Opportunistic Infections, Medical Conditions, and Neoplasms
It is necessary to note that some of the illnesses and medical conditions may not necessarily be the result of HIV/AIDS. There may be present pre-existing or other risks for those with HIV/AIDS that are unrelated to the disease. Factors from HIV/AIDS may contribute to the infections and conditions that are found with HIV/AIDS. So those responsible for diagnosing of opportunistic infections need to rule out other factors before a diagnosis of an opportunistic infection or neoplasm is made. The following information provides a summary on typical infections, medical conditions, and neoplasms found with HIV/AIDS.
Information has been paraphrased from the Website: http://hivinsite.ucsf.edu/InSite?page=kb-00&doc=kb-04-01-02
Problems in the neurological system can arise from the HIV infection itself, opportunistic infections, and the antiviral drugs that given to treat the infection. 90% of deceased patients at autopsy suggested some neurological involvement. Also 5 to 10% of AIDS patients initially presented with some type of neurological problem. It can cause chronic encephalitis and may be the source of these problems. Other specific problems include:
AIDS Dementia Complex - This diagnosis usually comes by exclusion since it resembles other conditions. The blood brain barrier is traversed by infected macrophages that adher to endothelial cells. The neurotoxins that are produced in the brain cells cause increased calcium to be taken into the cells and leads to neuron death. Patients with HIV-1 form present cognitive dysfunction, impaired motor performance, and behavioral changes. All stages of HIV may have some presentation of impairment. Specific changes are mental slowing, forgetfulness, poor concentration, apathy, social withdrawal, loss of spontaneity, and reduced libido. Other changes may be reduced emotional expression, increased irritability, mania, disinhibition, loss of fine motor control, slowing gait, unsteadiness, urinary incontinence, and tremor. 10% of patients have seizures and transient neurologic deficits occurred in advanced HIV-1 disease with dementia. Coma occurs before the patient dies. Antiretroviral treatment with Retrovir, cytokine antagonists and inflammatory mediators should be included especially if the cross the blood brain barrier.
Myleopathy - This condition has spinal cord involvement but is rare. The bowel becomes spastic and the bladder has dysfunction. The gait is ataxic and sensory loss may be common. Treatment is similar to dementia and involves preserving functional status and decreasing symptoms.
Distal symmetric polyneuropathy - Neuritis in the fingertips and toes occurs with advanced infections and the use of antiviral agents of zalcitabine (HIVID), didanosine (Videx), and stavudine (Zerit). Since symptoms may be dose related, dosage of the medicine should be adjusted or discontinued with symptom treatment.
Inflammatory demyelinating polyneuropathy
This condition appears early in the course of disease and found less often then distal symmetric polyneuropathy. It may be autoimmune in nature and reported with primary infection. Symptoms resemble Guillain-Barrè syndrome such ascending weakness. Patients may show improvement with plasmapheresis, intravenous immunogobulin, and steroid therapy.
Autonomic neuropathy-Since this affects the autonomic nervous system, some presenting symptoms areorthostatic hypotension, resting tahycardia, impotence, urinary dysfunction, syncope, and diarrhea. Cardiac conduction problems can lead to cardiopulmonary arrest.
Neurological Infections:
Bacterial, fungal, viral, and parasitic can run vampant in the HIV infected person.
Cerebral toxoplasmosis - Identified by positive IgG titers, usually it is reactivated in 2% to 10% of patients that had prior infection. It occurs usually when CD4+ counts are less than 100. If it occurs treatment is with Cleocin or Daraprim with remission in 10 to 14 days. However, lifetime therapy should be instituted. Primary prophylaxis should be given if patient is at risk.
Cryptococcal pneumonia - The organism, Cryptococcus neoformans, can cause fungal meningitis. It is contracted via the respiratory system with rapidly spreading infection to the central nervous system. Symptoms may be nonspecific in some patients. Cerebral Spinal Fluid (CSF) culture confirms diagnosis. Mortality rate is 10% to 20%. Poor prognosis indicators include age 35 or older, cognitive impairment, CSF cryptococcal antigen > 1:1,024, CSF white blood cell count less than 20/mm3, low CSF glucose level, positive extraneural cultures, high opening spinal pressure, and hyponatremia. Intrcranial pressure is high because of impaired CSF reabsorption.
