Continuing  Education  (CEU)  course  for  healthcare  professionals.   View  the  course  online  at  wildirismedicaleducation.com  for   accreditation/approval  information,  course  availability  and  other  details,   and  to  take  the  test  for  CE  credit.  The  information  provided  in  this  course   is  to  be  used  for  educational  purposes  only.  It  is  not  intended  as  a   substitute  for  professional  healthcare.    

Contact Hours: 7

HIV/AIDS: A Comprehensive Review COPYRIGHT  ©  2014,  WILD  IRIS  MEDICAL  EDUCATION,  INC.    ALL  RIGHTS  RESERVED.   BY Nancy Evans, BS; Judith Swan, MSN, RN

COURSE OBJECTIVE: The purpose of this course is to prepare healthcare professionals to care for those with HIV/AIDS, based on a review of HIV etiology and epidemiology, transmission of HIV and infection control, clinical manifestations and treatment, legal and ethical issues, and psychosocial issues associated with this disease process. LEARNING OBJECTIVES Upon completion of this course, you will be able to: •

Discuss the etiology and epidemiology of HIV worldwide and in the United States.

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List the risk factors for transmission of HIV in general and among healthcare workers in particular.

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Identify preventive and control measures for HIV/AIDS.

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Discuss accepted procedures and regulations for HIV testing and post-test counseling.

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Describe the clinical manifestations and treatment guidelines for HIV/AIDS.

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Explain legal and ethical issues related to HIV/AIDS.

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Summarize the psychosocial issues associated with HIV/AIDS.

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HIV/AIDS: A Comprehensive Review

ETIOLOGY AND EPIDEMIOLOGY OF HIV/AIDS Upon completion of this section, you will be able to discuss the etiology and epidemiology of HIV worldwide and in the United States.

Defining HIV and AIDS The human immunodeficiency virus (HIV) is like most other viruses contracted by humans, but with one important difference—the body’s immune system can destroy most viruses and clear them from the body, but that is not true for HIV. The immune system cannot get rid of HIV because the virus attacks a key component of the system (the T-cells or CD4 cells), invades them, uses them to produce copies of itself, and then destroys them. AIDS (acquired immunodeficiency syndrome) is a complex condition caused by HIV, which kills or impairs 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. The term AIDS applies to the most advanced stages of HIV infection. Medical treatment is available to delay the onset of AIDS. AIDS is acquired. This disease is not hereditary. It is not passed casually from one person to another. To infect someone, the human immunodeficiency virus must enter the bloodstream. The virus causes an immune deficiency, and the body cannot defend against infection and disease. Over time, a person with a deficient immune system may become vulnerable to infections by disease-causing organisms such as bacteria, viruses, parasites, or yeasts. These opportunistic infections may cause life-threatening illnesses. HIV infection causes a combination of symptoms, infections, and diseases. This combination of health effects is known as a syndrome.

Origin and Strains of HIV DNA analysis has identified the HIV-1 virus as originating in a substrain of chimpanzees in west equatorial Africa (Gao et al., 1999). Scientists theorize that HIV-1 moved from chimps to humans when hunters were exposed to infected blood while handling bush meat (the flesh of various primates, including chimps and gorillas). Once in the human population, HIV quickly became a global pandemic, driven by travel and migration patterns, sexual practices, drug use, war, and economics. There are at least two types of HIV virus: HIV-1 is the cause of AIDS, and HIV-2 is a related group of viruses found in West African patients that is less easily transmitted. Worldwide, the predominant virus is HIV-1. Most of the West Africans infected with HIV-2 show none of the symptoms of classical AIDS. Viral load tends to be lower in persons infected with HIV-2, which may explain this type’s lower transmission rates and nearly complete absence of perinatal transmission. Most persons infected with HIV-2 do not develop AIDS, although when they do, the symptoms are indistinguishable from HIV-1. A few cases of HIV-2 infections have been found in people in the United States. !   ©  2014  WILD  IRIS  MEDICAL  EDUCATION,  INC.  

