HIV / AIDS: An Overview

Course #992 - 3 Contact Hours

Author: Shelda L. Shank, RN, BSN, PHN
©2008 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.
The "No Electronic Theft Act" makes it a felony to download copyrighted material over the Internet without permission. National Center of Continuing Education, Inc. grants permission for a single download of our on-line course(s) to your computer solely for the use of obtaining continuing education credits. Details on the copyright usage of our courses are specified at the end of this page.

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 to provide the knowledge that will assist you in educating and caring for these special clients and their families.
In an effort to combat the threat of AIDS, healthcare facilities have mounted an intensive education and training effort to ensure that people know and follow the recommended measures to prevent the transmission of HIV, and are given the tools to pass on this vital information to others.

What is AIDS?

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). The HIV virus 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. 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, it inserts itself into the host cell's DNA. Once in the cell's genes, HIV DNA is called a provirus that can replicate and release new infectious viral particles.
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 Center 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). Since January 1, 1993, AIDS cases have been defined as adults/adolescents (>13 yrs. of age) who are HIV-infected with a CD4 T-lymphocyte count 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 definition also added three new indicator 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.
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. The National Academy of Sciences has said that the various points along the spectrum of HIV/AIDS 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 such wide diversities in the clients' clinical history.
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 cure 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.

Epidemiology/Trends

Today the number of persons diagnosed with either HIV or AIDS continues to increase. In the United States, for the 753,907 total reported cases of AIDS there have been 438,795 deaths, for an approximate mortality rate of 58 percent. (See Table 1)

The most recent information from the Centers for Disease Control (December 2000) indicates that both the incidence and death rate from AIDS continue to decline in the United States, but the rates of decline have been leveling since 1998. As new treatments have extended the healthy lifespan of many people with AIDS, however, the prevalence has continued to increase. Moreover, despite the trend toward declining AIDS diagnoses, the number of HIV diagnoses has remained relatively stable, and the proportion of HIV cases among women and minorities is higher than with AIDS cases. Growing numbers of cases of HIV are diagnosed in youth aged 13 to 24, the majority in African Americans and women; in all, as many as 900,000 Americans are now living with HIV, and 40,000 new cases occur each year.
The overwhelming majority of persons with HIV - approximately 95% of the global total - now live in the developing world, and 5.3 million adults became infected in 2000. Women are increasingly affected, accounting for 46% of all HIV and AIDS cases worldwide. Not only did AIDS-related diseases claim the lives of 470,000 children under the age of fifteen in 1999, but by the end of that year more than 11.2 million children had been orphaned by the epidemic. Clearly, prevention and treatment remain a significant challenge.
The greatest percentage of AIDS cases has been drawn from men who have sex with men, and men and women of the injecting drug communities (485,870). (See Table 2)

....341,597

Females...50,073

...184,429

Men who have sex with men
& inject drugs

.....46,582

Females...272

.......5,075

.....74,477

.......8,531

Total:

.....63,965

TABLE 6. Estimated pediatric AIDS incidence, by year of diagnosis, 1992 through 1999, United States

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

Centers for Disease Control & Prevention National Center for HIV, STD, and TB Prevention Divisions of HIV/AIDS Prevention.

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 were put into practice. As healthcare providers across the country incorporated these guidelines into clinical practice, assessed risk factors, and offered confidential testing and drug treatment, perinatal AIDS incidence dropped dramatically.
According to a study released in 1998, even if only given after birth, AZT appears to substantially reduce the chances of transmission of the AIDS virus to newborns. The most recent Public Health Service Task Force treatment guidelines (issued January 24, 2001) recommend that AZT be given to HIV-infected mothers beginning at 14-34 weeks' gestation and continuing throughout the pregnancy, and then to their babies for six weeks after birth. Infected mothers do not always seek prenatal care, however, so it is not always -possible to provide the full course of treatment.
Between 1992 and 1999, the number of children with perinatally acquired AIDS dropped 83%. But despite declines in all racial/ethnic groups, the majority of perinatally acquired AIDS cases continue to occur among African-American and Hispanic children, and rates for Hispanic children appear to be increasing. This indicates the need for intensified efforts to prevent infection among minority women, and to reach infected women with early prenatal care and preventive treatment.

Signs and Symptoms of AIDS

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 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
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
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.

Night Sweats and/or Fever
Fevers and night sweats will often occur with AIDS as well as tuberculosis (TB) and other serious diseases.

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.

