*Valid for P.A.C.E.

credit through 12/31/2015*

COURSE DESCRIPTION
This CE course reviews the immune system, HIV, and AIDS. The
course includes discussions on the diagnosis and treatment of
HIV, a timeline of the HIV/AIDS epidemic, HIV/AIDS today, and
safe working practices for healthcare professionals.

Rev 4.0
October 2014
1

COURSE TITLE: HIV & AIDS-The Anatomy of a Pandemic

Author: Lucia Johnson, MA Ed, MT(ASCP)SBB
Vice President, Recertification
National Center for Competency Testing
Number of Clock Hours Credit: 3.0
Course # 1221814
P.A.C.E. Approved: _ X Yes

_ No

OBJECTIVES
Upon completion of this continuing education course, the professional
should be able to:
1. Identify the cells, tissues, and organs that comprise the immune system.
2. Describe the function of each component of the immune system.
3. Describe the role of phagocytes and lymphocytes in the immune system.
4. Describe three types of T cells.
5. Summarize the basic immune response.
6. Identify the mechanisms by which HIV disables the immune system.
7. Describe three stages of HIV infection.
8. List ways in which HIV can be transmitted.
9. Describe the diagnostic criteria used for AIDS.
10. List common opportunistic illnesses seen in AIDS.
11. Describe three laboratory tests used to diagnose, monitor, and treat HIV and
AIDS.
12. Identify five classes of antiretroviral therapy used for HIV and AIDS.
13. Describe short term and long term side effects of antiretroviral therapy.
14. Describe the HIV and AIDS 30 year timeline.
15. Identify ways in which HIV can be transmitted to healthcare professionals.
16. List U.S. statistics for HIV transmission to healthcare professionals.
17. Identify methods to minimize occupational exposure to HIV and other bloodborne
pathogens.
18. Describe the importance of needlestick injuries in todays healthcare
environment.
19. Describe HIV and AIDS today both worldwide and in the U.S.
20. Describe reports of HIV cures.

Disclaimer
The writers for NCCT continuing education courses attempt to provide factual information based
on literature review and current professional practice. However, NCCT does not guarantee that
the information contained in the continuing education courses is free from all errors and
omissions.

GLOSSARY
Cell mediated immunity

Cytokines

Disseminated infection
Epidemic
Humoral immunity
Interferon

Interleukin
Latent infection

Opportunistic illness

Pandemic

Perinatal
Phagocytosis

One of the components of the immune response; refers to biochemical

reactions of phagocytes, cytotoxic T cells, and the release of various cytokines
in response to an antigen
Proteins secreted by cells in the immune response that communicate with
other cells in the immune system to heighten and suppress the immune
reaction; includes growth factors, interleukins, and interferons
An infection that has spread throughout the body usually by the bloodstream
A disease outbreak that spreads rapidly to many people in a geographic area
One of the components of the immune response; refers to the production of
specific antibodies by B cells to the presence of a foreign antigen
One of the cytokines produced by cells as part of the immune response; along
with other functions, interferons interfere with the replication of viruses within
host cells
One of the cytokines produced by cells as part of the immune response;
promotes the growth and activation of white blood cells
A condition in which a virus is present in the host cells, but dormant, i.e., not
replicating; not to be confused with clinical latency where a virus is slowly
replicating
Any infection caused by a microorganism that does not normally cause
disease; also refers to rapid aggressive development of certain types of
cancers seen in individuals with impaired immune systems
An epidemic that has spread over several countries or continents, usually
affecting a large number of people; HIV/AIDS is an example of one of the most
destructive global pandemics in history
Happening during or around the time of birth
Process by which macrophages and other cells engulf and destroy
microorganisms, dead cells, and other foreign bodies

INTRODUCTION
HIV is the abbreviation for the human immunodeficiency virus. HIV is the virus that
causes acquired immunodeficiency syndrome (AIDS). The virus infects specific cells in
the immune system weakening the individuals ability to fight infections and cancer. HIV
infection is not the same as having AIDS. Individuals can be infected with the virus but
have no infections or cancer. It may take years for an HIV-infected individual to develop
AIDS.
This CE course reviews the immune system, HIV, and AIDS. The course includes
discussions on the diagnosis and treatment of HIV, a timeline of the HIV/AIDS epidemic,
HIV/AIDS today, and safe working practices for healthcare professionals.

THE IMMUNE SYSTEM

To understand the way in which HIV causes the development of AIDS, a basic review of
the immune system is necessary. The immune system is subdivided into two general
categories: the innate or naturally occurring immune system and the adaptive immune
system. For the purposes of this CE course, only the basics of the adaptive immune
system will be discussed.
The immune system of a healthy adult has the ability to recognize self from non-self.
3

When foreign substances such as bacteria or viruses enter the body, the immune
system recognizes them as non-self and initiates a series of reactions to destroy the
foreign substance. However, an individuals immune system pays no attention at all to
the millions of cells that compose the self. Anything that triggers an immune reaction
is called an antigen.
The immune system is a large network of cells, tissues, organs. The organs include the
thymus, lymph nodes, bone marrow, spleen, and mucosa-associated lymphoid tissue
(MALT).

Graphic courtesy of AIDS.gov and is in the public domain

Bone Marrow
The bone marrow is the soft tissue in the hollow center of bones. This is where blood
cells are produced. This includes red blood cells (erythrocytes), white blood cells
(leukocytes), and platelets (thrombocytes). One specific type of white blood cells is very
important in the immune response the lymphocyte. Other white blood cells produced
are monocytes, neutrophils, eosinophils, and basophils. These white blood cells also
function as part of the immune system.
Lymph Nodes
Lymph nodes are also called lymph glands. The lymph nodes are small clusters of
bean-shaped structures located throughout the body in areas such as the neck,
axillaries (arm pits), abdomen, and groin. Lymph nodes contain lymph fluid and cells
that fight infection and disease. The lymph fluid and cells move throughout the body via
lymph vessels. The cells move freely back and forth to the venous bloodstream and to
certain organs.

Thymus
The thymus is a small organ located behind the sternum in front of the heart. It is an
important organ for the maturation of certain blood cells.
Spleen
The spleen is located in the upper-left quadrant of the abdomen. One of the functions
of the spleen is to initiate the immune response of certain blood cells in response to
antigens circulating in the blood. In addition, the lymphatic vessels drain lymph fluid
from the spleen.
Mucosa-associated lymphoid tissue (MALT)
MALT is located beneath the mucous membranes throughout the body. It is found in
the tonsils, walls of the small intestine in areas called Peyers patches, walls of the
appendix, and walls of the vagina. Immune-functioning cells can be found in MALT
tissue.
IMPORTANT CELLS IN THE IMMUNE SYSTEM
Phagocytes
Phagocytes are large cells that engulf and destroy foreign particles and
microorganisms. There are many types of phagocytic cells, including monocytes and
segmented neutrophils found in the peripheral blood. Monocytes in the peripheral blood
move into the tissues and they develop into macrophages. Macrophages of many types
are found throughout the body.
One of the functions of macrophages is that of a scavenger. They move throughout the
body, searching for debris, worn out cells, and microorganisms. When macrophages
encounter these things, they engulf (phagocytize) and destroy them. Antigens of the
destroyed items end up on the cell surface of the macrophage, drawing the attention of
lymphocytes.
Lymphocytes
Lymphocytes are vital to a functioning immune system. There are two general
categories of lymphocytes T lymphocytes or T cells and B lymphocytes or B cells.
Both T and B cells develop from stem cells in the bone marrow.
T cells migrate out of the bone marrow and go to the thymus gland to mature. After
maturation, T cells migrate to other immune system tissues via lymph and blood
vessels. B cells remain in the bone marrow to mature. They then move to various
immune system tissues through the body also via the lymph and blood vessels.
T and B cells move freely between the lymphatic system and the bloodstream, looking
for foreign antigens to seek out and mount an immune response to destroy them.

