ATrain Education

 

Continuing Education for Health Professionals

Washington: HIV/AIDS, 7 units

Module 4

Part IV: Clinical Manifestations and Treatment

The Natural History of HIV Infection

A person with untreated HIV infection will experience several stages in infection. These include: viral transmission, primary HIV infection, seroconversion, asymptomatic HIV infection, symptomatic HIV infection, and AIDS. These stages as sometimes called the “natural history” of disease progression and are described below. The natural history of HIV infection has been altered dramatically in developed countries because of new medications. In countries where there is no access to these expensive medications, or in cases where people do not become aware of their HIV infection until very late, the disease progresses as described below.

Natural History of HIV Infection

  • Viral transmission
  • Primary HIV infection
  • Seroconversion
  • Asymptomatic HIV infection
  • Symptomatic HIV infection
  • AIDS

The first three constitute the window period.

Viral Transmission

Viral transmission is the initial infection with HIV. People infected with HIV may become infectious to others within 5 days. They are infectious before the onset of any symptoms, and they will remain infectious for the rest of their lives.

Primary HIV Infection

During the first few weeks of HIV infection, individuals have a very high level of virus (viral load) in their bloodstream. The high viral load means the individual can easily pass the virus to others. Unfortunately, during primary infection many people are unaware that they are infected.

In this stage, about half of infected people have symptoms of fever, swollen glands (in the neck, armpits, groin), rash, fatigue, and a sore throat. These symptoms, which resemble mononucleosis, go away in a few weeks, but the individual continues to be infectious to others.

It is extremely important that healthcare providers consider the diagnosis of primary HIV infection if clients engage in behaviors that put them at risk for HIV and are presenting with the above symptoms. If individuals experience these symptoms after having unprotected sex or sharing needles, they should seek medical care and tell their provider why they are concerned about HIV infection.

Window Period and Seroconversion

The window period begins with initial infection and continues until the virus can be detected by an HIV antibody test. Seroconversion is the is the term for the point at which HIV antibodies are detectable and the window period ends. See graph below.

Natural Course of Untreated HIV Infection

image: course of untreated HIV (graph)

The first two weeks following infection are highly contagious but not detectable by HIV tests. Antibodies may begin to appear after 2 weeks but take up to 12 weeks or longer to reach seroconversion (eg, be detectable by current testing). As is seen on the line curves, the viral load continues to increase until there are sufficient antibodies to suppress, but not kill, the virus. Once the antibodies become active, an untreated patient may be asymptomatic for 10 years before the antibodies are no longer able to suppress the virus and the person becomes symptomatic. Source: Adapted from Conway & Bartlett, 2003.

Asymptomatic HIV Infection

Following seroconversion, a person infected with HIV is asymptomatic (has no noticeable signs or symptoms). The person may look and feel healthy, but can still pass the virus to others. It is not unusual for an HIV-infected person to live 10 years or longer without any outward physical signs of progression to AIDS. Meanwhile, the person’s blood and other systems are affected by HIV, which would be reflected in laboratory tests. Unless a person in this stage has been tested for HIV, they will probably not be aware they are infected.

Symptomatic HIV Infection

During the symptomatic stage of HIV infection, a person begins to have noticeable physical symptoms that are related to HIV infection. Although no symptoms are specific only to HIV infection, some common symptoms are:

  • Persistent low-grade fever
  • Pronounced weight loss that is not due to dieting
  • Persistent headaches
  • Diarrhea that lasts more than 1 month
  • Difficulty recovering from colds and the flu
  • Being sicker than they normally would with ordinary illnesses
  • Recurrent vaginal yeast infections in women
  • Thrush (a yeast infection) coating the mouth or tongue

Anyone who has symptoms like these and has engaged in behaviors that transmit HIV should seek medical advice. The only way to know for sure if you are infected with HIV is to take an HIV antibody test.

AIDS

Did you know . . .

An AIDS diagnosis can only be made by a licensed healthcare provider and, once the diagnosis is made, the person is always considered to have AIDS.

An AIDS diagnosis is based on the result of HIV-specific blood tests and/or on the person’s physical condition. Established AIDS-defining illnesses, white blood cell counts, and other conditions are specifically linked to making an AIDS diagnosis. Once a person is diagnosed with AIDS, even if they later feel better, they do not “go backwards” in the classification system for HIV infection. They are always considered to have AIDS.

People who have an AIDS diagnosis may often appear to a casual observer to be quite healthy, but continue to be infectious and can pass the virus to others. Over time, people with AIDS frequently have a reduced white blood count and develop poorer health. They may also have a significant amount of virus present in their blood, measureable as viral load.

Cofactors

A cofactor is a separate condition that can change or speed up the course of disease. There are several cofactors that can increase the rate of progression to AIDS. They include a person’s age, certain genetic factors, and possibly drug use, smoking, nutrition, and HCV.

Time from Infection to Death

Currently, if the infection is untreated, the average time from HIV infection to death is 10 to 12 years. Early detection and continuing medical treatment have been shown to prolong life for many more years.

