AIDS/HIV Four Hour, Current Evidence Based Practice - 4 Contact Hours

Healthcare professionals will apply current evidence-based practice for HIV/AIDs patients.

After completing the course, the learner will be able to:

1. Relate the overall social impact of the HIV/AIDS pandemic in terms of incidence, diagnoses and deaths.

2. Identify the civil rights of the HIV/AIDS infected individual and their family/friends.

3. Differentiate between high-risk groups in terms of behavior and race/ethnicity.

4. Discuss Human Immunodeficiency Virus (HIV) and the pathophysiologic changes in the human body following HIV infection.

5. Relate the three stages of an HIV infection encompassing signs and symptoms and changes in laboratory values.

6. Describe the modes of transmission of HIV and various strategies to prevent the spread of HIV.

7. Discuss informed consent relating to HIV along with pre and post-test counseling.

8. Discuss HIV test results and their implication to the individual.

9. Compare and contrast current medication regimens prescribed for the HIV infected individual and those medications used to prevent the transmission of the virus in high-risk individuals.

Referred to as the "Scourge of Our Time," the Human Immunodeficiency Virus (HIV) and its fatal end-stage, Acquired Immunodeficiency Syndrome (AIDS), brings dread to those with knowledge of its effects and impacts (Wolitski, 2016). New treatments have extended, by decades, the lifespan of those infected, which has shifted HIV from an acute terminal illness to a chronic condition requiring care and monitoring. As healthcare professionals, we must keep current on new information regarding HIV, the effects seen with HIV, its transmission, treatment, and the best care for HIV victims who progress into the final stage of AIDS as we help those infected live healthier, more satisfying lives.

Image 1: HIV overwhelming Immune cells

HIV as an infectious virus came into focus in the United States in 1981, when an unusual number of deaths among homosexual men experiencing uncommon and life-threatening multi-organism syndromes was highlighted as a statistical anomaly. The Centers for Disease Control and Prevention (CDC) published a description of cases involving a rare lung infection, Pneumocystis carinii pneumonia, in its weekly Morbidity and Mortality Report and provoked a flood of stories from physicians who were currently encountering similar rare infections among the gay male population. This June 1981 publication marked the first reporting of what was soon to be known as the AIDS epidemic, currently referred to as the "Scourge of Our Time" by scientific organizations and media outlets alike (Weinstien, 2019).

Over the past forty years, many healthcare professionals have followed the theories and discussions of where HIV originated and why it escaped identification until 1981, when it suddenly emerged as the AIDS epidemic. For the purpose of this discussion, we will skip past the internet popular notions of extraterrestrial experiments or hidden government bioweapons gone rogue as sources of HIV and/or AIDS as they seem somewhat unworkable as theoretical epidemiological working models (Horovitz, 2016).

Information uncovered by more mainstream researchers relates to the history and origins of HIV. It includes a 1959 HIV-positive plasma sample from an adult African male living in the Democratic Republic of Congo (Averrt.org, 2018). This sixty-year-old sample related well to genetic markers from the four known HIV type 1 human viral groups, all showing viral sharing with apes in Cameroon, Gabon, the Democratic Republic of Congo, and Uganda. These shared markers, along with other trace information, supports the strong probability that HIV originated in Africa among humans who hunted local chimpanzees and apes infected by the Simian Immunosuppressant Virus (SIV). The likelihood of SIV being transmitted to humans is not without reason due to the quickly replicating, frequent alterations into new strains tendency found in the ape bound virus (Sauter & Kirchhoff, 2018).

Close-up of a HIV viral particle free floating in bloodstream

At least four cross-species transmissions of SIV infected ape blood to local humans. The four subgroups of the HIV-1 strain found in humans, groups M, N, O, and P, were from separate cross-species transmissions that each had a different impact on the human population. Group M is central to the current AIDS pandemic, which has infected more than 40,000,000 individuals by spreading across Africa and throughout the rest of the world. Although not as widespread as group M, Group O has infected about 100,000 individuals in west-central Africa. Groups N and P, at the other extreme, have only been found in a few individuals who lived in or visited Cameroon.

The leap from simian to human, researchers postulate, may have even occurred in less recent times, when the spread of the virus was isolated to single villages rather than the spread via modern vectors of mass transportation which can swiftly whisk an infected individual away from an isolated village and into the global population.

Politics, economics, and propaganda surround the topic of HIV and its origins that we may never recognize or have the opportunity to seriously discuss the actual roots of the AIDS epidemic, should it ever be fully known. Those who believe this is a somewhat cynical view of how scientifically important endeavors can be derailed need only look to the history of HIV vector studies with careers put in jeopardy and efforts to suppress or spin findings.

