Care of the Patient With HIV/AIDS

Throughout the world, HIV is one of the leading causes of death and results in more deaths than does any other disease caused by infection. As of 2011, approximately 34.2 million people were infected with HIV (CDC, n.d.). Approximately 2.5 million new diagnoses were made, and 330,000 children were infected with HIV in 2011. Almost all of those people reside in countries with low or middle incomes.

Sub-Saharan Africa has been hit especially hard (WHO, 2013a). This region contains more than 69% of the world's population with HIV but only 12% of the total world population (Henry J. Kaiser Family Foundation, 2013). In 2011, 17.3 million children in that region had lost one or both of their parents to AIDS. Death related to AIDS is associated largely with poor access to prevention and treatment services (Henry J. Kaiser Family Foundation, 2013). Since 2005, the number of people infected with HIV has steadily declined (AVERT, n.d.). This decreasing infection rate is thought to be related to increased access to antiretroviral treatments. Managing and treating this disease will remain a challenge for years to come, especially in the sub-Saharan region of Africa.

In the United States approximately 50,000 new cases of HIV are diagnosed each year. More than 1.1 million people in the United States are currently living with HIV/AIDS (CDC, 2013a). Between 2003 and 2006, the number of new HIV/AIDS cases in the United States stabilized, but the number of people who were living with the disease increased. At the end of 2006, almost 500,000 people were infected and living with HIV/AIDS (CDC, 2008). California, Florida, and New York accounted for most of the patients with AIDS diagnoses (CDC, 2008).

Trends and Most Affected Populations

Beginning in 1996, the use of highly active antiretroviral therapy (HAART) in people with HIV infection increased greatly in the United States. Since that time, fewer people with HIV infection have developed AIDS. New HIV and AIDS cases affect various racial groups, ethnic groups, geographic areas, and demographic populations; thus this epidemic has affected nonwhite people, women, heterosexuals, and people who use injection drugs. However, people with HIV are living longer (CDC, 2008).

In 2010, the CDC reported that the population of men who have sex with other men constitutes the biggest proportion of HIV/AIDS patients, accounting for 78% of the total number of HIV infections in male patients 13 years of age and older (CDC, 2013b). The HIV infection rates among this population decreased from 71% in 1983 to 44% in 1996. Holmberg (1996) predicted that this rate would continue to decrease to approximately 25%. Instead of decreasing, however, the number of new HIV infections in men who have sex with men has not continued the hoped-for decline. In response the CDC is implementing a system of “High Impact HIV Prevention” by targeting at-risk populations with direct measurable strategies (CDC, 2013c).

During the first 25 years of this epidemic, the distribution of new cases on the basis of ethnicity and race changed (see Cultural Considerations box). Disproportionate numbers of Hispanic Americans and African Americans have been infected with HIV. In 2006, although African Americans made up only 13% of the population in the United States, they accounted for almost half of the total number of HIV/AIDS cases that were diagnosed. African American adults and adolescents are 10 times more likely to receive a diagnosis of AIDS than are white adults and adolescents. The primary risk factor for African American men who developed HIV was sexual contact. In 2005, African American men who have sex with men (MSM) were much more likely than other MSM to be infected with HIV. Another risk factor for African American men is engaging in high-risk heterosexual behavior (CDC, 2013d).

Some African American men who engage in sex with other men identify themselves as heterosexuals because of the stigma and homophobia issues. Many African American MSM are secretive about their homosexuality or choose not to identify their sexual orientation. Prevention programs are challenged when people do not identify themselves as engaging in risky behaviors or having increased risk factors.

Initially the face of HIV/AIDS was predominately homosexual men and people who used injection drugs. Rates of transmission of the disease to women have been startling. Currently, an estimated 25% of HIV/AIDS sufferers are women (Womenshealth.gov, 2011a). HIV was the leading cause of mortality in African American women between 25 and 34 years of age. African American women are 23 times more likely to be diagnosed with AIDS than are white American women. Young people between ages 13 and 29 reflected an estimated 39% of new infections in the United States.

Although Hispanic Americans account for 16% of the population, they accounted for almost 20% of new HIV infections in 2009 (U.S. Department of Health and Human Services [HHS], 2012). Many socioeconomic and cultural factors have contributed to this epidemic and associated prevention challenges in the U.S. Hispanic and Latino communities. For Hispanic men and women, the primary risk factor for developing HIV is sex with men. Rates of other sexually transmitted infections (STIs), including chlamydia, gonorrhea, and syphilis, are also higher among Hispanic Americans than among non-Hispanic white Americans (CDC, 2013e). Transient Hispanic populations often have difficulty receiving access to health care because of social structure, language barriers, and migration patterns (CDC, 2008). The predicaments caused by poverty limit access to appropriate health care, housing, and HIV prevention. All these factors may directly or indirectly increase risk factors for HIV infection in the Hispanic population.

In 1996 researchers incorrectly predicted that HIV cases would increase among people who use injection drugs (Holmberg, 1996). The biggest increase in new HIV cases has occurred in heterosexual populations. In 1983, heterosexuals made up 5% of new HIV cases. By 2009 this number had grown to 27% (HHS, 2012). Drugs that are not injected also affect the spread of HIV because drug users often engage in high-risk behaviors when they are under the influence (CDC, 2008).

As treatment for HIV has advanced, the progression from HIV to AIDS has slowed, resulting in a decreased mortality rate among people infected with HIV. Data from 2006 indicate that although the number of AIDS cases has remained stable, the death rate has decreased (CDC, 2008). Advanced treatment options mean that people are living longer after their AIDS diagnoses. Unfortunately, in countries where HIV-infected people are without adequate access to health care, HIV infection is still one of the leading causes of death.

Sexual Transmission

Sexual intercourse remains the most common mode of transmission of HIV in the world today and is responsible for the majority of the world's total AIDS cases. Sexual activity provides the potential for the exchange of semen, cervicovaginal secretions, and blood. Important risk factors are the presence of HIV in one or both partners and the occurrence of behaviors that put one or both partners at risk for transmission. Some individuals become infected with HIV after a single unprotected sexual encounter, whereas others remain free from infection after hundreds of such encounters.

Although the majority of HIV transmissions in the United States occur among MSM via receptive anal intercourse, heterosexual transmission via anal intercourse is becoming increasingly prevalent. Heterosexual couples may prefer this method of sexual expression or use it because it eliminates the risk of pregnancy. Unfortunately, the most risky sexual activity is unprotected receptive anal intercourse. Because the rectum is generally tighter and the rectal mucosa is less lubricated than the vagina, the rectal mucosa may be torn, providing an excellent portal for the virus to enter the blood stream.