AIDS Surveillance Case Definition, Revised 2008

Since the beginning of the HIV epidemic, case definitions for HIV-infection and AIDS have undergone several revisions in order to (1) respond to diagnostic and therapeutic advances, and (2) improve standardization and comparability of surveillance data regarding people at all stages of HIV disease.

HIV testing is now widely available, and diagnostic testing has continued to improve; these changes are reflected in the 2008 revised case definition for HIV infection, which now requires laboratory-confirmed evidence of HIV infection. Diagnostic confirmation of an AIDS-defining condition (see box below), without laboratory-confirmed evidence of HIV infection, is no longer sufficient to classify an adult or adolescent as HIV-infected for surveillance purposes.

The 2008 HIV infection case definition for adults and adolescents over age 13 replaces the earlier definitions and the HIV infection classification system. The case definition is intended for public health surveillance only and not as a guide for clinical diagnosis. The definition applies to all HIV variants (HIV-1 or HIV-2). For surveillance purposes, a reportable case of HIV infection among adults and adolescents over age 13 is categorized by increasing severity as stage 1, stage 2, or stage 3 AIDS, or as stage unknown.

In addition, for children aged 18 months to 13 years, laboratory-confirmed evidence of HIV infection is now required to meet the surveillance case definition for HIV infection and AIDS. Diagnostic confirmation of an AIDS-defining condition is no longer sufficient to classify a child as HIV-infected for surveillance purposes.

No changes have been made to the HIV infection classification system, the 24 AIDS-defining conditions for children under 13 years, or the AIDS case definition for children under 18 months.

AIDS Indicator Conditions

  • Bacterial infections, multiple or recurrent*
  • Candidiasis of bronchi, trachea, or lungs
  • Candidiasis of esophagus†
  • Cervical cancer, invasive§
  • Coccidioidomycosis, disseminated or extrapulmonary
  • Cryptococcosis, extrapulmonary
  • Cryptosporidiosis, chronic intestinal (>1 month’s duration)
  • Cytomegalovirus disease (other than liver, spleen, or nodes), onset at age >1 month
  • Cytomegalovirus retinitis (with loss of vision)†
  • Encephalopathy, HIV related
  • Herpes simplex: chronic ulcers (>1 month’s duration) or bronchitis, pneumonitis, or esophagitis (onset at age >1 month)
  • Histoplasmosis, disseminated or extrapulmonary
  • Isosporiasis, chronic intestinal (>1 month’s duration)
  • Kaposi sarcoma†
  • Lymphoid interstitial pneumonia or pulmonary lymphoid hyperplasia complex*†
  • Lymphoma, Burkitt (or equivalent term)
  • Lymphoma, immunoblastic (or equivalent term)
  • Lymphoma, primary, of brain
  • Mycobacterium avium complex or Mycobacterium kansasii, disseminated or extrapulmonary†
  • Mycobacterium tuberculosis of any site, pulmonary,†§ disseminated,† or extrapulmonary†
  • Mycobacterium, other species or unidentified species, disseminated† or extrapulmonary†
  • Pneumocystis jirovecii pneumonia†
  • Pneumonia, recurrent†§
  • Progressive multifocal leukoencephalopathy
  • Salmonella septicemia, recurrent
  • Toxoplasmosis of brain, onset at age >1 month†
  • Wasting syndrome attributed to HIV

*Only among children aged <13 years.
†Condition that might be diagnosed presumptively.
§Only among adults and adolescents aged >13 years.

Clinical Manifestations vs. Opportunistic Infections

When their immune system is suppressed, people have weaker defenses against the wide variety of bacteria, viruses, fungi, and other pathogens that are present almost everywhere. A clinical manifestation is the physical result of some type of illness or infection.

The opportunistic infections associated with HIV include any of the infections that are part of an AIDS-defining classification. For example, the opportunistic infection cytomegalovirus often causes the clinical manifestation of blindness in people with AIDS.

HIV in the Body

Scientists are always learning new information about how HIV affects the body. HIV infection seems to affect many body systems. It is well known that HIV infection causes a gradual, pronounced decline in the immune system’s functioning. People with HIV are at risk for a wide variety of illnesses, both common and exotic.

HIV affects the:

  • Kind and number of blood cells
  • Amount of fat and muscle distribution in the body
  • Structure and functioning of the brain
  • Normal functioning of the immune system
  • Body’s basic metabolism

HIV infection can cause many painful or uncomfortable conditions, including:

  • Confusion or dementia
  • Diarrhea
  • Fatigue
  • Fever
  • Nausea or vomiting
  • Painful joints, muscles, or nerve pain
  • Difficulty with breathing
  • Urinary or fecal incontinence
  • Vision or hearing loss
  • Thrush (yeast infections in the mouth)
  • Chronic pneumonias, sinusitis, or bronchitis
  • Loss of muscle tissue and body weight

HIV in Children

Children show significant differences in their HIV disease progression and their virologic and immunologic responses, when compared to adults. Without drug treatment, children may have developmental delay, P. carinii pneumonia, failure to thrive, recurrent bacterial infections, and other conditions related to HIV. The antiretroviral treatments that are available for HIV infection may not be available in pediatric formulations. The medications may have different side effects in children than they do in adults.