Antifungal treatments with highly toxic medications such as Amphotericin B and Diflucan should be instituted. Diamox, CSF drainage, and ventriculoperitoneal shunting is required because aggressive treatment is needed. The prostate may act as a resevoir for the organism. Lifelong therapy needs to be instituted if the patient survives. Primary infection prophylaxis is not recommended because of low incidence of the infection, lack of proven survival benefits, drug interactions, drug resistance, and cost.
Cytomegalovirus (C MV) encephalitis
CMV develops in less than 2 years at a rate of 21% if CD4+ counts are less than 100. Antiretroviral therapy has helped to decrease the incidence. Retinitis and esophagitis may be present in CMV disease as well as colitis, pneumonitis, and hepatitis. CNS infection may be seen as encephalitis or as a disseminated infection. Ganciclovir sodium (Cytovene0 or foscarnet sodium (Foscavir) have been used with variable results.
Neurosyphilis-The disease interval is shorter than the normal interval for neurosyphilis. Acute syphilic meningitis, ocular disease, or hearing loss occurs more frequently. Positive serologic findings should be explored for CSF involvement.
Tuberculosis meningitis-This infection has been on the rise since the start of the HIV pandemic. The clinical manifestations have changed with extrapulmonary disease being common with advanced immunosuppression of the disease. Brain abscesses and tumors are more common.
Neoplasm-Lymphoma occurs in 5% of AIDs patients. A Thallium single photon emission CT Brain scan helps distinguish lymphoma from toxoplasmosis but brain biopsy is confirmatory. Prognosis is poor. Radiation therapy response is variable. Chemotherapy and radiation regimens may be helpful someday.
There is still much to be explored in neurological findings for diagnosis and treatment. Newer drug availability may diminish the number of neurological complications in the future.
This information has been paraphrased from http://hivinsite.ucsf.edu/InSite?page=kb-04-01-08
Nutrition
Nutrition is important to everyone but even more so in the late stages of HIV infection. Malnutrition contributes to increased resource usage in the United States. Only by understanding the role nutrition plays in HIV can management of AIDS related treatment and mortality be reduced.
Various studies have presented differing points of view for HIV and AIDS malnutrition. Studies have shown that body cell mass reduction was out of proportion to the loss of body weight. The individual with AIDS is not in a starved state but an injured state. It is a complication but can be treated. Other studies indicate that death from wasting in AIDS disease was related to the degree of body mass depletion. Still other studies indicate a micronutrient deficit with normal food intake and supplements may be helpful.
Early HIV phase does not show any nutritional compromise. The middle phase of HIV shows lab value abnormalities but not clinical abnormalities of immune deficiencies. Some weight loss, variable fatigue, and non specific symptoms contribute to the list of changes. Elevated resting energy expenditure and chronic inflammation in the serum provides evidence of the metabolic response to HIV infection. Weight gain does occur after antiretroviral treatment has begun. In the late phase of HIV and advanced immunodeficiency, malnutrition is severe and progressive. Weight loss in this stage has a reason. There are two patterns of weight loss that have been identified. Opportunistic infections are often associated with one pattern of rapid weight loss and the pattern has its focus on gastrointestinal (GI) disorders that are slow but progressive. GI disorders involve food intake or absorption.
These patterns may be the result of a single factor or multiple factors from alteration in intake, absorption, and body metabolism. Food intake problems can result from lesions in any part of the oropharynx and esophagus, neurologic problems, infections, and medication side effects. Studies have shown that short term weight loss generally occur from decreased food intake from anorexia but also showed an increase in body metabolism from the disease itself. Most of these patients were sedentary and expended very little voluntary energy. Disease specific complications result in malabsorption problems. Failing to increase food consumption for calories lost also was a contributor to the problem.
Systemic infections require increased calorie consumption from metabolic hyperactivity and protein wasting in infected individuals. Large amounts of essential amino acids are used at this time by the skeletal muscles to respond to the systemic effects of inflammatory responses and other mechanisms in protein metabolism. Infections need to be treated since they are responsible for suppress appetite stimulation. Other metabolic alterations can occur as well.
Only by accurately diagnosing and treating HIV complications can the wasting syndrome be contained as well as conditions related to GI tract. Small bowel involvement is usually localized and nutrients are malabsorbed whereas the large bowel or colon is inflamed with dissemination throughout. Studies have shown that infection and mucosal injury was most often associated with malabsorption and AIDS patients had normal absorption. Non-invasive studies can be completed on the small intestine and tissue samples done as needed for specific diagnoses.