During any form of sexual intercourse (anal, vaginal, oral), the risk of infection is considerably higher for the receptive partner, although infection can be transmitted to an insertive partner as well. The receptive partner generally has prolonged exposure to semen (National Institute of Allergy and Infectious Diseases, 2009). Other factors that may increase the risk of sexual transmission include ulcerating genital diseases, such as herpes simplex virus (HSV) and syphilis; chancres secondary to STIs; intact (uncircumcised) foreskin; sex that is “forceful or vigorous”; immunosuppression due to drug use; and drug use that may lead to high-risk behavior. Infection risk for HIV can also be increased during intercourse when the infected partner has a high viral load (Benotsch et al., 2012; Cohen, 2012; Gray et al., 2012). The viral load is often increased in the primary and late stages of infection (Klimas et al., 2008). Oral-genital transmissions have been reported, and the HIV transmission risk increases if the receiving partner already has an STI that has caused open sores, such as HSV infection.

HIV may be transmitted by exposure to contaminated blood through the accidental or intentional sharing of injecting equipment and paraphernalia. Such equipment includes syringes, needles, cookers (spoons or bottle caps used for mixing the drug), and filtering devices (such as cotton balls). People who use injection drugs are the population with the second highest rates of HIV exposure, following MSM (CDC, 2006). Although typically seen in large metropolitan areas, injection drug use occurs in smaller cities and rural areas as well. Such drugs are not limited to illicit drugs; HIV can be transmitted via contaminated equipment used to inject steroids, vitamins, and insulin.

People who use injection drugs confirm needle placement in a vein by drawing back blood into the syringe; the substance is then injected into the vein. They may also draw blood back into the syringe and inject numerous times (“booting”). This ensures that no substance remains in the syringe. Other factors that put people who use illicit injection drugs at risk for HIV include poor nutritional status, poor hygiene, and impaired judgment due to mood-altering substances. People who use illicit injection drugs are also less likely to use condoms during sexual intercourse and may engage in sexual activity in exchange for drugs. The long-term effects of illicit injection drug use include increased risk for other diseases, such as hepatitis B, hepatitis C, and other bloodborne illnesses.

Perinatal (Vertical) Transmission

HIV infection can be transmitted from a mother to her infant during pregnancy, at the time of delivery, or after birth through breastfeeding. In the United States, it is estimated that approximately 30% of infected mothers transmit HIV to their infants and that approximately 50% to 70% of the transmissions occur late in utero or during birth. The rate of vertical transmission varies around the world; in France the rate is approximately 11%, but it is nearly 50% in parts of Africa. Factors such as the stage of maternal HIV disease (transmission is more likely to occur during the initial and later stages of infection, when more of the virus is circulating in the mother's blood and body fluids), a decreased CD4⁺ cell count or high viral load, the presence or absence of STIs, and the mother's nutritional status all play a role in vertical transmission. Factors that increase the risk of transmission during delivery include extreme prematurity; lack of health care; gestational complications that lead to extended labor; the mixing of maternal and fetal blood; newborn ingestion of maternal blood, amniotic fluid, or vaginal secretions; skin excoriation in the newborn; and being the first child born in a multiple gestation.

Clinical trials have demonstrated that the administration of zidovudine therapies to pregnant women who are HIV positive can reduce transmission to approximately 2% of infants. Studies on the outcomes of the infants whose mothers had these antiviral therapies have not found significantly different outcomes from infants born to HIV-positive women who did not receive the antiviral therapies during pregnancy (Marino, 2012).

In addition to drug therapy, substantial advances have been made in understanding the pathophysiology, treatment, and monitoring of HIV infection. These advances have resulted in changes in the standard of care for patients, including pregnant women, with HIV infection. More aggressive combination drug regimens that provide maximal viral suppression are now recommended. Although pregnancy alone is not a reason to defer treatment, the use of anti-HIV drugs during pregnancy requires special consideration. Unfortunately, no long-term data regarding the long-term effects on the fetus exist. Because of this, offering antiretroviral therapy (ART) to HIV-infected women—whether primarily to treat HIV infection or to reduce the likelihood of perinatal transmission—should be accompanied by a discussion of the known and unknown short- and long-term benefits and potential risks. Because of the findings of ACTG 076, zidovudine should be a part of this treatment regimen.

Current recommendations call for routine HIV counseling and voluntary HIV testing of pregnant women and women considering pregnancy. An HIV-positive pregnant woman should be given information to make an informed decision about treatment options. The HIV transmission rates from mother to child have been reduced due to several recommended inter­ventions, including ART, formula feeding, and cesarean section. In developed countries, this number has decreased from 25% (without interventions) to approximately 1% (CDC, 2013f). In countries where ART is not available and mothers continue to breastfeed, the infection rate by age 2 for children born to HIV-infected mothers can be as high as 45% (WHO, 2013b). Infants born to HIV-infected mothers have positive HIV antibody results as long as 15 to 18 months after birth. This finding is caused by maternal antibodies that cross the placenta during gestation and remain in the infant's circulatory system. HIV infection can be diagnosed earlier by means of an HIV viral culture or measuring the amount of HIV RNA or viral load through polymerase chain reaction (PCR) or branched-chain DNA (bDNA) testing.

Influences on Viral Load and Disease Progression

HIV replicates quickly after entering the host body. It can rapidly produce billions of copies, which infect CD4⁺ cells and the lymphatic system (see Figure 55-2). The viral load of the host during the early stage of the infection can be extremely high and increases risk of virus transmission to other people who are exposed. The severity and progression of the infection are related to the host's infection with other STIs, age, and immune response. Basic host immune defenses (cellular and humoral) help limit replication and slow progression of HIV. Unfortunately, these immune responses cannot completely eliminate HIV from the host. The host can continue to appear healthy even when infected with the virus (Table 55-1). Some patients live with the virus for at least 10 years without any treatment and appear healthy. They are referred to as long-term nonprogressors. Cheng and colleagues (2007) found that when HIV-infected patients who were also co-infected with another type of virus took ART, their CD4⁺ cell count was low. When older HIV-infected patients do not use ART, their rate of disease progression is much faster than in younger patients. This discrepancy is thought to be related to the facts that older patients have more pathogen exposure, an increased number of memory CD4⁺ cells (which are targeted by HIV), and fewer numbers of naïve CD4⁺ cells. Older patients tend to have more difficulty producing more CD4⁺ cells.

Many factors can increase HIV disease progression. People who use drugs and engage in high-risk sexual behavior are less likely to employ infection-preventive methods. Depression may impair their use of resources to help manage their infection (Kalichman, 2008). Poor coping mechanisms and high levels of emotional stress have a negative effect on HIV disease progression (Ironson and Hayward, 2008; Leserman, 2008; Temoshok et al., 2008).

The virus can make amazing numbers of copies of itself daily (Ho et al., 1995; Wei et al., 1995). HIV contained in blood plasma has a half-life of less than 2 days. While the virus continues to replicate, many millions of CD4⁺ cells are produced and destroyed each day. The viral load in the patient's blood determines how quickly the CD4⁺ cells are destroyed.

