ATrain Education

 

Continuing Education for Health Professionals

Course Modules

  • Course Introduction
  1. The Millennium Development Goals
  2. Epidemiology of HIV
  3. Groups Identified at Higher Risk for HIV
  4. Cause of HIV/AIDS
  5. Transmission and Prevention of HIV
  6. HIV Testing
  7. Evaluation and Clinical Management of HIV
  8. Occupational Exposures
  9. Legal Issues with HIV/AIDS
  10. Attitudes Toward Those with HIV
  11. Conclusion
  12. Kentucky Resources
  13. References
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KY: HIV/AIDS

This multidisciplinary course is approved by the Kentucky Cabinet for Health and Family Services and is suitable for all professional groups impacted by KRS 214.610/615/620. Kentucky CHFS approval #0316-1602-M.

  • Author:
    • Lauren Robertson, BA, MPT

      Lauren Robertson earned a BA in Biology from Mills College in Oakland, California, and a Master's degree in Physical Therapy from the University of California at San Francisco.

      Lauren is the founder and co-owner of ATrain Education (atrainceu.com) and she has written or co-written more than two hundred courses on a wide range of topics for her continuing education website. She is certified as a trainer on Alzheimer's disease and related dementias by the Florida Department of Elder Affairs.

    • Susan Walters Schmid, PhD

      Susan Schmid earned BA degrees in History and European Studies from George Mason University, a Master's degree in Public History from Appalachian State University, and a PhD in History from Arizona State University.

      In addition to her PhD she earned a Certificate in Scholarly Publishing from ASU. Susan has served as an editor for several scholarly presses. She worked as a desktop publishing specialist for Arizona State University and taught several courses for the History Department as well as "Introduction to Scholarly Publishing" and "Scholarly Editing" for the Scholarly Publishing Program.

       

  • Contact hours: 4
  • Pharmacotherapy hours: 1
  • Expiration date: October 1, 2020
  • Course price: $29

Course Summary

Overview of HIV and AIDS in Kentucky, including the cause and mechanism of HIV infection, basic components of HIV antibody testing and confirmation, and initial evaluation and clinical management of HIV patients. Summarizes HIV prevention strategies, clinical evaluation and management of HIV, and management of occupational exposures. Continues with an analysis of HIV laws in Kentucky and attitudes and behaviors towards those infected with HIV. Concludes with Kentucky’s programs for HIV patient care.

The following information applies to occupational therapy professionals:

  • Target Audience: Occupational Therapists, OTAs
  • Instructional Level: Intermediate
  • Content Focus: Content Focus: • Category 1—Domain of OT, Client Factors • Category 2—Occupational Therapy Process, Outcomes

Criteria for Successful Completion

80% or higher on the post test, a completed evaluation form, and payment where required. No partial credit will be awarded.

Conflict of Interest/Commercial Support

Conflict of Interest/Commercial Support

Accredited status does not imply endorsement by ATrain Education Inc. or by the American Nurses Credentialing Center or any other accrediting agency of any products discussed or displayed in this course. The planners and authors of this course have declared no conflict of interest and all information is provided fairly and without bias. No commercial support was received for this activity.

Accreditation Information

Objectives: When you finish this course you will be able to:

  • Trace the epidemiology of HIV as related to Kentucky and the United States.
  • Describe five groups that are at higher risk for contracting HIV or passing it on to others.
  • Identify the cause and mechanism of HIV infection.
  • Describe one prevention measure each for sexual, bloodborne, and mother-to-child transmission of HIV.
  • Outline the basic components of HIV antibody testing and confirmation.
  • Explain initial evaluation and clinical management of HIV patients.
  • Enumerate the steps to take if you experience an occupational exposure.
  • Describe the attitudes and behaviors associated with the care of HIV/AIDS patients.

The Millennium Development Goals

In 2011 United Nations member states signed off on a set of targets and commitments aimed at reversing the spread of HIV and AIDS throughout the world. Called the Millennium Development Goals, the 193 member countries set 10 goals to be achieved by 2015. The overall purpose is to halt and begin to reverse the HIV epidemic by 2015. This commitment by member nations has had a profound effect and represents unprecedented cooperation and agreement toward the eventual elimination of HIV.

2011 U.N. Political Declaration of HIV and AIDS:
Targets and Elimination Commitments

  1. Reduce sexual transmission by 50% by 2015.
  2. Reduce transmission of HIV among people who inject drugs by 50% by 2015.
  3. Eliminate new HIV infections among children by 2015 and substantially reduce AIDS-related maternal deaths.
  4. Reach 15 million people living with HIV with lifesaving antiretroviral treatment by 2015.
  5. Reduce tuberculosis deaths in people living with HIV by 50% by 2015.
  6. Close the global AIDS resource gap by 2015 and reach annual global investment of US$ 22 to 24 billion in low- and middle-income countries.
  7. Eliminate gender inequalities and gender-based abuse and violence and increase the capacity of women and girls to protect themselves from HIV.
  8. Eliminate stigma and discrimination against people living with and affected by HIV through promotion of laws and policies that ensure the full realization of all human rights and fundamental freedoms.
  9. Eliminate HIV-related restrictions on entry, stay, and residence.
  10. Eliminate parallel systems for HIV-related services to strengthen integration of the AIDS response in global health and development efforts.

Source: UNAIDS, 2014.

Epidemiology of HIV

The human immunodeficiency virus (HIV) has infected tens of millions of people around the world in the past three decades, with devastating results. In its advanced stage—called acquired immunodeficiency syndrome (AIDS)—infected individuals have no protection from diseases that threaten their immune systems. Although medical treatment can delay the onset of AIDS, no cure is available.

Worldwide, the overall growth of the AIDS epidemic began to stabilize in the late 1990s and the annual number of new HIV infections has been steadily declining since then. As treatment has become more effective, people with HIV are living longer and, consequently, the number of people living with HIV worldwide has increased to about 35 million people (UNAIDS, 2013a). There has been a 33% decline in new infections since 2001. Nevertheless, 2.3 million people worldwide were new HIV infections in 2012 (UNAIDS, 2013a).

Although there are notable exceptions within certain high-risk groups, the number of AIDS deaths declined to 1.6 million deaths in 2012 (UNAIDS, 2013a). In many countries, prevention efforts among sex workers and men who have sex with men still lags behind prevention efforts for other high-risk groups. In addition, the prevalence of HIV among injection drugs users remains high and prevention efforts remain low in many countries (UNAIDS, 2013a).

Much of the success in reducing the number of deaths related to HIV is due to an increase in the number of HIV-infected people receiving antiretroviral therapy. This prevents HIV-related illness and death, reduces the risk of HIV transmission, and reduces the spread of tuberculosis. In low- and middle-income countries, the number of people receiving antiretroviral therapy has increased dramatically over the past ten years, from 300,000 in 2002 to 9.7 million in 2012 (UNAIDS, 2013b). The United Nations has established a goal of providing antiretroviral therapy to 15 million people by 2015.

The dimensions and pace of the epidemic nevertheless remain staggering—especially in sub-Saharan Africa, home to 12% of the world’s population but 70% of all new HIV infections in 2012. In eight countries in this region, 10% of the adult population is estimated to be HIV-positive (KFF, 2013). However, since 2001 the annual number of new HIV infections among adults in sub-Saharan Africa has declined by 34%. Two other regions, however, experienced significant increases in mortality from AIDS: Eastern Europe/Central Asia and the Middle East/North Africa (UNAIDS, 2013b).

In the United States

Since the height of the epidemic in the mid-1980s, the annual number of new HIV infections in the United States has been reduced by more than two-thirds, from roughly 130,000 to 50,000 people newly infected each year. Overall, more than 1.8 million people in the United States are estimated to have been infected with HIV, including over 650,000 who have already died. Today, more than 1.1 million people in the United States are living with HIV and about 200,000 are unaware that they are infected with the virus (CDC, 2013a).

By transmission category, the largest number of new HIV infections currently occurs among men who have sex with men of all races and ethnicities, followed by African American heterosexual women. By race/ethnicity overall, African Americans are the most heavily affected, followed by Latinos (CDC, 2013a).

Estimated Number of New HIV Infections in U.S., 2010

graph: estimated new HIV infections in US (2010)

Subpopulations representing 2% or less of the overall US epidemic are not reflected in this chart.

Estimated new HIV infections in the United States, 2010, for the most affected subpopulations.

MSM = men who have sex with men, IDU = injection drug users. Source: CDC, 2010.

In Kentucky

As of June 30, 2013, Kentucky had recorded 8,904 cumulative AIDS cases since the health department’s surveillance program began in 1982. The majority (83%) of HIV infections diagnosed in Kentucky have been among males. Among all males, 35% percent of cumulative cases were aged 30 to 39 years at the time of diagnosis (KCHFS, 2013). As in the United States generally, minorities in Kentucky are disproportionately affected by HIV/AIDS, with African Americans accounting for about 40% of the cumulative cases and Hispanics 19%.

People Newly Diagnosed with HIV in Kentucky

In 2011 (latest data available), 55% of newly diagnosed HIV cases were among white, non-Hispanic Kentuckians. Related to their representation in the general population, there are higher rates of infection among blacks and Hispanics. Blacks accounted for 35% of new HIV infections diagnosed in 2011, yet comprised just 8% of Kentucky’s population in 2011. Similarly, Hispanics accounted for 7% of newly diagnosed HIV infections in 2011, yet comprised only 3% of the population in that year. AIDS is the fourth leading cause of death among Kentucky’s young (25–44) African American men (KCHFS, 2013).

Pediatric Cases

There have been 81 pediatric HIV infections reported to the Kentucky HIV/AIDS surveillance program since AIDS reporting began in 1982. The majority of reported pediatric infections (75%) were due to perinatal transmission through an HIV-infected mother, 11 infections were reported with a primary exposure route of pediatric hemophilia or coagulation disorders, and 2 infections were reportedly due to pediatric transfusion or transplant (KCHFS, 2013).

Since 1991 there have been no pediatric HIV infections with hemophilia or coagulation disorders reported as the route of exposure in Kentucky. The two pediatric infections reported with pediatric transfusion or transplant as the risk factor were diagnosed in 1987 or earlier. Thirty-six of the 43 pediatric HIV infections among blacks were due to perinatal exposure, compared to 36 pediatric HIV infections among whites. Only one pediatric HIV infection has been reported among Hispanics (KCHFS, 2013).

Groups Identified at Higher Risk for HIV

Identified risk groups are those groups of people that carry an increased risk of either becoming infected with HIV or, when infected, transmitting the virus to another person. In some cases, increased risk is the result of unsafe behaviors, while in other cases it is related to socioeconomic factors or other factors beyond the control of the individual or group.

The most important aspect of identifying groups at high risk for contracting HIV is how to structure support and prevention efforts. Public health officials and governments are most efficient in their efforts when they are able to identify groups that are most vulnerable to HIV infection. This is done with up-to-date information on the most likely sources of new infections as well as an understanding of epidemic patterns (WHO, 2012a).

The World Health Organization recommends a “mode of transmission” model to understand, at the local level, which subpopulations are most at risk of HIV infection and which risk behaviors may facilitate transmission. This information is used to develop national responses (WHO, 2012a). Using current epidemiologic and behavioral information, the proportion of the adult male and female population that belongs to each of several risk groups are precisely defined by each country. This includes:

  • Sex workers and their clients
  • Injecting drug users
  • Men who have sex with men
  • Individuals with multiple heterosexual sex partners in the last year
  • Spouses of individuals with higher-risk behavior
  • Individuals in stable heterosexual relationships (WHO, 2012a)

The mode of transmission model also looks at the prevalence of HIV infection and other sexually transmitted infections within each risk group. The average number of sexual or injecting partners per year and the average number of exposures per partner are considered, taking into account the average level of protective behavior (eg, condom use or use of clean needles), for individuals in each risk group. The probability of HIV transmission per exposure act in each risk group is determined, taking into account the effect of sexually transmitted infections and the prevalence of male circumcision (WHO, 2012a).

Mode of transmission groupings are reflected in public health figures in Kentucky and are used to analyze the effects of the HIV epidemic in the state. In Kentucky, as in other parts of the world, men who have sex with men account for the largest percentage of cumulative HIV cases, followed by injection drug users. Although representing a smaller percentage of cumulative cases, heterosexual transmission accounts for a significant percentage of cumulative HIV cases in Kentucky.

 

*Female Heterosexual = A female not reporting drug use, but reporting sex with males.
**“Other” includes persons with “transfusion/transplant” or “hemophilia/coagulation” listed as mode of transmission. Also includes persons with perinatal exposure but were diagnosed as an adult.
Note: Excludes 81 pediatric cases (<13 years).
Source: KCHFS, 2013.

 

Cumulative Adult/Adolescent HIV Cases by Transmission Route
(through June 30, 2013, Kentucky)

Transmission route

Number

Percent

Men who have sex with men (MSM)

4,794

54

Injection drug users (IDU)

942

11

MSM/IDU

444

5

Heterosexual

1,237

14

Femaleh*

269

3

Other**

118

1

Undetermined

1,019

12

Men Who Have Sex with Men

In Kentucky, as well as nationally, gay, bisexual, and other men who have sex with men (MSM) of all races and ethnicities remain the population most profoundly affected by HIV. In 2010 the estimated number of new HIV infections among MSM in the United States was 29,800, which is a 12% increase in the number of new infections among MSM since 2008 (CDC, 2013a).

Although MSM represent about 4% of the male population in the United States, in 2010 MSM accounted for 78% of new HIV infections among males and 63% of all new infections. MSM accounted for a little more than half of all people living with HIV infection in 2009. In 2010 white MSM continued to account for the largest number of new HIV infections, by transmission category, followed closely by black MSM. Since the epidemic began, an estimated 302,148 MSM with an AIDS diagnosis have died, including an estimated 5,909 in 2010 (CDC, 2013a).

Bisexual men—men who have sex with both men and women—face some of the same challenges as MSM. However, it has been more difficult to reach men who do not identify as being gay with HIV prevention efforts and activities. HIV-negative men who have sex with men may also be less diligent in their prevention efforts. As with any behavior change, people can become “tired” of safer sex messages, and may make choices that place them at risk. Some may feel that HIV infection is inevitable (although it is not) and purposely engage in unprotected sex.

Injecting Drug Users

Significant challenges persist in addressing HIV prevention among injecting drug users [IDUs]. Perhaps the greatest obstacles are country laws, policies, and regulations that criminalize drug use; the continued stigma associated with injecting drug use, addiction, and HIV; a lack of knowledge about the effectiveness of interventions that limit both unsafe injection practices and HIV transmission; and a failure among policymakers to grasp the human and public health consequences of failure to reach IDUs with effective treatment, care, and prevention services.

Center for Strategic and International Studies, 2010

Injecting drug use (IDU) is responsible for HIV infections in 10% of all cases worldwide. Injecting drug use is not only a risk factor for HIV transmission but it may also change the natural course of HIV infection. In addition, heroin and other opioids have immune-modulating effects that may alter the progression of HIV infection and susceptibility to infections (Meijerink et al., 2014).

Harm reduction measures such as syringe exchange programs have been proven to reduce the transmission of bloodborne pathogens like HIV and hepatitis. Although research has repeatedly shown that needle exchange programs are effective in curbing infection, these programs are controversial because some people believe that providing clean needles and a place to exchange used needles constitutes “approval” of injection drug use.

Poverty and self-esteem and psychological issues may complicate the lives of injecting drug users. The desire to stop using illegal drugs may not be matched with the ability to stop. The reality about inpatient treatment facilities is that, while there is a large demand for spaces, very few are available. Many substance abusers are placed on waiting lists when they want treatment, and by the time there is a place for them, they may be lost to followup.