For best nutritional support, underlying conditions and diseases need to be effectively diagnosed and treated. Enteral and parenteral forms of nutrition are available to compensate for losses or malabsorptions. Functional improvement, body cell mass increases, and increased serum protein concentrations can occur. Appetite stimulants such as Megace have shown to be effective in treating malnutrition with increased appetite and body mass. Any indication of anorexia should be evaluated.
Clinical signs and symptoms need to be evaluated to differentiate between all forms of pneumonia and other opportunistic respiratory conditions and neoplasms in the HIV patient. Laboratory values such as WBCs and serum lactate dehydrogenase as well as the CD4+ and viral load, pulse oximetry, radiographic exam, and lung auscultation help to differentiate between the findings present in the different types of pulmonary conditions. Risk factors such as exposure to initial exposure to HIV, demographics, and regional differences also help in diagnosis. Sputum cultures, blood cultures, and bronchoscopy help to provide a definitive diagnosis. Bacterial pneumonia is more frequent in causing clinical signs and symptoms than Tuberculosis and neoplasms.
Information was paraphrased from the MMWR: Recommendations and Reports, Treatment of Tuberculosis, June 20, 2003, 52(RR11), 1-77. The report appeared originally in the American Journal of Respiratory and Critical Care Medicine (2003) Vol.167, 603-662.
An HIV positive person should be checked for TB and vive versa. Tests that should be performed for positive TB confirmation include: Three sputum specimens need to be obtained for acid fast bacillus (AFB) smear. Susceptibility test for the TB treatment drugs should also be performed. A chest x-ray should be performed. During the treatment, all patients should have a minimum of monthly AFB smear until two consecutive specimens are negative on culture. Treatment should last for a minimum of 6 months if on the standard daily regiment of three drugs: Izoniazide (INH); Rifampin, Rifabutin, or Rifapentine; and Pyrazinamide (PZA). Some of these drugs are available in two drug combinations and 2-3 times/week regiment instead of daily. HIV related TB has a high rate of relapse with the drug, Rifampin. A healthcare provider specializing in HIV related tuberculosis should be consulted particularly because of the interactions that could occur with HIV medications and Rifampin. Patients with HIV related TB might experience a temporary exacerbation of signs, symptoms, or radiographic manifestations of TB while on TB treatment. It is a paradoxical reaction that may be from immune reconstitution from effective antiretroviral therapy. All other etiologies for high fevers, lymphadenopathy, and worsening chest radiographic findings should be looked at including TB treatment failure. Non steroidal anti-inflammatory drugs and prednisone may be useful for symptom relief. It is especially important the HIV infected individual adheres to their treatment plans to prevent multiple drug resistance. Education and counseling should be done as well.
For complete monologue on Treatment of Tuberculosis, go to the Website: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm
The following information has been paraphrased from http://hivinsite.ucsf.edu/InSite?page=kb-04&doc=kb-04-01-05
Some of the most common pneumonias associated with HIV/AIDS are Pneumocystic carinii (PCP), Cryptoform neoforms, Haemophilus influenzae, and Streptococcus pneumonia. Pneumonias in the HIV/AIDS patient are generally from "dysfunctional host defenses rather than increased colonization of the disease" (Daley, 1998). In one study the most common pathogen found to cause pneumonia was Streptococcus pneumonia. Fever, productive cough, and a CBC shows a relative leukocytosis. Chest x-rays are abnormal.
Bacterial pneumonias
Sputum Gram stain and blood cultures should be obtained and evaluated in all HIV/AIDS patient if the patient presents with respiratory problems. Acute sinusitis and otitis media may be present prior to the pneumonia diagnosis. Patients with severe moderate to severe pneumonia should be hospitalized and treated with parenteral antibiotics. Milder cases of community acquired pneumonias can be treated as an outpatient on oral antibiotics. A rapid response to therapy is usually achieved in bacterial pneumonias and if not, other pathogens should be evaluated such as PCP. Prevention is important and could be achieved through pneumococcal vaccination, intravenous immunoglobulin, and oral antibiotics. CDC recommends that all those with HIV-1 infections over the age of 2 be vaccinated with 23-valent pneumococcal polysaccharide vaccine.
Information has been paraphrased from an article by the AIDS Research Alliance in America, Searchlight, Spring, 2000, pages 1, 4-5, 7-8,13-18.