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HIV mutates readily, leading to many different strains of HIV, even within the body of a single infected person. Based on genetic similarities, the numerous viral strains may be classified into types, groups, and subtypes. HIV-1 comprises four distinct groups: M, N, O, and P. Group M was the first to be discovered and represents the pandemic form of HIV-1 (Sharp & Hahn, 2011).

Disease Mechanism Although the mechanisms of HIV and the way it affects the immune system are not fully understood, the primary event is the entrance of HIV into the body’s CD4 cells (T-Helper lymphocytes, also called T4 cells). These white blood cells are essential to the function of the immune system in fighting infection. Once inside a T4 cell, HIV replicates and signals other cells that produce antibodies, which are essential for immune system function. It is not known whether HIV replication directly kills the infected cells or the anti-HIV immune response destroys them, but HIV demolishes the T4 cells and damages their ability to signal for antibody production. Thus, it steadily deactivates the immune system, leading to dysfunction of various organ systems. Acute HIV infection is the time period immediately following infection with the virus. HIV replication is very rapid in the 6–8 weeks after acquiring the HIV infection and results in a high amount of HIV in the blood (viral load). During this time, the infected person may be symptomfree and unaware of the infection, but the viral load is the highest it will ever be because the body’s defenses have not yet responded. It is at this time when the risk of contagion is much higher than that from patients with established infections (Cohen et al., 2011). Once infected, the person remains infectious for life. Some researchers use the term acute HIV infection to describe the 6- to 12-week interval between initial infection and production of antibodies that can be detected by an HIV test. Others refer to this period as primary HIV infection, acute retroviral syndrome, or acute HIV syndrome. This interval is also called the window period. During this period the person can infect other people through unprotected anal or vaginal sex, oral sex, or sharing of needles. Following this period, the person can remain asymptomatic for many years before the start of symptomatic AIDS.

Impact of HIV/AIDS A  GLOBAL  PANDEMIC   Since the first case of AIDS was diagnosed in 1981, AIDS has killed more than 630,000 Americans (CDC, 2013a). The daunting human and economic costs of this disease in the United States are eclipsed only by its international impact. Since 1981, 33.4 million people worldwide have died from AIDS, and an estimated 35.3 million people were living with HIV in 2012. Although HIV infection rates are declining globally, AIDS deaths totaled 1.6 million in 2012.

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Almost all (95%) of the newly infected people live in the developing world, particularly southern Africa, where it is the leading cause of death. Sixty-nine percent of all people living with HIV are living in this region, and nearly 1 in every 20 adults is infected with HIV (amfAR, 2013). In 2012 more than 9.7 million people were receiving AIDS drugs in low- and middle-income countries, and the United Nations has set a target to raise that to 15 million by 2015 (WHO, 2013).

GLOBAL  HIV/AIDS  STATISTICS,  2012   •

35.4 million people living with HIV o 32.1 million adults (17.7 million women) o 3.3 million children under 15 years

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2.3 million people newly infected with HIV o 2.0 million adults o 260,000 children under 15 years o 0.8% prevalence among people 15–49 years

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1.6 million AIDS deaths o 1.4 million adults o 210,000 children under 1

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6,300 new HIV infections a day o o o o

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95% in low- and middle-income countries 700 in children under 15 years 5,500 in adults 15 years and older 47% in women

39% in young people 15–24 years Source:  WHO,  2013.  

HIV/AIDS  IN  THE  UNITED  STATES   In 1984, the Centers for Disease Control and Prevention (CDC) began to develop a surveillance system in order to uniformly track the HIV/AIDS epidemic in the United States. Information is collected from state and local health departments and reported to the CDC for analysis to determine who is being affected and why. The main goal is to have in a place a nationwide system that combines information on AIDS cases, new HIV infections, and the behaviors and characteristics of people at high risk. As of 2013, all 50 states, the District of Columbia, and six U.S. dependent areas use a uniform HIV infection reporting system for collecting data on HIV infection (CDC, 2013b). The HIV Surveillance Report for 2012 (issued in 2014) will be the first time the data from all these areas will be included in the estimates.