People of Color

African Americans and Hispanics have disproportionately higher rates of AIDS in the United States, despite the fact that there are no biologic reasons for the disparities. There is no single reason why these disparities exist. One factor is inadequate healthcare linked to socioeconomic conditions. Another factor is distrust of the healthcare system. Both legacies of the past and current issues of race mean that many people of color do not trust “the system.” Thus, even when income is not a barrier, access to early intervention and treatment may be limited. Furthermore, HIV may be only one of a list of problems that also includes inadequate housing, food, and employment.

Another factor may be the diversities within these populations. Diversity is evident in immigrant status, religion, language, and geographic location, as well as socioeconomic conditions. Providing targeted information to these diverse populations is challenging.

Blacks/African Americans

Blacks/African Americans represent about 13% of the U.S. population but continue to experience the most severe burden of HIV, compared with other races and ethnicities. Since the epidemic began, more than a quarter of a million blacks with an AIDS diagnosis have died. Unless the course of the epidemic changes, at some point in their lifetime, an estimated 1 in 16 black men and 1 in 32 black women will be diagnosed with HIV infection (CDC, 2013a).

African American gay, bisexual, and other men who have sex with men represented an estimated 72% of new infections among all African American men and 36% of new HIV infections among all gay and bisexual men. More new HIV infections occurred among young African American gay and bisexual men than any other subgroup of gay and bisexual men. The rate of new HIV infection in African Americans is 8 times that of whites based on population size (CDC, 2014a).

In 2010 African American women accounted for 29% of the estimated new HIV infections among all adult and adolescent African Americans. Most new HIV infections among African American women are attributed to heterosexual contact. The estimated rate of new HIV infections for African American women was 20 times that of white women and almost 5 times that of Hispanic/Latino women (CDC, 2014a).

Hispanics/Latinos

Hispanics/Latinos represent nearly 17% of the population but accounted for 21% of new HIV infections in 2010. About 20% of people living with HIV infection in 2009 were Hispanics/Latinos. In 2010 the rate of new HIV infections for Latino males was 2.9 times that for white males, and the rate of new infections for Latinas was 4.2 times that for white females. Since the epidemic began, more than 96,200 Hispanics/Latinos with an AIDS diagnosis have died (CDC, 2013a).

Almost 80% of the HIV diagnoses among Hispanic/Latino men in the United States and dependent areas in 2011 were attributed to male-to-male sexual contact. Eighty-six percent of the HIV diagnoses among Hispanic/Latino women were attributed to heterosexual contact (CDC, 2014a).

American Indians and Alaska Natives

American Indians and Alaska Natives represent about 1.2% of the U.S. population or about 5.2 million people. Although American Indians and Alaska Natives represented less than 1% of new HIV infections in 2010, HIV is a critical public health issue. Compared with other races/ethnicities, American Indians and Alaska Natives have poorer survival rates after an HIV diagnosis and also face special HIV prevention challenges, including poverty and culturally based stigma. In 2011 men accounted for 76% and women accounted for 24% of the estimated 212 American Indians and Alaska Natives diagnosed with HIV infections (CDC, 2014a).

Asian Americans

Asian Americans make up about 5% of the U.S. population. Despite being a rapidly growing population in the United States, Asians have experienced stable numbers of new HIV infections in recent years. Overall, Asians continue to account for only a small proportion of new HIV infections in the United States and dependent areas (CDC, 2014a).

In 2010 Asians accounted for 2% of new HIV infections in the United States. Eighty-six percent of the estimated 821 HIV diagnoses among Asian men in the United States and dependent areas in 2011 were attributed to male-to-male sexual contact. Ninety-two percent of the estimated 153 HIV diagnoses among Asian women were attributed to heterosexual contact (CDC, 2014a).

Estimates of New HIV Infections in the United States
for the Most-Affected Subpopulations, 2010

chart: estimates of new HIV infections

Estimated HIV incidence among adults and adolescents in the United States, 2007–2010. HIV Surveillance Supplemental Report 2012;17(4). Subpopulations representing 2% or less of the overall U.S. epidemic are not reflected in this chart. Abbreviations: MSM, men who have sex with men; IDU, injection drug user. Source: CDC, 2012.

Women and HIV

Thirty years into the epidemic, women make up half of those living with HIV worldwide. In sub-Saharan Africa young women are as much as eight times more likely than men to be living with HIV (Hardee et al., 2014). In the United States and worldwide women are becoming infected with HIV at higher rates than any other group of people.

Women often become infected with HIV from a partner who has either used injecting drugs or has had other sexual partners. Prevention efforts can be ineffective because some women are unable to discuss or implement safer sex practices or because domestic violence is present in their relationship. Still others are forced into non-consensual sex and lack the power to refuse.

Women who are infected with HIV, or who have family members who have HIV, face unique challenges. They may postpone taking medication, or going to medical appointments, in order to care for their children or other family members. Women (as with men) may fear disclosing their HIV status to others, fearing loss of their jobs or housing, or other forms of discrimination.

Because of these issues, many women who are infected with HIV do not consider this to be their worst problem. Their symptoms may be mild and manageable for many years. Meanwhile, they may have more pressing concerns, such as their lack of income, housing, access to medical care, possible abusive relationships, and concerns about their children.

A number of strategies have been identified to empower women and reduce their vulnerability to HIV:

  • Promoting women’s employment, income, and livelihood opportunities
  • Transforming legal norms to empower women, including marriage, inheritance, and property rights
  • Providing universal education for girls
  • Enacting and enforcing laws against sexual violence, including intimate partner violence
  • Eradicating human trafficking
  • Developing HIV prevention methods that women can control
  • Transforming gender norms (Hardee et al., 2014)

People with Hemophilia

Hemophiliacs lack the ability to produce certain blood clotting factors. With the advent of anti-hemophilic factor concentrates (clotting material pooled out of donated blood plasma) hemophiliacs can receive injections of the clotting factors that they lack, which in turn allows them to lead relatively normal lives.

Unfortunately, because the raw materials for these concentrates came from donated blood, many hemophiliacs were infected with HIV prior to the advent of blood testing. During the 1980s, 90% of severe hemophiliacs contracted HIV or HCV through use of these products. There is anger within this community because there is evidence to show that the companies who manufactured the concentrates knew their products might be contaminated but continued to distribute them anyway.

Some people considered hemophiliacs to be innocent victims of HIV, but there has been discrimination against them. The Ryan White Care Act (funding HIV services) and the Ricky Ray Act (providing compensation to hemophiliacs infected with HIV) were both named for HIV-positive hemophiliacs who suffered significant discrimination (arson, refusal of admittance to grade school) in their home towns.

HIV-Infected Children

According to UNAIDS, there are 3.4 million children under the age of 15 and 2 million adolescents who are infected with HIV (Sohn & Hazra, 2013). The vast majority of these children were perinatally infected.

Effective pediatric HIV treatment involves early diagnosis, prompt initiation of antiretroviral therapy, and frequent monitoring to ensure quality care. Antiretroviral therapy initiation in the first 3 months of life can reduce mortality by 76%. Without antiretroviral therapy, 52% of perinatally HIV-infected infants and 26% of postnatally HIV-infected infants will die within 12 months (MMWR, 2014a).

In 2011 approximately 4500 HIV-infected children under the age of 15 lived in North America, the vast majority in the United States. Approximately two-thirds of perinatally HIV-infected adolescents in the United States are African-American/non-Hispanic, and approximately 20% are Hispanic; 53% are female. Given the low mortality and very low number of newly infected babies (<100 per year), the perinatally infected population in the United States is at a relatively stable number of over 10,000 individuals, most of whom are now young adults and with the oldest members now entering the fourth decade of life (Sohn & Hazra, 2013).

Depending on the setting, the pediatric HIV epidemic has entered or is entering the next phase of its evolution as children grow up and face new challenges of living with HIV. Perinatally HIV-infected adolescents are a highly unique patient sub-population, having been infected before development of their immune systems, been subject to suboptimal antiretroviral therapy options and formulations, and face transitioning from complete dependence on adult caregivers to becoming their own caregivers (Sohn & Hazra, 2013).

The evolution of HIV into a chronic disease has no greater impact than on the life of a child. Children that families, clinicians, and policymakers at one time expected to die are living into their twenties and having children of their own. Unanticipated issues such as reproductive health, higher education, and career training are now urgent needs (Sohn & Hazra, 2013).

Sex Workers

The HIV epidemic continues to have a profound effect on female, male, and transgender sex workers who engage in sexual activity for income, employment, or non-monetary items such as food, drugs, and shelter (CDC, 2013c). Globally, female sex workers are 14 times more likely to be infected with HIV than adult women overall (Wirtz et al., 2014).

HIV prevalence among sex workers varies across the world, from 22% in Eastern and Southern Africa and 17% in Western and Central Africa to less than 5% in all other regions. HIV prevalence among female sex workers may be as high as 37% in sub-Saharan Africa, 11% in Eastern Europe, and 6% in Latin America (UNAIDS, 2013a).

Exceptionally high HIV prevalence has been found among female sex workers in urban settings in some countries: 57% in Kisumu, Kenya; 32% in Mauritius; and 20% in Bangkok, Thailand (UNAIDS, 2013b).

Among sex workers, a number of factors work against the use of preventive measures. Social stigma, isolation, legal and issues, gender bias, higher payments for sex without condoms, forced sexual acts, and drug use combine to make sex workers vulnerable to sexually transmitted diseases such as HIV.

Although condom use is known to be highly effective in preventing the spread of HIV, many sex workers do not carry condoms due to fear of police harassment. To look more closely at this problem, Research conducted by Human Rights Watch in New York, Washington, DC, Los Angeles, and San Francisco found that police often seize condoms as evidence of prostitution-related offenses and introduce the condoms as evidence in criminal proceedings (Wurth et al., 2013).

Because of these police practices, some members of the groups most at risk of infection have stopped carrying condoms or carry only a few and sometimes engaged in sex without protection as a result. To address this issue, the U.S. Presidential Advisory Council on HIV/AIDS has adopted a resolution recognizing that the use of condom possession as evidence of prostitution-related offenses undermines HIV prevention and testing efforts. District attorneys in two jurisdictions—Nassau County, NY, and San Francisco—have stopped using condoms as evidence of prostitution and police in Washington, DC, are distributing know-your-rights cards clarifying that the Metropolitan Police Department cannot interfere with possession of condoms and providing information on how to file a complaint against an officer for harassing, stopping, or searching a person on the basis of carrying condoms (Wurth et al., 2013).

Cause of HIV/AIDS

The HIV Virus

illustration: HIV Virus

HIV has a protein shell, a lipid membrane, and glycoproteins that dot the outer surface of the virus. Source: Illustration provided by 3DScience.com.

AIDS is a complex condition caused by the human immunodeficiency virus, which attacks the cells of the immune system and progressively destroys the body’s ability to fight infection and disease. People with damaged immune systems are vulnerable to diseases that do not threaten people with healthy immune systems. AIDS is acquired—it is not hereditary and it is not passed casually from one person to another—and it is a syndrome because it causes a combination of symptoms, diseases, and infections.

HIV-1 and HIV-2

Two types of HIV are known: the most common HIV-1, which is responsible for the worldwide AIDS epidemic, and the immunologically distinct HIV-2, which is much less common and less virulent but produces clinical findings similar to HIV-1. The HIV-1 type itself includes four groups (M, O, N, and P), having different geographic distributions but all four producing similar clinical symptoms. The HIV-1 M group further splits into 9 subtypes (A through J) (Santoro & Perno, 2013).

T-helper Lymphocytes

When HIV enters the bloodstream it looks for T-helper lymphocytes, white blood cells essential to the functioning of the immune system. The T-helper lymphocytes are also referred to as T4 or CD4 cells and are the primary target for HIV infection. These cells regulate immune response when disease-causing organisms such as bacteria or viruses enter the body. When HIV attacks a T-helper lymphocyte, the T-helper cell sends signals to other cells, which produce antibodies to fight the infection. HIV infects and destroys the T-helper lymphocytes and damages their ability to signal for antibody production.

HIV Entry into a T-helper Cell

illustration: HIV entry into T-helper cell

The top panel shows HIV attaching itself to a T cell (surface shown in pale blue). The second and third panels show HIV (dotted with red glycoproteins) successively attaching to the T cell and depositing HIV particles into the T cell. Source: Sougrat et al., 2007. Image courtesy of PLoS Creative Commons Attribution 2.5 license.

The CD4 T-lymphocytes coordinate a number of important immune functions. Loss of these functions causes a progressive impairment of the immune system. Disease manifestations range from asymptomatic infection to life-threatening conditions characterized by severe immunodeficiency, serious opportunistic infections, and cancers. A strong association exists between the development of life-threatening opportunistic illnesses and both the absolute number and percentage of CD4+ T- lymphocytes. As the number of CD4+ T-lymphocytes decreases, the risk and severity of opportunistic illnesses increases.

Stages of Infection

HIV infection has a well-documented progression. If a person is infected with HIV and does not get treatment, the virus will eventually overwhelm the immune system and lead to Acquired Immune Deficiency Syndrome (AIDS).

Acute Infection

Within 2–4 weeks after being infected with HIV, many, but not all, people develop flu-like symptoms, often described as “the worst flu ever.” Symptoms can include fever, swollen glands, sore throat, rash, muscle and joint aches and pains, fatigue, and headache. This is called “acute retroviral syndrome” (ARS) or “primary HIV infection,” and it’s the body’s natural response to the HIV infection.

During this early period of infection, large amounts of virus are being produced in the body and there is a great risk of transmitting the virus to another person because of the high levels of virus in the blood. The virus uses the body’s CD4 cells to replicate, which destroys the CD4 cells; because of this, an individual’s CD4 count can fall rapidly. Eventually the immune response will begin to bring the level of virus in the body back down to what is called a viral set point, which is a relatively stable level of virus in the body. At this point, the CD4 count begins to increase, but it may not return to pre-infection levels. It may be particularly beneficial to begin ART during this stage.

Key Points About Acute Infection

  • Flu-like symptoms occur—“The worst flu ever!”
  • CD4 count can fall rapidly.
  • Great risk of transmitting HIV exists because of high levels of virus in the blood.
  • Antiretroviral therapy may be beneficial at this stage.

Clinical Latency

Following the acute stage of HIV infection, the disease moves into what is called the clinical latency stage. Latency describes a period where a virus is living or developing in a person without producing symptoms. During the clinical latency stage, people who are infected with HIV experience no HIV-related symptoms, or only mild ones. This stage is sometimes called asymptomatic HIV infection,* or chronic HIV infection.

*Asymptomatic HIV infection—the person is infectious but looks and feels healthy. The virus is active and continuing to damage the immune system.

During the clinical latency stage, the HIV virus continues to reproduce at very low levels although it is still active. If antiretroviral therapy has been started, an individual may live with clinical latency for several decades because treatment helps keep the virus in check. For people who are not on antiretroviral therapy, the clinical latency stage lasts an average of 10 years, but some may progress faster through this stage. During this symptom-free stage people are still able to transmit HIV to others, even if they are on antiretroviral therapy, although antiretroviral therapy greatly reduces the risk of transmission.

If individuals have HIV and are not on ART, their viral load will eventually begin to rise and their CD4 count will begin to decline. As this happens, they may begin to have constitutional symptoms of HIV as the virus levels increase in the body.

AIDS

AIDS is the most advanced stage of HIV infection and is determined by a CD4+ T-lymphocyte count of <200 cells/µL* or a CD4+ percentage of <14% and the appearance of specific conditions or diseases known as “AIDS-defining conditions” (see box below). These measures identify those who are severely immunosuppressed, who are in greatest need of close medical followup, and who are at greatest risk for the full spectrum of severe HIV-related morbidity.

*In someone with a healthy immune system, CD4 counts are between 500 and 1,600 cells/mm3.