The HIV viral load in the blood can remain low or difficult to detect for weeks or even months after the initial exposure and infection (Figure 55-3). When the immune system responds, the viral load decreases quickly as the body effectively contains the infection. Normally, antigens that are deemed foreign intermingle with B cells. At this stage, antibodies are produced. T cells start a cell-based immune response. In the early stages of the infection, the antibodies are able to reduce the viral load. T cells are beckoned to the lymph nodes, where the virus is trapped (see Table 55-1). The virus replicates in the lymph system (nodes, tissue, spleen, and tonsils).

The lymphatic system carries the infection from one site to another. During this time, the HIV-infected person does not have any signs or symptoms. Over time, the lymphatic system is damaged by the HIV. The virus enters the blood, which increases the rate of disease progression. The body is not able to mount an adequate response to new infections. The immune system damage is apparent on examination of B cell dysfunction, but more important CD4⁺ cells are destroyed and their levels depleted (see Figure 55-2).

As the CD4⁺ cells are destroyed, the immune system fails. Immune dysfunction can occur when the CD4⁺ lymphocyte count falls below 500/mm³ of blood. When the count falls below 200/mm³, severe immune system dysfunction is apparent. This results in the development of possibly fatal opportunistic infections in the host.

Monocytes can be infected by HIV because some of them also have CD4⁺ receptors. When a monocyte is infected, it can change into a phagocyte (a cell that ingests and digests bacteria). When a phagocyte is infected with HIV, it merely works as a factory to create more HIV. An infected phagocyte can rupture as a result of a normal local inflammatory response. When this happens, the HIV is spread even deeper into the body. In this way, the skin, the lungs, bone marrow, the central nervous system, and lymph nodes become directly infected.

Acute Retroviral Syndrome

Viral replication occurs during the acute infection period. The viral load peaks at millions of copies of virus per milliliter of plasma. The viral load declines right before the appearance of detectable antibodies that can be measured in the blood. The viral set point, or stabilizing of the viral load, is reached 4 to 6 months after exposure. This viral set point is important in that some researchers believe it to be a prognostic indicator of long-term survival: that is, the lower the viral set point, the longer the individual will survive with HIV disease. Postexposure prophylaxis (PEP), begun as soon as possible after exposure, may help lower this viral set point. This theory is demonstrated in cases in which health care personnel initiate PEP medications after an exposure and do not undergo seroconversion.

Seroconversion, as defined previously, is the development of antibodies from HIV, which takes place approximately 5 days to 3 months after exposure (generally within 1 to 3 weeks). This process is accompanied by a flulike or mononucleosis-like syndrome consisting of fever, night sweats, pharyngitis, headache, malaise, arthralgias, myalgias, diarrhea, nausea, and a diffuse rash prominent on the trunk. These symptoms last approximately 1 to 2 weeks, although some symptoms may last for several months. Seroconversion illness occurs in approximately 89% of HIV-infected people. HIV antibodies appear in 95% of people within 3 months of infection, and seroconversion occurs in 99% within 6 months. The viral load during the period of seroconversion is extremely high, with a short-term drop in CD4⁺ cells. The CD4⁺ cell level quickly returns to normal as the immune system mounts an attack against the viral infection; as a result, viral loads exist at nearly undetectable levels in the blood. In most people with HIV infection, the acute retroviral illness is mild and may be mistaken for a cold or other minor viral infection (Table 55-3).

Early Infection

The median time between HIV infection and the development of end-stage HIV disease, or AIDS, in an untreated individual is between 8 and 14 years. This phase of HIV disease is sometimes called the asymptomatic phase because the HIV-infected individual looks and feels healthy. Some individuals have vague symptoms of a viral infection, including fatigue, headaches, low-grade fever, and night sweats. Because many of the symptoms of early infection are nonspecific, a diagnosis of HIV infection might not be made. Consequently, individuals may continue to engage in risky sexual and drug-using behaviors. Although seemingly healthy, the HIV-infected individual can transmit HIV to others. Lack of knowledge of one's HIV antibody status puts one at risk for earlier development of more advanced disease because changes in behaviors, such as those that promote health, are not instituted. Furthermore, if an individual is aware of being infected with the virus, early intervention with antiretroviral medications may prolong the asymptomatic phase and prevent progression to AIDS.

Early Symptomatic Disease

The early symptomatic phase of HIV infection occurs when the CD4⁺ cell count drops below 500/mm³. Early symptoms include constitutional problems such as persistent, unexplained fevers; recurrent drenching night sweats; chronic diarrhea; headaches; and fatigue. These signs and symptoms become severe enough to affect activities of daily living. A physical examination may reveal persistent generalized lymphadenopathy; recurrent or localized infections; and neurologic manifestations, such as numbness and tingling or weakness in the extremities (Box 55-1).

One of the most common infections in individuals with early symptomatic disease is oral candidiasis (thrush), a fungal infection that is rare in healthy adults (Figure 55-4). Other infections that signal immune dysfunction include varicella-zoster virus (shingles), persistent vaginal candidiasis (yeast infections), and increased frequency of oral or genital HSV outbreaks. Oral hairy leukoplakia, a condition related to the Epstein-Barr virus, and oral thrush are early indicators of HIV disease and prognostic markers for disease progression. Because of this, dental health professionals have a key role in identifying cases of early HIV disease.

Persistent generalized lymphadenopathy is defined as enlargement (≥1 cm) of two or more lymph nodes, located in places other than the inguinal region, that persists for at least 3 months. This condition may be present for many years before AIDS is diagnosed.

Neurologic manifestations of HIV disease occur in more than 90% of individuals who are infected. Neurologic symptoms include peripheral neuropathies, headaches, aseptic meningitis, cranial nerve palsies, and myopathies. These conditions may be caused by the HIV infection itself or may be side effects related to antiretroviral medications.

Several cofactors may influence a more rapid progression of HIV disease. In very young children and very old adults, the disease progresses more quickly. Concurrent infections such as HSV, cytomegalovirus, or Epstein-Barr virus affect progression. Drug and alcohol use, including smoking, may suppress the immune system. Malnutrition is also known to affect immune function, but further study relative to HIV is needed.

AIDS

Acquired immunodeficiency syndrome is the term used to describe the end stage, or terminal phase, of the spectrum of HIV infection. The CDC has developed specific diagnostic criteria that must be present to make this diagnosis. These conditions are more likely to occur with severe immunosuppression. As HIV disease progresses, the CD4⁺ lymphocyte count decreases, and the ratio of CD4⁺ to CD8⁺ cells (T helper cells to T suppressor cells), which is normally 2 to 1, gradually shifts, resulting in more CD8⁺ than CD4⁺. The amount of virus detectable in the blood increases rapidly and remains high despite pharmacologic interventions. The number of white blood cells may also decline, and the person's reactivity to skin tests, such as purified protein derivative (tuberculin), is decreased or absent. An individual is said to be anergic if no skin response is noted.