Haitian HIV studies, for example, faced extreme pressures to suppress serious investigation or findings made in the mid-1980s, until UCLA's Dr. Michel Worobey's meticulous and hard gained data was finally presented to March 2007, Fourteenth Conference on Retroviruses and Opportunistic Infections (CROI) among his hometown crowd in Los Angeles. Dr. Worobey's complex genetic analysis of a single HIV subtype demonstrated strong evidence that HIV had been brought to Haiti by a single individual around 1966. This Haitian strain of HIV then slowly began to circulate from individual to individual among the closed population of the island before being brought to the United States. The research published by Dr. Worobey and colleagues gave a 99.7% certainty of the travels of that one particular subtype and strain and, thus, immediately came under the weight of political, commercial, and tourism opposition of the type which had crushed findings of previous researchers examining the Africa - Haiti - United States transmission link.

Table 1: Brief Timeline of the HIV/AIDs Epidemic

The CDC estimates that at the end of 2015, the most recent year for which the United States prevalence statistics are currently available, there were approximately 990,000 adults and adolescents living with HIV infection nationally, over 520,000 of whom had infection classified as HIV stage 3 (AIDS) (Bennett, 2019).

In 2016, the rate of HIV stage 3, a.k.a. AIDS diagnosed in the United States, was 5.6 per 100,000 population. Or, to put it another way, from 1981-2016, 1,232,346 persons were diagnosed with AIDS in the United States, with 692,789 people going on to die from the direct effects of AIDS.

These numbers from over the past decade are a mix of good news/ mixed news. The good news is that from 2011 to 2016, the annual number of new HIV infection diagnoses decreased by 5.3% (Bennett, 2019). The mixed news is that there remains a slow progressive annual increase in the total number of HIV infections as HIV sufferers live longer with the advent of new treatments, resulting in an ever-expanding number of active HIV cases in the United States and worldwide. Still, reducing new cases is an important achievement as there is currently no cure for HIV infection. For this reason, the primary research focus remains on prevention.

The prospect of having HIV can provoke fear and dread. This anxiety is reasonable given the history surrounding HIV and AIDS in the United States and globally. HIV infection is a very serious medical condition, though not quite the sentence of an agonizing wasting death that it was during the 1980s and 1990s. There are now medications that can slow the progression of the disease by decades in many cases, giving a new quality of life to those diagnosed rather than the specter of a wasting, suffering death.

The questions remain why so many in the United States avoid HIV testing when it is so important to become aware of infection early to begin treatment and slow or avoid the fate they see portrayed by the news media visiting impoverished AIDS-stricken countries in Africa's west and southern regions. Perhaps it also is the fear of the possibility of a diagnosis of a fatal infectious disease or the fear of living with the responsibility of keeping a demanding disease such as HIV/AIDS under control. Keeping HIV under control is a time and resource consuming task. But then the option of letting the disease run its course unchecked would be a very poor choice to make as well.

Whatever factor(s) that brings hesitation to those needing HIV prevention counseling, screening, or treatment is the stigma attached to having HIV or AIDS. Having HIV brings a "scarlet letter," fear of repercussions due to having an unwanted health status. When questioned, many of those newly diagnosed with HIV seem unaware that federal laws exist to protect them from discrimination and ensure that benefits such as social or medical services they would qualify for will not be withheld. As healthcare professionals, it is important to share with those in high-risk groups that key legislation pieces exist that offer protection from discrimination. Interestingly, some of the mandates and pieces of legislation protecting those with current needs predate the HIV/AIDS epidemic, e.g., Section 504 of the Rehabilitation Act of 1973 and Title II of the Americans with Disabilities Act (ADA). These well-established laws mean services that apply to an otherwise qualified individual will also be available to HIV infected individuals.

Title II of the ADA prohibits discrimination by state and local government organizations, even those not dependent on federal funding. For those nervous or fearful concerning how those close to them might be treated should they acquire HIV, Title II of the ADA also protects an HIV positive individual's friends and family against discrimination or denial of services that might come from being related to someone with HIV.

Information privacy regarding an individual's HIV status is guaranteed by the 1996 Health Insurance Portability and Accountability Act (HIPAA), whose Privacy Rule is enforced by the Office for Civil Rights (OCR). HIPAA protects health information privacy while allowing each individual access to their records to see what is written about them and even ask to make corrections to what is documented.

Awareness of their individual rights and the value that each life inherently possesses are crucial foundational steps to include those suffering from HIV into society and better health. By emphasizing the importance of each individual's life, we, as healthcare professionals, can increase participation of the HIV infected individual in their own care by educating them to:

• Keep informed of any changes in HIV knowledge and care
• Use preventative measures to stop the transmission of HIV
• Avoid high-risk behaviors
• Have routine screening for HIV infection, if necessary
• Actively participate in treatment should the individual become infected

Therefore, as we progress to viewing the magnitude of the current HIV epidemic with its slowly widening reach into our culture and homes, remember that what we are really dealing with is the frightened and wounded, each one faced with the sudden overwhelming burden that comes with managing the chronic terminal condition of HIV/AIDS.