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The CDC estimates that more than 1.1 million people in the United States are currently infected with HIV. More than 200,000 of them do not know they are infected and are at high risk for transmitting the virus to others. While antiretroviral drugs have reduced deaths from AIDS, the number of new infections has not changed since the late 1990s. The estimated incidence of HIV has remained stable overall in recent years, at about 50,000 new HIV infections per year and 15,000 deaths from AIDS in the United States (CDC, 2013b). HIV has been reported in all 50 states, the District of Columbia, and U.S. dependencies. It has not, however, been uniformly distributed. In 2011 ten states accounted for about 65% of HIV diagnoses, and the South accounted for about 48% of HIV diagnoses. The state with the highest number of cases diagnosed in 2011 was California, reporting 5,965 new infections; the District of Columbia had the highest number of HIV diagnoses per 100,000 population (177.9) (Henry J. Kaiser Family Foundation, 2013). New HIV cases center primarily in large U.S. metropolitan areas (81%), with New York, Los Angeles, and Miami at the top of the list (CDC, 2013b). The epidemic’s scope varies across the country and continues to have a disproportionate impact on certain populations, in particular racial and ethnic minorities and gay and bisexual men. HIV transmission patterns have shifted over time. New infections among men who have sex with men, who represent about 4% of the population, increased between 2008 and 2010 by 12%. Heterosexual sex has accounted for a growing share of transmissions over time, representing 25% of new infections in 2010. A 3% reduction in infections has occurred among men who have sex with men and also have a history of injection drug use. New infections related to injection drug use also have declined, accounting for 8% of new infections in 2010 (CDC, 2012a). U.S.  HIV/AIDS  STATISTICS,  2011   • 1,148,200 persons 13 and older living with HIV infection o o o •

Deaths from AIDS o o

•

15,529 in 2011 636,000 since epidemic began

New infections o o o o o

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207,600 (18.1%) are unaware 510,000 blacks 280,000 women

49,273 people diagnosed with HIV 32,052 diagnosed with AIDS 217 children under 13 diagnosed with HIV 20% diagnosed with HIV are women 31% in adults 25–34 years

26% in young people 13–24 years !   ©  2014  WILD  IRIS  MEDICAL  EDUCATION,  INC.  

Source:  CDC,  2013b.  

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In the United States, HIV/AIDS has forever altered the landscape of healthcare. Patient activism early in the epidemic spurred a massive research effort that led to greater understanding of AIDS and accelerated the development of innovative drugs. These drugs have slowed the death rate from AIDS in the United States and other countries since 1996, but without a cure and/or increased emphasis on prevention, there is no end in sight to the epidemic. Antiretroviral drugs have reduced not only morbidity and mortality from AIDS. They have also reduced the public’s level of concern about the deadly nature of this epidemic, creating widespread complacency about the disease. This complacency, coupled with our society’s belief in the power of pharmaceuticals, has undermined prevention efforts. By extending the lives of people with HIV infection, drug treatment has also increased the prevalence (or number of cases per 100,000 people) of the disease and increased the likelihood of transmission. The CDC (2012a) reports that of Americans with HIV, only 28% are currently being treated effectively. Effective treatment reduces the level of virus in the body so transmission to others is less likely to occur. NATIONAL  HIV/AIDS  STRATEGY   In 2010, the government outlined the National HIV/AIDS Strategy for the United States (NHAS), which has three overarching goals: •

Reducing infection rates

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Increasing access to care for those infected and optimizing health outcomes

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Eliminating disparities in prevalence, diagnosis, and treatment

The NHAS envisions a future in which “the United States will become a place where new HIV infections are rare and, when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socioeconomic circumstance, will have unfettered access to high-quality, life-extending care, free from stigma and discrimination” (White House, 2010). The NHAS includes major outcomes to be achieved by 2015, such as: •

