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*Valid for P.A.C.E. ® credit through 12/31/2015* COURSE DESCRIPTION This CE course reviews the immune
*Valid for P.A.C.E. ® credit through 12/31/2015* COURSE DESCRIPTION This CE course reviews the immune
*Valid for P.A.C.E. ® credit through 12/31/2015* COURSE DESCRIPTION This CE course reviews the immune

*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

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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:

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 today’s 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.

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_ X

Yes

_

No

GLOSSARY

Cell mediated immunity

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

Cytokines

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

Disseminated infection

An infection that has spread throughout the body usually by the bloodstream

Epidemic

A

disease outbreak that spreads rapidly to many people in a geographic area

Humoral immunity

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

Interferon

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

Interleukin

One of the cytokines produced by cells as part of the immune response; promotes the growth and activation of white blood cells

Latent infection

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

Opportunistic illness

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

Pandemic

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

Perinatal

Happening during or around the time of birth

Phagocytosis

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 individual’s 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”.

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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 individual’s 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).

spleen, and mucosa-associated lymphoid tissue (MALT). Graphic courtesy of AIDS.gov and is in the public domain

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.

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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 Peyer’s 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.

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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 infant’s B cells see the bacteria’s 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

Also known as

Function in the Immune Response

T Helper Cells

CD4+ cells

Produce and release cytokines*

T 4 cells

Communicate with B cells about antibody production

Maximize the activity of phagocytic cells such as macrophages

Cytotoxic T Cells

CD8+ cells

Kill cancer cells

T 8 cells

Kill cells that are infected with viruses

Killer T cells

Kill cells that become damaged in some way

Regulatory T Cells

T suppressor cells

Regulate and suppress the reactions of other cells in the immune response therefore preventing excessive

T reg cells

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

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THE IMMUNE SYSTEM IN ACTION

The chart below summarizes the basic immune response. Step • Foreign antigen enters the body
The chart below summarizes the basic immune response.
Step
• Foreign antigen enters the body
1
Step
• Macrophage ingests the foreign antigen
2
Step
• Macrophage displays the foreign antigen proteins on the exterior of its cell thus signaling a T helper
cell
3
Step
• T helper cell produces substances to activate other parts of the immune system including B cells
which respond and begin to produce antibodies
4
Step
• B cells produce millions of antibodies that are specific to the antigen
5
Step
• Antibodies signal other macrophages and other T cells to assist with further destruction of the
foreign antigen
6
Step
• 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
7
Step
• 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
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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 body’s response to the viral infection and it is known as acute retroviral infection (ARS) or primary HIV Infection.

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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 individual’s 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 individual’s 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

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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

Description

Candidiasis of bronchi, trachea, esophagus or lungs

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

Invasive cervical cancer

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

Cryptococcosis

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

Cytomegalovirus (CMV)

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

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Opportunistic Illness

Description

Herpes simplex virus (HSV)

Causes frequent or persistent lesions, often with extensive or deep ulcerations in the oral and anogenital regions

Also causes bronchitis, pneumonitis, and esophagitis

Histoplasmosis

Disseminated fungal infection caused by Histoplasma capsulatum

Can result in hypotension, adult respiratory distress syndrome, hepatic failure, renal failure, and disseminated intravascular coagulation

Kaposi’s sarcoma (KS)

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

Lymphoma

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 antigen- driven B cells with growth control influenced by abnormal T-cell and antigen-presenting cell processes

Mycobacterium avium complex

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

Tuberculosis (TB)

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

Progressive multifocal leukoencephalopathy

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

Toxoplasmosis

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

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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

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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

Interpretation

600 1,500 cells per mcL

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.

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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

Abbreviation

Reverse transcriptase (RT) Inhibitors

 

Atripla®

Efavirenz + tenofovir + emtricitabine

-

Combivir®

zidovudine + lamivudine

AZT + 3TC

Rescriptor®

delavirdine

-

Sustiva®

efavirenz

-

Epivir®

lamivudine

3TC

Hivid®

zalcitabine

ddC

Retrovir®

zidovudine

AZT or ZDV

Truvada®

tenofovir DF + emtricitabine

TDF + FTC

Videx®

didanosine

ddl

Viread®

tenofovir disoproxil fumarate

TDF or Bis

Zerit®

stavudine

D4T

Ziagen®

abacavir

ABC

Protease inhibitors (PI)

 

Agenerase®

amprenavir

APV

Aptivus®

tipranavir

TPV

Invirase®

saquinavir

SQV

Kaletra®

lopinavir + ritonavir

LPV

Prezista®

darunavir

DRV

Viracept®

nelfinavir

NFV

Fusion inhibitors

Fuzeon®

enfuvirtide

ENF

Entry inhibitors

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Selzentry®

maraviroc

-

Brand Name

Generic Name

Abbreviation

Integrase inhibitors

Tivicay®

dolutegravir

-

Isentress®

raltegravir

-

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 individual’s 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.

