted perspective of the transmission and prevention of the HIV is based on two distinct findings.
First, it has been revealed that the HIV can be transmitted through infected blood or semen.  Additionally, the production of an overt disease by a transmitted virus seems to demand additional conditions such as a significant level of infection or repeated exposure. As a result and one that can be predicted, the HIV spreads through persons who engage in risky behavior where these conditions are most likely to be met. HIV can also be transmitted from pregnant women to their unborn babies during the birthing process.

Preventing the Spread of the HIV

People are demonstrating concern regarding this life-threatening disease that so far has eluded a cure. These fears are usually out of proportion to the actual risks revealed by scientific studies. The known facts are now being presented by groups, counseling, 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 the HIV. The following list offers some of the ways the HIV is NOT transmitted:

1. The HIV is not spread by shaking hands or otherwise touching someone who is HIV positive.
2. The HIV is not spread by insect bites such as those inflicted by mosquitoes.
3. The HIV is not spread by sharing eating utensils with someone who is HIV positive.
4. The HIV is not spread by sharing drink glasses or cups.
5. The HIV is not spread by kissing although some researchers advise avoiding "deep kissing."

To prevent HIV infection CDC offers the following suggestions:

• Do not have sex with an infected person.
• Do not share needles with an infected person.
• Avoid 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."

The following prevention measures apply to personal sexual practices and injecting drug use (IDU):

1. To prevent sexual transmission of HIV, abstain from sex with an infected person.
2. Ask about the sexual history of current and future sex partners.
3. Reduce the number of sex partners to minimize the risk of HIV infection.
4. Always use a condom from start to finish during any type of sex (vaginal, anal, and oral). Use latex condoms rather than natural membrane condoms. If used properly, latex condoms offer greater protection against sexually transmitted diseases, including HIV.
5. Use only water-based lubricants. Do not use saliva or oil-based lubricants such as petroleum jelly or vegetable shortening. If you decide to use a spermicide along with a condom, it is preferable to use spermicide in the vagina according to manufacturer's instructions.
6. Avoid anal or rough vaginal intercourse. Do not do anything that would tear the skin or moist lining of the genitals, anus, or mouth and cause bleeding.
7. Condoms should be used even for oral sex.
8. Avoid deep, wet, or "French" kissing with an infected person. Even though transmission of HIV has not been documented by this method, possible trauma to the mouth may occur, which could result in the exchange of blood.
9. Avoid alcohol and illicit drugs. Alcohol and drugs can impair your immune system and your judgment. Do not share needles, syringes, cookers - "works".
10. Do not share personal items such as toothbrushes, razors, or devices used during sex which may be contaminated with blood, semen, or vaginal fluids.
11. If you are Infected with HIV or have engaged in sex or needle-sharing behaviors that lead to infection with HIV, do not donate blood, plasma, sperm, body organs, or tissues.

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

What's My RISK?

Any one of the following behaviors can put you at risk for contracting the AIDS virus.

• Unprotected sex with someone whose HIV status you didn't know.
• Unprotected sex with someone you knew was HIV positive or had AIDS.
• Unprotected sex with multiple partners or with someone who has had unprotected sex with multiple partners.
• Unprotected sex with someone who uses needles to take drugs.
• Use of drugs (heavy alcohol, barbiturates, sedatives, etc.) which could have affected your ability to remember whether or not you had unprotected sex.
• Having a sexually transmitted disease such as genital herpes or warts, gonorrhea, syphilis, chlamydia, etc.
• Sharing needles with another person.
• Mother was HIV positive when she was pregnant with you.
• Having had an open wound or cut that was exposed to another person's body fluids, such as blood or semen.
• Had a blood transfusion before March 1985.

Diagnostic Tests

Testing is an important tool in the nation's efforts to curtail the spread of HIV. Testing allows researchers to track the course of the epidemic, and provides information to help in developing prevention strategies and allocating resources for HIV-related services. Counseling which should be provided before and after testing, provides a unique opportunity to educate individuals about HIV, including risks, how to avoid infection, and if they are positive, how to protect others, and treatment options and follow-up.
In addition to its value as a prevention tool, testing is the first step in helping people who are infected receive appropriate treatment. Early detection of the HIV, followed by certain drug combinations, can greatly improve both the quality and quantity of life. It also plays a vital role in reducing the transmission of HIV from mother to infant. Pregnant women who are tested and find out they are infected have the opportunity to take drugs which may prevent the infant from becoming infected.
The primary means of documenting HIV infection is by HIV antibody testing and viral culture. Viral cultures are both expensive and time consuming, so antibody testing is the method of choice for rapid and inexpensive confirmation of HIV exposure. You should be aware that antibody testing alone is not diagnostic for AIDS. As early as 1985 the enzyme-linked immunoabsorbent assay (ELISA) test was available. It is a commercial test used for many purposes other than the detection of HIV antibodies. The ELISA test is not a test for AIDS and it does not detect the actual virus but only indicates that there is the presence of antibodies to the HIV.
The reliability of the ELISA test is high and it is considered sensitive and specific. The Centers for Disease Control and Prevention estimates the sensitivity and specificity of the licensed ELISA tests are 99% or higher when the double ELISA test is done.
The Western blot technique is one that uses electrophoresis to separate viral antigens and measures serum antibody reaction to specific viral proteins (core and envelope proteins).
HIV testing can also be done with saliva. The FDA has approved the first test that uses a saliva sample rather than blood. Marketed under the name of Ora SureT, the test kit consists of a cotton swab on a stick and a vial containing a preservative solution. The client holds the swab between the lower cheek and gums for two minutes; then, the entire stick is put into the vial and sent to the lab. The test is not intended or approved for home use.
Because the test produces false negatives or false positives in up to 2% of clients, it is considered less accurate than the standard blood test for HIV. As a result, it is not approved for screening potential blood donors. Furthermore, the FDA requires positive results to be confirmed by a blood test.
A new alternative in HIV testing can now be performed conveniently, in the comfort and privacy of the home. Home AccessT HIV testing provides fast test results that are just as reliable as those used by doctors, hospitals, and public clinics. Everything needed for an accurate result is included.
Also, the option to speak with a professional counselor 24 hours, 7 days a week is available. This self-administered test is complete in 4 short steps.

1. Call to register a code number and receive pre-test information.
2. Collect a blood sample by pricking a finger with a safety lancet. Then apply blood to a specimen collection card.
3. Package the specimen card and ship to Home AccessT laboratory.
4. Call for the results. Blood is screened using the ELISA system. If this screen is positive, a more specific confirmatory test, Immunoflouresence Assay (IFA) will be used. Home AccessT guarantees anonymity with every call. No names are ever associated with a test result. This test kit can be ordered over the Internet at www.hiv-test.net.