It is vital that women know their HIV status before and during pregnancy. Antiretroviral treatment significantly reduces the chance that their child will become infected with HIV. Prior to the development of antiretroviral therapies, most HIV-infected children were very sick by 7 years of age. In 1994 scientists discovered that a short treatment course of the medication AZT for pregnant women dramatically reduced the number, and rate, of children who became infected perinatally. Cesarean sections for delivery may be warranted in certain cases to reduce HIV transmission. As a result, perinatal HIV infections have substantially declined in the developed world.

Early diagnosis of HIV infection in newborns is now possible. Antiretroviral therapy for infants is now the standard of care, and should be started as soon as the child is determined by testing to be HIV-infected. Apparently uninfected children born to HIV-positive mothers are currently treated with antiretroviral medicines for 6 weeks to reduce any possibility of HIV transmission.

HIV in Women

Certain strains of HIV may infect women more easily. The strain of HIV present in Thailand seems to transmit more easily to women through sexual intercourse. Scientists believe that women and receptive partners are more easily infected with HIV than insertive partners. Receptive partners are at greater risk for transmission of any sexually transmitted disease, including HIV.

Women infected with HIV are at increased risk for a number of gynecologic problems, including pelvic inflammatory disease (PID), abscesses of the fallopian tubes and ovaries, and recurrent yeast infections.

Some studies have found that HIV-infected women have a higher prevalence of infection with the human papilloma virus (HPV). Cervical dysplasia is a precancerous condition of the cervix caused by certain strains of HPV. Cervical dysplasia in HIV-infected women often becomes more aggressive as the woman’s immune system declines. This may lead to invasive cervical carcinoma, which is an AIDS-indicator condition. It is important for women with HIV to have more frequent Pap tests.

Several studies have shown that women in the United States who have HIV receive fewer healthcare services and HIV medications than men. This may be because women aren’t diagnosed or tested as frequently.

Access to Medical Care

As the medications that are available to treat HIV infection have become more numerous and complex, HIV care has become a medical specialty. If possible, people who have HIV infection should seek out a physician who is skilled in the treatment of HIV and AIDS.

People in Washington State may gain access to an HIV specialist through the assistance of the case manager(s) in their county. Call your local health department or health district for information on case management programs.

Impact of New Drug Therapies on HIV Clinical Progression

Before 1996 there were three medications available to treat HIV. These drugs were used singly and were of limited benefit. Researchers in 1996 discovered that taking combinations of these and newer medications dramatically reduced the amount of HIV (viral load) in the bloodstream of a person infected with HIV. Two or three different medications are used in combination. Each one targets a separate part of the 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).

Not everyone with HIV infection benefits from the new drug therapies. Some people cannot tolerate the unpleasant or serious side effects from the medications. Others cannot adhere to the complex treatment schedule. If patients do not take their medication every day according to their physician’s instructions, the drugs do not work effectively and viral resistance may develop.

Cost of new drug therapies can be prohibitive. Insurance programs and government programs for individuals with low income pay for much of the cost of the HIV medicines in Washington State. These medicines may cost upwards of $2,000 per person each month. People who live in other countries where the medication is unaffordable have very limited access to the newer therapies.

Although the new drug therapies work for many people to keep the amount of virus in their bodies to very low levels, they are not a cure for HIV. Once therapy is discontinued, viral load will increase. Even during treatment, viral replication occurs and the person remains infectious to others.

Resistance

Many people find that over time the virus becomes resistant to their medication and they must change medications. This is especially true when the medications are not taken correctly, but it limits the number of possible drug therapies the person might be able to use.

Side Effects

Patients often have unpleasant side effects when they use prescription medications to treat their HIV infection. These side effects include:

  • Nausea
  • Diarrhea
  • Peripheral neuropathy (numbness or pain in feet and hands)
  • Lipodystrophy: changes in body fat distribution, which presents with large fat deposits on the back of the neck, on the stomach area and in breast size in women and with pronounced thinning of the arms and legs
  • Interference with the metabolism of oral contraceptives
  • Osteoporosis
  • Diabetes or other changes in glucose metabolism
  • Very high cholesterol or triglycerides
  • Damage to the nervous system, liver, and/or other body organs

Treatment as Prevention

Treatment as prevention is the biggest scientific revolution in HIV/AIDS since the first antiretrovirals became available in 1996, and access to antiretrovirals has saved millions of lives.

Elly Katabira, AIDS 2012
International Chair and President
International AIDS Society (IAS)

Treatment as prevention is “giving antiretroviral therapy to HIV-infected individuals to dramatically reduce their infectiousness while protecting their health” (NIAID, 2012b). The Katabira quote above was released during the 2012 XIX International AIDS Conference, where treatment as prevention and related topics were among many promising and important presentations (IAS, 2012).

Antiretroviral therapy has, of course, been used to treat the AIDS virus in later stages and used quite successfully to help prevent transmission of HIV from pregnant women to their babies, but the knowledge that it can be used at much earlier stages to improve the health of the HIV-positive person and help protect their HIV-negative partners is an important breakthrough. Especially heartening was the presentation of results from a French study in which the participants received early antiretroviral therapy and “were able to successfully stop therapy without having a resurgence of their HIV infection” (IAS, 2012a).