In the advanced stage of HIV infection the immune system is already badly damaged and becomes vulnerable to infections and infection-related cancers called opportunistic infections. People are considered to have progressed to AIDS if they develop one or more opportunistic illnesses, regardless of their CD4 count.

Without treatment, people who progress to AIDS typically survive about 3 years. If a dangerous opportunistic illness occurs, life expectancy without treatment falls to about 1 year. However, with antiretroviral therapy and a low viral load, a person may have a near-normal lifespan and will most likely never progress to AIDS.

The natural history of HIV infection has been altered dramatically in developed countries because of antiretroviral medications. In countries where there is no access to these medications, or in cases where people do not become aware of their HIV infection until very late, the disease progresses as described above.

AIDS-Defining Conditions

  • Bacterial infections, recurrent (2 or more episodes in 2 months)
  • Candidiasis of bronchi, trachea, or lungs
  • Candidiasis of esophagus
  • Cervical cancer, invasive, confirmed by biopsy
  • Coccidioidomycosis, disseminated or extrapulmonary
  • Cryptococcosis, extrapulmonary
  • Cryptosporidiosis, chronic intestinal (>1 month’s duration)
  • Cytomegalovirus disease (other than liver, spleen, or nodes)
  • Encephalopathy, HIV-related
  • Herpes simplex: chronic ulcers (>1 month’s duration) or bronchitis, pneumonitis, or esophagitis
  • Histoplasmosis, disseminated or extrapulmonary
  • Isosporiasis, chronic intestinal (>1 month’s duration)
  • Kaposi sarcoma
  • Lymphoma, Burkitt, immunoblastic, or primary central nervous system
  • Mycobacterium avium complex (MAC) or Mycobacterium kansasii, disseminated or extrapulmonary
  • Mycobacterium tuberculosis, pulmonary or extrapulmonary
  • Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
  • Pneumocystis jirovecii ( formerly carinii) pneumonia (PCP)
  • Progressive multifocal leukoencephalopathy (PML)
  • Salmonella septicemia, recurrent (non-typhoid)
  • Toxoplasmosis of brain
  • Wasting syndrome attributed to HIV ((involuntary weight loss >10% of baseline body weight) associated with either chronic diarrhea (two or more loose stools per day for ≥1 month) or chronic weakness and documented fever for ≥1 month)

Source: Bidwell, 2011.

Non AIDS Defining Cancers

Since the introduction of combination antiretroviral therapy, there has been a dramatic decrease in the incidence of AIDS-related morbidity and mortality in HIV-positive patients. However, while the incidence of AIDS-defining cancers has steadily declined, there have been reports of an apparent increase in the number of non AIDS-defining cancers and increases in cancer-related mortality. This apparent increase in incidence may in part simply reflect the normal ageing process in this population (Worm et al., 2013).

Before combination antiretroviral therapy, and in its early stages, the survival of HIV-positive patients diagnosed with cancer was significantly poorer than that of uninfected patients with cancer. These findings may be attributable to more advanced cancer stage and low performance status at cancer diagnosis and other HIV-associated opportunistic diseases among HIV-positive patients as well as the impact of an increased burden of traditional risk factors, such as smoking. There are only limited data on the underlying causes of death in HIV patients with a non AIDS-defining cancer (Worm et al., 2013).

Oral Manifestations

Oral manifestations are common in people with HIV infection and are considered one of its earliest clinical features. By some estimates, more than 90% of AIDS patients will have at least one HIV-related oral manifestation in the course of their disease (KCHFS, 2011).

For some patients, the presence of oral lesions may be the first sign of HIV infection, leading to testing and diagnosis, while for others oral lesions may signify a decline in immune function. Lesions caused by oral candidiasis or hairy leukoplakia in particular are highly suggestive of HIV in patients with no other obvious cause of immunodeficiency (McPhee & Papadakis, 2011). Patients with candidiasis have been shown to have a high rate of progression to AIDS (KCHFS, 2011).

In developed countries, CD4 lymphocyte counts and HIV viral load are the two main laboratory markers that are used to determine disease progression. However, in certain developing countries, people do not always have access to these tests, and severity of the oral lesions can serve as good indicators of disease progression (Krishna et al., 2011).

HIV and Oral Lesions

The EC-Clearinghouse on Oral Problems Related to HIV Infection and the World Health Organization Collaborating Centre on Oral Manifestations of the Immunodeficiency Virus have developed guidelines listing three groupings of oral lesions associated with HIV/AIDS:

Group 1: Lesions strongly associated with HIV infection

  • Candidiasis
  • Hairy leukoplakia
  • Kaposi’s sarcoma
  • Non-Hodgkin’s lymphoma
  • Periodontal disease (linear gingival erythema, necrotizing ulcerative gingivitis, necrotizing ulcerative periodontitis)

Group 2: Lesions less commonly associated with HIV infection

  • Bacterial infections
    • Mycobacterium avium complex (mycobacterium tuberculosis)
    • Melanogic hyperpigmentation
    • Necrotizing (ulcerative) stomatitis
    • Salivary gland disease
    • Dry mouth due to decreased salivary flow
    • Unilateral/bilateral swelling of salivary glands
    • Thrombocytopenia purpura
    • Nonspecific ulcerations
  • Viral infections
    • Herpes simplex virus
    • Human papillomavirus
    • Condyloma acuminatum
    • Focal epithelial hyperplasia
    • Verruca vulgaris
    • Varicella zoster virus

Group 3: Lesions seen in HIV infection

  • Bacterial infections
    • Actinomyces israelii
    • Escherichia coli
    • Klebsiella pneumoniae
    • Cat-scratch disease
    • Drug reactions (ulcerative, erythema multiforme, lichenoid, toxic epidermolysis)
    • Epithelioid (bacillary) angiomatosis
  • Fungal infection other than candidiasis
    • Cryptococcus neoformans
    • Geotrichum candidum
    • Histoplasma capsulatum
    • Mucormycosis (zygomycosis)
    • Aspergillus flavus

Source: Krishna et al., 2011.

Oral Exam

Examination of the oral cavity should be included in both the initial and interim physical examination of all HIV-infected patients. Clinical appearance and symptoms may be nonspecific or atypical. Patients with lesions suspected to be oral manifestations of HIV disease should be referred to a dental health expert with experience in treating oral lesions associated with HIV/AIDS. Other oral lesions may be a sign of a systemic disease, a side effect of medications, or a result of poor oral hygiene (Bidwell, 2011).

Careful diagnostic techniques are required, including laboratory tests for viruses, fungi, and bacteria, and biopsy of lesions. Aggressive treatment is needed because response to treatment can be slow. Relapse and recurrence is common and resistance to treatment must be taken into consideration (KCHFS, 2011).

Transmission and Prevention of HIV

HIV is a relatively fragile virus—it is not easy to “catch”—and it is not spread by casual contact. In order for HIV to be transmitted, three conditions must occur: (1) there must be an HIV source, (2) there must be a sufficient dose of virus, and (3) the virus must have access to the bloodstream, mucous membranes, or broken skin of another person.

HIV can be transmitted through:

  • Sexual contact or needle sharing by a person unaware of their HIV-positive status
  • A mother passing the virus to her baby either before or during birth
  • Unprotected anal, vaginal, and oral intercourse
  • An infected woman breastfeeding her infant
  • Accidental needle stick injuries
  • Infected body fluid coming into contact with the broken skin or mucous membranes of another person
  • A transfusion prior to 1986 of HIV-infected blood or blood products
  • Sharing needles or other injection equipment

In extremely rare cases, HIV can be transmitted by sharing razors or toothbrushes if infected blood from one person was deposited on the toothbrush or razor and the blood were to enter the bloodstream of another person.

In some medical settings, other fluids—such as cerebrospinal, synovial, pleural, pericardial, and amniotic fluid—may be considered infectious if the source is HIV-positive. These fluids are generally not found outside the hospital setting. Sweat, tears, saliva, urine, and feces are not capable of transmitting HIV unless visibly contaminated with blood.

HIV transmission can occur during practices such as tattooing, blood-sharing activities like “blood brother“ rituals, or any other type of ritualistic ceremonies where blood is exchanged or when unsterilized equipment contaminated with blood is shared. HIV transmission may also occur in occupational settings.

Viral load—how much HIV is present in the bloodstream—is one of the most important predictors of the infectiousness of an HIV-positive person. Studies show a clear connection between higher viral load in the blood and increased transmissibility of HIV.

Effective prevention strategies have been identified for all routes of HIV transmission—sexual, bloodborne, and mother-to-child. UNAIDS and the World Health Organization estimate that expanded access to proven prevention strategies could avert half of the 62 million new HIV infections projected to occur worldwide between 2005 and 2015. Since no single strategy provides complete protection or is right for all individuals, a combination of methods is needed to help reduce HIV transmission.

CDC and its partners are currently pursuing a High-Impact Prevention approach to reducing the continued toll of HIV. This approach seeks to use the best mix of proven, cost-effective, and scalable interventions for high-risk populations and areas of the nation. A key element of high-impact prevention is to prioritize funding for areas with the greatest burden of HIV (CDC, 2013b).

Preventing Sexual Transmission

Sexual transmission is responsible for the majority of new HIV infections. Prevention efforts have focused on behavior change programs, condoms, dental dams, HIV counseling and testing, prompt diagnosis and treatment of other sexually transmitted diseases (STDs), and male medical circumcision.

Behavior Change Programs

Behavioral interventions can be highly effective in reducing sexual risk behaviors and associated HIV infections. Studies in high-income countries indicate that a comprehensive risk reduction program is more effective in promoting safe sexual behaviors among young people than interventions that exclusively promote abstinence.

Behavior change programs typically have one or more aims:

  • Encourage young people to remain sexually abstinent.
  • Delay age of initiating sexual activity.
  • Decrease the number of sex partners.
  • Use condoms consistently and correctly if sexually active.

Condoms

Condoms are proven to be effective HIV prevention technologies, and male condoms are widely accepted and easily accessible. Female condoms are far less accepted and accessible, and have remained expensive and highly underfunded (Peters et al., 2013).

Male Condoms

Male latex or polyurethane condoms are highly effective at preventing sexual transmission of HIV. Laboratory studies have demonstrated that latex condoms provide an essentially impermeable barrier to particles the size of HIV.

To achieve maximum protection by using condoms, they must be used consistently and correctly. Inconsistent or nonuse of condoms can lead to infection. Transmission of HIV and other STIs can occur during a single sex act with an infected partner. Incorrect use diminishes the protective effect of condoms by leading to breakage, slippage, or leakage. Incorrect use commonly occurs because of a failure to use condoms throughout the entire sex act, from start of sexual contact to finish (after ejaculation). Consistent use of condoms can reduce an individual’s risk of HIV transmission by as much as 85% (CDC, 2013b).

Female Condoms

The importance of female condoms as a prevention method has been widely recognized. Years of empirical research confirm that female condoms have good acceptability among diverse populations, high rates of efficacy, and numerous advantages for women, men, and young people. Yet, remarkably, investment in female condom procurement and programming has been negligible in comparison to other prevention approaches.

Center for Health and Gender Equality, 2011

 

photo: Reddy brand female condom

Reddy brand female condom. Source: Madhualla at en.Wikipedia.

The female condom is a relatively new product and has not been widely available. This is changing rapidly following the publication of design specifications by the World Health Organization in 2012. Female condoms have a number of essential features that are not found in male condoms:

  1. A sheath that lines the vagina and may extend to cover or partially cover the external genitalia
  2. An external retention feature that prevents the condom from being pushed into the vagina, commonly a ring or frame
  3. An internal retention feature that retains the condom within the vagina and permits safe withdrawal of the penis after use
  4. An insertion feature that facilitates insertion of the condom into the vagina (WHO, 2012b)

 

photo: female condom developed by PATH

Women around the world helped us design the Woman’s Condom. Photo: PATH/Glenn Austin. Used with permission.

In 2009 the U.S. Food and Drug Administration (FDA) approved the Female Condom 2 (FC2), a low-cost female condom. The FC2 is made of polyurethane fitted with larger and smaller rings at each end that help keep it inside the vagina. A soft ring at the closed end of the condom covers the cervix. Because female condoms are made of polyurethane any lubricant can be used without damaging them. Laboratory studies indicate that the female condom is an effective mechanical barrier to viruses, including HIV, and to semen (CDC, 2011).

The female condom is the only female-initiated protection method that protects against HIV, sexually transmitted infections, and unwanted pregnancy at a level equivalent to a male condom. Unfortunately, full integration of the female condom has lagged far behind in HIV prevention efforts. In the United States, studies looking at interventions aimed at high-risk populations frequently omit information and counseling on the female condom, although most studies were targeted to heterosexual risk groups. Formal CDC documents on voluntary counseling and testing do not specifically refer to the female condom as integral to the counseling approach. Adoption of the female condom into routine counseling has been inconsistent and lacking energy and funding (Gollub et al., 2013).

Other female condoms include:

  • Woman’s condom—developed by PATH
  • Cupid female condom—manufactured in India
  • Phoenurse female condom—produced and distributed in China
  • VA wow—manufactured in India
  • Panty condom—manufactured in Columbia

Dental Dams

Dental dams are small squares of latex that were made originally for use in dental procedures. They are now commonly used as barriers when performing oral-vaginal or oral-anal sex, or to protect the mouth from vaginal fluids or menstrual blood that could transmit HIV or other STDs.

STI/HIV Counseling and Testing as Prevention

Counseling directed at a patient’s personal risk, the situations in which risk occurs, and the use of personalized goal-setting strategies are effective STI/HIV prevention tools. One such approach, known as client-centered STI/HIV prevention counseling, involves tailoring a discussion of risk reduction to the patient’s individual situation. Client-centered counseling can increase the likelihood that a patient undertakes or enhances current risk-reduction practices, especially among persons seeking STI care (CDC, 2011b).

Timely testing and diagnosis of HIV infection also promotes HIV prevention. Infected people who are aware of their HIV status often decrease behaviors that can spread HIV. People who are not aware that they are HIV-positive are 3.5 times more likely to transmit HIV than individuals who have knowledge of their HIV-positive status.

CDC’s Expanded Testing Initiative

graphic: testing initiative

One of the key components of the CDC’s high-impact prevention program is expanded HIV testing. The Expanded Testing Initiative helps to identify those who are unaware that they are infected with HIV. Between 2007 and 2010, the program provided nearly 2.8 million HIV tests in 25 of the U.S. areas most affected by HIV, and diagnosed more than 18,000 individuals who were previously unaware that they were HIV-positive (CDC, 2013f).

Prompt Attention to Other Sexually Transmitted Infections

Prompt diagnosis and treatment of sexually transmitted infections (STIs) plays a critical role in efforts to prevent sexual HIV transmission. STIs such as syphilis, gonorrhea, and herpes simplex virus type 2 increase the risk of HIV acquisition and transmission by 2 to 5 times. Prompt diagnosis and treatment reduces the chance of passing on a STI to sexual partners and newborns.

Medical Male Circumcision

In the HIV prevention toolbox of behavioral, biomedical, and structural approaches, voluntary medical male circumcision is an essential tool in all high-HIV-prevalence, predominantly heterosexual epidemic settings. It provides lifelong partial protection for men against HIV infection and reduces their likelihood of genital ulcers, syphilis, and penile cancer. Observational data and ecologic studies have suggested for decades that male circumcision provides a level of protection from HIV infection for men. Three randomized controlled trials conducted in the last decade found a 57% protective effect against HIV for men who became circumcised (Hankins et al., 2011).

