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This course fulfills the continuing education requirement for the District of Columbia on HIV/AIDS. 

Introduction and Objectives  

An estimated 1.2 million Americans are living with HIV. As many as 1 in 7 of them do not even know they are infected. The others utilize the healthcare system in a variety of ways, from testing and treatment regimens to hospitalizations for symptoms and opportunistic infections. Healthcare professionals in nearly every setting have the potential to encounter patients with HIV as the disease can affect patients of any age or stage of life (4). Proper understanding of HIV is important in order to provide high–quality and holistic care to these patients.

Upon completion of this course, the learner will:  

1. Have an increased understanding of the history of HIV and how stigma around the disease developed and is being combated today.
2. Demonstrate an understanding of how a person is infected with HIV and the various stages of the disease.
3. Demonstrate understanding of transmission modalities and appropriate infection control measures.
4. Have a basic knowledge of treatment approaches, common side effects, and barriers to proper treatment.
5. Understand comorbidities and coinfections common with HIV.
6. Understand ethical issues and confidentiality surrounding the care of HIV patients.

Epidemiology 

In the early 1980s, a series of unusual and aggressive illnesses began popping up in clusters across the United States, affecting previously healthy men. Illnesses such as pneumocystis pneumonia, Kaposi‘s sarcoma, and severe wasting, all related to unexplained immunodeficiency, were suddenly rapidly increasing in prevalence, and the only common link seemed to be that it was occurring in gay men. By 1982, the term Acquired Immune Deficiency Syndrome (AIDS) was being used to describe a “moderately predictive…defect in cell–mediated immunity,“ but the details of disease trajectory and how men were contracting it were still foggy (2). 

Over the next several years, cases continued to rise, and women and children began presenting with the disease, bringing scientists to the realization that it could be contracted through more ways than just homosexual sex. Amid the social panic, the retrovirus responsible was identified and named Human Immunodeficiency Virus, more reliable testing developed, and various other modes of transmission (like needle sharing, contaminated blood products, childbirth, and breastfeeding) were recognized. By 1989, less than a decade after the first cases were garnering attention, 142,000 cases were reported by 145 countries worldwide (2).  

Over the next several decades, more and more information was discovered about HIV and AIDS, and scientists and legislators worked hard to understand and reduce transmission, increase quality and duration of life for those already infected, and fight the stigma and discrimination that had developed during the 1980s (2).  

Today, approximately 1.2 million people in the United States are living with HIV, though 1 in 7 people don‘t know it. Rates of infection are not equal across demographic groups, and certain factors may increase a person‘s risk (10). Patient information to consider when determining someone‘s risk includes:  

• Age: As of 2018, the age group with the highest incidence of new HIV diagnoses is 25-34 years or approximately 36% of new infections. Ages 13-24 are next, though the numbers in this age range are coming down in recent years. From there, the risk seems to decrease as people age, with the 55 years and older group accounting for only around 10% of new diagnoses each year (10).  
• Race/Ethnicity: Currently, the highest rate of new infections is in African Americans, at approximately 45%. This is incredibly high when you consider that African Americans only make up 13% of the general population. This is followed by Hispanic/Latinos at 22% of new infections and people of multiple races at 19% (7).  
• Gender: Men are disproportionately affected by HIV, accounting for five times the amount of new infections as females each year. This data refers to the sex of someone at birth. When looking at the transgender population, there is a nearly equal rate of new infections among those who have transitioned male-to-female and female-to-male. Together, transgender people account for 2% of new cases in 2018 (7).  
• Sexual orientation: Gay and bisexual men remain the population most at risk of HIV, accounting for around 69% of all new infections in 2018 and 86% of all males diagnosed. Similar racial and ethnic disparities affecting all people with HIV still existed among gay and bisexual men (7).  
• Location: Different areas of the country are affected at different rates for a variety of factors, including population density, racial distribution, and access to healthcare. The southern states are unmistakably more affected than other regions, with anywhere from 13-45 people per 100,000 having a diagnosis of HIV. California, Nevada, New York, and D.C. all having similar rates of infection as the southern states and are among the highest in the country. The Midwest and Pacific Northwest are next most affected, with 9-13 people per 100,000. The Northeast and Northwest have the lowest rates nationally at just up to 5 people per 100,000 (7). 