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 clients' blood demonstrates an unusually delayed clotting time.

Coughing and Shortness of Breath
"Pneumocystis carinii pneumonia" (PCP) is a major defining condition for AIDS diagnosis. Usually it will begin as a cough that can be either productive or dry. If your client is HIV positive, the cough will often persist for weeks and lead to 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.
Pneumocystis carinii pneumonia is the most frequent life-threatening opportunistic infection in patients with HIV. The incidence has fallen with the use of primary prophylaxis in persons with CD4⁺ T-lymphocyte counts below 200/ml.

Skin Rashes and Spots
Red, brown, pink, or purplish blotches on or under the skin or inside the mouth, nose, or eyelids may indicate the presence of Kaposi's sarcoma, a malignant multifocal neoplasm which can metastasize to the lymph nodes and viscera, that has become a visible hallmark of the AIDS patient. If these lesions develop they will range in size from an insect bite to large nodules or plaques. The manner and location of the lesions as they develop will vary.

Persistent Generalized Lymphadenopathy (PGL)
(Swollen Glands)
Lymph nodes may routinely become swollen due to infection, malignancies, or reaction to drugs. Both viral and bacterial infections can cause the enlargement. The glands in the groin and neck will often become enlarged without an obvious cause.

Candidiasis
(Oral Thrush)
A fungal infection involving the tongue, oral cavity and the throat that is common with AIDS is Candida albicans. Usually it is a serious factor only in debilitating illnesses, malnutrition and instances where there is frequent ingestion of antibiotics that suppress microorganisms, allowing the overgrowth of fungus. Thrush presents as a persistent, creamy-white curd-like patch that coats the tongue and surrounds the throat and esophagus. It is the esophageal thrush that is case-defining.
A condition similar to thrush that is often observed in HIV-infected clients is called "hairy leukoplakia." Lesions associated with hairy leukoplakia erupt on each side of the tongue as grayish-white patchy discolorations.

Neurologic Problems
HIV has been isolated and readily reproduces in the brain tissues of clients with HIV disease. Some clients with HIV have exhibited subtle neurologic symptoms even without 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 when they accompany other medical problems. The availability of a consultant in neurology to help clarify difficult diagnostic issues is essential. Psychiatric symptoms such as depression, delusions, hallucinations and paranoia have also been noted.

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 use 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 from pregnant women to their babies during the birthing process.

Preventing the Spread of HIV

People's concerns regarding this life-threatening and incurable disease are often out of proportion to the actual risks revealed by scientific studies. The known facts are now being 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."

Specific prevention measures applicable to personal sexual practices and injecting drug use (IDU) include:

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. Dental dams may also be used during oral sex.
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." If these items are shared, they should be disinfected with bleach.
10. Do not share personal items such as toothbrushes, razors, or devices used during sex that 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 behaviors through educational efforts is still the best way to prevent HIV infections.

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, as well as 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 to receive appropriate treatment. Early detection of HIV, followed by administration of certain drug combinations, can greatly improve both the quality and length 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 that 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; it only indicates the presence of antibodies to 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 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 Sure™, 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 gum 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 Access™ 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 a day, 7 days a week is available. This self-administered test is completed in four 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 the Home Access™ laboratory.
4. Call for the results. Blood is screened using the ELISA system. If this screen is positive, a more specific confirmatory test, Immunofluorescence Assay (IFA) will be used.

Home Access™ 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 has been tested. You should be aware that neither the CDC nor WHO has endorsed universal mandatory testing at any time. The suggestion has also been rejected by the American Nurses Association (ANA).

 Caregiver Concerns

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 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 has broadened these requirements to include taking precautions with ALL body fluids and substances. The 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 high 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
  

Standard Precautions

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, 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 that may be contaminated.

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 health 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 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.

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.

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.
After use, disposable syringes and needles, scalpel blades, and all other sharps that are to be disposed of 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.
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.
You should 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 the 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 needle stick injury.

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.

