Released August 1998 / Revised July 2003
Patent Pending

The Medical Educational Council of Pensacola is accredited by the ACCME to sponsor CME for physicians.

The Medical Educational Council of Pensacola does not warrant the competence, accuracy or usefulness of any opinions, advice, services, or other information provided through this activity.  In no event will the Medical Educational Council of Pensacola be liable for any decision made or action taken in reliance upon the information provided through this activity.

This Home Study Course, devoted to HIV and AIDS, covers essential educational information on the topics of the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS); modes of transmission (including transmission from health care worker to patient and patient to health care worker), infection control procedures (including Universal Precautions), clinical management, epidemiology of the disease, prevention, as well as Florida law on AIDs and its impact on testing, confidentiality of test results and treatment of patients.

This Home Study Course, when used with the post test, has been developed to meet the educational requirements for doctors of medicine and doctors of osteopathy who are seeking licensure in the State of Florida and is approved for three (3) continuing AIDS education hours by the Medical Educational Council of Pensacola.

- Review purpose, objectives and post-test before reading module. This will help you master the important points.

- Read articles.

- Complete post-test on accompanying answer sheet.

- Enclose check for $75.00 made payable to the Medical Educational Council of Pensacola.

- Return answer sheet, booklet, and check to the Medical Educational Council of Pensacola, 8880 University Parkway Suite C, Pensacola, Florida 32514.

- Test will be graded and reviewed for you.

- 70% is a passing score.

- Receive Certificate of Completion for your records. KEEP this with your other continuing education records.

Pathogenesis

Human immunodeficiency virus (HIV) is a retrovirus consisting of a central ribonucleic acid (RNA) surrounded by coats of virus-specific protein. In HIV-infected persons, the immune system recognizes the virus protein as foreign material and produces antibodies that are directed against this material. This is accomplished through complex mechanisms involving the white blood cells and the virus (5). Usually within 6-12 weeks of infection, the number of antibodies against the virus has risen to detectable levels.  Recent advances in laboratory technology have enabled measurement of viral load in plasma, confirming that the virus actively replicates throughout the course of the disease.  This refuted earlier theories that the long asymptomatic period after primary infection was a period of latency.  More than 50% of the living estimated 750,000 infected persons in the United States are unaware of their positive serostatus.

One important type of white blood cell is the lymphocyte, of which there are two types: B lymphocytes (B cells) and T lymphocytes (T cells). T cells include helper (CD4+) cells and suppressor (CD8+) T cells. In persons affected with HIV, the total number of helper T cells is decreased because the virus infects the cells, reproduces within them, and then destroys them. As a result, immune defense mechanisms are impaired.

The helper (CD4+) T cell is the primary target for HIV infection because the virus is attracted to the CD4+ surface marker. Because the CD4+ T cell coordinates a number of immunologic functions, a loss of these cells leads to a progressive impairment of the immune response. For example, low CD4+ counts are associated with anergy, the inability to mount a response to delayed-type hypersensitivity skin test antigens. Therefore, some HIV-infected persons with CD4+ absolute cell counts of less than 200 cells per microliter who are co-infected with tuberculosis (M. tuberculosis) may have a false-negative reaction to the tuberculin skin test.

In addition, as the number of CD4+ T cells decrease, the risk and severity of opportunistic diseases increases. Persons who are infected with HIV, and who are diagnosed with life-threatening opportunistic diseases and cancers, or have CD4+ absolute cell counts <200, or <14% of total lymphocytes meet criteria for CDC-defined AIDS. (AIDS) (5).

Types of HIV

In 1984, almost seven years after the first cases identified in the U.S., researchers discovered the causative agent, HIV type 1 (HIV-1). In 1986, a second type of HIV, called HIV-2 was isolated from AIDS patients in West Africa, where it may have been present decades earlier. Although HIV-1 and HIV-2 are similar in their viral structure, modes of transmission, and resulting opportunistic illnesses, they have differed in their geographic patterns of infection, with the U.S. having only 67 reported cases as of December 1996. Yet since 1992, all U.S. blood donations have been tested with a combination HIV-1/HIV-2 enzyme immunoassay test kit that is sensitive to antibodies of both viruses. According to some reports, HIV-2 has a longer incubation period than HIV-1. However, prevention aimed at HIV-1 can also help prevent and control the spread of HIV-2.(6)

Modes of Transmission

The ways in which HIV can be transmitted have been clearly identified. HIV can be spread by sexual contact with an infected person, by sharing needles and/or syringes (primarily for drug injection) with someone who is infected, through transfusions of infected blood or blood clotting factors (now very rare in countries where blood is screened for HIV antibody), and contact between mucous membranes or non-intact skin and infected blood. Babies born to HIV-infected mothers may become infected before birth without intervention, about 30% of the time, during delivery or through breast-feeding after birth.( )

Common misperceptions about the transmission of HIV have included the virus living in the environment or in the air, through kissing, biting, contact with saliva, tears or sweat, and insects (such as a mosquito). Unless there has been a potential for contact with blood, semen, vaginal fluid, other body fluids visibly contaminated with blood, or body fluids to which Universal Precautions apply, there have not been any cases reported where HIV was transmitted. HIV can only survive outside of the human body for a very short period of time.(7)

Heterosexual transmission is the most rapidly increasing transmission category among women with HIV, especially young women. Among women reported with AIDS in 1996, 40% acquired HIV through heterosexual contact with at-risk partners.

Other sexually transmitted diseases facilitate HIV transmission. Epidemiologic studies from four continents (including North America) have repeatedly linked STDs with a three- to five-fold increased risk for HIV transmission. This is true for both STDs that cause genital ulcers (e.g., syphilis, herpes, or chancroid) and non-ulcerative STDs (e.g., chlamydia, gonorrhea, or trichomoniasis). Infection with another STD can significantly increase a woman’s risk for acquiring HIV infection if exposed to the virus through sexual contact. Co-infection with other STDs also increases the infectiousness of HIV-infected individuals: these individuals are more likely to shed HIV in genital secretions, and they are more likely to shed HIV in greater amounts.

The second leading cause of HIV infection among women is injection drug use. Among women reported with AIDS in 1996, 34 percent acquired HIV through injection drug use. But IDU is not the only way that drug use is fueling the AIDS epidemic among women. Data from a CDC study of young adults, ages 18 to 29, showed a high prevalence of HIV among women who had recently had unprotected sex in exchange for crack cocaine or for money. In fact, these women were as likely to be HIV-infected as men who have sex with men.

Female-to-female transmission is relatively rare; the majority of cases of HIV infection among women who have sex with women have been ascribed to heterosexual intercourse or injection drug use.(3)

The current facts about the spread of HIV/AIDS are quite startling. While the reported number of AIDS cases is approximately 1.6 million, the estimated number of AIDS cases is 8.4 million. There are 29.4 million adults globally who are estimated to be living with HIV. By the year 2000, an estimated 50 million persons will be infected worldwide. Also by that year, the projected worldwide cost will exceed $514 billion. The global HIV infection rate is estimated to be 15,000 adults and 1,000 children daily. This would mean that more than ten persons are infected per minute. In the United States, it is the leading cause of death among African-Americans and the second leading cause of death of all races and genders aged 25-44. (In the U.S., there are about 1.0 million estimated cases of HIV. Yet half of all new infections occur in persons under 25. One in ten young gay men becomes seropositive by age 25. However 75% of new infections are due to heterosexual transmission. Infection is rising exponentially in African American women. In Florida, HIV/AIDS deaths dropped 25% in all ethnic groups and both sexes since 1995 due to recent advances in combination antiretroviral treatment. HIV/AIDS is growing fastest among women, persons aged 14-23, persons of color, and persons exposed to HIV through heterosexual contact.