Reducing the number of new annual infections by 25%

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Increasing to 90% the percentage of people with HIV who know they are infected

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Reducing the HIV transmission rate in relation to the number of people living with HIV by 30%

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Increasing the proportion of newly diagnosed patients linked to care within 3 months from 65% to 85%

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Increasing by 20% the proportion of HIV-positive men who have sex with men (MSM), blacks, and Hispanics with undetectable viral loads

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If the NHAS target outcomes are achieved, then approximately 76,000 infections will be prevented and an estimated 219,000 more people living with HIV will be in care by 2015. Achieving these outcomes would substantially alter the trajectory of the epidemic in the United States and could prevent a total of nearly 238,000 infections through 2020 (Holtgrave, 2010). Since 2010, NHAS has become a significant factor in the progressive change occurring to improve the United States’ approach to ending the HIV epidemic here at home. There are successful, innovative programs being implemented across the country to get more people tested, treated, and engaged in care. In addition, the discovery that medical treatment for persons living with HIV can significantly reduce the rate of HIV transmission provides an additional reason for integrating prevention and care. The success so far bolsters the belief that we can achieve remarkable progress against the epidemic. See also “National HIV/AIDS Strategy” under “Resources” at the end of this course.

Risk Groups Nationally, HIV/AIDS takes a heavy toll on people of all ethnicities, genders, ages, and income levels. However, three primary risk groups account for nearly three quarters (73%) of new HIV infections in the United States: 1. Men who have sex with men (MSM) (63%) 2. Injecting-drug users (IDUs) (6%) 3. MSM who also use injection drugs (4%) Heterosexual transmission accounts for the remainder (27%) of new cases. Other important groups at risk for HIV include blacks, women and children, seniors, incarcerated populations, commercial sex workers, and transgender (TG) people. Each of these groups has unique needs for outreach and education on prevention and treatment of HIV infection. MEN  WHO  HAVE  SEX  WITH  MEN     Although MSM are only a small percentage of the population, they account for more than half of all estimated new HIV infections. It is estimated that about 1 in 5 MSM is living with HIV. In 2010 MSM accounted for 63% of estimated new HIV infections in the United States and 78% of infections among all newly infected men (CDC, 2013c). Among MSM, whites account for the highest number of new infections. In 2011 MSM HIV prevalence was highest among older age groups, blacks, and men with lower education and income. Black MSM had the highest HIV prevalence but the lowest awareness among racial/ethnic groups. HIV-positive MSM overall are increasingly aware of their infections (Wejnert et al., 2013). !   ©  2014  WILD  IRIS  MEDICAL  EDUCATION,  INC.  

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The age of acquiring HIV infection among MSM varies by race. The majority of new infections among young African American MSM occur between ages 13–24; the largest number of new infections in Hispanic/Latino MSM (39%) occur between ages 25–34; and the most infections among young white MSM occur during their 20s and 30s (CDC, 2013d). HIV  INFECTION  AMONG  U.S.  MSM  BY  RACE,  2011   • 38% African Americans • 34% whites • 24% Hispanics/Latinos • 2% Asians • 2% multiracial • 1 month Wasting syndrome attributed to HIV

People with HIV/AIDS are at high risk for developing certain cancers, such as Kaposi sarcoma, non-Hodgkin’s lymphoma, and cervical cancer. These three cancers are referred to as “AIDSdefining conditions,” and if a person has one of these cancers, it is very likely to signify HIV and the development of AIDS. The connection between HIV/AIDS and cancer is not completely understood but is believed to be the result of a weakened immune system. The following types of cancer are also common for people with HIV/AIDS: • • • • • • •

Hodgkin’s lymphoma Angiosarcoma Anal cancer Liver cancer Mouth or throat cancer Lung cancer Testicular cancer !   ©  2014  WILD  IRIS  MEDICAL  EDUCATION,  INC.  