B cells
B cells are designed to make antibodies against foreign or non-self antigens. For
example, when an infant receives a vaccination for pertussis (whooping cough), the
vaccine contains antigens from the bacteria that cause whooping cough (Bordetella
pertussis). The infants B cells see the bacterias antigens, recognize them as foreign,
and make antibodies against them. As a result, the infant develops antibodies and
immunity to pertussis. If he/she encounters the bacteria in the environment in the
future, and it enters his/her body, the antibodies developed by the B cells at the time of
vaccination recognize the antigens on the bacteria. There is an antigen-antibody
interaction which essentially destroys the bacteria. Therefore, no illness results from
the encounter with the infectious bacteria.
The production of antibodies by B cells and the ensuing antigen-antibody reactions is
called humoral immunity. The B cells that have been programmed to produce
antibodies become plasma cells that reside in the spleen, MALT, and lymph nodes. If
the antigen is seen again, the plasma cells can rapidly begin to produce antibodies
against the antigen to destroy it.
T cells
T cells do not recognize free floating antigens as B cells do. Instead, T cells have
receptors on their surface that see fragments of antigens on the surfaces of phagocytic
cells such as macrophages that are infected with pathogens or cancerous cells. As an
example, research has shown that every individual routinely produces cells with
deranged DNA that have the potential to develop into cancer. However, T cells identify
these cells and mount an immune response to destroy them. The type of immune
reaction produced by T cells is called cell-mediated immunity.
There are several types of T cells. The table below describes the T cell types of most
importance for this CE course.
Name
T Helper Cells

Also known as
CD4+ cells
T 4 cells

Cytotoxic T Cells

Regulatory T Cells

CD8+ cells
T 8 cells
Killer T cells
T suppressor
cells
T reg cells

Function in the Immune Response

Produce and release cytokines*
Communicate with B cells about antibody production
Maximize the activity of phagocytic cells such as
macrophages
Kill cancer cells
Kill cells that are infected with viruses
Kill cells that become damaged in some way
Regulate and suppress the reactions of other cells in the
immune response therefore preventing excessive
responses

*cytokines = chemical substances such as interleukin, interferon, and growth factors; these proteins
signal other cells in the immune system to enhance and regulate the immune response

THE IMMUNE SYSTEM IN ACTION

The chart below summarizes the basic immune response.
Step Foreign antigen enters the body
1
Step Macrophage ingests the foreign antigen
2
Step
3
Step
4

Macrophage displays the foreign antigen proteins on the exterior of its cell thus signaling a T helper
cell
T helper cell produces substances to activate other parts of the immune system including B cells
which respond and begin to produce antibodies

Step B cells produce millions of antibodies that are specific to the antigen
5
Step
6
Step
7
Step
8

Antibodies signal other macrophages and other T cells to assist with further destruction of the
foreign antigen
Regulatory T cells (suppressor T cells) identify when the level of foreign antigens has dropped and
signals other cells in the immune system to stop their actions
The B cells that produced antibodies migrate to the spleen, lymph nodes, and MALT where they
become plasma cells and wait to be challenged again by the antigen

THE HUMAN IMMUNODEFICIENCY VIRUS

The human immunodeficiency virus (HIV) infects multiple cells in the body, including
brain cells. However, the primary cells invaded and destroyed are the T helper cells
(CD4+ cells). As T helper cells are vital for a normally functioning immune system,
without treatment, an individual infected with HIV is unable to fight off infections and
disease.
STAGES OF HIV INFECTION
If not treated, HIV infection can have three stages of infection. This section will discuss
only the stages of infection. Treatment options will be discussed later in the CE course.
Laboratory tests will be mentioned as these results are important in identifying the
stages of infection. However, the tests will be discussed in detail later in the reading
material.
Stage 1: Acute infection
Some individuals infected with HIV have no symptoms of an acute infection. However,
most individuals experience symptoms of an acute infection two four weeks following
the infection. Symptoms are similar to an infection with other viruses and include fever,
fatigue, swollen lymph nodes, and headache. These are symptoms of the bodys
response to the viral infection and it is known as acute retroviral infection (ARS) or
primary HIV Infection.

Large amounts of virus are being produced in the body during the initial infection
depleting the number of T helper cells. If a laboratory test called a CD4+ cell count is
performed at this time, it will detect rapidly falling numbers of these cells. However, at a
certain point, the CD4+ count begins to increase but it may never return to a normal
number.
At this stage of the infection, antibodies to HIV are not detectable. Infected individuals
and even physicians may not recognize this stage of HIV infection as the symptoms are
similar to those of other viral infections such as influenza and infectious mononucleosis.
The individual is acutely ill for a period of time and then feels better.
Stage 2: Clinical Latency
During this stage of infection, the disease becomes latent the virus is still present in
the individuals cells but it is reproducing at very low levels. The virus rapidly mutates
and this is what allows it to escape recognition by cells in the immune system such as
cytotoxic T cells and B cells that have produced antibodies.
The latency period can last up to 8 years or longer. Some individuals move through this
second stage of infection faster than others do. Towards the end of the latency period,
the CD4+ levels begin to drop and the amount of virus (viral load) present begins to
increase. At this time some individuals start to have constitutional symptoms of HIV
infection. Constitutional symptoms include muscle aches, weight loss, night sweats,
diarrhea, fever, and increased fatigue. It is during the latter part of the clinical latency
period that many individuals are diagnosed with HIV infection. While they are
ineffective in fighting the infection, antibodies to HIV can be detected at this stage.
Stage 3: Acquired Immunodeficiency Syndrome
Acquired immunodeficiency syndrome (AIDS) is the third stage of HIV infection. In
stage, an infected individuals immune system is damaged enough to be vulnerable to
opportunistic bacterial, fungal, and viral infections, and unusual types of cancer.
Opportunistic infections are those that rarely cause infections in people with healthy
immune systems.
TRANSMISSION OF HIV
HIV is one of many bloodborne pathogens meaning the virus is present in blood and
body fluids, and it can be transmitted to others via contact with blood and body fluids.
In the U.S., hepatitis B and hepatitis C are other important bloodborne pathogens.
An individual gets an HIV infection when the blood or body fluids of an infected person
enter his/her bloodstream. The virus can enter the blood via the mucosal linings of the
mouth, anus, penis, vagina, or through broken skin. HIV is transmitted in the following
ways.

Having unprotected sex with an infected individual; includes vaginal, anal, and
oral intercourse
Reusing/sharing needles to inject drugs, including steroids
Reusing needles for body piercing and tattoos
8

Receiving blood, blood products, or organs from an infected individual (very

unlikely in the U.S. as all blood and organs are tested for HIV)
Being born to a HIV-infected mother
Feeding a baby breast milk from an HIV-infected woman
Reusing needles in healthcare practices (very unlikely in the U.S. as all needles
for injections and blood collection are intended to be one-use only items)

As the initial stage of HIV is often asymptomatic or unremarkable, infected individuals

can unknowingly transmit the virus to others. The CDC reports that more than 1.1
million people in the U.S. are living with HIV infection, and almost 1 in 5 (18.1%) of
those are unaware of their infection. This is almost 200,000 individuals who can
unknowingly spread infection. These statistics identify the importance of routine testing
of all individuals to screen for the presence of HIV infection, especially in those who
participate in high-risk activities.

AIDS
AIDS is diagnosed when the CD4+ cell count has dropped below 200 cells/mcL, or
when one or more opportunistic illnesses have developed. A discussion on CD4+
counts and opportunistic illnesses follows. Without treatment, individuals diagnosed
with AIDS typically survive about three years. Opportunistic infections in individuals
with AIDS are the usual cause of death.
OPPORTUNISTIC ILLNESSES
The development of an opportunistic illness is a sign of a declining immune system.
The infections are generally very rare in individuals with a healthy immune system. The
CDC has a list of more than 20 opportunistic illnesses that are considered to indicate an
AIDS diagnosis. The most common are summarized in the table that follows.
Opportunistic Illness
Candidiasis of bronchi, trachea,
esophagus or lungs

Invasive cervical cancer

Cryptococcosis

Cytomegalovirus (CMV)

Description
Infection caused by the Candida spp. yeast; also called thrush
Symptoms include white patches on gums, tongue, mouth,
throat; pain; difficulty swallowing; loss of appetite
Can spread down respiratory tract, and disseminate to
gastrointestinal tract, renal system, genitourinary system
Cervical cancer in women with normal functioning immune
systems is slow growing, taking years for precancerous cells to
develop into malignant cells
AIDS infected women have a higher rate of developing
precancerous cells that quickly develop into malignant cells
Meningitis caused by the yeast Cryptococcus neoformans
Symptoms include headache, fever, neck pain, nausea and
vomiting, sensitivity to light, and altered mental status ranging
from confusion to coma
Most frequent disseminated opportunistic infection seen in
individuals with AIDS
Causes serious disease as pneumonia, meningitis, and
gastrointestinal tract infections
Common cause for retinitis and blindness in persons with AIDS

Opportunistic Illness
Herpes simplex virus (HSV)

Histoplasmosis

Kaposis sarcoma (KS)

Lymphoma

Mycobacterium avium complex

Tuberculosis (TB)