It is likely that the proportion of male to female cases in the U.S. will be equal by the year 2000. The first year of HIV surveillance in Florida (beginning 7/1/97) demonstrated a ratio of 1.7:1 males to females respectively (compared to 4 to 1 at the beginning of the epidemic).  However, it is still potent among gay males and injecting drug users. By 2010, forty million children in developing nations will lose one or both parents to AIDS. Florida is ranked third in adult cases (10% of the U.S. total), second in pediatric cases (16%), and second in cases in women (15%). HIV/AIDS is still the leading cause of death of persons aged 25-44 in Florida (2nd nationally). In northwest Florida, including the counties of Escambia, Santa Rosa, Okaloosa, and Walton, AIDS cases increased nearly 460% during the five years 1990-94.

In the United States in 1996, between 120,000 and 160,000 adult and adolescent women were estimated to be infected with HIV. In just over a decade, the proportion of female adult and adolescent AIDS cases has nearly tripled, from 7 percent of the annual total in 1985 to 20 percent in 1996. In particular, women with heterosexually acquired HIV comprise one of the fastest growing populations with AIDS.

However the proportion of females among adolescent AIDS cases has almost tripled—from 14% in 1987 to 43% percent of the reported cases in 1994.()

Young women and women of color are disproportionately affected by HIV and AIDS. Female adolescents (ages 10 – 19) and young adult women (ages 20-24) are at higher risk of HIV/STD infection for several reasons: they may be more likely to have multiple partners, they may be more likely to engage in risky behaviors, they may be more likely to have partners at higher risk of infection, and they may be more biologically susceptible to cervical infections. Although African American and Hispanic women comprise less than one-fourth of all U.S. women, they account for more than three-fourths of AIDS cases among women. Race and ethnicity in the United States are risk markers that correlate with more fundamental determinants of health status such as poverty, access to quality health care, health-seeking behavior, illicit drug use, and living in communities with high prevalence of HIV and other STDs.(5)

Adolescents and HIV/AIDS

Although the number of adolescents with AIDS is relatively small, we know that many more young people are infected with HIV. Since 1 in 5 reported AIDS cases is diagnosed in the 20-29 year age group, and the incubation period between HIV infection and AIDS diagnosis is 8 to ten years (1), it is clear that large numbers of people became infected with HIV as teenagers. Among those adolescents reported with AIDS, older teens, males, and racial and ethnic minorities are disproportionately affected. Still, in December 1995, HIV/AIDS was the sixth leading cause of death among 15- to 24-year-olds in the United States.

Many young Americans are engaging in behaviors that may put them at risk of acquiring HIV infection, other sexually transmitted diseases, and/or infections associated with drug injection. Studies conducted every two years in grades 9-12 by the Centers for Disease Control and Prevention (CDC) consistently indicate that by twelfth grade, approximately three-fourths of high school students have had sexual intercourse; less than half report using latex condoms, and about one-fifth report having had more than four lifetime partners. One in 62 students reported having injected an illegal drug.( )

Since the early years of the epidemic, African Americans and Hispanics have been disproportionately affected by HIV/AIDS. Although 52% of the 548,102 reported AIDS cases through 1996 occurred among African Americans and Hispanics, these two population groups represent an estimated 13% and 10%, respectively, of the total U.S. population. ( )

HIV/AIDS Exposure

Among men and women who have been reported with AIDS, three HIV exposure groups continue to account for nearly all cases of AIDS through December 1996. These are men who have sex with men (51%), injecting drug use (25%), and heterosexual contact (8%). In pediatric cases, nearly 90% of reported cases result from perinatal transmission. (0)

As HIV begins to destroy the body’s defense against diseases, the body becomes extremely susceptible to opportunistic infections. During the past decade, researchers have learned of several illnesses that can cause disease in HIV patients. This has then increased the awareness of reducing the risk of exposure of opportunistic pathogens. It has also increased the number of chemoprophylactic regimens for preventing and treating disease.

When HIV is first recognized, the patient should receive a tuberculin skin test by administration of intermediate-strength (5 tuberculin units) purified protein derivative by the mantoux method. Routine evaluation for anergy is not recommended. All HIV-infected persons who have a positive result on the tuberculin skin test should undergo chest radiography and clinical evaluation for the exclusion of active tuberculosis. HIV-infected persons who have the symptoms suggestive of tuberculosis should undergo chest radiography and clinical evaluation regardless of their tuberculin skin test status.

All HIV-infected persons who have a positive tuberculin skin test result yet have no evidence of active tuberculosis and no history of treatment or prophylaxis for tuberculosis should be administered twelve months of preventive chemotherapy with isoniazid. Since HIV-infected persons are at risk for peripheral neuropathy, those receiving isoniazid should also receive pyridoxine (vitamin B6). The decision to use alternative antimycobacterial agents for chemoprophylaxis should be based on the relative risk of exposure to resistant organisms and may require consultation with public health authorities. Rifamycin/protease inhibitor interactions must be considered when non-isoniazid preventive therapy is considered. The need for direct observation as a means of documenting adherence to chemoprophylaxis should be considered on an individual basis.

HIV-infected persons who are close contacts of persons who have infectious tuberculosis should be given preventative therapy—regardless of tuberculin skin test results or previous courses of chemoprophylaxis—after the diagnosis of active tuberculosis has been excluded. In addition to household contacts, such persons might also include contacts in the same drug treatment or health care facility, coworkers and other contacts if transmission of tuberculosis is demonstrated. If the tuberculin skin test is initially negative, the person should be evaluated three months later after the discontinuation of contact with the infectious source, and the information obtained should be considered in decisions about whether chemoprophyxis should continue.

In addition to documenting tuberculosis infection, tuberculin skin test conversion in an HIV-infected person should alert the health care providers to possibility of recent M. tuberculosis transmission and should prompt notification of public health officials for investigation to identify a possible source case.

Adults and adolescents with HIV infection (including those who are pregnant) should receive chemoprophylaxis against PCP if they have a CD4+ lymphocyte count of less than 200/ul or mm3 unexplained fever (>100 degrees F) for two or more weeks, or a history of oropharyngeal candidiasis.

Trimethoprim-sulfamethoxazole(TMP-SMZ) is the preferred prophylactic agent. TMP-SMZ may confer cross-protection against toxoplasmosis and many bacterial infections. For patients with an adverse reaction that is not life-threatening, treatment with TMP-SMZ should be continued if clinically feasible; for those who have discontinued such therapy, its reinstitution should be strongly considered. Whether it is best to reintroduce the drug at the original dose or to try a desensitization regimen is unknown.

If TMP-SMZ cannot be tolerated, alternative prophylactic regimens include dapsone (AI),  pyrimethamine plus sulfadiazine (Fansidar), and intravenous or aerosolized pentamidine administered by the Respirgard II nebulizer Marquest. Trimetrexate, leucocovorin, clindamycin-primaquin and peritrexim are all experimental.