Alternative Therapies

People have relied on alternative (sometimes called complementary) therapies to treat HIV infection for as long as HIV has been known. Many people use these treatments along with therapies from their medical provider. Other people choose to use only alternative therapies. These therapies comprise a wide range of treatments, including vitamins, massage, herbs, naturopathic remedies, and many more. While there is no evidence of harm from these treatments, there is also very little evidence of benefit. Many of these remedies have not been studied to see if they help.

It is important for people who are taking alternative therapies to tell their medical provider. There may be harmful side effects from the interactions of the “natural” medicine and antiretrovirals. For example, St. John’s Wort is an herbal remedy that interacts significantly with HIV medications.

Other drugs, including over-the-counter (OTC) medications, prescription medications, and street drugs, may have serious interactions with antiretroviral medications. It is extremely important that people on HIV medications tell their doctor, pharmacist, and social worker about all other drugs they take.

Case Management

People living with HIV often seek the assistance of an HIV case manager who can help explain the different types of services available. Washington State has several systems in place to provide prescription and medical assistance to people living with HIV and AIDS. Contact your local health department or district to find case management in your community. You can also call the Washington State Department of Health Client Services toll-free at 877 376 9316.

Children with HIV may also benefit from the Children with Special Health Care Needs program. Care coordinators for this program are located at every county health department or district. Local community-based organizations like the Northwest Family Center in Seattle, and specialty hospitals like Children’s Medical Center in Seattle and Mary Bridge Children’s Hospital in Tacoma may provide additional support to children and families.

Prevention Strategies

Vaccine

Many people involved in the prevention and treatment of HIV/AIDS share the sentiment expressed on HIV Vaccine Awareness Day, May 18, 2012, by Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID):

There is a growing consensus that we can significantly curtail the HIV/AIDS pandemic by implementing scientifically proven HIV prevention strategies. . . however, it is likely that controlling and ultimately ending the HIV/AIDS pandemic will require an effective vaccine as well. (NIAID, 2012b)

A series of promising vaccine research announcements were made over the last few years. Results of a study in Thailand in 2009 showed a modest but encouraging 31% protection rate, enough to show scientists they are moving in the right direction (UNAIDS, 2010). Then in fall 2011 news began to come out that scientists were making progress in understanding the success in the Thailand study (Calloway, 2011). In his 2012 talk, Fauci noted that analysis of specimens from that clinical trial had “yielded important clues about how the vaccine might have worked”an important step toward “improving upon the original vaccine regimen to confer a broader, more potent and longer-lasting effect” (NIAID, 2012a; 2012b). NIAID has a number of ongoing sponsored vaccine research projects (NIAID, 2012b).

In addition, at the end of 2011 it was announced that a Canadian-developed vaccine had been approved by the FDA to begin human clinical trials. This vaccine, unlike others in clinical trials, uses a killed whole virus instead of a live virus. Phase 1 of the three-phase trial was set to begin in January 2012 (CBC News, 2011).

On July 8, 2010, two papers published in Science announced discovery of “an antibody that can block more than 90% of strains of HIV-1, the most common form of the disease. . . It is the latest step in the quest to find a “broadly neutralizing” antibody, capable of blocking a large quantity of the many HIV-1 strains known around the world” (Ledford, 2010). In addition, MIT/Harvard researchers announced in the May 5, 2010, online edition of the journal Nature findings from a study investigating super controllersthe 1 in 200 people infected with HIV who never get AIDS.

It appears that super controllers “have a rare set of genes that allow their immune systems to unleash killer T cells with unusual powers.” Because normal people have a few of these killer T cells it is thought that a vaccine that could activate them and direct them against HIV, causing them to clone themselves, could be effective (DeNoon, 2010).

More information on vaccines, a glossary, media updates, and a list of vaccine trials for both preventive (for HIV-negative individuals) and therapeutic (for HIV-positive individuals) vaccines may be obtained at the NIH AIDS info website (http://www.aidsinfo.nih.gov/), and from the HIV Vaccine Trials Network (http://www.hvtn.org/), which is headquartered at the Fred Hutchinson Cancer Research Center in Seattle.

Pre-Exposure Prophylaxis (PrEP)

Pre-exposure prophylaxis (PrEP) is a new HIV prevention method in which people who do not have HIV infection take a pill daily to reduce their risk of becoming infected. The pill contains medications that prevent HIV from making new virus as it enters the body. Thus PrEP medicines can help keep the virus from establishing a permanent infection (CDC, 2012b).

The first PrEP medicine is a combination of 300 mg tenofovir and 200 mg emtricitabine known as TDF/FTC, or by its brand nameTruvada. Truvada was approved in 2004 for use as an HIV treatment, and on July 16, 2012 it was approved by the U.S. Food and Drug Administration (FDA) for “daily use by uninfected adults to help prevent the sexual acquisition of HIV” (CDC, 2012a, 2012b).