While the effects of HIV and AIDS have resulted in a staggering 32 million deaths worldwide since the start of the epidemic, global and national numbers indicate that it peaked around 2005. Numbers of infections and deaths have been on a slow decline since then, mostly due to earlier and more accurate diagnosis, increased knowledge of how to prevent transmission, and effective and accessible treatments. An estimated 65% of Americans currently diagnosed with HIV are considered “virally suppressed,“ demonstrating that adherence to treatment guidelines means most infected people have virtually no risk of transmitting the virus to their partners and have a life expectancy nearly the same as non-infected people (6).  

HIV/AIDS’s financial impact is also significant, with an estimated $380,000 spent throughout an individual‘s lifetime with the disease. In 2009, it was estimated that $16.6 billion was spent on HIV treatment in the U.S. alone. However, federal prevention programs do more than improve health outcomes and decrease the number of new infections; they also claim financial benefits and saved approximately $129 billion in the last two decades by averting new infections.  

The Ryan White Program is notable and has been in place since 1990. It is a significant source of expanded coverage and funding for patients living with HIV who cannot afford health insurance or proper treatment. This safety net program is federally funded and named after a teenager who died from AIDS after receiving an HIV–contaminated blood transfusion. Ryan‘s story was also a turning point in the public perception of the disease, and the program helps fight the stigma surrounding HIV today (5). 

Etiology and Pathogenesis 

So just what is this virus that can cause so much devastation but took scientists years to understand? HIV is a type of retrovirus known as lentiviruses; these viruses have long incubation periods and lead to chronic and deadly infections in mammals. Studies indicate that the virus may have first infected humans hunting and eating the meat of infected chimpanzees in central Africa as early as the late 1800s. Once the virus jumped to humans, it spread slowly over many decades and across countries before picking up steam and attracting attention in the United States in the 1980s (7).  

Once a host has been infected, the virus seeks out, attaches to, and enters CD4-T cells, immune cells largely responsible for attacking and clearing pathogens in the body. Once inside the cell, viral mRNA (or genetic code) directs the cell to become a factory of more HIV virions, which are then released through a process known as budding. Those virions travel through the body, enter other CD4-T cells, and produce more viruses in a slow but deadly cascade. As part of the body‘s defense against such pathogens, CD4-T cells are programmed for apoptosis (cell death) upon being taken over by a host. Others will experience cell death due to close proximity to infected cells. Still, others will be killed by other types of immune cells. While HIV ravages the body and continues to rise in viral load, the number of CD4-T cells will drop lower and lower until, eventually, the body‘s cell-mediated immunity is no longer viable. Without cell-mediated immunity, opportunistic infections and cancers can take over, and the infected person progresses from HIV infection to full–fledged AIDS (12). 

Typically, the disease progresses in 3 stages.  

• Stage 1 is acute HIV infection. The virus is reproducing rapidly, and affected individuals may experience flu–like symptoms, including fever, chills, headache, and fatigue. Not everyone experiences symptoms during Stage 1, but all are highly contagious during this period.  
• Stage 2 is Chronic HIV infection; viral replication slows, and this stage can last for many years. A person in this stage is still contagious, but they may have no symptoms. Proper use of medication treatment may mean an infected person never moves past this stage.  
• And finally, if the viral load continues to increase and the CD4-T cell count gets below 200 cells/mm, the illness transitions to Stage 3, AIDS. In this stage, even minor opportunistic pathogens can make a person very ill due to the lack of a properly functioning immune system. Symptoms and infections such as thrush, pneumonia, peripheral neuropathy, and Kaposi sarcoma are common. Stage 3 is very contagious and life expectancy is about 3 years if left untreated (7). 

Transmissibility

Perhaps the most elusive part of this virus for many years was how it spreads. We now know that HIV is spread only through certain bodily fluids. An accurate understanding of HIV transmission is important for healthcare professionals to provide proper education to their patients, reduce misconceptions and stigmas, and prevent transmission and protect themselves and other patients (11). 