By Behavior

By Race/Ethnicity

HIV belongs to a viral family known as retroviruses. Some viruses are known as retro, or backward, due to their ability to transcribe or copy their genetic code from RNA to DNA in a host cell, as opposed to the more common DNA to RNA method of transcription. Like other viruses, HIV can neither reproduce nor grow independently. HIV requires a living host, in this case, a human, to make copies of themselves, a process known as replication. This process ultimately destroys the host cell. The body's immune system responds and quickly destroys the invader for most viruses. Unfortunately, the immune system itself that the HIV virus desires to invade and then replicate in. This progressively leads to the destruction of the body's immune defenses and the proliferation of masses of new viral particles.

Becoming infected with HIV means the virus has entered the human host's bloodstream, and HIV viral particles have begun to invade CD4 T-cells, macrophages, and dendritic cells. HIV viral particles then lock onto the invaded cells and quickly regurgitate their core into the inside of the doomed cell, thus allowing the HIV viral RNA to begin the process of transcribing itself into the host cell's DNA using an enzyme called reverse transcriptase. The resulting rewritten DNA integrates into the human genome of the body's cell. HIV may remain relatively silent in the genome of its human host cell for some time, or it may immediately exert itself, forcing the human genome to make more copies of viral particles. The human genome becomes a mass producer of new viral particles ready to continue spreading and conquering the human victim's body.

Human Immunodeficiency Virus (HIV) (AIDSinfo, 2019)

Diagram of HIV structure.

HIV is a prolific breeder, able to create trillions of copies of itself within a short period. A single milliliter of blood may contain more than one million virus copies during periods of active viral replication. As is the way with viruses, a small percentage of these trillions of copies will have minuscule differences from the original. These minuscule differences make HIV more resistant to medications or treatments that would have successfully controlled the original virus.

Two significant varieties of HIV virus have been recognized: type 1 (HIV-1) and type 2 (HIV-2). Both have propagated into multiple subtypes, known as clades (Bennett, 2019). HIV-1 is the more virulent variety and the primary cause of infections worldwide. In general, HIV-1 is being discussed when HIV is being referred to without clarification. HIV-2 is less easily transmitted and less commonly occurring, appearing mostly in West Africa or in individuals who have had contact with those infected with HIV-2 from West Africa. Both HIV-1 and HIV-2 progress to the terminal stage of AIDS. Both are transmitted through blood, sexual contact, and virus harboring body fluids. Current tests are available to detect HIV-1 and HIV-2 (Kleinman, 2019). Since the HIV virus changes and mutates readily, a single infected individual may have several differing clades of HIV. Therefore, it is essential to realize that the future will bring more significant, recognized subtypes of HIV.

HIV is a viral infection that progresses through three distinct stages terminating in the condition known as AIDS. HIV enters the bloodstream and attaches to T-helper lymphocytes (Helper-T cells), which are one type of white blood cells, called by the general name of lymphocyte, which is necessary to the proper functioning of the immune system. Helper-T cells are also referred to as T4 or CD4 cells.

Helper-T cells coordinate the body's immune response by communicating with other white blood cells, such as B cells which produce antibodies, phagocytes which are cells that engulf microbes to protect the body's immune system, and cytotoxic T lymphocytes (CTLs) (also known as Killer T cells) which use chemical weapons to directly attack foreign cells and even the body's own cells which have been altered or are carrying foreign or abnormal molecules such as viral shells on their surface. All immune cells summoned and directed by CD4 Helper-T cells work together to fight the invasion and ward off infection.

Antibodies target specific complex molecules produced by B cells in the body's immune system at the behest of CD4 Helper-T cells. Normally, antibodies work by attaching to and attacking microorganisms that have not yet infected the body's cells but lurk in blood or the spaces between cells. Microorganisms swarmed by antibodies cannot function and are swept up by macrophages and other defensive immune cells to be destroyed and disposed of.

HIV infection does a hostile takeover of our CD4 Helper-T cells. It prevents the chemical commands needed by the B cells in the immune system from making antibodies to a new infectious agent. This leaves the body vulnerable to opportunistic bacteria, fungal infections, parasites, or other viruses as the production of antibodies is blocked.

HIV infection has three stages defined by the CDC: HIV Primary or Acute infection, HIV Chronic or Asymptomatic infection, and HIV as AIDS.

HIV Chronic or Asymptomatic Infection

Progressing to AIDS

HIV as AIDS: The Final Stage of Infection

The earliest stage of HIV infection is known as the primary or acute stage. Acute HIV infection generally develops around two to four weeks after an individual has been infected by sufficient amounts of the virus, e.g., a high enough viral load (Sax, 2018). Many newly infected individuals report having flu-like symptoms such as generalized aches, headache, fever, and perhaps even a rash (Bennett, 2019). The virus begins taking possession of CD4 Helper-T cells during this stage, destroying them by multiplying themselves.