FYI: Fewer than 40% of people in the U.S. who are potentially at risk for HIV infection have been tested! You should be aware that neither the CDC nor WHO endorsed universal mandatory testing at any time. The suggestion has also been rejected by the American Nurses Association (ANA).
Despite the myths and half-truths that exist concerning the HIV and AIDS,and 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 the HIV is the CDC's recommendation of Standard Precautions: to treat every client as though they are HIV positive. This recommendation is repeated numerous times within this course and its importance cannot be overemphasized.
OSHA law, which protects healthcare workers, requires the practice of Universal Precautions. CDC broadens this to include taking precautions with ALL body fluids and substances. This expanded definition is 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 as how to best protect ourselves and others in the daily requirements of our responsibility to clients and not contribute to a feeling of discrimination? Using Standard Precautions suggested by the CDC, you can best 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 high risk of exposure to blood or body fluids. It is in those situations the risk of being exposed to contaminated blood or body fluids is greatest. These 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

The Caregiver and Special Precautions

During early attempts to find treatment or at the very least, control the HIV, numerous treatment and control techniques were suggested. Special isolation procedures would only be necessary if associated conditions such as infectious diarrhea, tuberculosis or other communicable diseases were present. Therefore, Standard Precautions carried out by all healthcare workers (HCWs) are as follows:

Handwashing - Hands should be washed for 15 seconds using soap and water, rinsing, and using paper towels to turn off the faucet. Hands must be washed before any patient contact and after any contact with body substances as listed above as well as any contaminated items or linens used by patients. Hands must be washed before and after the use of protective gloves, and after the caregiver's use of the toilet and before and after the caregiver eats or takes beverages.    
You should also be aware of the dangers of placing fingers or other items in the mouth, rubbing the eyes, or eating and drinking in any environment which may be contaminated. HANDWASHING IS THE SINGLE MOST IMPORTANT FACTOR IN PREVENTING HIV OR OTHER DISEASES.

Barrier Precautions - Health-care professionals should always use barrier precautions to prevent skin or mucous membrane exposure to blood or body fluids.

Gloves - Latex or vinyl gloves must be worn before touching any blood, body fluids, excretions, non-intact skin, or mucous membranes. Gloves should be changed between patients and between tasks for the same patient if in contact with material that may spread the organisms to other body parts. They should also be worn when performing venipuncture or other vascular access procedures. With the possibility of undetectable holes in exam gloves, and in an effort to improve overall safety, many healthcare professionals elect to double-glove for the above procedures. Always examine gloves closely before wearing.

Protective Equipment - Use a mask and eye protection or a face shield when performing procedures where splashing of blood, body fluids, or secretions and excretions may occur.

Gowns - Wearing a clean, non-sterile gown can protect the caregiver from soiling of clothing during patient procedures where body fluids may contaminate.

Saliva - Although it has not shown to be implicated in the transmission of the HIV, saliva has not been removed from the list of body fluids that require the caregiver to exercise standard precautions. The CDC suggests 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 that saliva contaminated with blood can potentially carry the HIV.

Patient/Resident Equipment - Use Standard Precautions when handling, discarding, or cleaning any medical equipment. Although the 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.

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, or disinfecting, or cleaning these items. Needles should NEVER be recapped with both hands, purposely bent, broken, manipulated, or removed from disposable syringes by hand.    
After use, disposable syringes and needles, scalpel blades, and all other sharps that are to be disposed should be placed in a puncture-resistant container that is placed as close to the use area as is practical. Large bore reusable needles should be placed into a puncture-resistant container and then transported to the nearest reprocessing area. Housekeepers and other environmental workers must adhere to the same precautions when disposing of contaminated rubbish.

Exercise Caution!

HCWs must take precautions to avoid becoming infected by accidental parenteral incidents. Nurses, phlebotomists, physicians, laboratory workers, paramedics, housekeepers and laundry workers, and others with a one-to-one patient contact may inadvertently infect themselves by accidental stick from a needle or lancet, cut by a surgical instrument, or having blood or body fluids splashed into mucous membrane or non-intact skin.    
The documented instances of transmission of the HIV to a practicing caregiver have been low in spite of the number of personal contacts between clients who have AIDS. This can most probably be attributed to the caregiver's education, training, attention to detail and procedure along with following standard precautions have all contributed significantly to these statistics.
However, in an attempt to prevent even one additional contracted case occurring, you should personally be concerned and dedicated to avoiding personal injury in your caregiving environment.    
The CDC has determined that the needle stick injury is most often the result of inadequate attention to detail by the caregiver during the accomplishment of a procedure.
Research has revealed that the use of protected needles or needleless equipment will significantly decrease the chances that nurses or other HCWs will obtain needlestick injuries.
Safe-working practices are the first priority. Immediately after use, contaminated needles and other sharps must be disposed of in an approved container as near to the care area as possible. This container must be puncture-resistant, leak-proof, color-coded, and labeled with the biohazard label. NEVER bend, recap with two hands, or break needles or other contaminated sharp items. Needle safety devices are available. If you MUST recap, use the one-handed scoop method only.
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 reuse disposable equipment.
About one out of every four needlestick injuries involves IV therapy equipment. Many injuries result during disassembly, but they may also occur during steps of the assembly/use/discard process, including insertion into drip chambers, injection ports and IV bags.
You should also be aware that needles attached to discontinued IV lines may also present a problem. The federal government offers sanctions to discourage health facilities from continuing to use conventional devices. It is documented that Occupational Safety and Health Administration (OSHA) has levied fines against hospitals for failure to evaluate and consider the adoption of engineering controls, equipment or devices that reduce the risk of needlestick injury.