Commenting on the FDA’s approval, the director of the CDC’s HIV/AIDS center noted:

With 50,000 new HIV infections in the United States each year, additional prevention methods are urgently needed. . . . If delivered effectively and targeted to those at highest risk, pre-exposure prophylaxis (PrEP) could play an important role in our response to the HIV epidemic. Strong research evidence indicates that PrEP, when used consistently, is safe and effective at reducing the risk of acquiring HIV sexually” (CDC, 2012a).

Shortly after the announcement, the CDC released basic information on PrEP and interim guidance on the use of PrEP by men who have sex with men (MSM), the group for which it currently has the best demonstrated results. The CDC is reviewing data on the trials among heterosexuals and sponsoring a clinical trial of PrEP among injection drug users that is being done in Thailand. It is also participating in a joint effort to prepare more detailed guidance on the use of PrEP by MSM and by high-risk heterosexual men and women (CDC, 2012b).

Did you know . . .

In 2012 the FDA approved another PrEP medication, Stribild, a combination of four antiviral medications that can be taken just once a day (see bulletin at top of course).

Tuberculosis, Other STDs, and Hepatitis B and C

Because of the interrelationships between HIV, tuberculosis (TB), sexually transmitted diseases, HBV, and HCV, a brief discussion of each is included here.

Tuberculosis and HIV

Mycobacterium tuberculosis (TB) is transmitted by airborne droplets from people with active pulmonary or laryngeal TB during coughing, sneezing, or talking. Although TB bacteria can live anywhere in the body, infectious pulmonary or laryngeal TB poses the greatest threat to public health.

Cause of TB

Latent infection, which is asymptomatic and not infectious, can last for a lifetime. A presumptive diagnosis of active TB is made when there are positive test results or acid-fast bacilli (AFB) in sputum or other bodily fluids. The diagnosis is confirmed by identification of M. tuberculosis on culture, which should be followed by drug sensitivity testing of the bacteria.

Epidemiology of TB

Globally, there are probably 2 billion people (a third of the world’s population) infected with TB, and 8 million active cases each year. Tuberculosis is one of the leading causes of death in the world. In its Communicable Disease Report 2010 the Washington State Department of Health notes that there are approximately 250 new cases of TB each year and the number of deaths range from 2 to 18. However, the crude incidence rate continues to decrease.

In 2010 there were 236 cases of TB reported and in 2011 that number was 200. In 2011 only 7 of 39 counties had 5 or more cases. These 7 counties represent 92% of the cases, and over one-half (53%) were in King County (DOH, 2010; DOH 2012; DOH 2012a).

The incidence rate in Washington State for 2011 was 3.0%, slightly below the national rate of 3.4%, which itself saw a dramatic decline of 6.4% over the previous year (CDC, 2012c).

Transmission and Progression

When infectious secretions sneezed or coughed by an adult with pulmonary TB are breathed in by another person, the bacteria may come to rest in the lungs. After several weeks the bacteria multiply, and some asymptomatic, pneumonia-like symptoms may occur. The TB bacteria are carried through the bloodstream and lymph system, pumped through the heart, and then disseminated through the body.

The largest amount of bacteria goes to the lungs. In most cases, this process, called primary infection, resolves by itself and something called “delayed-type hypersensitivity” is established. This is measured with the tuberculin skin test. The incubation period for this primary infection is 2 to 10 weeks. In most cases, a latent state of TB develops. Ninety percent of people with latent TB (or LTBI) never experience subsequent disease. Other than a positive tuberculin skin test, people with latent TB infection have no clinical, radiographic (x-ray), or laboratory evidence of TB and cannot transmit TB to others.

Among the other 10% of infected individuals, the TB infection undergoes “reactivation” at some time and they develop active TB. About 5% of newly infected persons reactivate within the first 2 years of primary infection and another 5% will do so at some point later in life.

Symptoms of TB

The period from initial exposure to conversion of the tuberculin skin test is 4 to 12 weeks. During this period, the patient shows no symptoms. The progression to active disease and symptoms (such as cough, weight loss, and fever) usually occurs within the first 2 years after infection, but may occur at any time.

Prevention of TB

It is important to recognize the behavioral barriers to TB management, which include deficiencies in treatment regimens, poor client adherence to TB medications, and lack of public awareness. Primary healthcare providers need adequate training in screening, diagnosis, treatment, counseling, and contact tracing for TB through continuing education programs and expert consultation.

Promoting patient adherence to the sometimes-complicated medication schedule also requires consideration of patients’ cultural and ethnic perceptions of their health condition. Providing strategies and services that address the multiple health problems associated with TB (such as alcohol and drug abuse, homelessness, and mental illness) also builds trust and promotes adherence to treatment plans.

A daily regimen of Isoniazid for 9 months is recommended because prospective, randomized trials in HIV-negative persons indicate that 12 months of treatment is more effective than 6 months of treatment. Although a 9-month regimen of Isoniazid is the preferred regimen for the treatment of LTBI, a 6-month regimen does provide substantial protection.

In some situations, treatment for 6 months rather than 9 months may be cost-effective and still provide a favorable outcome. Thus, based on local conditions, health departments or providers may conclude that a 6-month rather than a 9-month course of Isoniazid is preferred.