Seroconversion denotes the period from initial infection to when the body begins to create antibodies in sufficient amounts to be detected by HIV antibody testing (Sax, 2018). This brief, though variable, period is also referred to as the "window period" of acute HIV infection. An individual may have the infection during this period yet still not register as positive on current screening tests. Unfortunately, viral levels are generally high enough during this window period that newly infected individuals are themselves able to infect others and can easily transmit HIV by sexual acts, sharing drug paraphernalia, and other modes of transmission specific to HIV. The length of this dangerous window period can be as little as 2 weeks or up to 6 months, making lifestyle screening an important tool during HIV pre-test counseling sessions.

Due to the window period and the initial high viral particles in the bloodstream, it is generally considered that the acute stage of HIV infection holds the greatest risk of disease transmission to others. However, HIV can be transmitted during any of its stages.

Our bodies are masterpieces of engineering and design that show incredible tenacity when given a chance. This is demonstrated even during the massive invasion of new viral particles permeating the acute HIV infection stage. The body's immune response rallies and fights to bring the number of virus particles down to a stable level. It is common toward the end of the acute stage for the infected individual to reproduce some of the CD4 T-helper cells lost earlier. However, CD4 counts rarely return to the levels they had pre-infection.

HIV viral particles must enter the bloodstream for an individual to become infected. Various carrier fluids can provide the vehicle for this blood exposure, including the fluids encountered during sexual contact resulting in HIV being listed among sexually transmitted diseases (STDs), aka, sexually transmitted infections (STIs). Sex does not need to occur for the HIV virus to be transmitted. The true mode of HIV transmission from an infected person to a non-infected person is from blood to blood or from virus plentiful secretions to vascular-rich thin mucous membranes.

Direct blood exposure from:

• Sharing of needles, e.g., intravenous drug users (IDUs)
• Use of equipment exposed to blood from multiple individuals without proper sterilization, i.e., tattoo needles, body piercing tools, medical equipment, etc
• Body fluid
• Pre-seminal fluid
• Rectal fluids
• Vaginal fluids
• Breast milk

Less common exposures include:

• Being born to an HIV infected mother
• Receiving infected medical blood products, organ or tissue transplants
• Eating food pre-chewed by an infected individual
• Bites or other penetrating wounds from an infected individual
• Deep open-mouthed kissing in the presence of sores or bleeding gums (Transmission through kissing alone is rare.)

HIV, once having invaded the body, is tough, resilient, and impossible for the infected individuals' body defenses to destroy. However, HIV is fragile outside the body and does not survive for long. Misleading rumors about the ease of viral spread have led the CDC to provide a list of ways HIV cannot be spread (CDC, 2019c):

• HIV cannot be spread in the air or water
• HIV cannot be spread by insects, including bed bugs, ticks, or mosquitoes
• HIV cannot be spread in saliva, sweat, or tears, and no documented case exists of HIV being transmitted by spitting
• HIV cannot be spread by casual contacts, such as sharing dishes or shaking hands
• HIV cannot be spread by closed mouth or social kissing
• HIV cannot be spread from toilet seats

HIV Sexual Transmission

HIV Blood Transmission

Pre-exposure prophylaxis (PrEP) is a way for individuals who do not have HIV but are at substantial risk of contracting it to prevent HIV infection by taking a pill every day. One PrEP option currently recommended is TDF-FTC (tenofovir disoproxil fumarate- emtricitabine). These component drugs are combined with other medicines to treat existing HIV. When an individual is exposed to HIV through sex and/or injection drug use, these medicines can help to keep the virus from establishing a permanent infection. PrEP is much less effective if it is not taken consistently. PrEP is only for individuals at substantial ongoing risk of HIV infection.

PrEP is a powerful HIV prevention tool and can be combined with condoms and other prevention methods to provide even greater protection than when used alone. Individuals who use PrEP must commit to taking the medication every day and follow-up with their healthcare professional every three months for a repeat HIV test and other follow-ups. At this time, the healthcare professional should write a prescription refill, offer to counsel about medication adherence and risk reduction, test for STDs if necessary, and assess side effects (Delgado, 2019).

On May 14, 2014 (updated in 2017), the United States Public Health Service released the first comprehensive clinical practice guidelines for PrEP (USPHS, 2017). The guidelines were developed by a federal inter-agency working group led by the CDC and reflect input from healthcare professionals, individuals with HIV, their partners, and affected communities. These new CDC guidelines include:

• Provide clear criteria for determining an individual's HIV risk and indications for PrEP use.
• Require that individuals be HIV tested to confirm negative status before starting PrEP.
• Underscore the importance of counseling about adherence and HIV risk reduction, including encouraging condom use for additional protection.
• Recommend regular monitoring of HIV infection status, side effects, adherence, and sexual or injection risk behaviors.
• Include some form of providers' supplement with sources for additional materials and health or compliance tools when prescribing PrEP.