Management of Infected Caregivers

There have been only a few instances where the HIV has been transmitted from a caregiver (only a dentist in Florida, to date) to a client, but there is an ever-present possibility it can occur during an invasive procedure. You should be aware that transmission of the Hepatitis B virus (HBV), another blood-borne pathogen, is more easily transmitted. In all instances, such transmissions occurred during invasive procedures when the caregiver sustained a puncture wound or had exudative or weeping lesions or microlacerations that allowed the virus to contaminate instruments or the open wounds of clients.
The CDC is aware of 54 healthcare workers in the US who have been documented as having seroconverted to HIV following occupational exposures. Twenty-five have developed AIDS. When the very high number of caregivers with a high rate of exposure is considered, this number, although regrettable represents an extremely low occurrence of the disease.
These individuals who seroconverted include 22 nurses, 19 laboratory workers (16 of whom were clinical laboratory workers), 6 physicians, 2 surgical technicians, 1 dialysis technician, 1 respiratory therapist, 1 health aide, and 1 housekeeper/maintenance worker and 1 embalmer/morgue technician. (CDC, HIV Surveillance Report, 10(1), 24,1998)
UPDATE: MMWR 1998; 47(No.RR-7) Public Health Service Guidelines for the Management of Healthcare Worker Exposures to HIV and Recommendations for Postexposure Prophylaxis (PEP)
This summary information updates and consolidates all previous public health service (PHS) recommendations for the management of health care workers (HCWs) who have occupational exposure to blood and other body fluids that may contain HIV; it includes recommendations for HIV postexposure prophylaxis (PEP) and discusses scientific rationale for PEP. The decision to recommend HIV PEP must take into account the nature of the exposure (e.g., needlestick or potentially infectious fluid that comes in contact with a mucous membrane) and the amount of blood or body fluid involved in the exposure. Other considerations include pregnancy in the HCW and exposure to virus known or suspected to be resistant to antiretroviral drugs. Assessments of the risk for infection resulting from the exposure and the infectivity of the source are key determinants of offering PEP. Consent from the possibly infected patient (source of HIV) must also be given to test. Systems should be in place for the timely evaluation and management of exposed HCWs and for consultation with experts in the treatment of HIV when using PEP.
Recommendations for PEP have been modified to include a basic 4-week regimen of two drugs (zidovudine & lamivudine) for most HIV exposures. An expanded regimen includes the addition of a protease inhibitor (indinavir or nelfinavir) for HIV exposures that pose an increased risk for transmission; or where resistance to one or more of the antiretroviral agents recommended for PEP is known or suspected.
Occupational exposures should be considered urgent medical concerns to ensure timely administration of PEP. Health care organizations should have protocols that promote prompt reporting and facilitate access to post-exposure care. Enrollment of HCWs in registries designed to assess side effects in HCWs who take PEP is encouraged. For the complete document on PEP recommendations:
Single copies are available from the CDC, National AIDS Clearinghouse, PO Box 6003, Rockville, MD 20850, or (800) 458-5231 or online at www.cdcnac.org.

First-Line Drugs for HIV (PEP)

Nucleoside Reverse Transcriptase Inhibitors
Zidovudine (Retrovir; ZVD, AZT)
Dosage: 600mg QD divided doses
Side Effects: Neutropenia, anemia, fatigue, malaise, HA, insomnia, asthenia.
Caution: if coadministered with bone marrow suppressive drugs or cytotoxic therapy.

Lamivudine (Epivir; 3TC)
Dosage: 150mg BID
Side Effects: HA, abd. pain, diarrhea, & rare cases, pancreatitis. Toxicity of AZT & 3TC in combo is equal to AZT alone.

ZDV plus 3TC (Combivir)
Dosage: 1 tab BID; each tab contains 300mg ZVD and 150mg 3TC
Side Effects: see above for ZVD & 3TC
Caution: same as Zidovudine

Protease Inhibitors (PIs)
Indinavir (Crixivan; IDV)
Dosage: 800 mg Q 8 h on an empty stomach
Side Effects: Nephrolithiasis, crystalluria, hematuria, nausea, HA, indirect hyerbillirubinemia, elevated liver function tests (LFTs), and hyperglycemia/diabetes.
Comments: Nephrolithiasis may be reduced by consuming large quantities of water (six 8oz. [tot. 48 oz.] throughout the day).

Nelfinavir (Viracept)
Dosage: 750 mg TID with meals
Side Effects: Diarrhea, hyperglycemia/diabetes.
Comments: If oral contraceptives are used, alternative or additional contraceptive measures should be used while taking nelfinavir.
There are additional antiretroviral drugs used for PEP that may be considered in special circumstances. They are listed as follows, and details may be obtained in the complete document available from the CDC: Zalcitabine; Didanosine; Stavudine; Ritonavir; Saquinavir; Nevirapine; Delavirdine.

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 caregiver. Clients will require physical care, emotional support and counseling for a debilitating disease. They will not only be aware 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. Your sincere, dedicated emotional support to AIDS clients during this period cannot be overemphasized.
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, the 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 experience 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 provider 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.
In the following sections we will discuss some important needs and requirements of AIDS clients in a hospital care setting.

Hospital Care of the AIDS Client

The CDC has suggested 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 an inefficient immune system.     The AIDS client who is admitted to the hospital will often be acutely ill, physically debilitated and extremely apprehensive. One of your most important roles in admission will be one of support and reassurance. As an initial step, you can explain the necessity of having a complete physical examination, various other procedures and diagnostic tests. A factor of extreme importance and concern to the client is confidentiality.
During the past decades the legislatures of many states have enacted strict HIV testing and confidentiality laws. You must give assurance of strict confidentiality of the information that is divulged and also assure the client this applies to results of all diagnostic procedures and laboratory tests.
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 the opportunistic infections and malfunctioning organs or systems. Objectives and 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.

Current Medical Pharmaceutical Treatment

Recent years have marked major advances in AIDS treatment. For the first time since the epidemic began, death rates have dropped in the US, in large part because new drugs are helping patients live longer. These new drugs, known as protease inhibitors, stop the virus from replicating. Crixivan and Norvir, the first two powerful drugs of this class, came on the market in 1996. These drugs are expensive and involve a complicated regimen of up to 20 pills a day.
Protease inhibitors are often used in combination "cocktails" with older drugs called reverse transcriptase inhibitors. These drugs, which include AZT and 3TC, may slow the spread of the HIV in the body and delay the onset of opportunistic infections. Unfortunately, the virus can become resistant to both classes of drugs.
In addition the following drugs have been approved: Zidovudine (AZT), Crixivan (idinaver), and Sustiva (efavirenz) and others listed previously under the PEP section are in clinical use against HIV.

Antiretroviral Agents: The Next Generation
Despite dramatic progress over the past few years, antiretroviral therapy continues to have limitations. Currently available drugs often have inconvenient dosing schedules, high pill burden, significant side effects, and complex drug-drug interactions.
In addition, a growing number of patients no longer appear to respond to current therapies. Thus, new antiretroviral agents are urgently needed.
Fortunately, over the next year three new drugs are expected to become widely available: abacavir (BU1592U89), adefovir dipivoxil (Preveon, bisPOM PMEA), and amprenavir (141W94). In short-term studies, each drug appears to be safe, well tolerated, and effective, particularly in treatment-naive patients.
Information provided by the Food and Drug Administration (FDA) states there are presently more than 300 ongoing human studies sanctioned to study drugs that may be used to treat AIDS or related conditions. Many of these studies use two or more experimental therapies in combination. The Administration advised that requests for information should be directed to the sponsor of the AIDS Clinical Trials Information Service, which can be reached by telephone at 1-800-TRIALS-A.
The FDA has made drugs available under its Investigational New Drug (IND) treatment program. This allows clients with serious or life-threatening conditions for which there are no satisfactory treatments, to obtain promising experimental drugs if clinical testing shows safety and effectiveness.
One research development in its final stages is the three-year study conducted by VaxGen, of San Francisco, CA. VaxGen has developed AIDSvax, the first vaccine approved for testing in human volunteers. These trials are not dangerous to the subjects because a live strain of the virus is not used. The trials will be conducted on healthy people who are at high risk for contracting the HIV virus, such as women and men who have sex with men whose partners are infected. The trials will take four years to complete at which time the FDA will make a decision to approve the vaccine for use.