Bodily fluids that can transmit the virus include: 

• Blood 
• Semen and pre-seminal fluid 
• Rectal fluid 
• Vaginal fluid 
• Breastmilk 
• Fluids that may contain blood such as amniotic fluid, pleural fluid, pericardial fluid, and cerebrospinal fluid 

If one of these fluids comes in contact with a mucous membrane such as the mouth, vagina, rectum, etc., or damaged tissue such as open wounds, or is directly injected into the bloodstream, then transmission of HIV is possible (11). 

Scenarios where transmission is possible include: 

• Vaginal or anal sex with someone who has HIV (condoms and appropriate treatment with antivirals reduce this risk) 
• Sharing needles or syringes with someone who has HIV 
• Mother-to-child transmission during pregnancy, delivery, or breastfeeding (appropriate treatment during pregnancy, c-section delivery, and alternative feeding methods reduce this risk) 
• Receiving a transfusion of infected blood or blood products (this is very rare now because of screening processes for blood donations) 
• Oral sex with someone who has HIV (though this is very rare) 
• A healthcare worker receiving a needle stick with a dirty sharp (risk of transmission is very low in this scenario) 

HIV cannot be transmitted via: 

• Saliva 
• Sputum 
• Feces 
• Urine 
• Vomit 
• Sweat 
• Mucous  
• Kissing 
• Sharing food or drink 

Reducing Transmission 

Patient education about risk and protection against HIV, testing, and what to do if exposed should be standard practice for healthcare professionals in nearly all healthcare settings. Primary care should include risk screenings and patient education routinely to ideally help prevent infections from even occurring or catch those that have occurred early on in the disease process (11). 

Strategies include: 

• Identifying those most at risk, incredibly gay or bisexual men, minority patients, and those using drugs by injection 
• Ensure patients are aware of and have access to protective measures such as condoms and clean needle exchange programs 
• Provide routine screening blood work for anyone with risk factors or desiring testing 
• Providing access to PrEP medications where indicated (discussed further below) 
• Staying up to date on current CDC recommendations and HIV developments 
• Maintaining a nonjudgmental demeanor when discussing HIV with patients to welcome open discussion (11) 

For patients with a repeated or frequent high risk of HIV exposure, such as those with an HIV+ partner or those routinely using IV drugs, pre-exposure prophylaxis (PrEP) may be a good choice to reduce the risk of them contracting the virus. When used correctly, PrEP is 99% effective at preventing infection from high–risk sexual activity and 74% effective at preventing infection from injectable drug use. Depending on the type of exposure risk (anal sex, vaginal sex, needle sharing, etc.), PrEP needs to be taken anywhere from 7-21 days before it reaches its maximum effectiveness. Most insurances, including Medicaid programs, cover PrEP at least in part. There are also federal and state assistance programs available to make PrEP available to as many people who need it as possible. Some side effects are commonly reported, primarily G.I. symptoms, headaches, and fatigue (11).  

For those who have a confirmed diagnosis of HIV/AIDS, the focus should be promoting interventions that will prevent further transmission. One of the biggest determinants for transmission is the infected person’s viral load. Individuals being treated for HIV can have their viral load measured to ensure viral replication is being controlled as intended. A viral load lower than 20-40 copies per milliliter of blood is considered undetectable, meaning the virus is not transmissible to others. Even for those not receiving treatment, there are methods to reduce transmission (11). 

Important considerations for transmission in patients who are HIV+ include: 

• Referral for treatment and educating on the importance of treatment compliance in order to keep the viral load as low as possible 
• Education on the importance (and possible legal consequences) of proper disclosure to any sexual or needle–sharing partners who may be at risk of exposure 
• Encouraging and assisting with access to condom use and clean needle programs 
• Providing information to HIV+ pregnant women about how interventions such as proper treatment during pregnancy, c-section delivery, and formula feeding can keep the risk of transmission as low as 1% (11) 

Methods of infection control for healthcare professionals include: 

• Universal precautions when handling any bodily fluids 
• Eyewear when at risk for fluid splashing 
• Careful and proper handling of sharps 
• Facilities having a standard plan in place for potential exposures 

If exposure or needlestick do occur for healthcare professionals, the patient would ideally submit to testing for HIV to determine if the staff member is even at any risk. If the HIV status of the patient is unknown or confirmed to be positive, four weeks of post–exposure prophylaxis (PEP) may be advised within 72 hours of exposure (11).  