Adults and adolescents who have HIV infection should receive chemoprophylaxis against disseminated Mycobacterium avium complex (MAC) disease if they have a CD4+ t-lymphocyte count of less than 50 cells per cubed millimeter. Clarithromycin or azithromycin are the preferred prophylactic agents. The combination of azithromycin with rifabutin is more effective than azithromycin alone, but he additional cost, increased occurrence of adverse effects and absence of a difference in survival when compared with azithromycin alone do not warrant a routine recommendation for this regimen. If clarithromycin or azithromycin cannot be tolerated, rifabutin is an alternative prophylactic agent for MAC disease.

Other Common Diseases

During the past decade, clinicians and researchers have learned that, in addition to P. carinii and MAC, other pathogens can cause disease in patients with HIV infection. This list includes Toxoplasmic encephalitis, Cryptosporidiosis, Microsporidiosis, bacterial respiratory infections, bacterial enteric infections, infection with Bartonella (formerly Rochalimaea), Candidiasis, Cryptococcosis, Histoplasmosis, Coccidioimycosis, Cytomegalovirus disease, Herpes Simplex virus disease, Varicella-Zoster virus infection, Human Papillomavirus, and others.

Since 1985, HIV counseling and testing has been publicly funded in order to find an alternative to the donation of blood as a means for high-risk persons to determine their HIV status. The counseling addressed the accuracy and consequences of the test and was designed to help persons interpret the meaning of negative or positive results. HIV counseling was based on the recognition that learning HIV status would be difficult for some clients. In 1987, HIV counseling and testing were expanded due to the increased understanding of the scope and severity of the HIV epidemic and the predictive value of the HIV test. Those seeking care for sexually transmitted diseases, family planning, childbirth, or substance abuse were counseled in an attempt to reduce their risk for HIV transmission. Even more so now, the HIV tests have been proven in their reliability and predictive value and public awareness has greatly increased. Also, experience and increased knowledge have set up counseling standards and guidelines. By catching the virus early, the patient can benefit from early antiviral and prophylactic treatment.

Counseling is a direct, personalized, and client-centered intervention designed to help initiate behavior change to avoid infection, or, if already infected, to prevent transmission to others, and to obtain referral to additional medical care, preventive, psychosocial and other needed services in order to remain healthy.

Counseling before testing may not be practical when screening for HIV antibody is required. This is true for donors of blood, organs, and tissue; prisoners, and immigrants for whom testing is a Federal requirement as well as prisoners admitted to state correctional institutions in states that require testing. When there is no counseling before testing, persons should still be aware that testing for HIV antibody will still be performed, that individual results will be kept confidential to the extent permitted by law, and that appropriate counseling will be offered. However, it is crucial that individual counseling of those who are HIV-antibody positive or at continuing risk for HIV infection is critical for those reducing further transmission and for ensuring timely medical care.

1. To provide a convenient opportunity for persons to learn their current serostatus;
2. Allow such persons to receive prevention counseling to help initiate behavior change to prevent the transmission or acquisition of HIV;
3. Help persons obtain referrals to receive additional medical care, preventive, psychosocial, and other needed services;
4. Provide prevention services and referrals for sex and needle sharing partners of HIV-infected persons.

1. Identify persons who are unaware, uninformed, misinformed, or in denial of their risk for HIV infection and facilitate an accurate self-perception of risk.
2. Prepare clients for and provide them with knowledge of their HIV status.
3. Negotiate a relevant risk reduction plan and obtain a commitment from clients to reduce their HIV risk.
4. Refer clients to resources that will provide psychosocial support and facilitate desired behavior change.
5. Provide referral to appropriate drug treatment services for clients whose substance abuse problems enhance their HIV risk.
6. Provide information on the increased risk of HIV transmission associated with other sexually transmitted diseases (STDs) and give referrals for STD examination and treatment.
7. Provide family planning information and referrals for women of child-bearing age who are infected or at high risk for HIV.
8. Provide referrals to HIV positive and high risk negative persons for necessary medical, preventive, and psychosocial services
9. Communicate to the client the responsibility for appropriate disclosure including the notification of sex and needle-sharing partners.

Necessary Elements

1. Maintenance of confidentiality

Strict protection of client confidentiality must be maintained for all persons offered and receiving HIV counseling services.

     2. Risk Assessment

Client-centered discussion that encourages the client to identify, understand, and acknowledge his or her personal risk for acquiring HIV.

3. Prevention Counseling

Provides a critical opportunity for the client to identify his or her risk of acquiring or transmitting HIV and reduce or eliminate behavioral risks. Counseling before the HIV test should prepare the client for receiving, understanding, and managing his or her test result.

3. Providing test results

Involves interpretation that is based upon the test result and the client’s specific risk. Knowledge of HIV status is important information so that a client can plan behavioral change. Skillful, client-centered counseling is required to reassess behavioral risks which may influence the interpretation of the test results. The client will most often focus on the actual result itself rather than behavioral and preventive messages.

3. Provision of Referrals

Clients may require referral for physical and psychological evaluations, appropriate therapies (i.e. drug therapies), and support services to enhance or sustain risk reduction behaviors. Each program should maintain complete knowledge of referral services, including the availability, accessibility, and eligibility criteria for services.

1. Triage assessment- the process that determines whether someone should be referred to counseling. Facilitates access to prevention counseling services for those persons at increased risk for HIV.
2. Risk assessment -- the process of assisting the client to identify behaviors that place him or her at risk for HIV
3. Client-centered counseling -- counseling conducted in an interactive manner responsive to individual client needs. The focus is on developing prevention goals and strategies with the client and encouraging the client to do most of the talking rather than simply providing information to the client. An understanding of the unique circumstances of the client is required—behaviors, sexual identity, race/ethnicity, culture, knowledge, and social and economic status.
4. Appropriate disclosure -- involves all of the circumstances in which others should be informed of the client’s HIV infection status. This determination requires consideration of the local and state laws, client confidentiality, and the need to inform others. Disclosure to health care providers and current and subsequent sex and/or drug partners is essential. The client may need assistance on the methods of informing who need to know.

Risk Assessment

The risk assessment should include reason for visit and other relevant concerns, personal circumstances, the client’s resources and support systems, behavioral and other sources of risk, demographic and epidemiologic factors that influence risk, client’s awareness of risk, readiness to change behavior, and receptiveness to available services and referrals. Risk assessment is not intended solely as a screening tool for client eligibility for HIV testing. A negotiated risk reduction plan should be the result and be a realistic, attainable strategy that is developed with the client to achieve behavior changes to reduce the risk for acquiring or transmitting HIV. Listen for and address information such as:

In order to reduce the further spread of infection, there are several behaviors that suggest one should be routinely counseled and tested for HIV. Those who should be tested include:

1. Persons who may have a sexually transmitted disease
2. Persons who have used IV-drugs
3. Persons undergoing medical evaluation or treatment
4. Persons admitted to hospitals
5. Persons in correctional systems
6. Persons who have engaged in prostitution
7. Persons who have had a sexual partner who was infected
8. Hemophiliacs
9. Persons who have or are currently living in communities or born in countries where there is a known or suspected high prevalence of infection
10. Persons who have received a blood transfusion before blood was being screened for HIV antibody but after HIV infection occurred in the United States (between 1978 and 1985)
11. Persons who choose to have a sexual partner of the same sex.