Implementing the Recommended Precautions

Healthcare facilities should ensure that 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 as a condition for renewal of nursing licenses.
Policies should exist for:

1. Education of all employees 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 and 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. Provision, at the employer's expense, of all equipment, supplies and personal vaccinations necessary to minimize the risk of infection with HIV and/or other blood-borne pathogens.
3. Provision of 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 taken.
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 HIV in the Environment

Disinfection and Sterilization
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.
They have, however, emphasized the following factors to be included in 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 do 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.
• Equipment or devices that do not contact the client's skin, or contact only intact skin of the client, 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 manufacturer's instructions allow.
Be especially careful to adhere to the manufacturer's 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, the CDC has stated that:

• 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 one week, and possibly longer. In contrast, the concentrations of HIV in the blood of infected persons are much lower. Neither HBV nor HIV is 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.
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 HIV. These concentrations are effective depending entirely on the amount of organic material present on the instrument, object, device or surface.
The CDC and OSHA continue to recommend 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 client care areas where 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 are applicable for HIV. Usually, environmental surfaces such as walls, floors and other surfaces are not associated with the transmission of infections. HIV is a fragile virus and has been shown to be easily killed by routine disinfecting techniques, so the frequency of 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 HIV from soiled linen is negligible. In fact, the CDC has suggested the use of hygienic principles coupled with common sense as guidelines when handling soiled linen. Those recommendations include:

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 71 C. (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, includes 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, suctioned 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.

Management of Infected Caregivers

There have been only a few instances where HIV has been transmitted from a caregiver to a client, but there is an ever-present possibility that it can occur during an invasive procedure. You should be aware that 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 56 healthcare workers in the U.S. 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. The individuals who seroconverted include 23 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, 2 housekeeper/maintenance workers and 1 embalmer/morgue technician. (CDC, HIV Surveillance Report, 12(1), 2000)

UPDATE: MMWR 1998; 47(No.RR-7) Public Health Service Guidelines for the Management of Healthcare Worker Exposures to HIV and Recommendations for Post-Exposure Prophylaxis (PEP):
This summary document updates and consolidates all previous public health service (PHS) recommendations for the management of healthcare workers who have occupational exposure to blood and other body fluids that may contain HIV; it includes recommendations for HIV PEP and discusses the scientific rationale for PEP. The decision to recommend HIV PEP must take into account the nature of the exposure (e.g., needle stick 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 healthcare worker 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 healthcare workers 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. Healthcare organizations should have protocols that promote prompt reporting and facilitate access to post-exposure care. Enrollment of healthcare workers in registries designed to assess side effects in those who take PEP is encouraged.
Single copies of the complete document on PEP recommendations are available from the CDC, National AIDS Clearinghouse, PO Box 6003, Rockville, MD 20850, by calling (800) 458-5231, or online at www.cdcnac.org.

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 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 during this period cannot be over-emphasized.
As the profile of AIDS clients changes to include more young people, women and minorities, caregivers 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 caregiver 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.
In the following section we will discuss some important needs and requirements of AIDS clients in a hospital care setting.

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.
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 will be to provide support and reassurance. As an initial step, you can explain the necessity of having a complete physical examination, as well as various other procedures and diagnostic tests. A factor of extreme importance and concern to the client is confidentiality.
During 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 that 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 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. The new combinations of three or four antiretroviral agents usually include two nucleoside reverse transcriptase inhibitors (NRTIs) with either one or two protease inhibitors (PIs), or one of the nonnucleoside reverse transcriptase inhibitors (nNRTIs). (See Tables 8 and 9)

This table provides a guide to the use of available treatment regimens for individuals with no prior or limited experience on HIV therapy. In accordance with the established goals of HIV therapy, priority is given to regimens in which clinical trials data suggest the following: sustained suppression of HIV plasma RNA (particularly in patients with high baseline viral load) and sustained increase in CD4+ T cell count (in most cases over 48 weeks), and favorable clinical outcome (i.e., delayed progression to AIDS and death). Particular emphasis is given to regimens that have been compared directly with other regimens that perform sufficiently well with regard to these parameters to be included in the "Strongly Recommended" category. Additional consideration is given to the regimen's pill burden, dosing frequency, food requirements, convenience, toxicity, and drug interaction profile compared with other regimens.
It is important to note that all antiretroviral agents, including those in the "Strongly Recommended" category, have potentially serious toxic and adverse events associated with their use.
Antiretroviral drug regimens are comprised of one choice each from columns A and B. Drugs are listed in alphabetical, not priority, order.

(1) More information on optimizing protease inhibitor exposure with ritonavir is available www.hivatis.org.
(2) Based on expert opinion.
(3) Co-formulated as Kaletra.
(4) Saquinavir-SGC, soft-gel capsule (Fortovase); Saquinavir-HGC, hard-gel capsule (Invirase).
(5) Pregnant women may be at increased risk for lactic acidosis and liver damage when treated with the combination of stavudine and didanosine. This combination should be used in pregnant women only when the potential benefit clearly outweighs the potential risk.
(6) This category includes drugs or combinations for which information is too limited to allow a recommendation for or against use.
(7) Zidovudine monotherapy may be considered for prophylactic use in pregnant women with low viral load and high CD4 + T cell counts to prevent perinatal transmission, as discussed under "Considerations in the Pregnant Woman."
(8) Use of Saquinavir-HGC (Invirase) is not recommended, except in combination with ritonavir.