Many skin conditions that manifest themselves in patients with HIV/AIDS are similar in nature and especially common with the disease. Careful testing and interpretation of results as well as a health history help in diagnosis the dermatology problems associated HIV/AIDS. Treatment protocols such as HAART have helped ameliorate many of the opportunistic infections associated with HIV/AIDS. However, this has not been the case with dermatology problems. One study estimates from surveys that 80-90% of patients have some type of dermatologic condition. Newer treatment drugs have also been responsible for some of these problems. Hollowed cheeks, dry lips and skin, inflamed nailbeds, and rashes are common side effects. Viral infections include: human papilloma virus (HPV), molluscum contagion, human herpes virus-8, herpes simplex virus, herpes zoster virus, and Epstein-Barr virus. Viruses may be allowed to grow unchecked from immune suppression. Most are treatable with drugs such as Acyclovir, famcyclovir, and valacyclovir. Antihistamines and cortisone have proven helpful in the treatment of skin problems.
Human papilloma virus have the patient present with warts on the beard area, fingers, feet, and genitals as well as the mouth and anus. Various treatments such as freezing, electrodessication, and topical agents.
Molluscum contagiosum usually appears on the face and groin areas. Hundreds of white and gray dome-shaped papules can appear on any place on the body. HAART therapy has helped limit some of this condition. Treatment includes curettage, electrodessication, or topical preparations.
Kaposi's sarcoma is a purple skin cancer that appeared quite a bit before HAART therapy. It is more common in gay patients than in heterosexual patients, drug users, and hemophiliacs. This fact may implicate that specific sexual practices via oral fecal route help in the transmission of the human herpes virus-8 causing the disease. HAART therapy is the best treatment for Kaposi's sarcoma. As the therapy helps to restore the immune system, the lesions disappear. Systemic chemotherapy may be used if resistant to HAART. Other localized treatments are available.
Many times with skin eruptions occur in patients with CD4+ count that is rising in response to HAART therapy. It is believed that the ineffective immune system is responding to "previously unrecognized cutaneous agents".
For a website to read more about dermatologic conditions in HIV, go to: http://www.emedicine.com/derm/topic792.htm
Information on classes of drugs has been paraphrased from The Body: The Complete HIV and AIIDs Resource - Read FirstWebsite at http://www.thebody.com/index/treat/antivir_basics.html/
There are four classes or types of FDA- approved antiretroviral medications: nucleoside reverse transciptase inhibitors known as NRTIs, non-nucleoside reverse transcriptase inhibitors known as NNRTIs, protease inhibitors (PIs), and fusion inhibitors. Newer classes such as nucleotide inhibitors and immune modulators should be available in the near future. Some of these drugs come in combinations so as to promote adherence to therapy.
NRTIs
This class of drug inhibits reverse transcriptase, an enzyme, that is used by
retroviruses such as HIV to convert RNA to DNA. If the DNA is not created in
the cell's core then HIV cannot infect the cell. HIV converts successfully into
proviral DNA within 72 hours after infection. This class of drug tricks the
HIV into using the drug instead of the body's nucleosides. One problem is that
these drugs also interfere with other body processes using other enzymes that
the body uses too. Drugs include: Zidovudine (Retrovir, ZDV,AZT); Stavudine(d4T,
Zerit); Emtricitabine (Emtriva), Lamivudine (Epivir, 3TC); Tenofovir (Viread);
Abacavir (Ziagen,ABC, and others. Some drugs cross the blood brain barrier.
NNRTIs
This class of drugs also interferes with reverse transcriptase by directly binding
with the virsus' reverse transcriptase to prevent HIV replication. These drugs
are metabolized by the liver so drug interactions are frequent. They have fewer
side effects are effective in crossing the blood brain barrier as well. Drugs
in this class include: Efavirenz ( Sustiva, EFV), Delavirdine (Rescriptor),
Entravirine (Intelence), and Nevirapine (Viramune, NVP).
Protease Inhibitors
This class of drugs do exactly what the drug is called - inhibit protease. Protease
is a digestive enzyme that breaks down protein in all living cells. HIV protease
cuts proteins and viruses into smaller pieces that infect new cells. Immature
virus particles are prevented from becoming mature virus particles. It works
on both newly infected cells and cells that have been infected for a long time.
Side effects tend to be gastrointestinal nature and cause tolerance problems.