Progressive multifocal
leukoencephalopathy

Toxoplasmosis

Description
Causes frequent or persistent lesions, often with extensive or
deep ulcerations in the oral and anogenital regions
Also causes bronchitis, pneumonitis, and esophagitis
Disseminated fungal infection caused by Histoplasma
capsulatum
Can result in hypotension, adult respiratory distress syndrome,
hepatic failure, renal failure, and disseminated intravascular
coagulation
KS is normally seen in older men of Mediterranean, Eastern
European, and Middle Eastern heritage
o Type of cancer that develops from the cells that line the
blood and lymph vessels
o Appears as purple, red, or brown lesions or tumors
usually on the face or mucous membranes, can also be
in lymph nodes or digestive tract
In individuals infected with AIDS, KS the lesions are widespread,
rapidly progressive, and cosmetically or functionally debilitating
o Lesions are a distinctive purple; occur on nose, ears,
around the eyes, lower legs or feet, upper thighs,
suprapubic and genital area
Lymphomas are cancers that develop in the lymphatic system
Lymphoma in individuals infected with AIDS is unusually
aggressive
Three main types: diffuse large B cell lymphoma, B cell
immunoblastic lymphoma, and small non-cleaved cell lymphoma
Most AIDS-related lymphomas appear to develop from antigendriven B cells with growth control influenced by abnormal T-cell
and antigen-presenting cell processes
Consists of several species of bacteria in the group
Mycobacterium avium
One of the most common serious opportunistic infections in
individuals with AIDS
Symptoms at first may be nonspecific and flu-like; Infection can
be in the respiratory or gastrointestinal tracks; can cause
disseminated infection from these locations
Caused by bacteria Mycobacterium tuberculosis
Common infection in AIDS individuals; begins as lower
respiratory tract infection as seen in individuals with normally
functioning immune systems
Infection is more likely to be extrapulmonary TB or cause
disseminated infections throughout the body
Very problematic to treat as drug resistance has occurred
Caused by polyomavirus JC
Disease of the white matter of the brain; symptoms include
clumsiness; progressive weakness; and visual, speech, and
sometimes personality changes; death frequently results
Caused by Toxoplasmosis gondii, a protozoan parasite
In individuals with AIDS, the infection is seen as encephalitis
Initial symptoms include headache, altered mental status and
fever; progresses to seizures, visual field defects, movement
disorders, and neuropsychiatric manifestations

10

DIAGNOSIS
There are three primary tests to detect HIV infection and to diagnosis and monitor
treatment of AIDS: the HIV antibody test, CD4+ cell counts, and viral load studies.
HIV Antibody Tests
HIV antibody tests detect antibodies against the HIV genetic material in blood. An HIV
antibody test is performed for the following reasons.

Screen blood, blood products, and organ donors to prevent the spread of HIV
infection
Detect HIV infection in individuals at high risk for infection or who have symptoms
of HIV infection
Screen the general population to detect HIV infection
Screen pregnant women for HIV infection to assure treatment is given to
minimize the risk of transmission of the disease to the fetus

Antibodies to HIV may not be detected until as long as 6 months after the initial
infection. HIV antibody tests are reported as positive or negative. The period between
the infection and the ability to detect HIV antibodies is called the window period. It is
important for anyone being tested to know that he/she can still transmit HIV to others
even if the HIV antibody test is negative.
If the HIV antibody test is being performed to determine if an individual is infected, i.e.,
has had a known exposure or participated in high risk behavior, the test may be
repeated at 6 weeks, 3 months, and 6 months after exposure.
HIV antibody tests are often called by the laboratory method used to detect the
antibody: enzyme immunoassay (EIA), enzyme-linked immunosorbent assay (ELISA),
Western blot, and polymerase chain reaction (PCR). EIA and ELISA tests are used to
screen for HIV infection; Western blot and PCR tests are used to confirm the HIV
infection.
Viral Load Measurement
After a positive HIV antibody test is confirmed, it is important to know how much virus is
in the blood. This is accomplished by performing a viral load test. A viral load test
measures the amount of the RNA genetic material of HIV in the blood. All HIV-infected
individuals should have a baseline viral load measurement upon diagnosis and
periodically after that. An increase in the viral load measurement indicates the HIV
infection is getting worse. Therefore, this test is done for the following reasons.

Monitor changes in the HIV infection

Identify treatment options
Monitor the effectiveness of treatments

11

If an HIV-infected individual is not receiving treatment, viral load studies are measured
every 3-4 months. If treatment is given, recommendations are to measure the viral load
at 4-8 weeks after start of treatment and then every 3-6 months.
The amount of viral load is determined using sophisticated laboratory methods such as
reverse-transcriptase PCR, branched DNS, or nucleic acid sequence-based
amplification. Test results are reports as the number of HIV copies per mL (copies/mL).
CD4+ Count
A CD4+ count determines the number of T helper cells in the blood. As HIV infects T
helper cells, a change in the number can identify the effect of the virus on the immune
system. A low CD4+ count generally indicates a weakened immune system and an
increased risk of getting opportunistic infections.
CD4+ counts are performed using flow cytometry instrumentation. Cell counts are
reported as the number per microliter (mcL). A CD4+ count is recommended upon
diagnosis of HIV infection and every 3-6 months thereafter.
CD4+ counts are performed for the following reasons.

Monitor HIV infection

Diagnose AIDS
Identify the need to begin treatment
Evaluate the risk for opportunistic infections
Identify the need to start preventative treatment for opportunistic infections

A summary of CD4+ count results follows.

CD4+ Count
600 1,500 cells per mcL

Interpretation
Normal
(individuals not infected with HIV)

>350 but <500 cells/mcL

Immune system beginning to weaken

< 350 cells/mcL

Increased risk for opportunistic illnesses

< 200 cells/mcL

Diagnosis of AIDS and high risk for opportunistic illnesses

TREATMENT
Treatment for HIV infection and opportunistic infections is detailed and complicated.
Many HIV-infected and AIDS patients take numerous medications several times a day.
Medications are also given to prevent and treat opportunistic infections, further
complicating the medication regimen. Many of the medications have serious
complications and major effects on the physical appearance of the HIV-infected patient.

12

HIV Drugs
The FDA currently has approved more than 25 antiretroviral drugs to treat HIV infection.
(HIV is a type of retrovirus.) The goals of treating HIV infections follow.

Control the growth of the virus

Improve overall immune system function and status
Suppress symptoms
Produce as few side effects as possible

It is important to note that antiretroviral drugs do not cure HIV infection. The goals of
treatment with antiretroviral drugs are to control the growth of the virus and delay the
onset of AIDS.
There are five classes of HIV drugs.

Reverse transcriptase (RT) inhibitors: Work by blocking an important step in the

HIV replication life cycle
Protease inhibitors (PI): Work by interfering with an enzyme used by HIV to
create infectious particles.
Fusion inhibitors: Work by blocking entry of HIV into healthy cells
Entry inhibitors: Work by blocking entry of HIV into healthy cells
Integrase inhibitors: Work by blocking insertion of viral DNA into the host cell
DNA

The table below provides the brand name, generic name, and abbreviation of some of
these drugs.
Brand Name
Generic Name
Reverse transcriptase (RT) Inhibitors
Atripla
Efavirenz + tenofovir + emtricitabine
Combivir
zidovudine + lamivudine
Rescriptor
delavirdine
Sustiva
efavirenz
Epivir
lamivudine
Hivid
zalcitabine
Retrovir
zidovudine
Truvada
tenofovir DF + emtricitabine
Videx
didanosine
Viread
tenofovir disoproxil fumarate
Zerit
stavudine
Ziagen
abacavir
Protease inhibitors (PI)
Agenerase
amprenavir
Aptivus
tipranavir
Invirase
saquinavir
Kaletra
lopinavir + ritonavir
Prezista
darunavir
Viracept
nelfinavir
Fusion inhibitors
Fuzeon
enfuvirtide
Entry inhibitors

13

Abbreviation
AZT + 3TC
3TC
ddC
AZT or ZDV
TDF + FTC
ddl
TDF or Bis
D4T
ABC
APV
TPV
SQV
LPV
DRV
NFV
ENF

Selzentry

maraviroc

Brand Name
Generic Name
Integrase inhibitors
Tivicay
dolutegravir
Isentress
raltegravir

Abbreviation
-

Guidelines recommend the use of a combination of antiretroviral therapy (ART) for

adults, adolescents, and pregnant women with early HIV infection. This is called highly
active antiretroviral therapy (HAART). It may be necessary to switch to other ART
combinations as a result of severe side effects or to provide more effective therapy.
Side Effects of ART
Short term side effects of antiretroviral therapy for HIV may include the following.

Anemia
Diarrhea, nausea, vomiting
Headaches, dizziness
Insomnia
Peripheral nerve pain
Rash
Weight loss

Long term side effects of antiretroviral therapy for HIV infection include the way the
body produces, uses, and stores fat. The two following side effects almost always
occur in individuals receiving antiretroviral therapy.

Lipodystrophy: Lipodystrophy is the redistribution of body fat. In individuals

receiving antiretroviral therapy, extra fat is often deposited in the face, breasts
(both men and women), neck, and abdomen. Subcutaneous fat is often lost from
the arms, legs, and buttocks. Throughout the body small deposits of fat called
lipomas may develop.