PEP is meant for emergency use only, such as for healthcare workers with a potential exposure or patients with an exposure that is not expected to become routine. PEP is not meant to replace the use of PrEP or other preventative measures. In order to be effective, PEP must be started within 72 hours of the potential exposure and must be taken for a 28–day course of treatment. When used correctly, it is highly effective and typically well–tolerated, with nausea being the most common side effect. For healthcare professionals taking it due to workplace exposure, your facility should cover the cost. For patients in the general population, insurance will usually cover it, or there are assistance programs available to make it affordable for everyone (11). 

Treatment Considerations

When HIV is appropriately treated, advancement from HIV to AIDS can be significantly reduced, and quality and longevity of life maximized. In 2018, the CDC estimated around 65% of all U.S. citizens living with HIV were virally suppressed, and 85% of those receiving regular HIV–related care were considered virally suppressed. However, an estimated13% of all HIV cases do not know they are infected. Appropriate medical care and keeping viral loads undetectable is one of the single most effective methods of preventing transmission (4, 6).  

For those receiving treatment, a multifaceted and individualized approach can reduce a person‘s viral load, reduce the risk of transmission, reduce the likelihood of developing AIDS, and preserve the immune system. Regardless of how early someone receives treatment, there is no cure for HIV, and an infected person will be infected for life. All individuals diagnosed with HIV (even asymptomatic people, infants, and children) should receive antiretroviral therapy or ART as quickly as possible after a diagnosis of HIV is made. There are seven different classes of antiretroviral medications that disrupt various points in the viral replication process. Most treatment regimens use several of these medications combined with the most effective results; some combination pills are also available for administration ease. Medication regimens are chosen based on a patient‘s health status and history, tolerance or sensitivity to medication, and stage and severity of HIV infection. Patient condition and viral load should be monitored closely, and changes or inadequate response to treatment may indicate the need for a change in medication regimen at any time (1). 

The classes and available medications for ART include (1): 

Nucleoside reverse transcriptase inhibitors (NRTIs): these inhibit the transcription of viral RNA to DNA 

• Abacavir (Ziagen) 
• Emtricitabine (Emtriva) 
• Lamivudine (Epivir) 
• Tenofovir disoproxil fumerate (Viread) 
• Zidovudine (Retrovir) 

Non-nucleoside reverse transcriptase inhibitors (NNRTIs): these inhibit the transcription of viral RNA to DNA 

• Doravirine (Pifeltro) 
• Efavirenz (Sustiva) 
• Etravirine (Intelence) 
• Nevirapine (Viramune, Viramune XR) 
• Rilpivirine (Edurant) 

Protease inhibitors: inhibit the final step of viral budding 

• Atazanavir (Reyataz) 
• Darunavir (Prezista) 
• Fosamprenavir (Lexiva) 
• Ritonavir (Norvir) 
• Saquinavir (Invirase) 
• Tipranavir (Apitvus) 

Fusion inhibitors: prevent the virus from fusing with CD4-T cells 

• Enfuvirtide (Fuzeon) 

Integrase strand transfer inhibitors (INSTIs): these stop HIV from inserting its DNA into cells 

• Dolutegravir (Tivicay) 
• Raltegravir (Isentress, Isentress HD) 

Chemokine receptor antagonists (CCR5 antagonists): prevent the virus from binding to CD4-T cells 

• Maraviroc (Selzentry) 

Entry inhibitors: prevent the virus from binding to and entering cells 

• Ibalizumab-uiyk (Trogarzo) (1) 