Hypercholesterolemia and fat redistribution are serious side effects. The drugs
do not usually have overlapping toxicities. Heart disease and diabetes may develop
in those with risk factors for these problems. PIs have poor penetration in
cerebral spinal fluid (CSF). They are highly protein bound which means that
there is less drug available to work against the HIV infection. Indiavir ( Crixivan,
IDV) as the highest CSF penetration rate of PIs. Other drugs include: Atazanavir
(Reyataz); Darunazir (Prevista); Fosamprenavir (Lexiva); Nelfinavir (Viracept,
NFV); Ritonavir (Norvir, RTV) for HIV-2; Amprenavir (Agenerase, AMP); lopinavir;
Saquiavir (Fortovase, SQV), and others.
Examples of Combination Drugs:
Combivir - AZT and Epivir
Trizivir - ZDV, 3TC, and ABC
Kaletra - Lopinavir and Ritonavir
Atripla - Emtriva, Viread, and Sustiva
Fusion Inhibitors
This class is a new type of drug as of March 13, 2003 and it works by blocking
the entrance to the cell from HIV virus. It specifically works by preventing
conformational changes needed for fusion of viral and cellular membranes. This
drug is given by subcutaneous injection. Side effects generally occurred at
local injection sites. Reactions include: pain or discomfort, induration, eruthema,
nodules and cysts, pruritus, and ecchymosis and more seriously abscess and cellulites.
Hypersensitivity reactions have also been noticed in the form of rash, fever,
nausea, vomiting, chills, rigors, hypotension, and elevated serum liver transaminases.
No drug interactions have been identified with antiretroviral medications. Earliest
drug developed was Enfuvirtide (Fuseon, T-20). Additional fusion inhibitors
are Enfuvirtide (Fuzeon); Maraviroc (Selzentry, Celsentri); and Reltegravir
(Isentress).
Specific information on HIV drugs is available at the U.S. Department of Health and Human Services AIDSinfo Website: http://aidsinfo.nih.gov/drugs and the Centers for Disease Control website: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a4.htm
HIV Vaccination
In 2009, The National Institutes of Allergy and Infectious Disease received approval to test a vaccination for prevention called HVTN 505. However, the National Institutes of Health halted this trial because the vaccine did not prevent HIV nor reduce the amount of HIV found in blood (National Institutes of Health, 2013).
HAART Therapy
HAART stands for Highly Active Antiretroviral Therapy. HAART is the
recommended treatment protocol for HIV and is a combination of three or more
medications. The treatment itself is prescribed for each individual patient
based on diagnostics such as CD4+ and viral load. The first recommended regimen
normally consisted of Sustiva + Epivir + Retrovir or Kaletra + Epivir + Retrovir.
There are other combinations available. Three drugs or more should be taken
because a decrease in viral load will be temporary. Pregnant women may not take
the standard treatment.
Negative side effects from HAART include:
Liver problems
Diabetes
Lipodystrophy syndrome
Hypercholestolemia
Hemorrhage with hemophilia
Osteoporosis
Skin rash
From the website - The Body: The Complete HIV and AIDs Resource: HIV Medications:
The Basics that is available at: http://www.thebody.com/index/treat/antivir_basics.html
Early vs. Later Treatment for HIV
Reasons for early treatment include:
An intact immune system offers better control
Viruses are more homogenous that is not present in long term infection
Fewer resistant isolates of infection
Enhanced efficacy of the treatment
Earlt treatment does not eradicate the disease but holds it in check for many
years. The definition of eradiation of the disease should include: absence
of any detectable virus from blood, plasma, and tissue compartments such as
lymph, prostate, central nervous system, no evidence of horizontal or vertical
transmission, and complete cessation of immune suppression. Detection will
improve as the tests for sensitivity in the identification of the virus improve.
Viral rebound has occurred in some patients with early HIV infection after treatment
so optimism in eradiation of the disease has not been founded.
In April, 2012, the World Health Organization made a new recommendation for couples if one partner is HIV positive. If only one partner is HIV positive and regardless of immune status, the HIV positive partner should receive antiretroviral treatment to reduce the likelehood of transmission to the HIV negative partner - http://www.who.int/hiv/pub/guidelines/9789241501972/en/
From Surveillance of Healthcare Personnel with HIV/AIDS (December, 2002)
This information provides an early overview of the healthcare worker exposure.