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Opportunistic Infection

Medication

Cryptococcal meningitis

amphotericin B (Fungizone®)

flucanazole (Diflucan®)

Cryptosporidiosis

nitaxoanide (Alinia®)

Cytomegalovirus

ganciclovir (Cytovene®)

foscarnet (Foscavir®)

cidofovir (Vistide®)

Kaposi’s sarcoma

various chemotherapy and immunomodulator medications

Mycobacterium avium complex

clarithromycin (Biaxin®)

azithromycin (Zithromax®)

rifabutin (Mycobutin®)

Pneumocystis

atovaquone (Mepron®)

pentamidine (NebuPent®)

sulfamethoxazole and trimethoprim (Bactrim® and Septra®)

AN EPIDEMIC TIMELINE

June 5, 2011 marked the 30 th 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

EVENTS

U.S. STATISTICS

1981

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

159 cases

On 7/3/1981, CDC publishes a report on 26 cases of Kaposi’s 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

1982

More cases of opportunistic infections and Kaposi’s sarcoma seen in homosexual men

771 cases reported to date

Similar diseases and symptoms seen in homosexual men are identified in hemophiliacs and a few women, infants, and blood transfusion recipients

618 deaths

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

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1983

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

2,807 cases reported to date

AIDS cases identified in 33 countries

2,118 deaths

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

1984

Scientist at the US National Cancer Institute reports his lab has isolated a virus believed to cause AIDS; he names it human T- lymphotropic virus type III (HTLV-III)

7,239 cases reported to date

5,596 deaths

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

1985

The US government licenses an HIV antibody test and screening of blood donors begins

15,527 cases of AIDS reported to date

12,529 deaths

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

1986

The American Foundation for AIDS Research (amfAR) releases first HIV/AIDS Treatment Directory

28,712 cases of AIDS reported to date

25,559 deaths

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

1987

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

50,378 cases of AIDS reported to date

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

40,849 deaths

U.S. bans HIV-infected immigrants and travelers from entering the country

1988

The U.S. federal government mails an educational pamphlet “Understanding AIDS” to 107 million homes

82,362 cases of AIDS reported to date

61,816 deaths

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

1989

amfAR established a Community-Based Clinical Trials (CBCT) program and awards grants to 16 research facilities

117,508 cases of AIDS reported to date

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

89,343 deaths

16

The 1990s

YEAR

EVENTS

U.S. STATISTICS

1990

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

160,969 cases of AIDS reported to date

Data shows a disproportionate number of U.S. black and Latina women are diagnosed with HIV

120,453 deaths

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

1991

The CDC reports that one million Americans are infected with HIV

206,563 cases of AIDS reported to date

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

156,143 deaths

The red ribbon becomes a symbol of hope and compassion for people with HIV and AIDS

1992

The first clinical trial of combination antiretroviral therapy begins

254,147 cases of AIDS reported to date

President Clinton establishes a White House Office of National AIDS Policy

The FDA issues new rules that accelerate approval of AIDS drugs

194,476 deaths

1993

AIDS patients begin to show resistance to AZT treatment

360,909 cases of AIDS reported to date

234,225 deaths

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

1994

An NIH study identifies that AZT reduces the risk of mother-to-infant HIV transmission

441,528 cases of AIDS reported to date

270,870 deaths

Researchers show that following infection, HIV replicates continuously producing millions of copies of the virus each day

1995

The use of dual combination therapy with AZT and other nucleoside analogues becomes the standard treatment for HIV

513,486 cases of AIDS reported to date

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

319,849 deaths

Between 1991 and 1995, the number of American women diagnosed with AIDS increased by more than 63%

1996

For the first time, more AIDS cases in the U.S. are in African Americans than in Caucasians

581,429 cases of AIDS reported to date

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 patient’s blood

362,004 deaths

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

 

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

1997

In the U.S. AIDS patients are living longer due to new antiretroviral therapies called drug “cocktails”

641,086 cases of AIDS reported to date

390,692 deaths

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

 

1998

Researcher shows the first 3-D images of HIV; this knowledge is critical to development of an effective vaccine