Without treatment, the median time from an AIDS diagnosis to death averages years, but this varies greatly. With the advent of more effective antiretroviral and opportunistic disease prophylaxis, the life span of an HIV-infected individual is difficult to predict. Morbidity in people with advanced HIV disease also varies widely. Some people are severely ill and die rather quickly, whereas others have only to make minor adjustments in their lifestyle to cope with medical regimens or physical symptoms, such as fatigue or pain. Significant advances in the management of HIV disease have made it resemble a chronic illness. The effects of therapy on mortality have been significant: The number of new AIDS cases reported to the CDC every year has leveled off. This can be attributed to effective prophylaxis for opportunistic infections and to the development of HAART.

Hiv Antibody Testing

Patients need to understand the implications of an HIV antibody test (Box 55-2):

CD4⁺ Cell Monitoring

Monitoring CD4⁺ cells is one of the laboratory parameters used to track the progression of HIV disease. As the disease progresses, the number of CD4⁺ cells decreases. The more significant the loss, the more severe the immunosuppression becomes. The CD4⁺ cell count is the best marker of the immunodeficiency associated with HIV infection. As such, the CD4⁺ cell count influences making decisions about antiretroviral and prophylactic drug therapy and is used to evaluate specific complaints related to the risk for contracting particular opportunistic infections. For example, Mycobacterium avium complex and cytomegalovirus infections are rare in patients with CD4⁺ cell counts higher than 50/mm³. P. jiroveci pneumonia and cryptococcosis are unusual in patients with CD4⁺ cell counts higher than 200/mm³. The CD4⁺ cell count is not a perfect surrogate marker of immunodeficiency, and factors such as the patient's clinical status must always be taken into account.

The CD4⁺ cell count reflects the number of CD4⁺ cells per cubic millimeter (or per microliter) of blood. It does not indicate the total number of CD4⁺ cells in the body. Millions of new CD4⁺ cells are produced daily and cleared by normal body processes (unrelated to the virus). The absolute CD4⁺ cell count can vary greatly in the same individual, depending on the time of day the blood is drawn; which laboratory is used; and the presence of acute illness or other factors, such as alcohol. Therefore the nurse should continue to use the same laboratory, draw blood at the same time of day, and avoid testing on days when the patient is acutely ill or under abnormal stress. When using the CD4⁺ cell count to make important treatment decisions, such as initiating prophylaxis for opportunistic infections, the nurse should collect two separate samples a few weeks apart.

Viral Load Monitoring

The ability to detect HIV viral load measurements in plasma is a significant advancement in the monitoring of HIV disease. Viral load or burden is a quantitative measure of HIV viral RNA in the peripheral circulation, or the level of virus in the blood.

Three quantitative assay tests are available to measure viral load levels: NASBA, RT-PCR, and bDNA. Even very small numbers of infected cells can be detected by identifying virions. These tests can be used only to identify HIV. These tests are helpful for identifying HIV in people who have a negative ELISA (antibody) result.

Important characteristics of viral load monitoring include the following:

Viral load and CD4⁺ cell counts are distinct markers that provide different information. Viral load can indicate disease progression and long-term clinical outcome; CD4⁺ cell measurements can indicate the damage sustained by the immune system (the loss of CD4⁺ or T cells) and the short-term risk for developing opportunistic infections. Each is an independent predictor of clinical outcome, and in combination they can give a more complete indication of clinical status, treatment response, and prognosis. Coffin (1996) used a metaphor to describe the infected patient without symptoms: as a train rushing along a track, heading for a bridge that has been destroyed. The time the crash will occur is determined by two variables: (1) where the train is at a particular instant (CD4⁺), and (2) how fast it is going (viral load).

A baseline determination of viral burden is recommended, with subsequent measurements every 3 to 4 months, in conjunction with CD4⁺ cell monitoring and clinical evaluations such as a history and physical examination. Guidelines continue to be revised as the implications of viral measurement evolve and its interpretation and use become better understood. In the future, opportunistic infection prophylaxis may be based on viral load, as well as on CD4⁺ cell counts.

Resistance Testing

Drug resistance to HAART can make effective treatment of HIV challenging. In North America and Europe, approximately 8% to 16% of cases of HIV involve at least one resistant mutation (Li et al., 2011). HIV mutates easily, which makes it hard to treat and contain. After multiple genetic mutations, the replication of HIV is chaotic and disorderly, which makes it more resistant to medication treatment and has prevented the development of an effective vaccine. ART resistance results from a patient's inability to adhere to ART protocols. Assay tests can detect HIV genetic mutations that result in ART resistance. Results of these tests are available in less than a month. A list of ART-resistant mutations has been developed by the International AIDS Society–USA. Phenotyping is available to help estimate how well the specific strain of virus will respond to treatment in people who have been receiving ART for a long time. In order to perform phenotyping, the patient must have a high viral load (Panel on Antiretroviral Guidelines for Adults and Adolescents, 2013). Genotyping is less expensive to perform, and the results are often available faster than those of phenotyping. Genotyping is recommended for patients who have not received ART (US DHHS, 2011).

During the acute stage of HIV, resistance testing is important for administering appropriate ART to prevent extensive replication of HIV. Some health care providers identify baseline genetic mutations before starting ART. A patient-specific ART regimen can be created to avoid medications that would not work. Patients who are resistant to some ART medications may have cross-resistance issues with other ART medications. Resistant HIV strains are found in people who have undergone ART, as well as in other people who are newly infected and have not received treatment. Resistance to some ART drugs and the ability to transmit resistance to newly infected people are important issues for public health officials who are battling to control and prevent HIV infection.

Other Laboratory Parameters

Hematologic abnormalities are common in HIV infections and may be caused by the HIV itself, by opportunistic infections, or by drug or radiation therapy. The white blood cell is often decreased, usually in conjunction with lymphopenia (decreased numbers of lymphocytes). Thrombocytopenia (decreased platelet count) may be caused by antiplatelet antibodies. Anemia is related to the chronic disease process and to HIV invasion of the bone marrow; it is a common adverse effect of antiretroviral agents.

Alterations in liver function tests are not uncommon. Abnormalities may be caused by viral hepatitis, alcohol abuse, opportunistic infections, neoplasms, or medications. Early identification of hepatitis B and hepatitis C viral infections is important because these infections may follow a more serious course in patients with HIV disease. Patients who are HIV-positive are often also seropositive for hepatitis B, inasmuch as both infections are bloodborne and sexually transmitted. In addition, about 25% of HIV-infected people in the United States are co-infected with hepatitis C, one of the most significant causes of chronic liver disease.

Syphilis testing is important because syphilis is more complicated and aggressive in HIV-infected patients. It is also more difficult to treat with standard therapies and more likely to advance quickly to neurosyphilis. If a person with HIV infection is seropositive for syphilis, assessment and treatment must be performed immediately.

Probably the most difficult aspect of the medical management of HIV is dealing with the many opportunistic diseases that develop as the immune system degenerates. Although it is usually impossible to totally eradicate opportunistic diseases, the use of ART and prophylactic interventions can control their emergence or progression. However, these regimens must continue throughout the patient's life; otherwise, the disease will return. Advances in the diagnosis and treatment of opportunistic diseases have contributed significantly to increased life expectancy and decreased morbidity. Box 55-4 lists common opportunistic diseases associated with HIV disease.