This information may be obtained by the clinician during the drug/sexual/medical history prior to or as a component of the counseling session. Also, the information can be obtained by utilizing a risk assessment tool completed by the client prior to the counseling session. Document acknowledged risk behavior, decisions about testing, and negotiated risk reduction plans in the client’s record.

What Else to Discuss

As part of the assessment the counselor should ascertain the client’s understanding of HIV transmission and the meaning of HIV antibody test results. When appropriate and relevant to the client, the counselor may:

          Discuss what the virus is and how it is transmitted;
          Discuss what the test results mean and how they are used in medical management:

          Discuss the need for retest:
          Clients engaging in high risk behavior should be retested six months after the last possible exposure to HIV;
          Review risk reduction options with the client, for example:
          Abstain from sex and injecting street drugs, enroll in a drug treatment program;
          Practice mutual monogamy between two HIV negative persons;
          Limit the number of sex partners;
          Use condoms;
          Disinfect drug injecting equipment and avoid sharing paraphernalia;
          Advise persons with behavioral risk for HIV not to donate blood and not to use the blood bank as a means of periodic HIV testing;
          Discuss related healthy behaviors, for example: limit the use of alcohol and other drugs;
          Obtain family planning assistance;
          Obtain early diagnosis and treatment for STDs,
          When appropriate; explain authorized disclosures and anti-discrimination protection;
           Discuss bringing a supportive person of the client’s choice at the time of receiving the test results.
          Assess the client’s concerns and anxieties during the waiting period. If necessary, arrange  psychological referral to assist the client with coping during waiting time; provide a hotline               telephone number(s) as a referral option; provide a subsequent counseling session or a follow-up telephone call.

Guidelines for Informing Client of Results

Negative Results

Ensure that the client understands what the test result means including

Some HIV positive clients may be better prepared to receive positive test results than others. Counseling of patients with positive test results must be directed to the client’s specific circumstances and may require more than one session. Counselors should recognize that the emotional impact of learning about HIV positive results often prevents clients from absorbing other information during this encounter.

Allow time for the client’s emotional response after learning his or her positive HIV result. A subsequent counseling session or follow-up telephone call may be required. Keep in mind the following:

Interpretation of HIV-Antibody Test Results

A test for HIV is considered positive when a sequence of tests, starting with a repeatedly reactive enzyme immunoassay (EIA) and including an additional, more specific assay, such as a Western Blot, are consistently reactive.

The sensitivity (the probability that a test will be positive when the infection is present) of the currently licensed EIA tests is 99% or greater when performed under optimal laboratory conditions. This makes the chance of a false-negative result remote, except during the first few weeks of infection before antibody is detectable.

The specificity (the probability that a test will be negative when the infection is not present) of the currently licensed EIA tests is approximately 99% when repeatedly reactive tests are considered.

Partner Notification/Contact Tracing

Sexual partners and those who share needles with HIV-infected persons are at risk for HIV infection and should be routinely counseled and tested for HIV antibody. Persons who are HIV-antibody positive should be instructed in how to notify their partners and to refer them for counseling and testing. If they are unwilling to notify their partners or if it cannot be assured that their partners will seek counseling, physicians or health department personnel can assist with confidential procedures to assure that the partners are notified.

Confidentiality and Anti-discrimination Considerations

The ability of health departments, hospitals, and other health-care providers and institutions to assure confidentiality of patient information and the public’s confidence in that ability are crucial to efforts to increase the number of persons being counseled and tested for HIV infection. Moreover, to assure broad participation in the counseling and testing programs, it is of equal or greater importance that the public perceive that persons found to be positive will not be subject to inappropriate discrimination.

Every reasonable effort should be made to improve confidentiality of test results. The confidentiality of related records can be improved by a careful review of actual record-keeping practices and by assessing the degree to which these records can be protected under applicable state laws. State laws should be examined and strengthened when found necessary. Because of wide scope of "need-to-know" situations, because of the possibility of inappropriate disclosures, and because of established authorization procedures for releasing records, it is recognized that there is no perfect solution to confidentiality in all situations. Whether disclosures of HIV-testing information are deliberate, inadvertent, or simply unavoidable, public health policy needs to carefully consider ways to reduce the harmful impact of such disclosures.

Public health prevention policy to reduce the transmission of HIV infection can be furthered by an expanded program of counseling and testing for HIV antibody, but the extent to which these programs are successful depends on the level of participation. Persons are more likely to participate in counseling and testing programs if they believe they will not experience negative consequences in areas such as employment, school admission, housing, and medical services should they test positive. There is no known medical reason to avoid an infected person in these and ordinary social situations since the cumulative evidence is strong that HIV infection is not spread through casual contact. It is essential to the success of counseling and testing programs that people who are tested or HIV programs are not subjected to inappropriate discrimination.(4)

Of the adults reported with AIDS in the United States through December 31, 1996, 18,856 had been employed in health care. These cases represented 5.1% of the 373,369 AIDS cases reported to CDC for whom occupational information was known (information on employment in the health care setting was missing for 200,431 reported AIDS cases).

The type of job is known for 17,857 (95%) of the 18,856 reported health care workers with AIDS. The specific occupations are as follows: 1,545 physicians, 104 surgeons, 4,203 nurses, 424 dental workers, 353 paramedics, 2,526 technicians, 908 therapists, and 3,892 health aides. The remainders are maintenance workers, administrative staff, etc. Overall, 76 percent of the health care workers with AIDS, including 1,218 physicians, 81 surgeons, 3,194 nurses, 332 dental workers, and 246 paramedics, are reported to have died.

CDC is aware of 52 health care workers in the United States who have been documented as having seroconverted to HIV following occupational exposures. Twenty-four have developed AIDS. These individuals who seroconverted include 19 laboratory workers (16 of whom were clinical laboratory workers), 21 nurses, 6 physicians, 2 surgical technicians,1 dialysis technician, 1 respiratory therapist, 1 health aide, and 1 housekeeper/maintenance worker. The exposures were as follows: 45 had percutaneous (puncture/cut injury) exposure, 5 had mucocutaneous (mucous membrane and/or skin) exposure, 1 had both percutaneous and mucocutaneous exposure, and one had an unknown route of exposure. Forty-seven exposures were to HIV-infected blood, 3 to concentrated virus in a laboratory, 1 to visibly bloody fluid, and 1 to an unspecified fluid.

CDC is also aware of 111 other cases of HIV infection or AIDS among health care workers who have not reported other risk factors for HIV infection and who report a history of occupational exposure to blood, bloody fluids, or HIV-infected material, but for whom seroconversion after exposure was not documented. The number of these workers who acquired their infection through occupational exposures is unknown.(9)

In anonymous unlinked serologic surveys conducted by CDC, 0.2%-8.9% of persons receiving care in emergency departments and 0.1%-7.8% of persons admitted to acute-care hospitals were HIV antibody positive. In two studies in which data were obtained regarding previous HIV testing or diagnosis, 63% and 65% of the HIV seropositive patients were unaware of their HIV infection before hospital admission.