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• •

Colorectal cancer Multiple types of skin cancer including basal cell carcinoma, squamous cell carcinoma, and melanoma (Robert H. Lurie Comprehensive Cancer Center, 2013)

MULTISYSTEM  EFFECTS  OF  HIV/AIDS   HIV infection not only affects the immune system but also affects other body systems. Respiratory tract defenses are affected by HIV. Alveolar macrophages in persons with HIV may serve as reservoirs for the virus. These protected viruses may infect other cells and may contribute to the accelerated HIV disease in the presence of opportunistic infections (Hopewell, 2011). The gastrointestinal system is affected by AIDS enteropathy, a condition characterized by changes in the villus of the small bowel. This leads to malabsorption resulting in malnutrition and wasting (Barlett, 2011). Integumentary system problems increase in frequency and severity. There may be pruritus without evident skin lesions. Herpes zoster may be a reliable sign of the presence and progression of HIV in a person who is otherwise asymptomatic. Necrotizing gingivitis and recurrent oral ulcers are common (Penneys, 2011). The sensory system effects include visual impairment or blindness related to infectious or noninfectious ocular disorders, such as microvascular disease, retinitis, acute retinal necrosis syndrome, and optic nerve damage (Jacobson, 2011). The effects on the hematologic system include morphologic abnormalities in the bone marrow resulting in cytopenias, most commonly anemia (Scadden, 2011). Of great significance is the effect of HIV on the neurological system, resulting in HIV encephalopathy and AIDS dementia complex (ADC). The virus does not affect brain nerve cells but indirectly inflames or kills them. This occurs as CD4+ cell counts drop to less than 200. ADC varies from individual to individual, and symptoms may develop rapidly or slowly, affecting thinking abilities, behavior, coordination and movement, and mood. With the use of antiretroviral drugs, however, a less severe dysfunction known as minor cognitive motor disorder (MCMD) has become more common than ADC (Singh, 2013). HIV-­‐Related  Conditions  among  Special  Populations   HIV/AIDS imposes an additional burden on African Americans. The risk of end-stage renal disease (ERD) in HIV-infected black patients was 4–5 times greater than the risk of ERD in HIV-infected white patients. Studies reveal a gene variant that increases the risk of kidney disease in African Americans (NIH, 2011).

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Children infected with HIV/AIDS may have different reactions to the virus, its progression, and their virologic and immunologic response. Without drug treatment, children may be developmentally delayed, experience failure to thrive, and be vulnerable to Pneumocystis jirovecii pneumonia and recurrent bacterial infections. Antiretroviral treatments available for adults with HIV/AIDS may not be available in pediatric formulations and may cause different side effects in children. (Pediatric HIV/AIDS is a specialty that is beyond the scope of this course.)

Management and Care Optimal care of people with HIV/AIDS includes antiviral therapies, health maintenance, and referral to support services in addition to an emphasis on prevention of transmission to uninfected partners. HIV/AIDS  SELF-­‐MANAGEMENT   The Institute for Healthcare Improvement (2013) notes that it is extremely important that patients with HIV/AIDS play a major role in managing their condition. Each patient has unique desired outcomes and needs that require appropriate interventions. Each patient should be given basic information about HIV/AIDS and its treatment; assistance with self-management skill building; and ongoing support from the healthcare team, family, friends, and community. The Institute recommends that self-management include: •

Collaborative goal setting

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Monitoring of symptoms

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Lifestyle modifications to improve overall health and well-being

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Adherence to the medication regimen

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Good communication with the healthcare team, family members, and others

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Involvement in ongoing problem-solving to overcome potential barriers

The healthcare team is advised to assist the patient’s self-management efforts by supporting and emphasizing the patient’s role in self-management, making recommendations, using effective interventions, and assisting with care-planning and problem-solving to aid in reducing barriers to self-management activities. CASE  MANAGEMENT   HIV/AIDS has proved to be a moving target, spreading beyond gay white men in cities to women, children, and seniors in small towns and rural areas. As people with HIV live longer, needs for healthcare services are changing. Depending on their personal support system and other resources, some people may require the assistance of a case manager to link them with various care services. !   ©  2014  WILD  IRIS  MEDICAL  EDUCATION,  INC.  