Male circumcision is an old and common surgical procedure. With 30% of men globally and 67% of men in sub-Saharan Africa circumcised, social and cultural factors are the main determinants of acceptability. In sub-Saharan Africa, male circumcision was found to be acceptable to men and women in non-circumcising communities if readily accessible and provided safely. Medical male circumcision is highly cost-effective, with costs to avert one HIV infection ranging from US$ 150 to US$ 900 using a 10-year time horizon, and 1 new HIV infection averted for every 5–15 procedures performed (Hankins et al., 2011).

Preventing Bloodborne Transmission

Exposure to HIV-infected blood is the most efficient route of HIV transmission, whether through injection drug use, tainted blood, or an occupational exposure. A number of strategies have been used to reduce the transmission of HIV via blood. These include harm reduction programs for injection drug users, securing the safety of the blood supply, and strengthening infection prevention programs in healthcare settings.

Harm Reduction Programs for Injection Drug Users

Harm reduction is an approach to community health that seeks to reduce the adverse consequences of unhealthy behaviors. In the context of drug use and HIV, harm reduction attempts to reduce the risk of becoming infected with HIV or another sexually transmitted infection. A harm reduction perspective is pragmatic and should be based on the best available evidence. Reducing HIV transmission among people who continue to inject drugs may be the clearest example of reducing a serious adverse consequence of drug use without necessarily reducing the drug use itself (Des Jarlais et al., 2013).

Harm reduction for injection drug users involves a package of services, including access to clean syringes and injection equipment, substitution drug treatment therapy, counseling, HIV and other health services, and evidence-based programs to reduce demand for drugs. The first syringe exchange program was established in The Netherlands in 1984 and was quickly expanded when HIV infection was noted among persons who inject drugs. The United Kingdom soon followed and implemented a national syringe exchange program. Australia was also quick to implement national syringe exchange programs for individuals who inject drugs (Des Jarlais et al., 2013).

In the United States, there has been strong opposition to needle-exchange programs dating back to the 1980s despite extensive evidence demonstrating that harm reduction programs reduce the risk of HIV transmission without contributing to an increase in drug use. This is related to the politics of illegal drug use and the belief that providing clean syringes to injection drug users might “encourage” drug use.

Addressing this issue is of prime importance because HIV can spread rapidly among injection drug users. Conversely, large-scale implementation of HIV prevention programs, particularly needle/syringe access programs, when HIV prevalence is very low in a population of injection drug users can keep the prevalence low (under 5%) indefinitely (Des Jarlais et al., 2013).

Very large declines in HIV incidence have been observed after large-scale implementation of evidence-based prevention programs, particularly when multiple prevention programs (needle/syringe programs, substance use treatment programs, HIV testing, and antiretroviral treatment) are implemented simultaneously (Des Jarlais et al., 2013).

Blood Supply Safety

HIV is very diverse and new strains continue to emerge and spread rapidly worldwide. Newly developed tests for screening the blood supply for HIV must accurately detect all the existing and emerging strains of the virus in blood samples. Although testing for HIV has reduced the risk of transmitting the virus through donated blood, there are still three challenges to keeping the blood supply safe:

  • Existing tests are performed only on plasma, while many agents are found mostly in blood cells.
  • Testing requires large volumes and labor intensive instrumentation.
  • Existing tests cannot readily be modified to detect simultaneously the increasing number of infectious agents that pose new threats to the blood supply. (FDA, 2013)

Screening of a country’s blood supply is critical: receiving one or more units of HIV-infected blood results in HIV infection nearly 90% of the time. In developed countries, routine screening of the blood supply, combined with efforts to reduce unnecessary transfusions and to preclude high-risk donors, has virtually eliminated the risk of HIV transmission through donated blood. In the United States, blood donations have been screened for HIV antibodies since 1985 and for the p24 antigen since 1996.

Infection Prevention in Healthcare Settings

HIV transmission has become extremely rare in healthcare settings that follow Standard Precautions, which, when properly implemented, protect patients and healthcare workers from many bacterial and viral infections, including bloodborne pathogens. Standard Precautions tell us to avoid contact with:

  • Blood and all body fluids from all patients. Any body fluid may carry microorganisms.
  • Mucous membranes
  • Non-intact skin (abrasions, dermatitis, rash)

Employers are required to have a written exposure control plan (ECP) to eliminate or minimize employee exposures to bloodborne pathogens. The plan must be updated annually to reflect technological changes that help eliminate or reduce exposure. In the plan, employers must include information about the infection control system and infection prevention techniques used in the workplace. It should contain annual documentation of consideration and implementation of appropriate, commercially available safer medical devices designed to eliminate or minimize occupational exposure. Employers must also document that they have asked for input from frontline workers in identifying, evaluating, and selecting engineering controls.

Preventing Mother-to-Child Transmission

HIV transmission from mother to child during pregnancy, labor and delivery, or breastfeeding is known as perinatal transmission and is the most common route of HIV infection in children. When HIV is diagnosed before or during pregnancy, perinatal transmission can be reduced to less than 1% if appropriate medical treatment is given, the virus becomes undetectable, and breastfeeding is avoided. Since the mid-1990s, HIV testing and preventive interventions have resulted in more than a 90% decline in the number of children perinatally infected with HIV in the United States (CDC, 2014b). From 2001 to 2012, there was a 52% decline in new HIV infections among children. Expanded access to services to prevent mother-to-child transmission prevented more than 670,000 children from acquiring HIV from 2009 to 2012 (UNAIDS, 2013a).

An estimated 260,000 children became infected with HIV in 2012, with the vast majority contracting HIV during gestation or birth or as a result of breastfeeding. It is now estimated that half of all new episodes of HIV transmission to children occur during the breastfeeding period when the majority of lactating women are not receiving the prophylaxis necessary to prevent HIV transmission (UNAIDS, 2013a).

Continuing expansion of the HIV/AIDS pandemic among women has been recognized as an exceptional challenge to global maternal health. Each year, about 1.5 million women living with HIV become pregnant and deliver. About 90% of these women live in sub-Saharan Africa, where comprehensive health services and HIV medication regimens are limited (Ngemu et al., 2014).

In the absence of interventions, the HIV-infected mother has a 15% to 45% chance of transmitting the virus to her newborn during her pregnancy or birth, or via breast milk. A worrying trend indicates that 90% of new infections in children are due to mother-to-child transmission. In 2011 around 330,000 children under the age of 15 living in sub-Saharan Africa became infected with HIV via the mother-to-child transmission pathway. Thus prevention of mother-to-child transmission is critical in curbing the spread of new HIV infections (Ngemu et al., 2014).

Antiretroviral Drugs

In prevention of mother-to-child transmission, antiretroviral drugs (known as highly active antiretroviral therapy, or HAART) that decouple links between childbirth and HIV transmission are adopted. The use of multiple drugs, often referred to as a “cocktail,” serve as powerful defenses against the ways in which the HIV virus attacks the human body. Although these drugs are not able to rid the body of HIV, they can significantly delay the onset of AIDS and potentially slow down the replication of HIV, lowering the viral load in the mother’s body and hence reducing the chances of HIV transmission (Ngemu et al., 2014).

The current World Health Organization (WHO) recommended regimen is as follows:

  • Where the pregnant woman does not yet need to start antiretroviral therapy for therapeutic reasons, she should start Zidovudine (AZT) from 28 weeks or as soon as possible thereafter, be provided with single-dose Nevirapine when entering labor, and be given AZT + 3TC for 1 week following delivery.
  • Meanwhile, whether the mother was on the above or standard ART, the child should be given a single dose of NVP immediately after delivery and daily AZT until 1 week old.

Complementary measures that may also be used include cesarean section and formula feeding; in some settings, the combination of all these measures has been used with variable success. However, HAART is still often described as having miraculous effects. Not surprisingly, proponents of these drugs are less anxious to discuss the times when the drugs simply do not seem to do what they are supposed to in terms of effectiveness (Ngemu et al., 2014).

Breastfeeding Alternatives

The transmission of HIV through breastfeeding was first identified in 1985 and since then the issue of breastfeeding within the context of HIV and prevention of mother-to-child transmission has continued to be at the center of much debate and policy. The World Health Organization (WHO) recommends that all mothers, regardless of their HIV status, practice exclusive breastfeeding for the first 6 months of an infant’s life (Vallely et al., 2013).

In the absence antiretroviral therapy the risk of mother-to-child transmission of HIV through breastfeeding is between 20% and 45%. However, with the use of antiretroviral therapy by the mother this risk can be reduced to less than 5%, even among infants who are breastfed, because antiretroviral therapy reduces the HIV viral load in the mother’s milk.

While breastfeeding is associated with risk of transmission of HIV, exclusive breastfeeding for the first 6 months is associated with a lower risk of HIV transmission when compared to mixed feeding, even without antiretroviral therapy. The risk of infants acquiring HIV through breastfeeding, therefore, needs to be weighed against the increased risk of death from causes other than HIV, in particular malnutrition and serious illnesses such as diarrhea, among non-breastfed infants (Vallely et al., 2013).

Cesarean Delivery

A scheduled cesarean delivery at 38 weeks to prevent mother-to-child transmission of HIV is recommended in the following situations:

  • When a woman has a viral load greater than 1,000 copies/mL near delivery
  • When a woman’s viral load is unknown (CDC, 2013d)

In these situations, a woman with HIV should have a scheduled cesarean delivery even if she took HIV medication during pregnancy. The cesarean delivery should be performed before a woman goes into labor and before her water breaks. Once a woman goes into labor or her water breaks, a cesarean delivery may no longer prevent mother-to-child transmission of HIV. In this situation, the decision whether to deliver the baby by cesarean section is based on medical reasons and not to prevent mother-to-child transmission of HIV (CDC, 2013d).

The risk of mother-to-child transmission of HIV is low for women who take HIV medications during pregnancy and have a viral load less than 1,000 copies/mL near the time of delivery. In this situation, a woman with HIV should have a vaginal delivery unless there are other medical reasons for a cesarean delivery (CDC, 2013d).

HIV Testing

The first HIV antibody test was available in 1985. Since then, new antibody tests have been developed and approved by the Food and Drug Administration (FDA). These tests do not detect the presence of the HIV virus itself but detect the body’s reaction to the virus: the presence of antibodies to HIV. Currently, these antibody tests consist of two steps, a screening test and—when the screening test is reactive (positive)—a confirmatory test.

A positive test result means a person is HIV-positive and can infect others who come in contact with his or her blood, semen, or vaginal fluids. A negative result means there are no antibodies to HIV in the blood at the time of the test. A negative test does not mean a person is HIV-negative—he or she may be infected but not yet have detectable antibodies in the blood.

General Testing Recommendations

The U.S Preventative Services Task Force (USPSTF) recommends that clinicians screen for HIV infection in all adolescents and adults ages 15 to 65 years regardless of risk. Gay and bisexual men—and others at high risk—should get tested at least once a year. Younger adolescents and older adults who are at increased risk should also be screened. The Task Force also recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown (USPSTF, 2013).

HIV screening is recommended for all persons who seek evaluation and treatment for STIs. Testing must be voluntary and free from coercion—patients must not be tested without their knowledge. With notification of the patient that an HIV test will be performed, HIV screening is recommended in all healthcare settings. Specific signed consent for HIV testing should not be required. In most settings, general informed consent for medical care is considered sufficient to encompass informed consent for HIV testing (MMWR, 2010).

Use of rapid HIV tests should be considered, especially in clinics where a high proportion of patients do not return for HIV test results. Positive screening tests for HIV antibody must be confirmed by a supplemental test before the diagnosis of HIV infection can be established (MMWR, 2010).

Screening and Confirmation

In most cases the first test done is a sensitive screening test called an enzyme linked immunosorbent assay (ELISA, or EIA). This type of test, using blood, oral fluid, or urine, screens for the presence of antibodies to HIV, which the body starts producing between 2 and 12 weeks after becoming infected. The ELISA test can produce a result in as little as 3.5 hours but most HIV antibody screening tests are sent to a laboratory and tested in batches—a process that can take 1 to 2 weeks. The CDC recommends that laboratories retest all reactive (positive) ELISA tests.

If the screening test is reactive at the laboratory, a confirmatory test called the Western Blot is conducted on the same sample. The Western Blot is only used if the ELISA or rapid test is positive. A few labs use a faster confirmatory test called the indirect immunofluorescence assay (IFA), which also tests for the presence of antibodies in the blood.

Rapid Tests During Routine Office Visits

Because many people who are tested for HIV either wait until late in the course of their infection to be tested or fail to return to get the results of their test, the CDC recommends offering HIV testing as part of a routine office visit. Rapid tests were developed to accomplish this goal. Rapid HIV testing is recommended for use in settings in which the availability of rapid test results can influence medical care immediately, or as a routine screening tool in settings where HIV prevalence is high or the client is unlikely to return for the results of HIV tests (Bidwell, 2011).

Rapid tests are most commonly performed on a sample from the oral mucosa and have an accuracy rate exceeding 99%. They can be conducted onsite (often with the client present) and negative results can be made available in under an hour. A positive rapid test is considered to be preliminary until a confirmatory test verifies the result.

Kentucky law allows a patient to be informed of a rapid-test positive result while awaiting confirmatory tests. Counseling must be provided regarding the meaning of the test, the importance of confirmatory testing, and the importance of precautions to protect others. A patient may also be informed of a rapid-test positive result “in special cases where immediate actions may be necessary to protect a patient, such as potential perinatal transmission or incidents warranting post exposure prophylaxis.”

Opt-Out Testing Recommendations

HIV screening is done after notifying the patient that the test will be performed. Patients may elect to decline or defer the test, or opt out; if they don’t, their consent is assumed.

The goals of opt-out testing are to:

  • Increase HIV screening of patients, including pregnant women.
  • Foster earlier detection of HIV infection.
  • Identify and counsel persons with unrecognized HIV infection and link them to clinical and prevention services.
  • Reduce perinatal transmission of HIV.

Opt-out testing does not mean patients must take an HIV test; in general, a patient has the right to refuse an HIV test. (Exceptions include blood and organ donors, military applicants and active duty personnel, federal and state prison inmates under certain circumstances, newborns in some states, and immigrants.)

Under Kentucky law (2011):

  • HIV testing is included in general medical consent.
  • Post-test counseling is required with HIV positive test results.
  • Testing must be available anonymously.
  • Anonymous testing is available at designated anonymous testing sites.
  • A confirmatory test is required before notifying the patient of HIV test results.
  • Minors may consent to STD testing and treatment, HIV is not explicitly included. (NCCC, 2014)

For pregnant women, CDC recommends:

  • Universal opt-out HIV testing for all pregnant women early in every pregnancy
  • A second test in the third trimester in certain geographic areas or for women who are known to be at high risk of becoming infected (e.g., injection-drug users and their sex partners, women who exchange sex for money or drugs, women who are sex partners of HIV-infected persons, and women who have had a new or more than one sex partner during this pregnancy)
  • Rapid HIV testing at labor and delivery for women without a prenatal test result
  • Exploration of reasons that women decline testing (CDC, 2014c)

Point-of-Care CD4 Testing Devices

Loss of care prior to the start of antiretroviral therapy are of great concern for those individuals in clinical need of antiretroviral therapy. Reasons reported for loss of care vary and include long waiting times at clinics, concerns about the side effects of drug treatment, lack of CD4 testing, and delays in receiving CD4 results. The development of rapid testing devices that can simultaneously screen and confirm the presence of HIV is expected to reduce these gaps in the plan of care for a person who is newly HIV-positive (Wynberg et al., 2014).

One such device screens for anti-HIV antibodies and can then confirm the presence of the virus by detecting an HIV-specific RNA target. This combination of a diagnostic screening with a confirmatory test allows immediate initiation of therapy and counseling and removes the need for the patient to return to the testing facility for either subsequent testing or a final test result. In addition, for populations at high risk for HIV infection, it decreases the window between infection and seroconversion, which is a relatively short period when viral loads are highest and transmission (infection of others) is most likely (Chen et al., 2013).