These types of medication do not come without side effects or complications. Most side effects fit into a few major groups and may be bothersome but are not life–threatening or serious. More Serious or worrisome adverse effects may occur, and a patient‘s current health status, as well as medical history or existing conditions, should be carefully considered (3). The common categories of adverse medication reactions include:  

• Gastrointestinal: Nausea, vomiting, diarrhea, decrease in appetite, reflux, constipation, damage to liver or pancreas 
• CNS: Headache, dizziness, sleep disturbance, neuropathy, memory problems, hearing impairment or tinnitus 
• Hematological: Anemia, hematuria, hyperbilirubinemia  
• Psychological: Mood swings, anxiety, depression, confusion, nightmares/vivid dreams 
• Dermatological: Rash, face discoloration, pruritus 
• Musculoskeletal: Body aches, abnormal fat distribution 
• GU: Menstrual cycle disruption 

Due to the need to take medications for the rest of one‘s life and the long list of potentially bothersome side effects, medication adherence is a common issue in treating HIV appropriately (3).  

There are several scenarios that increase the likelihood of poor compliance, including:  

• Asymptomatic patients, since side effects of medications, maybe unpleasant and they are in a latent phase of disease without symptoms  
• Young patients, including children or teenagers who may not understand the necessity of taking daily medications and face a lifetime of treatment 
• Patients with substance abuse or mental health issues, as they may be in and out of cognitive and psychiatric crises 
• Poor literacy or education level, as these patients may be easily confused by a complicated medication regimen or simply not understand the importance of lifelong therapy, especially if they are feeling well 
• Social stigma, which may lead people to try and hide medications or not want their diagnosis to be discovered (3) 

Care Considerations for Comorbidities and Coinfections

Caring for patients with HIV or AIDS is a complicated task requiring compassion, patience, and understanding the many potential complications and ways that various body systems are affected. Many infections and comorbidities commonly present alongside HIV/AIDS, particularly as patients age, immune function declines, and effects of long-term medication use develop. The social stigma and psychological impact of such a devastating disease must also be considered to provide holistic care to these patients (9). Common coinfections/comorbidities include:  

Tuberculosis

T.B. is a highly contagious airborne illness that affects the respiratory system. It is an opportunistic infection that frequently affects people with weakened immune systems, like those with AIDS. The bacteria can live in the body without causing symptoms in a latent phase for long periods. As the immune system in HIV weakens, a latent T.B. infection may become active, causing symptoms and deteriorating health. Most common symptoms include cough, hemoptysis, fever, fatigue, night sweats, or poor appetite, and weight loss. Seriously immunocompromised people may even experience disseminated T.B. where the infection affects more than the lungs and can even lead to septic shock and death. Annual PPD tests for T.B., or chest X-ray for anyone with a history of positive PPD, should be conducted on patients with HIV (9).  

Hepatitis

About 1 in 10 people affected by HIV will also have viral hepatitis, as the diseases are spread in much the same way, particularly needle sharing and sexually and vertically (mother to fetus). Hepatitis infections progress quickly in immunocompromised patients and can greatly reduce liver function, which complicates the use of ART medications and can result in poor clearance from the body. All new HIV diagnoses should be screened for Hepatitis A, B, and C, and Hep A and B vaccines should be encouraged in unvaccinated patients (9).  

STIs

Because HIV can be acquired via high–risk sexual activity, infection with other STIs is common. Sometimes, other STIs may even increase the risk of contracting HIV as they result in open sores or breaks in the skin where HIV can more easily enter. Bacterial STIs can typically be cured with antibiotics, but other viral STIs like Herpes and HPV do not have a cure. Routine screening for patients engaging in high–risk sexual activity or those already infected with HIV should be a typical part of care (9).  

Cardiovascular Disease

Studies show that patients with HIV also increase inflammation of the arteries and plaque formations throughout the body due to a complicated effect on macrophages. Some of the ART medications also increase the risk of heart attack or stroke. Concurrent infection with hepatitis can increase cholesterol, which further deteriorates cardiovascular health and increases MI or stroke risk. Patients with HIV should be screened for family history and current heart health, and their plan of care should incorporate ways to reduce risks, including a focus on diet and activity level (9)l.  