688,200 cases of AIDS reported to date

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

410,800 deaths

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

1999

HIV infection in over 27 countries has doubled since 1996; at least 95% of HIV-infected people live in developing countries

733,374 cases of AIDS reported to date

429,825 deaths

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

The 2000s

YEAR

EVENTS

U.S. STATISTICS

2000

The CDC reports that black and Latino men now account for more AIDS cases among men who have had sex with men than Caucasians

774,467 cases of AIDS reported to date

Grants issued to identify new viral and cellular targets for antiretroviral drugs

448,060 deaths

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

2001

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

816,149 cases of AIDS reported to date

18

 

person’s immune system markedly declines

462,653 deaths

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

The 20 th 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

2002

AIDS is the leading cause of death worldwide among people aged

886,000 cases of AIDS reported to date

501,669 deaths

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

2003

An experimental AIDS vaccine fails to block HIV infection

930,000 cases of AIDS reported to date

T-20 is approved by the FDA providing hope to thousands of patients who are resistant to other anti-HIV drugs

524,060 deaths

2004

The FDA approves the use of oral fluid samples with a rapid HIV diagnostic test

940,000 cases of AIDS reported to date

529,113 deaths

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

2005

 

Statistics change

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

Estimated 37,367 new individuals

diagnosed with HIV/AIDS

Estimated 17,011 deaths from AIDS in 2005

2006

The CDC recommends that all adolescents and adults be routinely tested for HIV infection

Estimated 36,817 new individuals diagnosed with HIV/AIDS

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

Estimated 14,627 deaths from AIDS in 2006

The CDC reports mother-to-baby transmission in the U.S. has declined to less than 2%

2007

The United Nations estimated that 33 million people are living with HIV/AIDS worldwide

Estimated 56,300 new individuals diagnosed with HIV

Estimated 37,041 new individuals diagnosed with AIDS

The FDA approved two new drugs: maraviroc, a new class of anti- HIV drugs, and raltegravir, for patients whose treatment programs have failed

Estimated 14,561 deaths from AIDS

2008

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

Estimated 51,477

new individuals

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

diagnosed with

HIV

19

 

which is 40% more than previously estimated

Estimated 32,645 new individuals diagnosed with AIDS

Estimated 20,091 deaths from AIDS

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

2009

The U.S. ends the travel ban on HIV-positive visitors and immigrants

Estimated 48,283 new individuals diagnosed with HIV

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 31,211 new individuals diagnosed with AIDS

Estimated 19,1981 deaths from AIDS

The 2010s

YEAR

EVENTS

U.S. STATISTICS

2010

The White House develops a National HIV/AIDS Strategy to reduce HIV incidence, increase access to care, and reduce health-related inequities

Estimated 47,132 new individuals diagnosed with HIV

The XVIII AIDS Conference reveals that the use of a vaginal microbicide applied before heterosexual sex protects some women from HIV infection

Estimated 29,463 new individuals diagnosed with AIDS

Estimated 19,343 deaths from AIDS

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.

2011

The 30 th anniversary of the HIV/AIDS epidemic is commemorated

Estimated 49,273 new individuals diagnosed with HIV

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%

Estimated 32,052 new individuals diagnosed with AIDS

More than 33 million people are living with HIV/AIDS worldwide with 1.1 million of those in the U.S.

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; fluid- resistant 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

Alcohol-Based Hand Rub OK

After removing gloves that are visibly contaminated with blood/body fluids

After removing gloves that are not visibly contaminated

When bare hands are visibly contaminated with blood/body fluids

After bare hands come in contact with blood/body fluids, mucous membranes, and/or intact skin if hands are not visibly contaminated

Before eating

After using a restroom

After exposure to known or suspected Bacillus anthracis (anthrax)

Before direct patient contact

After contact with a patient’s intact skin

22

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 manufacturer’s 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 ⅔ 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 orange- red labels that say “biohazard” and show the biohazard symbol.

that say “biohazard” and show the biohazard symbol. NEEDLESTICK INJURIES Biohazard Symbol Any worker who may

NEEDLESTICK INJURIES

Biohazard

Symbol

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 patient’s 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.

Brown’s 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, Brown’s HIV viral load dropped to undetectable levels and his HIV antibody levels declined. At first, Brown’s 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 ½ 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 baby’s 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 ½ 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.

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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.