Adherence

Adherence to a prescribed regimen (following a prescribed regimen of therapy or treatment for disease) is paramount to survival and the success of treatment. The nurse is in a unique position to help patients adapt and maintain vigilance in their treatment. Nurses must assist patients to understand that ART is a lifelong, complex undertaking. The ability to incorporate anti-HIV treatment into a lifestyle is affected by multiple factors, including treatment knowledge or misinformation, underlying psychiatric or psychological pathologic conditions, physical status, family and caregiver support, socioeconomic status, culture, fear of side effects, denial, and skills (memory, impaired function) necessary to adhere to a medical regimen.

Patients with a higher level of motivation to take their medications as ordered can have much better outcomes than do patients who are less compliant. Drug resistance to ART can develop over a weekend of missing doses. Typical adherence to ART is poor even when patients have to take only one or two pills each day. Results of one Veterans Affairs study indicated that only 76% of that population were up to date with their drug refills (Braithwaite et al., 2007).

Strategies that can assist nurses in increasing patient adherence include determining their own level of comfort with regard to HIV, learning to listen, having knowledge about the disease, using therapeutic communication skills, giving the patient and caregivers permission to grieve and feel sad, acknowledging frustration and helplessness, providing a safe environment, and seeking expert assistance as needed. All of these can help patients incorporate this difficult treatment into their lifestyle (Box 55-7).

Palliative Care

The WHO defines palliative care as helping patients and families deal with possibly fatal illnesses and quality-of-life issues. The focus of palliative care is on preventing and relieving suffering by quickly identifying and treating pain. The goal of palliative care is to improve and maintain quality of life as much as possible by focusing on all physical, spiritual, psychological, social, and existential needs of the patient or the family that is dealing with a terminal illness (WHO, 2013a).

Palliative care is not seen as hastening the dying process or postponing death. Nurses realize that death is a natural process of life, but other people may believe that a patient's death signifies the failure of medicine and loss of hope. Palliative care is often delayed as a result of this false belief. Most hospice programs use a palliative care approach, with the understanding that impending death means a shift from curing to caring. Nurses must remember that the goal is to relieve suffering through management of pain and symptoms at any point in the patient's disease process.

For patients with HIV disease, it is important for palliative care not only to address the potential chronic debilitating conditions associated with HIV disease but also to address superimposed acute exacerbations of opportunistic infections and related symptoms. Intravenous therapy, blood transfusions, and antibiotic usage may be considered palliative in the end stage of HIV disease because these interventions help keep the patient comfortable and help maintain quality of life. In AIDS care, short-term aggressive, curative therapy is often important in treating acute infections such as pneumonia, but the overall goal remains palliation.

The complex needs of patients with HIV disease necessitate the services of a multidisciplinary team of physicians, nurses, social workers, dietitians, physical therapists, and clergy. The nurse is the “voice” and advocate for the patient who may or may not be able to communicate his or her treatment desires. Because of this unique role, it is important to be comfortable discussing treatment issues and options with patients, as well as respecting their decisions. Families and significant others of patients with end-stage HIV disease can experience disenfranchised grief, which occurs when a loss is not openly acknowledged, publicly mourned, or socially supported (Sherman, 2001). Symptoms such as pain, fatigue, anorexia, fever, shortness of breath, diarrhea, and insomnia are common among people who suffer disenfranchised grief. The nurse should become familiar with the causes and interventions necessary to alleviate these symptoms. The nurse must remember that symptoms such as pain are a subjective experience and must be treated appropriately until the patient indicates the treatment has worked. Although this phase of life is difficult for the patient and nurse, many nurses express significant satisfaction with these interactions, relationships, and their outcomes.

As the HIV pandemic has changed over time as a result of the use of ART and aggressive approaches to treatment, fewer patients with HIV infection are requiring hospice or palliative care. In some patients, however, HIV is not diagnosed until they are in a later stage of the disease process. These patients may choose palliative or hospice care instead of treatment.

Psychosocial Issues

People who have received a diagnosis of HIV infection deal with a complex set of psychosocial issues. Often, they are uncertain, fearful, depressed, and isolated. HIV infection can be treated, but it is incurable and contagious. Many infected people feel isolated and abandoned by friends and family because of the stigma associated with HIV. Like the health care costs associated with many chronic diseases, the expenses involved in treating HIV infection are daunting for many patients.

Nurses and health care providers must be empathetic during contact with patients. Listening is an important skill to help convey compassion. Therapeutic communication skills should be used to further develop rapport with a patient. The nurse should help the patient plan and decide about health care options. The patient has the right to be supported even when the decision seems imprudent.

Confidentiality

Respect for the patient's right to confidentiality is particularly important for a patient with HIV disease. The confidentiality of the diagnosis must be carefully protected and shared only with caregivers who need to know for the purpose of assessment and treatment.

Health care workers should use standard precautions with each patient to prevent exposure to the patient's blood or bodily fluids. Not every infected patient may know that he or she is seropositive for HIV. When this information is shared by the patient, the information should be shared with other health care workers who are managing this patient's care.

The patient should be in control of who is told of the diagnosis, but laws dictate the reporting of an HIV diagnosis to appropriate health agencies. As with any patient seeking health care services, guidelines of the Health Insurance Portability and Accountability Act (HIPAA) must be followed. Partner notification laws must also be considered when HIV infection is diagnosed. The health care provider must follow laws in his or her state regarding partner notification.

Acute Intervention

Early intervention after detection of an HIV infection can promote health and limit or delay disability. Because the course of HIV infection is extremely variable, assessment is of primary importance. Nursing interventions are tailored to any patient needs noted during assessment. The nursing assessment of HIV disease should focus on the early detection of constitutional symptoms, opportunistic diseases, and psychosocial problems (Box 55-9).

HIV disease progression may be delayed by maintaining the health of the immune system. Useful interventions for an HIV-infected patient include (1) nutritional changes that maintain lean body mass, maintain weight in the range of ideal body weight, and ensure consumption of appropriate levels of vitamins and micronutrients; (2) elimination of smoking and drug use; (3) elimination or moderation of alcohol intake; (4) regular exercise; (5) stress reduction; (6) avoidance of exposure to new infectious agents; (7) mental health counseling; (8) involvement in support groups; and (9) safer sexual practices.

The patient should be taught to recognize clinical manifestations that may indicate progression of the disease; this will ensure that medical care is initiated promptly. Early manifestations that need to be reported include unexplained weight loss, night sweats, diarrhea, persistent fever, swollen lymph nodes, oral hairy leukoplakia, oral candidiasis (thrush; see Figure 55-4), and persistent vaginal yeast infections. In addition, the patient should report unusual headaches, changes in vision, nausea and vomiting, and numbness or tingling in the extremities. The nurse must give the patient as much information as needed to make health care decisions. These decisions dictate the appropriate medical and nursing interventions.