In the period 1989-1990, CDC conducted anonymous unlinked serologic surveys to evaluate 13 hospital-specific variables as surrogate markers for hospital-specific HIV seroprevalence. The diagnosis rate for AIDS (annual number of individual AIDS patients diagnosed and reported to the health department/ annual number of discharges x 1000) was the only hospital-specific characteristic associated with hospital-specific seroprevalence.

Based on the 1989-90 surveys, an estimated 225,000 HIV-infected patients were cared for in the 5,558 acute-care U.S. hospitals in 1990; 163,000 of these HIV-infected patients were estimated to have a primary diagnosis other than HIV/AIDS. Of these 163,000 patients, 125,000 (77%) were admitted to the 593 (11%) hospitals with an AIDS diagnosis rate of greater than or equal to1.0 per 1,000 discharges; 110,000 (88%) of the 125,000 patients were ages 15-54 years. Thus, HIV testing of patients in this age range at these hospitals would potentially identify 68% of infected persons hospitalized in the United States for conditions other than HIV/AIDS.(10)

Recommendations have been made by the Centers for Disease Control (CDC) for the prevention of transmission of HIV in health-care settings. The recommendations emphasize adherence to universal precautions that require that blood and other specified body fluids of all patients be handled as if they contain blood-borne pathogens. This includes the appropriate use of hand-washing, protective barriers, and care in the use and disposal of needles and other sharp instruments. Proper application will help minimize the risk of transmission of HIV from patient to health care worker, health care worker to patient, or patient to patient. (11) Compliance with universal precautions and recommendations for disinfection and sterilization of medical devices should be scrupulously monitored in all health care settings. Training of health care workers in proper infection-control technique should begin in professional and vocational schools and continue as an ongoing process. Institutions should provide all health care workers with appropriate in-service education regarding infection control and safety and should establish procedures for monitoring compliance with infection-control policies.(**)

Characteristics of exposure-prone procedures include digital palpation of a needle tip in a body cavity or the simultaneous presence of the health care worker’s fingers and a needle or other sharp instrument or object in a poorly visualized or highly confined anatomic site. Performance of exposure-prone procedures presents a recognized risk of percutaneous injury to the health care worker, and – if such injury occurs—the HCW’s blood is likely to contact the patient’s body cavity, subcutaneous tissues, and/or mucous membranes.(11)

Recommendations

HCWs whose practices are modified because of their HIV infection status should, whenever possible, be provided opportunities to continue appropriate patient-care activities. Career counseling and job retraining should be encouraged to promote the continued use of the HCW’s talents, knowledge, and skills.

The public health benefit of notification of patients who have had exposure-prone procedures performed by HCWs infected with HIV should be considered on a case-by-case basis, taking into consideration an assessment of specific risks, confidentiality issues, and available resources. Carefully designed and implemented follow-up studies are necessary to determine more precisely the risk of transmission during such procedures. Decisions regarding notification and follow-up studies should be made in consultation with state and local health officials

Universal Precautions

Universal precautions are intended to prevent parenteral, mucous membrane, and non-intact skin exposures of health care workers to blood-borne pathogens. They apply to blood and other fluids containing visible blood. Blood is the single most important source of HIV and other blood-borne pathogens in the occupational setting. Universal precautions also apply to tissues and to the following fluids: cerebrospinal fluid (CSF), synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid, semen, and vaginal secretions. The risk of transmission of HIV from these fluids is unknown; epidemiologic studies in the health care and community setting are currently inadequate to assess the potential risk to health care workers from occupational exposures to them. All patients should be assumed to be infectious for HIV and other blood-borne pathogens. Also, when emergency and public-safety workers encounter body fluids under uncontrolled, emergency circumstances in which differentiation between fluid types is difficult, if not impossible, they should treat all body fluids as potentially hazardous.

Although semen and vaginal secretions have been implicated in the sexual transmission of HIV, they have not been implicated in the occupational transmission between health care worker and patient. This observation is not unexpected, since exposure to semen in the usual health-care setting is limited, and the routine practice of wearing gloves for performing vaginal examinations protects health care workers from exposure to potentially infectious vaginal secretions.

Universal precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine, and vomitus unless they contain visible blood. The risk of HIV from these fluids and materials is extremely low or nonexistent. HIV has been isolated in some of these fluids; however, epidemiologic studies in the health-care and community setting have not implicated these fluids or materials in the transmission of HIV. Some of the above fluids and excretions represent a potential source for nosocomial and community-acquired infections with other pathogens. Recent data regarding levels of viremia present in end-stage disease may warrant the use of Standard Precautions to prevent transmission of HIV in the health care setting when giving care to patients with advanced disease.

Human breast milk has been implicated in perinatal transmission of HIV. However, occupational exposure to human breast milk has not been implicated in the transmission of HIV. Moreover, the healthcare worker will not have the same type of intensive exposure to breast milk as the nursing neonate. Whereas universal precautions do not apply to human breast milk, gloves may be worn by health care workers in situations where exposure to breast milk might be frequent, for example, in breast milk banking.

Universal precautions do not apply to saliva. General infection control practices already in existence—including the use of gloves for digital examination of mucous membranes and endotracheal suctioning, and hand-washing after exposure to saliva—should further minimize the risk, if any, for salivary transmission of HIV. Gloves need not be worn when feeding patients or when wiping saliva from skin unless it is visibly bloody. However special precautions are recommended for dentistry. During dental procedures, contamination of saliva with blood is predictable, trauma to health-care worker’s hands is common, and blood splattering may occur. Infection control precautions for dentistry minimize the potential for nonintact skin and mucous membrane contact of dental health-care workers to blood-contaminated saliva of patients. In addition, the use of gloves for oral examinations and treatment in the dental setting may also protect the patient’s oral mucous membrane from exposures to blood, which may occur in the skin of dental worker’s hands.

Use of Protective Barriers

Protective barriers reduce the risk exposure of the health care worker’s skin or mucous membranes to potentially infective materials. For universal precautions, protective barriers reduce the risk of exposure to blood, body fluids containing visible blood and other fluids to which universal precautions apply. Examples of protective barriers include gloves, gowns, masks, and protective eyewear. Gloves should reduce the incidence of contamination of hands, but they cannot prevent penetrating injuries due to needles or other sharp instruments. Masks and protective eyewear or face shields should reduce the incidence of contamination of mucous membranes of the mouth, nose, and eyes. (12)

Needle and sharps disposal

All workers should take precautions to prevent injuries caused by needles, scalpel blades, and other sharp instruments or devices during procedures; when cleaning used instruments; during disposal of used needles; and when handling sharp instruments after procedures. To prevent needle-stick injuries, needles should not be recapped, purposely bent or broken by hand, removed from disposable syringes, or otherwise manipulated by hand. If recapping is necessary, it should be done with a one-handed technique or by using proper engineering controls such as a recapping block device.   After they are used, disposable syringes and needles, scalpel blades, and other sharp items should be placed in puncture-resistant containers for disposal. The puncture-resistant containers should be located as close as practical to the use area (e.g., in the ambulance or, if sharps are carried to the scene of victim assistance from the ambulance, a small puncture-resistant container should be carried to the scene as well). Reusable needles should be left on the syringe body and should be placed in a puncture resistant container for transport to the reprocessing area.