Clinical trials have shown that daily preventive therapy for 12 months reduces the risk for TB disease by more than 90% in patients with LTBI who complete a full course of therapy. There is evidence that 6 months of preventive therapy with Isoniazid may also prevent disease in approximately 69% of patients who complete the regimen. Every effort should be made to ensure that patients adhere to this therapy for at least 6 months. Children should receive at least 9 months of preventive therapy.

Treatment of TB and Multidrug-Resistant TB

In order to prevent drug resistance and cure TB, the CDC recommends that TB be treated with a multidrug regimen that may last 6 to 12 months. Current recommendations can be found in the Washington State Department of Health’s TB Services Manual, updated in 2012, which outlines how public health staff complete TB control tasks in Washington State and is available online here from the department.

TB/HIV Co-Infection

People co-infected with HIV/TB are at considerably greater risk of developing TB disease than those with TB alone. Studies suggest that the risk of developing TB disease is 7% to 10% each year for persons who are infected with both M. tuberculosis and HIV, whereas it is 10% over a lifetime for a person infected only with M. tuberculosis.

In an HIV-infected person, TB disease can develop in either of two ways. A person who already has latent TB infection can become infected with HIV, and then TB disease can develop as the immune system is weakened. Or, a person who has HIV infection can become infected with M. tuberculosis and TB disease can then rapidly develop because the immune system is not functioning.

Any HIV-infected person with a diagnosis of TB disease should be reported as having TB and AIDS. For more information on TB, contact the:

Other STDs and HIV

The term STD(sexually transmitted disease) refers to more than twenty-five infectious organisms transmitted through sexual activity and dozens of clinical syndromes that they cause. Sexually transmitted diseases affect men and women and can be transmitted from mothers to babies during pregnancy and childbirth. They are also called sexually transmitted infections (STIs).

Bacterial, Viral, and Other Causes of STD

Bacteria cause STDs including chlamydia, gonorrhea, and syphilis. Viruses cause herpes, genital warts, hepatitis B, and HIV. Scabies are caused by mites, and pubic lice cause “crabs.” Trichomoniasis is caused by tiny organisms called protozoa; “yeast” infections are caused by fungi. Some STDs, such as pelvic inflammatory disease, can have more than one causea woman may have both gonorrhea and chlamydia causing PID. A man may have more than one cause for epididymitis, usually gonorrhea and chlamydia. Non-gonococcal urethritis (NGU) is usually caused by bacteria.

STD, Nationally and Internationally

Since the beginning of the AIDS epidemic, researchers have noted the strong association between HIV and other STDs. The CDC estimates that there are 19 million new STD infections of gonorrhea, chlamydia, and syphilisthe three that physicians are required to reportevery year in the United States.

The CDC sees troubling trends in all three diseases: gonorrhea reported rates are at an historic low but cases increased slightly in 2010 over 2009; chlamydia cases have been increasing steadily for 20 years and more than 1 million cases were reported in 2010; and, while the overall rate of syphilis declined slightly in 2010 for the first time in a decade, over the last five years it has increased dramatically in certain populations (CDC, 2011b).

Primary STD infections may cause pregnancy-related complications, congenital infections, infertility, ectopic pregnancy, chronic pelvic pain, and cancers. STDs can also accelerate other infections like HIV.

HIV and STDs

The presence of infection with other STDs increases the risk of HIV transmission because:

  • STDs like syphilis and symptomatic herpes can cause breaks in the skin, which provide direct entry for HIV.
  • Inflammation from STDs such as chlamydia makes it easier for HIV to enter and infect the body.
  • HIV is often detected in the pus or other discharge from genital ulcers from HIV-infected men and women.
  • Sores can bleed easily and come into contact with vaginal, cervical, oral, urethral, and rectal tissues during sex.
  • Inflammation appears to increase HIV viral shedding and the viral load in genital secretions.
STD Transmission

STDs are transmitted in the same way that HIV is transmitted: by anal, vaginal and oral sex. In addition, skin-to-skin contact is important for the transmission of herpes, genital warts, and HPV infection, syphilis, scabies, and pubic lice.

Symptoms of STD

In the past there was a great emphasis on symptoms as indicators of STD infection. Research has changed this. We now know that 80% of those with chlamydia, 70% of those with herpes, and a great percentage of those with other STDs have no symptoms but can still spread the infections.

Along with prompt testing and treatment for those who do have symptoms, the emphasis in the United States is on screening for infection based on behavioral risk. Patients cannot assume that their healthcare providers do STD testing. In other words, women who are getting a Pap test or yearly exam should not just assume that they are also being tested for chlamydia or any other STD.

Prevention of STD

The following steps will help prevent STD infection:

  • Abstain or be in a mutually monogamous relationship with an uninfected partner.
  • Know that many STDs have no symptoms.
  • Know that birth control pills and shots do not prevent infectionsyou must use condoms along with other birth control methods.
  • Go with your sex partner(s) for tests.
  • Avoid douching.
  • Learn the right way to use condoms and then use them correctly and consistently every time you have sex.
  • Be sure all sex partners are examined and treated if an STD occurs.
  • Change the ways you have sex so that there is no risk of infection.
  • Learn how to talk about correct use of condoms with all sex partners.
  • Practice the prevention you have learned for HIV and hepatitis.
STD Tests

At most sites, new urine LCR (urinate in a cup) tests for some STDs are available. The Western Blot (blood) test for herpes and hybrid capture tests for genital warts may also be available. In most places, however, cultures, wet preps, and blood draws for syphilis remain the standard testing method. It is vital that women get Pap tests, and that both men and women disclose a history of STD during medical workups.