Partner Counseling and Referral Services (PCRS)

Partner Counseling and Referral Services (PCRS) have long been an important method for providing comprehensive HIV prevention and treatment services. The CDC recently issued guidelines for Partner Services programs which update the 1998 HIV Partner Counseling and Referral Services Guidance (Song et al., 2012).

Traditionally, PCRS is conducted by trained disease intervention specialists from state or local health departments. As part of service, HIV-infected persons are interviewed and asked to provide information about their sexual or needle-sharing partners. Partners are then located, notified of their potential exposure to HIV, counseled, and offered HIV testing. This approach effectively reaches a population with high HIV prevalence and has been shown to be cost-effective in preventing HIV transmission in the United States (Song et al., 2012).

Recently, novel approaches have been used in an attempt to increase numbers of people who accept PCRS. An enhanced approach, using HIV counselors from community-based organizations in addition to disease intervention specialists, has been demonstrated to be effective and, more recently, the Internet has increasingly been used for partner notification. In practice, the success of partner notification depends on whether HIV-infected individuals are willing to provide information about their partners, the content of the information that they provide, and how they choose to inform their partners that they have been exposed to HIV (Song et al., 2012).

Four referral approaches have been used to notify partners of HIV-infected individuals about their potential exposures to HIV:

  1. Self-referral (the HIV-infected individuals agree to notify their partners by themselves).
  2. Provider referral (the HIV-infected individuals agree to let disease intervention specialists or healthcare providers notify their partners).
  3. Dual referral (the HIV-infected individuals agree to notify their partners with a disease intervention specialist or healthcare provider present).
  4. Contract referral (the HIV-infected individuals agree to notify their partners within a certain timeframe, and if the notification is not completed within that timeframe, disease intervention specialists or providers notify them). (Song et al., 2012)

Most studies on partner notification have been focused on the assessment of provider referral or self-referral approaches. These studies have shown that the HIV-infected person, particularly men who have sex with men (MSM) and injection drug users, prefer the self-referral approach. However, several systematic reviews of referral strategies have indicated that provider referral, rather than self-referral, may be the most effective means of ensuring successful partner notification (Song et al., 2012).

HIV Counseling and Testing Sites, Kentucky

All state-sponsored testing sites in Kentucky offer free or minimal-cost anonymous or confidential HIV testing. A rapid test called the Ora-Quick test is a type of screening test that provides results within 20 minutes. Several agencies working in association with the Kentucky HIV Prevention Program are currently using rapid testing. Other agencies are being encouraged to begin using rapid testing. To find a testing site near you go to www.hivtest.CDC.gov.

Evaluation and Clinical Management of HIV

Suppression of HIV plasma viral load reduces HIV-related morbidity and mortality and can prevent onward transmission of HIV. However, less than 30% of individuals living with HIV in the United States have a suppressed viral load. Viral suppression is the outcome of sequential steps in the continuum of care, including diagnosis, linkage and retention in HIV care, and antiretroviral treatment prescription and adherence (Hall et al., 2013).

Entry to Care

Every HIV-infected patient entering into care should have a complete medical history, physical examination, and laboratory evaluation and should be counseled regarding the implications of HIV infection. The goals of the initial evaluation are to confirm the diagnosis of HIV infection, obtain appropriate baseline historical and laboratory data, ensure patient understanding about HIV infection and its transmission, and to initiate care as recommended in HIV primary care guidelines and guidelines for prevention and treatment of HIV-associated opportunistic infections (AIDSInfo, 2013).

The initial evaluation also should include introductory discussion on the benefits of antiretroviral therapy. Baseline information then can be used to define management goals and plans. In the case of previously treated patients who present for an initial evaluation with a new healthcare provider, it is critical to obtain a complete antiretroviral history (including drug resistance testing results, if available), preferably through the review of past medical records. Newly diagnosed patients should also be asked about any prior use of antiretroviral agents for prevention of HIV infection (AIDSInfo, 2013).

A number of laboratory tests are important for initial evaluation of HIV-infected patients upon entry into care, during followup (if antiretroviral therapy has not been initiated), and before and after the initiation or modification of therapy to assess virologic and immunologic efficacy of antiretroviral therapy and to monitor for laboratory abnormalities that may be associated with antiretroviral drugs (AIDSInfo, 2013).

The following laboratory tests performed during initial patient visits can be used to stage HIV disease and to assist in the selection of antiretroviral drug regimens:

  • HIV antibody testing (if prior documentation is not available or if HIV RNA is below the assay’s limit of detection)
  • CD4 T-cell count (CD4 count)
  • Plasma HIV RNA (viral load)
  • Complete blood count, chemistry profile, transaminase levels, blood urea nitrogen (BUN), and creatinine, urinalysis, and serologies for hepatitis A, B, and C viruses
  • Fasting blood glucose and serum lipids
  • Genotypic resistance testing at entry into care, regardless of whether ART will be initiated immediately (AII). For patients who have HIV RNA levels <500 to 1,000 copies/mL, viral amplification for resistance testing may not always be successful (AIDSInfo, 2013)

A complete list of recommendations for the frequency of testing can be found at this source.

Antiretroviral Therapy (ART)

Antiretroviral therapy for the treatment of HIV infection has improved steadily since the advent of potent combination therapy in 1996. New drugs that offer new mechanisms of action; improvements in potency and activity, even against multidrug-resistant viruses; dosing convenience; and tolerability have been approved. Antiretroviral therapy has dramatically reduced HIV-associated morbidity and mortality and has transformed HIV disease into a chronic, manageable condition (AIDSInfo, 2013).

Effective treatment of HIV-infected individuals with antiretroviral therapy is highly effective at preventing transmission to sexual partners. However, less than one-third of HIV-infected individuals in the United States have suppressed viral loads, which is mostly a result of undiagnosed HIV infection and failure to link or retain diagnosed patients in care. Despite remarkable improvements in HIV treatment and prevention, economic and social barriers that result in continuing morbidity and mortality, as well as new HIV infections, persist (AIDSInfo, 2013).

Before 1996 there were three medications available to treat HIV—they were used individually and were of limited benefit. Researchers soon discovered that using these medications in combination, along with new medications (either protease inhibitors or non-nucleoside reverse transcriptase inhibitors) dramatically reduced the amount of HIV (viral load) in the bloodstream of the infected person. When used in combination, each drug targets a separate part of the HIV virus and its replication.

The reduction of deaths from AIDS in the United States has been primarily attributed to this combination therapy, called highly active antiretroviral therapy (HAART). The drugs currently approved for clinical use by the U.S. Food and Drug Administration and used to treat HIV infection belong to six distinct classes. Each of these drug classes act at different steps in the HIV replication cycle:

  1. Nucleoside and nucleotide reverse transcriptase inhibitors (NRTIs)
  2. Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
  3. Protease inhibitors (PIs)
  4. Fusion inhibitor (FI)
  5. CC chemokine receptor 5 (CCR5) antagonist
  6. Integrase inhibitors (INIs) (Santoro & Perno, 2013)

Despite these tremendous advances in HIV management there remain several important complications related to antiretroviral drug use, one of the most notable being drug-related adverse events and toxicities , which can negatively impact patients’ quality of life, contributing to non-adherence and drug resistance and ultimately effectiveness. Adverse drug reactions to antiretrovirals are a major reason for discontinuing or changing therapy. Furthermore, these drug-related complications can significantly contribute to morbidity, hospitalizations, and mortality in this population (Loutfy et al., 2013).

Antiretroviral drug design, resistance research, and interpretation systems have been largely based on HIV-1 subtype B because of its predominance in the wealthy countries in which antiretroviral drugs were first introduced. However, HIV-1 B subtype represents only about 10% of the overall subtypes in the world. The extreme variability and the high evolution rate of HIV-1 favor the development of antiretroviral resistance (Santoro & Perno, 2013).

Continuum of Care

Continuum of care in HIV care is a framework for understanding the status of HIV care and treatment. The continuum of care includes diagnosis, linkage and retention in HIV care, and antiretroviral treatment (ART) prescription and adherence. Among those diagnosed with HIV in the United States, an estimated 1 in 5 are not promptly linked to care and less than half are in regular HIV care (Hall et al., 2013).

Studies have shown that individuals who enter care soon after diagnosis and maintain regular care initiate antiretroviral therapy earlier, have better adherence to ART, and have better health outcomes. In addition, adherence to clinic visits was associated with earlier viral suppression and lower cumulative viral load burden (Hall et al., 2013).

Health Status of HIV-Positive Individuals, United States, 2012

health status chart

Only 25 percent of people living with HIV in the United States have achieved viral suppression. Three out of four people living with HIV in the United States have not been successfully supported in navigating the entire HIV care continuum. Source: CDC, 2012.

Recently, President Barack Obama signed into law the HIV Care Continuum Initiative, which focuses on accelerating federal efforts to increase HIV testing, care, and treatment. CDC and its partners are seeking to advance the goals of the National HIV/AIDS Strategy and maximize the effectiveness of current HIV prevention and care methods. Testing is a critical first step of entry into the HIV continuum of care (MMWR, 2014b).

To reduce the impact of HIV in the United States, improvements are needed at each stage of the process—with particular efforts to reduce disparities by race and age. HIV testing is a first critical step in HIV prevention, and the only way to identify the more than 200,000 Americans with HIV who do not know they are infected. In addition, ensuring that people have access to care, stay in care, and remain on treatment will increase the proportion of HIV-infected individuals who achieve and maintain viral suppression, which is critical to improve health and realize the full potential prevention benefits of treatment (CDC, 2012).

Women and Antiretroviral Therapy

Women constitute one of the fastest-rising population groups at risk for infection with HIV, representing over 50% of cases worldwide, and approximately 25% of new cases in the United States and 28% of new cases in Canada. Surprisingly, little is known about the efficacy and toxicity of various antiretroviral drugs in women compared to men. This gap in knowledge is a result of the initial exclusion and continued under-representation of women in antiretroviral clinical trials. This circumstance has slowly started to change, and there are now more longitudinal studies examining women-specific issues (Loutfy et al., 2013).

Many studies in the general population have shown that adverse events are more common in women than in men. In the HIV-infected population, higher incidence rates of increased systemic symptoms (eg, nausea, vomiting, diarrhea), as well as organ toxicity (including anemia, hepatotoxicity, pancreatitis, lactic acidosis, peripheral neuropathy, and notable lipodystrophy), have been observed in women compared to men. For nevirapine, female gender and higher CD4+ cell counts were risk factors for fatal hepatitis, and this observation has led regulatory authorities to release warnings on its use in certain female populations (Loutfy et al., 2013).

For more information please visit www.AIDSinfo.NIH.gov for Adult, Adolescent, Pediatric, and Perinatal Guidelines, which include detailed information about current antiretroviral therapies for the treatment of HIV infection.

Occupational Exposures

An occupational exposure is defined as a reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials (OPIM) that may result from the performance of an employee’s duties (OSHA, 2013).

Since 1991, when OSHA first issued its Bloodborne Pathogens Standard to protect healthcare personnel from occupational exposure, the focus of regulatory and legislative activity has been on implementing a hierarchy of prevention and control measures. This approach treats every patient as potentially infectious, requires workers to wear protective gear, and trains workers to use syringes properly and sterilize all equipment and surfaces.

Employers are required to create and implement a written exposure control plan (ECP) specific to each workplace setting to eliminate or minimize employee exposures. The plan must be updated annually to reflect technological changes that help eliminate or reduce exposure to bloodborne pathogens. In the plan, employers must include information about the infection control system used in the workplace (OSHA, 2013).

The ECP should contain annual documentation of consideration and implementation of appropriate, commercially available safer medical devices designed to eliminate or minimize occupational exposures. Employers must also document that they have solicited input from non-managerial workers in identifying, evaluating, and selecting engineering controls. The ECP must be available to workers. You may legally ask your employer how you can review it (OSHA, 2013).

The exposure control plan should also include a written exposure determination that includes those job classifications and positions in which employees have the potential for occupational exposures. The exposure determination should be made without taking into consideration the use of personal protective clothing or equipment. Employees who are required or expected to administer first aid must be included (OSHA, 2013).

Standard Precautions

Workplaces are required to adhere to Standard Precautions to prevent occupational exposures to blood and OPIM. If any worker reasonably expects to have contact with blood or body fluids on the job, this law applies to their workplace.

Standard Precautions

Standard Precautions treats all body fluids, except sweat, as potentially infectious and involves the use of protective barriers and safe sharps handling to reduce the risk of exposure to blood and to prevent injuries caused by needles, scalpels, and other sharp instruments or devices.

Correct Use of Standard Precautions

Always

  • Use good hand hygiene.
  • Use gloves for contact with blood, body fluids, non-intact skin (including rash), mucous membranes, used equipment, linen, and trash.
  • Use a gown any time your clothing may become soiled and if a patient has uncontained body substances.
  • Use a mask and eye protection if you may be splashed. OSHA-compliant eye protection must have solid side shields.
  • Change gloves if they become heavily soiled or if you must go from a dirtier area to a cleaner one.

Never

  • Wear artificial fingernails—check your facility’s policy for details.
  • Touch a second patient with the same pair of gloves.
  • Reuse gowns, even for repeated contacts with the same patient.
  • Contaminate the environment with dirty gloves.
  • Wear gloves in the hall unless you can say why you are wearing them.

Bloodborne Pathogens

Bloodborne pathogens are infectious organisms in blood and other body fluids that can cause chronic and life-threatening disease in humans. The bloodborne pathogens of most concern are hepatitis B, hepatitis C, and HIV. Bloodborne exposures can occur when an infectious organism enters the body via a portal of entry such as a cut, dermatitis, or exposure of a mucous membrane. Intact skin is a good barrier against exposures.

The risk of HIV infection to a healthcare worker through a needlestick is less than 1%. The risks of HIV infection though splashes of blood to the eyes, nose, or mouth is even smaller—approximately 1 in 1,000. There have been no reports of HIV transmission from blood contact with intact skin. There is a theoretical risk of blood contact to an area of skin that is damaged, or from a large area of skin covered in blood for a long period of time.

The transmission of bloodborne pathogens can be minimized and even prevented through the use of safer techniques and personal protective equipment. This includes not recapping needles by hand, disposing of used needles in appropriate sharps disposal containers, and using medical devices with safety features designed to prevent injuries. Using appropriate barriers such as gloves, eye and face protection, or gowns when contact with blood is expected can prevent many exposures to the eyes, nose, mouth, or skin. Bloodborne pathogens can be present in both blood and other potentially infectious material (OPIM).

Blood and OPIM That Can Contain Bloodborne Pathogens

  • Human body fluids
  • Semen
  • Vaginal secretions
  • Cerebrospinal fluid, synovial fluid
  • Pleural fluid, pericardial fluid
  • Peritoneal fluid
  • Amniotic fluid
  • Saliva in dental procedures
  • Body fluid visibly contaminated with blood
  • Body fluids in situations where it is difficult or impossible to differentiate between type of body fluids
  • Any unfixed tissue or organ (other than intact skin) from a human (living or dead)
  • HIV-containing cell or tissue cultures, organ cultures
  • HIV- or hepatitis B-containing culture medium or other solutions
  • Blood, organs, or other tissues from experimental animals infected with HIV or hepatitis B

Personal Protective Equipment

Personal protective equipment (PPE) is specialized clothing or equipment worn by an employee for protection against hazards that remain after engineering controls and work practice controls are in place and, as such, is not the first line of defense. Nevertheless, the employer must provide PPE and ensure that the employee uses it, and must clean, repair, and replace this equipment as needed.