There is documentation that fifty-seven health care workers seroconverted post
occupational exposure to HIV. Twenty six of these workers went on to develop
AIDS. Exposures resulted from: percutaneous exposure from cut or puncture (48),
mucocutaneous exposure from mucous membrane or skin (5), both percutaneous and
mucocutaneous (2), and unknown exposure (2). Fluid type exposure includes: HIV
infected blood (49), concentrated virus in a laboratory (3), visibly bloody
fluid (1), and unspecified fluids (4). There are another 139 cases of health
care workers with HIV/AIDS who have no other reported risk factors for HIV/AIDS
exposure and have a history of exposure to blood, body fluids with blood, or
HIV laboratory material but for whom seroconversion after exposure was not documented.
According to the CDC, as of December 2002, adults with AIDS with a history of
employment in healthcare is as follows:
Nurses -5,378
Health aides - 5, 638
Technicians - 3,182
Physicians - 1,792
Therapists - 1, 082
Dental workers - 492
Paramedics - 476
Surgeons - 122
Other - 5,050
Total - 23,212
Overall, 73% of all healthcare workers reported with AIDS have died.
Prevention of Occupational Transmission to HIV
The following information has been paraphrased from the Center for Disease
Control Website: http://www.cdc.gov/niosh/topics/bbp/universal.html
Prevention of HIV infection is maintained through guidelines called "Universal
Precautions". Universal precautions were designed in response to HIV and hepatitis
in 1983 with the objective of preventing transmission of all blood-born and
bodily fluid pathogens in providing first aid or health care. It was initially
called "Blood and Body Precautions" in the CDC Guidelines for Isolation Precautions
in Hospitals. Conflict ensued with the development of these new guidelines because
these precautions do not eliminate the need for other isolation precautions
such as droplet precautions, airborne precautions, or contact isolation. For
those who do not know the difference between these isolation precautions, they
will be taught in your formal nursing courses.
Universal precautions refer to blood or body fluids that contain visible blood, semen, and vaginal secretions. Universal precautions apply to tissues and fluids from cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids. It does not apply to feces, nasal precautions, sputum, sweat, tears, urine, and vomitus unless visible blood is seen.
Protective Barriers
Protective barriers for universal precautions include:
Gloves
Gowns
Aprons
Masks
Protective eyeware.
These barriers protect the health care workers skin and mucous membranes from exposure to suspect materials. When in doubt, a healthcare worker should always use protective barriers. Injuries should be prevented from needles, scalpels, and other sharp instruments as well.
Consistent, routine usage of appropriate, protective barriers prevents skin and mucous exposure in contacting blood or other body fluids.
Gloves should be worn if you will be touching blood or body fluids or handling any items or surfaces soiled with blood or body fluids. Gloves should be changed after contact with each patient. Handwashing should be performed after gloves are removed. Gloves should always be available to all health care workers in adequate supply.
Masks and protective eyeware need to be worn to prevent exposure of mucous membranes of the mouth, nose, and eyes during procedures that could result in exposure to droplets of blood or body fluids. Gowns or aprons should be worn if splashing of blood or body fluids might occur during a procedure.
Prevention from Needle-Stick Injuries
Universal precautions for injury prevention from needles, scalpels, and other sharp instruments should be used during procedures, cleaning instruments, disposal of sharps, and handling of instruments after procedures. Do not recap needles on syringes after usage. All needles or sharps should be placed in a puncture-resistant container for disposal or reprocessing. Safety devices have been developed to prevent needlestick injuries. Strategies for safe disposal should be evaluated and investigated.
Other infection control processes should include:
Gloves should be worn for digital examination of mucous membranes and endotracheal suctioning
Handwashing after exposure to saliva
Minimize direct emergency mouth to mouth resuscitation with mouthpieces and other ventilatory devices
Gloves should be worn if frequent exposure to breast milk occurs.
All blood and body fluids should be considered potentially infectious.
Healthcare administrations are required to have procedures for infection control and a system to report and management occupational exposure. New and better safety devices are being developed. At place of employment, all healthcare facilities have written policies that dictate specifics for universal precautions. Consistent usage is the best key to preventing injuries.
Post exposure prophylaxis(PEP) needs to be up-to-date and consistent with recommendations by CDC.
Treatment for Exposure to Blood
This information was summarized from a brochure by Department of Health and Human Services, Centers for Disease Control, Exposure to Blood - What Healthcare Personnel Need to Know, July, 2003.
Health care workers need to know that being exposed to HIV does not mean that an infection will follow.