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Case managers are often the primary contact people for services, including medical care, insurance programs, volunteer groups, home care, hospice, and other types of care that may be needed during the course of a person’s or family’s living with HIV/AIDS. Local communitybased organizations may also provide additional support to adults, children, and families who are dealing with HIV/AIDS. Evolving  Treatment  Guidelines   Treatment guidelines are revised frequently based on ongoing research findings. The most up-to-date information can be found online at aidsinfo.nih.gov/guidelines.

Antiretroviral Therapy (ART) Antiretroviral therapy has become the gold standard for treatment of HIV/AIDS, with antiretroviral drugs administered in “cocktails” of three or more. (ART is also sometimes referred to as highly active antiretroviral therapy, or HAART.) People with HIV may also receive medications to treat or prevent opportunistic infections, boost the immune system, and prevent anemia. ART has dramatically reduced HIV-associated morbidity and mortality and has transformed HIV disease into a chronic, manageable condition. In addition, effective treatment of HIV-infected individuals with ART 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 continued morbidity, mortality, and new HIV infections persist (NIH, 2013b). Antiretroviral treatment of people with HIV continues to prove complex, controversial, dynamic, and expensive. These drugs do not constitute a “cure” for HIV/AIDS. If therapy is discontinued, viral load will increase. Even during treatment, the virus is replicating and the person remains infectious to others. HIV/AIDS  DRUGS     Seven major classes of drugs are used to treat HIV/AIDS: • Nucleoside reverse transcriptase inhibitors (NRTIs) • Nonnucleoside reverse transcriptase inhibitors (NNRTIs) • Protease inhibitors (PIs) • Fusion inhibitors • HIV integrase strand transfer inhibitors • Entry inhibitors, CCR5 co-receptor antagonists • Multi-class combination products

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Source:  U.S.  FDA,  2013.

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INITIATING  ART   In 1996, tests to measure an individual’s viral load became available, providing objective criteria for treatment decisions. Following are treatment recommendations by the Panel on Antiretroviral Guidelines for Adults and Adolescents (NIH, 2013a): •

Antiretroviral therapy (ART) is recommended for all HIV-infected individuals regardless of CD4 count to decrease the risk of disease progression.

•

ART also is recommended for HIV-infected individuals for the prevention of prenatal and behavior-associated HIV transmission.

•

Patients initiating ART should be willing and able to commit to lifelong treatment and should understand the benefits and risks of therapy and the importance of adherence. Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy based on clinical and/or psychosocial factors.

ART  TREATMENT  GOALS     Once ART therapy has begun, CDC recommends these goals of therapy:

 

•

Maximal and durable suppression of viral load

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Reduction of HIV-related morbidity and prolonging survival

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Improvement in quality of life

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Restoration and/or preservation of immunologic function

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Prevention of HIV transmission

ART  FOR  PREGNANT  WOMEN   Current recommendations for female patients with HIV who are pregnant are to start antiviral therapy during the second trimester. Those women who seek perinatal care after the second trimester should start treatment as soon as possible thereafter. Choice of therapy regimen should consider not only the effectiveness of drug treatment for maternal disease but also possible teratogenic effects of the drugs on the infant. Public Health Service guidelines emphasize that combination drug regimens—rather than zidovudine (ZDV) alone—are considered the standard of care both for treatment of maternal HIV infection and for prevention of perinatal HIV transmission (NIH, 2010). TREATMENT  EFFICACY   The efficacy of ART can be measured by plasma HIV RNA testing. Optimal viral suppression is defined as a viral load consistently below the level of detection (500 cell/mm3. In coinfected patients with lower CD4 counts (