STD Treatment

Treatment for STDs is based on lab work and clinical diagnosis. Treatments vary with each disease or syndrome. Because there is developing resistance to medications for some STDs, check the latest CDC treatment guidelines.

Hepatitis B and HIV

Hepatitis is inflammation of the liver that may be caused by many things, including viruses. Current viruses include hepatitis A (fecal/oral transmission), B, C, D, and others. Hepatitis B (HBV) is a virus that is transmitted by the blood and body fluids of an infected person.

Prevention of HBV

A vaccine to prevent HBV is available. Hepatitis B vaccine is administered intramuscularly as a three-dose series over 6 months. More than 90% of people who take the three injections become immune to HBV. Why isn’t everyone vaccinated for HBV? The HBV vaccine is relatively inexpensive for infants and children but more expensive for adults (costing about $150 per person). This cost is the likely reason that most adults are not vaccinated against HBV.

HBV Epidemiology

Each year tens of thousands of people become infected with HBV in the United States. Of these, about 2% to 6% of adults will become chronically infectious carriers of the virus. There are up to 1.4 million carriers of HBV in the United States.

HBV is not transmitted by:

  • Breastfeeding
  • Sneezing
  • Hugging
  • Coughing
  • Sharing eating utensils or drinking glasses
  • Food or water
  • Casual contact
Risk Factors for HBV Infection

Unvaccinated people are at higher risk for getting HBV if they:

  • Share injection needles/syringes and equipment
  • Have sexual intercourse with an infected person or with more than one partner
  • Are a man and have sex with a man
  • Work where they come in contact with blood or body fluids, such as in a healthcare setting, prison, or home for the developmentally disabled
  • Use the personal care items (razors, toothbrushes) of an infected person
  • Are on kidney dialysis
  • Were born in a part of the world with a high rate of hepatitis B (China, Southeast Asia, Africa, the Pacific Islands, the Middle East, South America, and Alaska)
  • Receive a tattoo or body piercing with equipment contaminated with the blood of someone infected with HBV
Progression of HBV

The average incubation period for HBV is about 12 weeks. People are infectious when they are “hepatitis B surface-antigen positive” (HBsAg), either because they are newly infected or because they are chronic carriers.

HBV causes damage to the liver and other body systems, which can range in severity from mild, to severe, to fatal. Most people recover from their HBV infection and do not become carriers. Carriers (about 26% of adults who become infected) have the virus in their body for months, years, or for life. They can infect others with HBV through their blood or other body fluid contact.

Symptoms of HBV

People with HBV may feel fine and look healthy. Some people who are infected with HBV display only mild symptoms, which could include:

  • Loss of appetite
  • Extreme fatigue
  • Abdominal pain
  • Jaundice (yellowing of the eyes and skin)
  • Joint pain
  • Malaise
  • Dark urine
  • Nausea or vomiting
  • Skin rashes

Others who are infected with HBV experience more severe symptoms, and may be incapacitated for weeks or months. Long-term complications may also occur, and include chronic hepatitis, recurring liver disease, liver failure, and cirrhosis (chronic liver damage).

Prevention of HBV

A vaccine for HBV has been available since 1982. This vaccine is suitable for people of all ages, even infants. People who may be at risk for infection should get vaccinated. To further reduce the risk of or prevent HBV infection, a person can:

  • Abstain from sexual intercourse and/or injecting drug use
  • Maintain a monogamous relationship with a partner who is uninfected or vaccinated against HBV
  • Use safer sex practices (as defined in the Transmission section)
  • Never share needles/syringes or other injection equipment
  • Never share toothbrushes, razors, nose clippers, or other personal care items that may come in contact with blood
  • Use Standard Precautions with all blood and body fluids

Infants born to mothers who are HBV carriers have a greater than 90% reduction in their chance of becoming infected with HBV, if they receive a shot of hepatitis B immune globulin and hepatitis B vaccine shortly after birth, plus two additional vaccine doses by age 6 months. It is vital that the women and their medical providers are aware that the woman is a HBV carrier. People with HBV should not donate blood, semen, or body organs.

Treatment of HBV

There are no medications available for recently acquired (acute) HBV infection. There are antiviral drugs available for the treatment of chronic HBV infection, however treatment success varies by individual. The vaccine is not used to treat HBV once a person is infected.

Hepatitis C and HIV

Hepatitis C is a liver disease caused by the hepatitis C virus (HCV), which is found in the blood of persons who have this disease. Hepatitis C is the leading cause of chronic liver disease in the United States. Hepatitis C was discovered in the late 1980s, although it was likely spread for at least 40 to 50 years prior to that.