General work clothes such as uniforms, pants, shirts, or blouses are not intended to function as protection against a hazard and are not considered to be personal protective equipment. Lab coats and scrubs are generally considered personal clothing. When contamination is reasonably likely, protective gowns should be worn. If lab coats or scrubs are worn as PPE they must be removed as soon as practical and laundered by the employer.

A worker must decide when to wear PPE and if exposure is likely. This is usually easy to determine:

If it is wet and not yours, stay out of it!

If exposure seems reasonably likely, you have the right to protect yourself with PPE. Wearing basic PPE is not optional.

Gloves

Gloves are a type of PPE and should be worn when:

  • It can reasonably be anticipated that the employee may have hand contact with blood, other potentially infectious material, mucous membranes, and non-intact skin
  • Performing all vascular access procedures or procedures involving uncontained blood, such as finger or heel sticks (CDC, 2013e)

Gloves must be changed between patients. Single-use gloves cannot be washed or decontaminated for reuse. Utility gloves may be decontaminated if they are not compromised. They should be replaced when they show signs of cracking, peeling, tearing, puncturing, or deteriorating.

Most gloves in the healthcare workplace are made of latex, although some workers are allergic to latex. In most circumstances, nitrile or other glove alternatives may be used in place of latex gloves. Employers are required to provide non-latex alternatives to employees with sensitivities to latex and other materials.

Hand Hygiene

Hand hygiene is the single most important procedure for preventing the spread of infections. Hand hygiene (soap-and-water washing or a waterless alcohol-based hand rub) must be performed:

  • After removal of gloves or other protective equipment
  • Immediately after hand contact with blood or other infectious materials
  • Upon leaving the work area

Hand hygiene should be performed before and after patient contact and after using restroom facilities. Soap-and-water hand washing must be performed whenever hands are visibly contaminated or there is a reasonable likelihood of contamination. It is advisable to keep fingernails short and to wear minimal jewelry.

Needlesticks and Sharps Disposal

The OSHA Bloodborne Pathogens Standard was amended in 2001 to add the provisions of the Needlestick Safety and Prevention Act of 2001. Since then, safety syringes are required for use whenever possible in healthcare facilities. This legislation mandates that institutions conduct annual product reviews of sharps safety devices and that non-managerial employees must be involved in the decision-making process (OSHA, 2013).

Needlesticks and other sharps injuries carry extra risk of exposure to infectious organisms because they bypass the protection of intact skin. The best way to prevent cuts and sticks is to minimize contact with sharps. That means:

  • Not using a sharp when an alternative method is available
  • Activating safety sharps immediately following completion of use
  • Disposing of used sharps immediately

Recapping, bending, or removing needles should not be done unless there is no feasible alternative or if required for a specific medical procedure. If recapping, bending, or removal is necessary, workers must use either a mechanical device or a one-handed technique. If recapping is required, a one-handed “scoop” technique may be used, using the needle itself to pick up the cap, pushing cap and sharp together against a hard surface to ensure a tight fit.

Puncture-resistant containers must be available nearby to hold contaminated sharps. When reusable sharps must be used, puncture-resistant transport containers must not require employees to reach a hand into the holding container.

Management of Occupational Exposures

The OSHA Bloodborne Pathogens Standard requires employers whose employees may have exposure to body fluids on the job to have a system in place for managing occupational exposures. This system must be available without delay, 24 hours per day, 7 days per week.

Employers must provide free medical evaluation and treatment to employees who experience an exposure incident. A licensed healthcare provider must evaluate the exposure and advise on how to prevent further spread of any potential infection. If known, the source patient’s blood will be tested for hepatitis B, hepatitis C, and HIV, with appropriate consent.

Sharps Injuries

If a sharps injury occurs, wash the exposed area with soap and water—do not “milk” or squeeze the wound. There is no evidence that using antiseptics (eg, hydrogen peroxide) reduces the risk of transmission for any bloodborne pathogens; however, the use of antiseptics is not contraindicated. In the event that the wound needs suturing, obtain emergency treatment.

Bite or Scratch Wounds

Exposure to saliva is not considered a substantial risk unless it is visibly contaminated with blood or the saliva is from a dental procedure. If you are exposed to saliva, wash the area with soap and water and cover it with a sterile dressing as appropriate. All bites should be evaluated. For human bites, the clinical evaluation must include the possibility that both the person bitten and the person who inflicted the bite were exposed to bloodborne pathogens.

Exposure to Urine, Vomitus, Feces, or Sputum

Exposure to urine, feces, vomitus, or sputum is not considered a potential bloodborne pathogens exposure unless the fluid is visibly contaminated with blood. Follow your employer’s procedures for cleaning up these fluids.

Reporting an Exposure

The OSHA Bloodborne Pathogens Standard requires medical followup for workers who have an exposure incident. Exposures should be reported within 1 hour if possible to allow for prompt intervention to reduce risk of infection if that is indicated.

If an exposure occurs, follow the protocol of your employer. After cleansing the exposed area, report the exposure to the department or individual at your workplace who is responsible for managing exposure. Obtain a medical evaluation as soon as possible and determine the extent of the exposure, treatment, followup care, personal prevention measures, need for a tetanus shot, and other care.

Your employer is required to provide an appropriate post exposure management referral at no cost to you. Your employer must also provide the following information to the evaluating healthcare professional:

  • A description of the job duties the exposed employee was performing when exposed
  • Documentation of the routes of exposure and circumstances under which exposure occurred
  • Results of the source person’s blood testing, if available
  • All medical records that the employer is responsible to maintain, including vaccination status, relevant to the appropriate treatment of the employee

Post Exposure Prophylaxis

Post exposure prophylaxis (PEP) has been the standard of care for occupationally exposed healthcare workers since 1996. It provides anti-HIV medications to someone who has had an exposure, usually to blood. To be effective, PEP must begin within 2 hours of exposure, before the virus has time to begin to replicate. A first dose of PEP should be offered while evaluation is underway. PEP should not be delayed while awaiting more information about the source patient or results of the exposed worker’s baseline HIV test (HIV Clinical Resource, 2012).

Rapid testing is strongly recommended for the source patient—and for those organizations subject to OSHA regulations, rapid testing is mandated for occupational exposures. If the source patient’s rapid HIV test result is negative but there has been a risk for HIV exposure in the previous 6 weeks, plasma HIV RNA testing of the source patient is also recommended. In this situation, PEP should be initiated and continued until results of the plasma HIV RNA assay are available (HIV Clinical Resource, 2012).

A baseline HIV test of the exposed worker should always be obtained after an occupational exposure, even if the exposed worker declines PEP. Regardless of whether the exposed worker accepts or declines PEP treatment, if the post-exposure evaluation determines that PEP is indicated, repeat HIV testing at 4 weeks and 12 weeks should be obtained. A negative HIV test result at 12 weeks post exposure reasonably excludes HIV infection related to the occupational exposure; routine testing at 6 months post exposure is no longer recommended (HIV Clinical Resource, 2012).

Highly active antiretroviral therapy (HAART) is always recommended for at-risk exposures. Any variance from the recommended regimens should be made in consultation with an HIV specialist or an occupational health clinician experienced in providing PEP. Antiretroviral (ARV) medications for PEP should be readily available to healthcare workers who sustain a known or highly suspect occupational exposure to HIV (HIV Clinical Resource, 2012).

The preferred PEP regimen is tenofovir + emtricitabine* plus raltegravir. Zidovudine is no longer recommended in the preferred PEP regimen. The first dose should be given as soon as possible after exposure, ideally within 2 hours. The recommended duration of PEP is 28 days (HIV Clinical Resource, 2012).

*Lamivudine may be substituted for emtricitabine.

 

HIV PEP Regimen Following Occupational Exposure

Tenofovirb 300 mg PO qd + Emtricitabineb,c 200 mg PO qd

Plus

Raltegravird 400 mg PO bid

Source: HIV Clinical Resource, 2012.

For detailed clinical information about post exposure prophylaxis please see: HIV Prophylaxis Following Occupational Exposure at this source.

Legal Issues with HIV/AIDS

In 1990 Kentucky enacted legislation to address the AIDS epidemic, and the legislation has been regularly amended and updated since then. The Kentucky Omnibus AIDS Act originally stipulated that all licensed healthcare providers, as well as athletic trainers, lab personnel, social workers, and all employees of health facilities who are not otherwise covered by professional licensure, were required to take a course on the transmission, control, treatment, and prevention of HIV/AIDS every 2 to 3 years. In 2000 the frequency requirement was changed to every 10 years.

State legislation also mandates education for anyone treated for HIV/AIDs at any licensed hospital or health facility, in secondary and post secondary schools; for all inmates of the Department of Corrections; and for law enforcement and correctional officers. The original 1990 legislation and subsequent revisions address rules for testing, informed consent, confidentiality, reporting requirements, state programs, and discrimination.

Kentucky Cabinet for Health and Family Services

Kentucky legislation has established the responsibilities of the Cabinet for Health and Family Services (CHFS) for HIV/AIDS surveillance, prevention, and services. Surveillance activities are conducted in accordance with Kentucky Communicable Disease Reporting regulations. The program provides forms and guidelines for interviewing clients and filing reports. Semi-annual statistical reports are prepared and made available on the CHFS HIV/AIDS website.

The Cabinet for Health and Family Services prevention responsibilities includes coordinating the planning, implementing, and evaluating of programs targeted for all at-risk groups. This includes counseling, testing, referral, and partner notification programs conducted by contract with community-based organizations and certain health departments. Testing sites are required to be located in every county across the state.

The services program encompasses the Kentucky HIV/AIDS Care Coordinator Program (KHCCP), which is expected to facilitate “quality care and services to HIV-infected individuals and their families” and is the umbrella organization for Kentucky’s health insurance continuation, outpatient healthcare support services, and financial and drug assistance programs, all of which are dependent on state and federal funding.

In 2000 the Cabinet was given the authority to create an HIV and AIDS Planning and Advisory Council. The council is broadly representative of both those affected by HIV/AIDS and those providing services for them. It is charged with advising and assisting the Cabinet for Health and Family Services by monitoring its activities, exploring options for centers for excellence, assessing current resources and services, and making annual reports to the state legislature (KY Legislature, 2014).

Consent to Test

Many members of the public are deterred from seeking testing because they misunderstand the nature of the test or fear that test results will be disclosed without their consent. To address these concerns, Kentucky law finds that “informed, voluntary, and confidential” testing for HIV infection is in the interests of public health and consent is required before a test to identify HIV, or its antigen or antibody, is performed by anyone in the state. A patient who has signed a general consent form for medical treatment is “not required to also sign or be presented with a specific consent form” relating to HIV during the period covered by the general consent form. In other words, HIV testing can be included in general medical consent. However, the general form must specifically state that HIV-related testing is covered (KY Legislature, 2014).

In an emergency, where prior informed consent cannot reasonably be obtained before providing services, a healthcare provider is not required to obtain such consent. In addition to emergencies, other situations where Kentucky law may allow testing without consent include:

  • Following conviction of a sexual offense (adults and juveniles)
  • Following conviction of prostitution or procuring another to commit prostitution
  • For juveniles charged with certain sexual offenses
  • For inmates known to have been exposed to HIV/AIDS, to have engaged in high-risk behaviors, and/or to have endangered the well-being of correctional employees
  • Testing of blood, organ, and human tissue donations
  • For healthcare facility residents after exposure
  • Post-test counseling is required with HIV-positive test results (NCCC, 2014)

Confidentiality

The Kentucky Cabinet for Health and Family Services has established a system for reporting all individuals who test positive for HIV infection. The reporting includes the CD4 count and viral load, as well as other information necessary to comply with the confidentiality and reporting requirements of the most recent edition of the CDC’s Guidelines for National Human Immunodeficiency Virus Case Surveillance (KY Legislature, 2014).

While confidential testing following CDC guidelines is recommended, Kentucky law stipulates that anonymous testing must also be available (and, by default, oral consent). Minors do not need parental consent for STI testing and physicians are not required to inform the parents of a minor’s HIV test or results.

In general, breach of confidentiality by deliberate release of the name of a person receiving an HIV test is a class A misdemeanor (KRS 214.995); however, there are circumstances under which test results and related information may be released to certain individuals or entities. For example, physicians are not prevented from giving information to a minor’s parent or legal guardian, and they are protected from liability under certain conditions specified by law when informing a co-habiting partner of the other partner’s positive test result. Healthcare providers should become familiar with all regulations that pertain to their field and follow all guidelines of their employer with regard to confidentiality requirements.

HIV/AIDS Reporting Requirements in Kentucky

The Centers for Disease Control and Prevention (CDC) recommends reporting of all HIV-related test results, including CD4+ T-lymphocyte (CD4) results and all viral load test results. Consistent with the terms of the CDC’s HIV surveillance cooperative agreement with state and local health departments, CDC requires entry of all HIV-related laboratory test results for individuals diagnosed with HIV into the state or local database for submission to CDC for inclusion in national analyses (HHS, 2013).

According to Kentucky state regulations, health professionals licensed under KRS chapters 311 through 314, health facilities licensed under KRS chapter 216B, and laboratories licensed under KRS chapter 333 are required to report HIV and AIDS cases to the Kentucky Department for Public Health or the Louisville Metro Department for Public Health and Wellness within five business days of diagnosis.

A positive test result must be confirmed by corroborating tests before informing the patient of the result, and the physician ordering the test (or the attending physician) must inform the patient of the result and provide information and counseling or referral to such counseling as specified by law. Kentucky law specifically allows a physician to inform a patient of a positive result from a rapid test in situations with proper counseling or where such knowledge addresses an urgent need for treatment.

Kentucky Disease Surveillance for HIV/AIDS

Section 7. Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) Surveillance.

  1. Physicians and Medical Laboratories shall report:
    1. 1.   A positive test result for HIV infection including a result from:
        • Elisa;
        • Western Blot;
        • PCR;
        • HIV antigen; or
        • HIV culture;
      1. CD4+ assay including absolute CD4+ cell counts and CD4+%;
      2. HIV detectable Viral Load Assay; and
      3. A positive serologic test result for HIV infection; or
    2. A diagnosis of AIDS that meets the definition of AIDS established within the Centers for Disease Control and Prevention (CDC) guidelines and reported in the:
      1. “Adult HIV/AIDS Confidential Case Report Form,” or
      2. “Pediatric HIV/AIDS Confidential Case Report Form.”
  2. An HIV infection or AIDS diagnosis shall be reported within five (5) business days and, if possible, on the “Adult HIV/AIDS Confidential Case Report form” or the “Pediatric HIV/AIDS Confidential Case Report form.”
    1. A report for a resident of Jefferson, Henry, Oldham, Bullitt, Shelby, Spencer, and Trimble Counties shall be submitted to the HIV/AIDS Surveillance Program of the Louisville-Metro Health Department.
    2. A report for a resident of the remaining Kentucky counties shall be submitted to the HIV/AIDS Surveillance Program of the Kentucky Department for Public Health, or as directed by the HIV/AIDS project coordinator.
  3. A report for a person with HIV infection without a diagnosis of AIDS shall include the following information:
    1. The patient’s full name;
    2. Date of birth, using the format MMDDYY;
    3. Gender;
    4. Race;
    5. Risk factor, as identified by CDC;
    6. County of residence;
    7. Name of facility submitting report;
    8. Date and type of HIV test performed;
    9. Results of CD4+ cell counts and CD4+%;
    10. Results of viral load testing;
    11. PCR, HIV culture, HIV antigen, if performed;
    12. Results of TB testing, if available; and
    13. HIV status of the person’s partner, spouse or children.
  4. Reports of AIDS cases shall include the information in subsections (1) through (3) of this section; and
    1. The patient’s complete address;
    2. Opportunistic infections diagnosed; and
    3. Date of onset of illness.
  5. (a)  Reports of AIDS shall be made whether or not the patient has been previously reported as having HIV infection.
    1. If the patient has not been previously reported as having HIV infection, the AIDS report shall also serve as the report of HIV infection. (Kentucky Legislature, 2014)

For reports from Jefferson, Henry, Oldham, Bullitt, Spencer, Shelby and Trimble counties contact Fay Davis at (502) 574-6574. Case reports can be mailed to:
   Louisville Metro Health Department
   400 E. Gray St., Room 317
   Louisville, KY 40202
   Attn: Fay Davis

For all other county reports contact Medina Tipton, Surveillance Coordinator or Julie Nakayima, Surveillance Technician at (866) 510-0008. Case reports can be mailed to:
   Kentucky Department for Public Health
   275 E. Main St., HS2E-C
   Frankfort, KY 40621
   Attn: Medina Tipton

The Americans with Disability Act (ADA)

The Americans with Disabilities Act (ADA) gives federal civil rights protections to individuals with disabilities similar to those provided to individuals on the basis of race, color, sex, national origin, age, and religion. It guarantees equal opportunity for individuals with disabilities in public accommodations, employment, transportation, state and local government services, and telecommunications (USDOJ, 2012).