Increased levels of cholesterol and/or triglycerides: Very high levels of

cholesterol and/or triglycerides almost always occur in individuals receiving
antiretroviral therapy. This increases the individuals risk for cardiac and other
diseases that result from excess levels of lipids in the blood.

Other side effects of long term antiretroviral therapy include decreased bone density
resulting in the increase of bone fractures, elevated blood glucose levels resulting in the
use of diabetic medications, and a buildup of lactic acid resulting in muscle aches and
liver failure.
Medications for Opportunistic Infections
The table on the following page shows the common opportunistic infections and
medications used to treat them. Some of these medications may actually be used in an
attempt to prevent the development of opportunistic infections.
14

Opportunistic Infection
Cryptococcal meningitis
Cryptosporidiosis
Cytomegalovirus

Kaposis sarcoma
Mycobacterium avium complex

Pneumocystis

Medication
amphotericin B (Fungizone)
flucanazole (Diflucan)
nitaxoanide (Alinia)
ganciclovir (Cytovene)
foscarnet (Foscavir)
cidofovir (Vistide)
various chemotherapy and immunomodulator
medications
clarithromycin (Biaxin)
azithromycin (Zithromax)
rifabutin (Mycobutin)
atovaquone (Mepron)
pentamidine (NebuPent)
sulfamethoxazole and trimethoprim (Bactrim
and Septra)

AN EPIDEMIC TIMELINE
June 5, 2011 marked the 30th anniversary of the CDC report on what eventually became
known as AIDS. In an essentially short time, a remarkable research effort identified the
causative agent, methods of transmission, a laboratory test to detect infection, and
effective treatment. What has eluded research efforts is a vaccine and cure for HIV.
However, researchers have learned vast amounts about the cellular-mediated aspects
of the immune system, and this knowledge has helped with the identification and
treatment of many autoimmune diseases, congenital immunodeficiency diseases, and
other types of acquired immunodeficiency diseases. Following is a 30 year timeline of
the HIV/AIDS epidemic describing important events and U.S. statistics.
The 1980s
YEAR
1981

1982

EVENTS
On 6/5/1981, the Centers for Disease Control and Prevention (CDC)
publishes a report of five cases of homosexual men in California with
Pneumocystis carinii pneumonia
On 7/3/1981, CDC publishes a report on 26 cases of Kaposis
sarcoma in homosexual men in both New York and California
The New York Times publishes the first news article about the
mysterious new disease among homosexual men
Terms gay-related immune deficiency and gay cancer used by media
More cases of opportunistic infections and Kaposis sarcoma seen in
homosexual men
Similar diseases and symptoms seen in homosexual men are
identified in hemophiliacs and a few women, infants, and blood
transfusion recipients
Scientists think disorder is an infectious agent spread through blood
and sexual contact
CDC established the term acquired immunodeficiency syndrome
(AIDS) and identifies four factors that increase the risk of having the
disease: homosexuality, intravenous drug use, Haitian origin, and
hemophilia A

15

U.S. STATISTICS
159 cases

771 cases reported

to date
618 deaths

1983

1984

1985

1986

1987

1988

1989

Report of a major outbreak of AIDS in both men and women in

Central Africa
AIDS cases identified in 33 countries
In France, a scientist isolates a retrovirus from a French patient with
AIDS symptoms; he names it lymphadenopathy-associated virus
(LAV)
The CDC adds female sexual partners of men with AIDS to list of risk
groups
The CDC warns blood banks of a possible risk of AIDS transmission
via blood transfusions
Scientist at the US National Cancer Institute reports his lab has
isolated a virus believed to cause AIDS; he names it human Tlymphotropic virus type III (HTLV-III)
At the University of California San Francisco, a scientist isolates a
virus from U.S. AIDS patients and healthy individuals in risk groups;
he names it AIDS-associated virus (ARV)
Scientific community worldwide concludes a new virus has emerged
that causes AIDS; it is later named human immunodeficiency virus
(HIV)
Many research grants issued to study HIV, AIDS, and treatments
The US government licenses an HIV antibody test and screening of
blood donors begins
AIDS has now been reported in 51 countries and all continents
except Antarctica
First international AIDS Conference is held in Atlanta, Georgia
CDC drops Haitian origin as a risk factor for AIDS because scientists
can no longer justify including them on statistical grounds
The American Foundation for AIDS Research (amfAR) releases first
HIV/AIDS Treatment Directory
U.S. Surgeon General calls for a comprehensive program of AIDS
and sex education; urges widespread use of condoms
The National Institutes of Health (NIH) begins controlled study of
zidovudine (AZT) treatment
In West Africa, a second type of HIV called HIV-2 is identified in
commercial sex workers
NIH approves in record time the use of AZT as the first anti-HIV drug;
cost is $10,000 for a one-year supply making it the most expensive
drug in history
Researchers conclude incubation period from the infection with HIV
to the development of AIDS can be long; recognize essentially all
cases of HIV infection lead to AIDS
U.S. bans HIV-infected immigrants and travelers from entering the
country
The U.S. federal government mails an educational pamphlet
Understanding AIDS to 107 million homes
New AIDS cases in New York City resulting from the reuse of needles
by intravenous drug abusers exceeds those contributed to sexual
contact; the city begins a needle exchange program
amfAR established a Community-Based Clinical Trials (CBCT)
program and awards grants to 16 research facilities
The NIH funds 17 community-based AIDS clinical research facilities
As a result of the community-based clinical trials results, the FDA
approves treatments for some AZT-induced complications

16

2,807 cases
reported to date
2,118 deaths

7,239 cases
reported to date
5,596 deaths

15,527 cases of
AIDS reported to
date
12,529 deaths

28,712 cases of
AIDS reported to
date
25,559 deaths

50,378 cases of
AIDS reported to
date
40,849 deaths

82,362 cases of
AIDS reported to
date
61,816 deaths
117,508 cases of
AIDS reported to
date
89,343 deaths

The 1990s
YEAR
1990

1991

1992

1993

1994

1995

1996

EVENTS
U.S. Congress passes the American with Disabilities Act which
protects individuals with disabilities, including both people with
HIV/AIDS and those suspected of being infected
Data shows a disproportionate number of U.S. black and Latina
women are diagnosed with HIV
As of this year, nearly twice as many Americans have died of AIDS
as died in the Vietnam War
The VI International AIDS Conference in San Francisco is boycotted
by domestic and international groups to protest the U.S. immigration
policy banning HIV-infected visitors
The CDC reports that one million Americans are infected with HIV
The World Health Organization (WHO) estimated that 10 million
people are infected with HIV worldwide
A woman is reported to have been infected with HIV by her dentist
The red ribbon becomes a symbol of hope and compassion for
people with HIV and AIDS
The first clinical trial of combination antiretroviral therapy begins
President Clinton establishes a White House Office of National AIDS
Policy
The FDA issues new rules that accelerate approval of AIDS drugs
AIDS patients begin to show resistance to AZT treatment
In major U.S. cities, sexual transmission identified as causing more
HIV infection in women than use of contaminated needles for drug
abuse
The CDC revises its definition of AIDS to include new opportunistic
infections, cervical cancer, and T-cell counts <200; this results in a
111% increase in the number of AIDS cases in the U.S.
Research begins on a compound called T-20 which has antiretroviral
properties
A European study shows no evidence that AZT delays the onset of
AIDS
An NIH study identifies that AZT reduces the risk of mother-to-infant
HIV transmission
Researchers show that following infection, HIV replicates
continuously producing millions of copies of the virus each day
The use of dual combination therapy with AZT and other nucleoside
analogues becomes the standard treatment for HIV
The FDA approves saquinavir as a new class of antiretroviral drugs
The New York Times reports that AIDS is the leading cause of death
among all Americans ages 25-44 years
Between 1991 and 1995, the number of American women diagnosed
with AIDS increased by more than 63%
For the first time, more AIDS cases in the U.S. are in African
Americans than in Caucasians
The FDA approves nevirapine as a new class of antiretroviral drug
The FDA approves a new laboratory test to measure the level of HIV
in a patients blood
Combination therapy is made available to HIV/AIDS patients for the
first time resulting in a dramatic decline in the number of deaths
Research is published identifying how HIV infects cells
The United Nations estimates that 22.6 million people are infected
with HIV and 6.4 million people have died of AIDS worldwide
For the first time, the number of Americans dying from AIDS declines;

17

U.S. STATISTICS
160,969 cases of
AIDS reported to
date
120,453 deaths

206,563 cases of
AIDS reported to
date
156,143 deaths

254,147 cases of
AIDS reported to
date
194,476 deaths
360,909 cases of
AIDS reported to
date
234,225 deaths

441,528 cases of
AIDS reported to
date
270,870 deaths
513,486 cases of
AIDS reported to
date
319,849 deaths