HCV Epidemiology

Globally, 180 million people are infected with HCV. An estimated 4.1 million Americans have been infected with HCV and about 3.2 million are chronically infected (meaning they have a current or previous infection with the virus). The CDC estimates that as many as 1 million Americans were infected with HCV from blood transfusions, and that 3.75 million Americans do not know they are HCV-positive. Of these, 2.75 million people are chronically infected and are infectious for HCV.

In the United States, 8,000 to 10,000 deaths per year are attributed to HCV-associated liver disease. The number of deaths from HCV is expected to triple in the next 10 to 20 years. An estimated 110,000 people in Washington State are infected with HCV.

Transmission of HCV

HCV is transmitted primarily by blood and blood products. Blood transfusions before 1992 and the use of shared or unsterilized needles and syringes have been the main causes of the spread of HCV in the United States. The primary way that HCV is transmitted now is through injecting drug use. Since 1992, all blood for donation in the United States is tested for HCV.

Sexual transmission of HCV is considered low, but it accounts for 10% to 20% of infections. If a pregnant woman is infected with HCV, she may pass the virus to her baby but this occurs in only about 5% of those pregnancies. Household transmission is possible if people share personal care items such as razors, nail clippers, or toothbrushes.

HCV is not transmitted by:

  • Breastfeeding (unless blood is present)
  • Sneezing
  • Hugging
  • Kissing
  • Coughing
  • Sharing eating utensils or drinking glasses
  • Food or water
  • Casual contact
Progression of HCV

The severity of HCV differs from HIV. The CDC states that, for every hundred people who are infected with HCV:

  • About 15% will fully recover and have no liver damage
  • 85% may develop long-term chronic infection
  • 70% may develop chronic liver disease
  • 20% may develop cirrhosis over a period of 2030 years
  • 1%5% may die from chronic liver disease
Symptoms of HCV

Persons with HCV may have few or no symptoms for decades. When present, the symptoms of HCV are:

  • Nausea and vomiting
  • Weakness
  • Fever
  • Muscle and joint pain
  • Jaundice (yellowing of the eyes and skin)
  • Dark-colored urine
  • Tenderness in the upper abdomen
Prevention of HCV

There is no vaccine to prevent HCV infection. The following steps can protect against HCV infection:

  • Follow Standard Precautions to avoid contact with blood or accidental needlesticks.
  • Refrain from acquiring tattoos or skin piercings outside of a legitimate business that practices Universal Precautions.
  • Refrain from any type of injecting drug use or drug equipment sharing.
  • Never share toothbrushes, razors, nail clippers, or other personal care items.
  • Cover cuts or sores on the skin.
  • Persons who are HCV-infected may lower the small risk of passing HCV to their sex partner by using latex condoms and practicing safer sex.
  • Women who are HCV-infected and wish to have children should discuss their choices beforehand with a medical specialist.

People with HCV should not donate blood, semen, or body organs.

Treatment of HCV

Currently there are approved antiretroviral treatments for HCV. The cost of the treatments can be high, and the side effects can be significant (fatigue, flu-like symptoms, nausea, depression, and anemia). People infected with HCV should abstain from alcohol use to avoid further damage to the liver.

Testing for HCV

Many people who are infected with HCV are unaware of their status. People who should consider testing are:

  • Current or former injecting drug users
  • Persons who received blood transfusions or an organ transplant prior to 1992
  • Hemophiliacs who received clotting factor concentrates produced before 1987
  • Persons who received chronic hemodialysis
  • Infants born to infected mothers
  • Healthcare workers who have been occupationally exposed to blood or who have had accidental needlesticks
  • Persons who are sex partners of people with HCV

Testing for HCV is available through physicians and some health departments. In 1999 the Food and Drug Administration approved the first home test for HCV. The test kit, called “Hepatitis C Check,” is available from the Home Access Health Company. The test is accurate if it has been at least 6 months since the possible exposure to HCV.

HIV/HCV Co-Infection

Many people who become infected with HIV from injecting drug use are already infected with HCV. Some estimate that 40% of HIV-infected people in the United States are also infected with HCV. People who are co-infected with both viruses and have immune system impairment may progress faster to serious, chronic, or fatal liver damage. Most new HCV infections in the United States are among injecting drug users. The majority of hemophiliacs who received blood products contaminated with HIV also are infected with HCV.

Treating HIV in someone with HCV may be complicated because many of the medicines that are used to treat HIV may damage the liver; however, treatment for co-infection is possible in some cases with close physician supervision.

Comparison Chart of HIV, HBV, and HCV

Transmission by

HIV

HBV

HCV

Blood

Yes

Yes

Yes

Semen

Yes

Yes

Rarely (more likely if blood present)

Vaginal fluid

Yes

Yes

Rarely (more likely if blood present)

Breast milk

Yes

No (but may be transmitted if blood is present)

No (but may be transmitted if blood is present)

Saliva

No

No

No

Target in the body

Immune System

Liver

Liver

Risk of infection after needlestick exposure to infected blood

0.5%

131%

23%

Vaccine available?

No

Yes

No

For more information on Hepatitis B or C, go to the CDC hepatitis website or call the Hepatitis Hotline at 888 443 7232.

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