Nursing interventions become more complicated as the patient's immune system deteriorates and new problems arise to compound existing difficulties. The nursing focus should be on quality-of-life issues and symptom management, rather than on issues regarding a cure.

When opportunistic diseases develop, the nurse should provide symptom-based nursing interventions, education, and emotional support. For example, an acute case of P. jiroveci pneumonia necessitates intensive nursing interventions, including monitoring the respiratory status, administering medications and oxygen, positioning the patient to facilitate breathing, managing anxiety, promoting nutritional support, and helping the patient conserve energy to decrease oxygen demand. Because advanced HIV disease can lead to death, emotional support for the patient, caregiver, or significant other is particularly important (Nursing Care Plan 55-1).

Diarrhea is often a long-term problem for HIV-infected people. Damage to the intestinal villi, malabsorption, infections of the gastrointestinal tract, and the side effects of medications all contribute to a large number of cases of diarrhea. Nursing interventions include recommending dietary interventions (Table 55-6), encouraging adequate fluid intake to prevent dehydration, instructing the patient about skin care, and managing excoriation around the perianal area. In some cases, antidiarrheal agents may help control diarrhea and prevent further complications. The nurse should recommend the use of incontinence products to prevent soiling of the clothes and bed linens. In addition, the nurse should assess for factors that may trigger the diarrhea, such as anxiety, medications, or lactose intolerance.

HIV wasting—the loss of lean body mass as a result of illness—has been a common clinical manifestation of HIV disease since early in the epidemic. Wasting is caused by disturbances in metabolism, which interfere with the effective use of nutrients, resulting in the loss of lean (muscle) body mass, often without reduction of body fat. This loss of lean body mass is a primary cause of functional decline in wasting, which results in increased risk of opportunistic infections, reduced quality of life, and reduced length of survival. A person with HIV is considered to have wasting syndrome when he or she has lost 10% of body weight and has had either diarrhea or weakness, and fever for 30 days. The person infected with HIV who has wasting syndrome is considered to have AIDS (Womenshealth.gov, 2011b).

The causes of wasting are probably multifactorial. Food intake may be inadequate because of mechanical difficulties (e.g., thrush or esophageal ulcers), loss of appetite (e.g., side effect of medications or neurologic disease), or psychological factors such as depression and anxiety. Absorption in the intestine may be decreased as a result of infections and a damaged mucosal barrier, which may lead to diarrhea. Some patients stop eating to decrease the number of bowel movements per day.

Wasting disturbs self-concept and self-image and can be one of the most difficult consequences of HIV infection to accept. Useful interventions for these disturbances include creating an atmosphere of acceptance and reassurance, encouraging a focus on past accomplishments and personal strengths, and facilitating the use of positive affirmations.

Decreased levels of testosterone have been reported in HIV-infected men. Testosterone has two distinct biologic properties: virilizing activity (androgenic effect) and protein building (anabolic effect). Because testosterone is an anabolic hormone, a deficiency may cause a loss of body cell mass, which contributes to HIV wasting. The role of gonadotropic hormones in women with wasting has not been studied sufficiently. Women with HIV wasting tend to lose a lot of body fat, but body cell mass is not significantly decreased. Conversely, men tend to lose a significant amount of lean body mass (e.g., exhibit skinny arms and legs), with preservation of fat, particularly in the truncal area.

With the advances in HIV treatment and opportunistic infection prophylaxis, serious malnutrition is less evident. However, nutrition does not return to normal after anti-HIV treatment begins. A syndrome of increased truncal obesity (visceral, abdominal), subcutaneous fat loss on the extremities and face (also called lipoatrophy), and metabolic abnormalities such as hyperlipidemia and insulin resistance have been reported in both men and women.

The management of wasting and lipodystrophy is difficult and generally requires multiple nursing interventions. Diminished appetite and weight must be assessed and documented. The nurse should encourage nutritional supplementation (see Table 55-6) and increased protein intake, provide enteral supplements (through nasogastric or gastric tubes if necessary), and assist with total parenteral nutrition when it is needed. Medications to stimulate appetite, such as dronabinol (Marinol), can help; unfortunately, these medications tend to increase body fat and not lean muscle mass. Testosterone (anabolic steroid) can be administered by mouth, intramuscularly, or transdermally to increase lean body mass and weight. The effect of testosterone can be enhanced by a low-weight resistance-training program (e.g., weight-lifting), which maintains muscle tone and improves appetite.

Nutrition counseling is vital to ensure that individuals with HIV disease maintain a well-balanced diet, including supplements if necessary. The dietitian can assist in counseling, provide the patient with high-protein and high-calorie diets, and suggest meal plans that fit the patient's lifestyle. Smaller, more frequent meals can be less overwhelming than larger meals. Teaching about food safety is of paramount concern because enteric infections (e.g., cryptosporidiosis, microsporidiosis, and amebas) in HIV disease are often not treatable or are relapsing. In some cases, enteral or parenteral feeding becomes necessary.

Management of elevated triglyceride and lipid (cholesterol) levels is becoming common in HIV disease. As in other patient populations, these elevations can lead to cardiovascular disease and, in some cases, diabetes. Lipid-lowering agents such as the statins may be effective in treating this complication. However, because the liver metabolizes many of the antilipid agents, it is important to choose a drug that is safer than those that must pass through the liver to be activated; safer anticholesterol drugs include pravastatin (Pravachol), fluvastatin (Lescol), and possibly atorva­statin (Lipitor). A program of diet, exercise, and medications can safely lower lipids and reduce the chances of a cardiovascular event.

Insulin resistance or diabetes sometimes responds to oral hypoglycemic agents (e.g., metformin or rosiglitazone [Avandia]). In some cases, the anti-HIV therapy needs to be changed to a protease-sparing combination. Diet management, smoking cessation, weight loss, and exercise can help control the elevations in blood glucose that can occur with the use of anti-HIV medications.

Unfortunately, as with any overwhelming viral infection, HIV infection increases the patient's metabolic needs. This hypermetabolism and consequent higher energy expenditure frequently exceed the number of calories taken in by the patient. Malnutrition, weight loss, and generalized wasting are common problems in patients with HIV disease (see Nursing Care Plan 55-1). Many patients with HIV disease experience wasting. Malnutrition contributes to wasting, and wasting hastens the negative immune consequences of HIV infection. HIV wasting contributes to slower recovery from infection, impaired wound healing, increased risk of secondary infection, and decreased cardiac and respiratory function. Wasting can lead to an earlier death. The weight loss associated with HIV disease is often severe and debilitating, producing a vicious cycle of anorexia, malnutrition, loss of tissue mass, muscle wasting, profound fatigue, and increased susceptibility to infections and drug interactions. Although typically seen in later stages of HIV disease, malnutrition and wasting can occur in the early stages of HIV infection.

HIV Testing and Counseling

An important part of preventing HIV transmission is HIV screening tests and follow-up education and counseling (see Box 55-3). However, patients must not be coerced into having an HIV screening test. The process of helping patients make the decision about whether to undergo testing and how to be tested is called test decision counseling. Nurses and health care providers should counsel their patients before and after HIV testing. HIV tests necessitate informed consent per state law before blood is collected. The informed consent is always accompanied by an explanation about the testing and implications of results. The limitations of the test must also be explained.