581,429 cases of
AIDS reported to
date
362,004 deaths

1997

1998

1999

decline is attributed to the success of new combination therapies

The FDA approves the first home HIV test
Between 1992 and 1996, the number of mother-to-infant HIV
transmissions in the U.S. dropped by two-thirds; attributed to AZT
treatment of HIV-infected mothers
In the U.S. AIDS patients are living longer due to new antiretroviral
therapies called drug cocktails
AIDS deaths in the U.S. decline by 42%, but the number of new HIV
infections remains constant
Research grants are issued to design a safe and effective AIDS
vaccine
Researcher shows the first 3-D images of HIV; this knowledge is
critical to development of an effective vaccine
In the U.S., AIDS deaths decline by 21%
Occurrence of drug-resistant viral strains and limitations of existing
treatments make researchers think there will be no further declines in
number of deaths from AIDS
Physicians become increasingly concerned about significant side
effects of antiretroviral drugs
Hope that combination therapy might be a cure for AIDS diminishes
In U.S., a large clinical trial begins comparing therapies for the
treatment of hepatitis C in people infected with AIDS
HIV infection in over 27 countries has doubled since 1996; at least
95% of HIV-infected people live in developing countries
Statistics identify that at least half of all new HIV infections worldwide
(including the U.S.) are in young people under age 25
A new class of antiretroviral drugs, T-20, begins clinical trials
In the U.S. women account for 23% of AIDS cases as opposed to 7%
in 1985
In sub-Saharan Africa, the epicenter of the global epidemic, 55% of
all HIV-positive adults are women

641,086 cases of
AIDS reported to
date
390,692 deaths

688,200 cases of
AIDS reported to
date
410,800 deaths

733,374 cases of
AIDS reported to
date
429,825 deaths

The 2000s
YEAR
2000

2001

EVENTS
The CDC reports that black and Latino men now account for more
AIDS cases among men who have had sex with men than
Caucasians
Grants issued to identify new viral and cellular targets for
antiretroviral drugs
The United Nations Security Council declares AIDS an international
security issue as it threatens social, economic, and political structures
worldwide
Joint initiatives involving major pharmaceutical companies are
created to lower the costs of AIDS drugs in developing countries
The XIII International AIDS Conference focuses attention on the
growing epidemic in sub-Saharan Africa where few people have
access to medical treatment
Statistics identify
o 36.1 million people are living with HIV/AIDS worldwide
o Over 1.3 million children have lost one or both parents to
AIDS
o Almost 22 million people have died of AIDS since the
epidemic began
The CDC recognizes serious side effects of AIDS treatments and the
development of HIV strains resistant to therapies; issues new
guidelines recommending that treatment be postponed until the

18

U.S. STATISTICS
774,467 cases of
AIDS reported to
date
448,060 deaths

816,149 cases of
AIDS reported to
date

2002

2003

2004

2005

2006

2007

2008

persons immune system markedly declines

U.S. studies show that 14% of newly infected people exhibit
resistance to at least one antiviral drug
The United Nations calls for a $7 to $10 billion global fund to be
created to combat AIDS in developing countries
th
The 20 anniversary of the HIV/AIDS epidemic is commemorated
Studies indicate that if current trends remain, more than 62 million
people will be living with HIV/AIDS by 2005, and more than 40 million
children will have been orphaned by AIDS in Africa alone by 2010
AIDS is the leading cause of death worldwide among people aged
15-59
Women now make up about half of all adults living with HIV/AIDS
worldwide
The FDA approved the OraQuick Rapid HIV-1 Antibody Test
A global partnership between government, civil society, the private
sector, and affected communities is established to fight AIDS,
tuberculosis, and malaria
An experimental AIDS vaccine fails to block HIV infection
T-20 is approved by the FDA providing hope to thousands of patients
who are resistant to other anti-HIV drugs
The FDA approves the use of oral fluid samples with a rapid HIV
diagnostic test
amfAR launches an initiative to raise awareness about the spread of
HIV among young women and girls
The United Nations warns of the growing AIDS epidemic in Eastern
Europe and the former Soviet Union
Worldwide, 15 million children have lost one or both parents to
HIV/AIDS
CDC reports that more than one million Americans are living with
HIV/AIDS
Breakthrough discoveries occur that could help speed the
development of an AIDS vaccine
The World Health Organization and United Nations estimates that
more than 40 million people are living with HIV worldwide
The first one-a-day drug (Kaletra) is approved by the FDA
The CDC recommends that all adolescents and adults be routinely
tested for HIV infection
A report from the CDC states that African Americans account for
more than half of new HIV infections in the U.S.
The first once-a-day one pill anti-HIV drug is approved by the FDA
The CDC reports mother-to-baby transmission in the U.S. has
declined to less than 2%
The United Nations estimated that 33 million people are living with
HIV/AIDS worldwide
The FDA approved two new drugs: maraviroc, a new class of antiHIV drugs, and raltegravir, for patients whose treatment programs
have failed

Scientists capture on film the birth of new HIV virus particles; this is
the first time this has been seen for any type of virus
The CDC revised estimates of the new HIV infections that occurred in
the U.S. in 2006; the estimates identify 56,300 new HIV infections

19

462,653 deaths

886,000 cases of
AIDS reported to
date
501,669 deaths

930,000 cases of
AIDS reported to
date
524,060 deaths
940,000 cases of
AIDS reported to
date
529,113 deaths

Statistics change
Estimated 37,367
new individuals
diagnosed with
HIV/AIDS
Estimated 17,011
deaths from AIDS
in 2005
Estimated 36,817
new individuals
diagnosed with
HIV/AIDS
Estimated 14,627
deaths from AIDS
in 2006
Estimated 56,300
new individuals
diagnosed with
HIV
Estimated 37,041
new individuals
diagnosed with
AIDS
Estimated 14,561
deaths from AIDS
Estimated 51,477
new individuals
diagnosed with
HIV

2009

which is 40% more than previously estimated

The 2008 Nobel Prize is awarded to scientists for their discovery of
the virus later named HIV
The New England Journal of Medicine reports on a HIV-infected man
who was cured of HIV via a risky stem cell transplant to treat the
leukemia
The U.S. ends the travel ban on HIV-positive visitors and immigrants
For the first time, the U.S. government provides federal funding for
syringe exchange programs which have proved effective in greatly
reducing the spread of HIV among intravenous drug abusers

Estimated 32,645
new individuals
diagnosed with
AIDS
Estimated 20,091
deaths from AIDS
Estimated 48,283
new individuals
diagnosed with
HIV
Estimated 31,211
new individuals
diagnosed with
AIDS
Estimated 19,1981
deaths from AIDS

The 2010s
YEAR
2010

2011

EVENTS
The White House develops a National HIV/AIDS Strategy to reduce
HIV incidence, increase access to care, and reduce health-related
inequities
The XVIII AIDS Conference reveals that the use of a vaginal
microbicide applied before heterosexual sex protects some women
from HIV infection
A research study identified that preventive use of anti-HIV drugs can
significantly reduce infection among men who have sex with men
Since 1981, an estimated 1.2 million people diagnosed with AIDS in
the U.S.
th
The 30 anniversary of the HIV/AIDS epidemic is commemorated
Research to find a cure for HIV/AIDS intensifies as are the NIH and
the International AIDS Society both announce initiatives
Research study identifies that treating healthy people living with HIV
on antiviral therapies can limit transmission of HIV by 96%
More than 33 million people are living with HIV/AIDS worldwide with
1.1 million of those in the U.S.

U.S. STATISTICS
Estimated 47,132
new individuals
diagnosed with HIV
Estimated 29,463
new individuals
diagnosed with
AIDS
Estimated 19,343
deaths from AIDS

Estimated 49,273
new individuals
diagnosed with HIV
Estimated 32,052
new individuals
diagnosed with
AIDS

OCCUPATIONAL HIV TRANSMISSION AND PREVENTION

As HIV is a bloodborne pathogen, the potential exists for it to be transmitted to
healthcare professionals. Since HIV-infected individuals may not be aware of their
infection, healthcare professionals must assume that all individuals and their blood/body
fluids are potentially infectious. All professionals with potential exposure to bloodborne
pathogens must be aware of the hazards and the methods used to minimize exposure.
In the healthcare environment, HIV and other bloodborne pathogens can be spread by
exposure to blood and body fluids via needlestick; injuries with other sharps, touching
non-intact skin and mucous membranes without latex/vinyl gloves; and
splashes/splatters to non-intact skin and mucous membranes. Following are other
sources of infection.

20

Touching a contaminated object or surface (countertop, pen, dirty gloves, lab

coat/gown sleeve, etc.) and transferring the infectious material to the mouth,
eyes, or nose
Contact to non-intact skin or mucous membranes with
o unfixed tissue or organs from living or dead humans
o human cells or tissue cultures
o products/reagents made from human blood

U.S. STATISTICS
In an 8/6/2013 report, the CDC provides the following statistics regarding occupational
exposure to healthcare professionals.