No specific regimen is considered to be the treatment of choice. Because of the unique side effects of the protease inhibitors (including risks of lipid abnormalities and the potential for development of drug resistance), some clinicians prefer to use an nNRTI in combination with two NRTIs for initial therapy, reserving the PI class of drugs for subsequent regimens.
The principal goal of therapy is to prevent or reverse the progression of clinical illness. With effective therapy the clinician should see improvement in the clinical signs and symptoms of the disease, a rising CD4+ cell count, and decreasing viral load. 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.
Therapy complications are a major problem for the HIV/AIDS client, and the number of complications appears to increase with longer periods of survival. Recently attention has focused on lipid abnormalities, associated with body fat redistribution as well as long-term risk of coronary artery disease, and increased incidence of hepatotoxicity, especially with the nNRTI nevirapine.
Opportunistic infections have decreased markedly since the introduction of HAART. However, primary prophylaxis against Pneumocystis carinii pneumonia (PCP) and Mycobacterium avium complex (MAC) are still highly recommended.
The FDA has made additional 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.

End of Life Care
Terminal care is defined as assisting and providing support to a person who is in the end stage of life, as well as to his or her family system. The term "family system" is broad and encompassing: it includes the client's significant other(s), immediate and extended family members, friends, and in some instances even the community. Each person defines who is included in his or her family system, and this group will vary from person to person.
Terminal care may be administered to patients who are in the hospital or long-term care facility, or it may be for a person that the nurse is case managing. In the last 25 years, the principal setting for this care in the United States has shifted from the acute hospital and long-term inpatient settings to the home. Part of the reason for this shift can be attributed to the consumer movement and partly to escalating healthcare costs. Policy makers note that the greatest costs for healthcare are incurred in the last two to four months of life; that is, during the end stage of disease when terminal care is needed. More importantly, however, the dying person often prefers to remain at home with loved ones whenever possible.
With terminal care, such as that provided by an organized hospice service, a continuum of care is promoted. In other words, services continue uninterrupted for a client even when there are changes in the care setting. Be it in the home, hospital, extended-care facility, or hospice inpatient unit, the client's care continues to be offered by the same team and in a holistic manner. Particular services that are to be administered are coordinated with the client, family, primary care physician, and interdisciplinary team members such as the nurse, social worker, chaplain, physical therapist, and nutritionist. For home care and hospice agencies, required services are regulated by state licensure requirements and Medicare/Medicaid certification guidelines.
Palliative care and symptom management are the essence of terminal care for a client experiencing end stage disease symptoms. Interventions are directed toward promoting a high quality of life, relief of suffering, and supporting a peaceful death.
Symptom management in many cases is the most important activity in providing terminal care to a client. Symptoms will vary from person to person, and his or her particular health problems. Likewise, the symptoms will change in intensity, frequency and duration as the disease progresses. Carefully listening to what the client is telling you, observing and assessing for changes from the baseline status, then intervening early on can go a long way to managing symptoms in the terminal client.
Symptoms encountered in terminal care that cause an intense degree of discomfort include nausea, vomiting, anorexia, pain, skin breakdown and decubitus ulcers, urinary and bowel irregularities, and respiratory problems. If these cannot be managed at home, short-term inpatient care is provided for symptom control, respite care, or terminal care (when death is imminent).

Challenges in HIV Care
Balancing the interest of patients against the interest of healthcare providers with regard to potential or actual HIV has created many legal and ethical issues. Some healthcare providers are reluctant to care for patients with HIV and have occasionally refused to treat HIV-seropositive patients. In addition, HIV-seropositive healthcare 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 meeting our clients' needs.
Attitude and behavior adjustments need to be made through education concerning prevention, transmission, and treatment of HIV. Courses and training programs have had remarkable success in dispelling myths and misconceptions concerning HIV and AIDS.

HIV and the Law

Signed into law on July 26, 1990, the Americans with Disabilities Act (ADA) is 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 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.

In June 1998 the U.S. Supreme Court ruled that 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 that 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.