Performing HIV testing early in the course of the disease is important for increasing survival rates of HIV-infected patients and preventing the transmission to other people through high-risk behaviors. Guidelines from the CDC (2006) mandated that all patients in health care agencies be informed about HIV screening and then be screened for HIV. However, these patients are allowed to refuse the test. HIV antibody testing should be offered to all patients, regardless of patient-specific risk factors. Also, test results should be made available rapidly to the patient so that education can be given to the patient, if needed. The CDC's recommendations state that informed consent is not needed. However, patients may opt out of testing if they wish. In rare emergency situations in which health care providers need to know a patient's HIV status to make a decision regarding health care and the patient is unable to speak, the patient may be tested without his or her consent.

Increasing numbers of people with HIV can be identified with the current push for routine HIV screening. The FDA approved the use of ELISA testing for routine use during blood bank screenings. ELISA can identify antibodies for HIV-1 and HIV-2. Researchers who conducted a study in Cameroon found that ELISA was highly sensitive even with the wide variations in the genetic makeup of the HIV (Lee et al., 2007). The FDA has approved four rapid tests for HIV detection. Multispot and Oraquick can detect HIV-1 and HIV-2. Uni-Gold Recombigen and Reveal can identify only HIV-1 (Greenwald et al., 2006). OraQuick is the first in-home, over-the-counter HIV test approved by the FDA (US FDA, 2013b).

HIV antibody testing may take place in a physician's office or at designated HIV counseling and testing sites. Many patients feel more comfortable being tested by someone who knows their medical and social history, but others prefer to be tested in a location where they are unknown. The nurse should be aware of the various options for HIV antibody testing in his or her state or community in order to advise patients appropriately.

HIV antibody testing can be done one of two ways: confidentially or anonymously. In confidential testing, patients provide identifying information, including a name; an address; and often demographic information such as age, sex, race, and occupation. Using this information, care providers can locate and provide information to an individual who does not return for the test results or counseling. All records are strictly confidential, and testing in physicians' offices, clinics, and hospitals is conducted in a confidential manner. Health care providers who share or use this information inappropriately can be sued for negligence and invasion of privacy, and they may be disciplined by licensing boards for unauthorized disclosure or breach of confidentiality. Patients should be informed that the results of their HIV antibody test will be linked to the patient's medical record.

In anonymous testing, individuals are not asked to provide identifying information. Records are kept through assigned numbers, and the patient must retain this number to receive test results. It is not possible to locate and provide information to an individual who does not return for test results and counseling. In either form of testing, the nurse can perform pretest and post-test counseling.

Risk Assessment and Risk Reduction

Testing for HIV is an important part of the public health response to HIV disease. Risk assessment should be patient centered, a joint process between the nurse and patient. The patient should take “ownership” of the risk for HIV infection. The nursing assessment should include an evaluation of risky behaviors by the patient or a history of STIs. A patient will not get tested unless he or she perceives a need for testing and feels safe doing so. The nurse should help the patient assess the risks by asking some basic questions:

A positive response to any of these questions requires further exploration with the patient. The nurse should be prepared to refer the patient to centers that provide testing and counseling services. All testing should include pretest and post-test counseling (see Boxes 55-3 and 55-9).

HIV infection in women has been frequently overlooked for several reasons. In the United States, the disease initially occurred mostly in men, and treatment models were developed accordingly. Providers did not assess the risks for women, and women did not seek testing and counseling because of denial or ignorance; thus interventions have not been implemented effectively. Heterosexual intercourse surpassed injection drug use as a vector for HIV transmission in women in the second decade of this pandemic and globally continues to be the highest risk factor in women. The CDC case definition includes at least one female-specific disease: cervical carcinoma. Women now need to be assessed for different manifestations, such as vaginal candidiasis, a common presenting condition for HIV-positive women (CDC, 1993).

Barriers to Prevention

HIV prevention has numerous barriers, not the least of which is a denial of risk, an attitude that “it won't happen to me.” Because the virus initially infected the MSM population in the United States, members of many other subpopulations have ignored their risks. Fear, misunderstanding, and the potential for social isolation and social stigma are significant barriers. Some individuals are so fearful that they no longer give blood or eat at a restaurant if they think a homosexual food handler works there. Such reactions reinforce the need for consistent, accurate information about the virus, the risks of transmission, and HIV disease itself.

Cultural and community attitudes, values, and norms can affect the success of prevention efforts. A community may be opposed to HIV/AIDS education in the local school district because of the fear that certain values will be compromised. Those values may include views on sexuality, abstinence, the use of condoms, the use of drugs, and the provision of instructions about cleaning needles and syringes. Community organizations, churches, educators, and leaders can determine the community's expectations or norms. Cooperative efforts are essential for successful prevention of HIV transmission. The issues related to the HIV epidemic—sex, drug use, death, and homosexuality—are not easy issues for most cultures or communities.

Fear of alienation and discrimination are significant additional barriers to prevention. Some individuals are reluctant even to pick up a pamphlet about HIV because they fear that someone will believe they are gay or using illicit drugs. Some people will not go to a physician or to a testing and counseling site for HIV testing for fear of being seen there by people they know. This fear is valid, particularly in rural parts of the country. Fear of discrimination includes fear of losing family, friends, prestige, job, housing, and insurance. Fortunately, many states have statutes to protect individuals with HIV disease from discrimination. Protection is also afforded by the Americans With Disabilities Act.

Reducing Risks Related to Sexual Transmission

When patients have acute HIV disease and high viral loads, they are 10 times more likely to transmit HIV during sexual intercourse than during the chronic stage of HIV. Infection risk is also increased when sex is forceful or when mucosal membranes are disrupted (situations often associated with STIs). Most HIV infections are transmitted during the primary stage of the infection. This is when most people are unaware of their infection because they have no symptoms. Men are less likely to be infected with HIV during heterosexual intercourse than are women because women have more mucosal surface that can be exposed to infected body fluids in comparison to men. Male circumcision can also minimize a man's risk of becoming infected with HIV via heterosexual intercourse, according to the WHO (2013a).

Safer sexual activities reduce the risk of exposure to HIV through semen and cervicovaginal secretions. Abstaining from all sexual activity is the most effective way to accomplish this goal. Limiting sexual behavior to activities in which the mouth, penis, vagina, or rectum do not come into contact with the partner's mouth, penis, vagina, or rectum is also safe because there is no contact with blood, semen, or cervicovaginal secretions. These activities may include massage and masturbation. Insertive sex is considered safe only in a mutually monogamous relationship with a partner who is not infected with, or at risk of becoming infected with, HIV. The problem with mutual monogamy is that both partners need to follow all of the rules all of the time. Unfortunately, cases of HIV infection occur in individuals who are not aware that their partner has not remained monogamous. Serial monogamy (maintaining a monogamous relationship, often including unprotected intercourse, with one partner for a short time, followed by another relationship, and then another) also increases the risk of HIV exposure (Box 55-11).