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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. Epithelial cells

b. Liver

c. Spleen

d. Thyroid

2. The small clusters of bean-shaped structures that function as part of the immune system are called

a. bone marrow

b. lymph glands

c. MALT

d. thymus

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

a. Bone marrow

b. Epidermis

c. Lymphatic vessels

d. Vaginal walls

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

a. B cells

b. CD4+ cells

c. Erythrocytes

d. Macrophages

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

a. Kill cancer cells

b. Produce antibodies specific to a foreign antigen

c. Produce and release cytokines

d. Regulate the actions of other cells in the immune response

6. HIV invades which of the following cells?

a. CD4+

b. CD8+

c. Cytotoxic T cells

d. Regulatory T cells

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

a. Acute infection

b. Clinical latency

c. Early AIDS

d. Late AIDS

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

a. Diarrhea

b. Night sweats

c. Swollen lymph nodes

d. Weight loss

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

a. Acute infection

b. Clinical latency

c. Early AIDS

d. Late AIDS

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

a. Being born to an HIV-infected woman

b. Having unprotected sex with an infected person of the opposite sex

c. Receiving a blood transfusion

d. Sharing needles to inject drugs

11. What is the usual cause of death in individuals diagnosed with AIDS?

a. Opportunistic infections

b. Side effects of treatment

c. Suicide

d. Weight loss

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

a. Cryptococcosis

b. Cytomegalovirus

c. Histoplasmosis

d. Kaposi’s sarcoma

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

a. Candidiasis

b. Herpes simplex

c. Lymphoma

d. Progressive multifocal leukoencephalopathy

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

a. Histoplasmosis

b. Mycobacterium avium complex

c. Tuberculosis

d. Toxoplasmosis

15. The in the blood.

test measures the amount of the RNA genetic material of HIV

a. anti-HIV EIA

b. anti-HIV Western blot

c. CD4+ count

d. viral load

16. The

test can be used to evaluate the risk for opportunistic infections in

an HIV-infected individual.

a. anti-HIV ELISA

b. anti-HIV PCR

c. CD4+ count

d. viral load

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

a. diagnosis of AIDS

b. individual NOT infected with HIV

c. increased risk for opportunistic illnesses

d. weakening immune system

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

a. Fusion inhibitors

b. Integrase inhibitors

c. Protease inhibitors

d. Reverse transcriptase inhibitors

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

a. Entry inhibitors

b. Fusion inhibitors

c. Protease inhibitors

d. Reverse transcriptase inhibitors

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

a. Anemia

b. Diarrhea

c. Increased cholesterol and/or triglycerides

d. Peripheral nerve pain

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

a. Amphotericin B

b. Azithromycin

c. Chemotherapy

d. Cidofovir

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

a. B cell immunoblastic lymphoma

b. Cryptococcosis meningitis

c. Kaposi’s sarcoma

d. Pneumocystis carinii pneumonia

23. In what year did the U.S. license the first HIV antibody test?

a. 1982

b. 1985

c. 1986

d. 1989

24. What was the first anti-HIV drug approved for use?

a. 3TC

b. AZT

c. ENF

d. ZDV

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

a. Combination therapy is made available for the first time

b. Nevirapine approved as a new class of antiretroviral drug

c. New laboratory test approved that measures the level of HIV in the blood

d. 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. 2000

b. 2001

c. 2002

d. 2003

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

a. 2008

b. 2009

c. 2010

d. 2011

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

a. 0

b. 3

c. 57

d. 143

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

a. Milk

b. Saliva

c. Sweat

d. Urine

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

a. After removing gloves visibly contaminated with blood

b. After using the restroom

c. Before direct patient contact

d. Before eating

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

a. Activating the safe needle device right after removal from the vein

b. Emptying sharps containers when they are about ⅔ full

c. Removing a venipuncture needle from a tube holder before discarding

d. 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. Applying lipstick in the waiting room

b. Drinking coffee in the break room

c. Storing urine specimens in the refrigerator marked “biohazard”

d. 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. 100

b. 1,000

c. 3,042

d. 385,000

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

a. 32,052

b. 49,272

c. 1.1 million

d. 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. Black Americans

b. Hispanic American

c. Latino Americans

d. White Americans

36. Which of the following groups remains the population most profoundly affected by HIV?

a. Children less than 13 years of age

b. Heterosexuals

c. Homosexuals, bisexuals, and other men who have sex with men

d. IV drug users

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

a. Less than 13 years

b. 13-24 years

c. 25-29 years

d. 30-35 years

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

a. 0

b. 1

c. 3

d. 5

*End of Test*

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P.A.C.E.® Course Evaluation

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Course Title: HIV & AIDS-Anatomy of a Pandemic

Course Number: 1221814

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