As of 2010, 57 documented transmissions and 143 possible transmissions of HIV

have been reported in the U.S.

No confirmed cases of occupational HIV transmission to healthcare professionals

have been reported since 1999. However, under-reporting is possible as
reporting cases of transmission to the CDC is voluntary.

Healthcare workers who are exposed to HIV-infected blood or body fluids have a
0.3% risk of becoming infected. This means that if untreated, 3 of every 1,000
injuries will result in infection.

Healthcare professionals are at a much greater risk of being infected with hepatitis C
virus (HCV) from a needlestick than HIV. After a needlestick or sharps exposure to
HCV-positive blood, the risk of HCV infection is approximately 1.8%.
MINIMIZING OCCUPATIONAL EXPOSURE
The chance of a healthcare professional becoming infected with a bloodborne pathogen
such as HIV at work is very small. Keeping that chance to the absolute minimum is so
important that the Occupational Health and Safety Administration (OSHA) established
the Bloodborne Pathogen Standard. This standard is a federal law. The law sets forth
requirements for employers regarding education and training of employees at risk, safe
work practices, use of personal protective equipment, availability of post-exposure
treatment, and more
Following are some of the Bloodborne Pathogen Standard requirements for minimizing
occupational exposure to HIV and other bloodborne pathogens in the workplace.
Standard Precautions
Standard precautions are the basic level of infection control that should be used in the
care of all patients all of the time. Using standard precautions reduces the risk of
transmission of bloodborne pathogens and other microbial infections from both
recognized and non-recognized sources of infection. Following are the components of
standard precautions.
21

Non-intact skin, mucous membranes, blood, all body fluids, secretions, and
excretions are considered potentially infectious whether or not they contain
visible blood. Sweat is the only body fluid not considered to be potentially
infectious.

Personal protective equipment must be used to carry out standard precautions.

This includes
o Gloves
Clean, non-sterile gloves are used when touching or coming into
contact with blood, body fluids, secretions, or excretions.
Gloves are applied just before touching mucous membranes or
contacting blood, body fluids, secretions, or excretions.
Gloves are removed promptly after use and discarded before
touching non-contaminated items or environmental surfaces, and
before providing care to another patient.
Hands are washed immediately after removing gloves.
o Gowns
Gowns should be fluid resistant but do not need to be sterile; fluidresistant sterile gowns must be used when indicated
Gowns should be used to protect soiling of clothing during activities
that may generate splashes or sprays of blood, body fluids,
secretions, and excretions.
Gowns should be put on prior to performing such activities.
o Masks/eye protection/face shields
These are used to protect eyes, nose, mouth, and mucous
membranes from exposure to sprays or splashes of blood, body
fluids, secretions, and excretions.
These are donned prior to performing such activities where sprays
or splashes of blood or body fluids are likely.

Appropriate hand hygiene should be followed. Hand hygiene can be washing

hands with soap and water or using an alcohol-based hand rub. Washing hands
with soap and water is always acceptable. However, using an alcohol-based
hand rub is not always acceptable. Following are the requirements per the CDC
Hand Hygiene Guideline.

Soap and Water Required

After removing gloves that are visibly
contaminated with blood/body fluids
When bare hands are visibly contaminated
with blood/body fluids
Before eating
After using a restroom
After exposure to known or suspected
Bacillus anthracis (anthrax)

22

Alcohol-Based Hand Rub OK

After removing gloves that are not visibly
contaminated
After bare hands come in contact with
blood/body fluids, mucous membranes,
and/or intact skin if hands are not visibly
contaminated
Before direct patient contact
After contact with a patients intact skin

Patient care equipment should be handled in such a way as to prevent spread of

infection from one patient to another.
o Avoid contamination of clothing and the transfer of microorganisms to
other patients, surfaces, and environments.
o Clean, disinfect, or reprocess non-disposable equipment before reuse with
another patient.
o Discard single-use items properly.

Safe Work Practices

Safe work practices must be followed to minimize needlestick and other sharps injuries.

Use only safe needle devices or needle-less systems following the

manufacturers instructions. Example: Activate the safety device on a blood
collection needle immediately upon removing from the vein, NOT just before
placing in the sharps disposal container.
Needles should never been removed from a venipuncture tube holder following a
venipuncture. Both the holder and needle must be disposed as a unit.
Blood collected in a syringe should never be transferred to an evacuated
collection tube by piercing the rubber stopper with the collection needle. The
needle must be removed from the syringe in a safe manner following
manufacturer instructions and a blood transfer device must be used to transfer
the blood from the syringe to the evacuated tube.
Never recap a needle by hand.
Plan for safe handling and disposal of needles before using them.
Dispose promptly of used needles in appropriate sharps disposal containers.
Empty sharps disposal containers before they are full.

Engineering and Work Practice Controls

Employers must take appropriate preventative measures against occupational
exposure. Measures include engineering controls and work practice controls.

Engineering controls are one of the first defenses against exposure to

bloodborne pathogens. They attempt to control the hazard at the source and
prevent it from reaching employees. Examples of engineering controls include
puncture resistant sharps containers, self-sheathing needles, and needle-less
systems.
Work practice controls reduce the likelihood of exposure through the alteration of
the manner in which the task is performed. Examples of work practice controls
include the following.
o hand hygiene practices
o sharps handling policies and procedures
o waste disposal techniques
o personal protective equipment
o patient/specimen handling policies and procedures

Housekeeping
23

Housekeeping policies and procedures must be identified and followed.

Areas in the workplace where exposure may occur (dirty) and areas where no
exposure (clean) should occur must be identified.
The following applied to areas identified as dirty.
o All surfaces are considered contaminated. These areas should be
properly decontaminated on a scheduled basis. The decontamination
must be documented. If it is not documented, accreditation agencies will
assume it has NOT been decontaminated.
o Food and drink are not allowed in areas of the workplace where exposure
may occur.
o Application of cosmetics/lip balm and manipulation of contact lenses
should not occur in areas of the workplace where exposure may occur.
The following applied to areas identified as clean.
o All surfaces are considered to be free of blood/body fluid contamination.
o Food can be eaten in clean areas.
o Personal protective equipment worn in dirty areas must be removed
before entering a clean area.
Housekeeping practices must include instructions for cleaning up a spill of blood
or body fluids.
Waste Disposal
Waste disposal policies and procedures must be identified and followed.

All forms of biohazard waste (blood, infectious materials, or contaminated items

that could release infectious materials) must be placed in closable, color-coded,
or properly labeled leak proof containers or bags.
o Biohazard waste not including sharps: Biohazard waste must be
separated from other waste. All biohazard waste must be labeled with the
biohazard symbol and the word Biohazard or in a red bag. If there is a
risk of the biohazard container leaking, it should be placed into a second
closable, leak proof, and labeled container.
o Sharps disposal: Contaminated sharps must be placed into puncture
resistant sharps containers that are closable. Sharps containers must
never be overfilled. Frequent checking and replacement is necessary to
prevent overflow. When full, sharps containers should be carefully
closed and taken to the assigned disposal area.
o Laundry: Used reusable PPE, linens, and other laundry may contain
infectious materials. It is best to assume all laundry is biohazardous.
Used laundry and reusable PPE should be placed in a labeled biohazard
or red containers for transportation to the laundry.
o General waste: Paper, non-sharp items that are not contaminated with
blood/body fluids can be discarded into general waste containers.

Biohazard Warning
Biohazard warning tags, labels, and bags must be used as appropriate.
24

As all blood, body fluids, & tissues are considered potentially infectious, specific
warning labels on specimen containers are not indicated.
Warning labels should be attached to all containers used for the storage or
transport of blood/body fluids. This includes refrigerators, transport bags,
transport coolers, etc.
To warn others of the danger, containers must be labeled with orange or orangered labels that say biohazard and show the biohazard symbol.

Biohazard
Symbol

NEEDLESTICK INJURIES
Any worker who may come in contact with needles is at risk for a needlestick injury,
including but not limited to nursing staff, laboratory professionals, doctors, and
housekeepers. Needles involved in needlestick injuries include hypodermic needles,
blood collection needles, suture needles, and needles used in IV delivery systems.
Past studies have shown that needlestick injuries are often associated with recapping
needles, transferring a body fluid between containers, and failing to dispose of used
needles properly in puncture-resistant sharps containers.
Even with the use of needle-less systems and safe needle devices, needlestick injuries
are still reported in what most consider unacceptable numbers. According to the CDC,
about 385,000 injuries occur annually to U.S. hospital employees - more than 1,000
injuries per day. The estimated costs attributed to laboratory testing for employees,
labor associated with testing and counseling and the costs of postexposure follow ups is
$1 billion per year. The amount needed to treat one healthcare professional for a
needlestick injury is estimated at $3,042.
The CDC report states the two primary causes of needlestick injuries are the use of
unsafe needle devices and the improper handling and disposal of needles and other
sharps. Mary Foley, PhD, RN, the chairperson of Safe in Common, a non-profit
organization established to enhance and save the lives of U.S. healthcare personnel at
risk of harm from needlestick injuries states, These completely preventable injuries,
needless cost burdens on the healthcare system and psychological trauma inflected on
personnel is startling when safer equipment and smarter work practices are available to
personnel across the healthcare spectrum. Foley recommends more education on
permanently preventing these types of injuries and the development of advanced safety
devices.