PrEP is ordered in an attempt to prevent the sexual transmission of HIV. Individuals who are at high risk for contracting HIV via sex include:

• Anyone who is in an ongoing relationship with an HIV-positive partner.
• Anyone who is not in a mutually monogamous relationship (i.e., an individual and their partner only have sex with each other and do not have sex outside of the relationship) who recently tested HIV-negative.
• A gay or bisexual man who has had anal sex without a condom or been diagnosed with an STD in the past 6 months.
• A heterosexual man or woman who does not regularly use condoms during sex with partners of unknown HIV status and are at substantial risk of HIV infection (e.g., individuals who inject drugs or have bisexual male partners).

PrEP is also ordered to prevent the transmission of HIV through the injection of drugs. Individuals who are at high risk for contracting HIV via this route include:

• Individuals who have injected illicit drugs in the past 6 months and who have shared injection equipment or
• Individuals who have been in drug treatment for injection drug use in the past 6 months

The use of PrEP should also be discussed with:

• HIV discordant heterosexual couples (i.e., one partner is HIV-positive and the other HIV-negative). It is one of several options to protect an HIV-negative mother (CDC, 2019d).

In all PrEP Clinical Trials, HIV transmission risk was lowest for participants who took the pill consistently. At times it reduced the risk of getting HIV from sexual intercourse by as much as 90% (Mayer & Krakower, 2019). Among those who inject drugs, PrEP showed a reduction of around 74% of contracting AIDS when taken daily (CDC, 2019j).

A client receiving PrEP should have regular appointments with a medical provider. Recommended is a follow-up one to three months after initiating PrEP treatment, with a visit every three months after that (Mayer & Krakower, 2019). Checkups are encouraged whenever exposure to, or symptoms from, a sexually transmitted infection (STI) occurs or should sign of kidney function issues appear. Should kidney function markers appear during the three-month visits (e.g., elevated creatinine, glycosuria, new proteinuria), consider halting the PrEP (Mayer & Krakower, 2019).

For individuals who need to prevent HIV after a single high-risk event of potential HIV exposure, such as unprotected sex, needle-sharing injection drug use, or sexual assault, there is another option called post-exposure prophylaxis ((PEP)). It involves taking antiretroviral medications as soon as possible. Still, no more than 72 hours (3 days) after exposure to HIV to try to reduce the chance of becoming HIV positive. These medications keep HIV from making copies and spreading throughout the body. Two to three medications are usually prescribed and must be taken for 28 days. (PEP) is not always effective. It does not guarantee that an individual exposed to HIV will not become infected with HIV.

Starting (PEP) as soon as possible after a potential HIV exposure is important. Research has shown that (PEP) has little or no effect in preventing HIV infection if it is started more than 72 hours after HIV exposure. It takes about three days for HIV to make copies of itself once it enters the body and spreads throughout the body. When HIV is only in a few cells where it entered the body, (PEP) can sometimes be halted, but when it is in many cells in many places of the body, (PEP) will not work.

(PEP) should only be used right after an uncommon situation with potential HIV exposure. If the individual is often exposed to HIV, for example, because the individual often has sex without a condom with an HIV-positive partner, repeated (PEP) use is not the right choice. When medications are given only after exposure, more medications requiring higher dosages are needed to block infection than when they started before and continued after that. In this situation, pre-exposure prophylaxis (PrEP) is indicated.

In the United States, HIV testing is governed by a range of state and federal laws, common law principles, and various wide-flung codes of ethics. While state laws vary widely, the concept of informed consent, achieved through the process of physician-patient communication, is a legal and ethical obligation spelled out by statute and case law in every state. To help settle this confusion, the CDC has formulated specific recommendations balancing the rights of individuals with the need of the public regarding the infectious disease. In 2006, the CDC published its Revised Recommendations for HIV Testing for Adults, Adolescents, and Pregnant Women in Healthcare Settings, which addressed the issue of HIV testing and the need for test consent and pre-test counseling.

As of 2018, all states have enacted laws that are consistent with the following CDC recommendations (CDC, 2019e):

Consent:

• A separate written consent for HIV testing is not recommended.
• A general informed consent for medical care, which notifies an individual that an HIV test will be performed unless specifically declined (opt-out screening), should be sufficient to encompass informed consent for HIV testing.

Prevention Counseling:

• It is an interactive process for assessing the risk of HIV infection, recognizing specific behaviors that increase infection risk, and developing a plan to reduce that risk.