SustivaT (efavirenz)

WILMINGTON, DE (September 18, 1998) - DuPont Pharmaceuticals announced that its anti-HIV drug, SustivaT (efavirenz), was approved by the US Food and Drug Administration (FDA). SustivaT is a once-daily non-nucleoside reverse transcriptase inhibitor (NNRTI) for treatment of HIV-1 infected individuals. SustivaT is the first anti-HIV drug to be approved by the FDA for once-daily dosing and will be used in combination with other anti-HIV drugs in both adult and pediatric patients.
Clinical trial results suggest that SustivaT, when used in combination with other antiretroviral agents, may not only simplify dosing and reduce patients' pill burden, but its potency and tolerability may also offer physicians and patients, including children, new treatment options.
Results from more than a dozen clinical trials involving more than 2,000 patients demonstrate the efficacy, safety and flexibility of SustivaT. These results indicate that SustivaT reduces plasma viral RNA to below quantifiable levels (less than 400 copies/mL using the standard Amplicor' assay) in a majority of HIV-1-infected naive and treatment-experienced individuals in two-,three-, and four-drug combinations. Studies have shown that efavirenz penetrates into the cerebrospinal fluid, a common viral sanctuary.
Finally, SustivaT can be taken only once a day with or without food, however, a high fat meal may increase the absorption of Sustiva and should be avoided.
SustivaT is priced in the mid-range of the antiretroviral class at $10.95 per day. When used in triple-combination therapy, as it was studied, SustivaT will be less expensive than the current standard of care including protease inhibitors. SustivaT will be available in 200 mg capsules for adult dosing of 600 mg per day, and in 100 mg capsules and 50 mg capsules for pediatric dosing.
The accelerated approval of SustivaT is based on analysis of plasma HIV-RNA levels and CD4 cell counts in controlled studies of up to 24 weeks in duration. At present, there are no results from controlled trials evaluating long-term suppression of HIV-RNA with SustivaT.
Safety data from clinical trials show SustivaT is generally well tolerated. The most significant adverse reactions are nervous system symptoms, which are reported in approximately half of patients (e.g. dizziness, insomnia, somnolence, impaired concentration and abnormal dreaming). These symptoms occur early in treatment and generally resolve within a few weeks. Rarely, patients have more serious side effects that may affect mood or ability to think clearly. Mild to moderate skin rash was reported in approximately one out of four patients. The incidence of severe rash was less than 1 percent. Women should not become pregnant while taking SustivaT because birth defects have been seen in animals given SustivaT.

For questions about SustivaT:
1-800-4PHARMA (1-800-474-2762)

A New View of AIDS

November 30, 1998
As the scientific community has gained more information about the life cycle of the HIV, it has been able to design drug therapies and direct them to the vulnerable stages of the virus. A team of Harvard researchers have discovered a way to watch how the HIV virus becomes resistant to drugs. They hope the images will assist drug companies devise more effective ways to attack the virus. These scientists were able to crystallize and make an image of the reverse transcriptase enzyme, which HIV uses to replicate itself. They caught the virus just after it attacked a cell using an instrument known as a synchrotron - a high intensity, high-energy x-ray crystallography machine - to capture the image.
Five drugs now on the market, including the original drug, AZT, target reverse transcriptase. The medications work by mimicking nucleotides, natural building blocks of DNA in the cell. The HIV uses nucleotides when it attacks a cell, injecting its own genetic material into them and forcing the cell to produce copies of the virus instead of dividing naturally.
Combined with drugs known as protease inhibitors that attack the virus at a different stage of its life cycle, the approach works fairly well to suppress viral infection. In many people however, HIV eventually mutates and becomes resistant to drugs. Drug researchers have found that seeing the physical structure of drugs and their biological targets can help them design compounds that work together; many like the lock and key concept.
The Harvard team confirmed that the virus mutates in specific ways that allow it to effectively ignore the drugs. Using the x-ray crystallography, they were able to see the physical structures including "every amino acid, every protein, in an atom."
Other researchers have found that the reverse transcriptase enzyme of the HIV has parts, or domains, referred to as " fingers," "palm," "thumb," and "connection." These are used by the enzyme to seize hold of the nucleotide, like a hand grasping an object. They captured the enzyme "in the act" of copying a viral gene. As it does this, the "fingers" curl toward the "palm". Not only could they see this, but also the changes in the amino acids that make up the protein that confer resistance to each drug.

Recommended Precautions

Invasive Procedures
Some procedures you perform will pose a greater threat of contracting the 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 (HCW) 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 to the HCW. 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, organs or repair of major traumatic injuries:

1. In the operating room, delivery room, emergency department, or out-patient 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.

Implementing the Recommended Precautions

Healthcare facilities should ensure policies exist for the implementation of recommended precautions and that employees are aware of these policies. Most state boards of nursing now require that HIV/AIDS education be completed to renew nursing licenses. Policies should exist for:

1. Continuing education of all employees stressed at the initial orientation, including students and trainees. The orientation should include but not be limited to epidemiology, modes of transmission and the prevention of the transmission of HIV or other blood borne pathogens. The need for routine use of the standard blood and body fluid precautions in the care of all clients should be emphasized.
2. Provide, at the cost to the employer, all necessary equipment, supplies and personal vaccinations necessary to minimize the risk of infection with HIV and/or other blood-borne pathogens.
3. Provide a monitoring program that assures all the recommended protective measures are followed by the persons concerned. If there is a problem with an individual(s) who will not adhere to the recommended program or procedures, counsel them first, educate and retrain. If they still persist, appropriate disciplinary action may be necessary and should be considered.
4. Professional associations and labor organizations can use continuing education to emphasize their support and the need for caregivers to follow the recommended precautions.

Controlling the HIV in the Environment

Disinfection and Sterilization
Standard procedures currently recommended for disinfection and sterilization are adequate to control the HIV. This includes the procedures and requirements of hospitals, clinics (medical and dental), offices, hemodialysis centers, and long-term care facilities. The HIV has not posed any special requirements or procedures of the caregiver in order to achieve proper sterilization or disinfection within the professional environment.
They have however, emphasized the following factors be included as a standard infection control practice:

• Sterilize all equipment and/or devices that enter the client's vascular system or other areas that are normally sterile.
• All devices and equipment that contact intact mucous membranes but does not penetrate the client's body surfaces should be sterilized when possible. If they cannot be sterilized before being used for each client, they should undergo high-level disinfection.
• If you have equipment or devices that do not contact the client's skin or if they contact only intact skin of the client, they only need to be cleaned with a detergent or as recommended by the manufacturer.