An individual has a “disability” under the ADA if he or she has a physical or mental impairment that substantially limits one or more major life activities, including major bodily functions such as the functions of the immune system; has a record of such an impairment; or has an actual or perceived mental or physical impairment that is not transitory and minor and is subjected to an action prohibited under the ADA. Individuals with HIV, both symptomatic and asymptomatic, have physical impairments that substantially limit one or more major life activities or major bodily functions and are, therefore, protected by the law (USDOJ, 2012).

Individuals who are discriminated against because they are regarded as having HIV are also protected. For example, a person who was fired on the basis of a rumor that he had AIDS, even if he did not, would be protected by the law. Moreover, the ADA protects individuals who are discriminated against because they have a known association or relationship with an individual who has HIV. For example, the ADA would protect a woman (who does not have HIV) who was denied a job because her roommate had AIDS (USDOJ, 2012).

In addition to being subject to the provisions of the federal Americans with Disabilities Act (ADA), Kentucky legislation specifically states that the results of any serologic test performed under the auspices of the Cabinet for Health and Family Services may not be used to determine eligibility for disability, health, or life insurance—or used to make decisions regarding employment suitability or discharge (KRS 214.181).

Attitudes Toward Those with HIV

Stigma and discrimination remain rife in many parts of the world and punitive laws continue to deter those most at risk from seeking essential HIV services.

UNAIDS, 2013a

A significant amount of denial about HIV risk exists in many communities. There is also fear and stigmatization of those who have HIV. HIV prevention programs are recognizing the importance of combating negative attitudes, misinformation, discomfort, stigmatization, and fear among the people and in the communities where they are working.

In the United States, although many continue to express discomfort at the idea of interacting with people living with HIV, the reported levels of discomfort have decreased over the past several years. In a 2011 survey by the Kaiser Family Foundation, the number of people saying they would be “very comfortable” working with someone who has HIV increased from about a third of those responding in 1997 to roughly half in 2011. There have also been striking declines since the early years of the HIV epidemic among those with the view that AIDS is a punishment or the belief that people who contract the disease are at fault (Kaiser Family Foundation, 2011).

HIV-Associated Stigma

Stigma occurs when an attribute creates a deep gap between who we think we are and how we are seen by others. This gap cuts the stigmatized person off from society and from himself, so that he stands as a discredited person against an unaccepting world. Stigma is enabled by underlying social, political, and economic powers. It begins when a difference is labelled, then is linked to negative stereotypes, leading to a separation of “us” from “them,” and finally to status loss and discrimination for those carrying the trait (Stangl et al., 2013).

Stigma originates from the ancient practice of branding or marking someone who was thought to be “morally flawed” or to have behaved badly and therefore ought to be avoided by other members of society. Stigma is often described as a process of devaluation. If you are stigmatized, you are discredited and seen as a disgrace or perceived to have less value or worth in the eyes of others (IPPF, 2008).

HIV-related stigma often builds upon and reinforces other existing prejudices, such as those related to gender, sexuality, and race. The stigma associated with HIV is often based upon the association of HIV and AIDS with already marginalized and stigmatized behaviors, such as sex work, drug use, and same-sex and transgender sexual practices. HIV-related stigma affects those living with HIV and—through association—those who they are associated with, such as their partner or spouse, their children and the other members of their household (IPPF, 2008).

Stigma is founded on fear and misinformation. Theodore de Bruyn observed that stigma is associated with HIV/AIDS because “It is a life-threatening disease; people are afraid of contracting HIV; it is associated with behaviors that are considered deviant; a belief that HIV/AIDS has been contracted through unacceptable lifestyle choices; and, some believe it is the result of a moral fault that deserves punishment.” The stigma associated with HIV/AIDS is such some patients may feel ambivalent about seeking medical care if, by doing so, they risk disclosing their condition. Others may have learned from experience to expect rejection and therefore may not trust care providers (Bidwell, 2011).

The United Nation’s Millennial Development Goals has established the elimination of stigma, discrimination, and gender inequalities in those with HIV or AIDS as one of its ten targets and commitments. Stigma, discrimination, and oppressive legal environments in many settings discourage men who have sex with men from seeking HIV testing and appropriate, high-quality prevention, care, and treatment services (UNAIDS, 2013a).

Cultural Sensitivity and Competence

Cultural sensitivity or cultural competency is the ability to interact effectively with people of different cultures, particularly in the context of health and social services where employees work with individuals from different cultural and ethnic backgrounds (Kentucky CHFS, 2012). Understanding cultural differences is particularly important because, although minorities currently make up 37% of the nation’s population, by 2060 they are expected to make up more than half of the population in the United States (Loftin et al., 2013).

An important aspect of cultural competency is the healthcare provider’s willingness to understand that a patient’s cultural background influences health-related beliefs and behaviors, and adverse experiences of a personal or cultural nature may have made some patients distrustful of medical care. In addition, some patients’ distrust of medical research impedes their willingness to accept new drug therapies. Culturally competent communication between provider and patient may substantially affect compliance with therapies.

Healthcare providers should carefully explore what each patient believes about his or her health, what would be appropriate treatment, and who should be involved in medical decision making. Additionally, healthcare providers must examine their own prejudices about high-risk behaviors and recognize that judgment has no place in medicine. Rather, they should apply the Golden Rule: Do unto others as you would have them do unto you.

Although in the United States attitudes are rapidly changing, many caregivers—both personal and professional—have moral judgments about those infected with HIV. How a person became infected is not an opportunity for a healthcare provider or caregiver to pass judgment or moralize. It is critical that we examine our prejudices about risk behaviors that may have led to infection. Caregivers and healthcare providers may find it necessary to acknowledge their own experiences, prejudices, and feelings when dealing with all aspects of this disease. The good news is that attitudes are changing as people become more educated about HIV and AIDS. In a 2011 Kaiser Family Foundation national poll, 29% of respondents agreed with the statement “In general, it’s people’s own fault if they get AIDS” (down from 51% in 1987). Additionally, 16% believed “I sometimes think that AIDS is a punishment for the decline in moral standards” (down from 43% in 1987) (Kaiser Family Foundation, 2011).

Conclusion

There have been many well-documented and successful strategies employed in the United States and throughout the world that have shown promise in slowing the devastating expansion of the AIDS epidemic. The United Nations Millennium Development Goals (MDG) and U.S. National HIV/AIDS Strategy have focused attention and funds on the HIV epidemic. The MDG (listed at the beginning of this course) represent the commitment by 193 countries to reach certain target and elimination goals by 2015.

The U.S. National HIV/AIDS Strategy represents the commitment of state, local, and tribal governments, businesses, faith communities, philanthropy, the scientific and medical communities, educational institutions, and people living with HIV to reduce new HIV infections, increase access to care, improve health outcomes for people living with HIV, and reduce HIV-related health disparities.

But despite these and other global efforts to eradicate HIV, the cost in lives and lost productivity remains a staggering problem. In the United States there are 50,000 new infections each year, and worldwide there are about 2.3 million new infections annually. Although more men are infected with HIV, women are becoming infected at higher rates than any other group of people and are increasingly becoming the face of the epidemic.

Good progress has been made in certain areas in reducing the sexual and bloodborne transmission of HIV. Use of male condoms, increased availability and use of female condoms, early testing and counseling, and keeping people with HIV in care have all contributed to a decrease in the rate of new HIV infections in the United States. Aggressive and early use of antiretroviral therapy has decreased the risk of transmitting HIV to another person.

Persistent problems remain, however, with only 25% of people diagnosed with HIV remaining in care consistently enough to reach viral suppression—the point at which the virus is effectively suppressed in an individual. Viral suppression is critical because it dramatically reduces the risk of transmitting the virus to another person. Retaining people in care is a point of focus of public health departments throughout the country.

As healthcare workers, we can help to reduce the spread of AIDS by engaging in safe sex and encouraging behavior change and prompt treatment of sexually transmitted infections. We can also support distribution and use of clean injection drug equipment, encourage routine HIV testing, provide good-quality patient education and counseling, and encourage consistent male and female condom use. The goal is to eliminate new HIV infections entirely in Kentucky, in the United States, and throughout the world. We all play a vital role in accomplishing this goal.

Kentucky Resources

Kentucky’s Ryan White and State-Funded Services Programs

The overall intent of the services programs is to provide clients with a continuum of care, utilizing existing community-based services to the greatest extent possible. This information is provided by the Kentucky Cabinet for Health and Family Services and is current as of August 2012.

Kentucky HIV Direct Services

To enhance access to, and retention in, primary healthcare and support services for qualifying Kentuckians (clients) living with HIV disease, it is necessary to:

  1. Promote client self-sufficiency (to the extent possible) through good care plan monitoring and holistic support
  2. Prevent duplication of health and support services among providers
  3. Provide education about HIV disease transmission and health choices
  4. Provide ongoing HIV disease education to the general and healthcare communities
  5. Promote efficient and effective use of resources
Community-Based HIV Services

Kentucky Care Coordination Program (KHCCP): A network of regional sites by which clients may access quality primary healthcare and other support services in or near the communities in which they live. To access direct services in Kentucky, an individual must enroll in the KHCCP.

Kentucky AIDS Drug Assistance Program (KADAP): Provides clients with HIV/AIDS-related medications.

Kentucky Health Insurance Continuation Program (KHICP): Assists clients with maintaining pre-existing private health insurance.

Funding

Kentucky receives federal funding through the Ryan HIV/AIDS Treatment and Modernization Act of 2006, and also non-federal funds through the State of Kentucky.

Eligibility Criteria (Proof Required)
  • Household income must be 300% or less of the current federal poverty level
  • Total cash assets must be less than $10,000
  • Must be a resident of Kentucky
  • Must be HIV-positive
  • Cannot be eligible for similar assistance from another payer source

 

For more information contact the nearest Care Coordinator, or the Care Coordinator Program Administrator, 502 564 6539, or 800 420 7431.

Kentucky HIV Care Coordinator Regions

map: Barren River Region

Barren River Region

Matthew 25
452 Old Corydon Road
Henderson, KY 42420
(270) 826-0200
(877) 428-1231
fax: (270) 826-0212

Counties Covered
Allen, Barren, Breckinridge, Butler, Daviess, Edmonson, Grayson, Hancock, Hardin, Hart, Henderson, Larue, Logan, McLean, Marion, Meade, Metcalfe, Monroe, Nelson, Ohio Simpson, Union, Warren, Washington, Webster

map: Cumberland Valley Region

Cumberland Valley Region

Cumberland Valley Dist HD
PO Box 158
Manchester Square Shopping Ctr
Manchester, KY 40962
(606) 599-0112
(888) 425-7282*
fax: (606) 864-3732

* for client use only
Some Cumberland Valley clients are covered by Lexington Region.

Counties Covered
Adair, Bell, Breathitt, Casey, Clay, Clinton, Cumberland, Floyd, Green, Harlan, Jackson, Johnson, Knott, Knox, Laurel, Lee, Leslie, Letcher, Magoffin, Martin, McCreary, Owsley, Perry, Pike, Pulaski, Rockcastle, Russell, Taylor, Wayne, Whitley, Wolfe

map: Lexington Region

Lexington Region

Bluegrass Care Clinic, UK
740 S. Limestone, 5D Room L528
UK Medical Center
Lexington, KY 40536
(859) 323-5544
fax: (859) 323-1694

Counties Covered
Anderson, Bath, Bourbon, Boyd, Boyle, Bracken, Carter, Clark, Elliott, Estill, Fayette, Fleming, Franklin, Garrard, Greenup, Harrison, Jessamine, Lawrence, Lewis, Lincoln, Madison, Mason, Menifee, Mercer, Montgomery, Morgan, Nicholas, Powell, Robertson, Rowan, Scott, Woodford

map: Louisville Region

Louisville Region

Volunteers of America
1436 South Shelby Street
Louisville, KY 40217
(502) 635-4511
fax: (502) 636-0597

Counties Covered
Bullitt, Henry, Jefferson, Oldham, Shelby, Spencer, Trimble

map: Northern Region

Northern Kentucky Region

No. KY Dist Health Dept
2388 Grandview Drive
Ft. Mitchell, KY 41017
(859) 341-4264
fax: (859) 578-3689

Counties Covered
Boone, Campbell, Carroll, Gallatin, Grant, Kenton, Owen, Pendleton

map: Purchase Region

Purchase Region

Heartland Cares, Inc.
619 N. 30th Street
Paducah, KY 42001
(270) 444-8183
(877) 444-8183
fax: (270) 444-8147

Counties Covered
Ballard, Caldwell, Calloway, Carlisle, Christian, Crittenden, Fulton, Graves, Hickman, Hopkins, Livingston, Lyon, McCracken, Marshall, Muhlenberg, Todd, Trigg

Kentucky Cabinet for Health and Family Services
Department for Public Health, HIV/AIDS Branch
275 E. Main St., HS2E-C, Frankfort, KY 40621
Phone: 502 564 6539 or 800 420 7431
Fax: 502 564 9865
Case reporting only: 866 510 0008
http://chfs.ky.gov/dph/epi/hivaids/

Community-Based Organizations Providing HIV Prevention Services

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Agencies funded in part with CDC Cooperative Agreement funds are indicated with the Kentucky AIDS logo.

AIDS Interfaith Ministries of Kentuckiana (AIM) provides support services to individuals living with HIV/AIDS and their families in the Louisville area. Phone: 502 574 6085; http://www.aimkyonline.org/.

AIDS Services Center Coalition (ASCC) is a coalition of agencies whose goals are to direct the public to appropriate AIDS service agencies, to distribute literature, and to provide an HIV/AIDS resource directory. The agency has an extensive volunteer network. Phone: 502 574 5490; www.asccinc.org.

AIDS Volunteers of Cincinnati (AVOC) located in Cincinnati, Ohio, is a community-based organization that provides a wide variety of services to individuals diagnosed with HIV/AIDS and to the broader community, especially high-risk populations where HIV exposure is more likely. Although AVOC primarily serves Cincinnati and southwest Ohio, they offer many of their services to individuals and groups in Northern Kentucky. These services include community outreach, prevention and education presentations, street outreach to women in underserved communities, testing and counseling services, an informational and referral hotline and a speaker’s bureau. Phone: 513 421 AIDS (2437); www.avoc.org

AIDS Volunteers of Northern Kentucky (AVNK), located in Florence, KY, was founded in 1990. AVNK seeks to understand and address the emotional, educational, social, spiritual and physical needs of the people in Northern Kentucky and surrounding communities who are living with HIV/AIDS, and the needs of their families, partners, friends, and caregivers. AVNK strives to inform the general community about HIV/AIDS-related issues for purposes of education, mobilization, prevention, and advocacy. AVNK provides a number of services including three support groups, a monthly dinner/social, healing weekends, respite care, emergency financial assistance, memorial services, outreach to minority communities, and World AIDS Day services. Phone: 859 512 7925; email mconnley@insightbb.com.