For specific information about each state's laws regarding HIV testing, informed consent, and prevention counseling rules, click this link to the CDC state HIV law information page: CDC State HIV Law Information Page.

Who should/ and how/when to receive testing has been a matter of vigorous debate and perhaps a few fistfights? The CDC recommends at least one HIV test for all individuals between ages 13 and 64.

Frequent testing is recommended for any individuals who have placed themselves at risk for exposure through:

• Unprotected anal, oral, or vaginal sex
• Having shared needles
• Having been in contact with potentially unsterilized blood exposed instrumentation (e.g., tattoo needles, body piercing implements, etc.)
• Occupational exposure to HIV (healthcare personnel, laboratory personnel, police, tattoo or body piercing artists, sex industry workers, etc.)

In addition to home HIV tests, screening is available through physician offices, urgent care clinics, public health departments, family planning, and sexually transmitted disease clinics.

Confidential HIV testing is offered in all states. Confidential HIV testing means that results go into the individual's medical file and may be shared with other healthcare providers and insurance companies according to HIPAA regulations. Some states offer anonymous HIV testing where a unique identifier is attached to the results allowing only the individual to access the results.

Tests positive for HIV or other sexually transmitted infections (STI's) will be reported to local or state health departments. This allows state tracking of new infections to plan public health response. State health departments take the compiled information and forward them to the CDC after stripping them of all personal information.

Anonymous testing may delay or prevent a timely initiation of treatment. It may lead to some individuals failing to receive care. Thus, anonymous testing is not an ideal option. Healthcare professionals should take the time to review whether anonymous HIV testing is in the individual's best interest and even if it is an alternative in the area of practice.

Comprehensive consent to medical treatment serves as consent for HIV testing as long as the individual is informed that it is included. Healthcare professionals need to take time with the individual, both before or after HIV testing occurs if possible, to discuss some key areas related to HIV testing, such as the following:

• Benefits that come from learning their HIV status, as well as benefits of early treatment if the HIV test returns positive
• Potential dangers of HIV infection
• Ways in which HIV is transmitted and how transmission can be prevented
• Potential results for the individual should the HIV test return positive

Conservative estimates place the current number of HIV-infected persons in the United States at around 1.1 million. Of these, around 15% (or 162,500) are unaware they have the disease and are highly contagious as they are untreated. Experts at the CDC recognize that around 40% of new HIV cases each year are transmitted by those who simply are unaware they are spreading a plague in the form of the HIV virus (CDC, 2019f).

Early HIV detection heralds the beginning of early medical treatment. New drug therapies have significantly lengthened the lifespan and added quality of life to individuals with HIV infections. Early testing also allows early counseling to help the newly infected limit the risk of exposing others to infection.

Pre-test HIV counseling is generally not required. However, the healthcare professional should offer the individual information or resources for further information. If the opportunity arises, the following should be provided:

• Information on behavior places the individual at risk and other individuals at heightened risk for contracting HIV.
• Assistance setting realistic goals for behavioral change to reduce the individual's risk for contracting or transmitting HIV.

Post-test HIV counseling should be offered to each individual even if they receive negative test results. Counseling can be performed by the healthcare professional providing the test results, or it can come in the form of a referral for the individual to the services of another healthcare professional. For those individuals who receive negative HIV test results, the information provided is much the same as in pre-test counseling, i.e., awareness of risk behaviors and assistance in reducing or eliminating the behaviors which have placed them and others at risk for contracting or transmitting HIV.

Individuals who test positive for HIV must be informed of the following, in addition to information relating to risk factors and high-risk behaviors. These individuals should be:

• Informed that HIV is a reportable public health condition.
• Offered assistance in the notification of past partners regarding their need to be tested or referring past partners to public health services.
• Offered assistance obtaining appropriate medical care.
• Offered assistance with appropriate referrals for HIV prevention services (to limit any illness spread from their behaviors) and support services such as alcohol or drug counseling, TB screening, and other condition-appropriate care.

When an HIV test is positive, the testing site must report the positive results to the state health department. This allows public health services to monitor the ebb and surge of HIV cases in their city or state. All personal identifying information is stripped from the result (name, home address, etc.) before it is reported to the national database at the CDC.

Be aware that many states have statutes known as "partner notification laws," which require either the positive testing person or the clinic where the testing was conducted to notify needle-sharing or sex partners that a physically intimate person has tested as HIV positive. (HIV.gov, 2017b)

Case Study

Almost 15% of HIV infected individuals in the United States are unaware of their infection and the possibility that they are infecting others (CDC, 2019f). Screening recommendations from the United States Preventive Services Task Force (USPSTF) strongly encourage healthcare professionals to routinely screen all adolescents and adults ages 15 - 65 for HIV infection. Screening should also include those younger or older who are at increased risk. The American College of Physicians (ACP) recommends routine HIV screening extending to age 75. The CDC guidelines suggest screenings begin at age 13. The consensus among these organizations persists that healthcare professionals need to be much more assertive in conducting HIV screenings.