When preparing medical devices or instruments requiring disinfection or sterilization, thoroughly clean them and then expose them to a germicide as the manufacturers instructions allow. Be especially careful to adhere to the manufacturers special instructions as they apply to the compatibility of the device or instrument with the germicidal cleaning agent. Concerning the survival of HIV in the environment, two facts offered by the CDC are:

• HIV does not survive well outside the body.
• HIV has to be grown in large amounts to be studied in laboratories. Although HIV has been kept alive under certain laboratory conditions, medical authorities agree that the virus does not survive well in the environment.

To put things into perspective, 1 milliliter (ml) of blood from a hepatitis B infected person may contain more than 100 million infectious viral particles. In a dried state, hepatitis B virus (HBV), may remain viable on surfaces for up to 1 week, and possibly longer. In contrast, the concentrations of HIV in the blood of infected persons are much lower. Neither HBV nor HIV are able to reproduce outside the human body, unlike bacteria or fungi which do so under suitable conditions. In laboratory studies of HIV and HBV, it was biologically necessary for these viruses to infect specific human cells to complete their life cycles and thereby reproduce themselves.
The HIV has been thought to be rapidly inactivated after it has been exposed to commonly used germicides at concentrations much lower than used in the average medical or dental practice. A 10% solution of household bleach prepared daily is an inexpensive, effective germicide when used to inactivate the HIV.
Concentrations of household bleach and water (1:10 dilution of household bleach) are effective depending entirely on the amount of organic material present on the instrument, object, device or surface. The CDC and OSHA continue its recommendation of the 10% bleach solution for disinfection. There are also commercial chemical germicides available that may be more compatible with certain medical devices or instruments to ensure they do not become corroded or damaged by extended use of the 1:10 hypochlorite dilution.

Cleaning and Decontaminating Blood Spills and Body Fluids

To clean and decontaminate spills of blood and other body fluids, always use chemical germicides that are EPA approved as tuberculocidal. In the client care areas when visible material is present, it should first be removed and then the area should be decontaminated. In instances where there are large spills of cultured or concentrated infectious materials, as may occur in a laboratory, first flood the area with an EPA approved germicide and then decontaminate the area with a fresh germicidal solution. Gloves should always be worn during cleaning and decontaminating procedures.
For routine housekeeping, the recommended rules apply and are applicable for the HIV. Usually, environmental surfaces such as walls, floors and other surfaces are not associated with the transmission of infections. The HIV is a fragile virus and has shown to be easily killed by routine disinfecting techniques so the frequency of the scheduled cleanings does not need to be altered to be effective against it.
When this is considered in the context of environmental conditions in healthcare facilities it does not require any changes in the sterilization or disinfecting procedures now recommended for housekeeping.

Laundry and Soiled Linen
Soiled linen has shown to be a source of large concentrations of certain pathogenic organisms. However, studies by the CDC have reported the risk of actual transmission of the HIV from soiled linen is negligible. In fact, the CDC has suggested that the use of hygienic principles coupled with common sense as guidelines when handling soiled linen. Those recommendations are listed:

1. Always wear gloves when handling soiled linen.
2. Always bag soiled linen on location.
3. Do not sort or rinse soiled linen in client care areas.
4. Always place linen that is soiled with blood or body fluids into bags that prevent leakage if it is to be transported.
5. Wash soiled linen in 71C. (160 F.) water for 25 minutes using a suitable detergent.

Precautions for Infective Waste
Hospital waste which requires special precautions regarding disposal in all cases include microbiology laboratory waste, pathology waste and blood specimens or blood products. Generally, infective waste should either be incinerated or be autoclaved before it is disposed into a sanitary landfill. Bulk blood, suctional fluid, and secretions may be carefully poured down a drain connected to a sanitary sewer. The sanitary sewer can also be used to dispose of other infectious wastes if they are capable of being ground and flushed into the sewer.

Challenges in HIV Care
Balancing the interest of patients against the interest of health care providers with regard to potential or actual HIV has created many legal issues. Some health care providers are reluctant to care for patients with HIV and have occasionally refused to treat HIV-seropositive patients. In addition, HIV-seropositive health care providers may be the target of widespread discrimination resulting in both personal and professional losses.
Anyone caring for patients with HIV/AIDS faces significant challenges whatever their area of practice. Working with clients who are facing an illness with a long, unpredictable course and fatal outcome, caregivers have the opportunity to help clients reach an optimal level of health. Whatever the stage, nurses are able to facilitate the client's role as an active participant in their health, work, family and community. Caring for clients with HIV can be exceptionally rewarding and, at the same time, frustrating and stressful. Stressors arise from specific issues directly related to HIV, and from more general concerns of a chronic illness, in an environment of limited resources. By recognizing positive and difficult aspects of HIV care, we can be more effective in caring for ourselves and our clients needs.
Attitude and behavior adjustments need to be made through education concerning prevention, transmission, and treatment of the HIV. Courses and training programs have had remarkable success in AIDS/HIV education, for dispelling myths and misconceptions concerning HIV.

HIV and the Law

Signed into law on July 26, 1990, the Americans with Disabilities Act (ADA) is a wide-ranging legislation intended to make American society more accessible to people with disabilities. The ADA's protection applies primarily, but not exclusively, to "disabled" individuals. One is considered "disabled" if he or she meets at least any one of the following criteria:

1. He/she has a physical or mental impairment that substantially limits one or more of his/her major life activities;
2. He/she has a record of such an impairment;
3. He/she is regarded as having such an impairment.

Supreme Court Says Disability Act Covers HIV June 25, 1998
WASHINGTON - HIV-infected people are protected by the federal ban on discrimination against the disabled even if they suffer no symptoms of AIDS. The ruling went against a Maine dentist who told an HIV-infected patient that he would fill her cavity in a hospital, but not in his office. The woman sued under the Americans with Disabilities Act, a federal civil rights law which bars disability discrimination.
This landmark decision was a victory not just for people with disabilities but for the Justice department, which has included people with HIV under the scope of this law. This federal law also protects those with disabilities in regards to employment issues, public accommodations including hospitals and clinics - and access to medical treatment.

Preventing Improper Disclosure/Confidentiality

Most people with HIV face, at least briefly, some issue regarding public knowledge of their status. They deal with discrimination issues of obtaining employment, insurance, and access to public accommodations. Therefore, public knowledge of their status may easily touch other parts of their lives, such as keeping custody of children or maintaining personal relationships. In the long run, only adequate public education will help solve these problems.
Laws that govern who should have knowledge of a patient's HIV/AIDS status are obscure at times. One thing is crystal clear; anyone who reveals information about a patient's HIV status could face both civil liability and disciplinary action for unauthorized disclosure of confidential information.
There are legal statutes that determine who can be forced to take an HIV test, have tests taken without their knowledge, or results revealed against their will. Similarly, statutes exist that offer general control over medical records, which may directly or indirectly reveal a person's HIV status; and federal and state constitutional protection of privacy in the face of government intrusion.
Unless they have given you explicit permission, do not discuss your patient's health status with anyone other than direct caregivers, his doctor or the patient. Check with the facility's risk manager or your supervisor to ascertain who is authorized to inform those who need to know.
When consent is needed to disclose health information, make sure it is in writing. It must specifically indicate what information will be released, to whom, and for how long the consent is valid. In releasing HIV-related data, include a statement that prohibits the receiving party from further disclosing the information without the patient's evidence of consent.
As with any patient, do not discuss health issues in public areas where others may overhear. For example, if you are giving HIV-related instructions to your patient, take him to a private room.
Remember we have a duty to advocate for the patient. Any incident suspected that health information has been disclosed improperly or without authorization should be reported.