Hand washing

Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood, other body fluids to which universal precautions apply, or potentially contaminated articles. Hands should always be washed after gloves are removed, even if the gloves appear intact. Hand washing should be completed using the appropriate facilities, such as utility or restroom sinks. When hand washing facilities are available wash hands with warm water and soap. When hand-washing facilities are not available, use a waterless antiseptic hand cleanser. The manufacturer’s recommendations should be followed.

Cleaning and decontaminating spills of blood

All spills of blood and blood-contaminated fluids should be promptly cleaned up using an EPA-approved germicide or a 1:10 solution of household bleach in the following manner while wearing gloves. Visible material should first be removed with disposable towels or other appropriate means that will ensure against direct contact with blood. If splashing is anticipated, protective eye-wear should be worn along with an impervious gown or apron which provides an effective barrier to splashes. The area should then be disinfected with the appropriate germicide. Hands should be washed following removal of gloves. Soiled cleaning equipment should be cleaned and decontaminated or placed in an appropriate container and disposed of according to agency policy. Plastic bags should be available for removal of contaminated items from the site of the spill.

Shoes and boots can become contaminated with blood in certain instances. Where there is massive blood contamination on floors, the use of disposable impervious coverings should be considered. Protective gloves should be worn to remove contaminated shoe coverings. The coverings and gloves should be disposed of in RED BIOHAZARD plastic bags. A plastic bag should be included in the crime scene kit or the car which is to be used for the disposal of contaminated items. Extra plastic bags should be stored in the police cruiser or emergency vehicle.

Laundry

Although soiled linen may be contaminated with pathogenic microorganisms, the risk of actual disease transmission is negligible. Rather than rigid procedures and specifications, hygienic storage and processing of clean and soiled linen are recommended. Laundry facilities and/or services should be handled as little as possible and with minimum agitation to prevent gross microbial contamination of the air and of persons handling the linen. All soiled linen should be bagged at the location where it was used. Linen soiled with blood should be placed and transported in bags that prevent leakage. Normal laundry cycles should be used according to the washer and detergent manufacturer’s recommendations.

Decontamination and Laundering of Protective Clothing

Protective work clothing contaminated with blood or other bloody fluids to which universal precautions apply should be placed and transported in bags or containers that prevent leakage. Personnel involved in the bagging, transport, and laundering of contaminated clothing should wear gloves. Protective clothing and station and work uniforms should be washed and dried according to the manufacturer’s instructions. Boots and leather goods may be brush-scrubbed with soap and hot water to remove contamination.

Infective Waste

The selection of procedures for disposal of infective wastes is determined by the relative risk of disease transmission and application of local regulations, which vary widely. In all cases, local regulations should be consulted prior to disposal procedures and followed. Infective waste, in general, should either be incinerated or should be decontaminated before disposal in a landfill. Bulk blood, suctioned fluids, excretions, and secretions may be carefully poured down a drain connected to a sanitary sewer, where permitted. Sanitary sewers may also be used to dispose of other infectious wastes capable of being ground and flushed into the sewer, where permitted. Sharp items should be placed in puncture-proof containers and other blood-contaminated should be placed in leak-proof plastic bags for transport to an appropriate disposal location.

Prior to the removal of protective equipment, personnel remaining on the scene after the patient has been cared for should carefully search for and remove contaminated materials. Debris should be disposed of as noted above.(13)

With over 1 million Americans infected with HIV, and an estimated 12 million cases of other sexually transmitted diseases each year in the U.S., effective strategies for preventing these diseases are critical. Practicing sexual abstinence or refraining from sexual intercourse with an infected partner are the best ways to prevent transmission of HIV and other STDs.

For those who choose to have sexual contact (vaginal, anal, or oral), latex condoms are highly effective when used consistently and correctly. In fact, recent studies provide compelling evidence that latex condoms are highly effective in protecting against HIV infection when used for every act of sexual intercourse.  Consistent use means using a condom with each sexual act of sexual activity. In addition, it is critical that condoms be used correctly as well:

There is substantial biological evidence that the presence of other STDs increases the likelihood of both transmitting and acquiring HIV especially if symptomology includes genital ulcers or inflammation.

It is strongly urged that all individuals who use drugs seek treatment to help them stop. Individuals who continue to inject drugs should avoid sharing or reusing needles or syringes. If reuse is unavoidable, syringes should be decontaminated with pure bleach three times, then rinsed with water three times (by drawing up and flushing out).

(This general analysis of certain sections of Florida law has been prepared for the Florida Board of Osteopathic Medical Examiners by Edwin Bayo, Assistant Attorney General, Office of the Attorney General, Department of Legal Affairs, The Capitol, Tallahassee, Florida.).

The State of Florida has been a leader in AIDS related legislation. With the passage of the Florida Omnibus AIDS Act in July, 1988, Florida became one of the first states in the nation to enact a comprehensive series of laws addressing various legal issues raised by the AIDS epidemic. These laws cover many different subjects such as: discrimination based on a person's HIV status; testing and confidentiality of test results; mandatory AIDS instruction in schools and universities; the effect of HIV positive status on insurance policies and membership in health maintenance organizations; and others. Of particular importance to health care professionals are the requirements for instruction on HIV and AIDS found in section 455.2226, Florida Statutes (hereafter F.S.). This law imposed a mandatory requirement to complete an approved HIV/AIDS educational course by a certain date on all currently licensed acupuncturists, physicians, osteopathic physicians, chiropractors, podiatrists, optometrists, nurses, pharmacists, dentists, nursing home administrators, occupational therapists, respiratory therapists, funeral directors, psychologists, mental health counselors, marriage and family therapists, and social workers. Completion of this educational course was also made a condition of initial licensure in all these professions.

Section 455.2226, F.S., was amended effective July 1, 1991. The HIV/AIDS educational course was made a required part of the biennial renewal of licensure or re-certification of most of the above listed professionals. In addition, to converting this instructional course into a continuing education requirement, the law specifically requires that said course include information on current Florida law on AIDS and its impact on testing, confidentiality of test results, and treatment of patients.

Testing

Section 381.004, F.S., is the single most important law regarding testing for the HIV virus. This law requires any person holding himself out of advertising as conducting testing programs for HIV or AIDS to register with the Florida Department of Health and Rehabilitative Services and comply with all applicable laws and regulations. Some of these requirements include:

1. Obtaining the informed consent of the person being tested, with certain exceptions enumerated in the Statute.
2. Providing counseling in conjunction with any testing, both prior to the test and after the results have been obtained. Pre-test counseling shall include information regarding measures for the prevention, exposure to, and transmission of the HIV virus. Pre-test counseling must also address the possibility of false results, the potential need for confirmatory testing, the potential social, medical and economic consequences of a positive test result, and the need to eliminate high-risk behavior.
3. No test result shall be determined as positive without a corroborating or confirmatory test being conducted.
4. No test result shall be revealed without affording the person being tested the opportunity of personal counseling. This post-test counseling must address the meaning of the test results, the possible need for additional testing, measures for the prevention of the transmission of the HIV virus, the availability of any appropriate health care, social and support services, and mental health care in the area, and the benefits of locating any individual by whom the person being tested may have been exposed to the virus.