Recommended intervals between routine HIV screenings vary as to risk levels and circumstances, with those showing positive for HIV needing placement into treatment rather than further follow-up screenings. Individuals actively engaged in risky behaviors (e.g., MSMs, IDU injection drug users, having sexually high-risk behaviors, etc.) or living in a high presence setting (e.g., homeless shelters, tuberculosis clinics, correctional facilities, etc.) should receive annual or more frequent screenings. For those with lesser degrees of risk, the amount of time between HIV screenings should be set according to circumstances and clinician judgment, with a suggestion of around every three to five years. The USPSTF acknowledges that routine HIV screening may not be necessary for individuals with a negative HIV initial screening who demonstrate the lack of an increased risk of exposure. However, all newly pregnant women should be screened as early as possible in their pregnancy (Sax, 2019).

Basically, there are three types of diagnostic tests for HIV infection: antibody tests, antigen/antibody (Ag/Ab) tests, and nucleic acid (RNA) tests. Antibody tests detect antibodies, proteins that the body produces to fight against HIV, not HIV directly. Ag/Ab tests and RNA tests detect HIV directly.

HIV Antibody Tests

HIV Antigen/Antibody Tests

HIV Nucleic Acid (RNA) Tests

Negative HIV Results

Positive HIV Results

Indeterminate HIV Results

HIV Viral Load Testing

Currently, there is no cure for HIV infection.

An individual's lifespan can be extended and quality of life enhanced. Yet, every individual diagnosed with HIV infection will die from it if another life-ending event does not take them first. Consequently, prevention is the key, the goal, and the focus of early intervention. Once an HIV diagnosis does occur, early and aggressive therapy can add decades of life and enhance the quality of life.

Optimal treatment of HIV infection frequently changes as viral strains become resistant to therapeutic agents and new pharmaceuticals come into use. Once a positive HIV diagnosis occurs, gaining the trust and cooperation of the individual is paramount. This has been demonstrated in the epidemiological history of HIV, with cases of infected individuals denying the presence of the illness, refusing treatment, and then infecting dozens of new victims in an exponentially expanding horror story of disease and death.

A complete medical history, physical examination, and general laboratory assay should be initiated as soon as possible after initial diagnosis. The results of these provide the foundational framework on which future results can be compared and serve to preclude or discover current comorbid disease processes also requiring treatment.

The following laboratory tests should be ordered so that their values establish an individual's baseline:

• HIV serology testing
• CD4 count
• Hepatitis screening and serology
• Chemistry profile
• Transaminase level
• Serum urea nitrogen
• Fasting blood glucose levels
• Serum lipid levels
• Urinalysis

The current best practice for HIV treatment is early and continuing antiretroviral therapy (ART) for all HIV infected individuals, especially infected pregnant women, to reduce the risk of transmission to the fetus (Fletcher, 2018). Antiretroviral medications do not kill the HIV virus or cure the disease. ART's are intended to slow or prevent the growth and spread of the virus.

Several antiretroviral agents are in use since the HIV virus has shown itself proficient in forming a single-agent therapy resistance. Highly active (or highly aggressive) antiretroviral therapy (HAART) combines three or more antiretroviral agents, which are given to provide the continuing benefit of the agents and prevent treatment resistance from forming within the infected individual.

Each drug class of antiretroviral medication works by a different mechanism to combat HIV. There are currently six classes of antiretroviral medications (Bennett, 2019).

• Nucleoside Reverse Transcriptase Inhibitors (NRTIs) or "nukes" block reverse transcriptase. An enzyme HIV needs to create altered DNA from viral RNA to make copies of itself.
• Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) or "non-nukes" bind to and later alter reverse transcriptase to block the altered DNA from creating any additional viral RNA, though in a different fashion from the NRTIs.
• Protease Inhibitors (PIs) interfere with the process of the newly formed HIV virus using the enzyme protease to gather components it needs to mature into full function.
• Entry Inhibitors block proteins on the CD4 cells that HIV needs to enter cells. This category includes the CCR5 antagonists, blocking viral entry into CD4 cells. The Fusion Inhibitor enfuvirtide works by preventing viral contents from binding to CD4 components.

• Post-Attachment Inhibitor, the monoclonal antibody Ibalizumab-uiyk, is the only PAI in current use. It does not block viral attachment to CD4 cells. However, it thwarts viral core entry into the cell core, thus preventing HIV replication.
• Integrase Strand Transfer Inhibitors (INSTI) act to prevent the DNA from the virus from being inserted into the chromosome of the host cell by interfering with the HIV integrase enzyme, the tool the virus uses to unzip and then patch in its own nucleic acid.