Osteoporosis

Bone density has been shown to decrease faster than normal in patients receiving ART medications, and it is recommended that patients over age 50 have annual bone density scans to estimate fracture risk. Treatment for osteoporosis should be added to the plan of care as needed (9).  

Cancer

As science has become better equipped to detect and treat HIV and concomitant infection, cancer has remained a leading cause of death for HIV patients and is a considerable risk for those living with the disease. Most commonly, cancers of the head and neck, anus, lungs, liver, and lymph system occur. Smoking cessation, regular pap tests for women, HPV vaccines, and routine screenings like colonoscopies after a certain age should be heavily counseled in HIV patients to reduce their risk further. Earlier and consistent ART has been shown to reduce the risk of developing cancer (9).  

Mental Health Issues

When considering the long–term and eventually fatal nature of this disease, along with the social stigma and complicated and expensive treatment regimens, it is no surprise that mental health disorders such as anxiety and depression are common for patients with HIV. Upwards of 22% of patients with HIV will suffer from depression, likely higher when you account for substance abuse disorders. In addition to assessing and treating body systems affected by the virus, it is important to screen patients for psychiatric disorders and be aware of the negative effects the diagnosis may be having on mental health. Medication treatment and therapy should be included in care where appropriate (9). 

Ethical Concerns

Maintaining confidentiality under HIPAA laws is essential in the care of patients with any diagnosis, but the social stigma attached to HIV infection–in addition to the frequency and intensity of medical care needed and the responsibility to notify partners and prevent further spread–makes confidentiality particularly challenging with many ethical considerations to navigate.  

The first issue with maintaining confidentiality occurs with testing itself. HIV is considered a reportable disease. Any positive results must be reported to a local health department and then on to the CDC for local and national statistics and to initiate follow–up with the positive person and provide education on the next steps. Patient names and identifying information are included with the positive result when reported to local and state health departments but is removed before it is reported to the CDC. There is an option for anonymous testing where patients are given a special identification number, and their names and identifying information are not included. These are often self–administered tests and are not available everywhere (8).  

Testing for HIV requires informed consent, meaning healthcare professionals must discuss the risks, benefits, and potential consequences of testing for HIV and cannot test someone for HIV without their consent. Minors’ ability to get testing and treatment for HIV without a parent or guardian’s consent varies from state to state (8).   

Once someone tests positive for HIV, the issue of disclosure presents itself. Patients need to inform their past and future sexual partners or anyone they share needles with of their HIV status. Health departments will help contact tracing and notifying past partners and help those potentially exposed with their testing and prophylactic treatment options. In some states, it is considered a criminal offense to withhold a positive infection status when a person may be exposing others. However, the responsibility to disclose falls on the patient, and healthcare professionals may not notify potential contacts without a patient‘s consent. Infected persons are not required to inform friends, family, employers, or others who are not at risk of contracting the disease (8).  

Employers who provide health insurance for their employees may be given information about the costs and benefits of disclosing an HIV diagnosis indirectly. So while insurance companies cannot directly tell an employer about an HIV diagnosis, employees should be aware the information may come out indirectly. However, all workers with HIV are protected under the Americans with Disabilities Act. As long as they can complete their job duties, employers may not discriminate against them (8). 

Finally, and of particular importance for healthcare professionals, is navigating the stigma or negative stereotypes that often accompany an HIV diagnosis. There are some societal misconceptions that HIV infections only occur as a result of immoral or taboo behavior or that those infected should be treated differently or avoided. People with HIV may have internalized these harmful stereotypes and feel a sense of shame around their diagnosis. It is important for healthcare professionals to understand that these stereotypes are untrue and harmful, but to provide non–judgemental and compassion that preserves dignity and views the patient as more than their diagnosis.  

Conclusion 

Professionals in any healthcare setting may encounter patients with HIV or AIDS. A basic understanding of this disease’s many considerations is fundamental to ensure that quality and compassionate care is being provided. Understanding the disease, treatments, and the unique struggles of these patients can significantly impact their healthcare experiences and promote quality of life.  

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