Infection risk varies with:
The pathogen itself
Type of exposure
Amount of fluid involved
Amount of pathogen in the infected person at time of exposure
All employers should have a reporting mechanism in place in order to evaluate the risk of infection, provide information on treatment availability to prevent infection, monitor the side effects of treatment, and determine of infection occurrence that should include testing and post exposure treatment (PEP).
What to Do If Exposed to Blood or Body fluids
The first rule is prevention of an HIV exposure as discussed in previous section "Prevention of Occupational Transmission to HIV". Follow universal precautions when coming in contact with blood or body fluids is strongly encouraged.
The second rule for exposure to blood or body fluids is to:
Wash all needlesticks or cuts with soap and water
Flush splashes to nose, mouth, and skin with copious amounts of water
Irrigate eye with clean water, saline, or sterile irrigants.
Each healthcare facility has a specific policy and procedure to follow for initial exposure.
The third rule after washing or flushing is to file a report to appropriate department for managing exposures. HIV testing and PEP may follow exposure depending on risk. Our school has a policy and procedure in the UCF School of Nursing Handbook for exposure to HIV. It is available online. Please read it carefully in the handbook.
Assessing HIV Risk to Infected Blood
Average risk of infection after exposure by needlestick or cut is less than 0.3%.
Average risk of infection after exposure of the eye, nose, or mouth is less than 0.1%.
Average risk of infection after exposure of non-intact skin is less than 0.1%.
A small amount of blood on intact skin has no risk at all. No documented cases have been reported.
Vaccine or Treatment of HIV Post Occupational Exposure
As discussed earlier, there is no vaccine against HIV. Some studies have suggested that antiretroviral drugs for post-exposure prophylaxis (PEP) might reduce the transmission of HIV. PEP is recommended for certain occupational exposures that may pose a risk of transmission. As discussed earlier, many of the drugs have serious side effects that outweigh the benefit of PEP when the risk is minimal.
Unknown HIV Status Post Exposure
Identifying risk and source of infection is key to decisions in testing or prophylaxis if uncertainty exists on any exposure to bloodborne pathogens. Testing should be available for those personnel or students that have concerns of occupational exposure.
Post Exposure Prophylaxis (PEP)
A 4-week course of treatment is recommended by the U.S. Public Health Service.
Either two antiretroviral drugs for most exposures to HIV or three antiretroviral
drugs for those at greater risk of contracting the disease may be given. Those
at greater risk include amount of exposure to the blood, time of exposure to
the infection in the HIV infected individual, or drug resistance to HIV. Drugs
selected for treatment depend on side effects and response. Consult with an
HIV specialist is advised for those at greater risk.
Treatment should start as soon as possible after exposure. Studies suggest that treatment started more than 24-36 hours after exposure is less effective. However treatment may be started at one week if there is an increased risk of transmission.
Review side effects listed for antiretroviral therapy in section on "HAART Therapy" in this reading.
Follow-Up After Post Exposure
Post-exposure to the HIV infection follow-up should include testing as soon as possible after exposure and then periodically for at least six months. Suggested interval times for testing are 6 weeks, 12 weeks, 3 months, and 6 months.
For those on PEP therapy, a CBC, kidney and liver function tests should be done prior to treatment and then two weeks into treatment.
Standard Precautions Post-Exposure to HIV
When personnel are exposed to the HIV infection, the first 6-12 weeks is when
someone would show signs and symptoms of contracting the disease. Standard recommendations
for preventing transmission of the disease should be followed. Breast feeding
women should not breast feed at this time.
Complete information is availabe from the CDC website on US Public Health Guidelines: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm
Florida's Omnibus AIDS Act of 1998
The following information was summarized and paraphrased from the following source:
Hartzog, J. P. (1999). Florida's Omnibus AIDS Act: A brief guide for health care professionals. The Department of Health, Division of Disease Control, Bureau of HIV/AIDS. Tallahassee, FL. For complete information of this legislation, the manual is available free of charge.
Florida initiated its first AIDS act known as the Omnibus AIDS Act in 1988. This act was amended in 1998. All legislation follows federal guidelines and accepted medical practice. Any violation of the act is heavily penalized - even good faith in compliance to the act could cause legal problems. Healthcare presonnel that includes health care providers, administrators, and front-line medical personnel such as nurses are required to have an understanding of the act.
Education and testing are the main thrust of the Florida Omnibus AIDS Act. In addition, any testing is to be informed, voluntary, and confidential. Protection of patient privacy is the primary focus in testing.