ART can be provided to people who have been exposed to HIV through unwanted sexual intercourse (rape) or through injection drugs. The HHS has developed some recommendations regarding these types of nonoccupational exposures. When a person has been exposed to body fluids from an HIV-infected person during high-risk activity less than 72 hours before seeking treatment, the exposed person should receive a 28-day supply of ART. This is recommended even if the HIV-infected source of the exposure has an undetectable viral load. However, if the activity is deemed to be low-risk exposure to body fluids, or if the exposed person seeks health care after the 72-hour window, ART is not recommended. Cases should be examined on an individual basis to determine the need for PEP, counseling, treatment, and education about preventing future exposures (CDC, 2005a).

The use of barriers (Figure 55-5) reduces the risk of contact with HIV during sexual activity. Barriers should be used when a person engages in sexual activity with a partner whose HIV status is not definitely known or with a partner who is known to be infected with HIV. The most commonly used barrier is the male condom. Although not 100% effective, male condoms are very effective in the prevention of HIV transmission when used correctly and consistently. Other barriers include female condoms and latex dental dams. Female condoms consist of a vinyl sheath with two spring-form rings. The smaller ring is inserted into the vagina and holds the condom in place internally. The larger ring surrounds the opening to the condom. It keeps the condom in place externally while also protecting the external genitalia. The use of the female condom is complicated and cumbersome, and practice may be necessary to use this method effectively. Female condoms can also be used for anal sex, in both men and women. Dental dams or microwave-safe plastic wrap can be used to cover the external genitalia or anus during oral sexual activity (“rimming”). Although the risk of HIV transmission is significantly reduced with the use of latex barriers, other STIs, such as human papillomavirus, warts, and HSV, can still be transmitted.

Reducing Risks Related to Drug Abuse

The use of illicit or recreational drugs can cause immunosuppression, malnutrition, and emotional difficulties. Although using illicit drugs can increase a person's risk for acquiring HIV infection, drug use itself is not to blame. The major risks of HIV transmission are related to sharing injection equipment and having unsafe sexual experiences while under the influence of mood-altering chemicals. Essentially, people can reduce the risk of HIV infection by not using drugs. If drugs are injected, equipment should not be shared with other people. People should not engage in sexual activity while under the influence of any drug, including alcohol, that impairs decision making.

Abstaining from drugs is not always a viable option for a user who has no access to drug treatment services or who chooses not to quit. The risk of HIV for these individuals can be eliminated if they can find alternatives to injecting, such as smoking, snorting, or ingesting drugs. Risk can also be eliminated if the user does not share injection equipment, including needles, syringes, cookers, cotton, and rinse water. The safest tactic is for the user to have ready access to sterile equipment. Many states have laws that prohibit over-the-counter sale of needles and syringes, such as diabetic supplies. Some communities have needle exchange programs that supply sterile equipment to users to help reduce the risk of HIV transmission. The fear that needle exchange programs will result in increased illicit substance use has led to a lack of community support. However, studies have shown that in communities that have established exchange programs, drug use does not increase and rates of HIV infection are controlled (Wodak and Cooney, 2006).

Reducing Risks Related to Occupational Exposure

As previously discussed, the risk of acquiring HIV through occupational exposure is low. The CDC and the Occupational Safety and Health Administration have instituted policies to protect employees from exposure to blood and other potentially infectious fluids (CDC, 2005b). The use of standard precautions and body substance isolation has been shown to reduce the risk of bloodborne pathogens, the risk of transmission of other diseases between the patient and the health care worker, and the risk of transmission between patients. Hand hygiene in the form of handwashing still remains the most effective means of preventing the spread of infection.

Results of epidemiologic and laboratory studies suggest that several factors might affect the risk of HIV transmission after an occupational exposure. In a retrospective study of health care workers who had percutaneous exposure to HIV, the CDC (2001) found that the risk of HIV infection was increased with exposure to a larger quantity of blood from the source patient, as indicated by (1) a device visibly contaminated with the patient's blood, (2) a procedure that involved a needle being placed directly in a vein or artery, or (3) a deep injury. The risk is also increased for exposure to blood from a patient with terminal illness, which possibly reflects the higher viral load of the patient late in the course of HIV disease (CDC, 2001). Information about primary HIV infection (seroconversion) indicates that a systemic infection does not occur immediately. This leaves a brief window of opportunity during which initiation of antiretroviral PEP might prevent or inhibit systemic infection by limiting the proliferation of the virus in the initial target cells or lymph nodes.

For best prophylactic effect, PEP must be initiated within 36 hours—but preferably within 1 to 4 hours—of the exposure. Depending on the type of exposure and many other variables, either a two- or a three-drug regimen is chosen (CDC, 2005a, 2005b). In addition to possible exposure to an antiretroviral-resistant strain of HIV, other factors that might contribute to failures include a high titer or large volume of inoculum exposure, delayed initiation or short duration of PEP, and factors related to the exposed health care personnel (e.g., immune status).

Completion of a 4-week course of therapy after an occupational exposure is fundamental. The medications used have many side effects, and health care workers may stop PEP prematurely because of these. It is important to consult with experts in occupational exposure if side effects (headache, nausea, vomiting, diarrhea) become unbearable. The use of PEP regimens has been associated with new-onset diabetes mellitus, hyperglycemia, hypertriglyceridemia, pancreatitis, elevated levels of lipids (cholesterol, low-density lipoproteins), and kidney stones. Despite these serious side effects, the exposed health care worker must continue therapy for 4 weeks or until it is determined that the source patient is not infected with HIV.

Hospitals or agencies should have policies that specifically address occupational HIV exposure, inasmuch as chemoprophylaxis must be undertaken immediately, even before testing of the source patient's and health care worker's blood for HIV or other bloodborne pathogens. Serial testing of the health care worker for HIV occurs immediately, 6 weeks, 3 months, and 6 months after the exposure.

Maintaining confidentiality for both the exposed health care worker and the source patient is of utmost importance. Many states and health care organizations have separate, distinct consent forms that are required before HIV antibody testing can be performed. Only in rare circumstances, such as the inability to give consent, can HIV antibody testing be completed without the patient's informed consent. Many ethical and legal issues surround HIV antibody testing; therefore, nurses must be informed of the applicable laws in the state in which they practice. In many states, charges of assault and battery can be brought against health care workers who perform HIV testing against a patient's will. Appropriate counseling and referrals should be made for the health care worker and patient when HIV testing is indicated.

Other Methods to Reduce Risk

HIV-infected people must be instructed not to give blood, donate organs, or donate semen for artificial insemination. They should not share razors, toothbrushes, or other household items that may contain blood or other body fluids. They should also avoid infecting sexual and needle-sharing partners, consider using birth control measures, and eliminate breastfeeding to avoid spreading the virus to infants.