25

HIV & AIDS TODAY

THE GLOBAL PANDEMIC
The UN has reported progress in the fight against HIV and AIDS worldwide. There has
been a 33% reduction in new infections among adults and children since 2001. The
report indicates that improved access to treatment is saving more lives and fewer
incidences of new infections are being reported. In 2012, the report states that there
are an estimated 35.3 million people living with HIV around the world.
Unfortunately, the UN report states that some areas need urgent intervention. Since
2006, new infections have increased by 13% in Eastern Europe and Central Asia, and
the Middle East and North Africa has had a doubling of new HIV infections since 2001.
An additional area of concern is that in some countries, only 3 in 10 children currently
receive HIV treatment.
The UN report proposes the gains seen in the past decade suggest that further
education, development of child-friendly medications, and improved access to treatment
can assist in controlling the pandemic further and in areas where infections have seen
an increase.
THE UNITED STATES
Key facts about HIV and AIDS today in the U.S. follow. These facts are based on the
most currently available statistics from the CDC.

More than 1.1 million people aged 13 years or older are living with HIV infection;
almost 18.1% are unaware of their infection.
In 2011, an estimated 49,272 people were diagnosed with HIV infection; in the
same year an estimated 32,052 were diagnosed with AIDS.
New HIV infections in gay, bisexual, and other men who have sex with men
significantly increased by 12% from 2008 to 2010; this remains the population
most profoundly affected by HIV.
Heterosexual spread of infection accounted for 25% of the estimated new HIV
infections in 2010 and 27% of the people living with HIV infection.
Injection drug users represented 8% of new HIV infections in 2010 and 16% of
those living with HIV.
Two race/ethnicity groups in the U.S. are disproportionally affected by HIV
infection.
o Black Americans represent approximately 12% of the U.S. population, but
they account for 44% of the new HIV infections in 2010 and 44% of
individuals living with AIDS in 2009.
o Hispanics/Latinos represent approximately 16% of the U.S. population, but
they account for 21% of new HIV infections in 2010 and 19% of individuals
living with AIDS in 2009.
Teens and young adults continue to be at risk, with those 13-24 years of age
accounting for 26% of new HIV infections in 2010.
26

Of HIV diagnoses among 13-19 year olds, almost 70% are in black Americans;
almost 80% of all infections are in males.
More than half of all undiagnosed HIV infections are thought to be in those aged
13-24.
Perinatal HIV transmission has declined significantly in the U.S., largely due to
antiretroviral therapy which can prevent mother-to-child transmission.

In July 2010, the U.S. government released the National HIV/AIDS Strategy, the first
comprehensive plan to address the epidemic in the U.S. The strategy has three primary
goals: reduce new HIV infections; increase access to care and improve health
outcomes; and reduce HIV-related health disparities.

POSSIBLE CURES
In the early years of the HIV/AIDS epidemic, a diagnosis of HIV was a death sentence.
At that time, HIV infections always led to the development of AIDS, and once a
diagnosis of AIDS was given, death from opportunistic infections and illnesses was
inevitable.
With the availability of antiretroviral therapy, now HIV-infected individuals can suppress
the infection and maintain sufficient immunity to prevent the development of
opportunistic infections and illnesses, and not develop AIDS. However, a vaccine to
prevent infection and a cure for the infection has eluded researchers. While an effective
vaccine has not yet been created, two recent reports of individuals cured of HIV
infection have been described.
THE BERLIN PATIENT
In 2005, Timothy Ray Brown, a 40-year-old American living in Berlin, Germany,
developed leukemia. He was also infected with HIV and his infection was under control
with a standard HIV drug regimen.
Leukemia is often treated with a bone marrow or stem cell transplant. Before the
transplant is given, the patients blood cells in the bone marrow are killed with
chemotherapy. The cells killed include those that function in the immune system T
cells and B cells. New blood cells are then transplanted into the patient, and these new
cells repopulate the immune system.
Browns physician had the idea to cure his patient of both diseases at one time. There
are rare individuals who carry a mutated gene that makes them highly resistant to HIV
infection. The physician found a compatible bone marrow donor with the mutated gene.
Brown ceased using antiretroviral drugs before the bone marrow transplant. The
transplant was given. After receiving the transplant, Browns HIV viral load dropped to
undetectable levels and his HIV antibody levels declined. At first, Browns name was
not released to the public. He was referred to as the Berlin patient in early reports
since the transplant occurred in Berlin.

27

Six years later and still not taking antiretroviral drugs, his viral load remains
undetectable and he has been pronounced cured. Brown now lives in San Francisco
where doctors frequently examine him and his blood to learn as much as possible about
his cure.
BABY REPORTED FREE OF VIRUS
In March of 2013, doctors announced that a baby born in rural Mississippi was
aggressively treated with antiretroviral drugs beginning around 30 hours after birth. The
baby, now 2 years old, has been off antiretroviral therapy for a year and has no HIV
detected in viral load studies.
The mother was unknowingly infected with HIV. She had no prenatal care. Laboratory
tests identified her as being infected with HIV when she entered the hospital in labor.
After the baby was born, laboratory tests identified the baby as being infected with the
HIV virus at a level that suggested the infection occurred in utero and not during
delivery. Typically, babies are infected with HIV during delivery and are given
prophylactic drugs to prevent any infection from developing. It is recommended that
HIV-infected mothers receive antiretroviral therapy during pregnancy to minimize the
risk of transmitting HIV to the baby. In the U.S., transmission of HIV to a baby from a
mother is rare due to the antiretroviral therapy.
The pediatrician decided to start the Mississippi baby on a three-drug regimen aimed at
treatment without waiting for the babys test results to be confirmed. The viral load
levels rapidly declined and remain undetectable at present. Antiretroviral therapy was
discontinued when the baby was 1 years old.
It is thought the virus in the baby was treated and killed off before it could establish an
infection in the CD4+ cells. As the virus was still circulating freely and not hiding in
cells, the drugs were able to kill it. The baby was never considered cured of HIV
because an actual infection never occurred. However, this event may lead to a new
protocol for quickly testing and treating newborns to assure any free circulating virus is
destroyed before it can enter CD4+ cells and cause an infection.
ARE THERE TWO MORE?
In July 2013, doctors in Boston reported on two men with HIV that received bone
marrow transplants to treat blood cancers. Both men have no detectable HIV per viral
load studies. One man has been off antiretroviral therapy for 7 weeks; the other for 15
weeks. It is too early to consider these men cured of HIV but test results are promising.

REFERENCES
30 Years of HIV: Looking Back, Looking Ahead. MedPage Today. www.medpagetoday.com. 20 May
2013. Accessed 19 November 2013
CD4+ Count. WebMD. www.webmd.com. 11 May 2011. Accessed 21 November 2013
Expanding HIV and AIDS Drug Options. WebMD. www.webmd.com. 16 June 2012. Accessed 21
November 2013
Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents. National Institutes
of Health. www.aidsinfo.nih.gov. 12 February 2013. Accessed 21 November 2013

28

HIV and AIDS. WebMD. www.webmd.com. 13 August 2012. Accessed 21 November 2013
HIV Cure is Closer as Patients Full Recovery Inspired New Research. National Public Radio.
www.npr.org. 18 July 2013. Accessed 30 November 2013
HIV in the United States: At A Glance. Centers for Disease Control and Prevention. www.cdc.gov.
February 2013. Accessed November 21 2013
Human Immunodeficiency Virus Test. WebMD. www.webmd.com. 8 April 2010. Accessed 21
November 2013
HIV Treatment: Coping with Side Effects. WebMD. www.webmd.com. 1 September 2012. Accessed 21
November 2013
Immune System 101. United States Government of Health and Human Services. www.aids.gov. 22
August 2011. Accessed 21 November 2013
In Medical First, a Baby with H.I.V. is Deemed Cured. The New York Times. www.nytimes.com. 3
March 2013. Accessed 21 November 2013
June 2012: Teens and the HIV/AID Epidemic. Health and Human Services. www.hhs.gov. June 2012.
Accessed 21 November 2013
Occupational HIV Transmission and Prevention Among Health Care Workers. Centers for Disease
Control and Prevention. www.cdc.gov. 6 august 2013. Accessed 21 November 2013
Opportunistic Infections. United States Government of Health and Human Services. www.aids.gov. 16
November 2010. Accessed 21 November 2013
Physical Changes. United States Government of Health and Human Services. www.aids.gov. 29 March
2010. Accessed 21 November 2013
Prevention of Needlestick Injuries Can Save U.S. Healthcare System More than $1 Billion Annually.
Infection Control today. www.infectioncontroltoday.com. 22 August 2013. Accessed 20 November 2013
Stages of HIV. United States Government of Health and Human Services. www.aids.gov. 6 August
2009. Accessed 21 November 2013
The HIV/AIDS Epidemic in the United States. The Henry J. Kaiser Family Foundation. www.kkf.org.
22 March 2013. Accessed 21 November 2013
The Immune System. National Institute of Allergy and Infectious Diseases. www.niaid.nin.gov. October
2008. Accessed 21 November 2013
UN Reports Progress in Fight Against HIV/AIDS. Al Jazeera. 21 November 2013. Accessed 22
November 2013
Viral Load Measurement. WebMD. www.webmd.com. 10 April 2010. Accessed 27 November 2013