Normally, public health epidemics mandated stringent measures such as isolation in order to prevent spread of infection.
AIDS was recognized as being different because:
Involuntary and non-confidential testing would promote HIV-infected individuals to hide
Regulation of private behavior is beyond government control
No effective cure leaves no incentive to enforce testing and notification of individuals who have been exposed.
Public reaction to the HIV infection has enforced the anonymity standard. Many individuals and children have been ostracized needlessly and through no fault of their own.
Performing HIV Tests
This requirement has three parts:
Disclosure of a test's subjects results are highly confidential. Both negative and positive results are superconfidential. Any information provided by a patient themselves to health care providers is excluded from the definition of confidentiality. Department of Health anonymous sites and home test results are not confidential. Any conditions associated with AIDS are not superconfidential either since they are not HIV test results. Any reference to AIDS or symptoms in a medical chart do not constitutue a test. Incentives to be tested are the main reason for confidentiality since many do not want the positive HIV label. There are legally effective releases of HIV status and they include:
Permitted Disclosures
In some circumstances, test results may be disclosed. The Act allows disclosure to the following:
Repercussions of Breaching Confidentiality
Disciplinary action may be taken against any health care provider who releases HIV test results. A first degree misdemeanor may result if the release was unintentional. Malicious release or monetary gain from disseminating information on a sexually transmitted disease could result in a third degree felony.
Health care providers do not have a duty to warn known partners or health providers of HIV status if the patient does not wish to disclose their HIV status. No criminal or civil liability will arise from honoring a patient's wishes. However, depending on the circumstances, superconfidentiality may be disregarded and patient HIV status may be released without permission if a sexual partner or needle sharing partner were identified by the patient. Acting in good faith, following ethical protocols of the health provider's profession and the Department of Health protects the health care provider from civil and criminal liability.
In order to comply with protocols and good faith for notifying third parties without permission, the health care provider should have the following requirements:
As part of the protocol, it is important that the health care provider counsels the patient repeatedly to disclose the HIV status to thethird party or to use the Department of Health voluntary partner notification services as directed by the 1996 federal legislation. Documentation of the reasons as well as the attempts to counsel the patient should be done.
Florida is one of the few states to require physicians and laboratories to report a positive HIV test result to local health authorities with patient identifiers. High incidence of AIDS in the state forced government to take action and enhance early medical and psychosocial service interventions. Better demographic data is obtained too.
HIV Reporting
Both private physicians and clinical laboratories are required to file reports with the Department of Health on all HIV positive tests.
Involuntary Measures
The Department of Health has the authority to take into custody, perform an HIV test without consent, hospitalize
and isolate an individual who is a danger to the public. Permission of the court is needed and requires high burdens of proof by the Department.
Testing Services
A statewide network of voluntary HIV testing programs is maintained by the Department of Health. Confidential or anonymous testing is provided and it is a crime to attempt to breach them for any purposes. Practitioners and laboratories that do not advertise their HIV testing program are not required to register with the state.
Significant Exposures
Recommendations to use universal precautions when a risk of exposure to blood or body fluids may occur.
Need to Know
Any health care worker experiencing a significant exposure to blood or body fluids have the right to know the HIV status of an individual. Documentation of the exposure needs to be recorded in the record for exception to superconfidentiality of the patient's record. Also, blood may be tested without patient approval if a blood sample is already drawn and available and the exposure occurred during emergency treatment of the patient. However, it is required that voluntary consent for the testing must be requested of the patient first. Then the exposed person must have tested negative in the previous six months or tested themselves for HIV. And that documentation of significant exposure is required in the record of the person exposed to HIV by a physician and the test was medically necessary for determining treatment of the exposed. Also, preliminary test results may be released to the exposed individual.
CDC Guidelines for HIV Counseling, Testing, and Referral
Those at risk and HIV infected persons should have:
Access to HIV testing
High quality counseling on the HIV disease, testing, modes of transmission, and the meaning of positive and negative tests
Access to appropriate medical and support services is offered
Protect the confidentiality to those receiving any HIV services
Obtain informed consent before any HIV testing is done. A written consent is preferable
Patient risk needs to be assessed and testing needs to be offered on a voluntary basis
Your readings are completed on HIV for Nursing course. Please go to the "Quiz" section and complete the quiz. Remember you need only receive a 70 to pass the complete the course and receive a certificate. You do have three attempts to make a 70 on the quiz.