Also important are Pharmacokinetic Enhancers and Combination HIV Medications commonly used in the ART and HAART regimens. Pharmacokinetic Enhancers are used in HIV treatment to increase the effectiveness of an HIV medication included within an individualized HIV regimen. Combination HIV Medications are two or more HIV medications from one or more drug classes given together for greater impact.

ART to HAART

HIV Medication Combination Therapies

Healthcare professionals who work closely with HIV positive individuals indicate that treatment adherence is one of the greatest challenges. HIV is a life-long chronic medical condition requiring significant lifestyle alterations, intensive and intrusive condition monitoring, harsh and, at times, expensive medications. HIV also has a relatively symptom-free middle stage that frequently leads individuals to question whether the treatment is worth it. It is no wonder that even when an individual is agreeable to actively treat their condition, they wander away from the necessities of the constant hassle.

Bolstering treatment adherence should start early, even before a diagnosis of HIV is made. Public service announcements targeting those engaging in high-risk behavior for contracting the disease can provide a foundation for building a therapeutic relationship between healthcare professionals and individuals if, or when, they present with symptoms or a positive HIV test. Question free needle exchange and easy access to community health clinics are important for the level of trust and rapport needed to limit the spread of HIV and help infected individuals return to the best health possible.

Early on, nonjudgmental, open dialogue about the benefits and unwanted effects of antiretroviral drug therapy is an important step toward an honest exchange of information. This allows those at higher risk of HIV to be aware that there are treatments that will help, though not cure, the disease if they become infected. New individuals should be made aware that HIV treatment is voluntary. Though they and those closest to them will benefit from treatment, they can decline treatment at any point without risk of being denied social service or medical benefits. If treatment, particularly ART therapy, is refused, follow-ups should be encouraged to monitor the progression of the illness and keep them informed of what is happening within their bodies. Periodically, ART should be reoffered, and they will be welcomed whenever they decide to initiate therapy.

The HIV infected individual should be involved in selecting which ART is preferred when they are ready to begin medication for their HIV infection. Information should be shared about the therapeutic agents best suited for their virus strain. Other factors such as potential adverse actions, dosing frequency, pill burden, nutritional requirements, and any unwanted effects that would arise from skipping or stopping dosages should also be reviewed. The client's daily activities should be reviewed to see if their life will be unduly altered by the limits placed on them by treatment needs and if they are willing to adapt to the needed changes. Share the cost or co-payment information for the medications with the individual to see if that will be a limiting factor that needs to be addressed. Involving the individual in important decisions at the beginning of treatment contributes to their treatment throughout the illness.

Adherence to the medication regimen should be addressed in a calm, matter of fact manner every time the individual visits. Questions that normalize the human factor should be utilized, understanding that sometimes there will be less than perfect adherence. Clients should be encouraged to be "accurate" about their activities rather than "right or wrong," focusing on being nonjudgmental. The "white coat phenomenon" is a phenomenon that occurs as individuals tell healthcare professionals what they think they want to hear, not the reality.

Positive reinforcement and celebration of successes, no matter how small, should be used in such situations as low or non-detectible viral loads, increases in CD4 cell counts, etc. Individuals should feel that the healthcare professional is glad to see them and encourage them to keep the appointment no matter how they feel.

The individual should be encouraged and helped connect with community and family support systems such as visiting nurses, family counseling services, community workers, peer advocates, support groups, and other available public services.

Case Scenario 2

HIV infection is a chronic medical condition that those infected will have until they succumb to it in its final stage of AIDS, or death ensues from another cause first. Ironically, those carrying HIV are unlikely to die directly from the infection. Since HIV attacks the immune system of its host, damaging the body's ability to fight off other infections and diseases, often underlying illnesses, exposure to unwanted organisms, or opportunistic infections arise to deal the actual mortal blow.

There is no cure for HIV infection. This means that prevention is key to controlling its spread. Distributing knowledge of HIV and information concerning infected individuals' rights and the value that their lives hold form key parts for positively affecting individuals/groups whose behaviors place them at a heightened risk for exposure and infection. It is important to share information concerning the transmission of HIV along with the risks of unprotected sex, sharing of needles, and exposure to unsterilized blood-contaminated devices as methods by which the HIV retrovirus can be transmitted to still another victim.

It is estimated that approximately 15% of HIV infected individuals are unaware of their infection and, therefore, unable to begin life-extending treatment. HIV testing is available both from healthcare professionals and using home tests. Once a positive test is confirmed, early aggressive treatment with antiretroviral medications is highly encouraged. The state of HIV medications allows those infected to live decades longer than they would without medication and with a greater quality of life. However, the medication regimen can be taxing. Support for adherence to the medication regime and behavioral changes that minimize the chance of spread of the virus by those infected are important objectives for healthcare professionals as they work toward helping the HIV infected live healthier, more satisfying lives.

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