Personal Safety vs. Duty to Care

The ADA protects clients with infectious diseases from discrimination in access to services, employment, etc. The same duty to treat in regards to healthcare facilities that receive Medicare and other federal funds, also applies.
Nurses who work for hospitals, home health agencies, or walk-in clinics, along with their employers, generally lack the legal backing to deny care to a patient with HIV/AIDS or any "infectious" disease. Refusing to care for a patient could result in a charge of insubordination or outright dismissal.
For example, what if you are a pregnant home health nurse who refused to care for an HIV-positive client. You feel that your unborn child is vulnerable to infection because you are in your first trimester of pregnancy. Can you legally refuse to care for this client?
The bottom line is you can ask for a different assignment if you do not want to care for a client with HIV-just as you can with any other situation-but your employer is not obligated to honor your request. In certain circumstances, policy may permit temporary reassignment for an immunosupressed nurse to decline care of infected clients. However, that policy must be applied consistently and fairly.
Public policy in the area of HIV/AIDS issues continues to progress. To help stay out of legal battles, keep current with laws and court rulings in your state, as well as employment policies and procedures.

HIV/AIDS Laws and Requirements for Florida Caregivers

The State of Florida has recently enacted the following legislation directed to confidentiality and testing for the 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 ore 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 health care professionals within their respective boards who are infected with Hepatitis B or the Human Immunodeficiency Virus."

HIV/AIDS Laws and Requirements for Kentucky Caregivers

902 KAR 2:020 (7). Disease Surveillance (HIV/AIDS) Relates to: KRS 211.180, 214.010, 333.130, Statutory Authority: KRS 194.050, 211.090(3), 214.010, 333.130, Section 7. Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) surveillance.
(1) Health professionals licensed under KRS Chapters 311 through 314, health facilities licensed under KRS Chapter 216B and laboratories licensed under KRS Chapter 333, shall report:

(a) A positive serologic test result for HIV infection; or
(b) A diagnosis of AIDS that meets the definitions of AIDS established in:

1."Adult HIV/AIDS Confidential Case Report Form"; or
2."Pediatric HIV/AIDS Confidential Case Report Form";

(2) HIV infection and AIDS diagnoses shall be reported within five (5) business days and, whenever possible, on the "Adult HIV/AIDS Confidential Case Report form" or the "Pediatric HIV/AIDS Confidential Case Report form".

(a) Reports for residents of Jefferson, Henry, Oldham, Bullitt, Shelby, Spencer, and Trimble Counties shall be submitted to the HIV/AIDS Surveillance Program of the Jefferson County Health Department.
(b) Reports for residents of all other Kentucky counties shall be submitted to the HIV/AIDS Surveillance Program of the Kentucky Department for Public Health, or as directed by the HIV/AIDS project coordinator.

(3) Reports for persons with HIV infection without a diagnosis of AIDS shall be identified by the initials of the patient's first and last name and shall include:

(a) Date of birth;
(b) Gender;
(c) Race;
(d) Risk factor, as identified by CDC, if known;
(e) County of residence;
(f) Name of facility submitting the report;
(g) Date and type of tests performed;
(h) Results of tuberculosis testing, if available;
(i) Identifying and locating information for the person's spouse, if applicable.

(4) Reports of AIDS cases shall include the patient's full name and the information in subsection (a) through (h) of this section; and

(a) The patient's complete address;
(b) CD4+ cell count, if known;
(c) Opportunistic infections diagnosed;
(d) Date of onset of illness.

(5)

(a) Reports of AIDS shall be made whether or not the patient has been previously reported as having HIV infection.
(b) If the patient has not been previously reported as having HIV infection, the AIDS report shall also serve as the report of HIV infection.

Complementary Therapies for HIV/AIDS

A documented association exists between nutritional status and immunologic function, development, and outcome of infectious processes, and treatment-related toxicity and vital organ function. In persons with AIDS, nutritional deficits precipitate a cycle that results in a downward spiral of weight loss, malabsorption, diarrhea, anorexia, body image disturbance, and increased risk of morbidity and mortality.
Because complementary medicine encompasses a wide array of interventions and is used for many different diseases and illnesses, it is important to show how it can all be put together in the real world of patient care
HIV/AIDS is a good example of how modern medicine is being forced to look at alternative forms of care simply because allopathic medicine cannot provide a cure. Because of the nature of HIV infection, there are no surgical interventions to help, and the few pharmaceutical interventions available have side effects that are intolerable by many HIV sufferers.
A basic premise of alternative medicine is that all diseases, if approached in the right way and treated in the right manner, are reversible. This includes AIDS, a disease marked by severe immune deficiency, but a disease that is difficult to define because of the complexity of symptoms and accompanying diseases. It is distinguished from almost all known diseases throughout history because it has no constant and/or specific symptoms.
Instead, once the immune system becomes compromised, a wide variety of approximately twenty-eight health complications set in. AIDS is the umbrella diagnosis given for this array of symptoms caused by a variety of opportunistic (microbial) infections. When one of these infections is found along with the presence of the HIV virus, a diagnosis of AIDS is made. Over the years the number of infections associated with AIDS has increased, and these statistics show an over-inflated rate of an increase in the disease.
People with HIV/AIDS use complementary approaches to improve their overall health, prevent opportunistic infections, treat symptoms, and to reduce side effects from allopathic treatment methods.
These new approaches include many nutritional interventions, exercise, psycho-social interventions, varying products being marketed for HIV relief, some traditional and ethnomedicine regimens, acupuncture, herbal medicine, hypothermia, oxygen therapy, a variety of mind/body techniques, and massage.
Allopathic medicine is now using combinations of antiretroviral drugs, such as AZT, to fight the HIV virus from a variety of positions within the cell. While there is insufficient evidence on the efficacy of combinations of alternative approaches and long-term survival rates, there is a growing number of literature reporting benefits in the use of alternative methods in the areas of nutrition, exercise, and psychosocial support.
For example, one study shows that a combination of botanical medicine, homeopathy, nutritional supplementation, hyperthermia, and counseling given to thirty patients with AIDS-related complex was just as effective in slowing disease progression rates as in a control group treated with AZT. The alternative therapies have the added benefit of significantly fewer side-effects. Results of this study were consistent with a previous study showing that those with alternative interventions had a significantly lower decrease in the rate of CD4 reduction than did those using allopathic approaches.
While more studies are necessary to support it, there appear to be several lifestyle co-factors for HIV progression. It is these cofactors that most complementary approaches address. Such cofactors include the belief that being HIV positive means certain death, stress, grief, depression, level of assertiveness, trusted support, breathing patterns, fluid intake, nutrition, sleep, exercise, exposure to infection, having a life purpose or goals to make one want to continue living, crisis coping methods, environmental toxins, an attitude of self-care and independence, relationship with the physician, and knowledge about the disease.
Because part of the disease process of AIDS involves a wasting away of lean body mass, resulting in a severe weight loss, nutritional approaches play a key role in stemming that process. Studies have shown a negative correlation between survival rates and the loss of more than 10% of lean body mass. GI distress and a change in nutritional status occur in about half of AIDS sufferers.
The exact mechanism for this is not understood, but it is postulated that inadequate nutrition decreases the body's total T-lymphocytes, helper cells and suppressor cells, causing increased susceptibility to the opportunistic infections associated with AIDS.
One study showed that decreased body mass index, serum albumin, and transferring were clearly associated.
When patients were given the appetite stimulants dronabinol and megestrol acetate, they exhibited increased appetite and an overall sense of well-being, and they did not lose as much weight. Other controlled clinical studies showed that the administration of recombinant human growth hormone can reverse the wasting process, causing the lost weight to be regained.
The use of Chinese herbs in the treatment of AIDS/HIV symptoms related to nutrition issues such as fatigue, nausea, vomiting, diarrhea, and difficulty swallowing is now being studied in clinical trials. The GI system has been a central part of Chinese medicine for centuries and has been traditionally treated with acupuncture (primarily the points associated with the lungs, liver, spleen, and kidneys), a variety of herbs, and dietary changes.
In cases of AIDS/HIV, practitioners recommend staying away from raw vegetables and poultry, because of the energy expenditure in digesting raw vegetables to prevent excess stomach acids from accumulating, and to avoid added stress on the liver. Poultry may cause a buildup of toxins in the body when the body cannot eliminate them easily. Public Health Officials and others trained in allopathic care suggest that AIDS/HIV sufferers avoid eating raw eggs and undercooked meat because these foods may lead to the opportunistic infections that are common in the disease process.  The three goals for good nutritional management of AIDS are:

1. preservation of lean body mass
2. providing adequate levels of nutrients
3. decreasing malabsorption.

Micronutrients are studied to see which are most useful in meeting these goals. One of the most promising is the supplementation of Vit A, a deficiency which has been associated with disease progression and death.
These substances proved to have an important effect on the immune system. One study showed that supplementation with Vit A decreased the incidence of transmission of the HIV virus from a pregnant woman to her unborn child, and reduced the virus in breast milk.
Vit B6 deficiency has been associated with changes in neuropsychiatric function, impaired interleukin-2 production, and increases in lymphocyte production. Supplementation with the vitamin over an 18-month study showed a significant decrease in the psychological distress symptoms associated with AIDS.
Because of these, and other studies, AIDS activists and clinicians are encouraging HIV positive people to supplement their dietary regimen with Vit A, Vitamin E, Vitamin C, all the B Vitamins, zinc, folate, potassium, manganese, biotin, and selenium. Due to the disruption in normal digestive patterns associated with AIDS, it is sometimes necessary to provide this supplementation through either i.m. or an i.v. injection.
Dietary recommendations include the following: eat whole foods, avoid additives and processed foods, eliminate refined carbohydrates, eat less fat and cook with monounsaturated oils, eat smaller meals often throughout the day to encourage absorption of nutrients, make sure fruits and vegetables are free from bacteria and/or parasites by steaming them before eating, eliminate chocolate and alcohol, and reduce caffeine intake.
Another way of dealing with the muscle wasting associated with HIV/AIDS is to encourage regular exercise.
One controlled study followed the effects of a six-week long, three times/week weight training program on 24 AIDS patients who had recently been hospitalized for pneumonia and were taking AZT. They were randomly selected into a group who followed a progressive resistance exercise program, and a control group who did not.  The results showed increases in muscle function and body weight in the exercise group, but not in the control group.
Another study tested the effects of a 12-week long, three times/week weight training program combined with aerobic exercise on psychological and immunologic measures. The exercisers showed increased cardiovascular function and CD4 lymphocyte counts when compared to a control group who had counseling intervention, but no exercise training. Both groups did show decreased symptoms of depression. Researchers are encouraged by these results, but hesitate to state a clear correlation on the benefits of exercise in HIV/AIDS patients until further research corroborates these results.
Wasting is a complex physiological process that is believed to involve metabolic abnormalities such as an increased resting basal metabolic rate, resulting in an increase in overall body energy expenditure. Lowering the metabolic rate through meditation, yoga, and other relaxation exercises can help.
These mind/body interventions have the benefit of helping to reduce stress, which is a major inhibitor of proper immune functioning. Many of these methods are taught in support groups for those just diagnosed. This setting provides the opportunity to teach effective coping skills, and a safe place to talk about feelings. While several small studies have shown these strategies to be effective, larger clinical trials are needed to validate the findings of these smaller studies. The importance of a positive mental attitude cannot be stressed enough in terms of supporting the immune system.
Studies have shown that there are four psychosocial factors that may relate to long-term survival. These include:

1. healthy self-care
2. maintaining connectedness
3. having a purpose or meaning in life
4. maintaining perspective.