Section 361.0041, F.S., requires that any donation of blood, plasma, organs, skin, or other human tissue for transplantation or use be tested for HIV prior to transfusion or other use, with certain exceptions enumerated in that Statute. Informed consent must be obtained from the donor, and counseling requirements, both pre-test and post-test, are also applicable. A blood donor who tests positive shall be sent written notification by certified mail that abnormal test results exist with respect to his blood donation, and that the blood bank shall give the donor opportunity to discuss the nature of the findings either in person or by phone. If the blood bank does not receive any response within 30 days, then the actual test results, along with written counseling materials, shall be sent to the donor.

Confidentiality

The general rule is that the identify of any person upon whom an HIV test has been performed, as well as the results of said test, are confidential, and they cannot be released without the patient's written consent or a court order. Pursuant to Section 384.25, F.S., every person who makes a diagnosis of a sexually transmissible disease must notify the Department of Health and Rehabilitative Services. In the case of AIDS, the reporting must be done in such a manner as to avoid the identification of the individual.

A patient's records which include the results of a HIV test must be kept confidential. The results of the test, and the written consent, must be kept within the patient's records. The outside of that patient's file or record may not be marked to indicate that said patient is HIV positive.

Section 455.2416, F.S., specifically provides that a physician shall not be civilly or criminally liable for disclosing a patient's HIV positive status to that patient's spouse or needle-sharing partners, and shall also not be civilly or criminally liable for his failure to do so.

Treatment of Patients

Subsection (11) of Section 381.609, F.S., makes it unlawful for any facility licensed by the Department of Health and Rehabilitative Services, (i.e., hospitals, nursing homes, etc.) or any person licensed by the Department of Professional Regulation (i.e., physicians) to require that any person submit to HIV testing as a condition of admission or treatment. This section is not intended to preclude any physician from declining, in good faith, to provide a particular treatment requested by the patient if the appropriateness of that treatment can only be determined through a HIV test.

Section 760.50, F.S., legally classifies persons suffering from HIV or AIDS as handicapped. Discrimination on the basis of gender, race, or handicap is prohibited by various federal and state laws. Because of the classification as handicapped, it conceivable that a physician refusing to treat a patient with HIV or AIDS could be subject to a civil rights type lawsuit.

Changes in reporting HIV made by Legislature

In response to 1996 legislative changes, the State Health Office filed administrative rule amendments to require physician and laboratory reporting of HIV infection effective January 1, 1997.

However, due to extensive and ongoing efforts to implement increased confidentiality and security policies/procedures, the effective date was changed to July 1, 1997. Although HIV infections identified prior to this date will not be reportable, physicians should continue to refer patients who test positive to HIV to the county health department for voluntary partner notification services if the patient gives permission for the referral.

The decision to delay implementation of HIV infection reporting represented my sincere commitment to implement a reporting process that is most productive in preventing disease and providing treatment at the early stage of the disease. We are committed to having a secure, comprehensive reporting as well as to maintaining well-trained, dedicated staff. With the success of new medications and therapies, HIV infection reporting will give us the opportunity to provide early intervention services which may extend the length and quality of life for persons already infected.

It is important to note that this delay did not effect the reporting of AIDS cases or the offering of HIV testing to pregnant women. Health care providers who treat pregnant women for conditions related to pregnancy are required by statute to offer HIV testing as a standard of practice. Cases fitting the Centers for Disease Control and Prevention definition of AIDS will continue to be reportable.

The following information is provided to facilitate the timely and accurate implementation of this new requirement:

1. All cases meeting the Centers for Disease Control and Prevention definition of AIDS will continue to be reportable.
2. Only positive tests which diagnose HIV infection are reportable. Examples of tests to diagnose HIV infection are antibody-based testing systems such as repeat ELISAs followed by a Western blot, and antigen tests such as p24 antigen or polymerase chain reaction (PCR) when these are used for confirmatory purposes.
3. Tests to determine viral load are not reportable unless done to diagnose HIV infection.
4. Indeterminate test results and unconfirmed positive antibody tests are not reportable.
5. Only positive test results obtained from specimens collected on or after July 1, 1997.
6. Anonymous testing will be readily available in all counties in the state. Persons who test positive to HIV through the anonymous testing system will not be reported. By signing a limited waiver of anonymity, individuals who choose anonymous testing may receive services through the public health departments and other health care providers without being reported. If persons who initially tested positive at an anonymous site are re-tested on or after July 1, 1997, outside the anonymous testing system, a positive result will be reportable.
7. In the rare event that positive HIV test results are obtained through employer testing of an employee who experiences documented significant exposure, e.g., needle stick, such results are not reportable without the written permission of the employee. Positive results obtained through testing the source of the significant exposure without consent as described in s.381.0049(3)(1), 11, F.S., are not reportable without the consent of the source. To ensure that individuals involved in a significant exposure are not reported by the laboratory, the department authorizes the submission of these specimens to the laboratory using a unique numerical identifier rather than the individual's name. Note: This provision also applies to nonmedical personnel who experience a noted significant exposure while providing emergency medical assistance.
8. The department has developed an information packet on HIV infection reporting. Among the items in the packet are a sample case report form, information on the availability of anonymous testing, and a copy of the administrative rule on HIV reporting. The information is available through your local county health department.

The new requirements will facilitate partner notification which plays a vital role in outreach to persons most at risk for HIV infection, including those who are already infected and may not know their status.

Whether positive or negative, all identified contacts will be offered public health information on preventing transmission and on the benefits of early treatment with new reporting requirements thereby furthering the department's goal to strengthen HIV prevention efforts while reducing morbidity and mortality. If the physician has concerns about a particular patient's well being, call Dr. Paul Arons, Medical Executive Director, Bureau of HIV/AIDS in the Florida State Health Office, (904) 921-2202. For additional information, call your local health department director or Landis Crockett, M.D., M.P.H., Director, Division of Disease Control, (904) 487-3684.

Any physician who is required to complete an educational course on human immunodeficiency virus and acquired immune deficiency syndrome as a condition of initial licensure must submit a notarized statement attesting to the completion of three hours of category 1, American Medical Association Continuing Medical Education which includes the topics of Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome; the disease and its spectrum of clinical manifestations; epidemiology of the disease; related infections including TB; treatment, counseling, and prevention; transmission from healthcare worker to patient; universal precautions and isolation techniques; and legal issues related to the disease.

Any physician who is required to complete an educational course on human immunodeficiency virus and acquired immune deficiency syndrome as a condition of licensure renewal must submit a notarized statement attesting to the completion of one hour of category 1, American Medical Association Continuing Medical Education, which includes the topics of Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome; the modes of transmission, including transmission from health care worker to patient and patient to health care worker; infection control procedures, including universal precautions; epidemiology of the disease; related infections including TB; clinical management; prevention; and current Florida law on AIDS, confidentiality, and treatment of patients. Any hours of said CME may also be counted toward the CME licensure renewal requirement.  In order for a course to count as meeting this requirement, licensees practicing in Florida must clearly demonstrate that the course includes Florida law on HIV/AIDS and its impact on testing, confidentiality of test results, and treatment of patients. Only category 1 hours shall be accepted.