TEST QUESTIONS
HIV & AIDS-The Anatomy of a Pandemic #1221814
Directions:
Before taking this test, read the instructions on how to complete the answer sheets
correctly. If taking the test online, log in to your User Account on the NCCT website
www.ncctinc.com.
Select the response that best completes each sentence or answers each question
from the information presented in the course.
29

If you are having difficulty answering a question, go to www.ncctinc.com and select

Forms/Documents. Then select CE Updates and Revisions to see if course content
and/or a test questions have been revised. If you do not have access to the internet,
call Customer Service at 800-875-4404.
1. Which of the following cells, tissue, or organ is part of the immune system?
a.
b.
c.
d.

Epithelial cells
Liver
Spleen
Thyroid

2. The small clusters of bean-shaped structures that function as part of the immune
system are called __________.
a.
b.
c.
d.

bone marrow
lymph glands
MALT
thymus

3. MALT is found in which of the following areas?

a.
b.
c.
d.

Bone marrow
Epidermis
Lymphatic vessels
Vaginal walls

4. Which of the following cells engulf and phagocytize microorganisms as well as

other things?
a.
b.
c.
d.

B cells
CD4+ cells
Erythrocytes
Macrophages

5. Which of the following is the function of T helper cells?

a.
b.
c.
d.

Kill cancer cells

Produce antibodies specific to a foreign antigen
Produce and release cytokines
Regulate the actions of other cells in the immune response

6. HIV invades which of the following cells?

a.
b.
c.
d.

CD4+
CD8+
Cytotoxic T cells
Regulatory T cells

30

7. What is the earliest stage at which HIV antibodies can most reliably be detected
in the blood?
a.
b.
c.
d.

Acute infection
Clinical latency
Early AIDS
Late AIDS

8. Which of the following can be a symptom of an acute HIV infection?

a.
b.
c.
d.

Diarrhea
Night sweats
Swollen lymph nodes
Weight loss

9. At what stage of HIV infection do constitutional symptoms begin?

a.
b.
c.
d.

Acute infection
Clinical latency
Early AIDS
Late AIDS

10. In the U.S., which of the following is least likely to result in the transmission of
HIV?
a.
b.
c.
d.

Being born to an HIV-infected woman

Having unprotected sex with an infected person of the opposite sex
Receiving a blood transfusion
Sharing needles to inject drugs

11. What is the usual cause of death in individuals diagnosed with AIDS?
a.
b.
c.
d.

Opportunistic infections
Side effects of treatment
Suicide
Weight loss

12. Which of the following is a common cause for retinitis and blindness in a person
with AIDS?
a.
b.
c.
d.

Cryptococcosis
Cytomegalovirus
Histoplasmosis
Kaposis sarcoma

31

13. Which of the following opportunistic illnesses is NOT caused by a

microorganism?
a.
b.
c.
d.

Candidiasis
Herpes simplex
Lymphoma
Progressive multifocal leukoencephalopathy

14. Which of the following opportunistic infections is caused by a parasite?

a.
b.
c.
d.

Histoplasmosis
Mycobacterium avium complex
Tuberculosis
Toxoplasmosis

15. The __________ test measures the amount of the RNA genetic material of HIV
in the blood.
a.
b.
c.
d.

anti-HIV EIA
anti-HIV Western blot
CD4+ count
viral load

16. The ________ test can be used to evaluate the risk for opportunistic infections in
an HIV-infected individual.
a.
b.
c.
d.

anti-HIV ELISA
anti-HIV PCR
CD4+ count
viral load

17. A CD4+ count of 50 cells/mcL indicates a/an __________.

a.
b.
c.
d.

diagnosis of AIDS
individual NOT infected with HIV
increased risk for opportunistic illnesses
weakening immune system

18. Which of the following antiretroviral drugs works by blocking the entry of HIV into
healthy cells?
a.
b.
c.
d.

Fusion inhibitors
Integrase inhibitors
Protease inhibitors
Reverse transcriptase inhibitors

32

19. Retrovir is an example of which type of antiretroviral drugs?

a.
b.
c.
d.

Entry inhibitors
Fusion inhibitors
Protease inhibitors
Reverse transcriptase inhibitors

20. Which of the following is considered a serious long term side effect of
antiretroviral therapy?
a.
b.
c.
d.

Anemia
Diarrhea
Increased cholesterol and/or triglycerides
Peripheral nerve pain

21. Which of the following medications is given to prevent and/or treat infection with
Mycobacterium avium complex?
a.
b.
c.
d.

Amphotericin B
Azithromycin
Chemotherapy
Cidofovir

22. What opportunistic illness was involved in the very first report of what later
became known as AIDS?
a.
b.
c.
d.

B cell immunoblastic lymphoma

Cryptococcosis meningitis
Kaposis sarcoma
Pneumocystis carinii pneumonia

23. In what year did the U.S. license the first HIV antibody test?
a.
b.
c.
d.

1982
1985
1986
1989

24. What was the first anti-HIV drug approved for use?
a.
b.
c.
d.

3TC
AZT
ENF
ZDV

33

25. In 1996, what occurred that resulted in a dramatic decline in the number of
deaths from HIV/AIDS?
a.
b.
c.
d.

Combination therapy is made available for the first time

Nevirapine approved as a new class of antiretroviral drug
New laboratory test approved that measures the level of HIV in the blood
The first home HIV test is approved for use

26. In what year did the CDC recognize the development of HIV strains resistant to
therapies?
a.
b.
c.
d.

2000
2001
2002
2003

27. In what year was the estimate made that 1.1 million people in the U.S. were living
with HIV/AIDS?
a.
b.
c.
d.

2008
2009
2010
2011

28. Per the CDC and as of 2010, how many documented occupational transmissions
of HIV have there been?
a.
b.
c.
d.

0
3
57
143

29. Per standard precautions, which of the following body fluids is NOT considered to
be potentially infectious for bloodborne pathogens?
a.
b.
c.
d.

Milk
Saliva
Sweat
Urine

30. In which of the following situations is it appropriate to use an alcohol-based hand

rub?
a.
b.
c.
d.

After removing gloves visibly contaminated with blood

After using the restroom
Before direct patient contact
Before eating

34

31. Which of the following is NOT a safe work practice to minimize needlestick
injuries?
a.
b.
c.
d.

Activating the safe needle device right after removal from the vein
Emptying sharps containers when they are about full
Removing a venipuncture needle from a tube holder before discarding
Using a transfer device to get blood from a syringe into an evacuated tube

32. Which of the following would violate the housekeeping policies?

a.
b.
c.
d.

Applying lipstick in the waiting room

Drinking coffee in the break room
Storing urine specimens in the refrigerator marked biohazard
Wearing a lab coat you have worn to collect blood into the lunch room

33. Despite the use of safe equipment and smarter work practices, approximately
how many needlestick injuries occur daily in the U.S.?
a.
b.
c.
d.

100
1,000
3,042
385,000

34. Approximately how many people in the U.S. are living with HIV/AIDS?
a.
b.
c.
d.

32,052
49,272
1.1 million
18.1 million

35. Which of the following race/ethnic groups represent 44% of the new HIV
infections in the U.S. in 2010?
a.
b.
c.
d.

Black Americans
Hispanic American
Latino Americans
White Americans

36. Which of the following groups remains the population most profoundly affected
by HIV?
a.
b.
c.
d.

Children less than 13 years of age

Heterosexuals
Homosexuals, bisexuals, and other men who have sex with men
IV drug users

35

37. What age group is thought to represent more than half of all undiagnosed HIV
infections in the U.S.?
a.
b.
c.
d.

Less than 13 years

13-24 years
25-29 years
30-35 years

38. Per this course, how many HIV-infected persons are reported to have been cured
of the infection?
a.
b.
c.
d.

0
1
3
5

*End of Test*

36

P.A.C.E. Course Evaluation

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Course Title: HIV & AIDS-Anatomy of a Pandemic

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