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AIDS Volunteers, Inc. (AVOL), located in Lexington, is a community-based organization that provides HIV and AIDS education, prevention initiatives, service programs, and financial assistance to persons infected and affected by HIV disease in all of Central and Eastern Kentucky. Some of the services provided by AVOL include: speakers’ bureau, support groups, financial assistance, case management, transitional housing for those who are homeless and HIV+, a community residence for those in the end stages of AIDS, community outreach, condom distribution, educational programs and materials, and prevention activities. Funding for AVOL comes from community donations, fundraisers, and grants from private foundations, as well as local, state, and federal sources including HUD (HOPWA) and the United Way. Approximately 75 to 100 volunteers are consistently involved throughout the year for day-to-day operations, programs and services, volunteer caregivers, and fundraising events. Program referrals and linkages are through the health departments, other volunteer organizations, and HIV Care Coordinators. Phone: 859 225 3000; Fax 859 225 9244; http://sites.google.com/site/avolky/.

American Red Cross (ARC) is located in nearly every county in Kentucky. The number of ARC employees range from one or two in the smaller communities to more than 300 in the Louisville chapter. Budgets are also diverse, with smaller chapters having budgets of a few thousand dollars to in excess of a hundred thousand dollars in Lexington and Louisville. There is disparity in the provision of HIV/AIDS services among counties: smaller rural counties believing that there is “no problem” in their community (thus no reason for services); larger urban chapters offering a full range of services. HIV/AIDS services include the distribution of brochures, AIDS 101 training, peer training for adolescents, African American AIDS 101 training, Hispanic AIDS 101 training, rural and church leader AIDS 101 training, prison personnel training, and a program specifically entitled “AIDS in the Workplace” that is designated for businesses and industries. Phone: 502 589 4450; http://www.louisville-redcross.org.

Bluegrass Care Clinic (BCC), located in Lexington, is a Ryan White CARE Act Part C grantee. The BCC provides both clinical and support services for HIV/AIDS patients and their affected families in 63 counties through Central and Eastern Kentucky. The BCC staff are trained to provide harm reduction information and counseling regarding drug use, sexual activity, and other high-risk activities for HIV transmission and infection. In addition, the BCC also provides pre/post-test counseling and testing. Phone: 859 323 5544; Fax: 859 257 2040; www.mc.uky.edu/bluegrasscareclinic.

Bluegrass Community Health Center (BCHC) (formerly Bluegrass Farmworker Health Center) is a nonprofit federally qualified health center with two Lexington clinic sites. The health center provides patient-centered preventive and primary healthcare, including HIV testing, for pediatric, adult, and geriatric patients. BCHC provides services to the uninsured and accepts Medicaid, Medicare, and many private insurances. Most of BCHC patients are charged on a sliding scale based on family size and income (federal poverty guidelines). BCHC was originally established in 2001 with a federal 330 health center grant to serve local farm workers. In 2007 additional grant funding awards allowed an expansion to serve the greater community, including uninsured patients and people experiencing homelessness. BCHC’s dedication to serving a diverse population encouraged the employment of many bilingual employees to supplement telephone interpreting services. Phone: 859 259 2635; Fax: 859 254 7874. BCHC sites: 1306 Versailles Rd. Lexington KY 40504; and 151 N. Eagle Creek, Lexington KY 40509; http://www.bfhc.eku.edu/.

Episcopal Diocese AIDS Ministry, located in Lexington, provides care and support through biannual social dinners. All meals and additional limited supportive services are provided free of charge. The Episcopal Diocese AIDS Ministry can also serve as a referral source/linkage for other ASOs in the region. Contact Lisa: lisainky@adelphia.net.

Harlan Countians for a Health Community located in Baxter, is a coalition of healthcare providers, consumers, and other interested agencies whose purpose is to improve healthcare in Harlan County. Phone: 606 573 6115.

Hazard Perry County Community Ministries is located in Hazard. The purpose is to meet community needs through supportive services (outreach and case management), crisis aid, homeless shelter, transitional housing and childcare. Phone: 606 436 0051; http://www.hpccm.org/.

Heartland CARES, Inc., located in Paducah, is a nonprofit organization serving people with HIV and AIDS in the Western Kentucky and Southern Illinois regions. The mission is to provide various components of care needed for persons living with HIV and AIDS regardless of ethnicity, gender, religious beliefs, sexual orientation, or ability to pay, and to provide education and prevention to the general public to help stop the spread of HIV and STDs. Medical services are primarily supported through Ryan White Part C funding. The clinic also has numerous supporting services, which include Ryan White Title II Care Coordinator Program, HOPWA Grant Emergency Assistance, Supportive Housing Grant Assistance, SAMHSA-CSAT Grant, HOPWA SPNS, and HOME Grant. Heartland CARES houses the Western Kentucky Prevention Team that is responsible for HIV/AIDS prevention in 42 counties. Phone: 270 444 8183; http://hcares-org.

House of Ruth provides social, emotional, and financial support to people living with HIV/AIDS in the Louisville/Jefferson County area. Phone: 502 587 5080; http://www.houseofruth.net/

I.N.D.Y. (I’m Not Dead Yet) Project founded in 1994, serves Northern Kentucky. INDY is an organization dedicated to the enhancement of life for individuals affected by HIV and AIDS by providing social outlets in a variety of environments and frameworks with one basic goal in mind: Having fun! Members and sponsors attend and host picnics, movie nights, dinners, camping trips, art events, and parties. The group is dedicated to the proposition that through the joy of celebrating life there is hope and healing, and celebration is best engaged through groups of likeminded individuals. Phone: 859 512 7925; email mconnley@insightbb.com.

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Matthew 25 AIDS Services, Inc.., located in Henderson, is a Ryan White CARE Act Parts B and C and CDC Prevention PA04064 Grantee. They are a provider of primary healthcare to PWHIV and LWA, in Daviess, Henderson, Union, and Webster counties. Services include medical case management and referral, a buddy program, literature, spiritual support and referral, financial assistance and referral, a speakers bureau, support groups (positive, family and friends), transportation and prevention education for the community, and medical professionals. Matthew 25 also distributes HOPWA funds and does counseling and testing for HIV (blood and oral testing). Phone: 270 826 0200; www.matthew25clinic.org.

Moveable Feast (MFL) is a nutritional support program, serving people living with HIV disease and their dependent children living in the Lexington/Fayette County area. Clients receive social support and a hot, freshly cooked dinner five days a week. MFL can also serve as a referral source to other ASOs in the region. All services are completely free of charge. Phone: 859 252 2867; www.feastlex.org.

North Central AHEC/HETC. The mission of the North Central AHEC is to promote healthy communities through innovative partnerships. This is accomplished by providing educational support services to health professions students and healthcare providers, community health education, and programs to encourage health professions as a career choice.

In order to address HIV prevention in Kentucky’s growing Hispanic community, the Kentucky DPH has identified agencies providing other services to our Hispanic population and provided capacity building assistance to help these agencies provide HIV prevention activities including HIV antibody testing.

North Central AHEC/HETC collaborates with Area Health Education Centers across the state who recruit individuals from Hispanic communities, provide training, and utilize them to conduct HIV prevention activities in their communities. AHECs in Lexington (covering 5 counties) and Covington (covering 4 counties) currently conduct outreach in Hispanic communities, provide HIV testing, and conduct two community level intervention (Juntos and Promotores de Salud). A third AHEC in Louisville conducts similar activities with African American communities. North Central AHEC/HETC also collaborates with the Bluegrass Community Health Center (formerly Bluegrass Farmworker Health Center) to provide additional outreach as well as testing to migrant farm workers.

The Lexington and Covington AHECs as well as the Bluegrass Community Health Center have been extremely helpful in providing interpreters and assisting Hispanic clients to receive services from other service providers who lack Spanish-speaking employees. http://www.nckyahec.org/.

Owensboro Area HIV/AIDS Task Force, Inc. is a nonprofit CBO funded by donations. This agency serves its clients with emergency financial assistance and transitional housing, and acts as an advocate with property owners, utility companies, Social Security, HOPWA, and other community service agencies. Volunteers also provide community outreach services with HIV prevention and risk reduction programs to targeted populations and various communities, medical professionals, and local organizations. Members of the Task Force are state-certified pre and post-test counselors as well as certified to administer OraSure for HIV testing. Members are also certified to inspect potential housing for clients wishing to obtain HOPWA funding. The Task Force is a certified partner of the Balm in Gilead. A support group for PWHIV is in place. They act as a referral source to all the available assistance programs for clients. The Task Force has some HIV-positive members who have made presentations at several high schools, a program describing the emotional, physical, and financial stresses of being HIV-positive. Phone: 270 683 6018; www.owensboro-aids.org.

Sisters and Brothers Surviving AIDS (SABSA) is a support group located in Louisville for all HIV-positive people and their friends and families. SABSA provides education and emotional support specific to the needs of those living with HIV and more specifically to the needs of the African American community. However, everyone is welcome regardless of gender, race, sexual orientation, creed, religion or ethnic background. Phone: 502 231 3871; http://www.sabsaonline.com/home.htm.

The Salvation Army of Central Kentucky, located in Lexington, operates a free medical clinic. The medical clinic, staffed by the University Kentucky’s College of Medicine, provides exams and physical therapy, and HIV pre/post-test counseling and testing. Phone: 859 252 7706; http://www.salvationarmylex.org/.

University of Cincinnati Hospital, Holmes Clinic, located in Cincinnati, Ohio, is the Infectious Disease Center for the University of Cincinnati Hospital. Holmes Clinic provides medical services to individuals diagnosed with HIV/AIDS and is funded primarily through Ryan White Part C funds. Holmes Clinic provides these services to individuals from several states, and a significant percentage of individuals diagnosed with HIV/AIDS and living in Northern Kentucky use Holmes Clinic for their infectious disease care. In addition, Holmes Clinic conducts partner testing for patients of the clinic. Phone: 513 584 6977.

The University of Cincinnati Emergency Room also has a grant to conduct HIV testing and counseling services with patients who are seen through the Emergency Room. This program targets high-risk individuals who receive their primary medical care through the Emergency Room. If an individual is diagnosed, a referral is made to Holmes Clinic. Phone: 513 584 5700.

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Volunteers of America, Inc. (VOA) in Louisville, provides HIV prevention education, focus groups, and risk reduction workshops to drug users, men, women, and youth at risk. The prevention services offered include pre-test and post-test counseling, factual information about reducing HIV risk factors associated with drug use and sexual behavior, alcoholism and drug abuse assessments, and referrals to HIV-related and nonrelated resources as needed or by request. VOA also provides an AIDS Housing Integration Project, which offers technical assistance to shelters, housing providers, and housing developers to help establish and implement new housing programs for homeless and low-income persons with HIV/AIDS. VOA also provides case management services to people living with HIV. This includes intake and assessment, goal setting, conflict resolution, crisis intervention, referral to community services, emergency financial assistance, linkage to rental and utility assistance, entry into support groups, and mental health and substance abuse counseling. Phone: 502 635 4511; http://www.voa.org/.

Westlake Primary Care, located in Columbia, KY, provides information and educational AIDS material, prevention kits with condoms, confidential testing, and pre and post-test counseling. Phone: 270 384 4764.

WINGS Clinic, located in Louisville, is a Ryan White CARE Act Part C grantee. WINGS provides both clinical and support services for HIV/AIDS patients and their affected families. This clinic project provides primary and infectious disease care, adult and pediatric nutrition services, adult support groups, social services, legal services, family and mental health counseling, as well as liaisons to community services. Phone: 502 852 5203; http://www.thewingsclinic.com/.

References

AIDSInfo. (2013). Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. Retrieved March 17, 2014 from http://www.aidsinfo.nih.gov/contentfiles/lvguidelines/aa_recommendations.pdf.

Bidwell R. (2011a). Guide for HIV/AIDS Clinical Care. Retrieved March 26, 2014 from http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/.

Center for Strategic and International Studies (CSIS). (2010). HIV Prevention Among Injection Drug Users Strengthening U.S. Support for Core Interventions. Retrieved March 5, 2014 from https://csis.org/files/publication/100408_Needle_HIVPrevention_web.pdf.

Centers for Disease Control and Prevention (CDC). (2014a). Who’s at Risk for HIV? Retrieved March 5, 2014 from http://www.cdc.gov/hiv/risk/index.html.

Centers for Disease Control and Prevention (CDC). (2014b). HIV Among Pregnant Women, Infants, and Children. Retrieved March 7, 2014 from http://www.cdc.gov/hiv/risk/gender/pregnantwomen/facts/.

Centers for Disease Control and Prevention (CDC). (2014c). Reducing HIV Transmission from Mother-to-Child: An Opt-Out Approach to HIV Screening. Retrieved March 13, 2014 from http://www.cdc.gov/hiv/risk/gender/pregnantwomen/opt-out.html.

Centers for Disease Control and Prevention (CDC). (2013a). The Scope and Impact of HIV in the United States. Retrieved March 26, 2014 from http://www.cdc.gov/nchhstp/newsroom/HIVFactSheets/Epidemic/Scope.htm.

Centers for Disease Control and Prevention (CDC). (2013b). Proven HIV Prevention Methods. Retrieved March 4, 2014 from http://www.cdc.gov/nchhstp/newsroom/docs/HIVFactSheets/Methods-508.pdf.

Centers for Disease Control and Prevention (CDC). (2013c). HIV Risk among Adult Sex Workers in the United States. Retrieved March 6, 2014 from http://www.cdc.gov/hiv/risk/other/sexworkers.html.

Centers for Disease Control and Prevention (CDC). (2013d). HIV and Women: Preventing Mother-to-Child Transmission of HIV During Childbirth. Retrieved March 7, 2014 from http://aidsinfo.nih.gov/education-materials/fact-sheets/24/70/preventing-mother-to-child-transmission-of-hiv-during-childbirth.

Centers for Disease Control and Prevention (CDC). (2013e; latest update 2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007. Retrieved March 14, 2014 from http://www.cdc.gov/hicpac/2007ip/2007isolationprecautions.html.

Centers for Disease Control and Prevention (CDC). (2013f). HIV Prevention in the United States: Expanding the Impact. Retrieved March 16, 2014 from http://www.cdc.gov/nchhstp/newsroom/hivfactsheets/future/high-impact-prevention.htm#Comprehensive.

Centers for Disease Control and Prevention (CDC). (2012). HIV in the United States: The Stages of Care. Retrieved March 25, 2014 from http://www.cdc.gov/nchhstp/newsroom/docs/2012/Stages-of-CareFactSheet-508.pdf.

Centers for Disease Control and Prevention (CDC). (2011). Sexually Transmitted Diseases: Treatment Guidelines, 2010. Retrieved February 13, 2014 from http://www.cdc.gov/std/treatment/2010/clinical.htm.

Center for Health and Gender Equity (CHANGE). (2011). Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health. Washington, DC: Center for Health and Gender Equity. Retrieved March 16, 2014 from http://www.genderhealth.org/
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Chen Z, Abrams WR, Geva E, et al. (2013). Development of a generic microfluidic device for simultaneous detection of antibodies and nucleic acids in oral fluids. BioMed Research International vol. 2013, Article ID 543294. Retrieved March 13, 2014 from http://dx.doi.org/10.1155/2013/543294.

Des Jarlais DC, Pinkerton S, Hagan H, et al. (2013). 30 years on selected issues in the prevention of HIV among persons who inject drugs. Advances in Preventive Medicine vol. 2013, Article ID 346372. Retrieved March 5, 2014 from doi:10.1155/2013/346372.

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