Most of these occur not when the diagnosis is made, but often once the symptoms begin to show. This is when anxiety and/or depression often develop as the individual realizes not only that the disease is progressing , but also that the reality of living with symptoms will be unpleasant. Most sufferers have at least four of the following symptoms, often simultaneously:
- weakness and numbness
- some memory loss
- dyspnea
- diarrhea
- fever
- chills
- seizures
With the onset of symptoms comes more contact with the medical community, medical tests, treatment of opportunistic infections, and other diagnostic necessities, which can prove disruptive to a person's normal routine. Eventually sufferers must deal with several losses, such as work, favorite activities, and financial resources. These losses often lead to depression and stress, which may further compromise immune functioning.
Many people (and AIDS sufferers are no different) deal with depression and stress by making negative lifestyle changes involving sleep patterns, alcohol consumption, cigarette use, and dietary changes, all which decrease the immune system functioning. Depression may also prevent one from complying with treatment regimens necessary to long-term survival.
Teaching positive coping skills such as maintaining the will to fight the disease, reframing stress as an opportunity for personal growth, seeking good social support, and having a plan for dealing with life as the disease progresses helps to lift depression, increases self-esteem, and provides a sense of control over a situation that is primarily out of one's control.
These skills and insights can be taught in behavioral-cognitive oriented support groups for those with AIDS. The support group format provides a good way to combat the common reaction of self-blame that follows diagnosis and the onset of symptoms.
Massage therapy can help an HIV/AIDS patient because the touching can make the patient feel cared for when the patient feels isolated and lonely as others refuse to touch them in fear of contracting the disease. This leaves many AIDS sufferers as essentially social outcasts.
One study showed that an increase in natural killer cells and other immune system improvements was directly related to massage therapy. Massage therapy for one with AIDS should be gentle, and not too fast or too deep, to avoid stimulating the adrenal glands and thus compromising the immune system. The therapist must be careful not to release too many toxins into circulation because the already compromised body may not be able to handle them as well as a healthy person would. For this reason, it is suggested that AIDS patients considering massage therapy look for a licensed therapist trained in dealing with the complexities of AIDS.
The use of herbal medicine in dealing with AIDS is widespread in some areas of the country (the San Francisco Bay Area is one), but remains controversial in other parts of the country.
Traditional Chinese Medicine (TCM) includes the following herbs which some believe have anti-bacterial, antiviral, and/or anti-retroviral properties.
Others say they work primarily by strengthening the immune system. These herbs include garlic, (which also inhibits carcinogenesis), ginseng, St John's Wort (which alleviates depression), bitter melon, Compound Q, Curcumin, Iscador, SPV30, NAC, and Kemron.
To clarify efficacy claims of TCM, a collaborative trial was conducted at San Francisco General Hospital using herbal formulations purported to have antiretroviral and immunologic properties. The results were compared to a control group which received placebos. Changes in weight, CD4 count, hemoglobin levels, depression, and adherence to the regime were not significant between the two groups.
However, measurements of life satisfaction and the number of symptoms improved for the herbal group, but not for the placebo group. TCM practitioners say that this type of study does not adequately assess the advantages of TCM methods because isolated herbs used without acupuncture and meditation are not the way TCM deals with AIDS. They stress the importance of a combination of all three approaches to boost the immune system. More research is being conducted to determine the role of each of these approaches in AIDS intervention.
Some researchers believe that the HIV virus cannot live in high temperatures and will become increasingly inactive as body temperature rises for an extended time. This is also believed to stimulate the immune system by increasing antibodies and interferon. The use of hyperthermia as an intervention has increased over the past few years.
Hyperthermia can be done as a form of self-care (but not without supervision) by taking hot baths, and then wrapping oneself in blankets with a hot water bottle over the abdomen for several hours, if it can be tolerated for that long. Hospitals offer sophisticated high-tech forms of hyperthermia using microwaves and ultrasound.
Hyperthermic treatments may decrease the incidence of night sweats, secondary infections, and boost self-esteem at the same time. Hyperthermia is contraindicated in people with anemia, heart disease, diabetes, seizure disorders, and TB.
Another form of alternative treatment for AIDS is oxygen therapy. The extra oxygen atoms in both ozone and hydrogen peroxide break off and adhere to invading pathogens, altering their molecular structure and killing them.  Sometimes the blood of AIDS patients is removed, treated with ozone, and then reinserted into the body. In other cases, the ozone, in a diluted form, is injected into the bloodstream. Hydrogen peroxide can be administered intravenously, rectally by enema, or by bathing in it. Sometimes ozone and hydrogen peroxide are used in combination.
One note of Caution: These substances leave free radicals in the system and therefore must be accompanied by nutritional support that is high in antioxidant therapy, especially Vitamin C
Other alternative self-care treatments that can be done at home under professional supervision include biofeedback training, meditation and guided imagery, aromatherapy using tea tree oil and garlic, and homeopathy using Hypericum, the Latin name for St. John's Wort.
There is a variety of complementary and alternative health care practices and traditions that are quickly assimilated into modern Western medical tradition; as more Western trained health care professionals recognize the benefits of these methods, and become trained in them. As the cost of health care skyrockets, the less expensive complementary methods are looking increasingly attractive to both the public and to healthcare professionals.
The role of the nurse is rapidly changing as the emphasis on holistic health increases because nurses have traditionally been taught to look at the whole patient and to care for the spiritual, psychosocial, physical and emotional aspects of their patients. The holistic approach of most complementary practices naturally lend themselves to nursing functions.
Naturopathic medicine, with its emphasis on diet and supplements, is naturally attractive to most nurses. Nurses have an important position in educating the public about the role of diet and supplementation to maintain optimal health, and to fight the disease process once it has started. Because of the holistic approach to health, nurses are becoming increasingly involved in mind/body medicine in a variety of ways by making appropriate nursing diagnoses, and interventions.
These interventions include teaching relaxation and meditation techniques to reduce stress, facilitate support groups to encourage psychosocial development, and use therapeutic touch and prayer, when requested, to meet the spiritual needs of their patient. Some nurses are trained in massage therapy to better serve their clients' holistic health care needs for comforting touch.
In other areas of complementary medicine the role of the nurse is to be informed on the subject to better serve patients by providing information about the advantages and disadvantages of these approaches, and to make referrals to the appropriate practitioners. These areas include Traditional Chinese Medicine (both herbal and acupuncture), other popular forms of herbal medicine distributed by naturopaths, chiropractic medicine, osteopathic medicine, and homeopathic medicine.
As we move into the twenty-first century, it is an exciting time to be a nurse because of the new techniques and theories of medicine. Nurses can play a key role in disseminating this information to an increasingly sophisticated public. As hospital census numbers decrease throughout the country, more nurses are finding employment in other environments such as home health, industries, and in entrepreneurial ventures of their own.
This helps to place the nurse in a position to teach not just sick people, but to the healthy, too, by providing important preventive information to obtain an optimum state of health. This not only improves their quality of life, but helps to reduce the astronomical costs of health care. Today's nurse is an integral part of the modern health care delivery system, and provide a positive influence.

Resources

The Centers for Disease Control and Prevention (CDC) maintains a Voice Information System that provides accurate and up-to-date information concerning the HIV and the disease of AIDS. Updated information about HIV PEP is available on the Internet at CDC's home page www.cdc.gov; CDC's fax information service, telephone (404) 332-4565.

Hospital Infections Program directory; the telephone number is (800) 458-5231; and the HIV Treatment Information Service, telephone (800) 448-0440.

National AIDS Clearinghouse Voice Information System 1-800-458-5231. Website address is: www.fda.gov.

TDD/TTY
The Cabinet for Health Services offers comprehensive human services to assist persons with HIV infection. The office has a TDD/TTY for individuals who are hearing or speech impaired. The number to call is (502)564-6539, from 8:00 a.m.- 4:30 p.m. EST.

. AIDS Clinical Trials Information Service (ACTIS) 800-TRIALS-A or (1-800-874-2572) www.hivpositive.com.

. Project Information Hotline, (800) 822-7422 or www.projinf.org.

. For more information on alternative approaches for treating AIDS/HIV contact the AIDS Alternative Health Project (AAHP) in Chicago, Illinois, (773) 561-2800.

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