Sources

1. Morbidity and Mortality Weekly Report, Public Health Service Guidelines for Counseling and Antibody Testing to Prevent HIV Infection and AIDS, Volume 36, Number 31, Pages 509-515, August 14,1987.
2. HIV/ AIDS Surveillance General Report; courtesy Florida Department of Health, Area One HIV/AIDS
3. Excerpt from Center for Disease Control and Prevention Facts Strategies for Preventing HIV in Women, April 1997.
4. HIV Counseling, Testing, and Referral Standards and Guidelines. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, and Prevention. May 1994.
5. TB and HIV: The Connection, What Health Care Workers Should Know; U.S. Department of Health and Human Services, Public Health Service; pp.1-2, September 1993.
6. Excerpt from the Centers for Disease Control and Prevention Facts About Human Immunodefiency Virus Type 2, February 1997.
7. Centers for Disease Control and Prevention HIV/AIDS Prevention Facts about the Human Immunodeficiency Virus and Its Transmission, July 1997.
8. Public Health Service Guidelines for Counseling and Antibody Testing to Prevent HIV Infection and AIDS, U.S. Department of Health and Human Services, Public Health Service, August 14, 1987.
9. Centers for Disease Control and Prevention HIV/AIDS Prevention, Facts about Surveillance of Health Care Workers with HIV/AIDS, March 1997.
10. Recommendations for HIV Testing Services for Inpatients and Outpatients in Acute-Care Hospital Settings, U.S. Department of Health and Human Services, Public Health Service, January 15, 1993.
11. Recommendations for Preventing Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Patients During Exposure-Prone Invasive Procedures, U.S. Department of Health and Human Services, Public Health Service, July 12,1991.
12. Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Blood borne Pathogens in Health-Care Settings, June 24, 1988.
13. Guidelines for prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, U.S. Department of Health and Human Services, Public Health Service, July 23, 1989.

Post Test

HIV/AIDS Home Study

     1.  The HIV virus targets which type of cells:
           a) Red blood cells
           b) B cells
           c) Helper cells
           d) Suppressor cells

   2. The specificity of the currently licensed EIA tests is approximately _____when repeatedly reactive tests are considered.
           a) 75%
           b) 99%
           c) 50%
           d) 91.5%

  3.  Universal precautions are intended to:
           a) reduce the risk of an AIDS patient from becoming infected with an opportunistic infection.
           b) prevent parenteral, mucous membrane, and nonintact skin exposures of health care workers to blood-borne pathogens.
           c) replace the practice of general infection control.
           d) eventually become standard practice in most health-care settings.

 4.  The interval between HIV infection and AIDS diagnosis:
          a) is shorter in older people.
          b) between 8 to 10 years.
          c) between 6 to 8 weeks.
          d) is when the patient is not infectious.

5.  HIV-1 and HIV-2 are similar except for:
          a) modes of transmission
          b) viral structure
          c) resulting opportunistic diseases.
          d) geographic patterns of infection.

6. Which of the following are common opportunistic infections of AIDS?
         a) Pneumocystis Carinii pneumonia
         b) Toxoplasmic Encephalitis
         c) Cryptosporidiosis
         d) Microsporidiosis
         e) Tuberculosis
         f) Mycobacterium Avium Complex
        g) Bacterial Respiratory Infections
        h) Bacterial Enteric Infections
         i) Bartonella
         j) Candidiasis
        k) Cryptococcosis
         l) Coccidioidomycosis
       m) Cytomegalovirus Disease
        n) Herpes Simplex Virus
        o) Varicella-Zoster Virus
        p) Human papillimavirus
        q) all of the above
         r) none of the above

7. To which of the following do universal precautions apply (if they do not contain visible blood)?
        a) nasal secretions
        b) vomitus
        c) pericardial fluid
        d) urine

  8. When did HIV infection reporting go into effect?

  9. What is reportable after July 1, 1997?

10. Are individuals who tested positive prior to July 1, 1997 reportable?

11. Are indeterminate tests reportable?

12. Are anonymous tests reportable?

13. Is there a form to report HIV infection?

14. Reports must be submitted to the county health department with jurisdiction for the area where the physician's office is located within____________ of the diagnosis;
      a) four weeks
      b) two weeks
      c) one week

15. HIV/AIDS is growing fastest among:
      a) women
      b) persons aged 14-23
      c) persons of color
      d) persons with heterosexual contact
      e) All of the above

On your answer sheet indicate (T) for TRUE or (F) for FALSE for the following questions:

16. Persons co-infected with HIV and m. Tuberculosis are at very high risk of developing TB disease.

17. Of the diseases associated with HIV infection, TB is one  of  the few that is transmissible, treatable, and preventable.

18. HIV-infected persons who have the symptoms  suggestive  of   tuberculosis  should undergo chest radiography and clinical evaluation regardless of their tuberculin skin test status.

19. The general rule is that the identity of any person upon whom an HIV  test has been performed, as well as the results of said test, are confidential, however, they can be released with the patient's written consent or a court order.

Mark the most appropriate answer for the following:
 
20. Who needs to report cases of HIV infection?
       a) physicians
       b) county health department
       c) nurses/paramedical personnel
       d) none of the above

21. The main causes of HIV transmission to the health care worker are:
       a) puncture/cut injury
       b) device visibly contaminated with patient's blood
       c) needle placed directly in patient's vein or artery
       d) terminal illness in the source
       e) all of the above

22. Indicate which of the following statement(s) are false regarding the epidemiology of the disease:
      a) By the year 2000, there will be 20 - 25 million people world wide predicted to have HIV/AIDS
      b) Heterosexual transmission rising exponentially - especially women
      c) Urban poor and ethnic minorities highest prevalence
      d) Still present and potent among gay males and intravenous drug users

23. The following denotes key proven principles of infection control. Which one represents the major method of preventing occupational exposure of HIV?
      a) Proper handling and disposal of "sharps"
      b) Washing hands between patients
      c) Proper cleaning/disinfection/sterilization of medical devices/instruments/equipment between patients.
      d) Protective Barriers
      e) All of the above

24. With over 1 million Americans infected with HIV, most  of  them  through sexual transmission, and  an estimated 12 million cases of other sexually transmitted diseases each year in the U.S., effective strategies for preventing these diseases are:
      a) Sexual abstinence
      b) Refraining from sexual intercourse with an infected partner
      c) Condoms
      d) Early Treatment if infected with any STD
      e) Avoid sharing needles or syringes
      f) All of the above

25. How do I report a case of HIV infection?
      a) contact local county health department
      b) contact HIV/AIDS surveillance staff
      c) contact STD staff
      d) all of the above
      e) only a and b

Do to possible and/or  frequent changes in requirements established by the State of Florida regarding  AIDS education, this home study is null and void if not returned by December 2003. We urge you to call the MECOP office at (850) 477-4956 before taking this test to ascertain no changes have occurred since this home study course was produced.

PROGRAM: HIV/AIDS Home Study

OBJECTIVES: At the conclusion, the participant should be able to discuss HIV and AIDS, the modes of transmission, including transmission from health care worker to patient and patient to health care worker; infection control procedures, including universal precautions; epidemiology of the disease; related infections including TB; clinical management; prevention; and current Florida law on HIV/AIDS and its impact on testing, confidentiality of test results, and treatment of patients.