HIV/AIDS - 2009 Barbara Russell RN, MPH, CIC
Schematic of a Chronic Incurable Infection Incidence (new infections)
Deaths (outflow) Prevalence
Global summary of the AIDS epidemic, December 2007 Number of people living with HIV in 2007
Total Adults Women Children under 15 years
33 million [30 – 36 million] 30.8 million [28.2 – 34.0 million] 15.5 million [14.2 – 16.9 million] 2.0 million [1.9 – 2.3 million]
People newly infected with HIV in 2007
Total Adults Children under 15 years
2.7 million [1.6 – 3.9 million] 2.3 million [1.3 – 3.4 million] 370 000 [330 000 – 410 000]
AIDS deaths in 2007
Total Adults Children under 15 years
2.0 million [1.8 – 2.3 million] 1.8 million [1.6 – 2.1 million] 270 000 [250 000 – 290 000]
Estimated number of adults and children newly infected with HIV, 2007 Western & Eastern Europe Central Europe & Central Asia
27 000
North America
54 000
[7600 – 130 000]
Caribbean
20 000
[3200 – 69 000]
Middle East & North Africa
[14 000 – 27 000]
Latin America
110 000
110 000
[53 000 – 200 000] East Asia
[37 000 – 200 000]
40 000
[18 000 – 69 000]
Sub-Saharan Africa
1.9 million
[1.3 – 2.4 million]
51 000
[27 000 – 86 000]
South & South-East Asia
330 000
[76 000 – 680 000] Oceania
13 000
[12 000 – 15 000]
Total: 2.7 million (1.6 – 3.9 million)
Estimated adult and child deaths from AIDS, 2007 Western & Eastern Europe Central Europe & Central Asia
8000
North America
23 000
[9100 – 55 000]
Caribbean
14 000
[4800 – 17 000]
Middle East & North Africa
[11 000 – 16 000]
Latin America
63 000
[49 000 – 98 000]
58 000
[41 000 – 88 000] East Asia
27 000
[20 000 – 35 000]
Sub-Saharan Africa
1.5 million
[1.3 – 1.7 million]
40 000
[24 000 – 63 000]
South & South-East Asia
340 000
[230 000 – 450 000] Oceania
1000
[>> vaginal >>> oral
Recreational blood exposure Occupational blood or bodily fluid exposure Receipt of tissue or blood products Partner or birth mother with above risks
HIV and Women One of the fastest growing groups Increased frequency and severity of GYN disorders – – – –
HPV Cervical intraepithelial neoplasia Candida vaginitis PID
Invasive cervical cancer: AIDSdefining
CDC HIVassociated conditions
How long after a possible exposure should I wait to get tested for HIV? •
Most HIV tests are antibody tests that measure the antibodies your body makes against HIV. It can take some time for the immune system to produce enough antibodies for the antibody test to detect, and this time period can vary from person to person. This time period is commonly referred to as the "window period." Most people will develop detectable antibodies within 2 to 8 weeks (the average is 25 days). Even so, there is a chance that some individuals will take longer to develop detectable antibodies. Therefore, if the initial negative HIV test was conducted within the first 3 months after possible exposure, repeat testing should be considered >3 months after the exposure occurred to account for the possibility of a falsenegative result. Ninety-seven percent of persons will develop antibodies in the first 3 months following the time of their infection. In very rare cases, it can take up to 6 months to develop antibodies to HIV.
Maternal-Fetus Transmission Rate (Vertical Transmission) Total rate: 13-60% – US: 25-30% – Europe: as low as 13% – Africa: 50-60%
In utero: 100,000
Transmission Rate 0% 16.5% 21.3% 30.9% 40.6%
Garcia, et al NEJM 1990;341:394
HIV/AIDS in the Elderly
Elderly (CDC): over 50 years of age 10% of diagnosed AIDS cases: elderly More males and African Americans Often not tested due to perceived low risk Late diagnosis common HIV encephalopathy and wasting common Dementia
MMWR, 55:44-14 September 2006
HIV Testing Guidelines in HC Settings MMWR, September 2006 Intended for all HC providers, public and private, all types of HC settings Major revisions:
– HIV screening recommended for patients after notification that testing will be performed unless patient declines (opt-out screening) – High risk patients should be screened annually – General consent for medical care should be sufficient to encompass HIV testing consent – Prevention counseling should not be required with HIV testing or screening programs
HIV Testing Guidelines in HC Settings MMWR, September 2006 Pregnant Women: – HIV screening as part of prenatal screening – Inform patient that HIV screening will be performed; patient can opt-out – General medical consent is adequate – Repeat in 3rd trimester in high-risk settings
HIV Diagnostic Tests
ANTIBODY TESTS ELISA Western blot Specimens Venous Rapid others Oral Home
Serum run twice Confirmatory Lab standard OraQuick® and OraSure® (mail) Home Access®
VIRAL RNA TESTS PCR or bDNA Earliest diagnosis
ELISA, enzyme-linked immunosorbent assay; PCR, polymerase chain reaction.
TEST RESULT TIMES: 1-7 days 3-20 minutes 1-2 weeks 1-2 weeks 1-2 weeks
Rapid HIV Antibody Detection OraQuick Advance Rapid Antibody Test Fingerstick blood, serum, oral fluids – Results in 20 minutes – $20-30
FDA approved, CLIA waived Negative test: definitive Positive test: needs standard serology confirmation
Rapid HIV Antibody Detection Results in 20 minutes Occupational exposure Women in labor with unknown HIV status Clients unlikely to return for visits Outreach ERs
Estimation of HIV Incidence in US Centers for Disease Control
• New assay (BED HIV-1) can differentiate new vs. long-standing HIV infection • 6,684 remnant specimens tested in 2006 from 22 states – 2,133 (31%) classified as recent – Statistical extrapolation → 56,300 new infections in 2006 (previously 40,000) • 22.8 per 100,000 population
• New infections concentrated in • Black: 45% • MSM: 53%
JAMA, 300:5, August 6, 2008
Viral Load/CD4 count Viral load: amount of HIV RNA in blood – Goal: undetectable – PCR: most common – bDNA: less common – Use consistent testing
CD4 cell count and percent –
