Edited by
Vijay Fadia
It was spring of 1996 when Beth Bye says she returned from the dead. The Wisconsin woman hadn't actually died, but with her body ravaged in the late stages of AIDS infection, she had run out of options, and death was, indeed, near. AIDS-related dementia and blindness had crept in-signs that her doctor told her meant time was short. She made funeral arrangements and considered moving to a hospice for her remaining days.
Then, as if to say "not so fast," medical science handed her another option. New drugs called proŽtease inhibitors, first approved in 1995, were about to revolutionize the treatment of patients inŽfected with the AIDS virus. These drugs usually are taken with two other drugs called reverse transcriptase inhibitors. The combined drug "cocktail" has helped change AIDS in the last three years from being an automatic death sentence to what is now often a chronic, but manageable, disease.
Within two months of beginning the triple cocktail treatment, also known as highly active antiretroviral therapy (HAART), Bye's viral load-a measure of new AIDS virus produced in the body-dropped to undetectable levels. Her red and white blood cell counts normalized, an imporŽtant sign that the immune system was starting to work again. Suddenly she could do simple things she had long given up, such as walk the dog for 2 miles. Bye, now 40, was even able to return to her teaching job and currently works 30 hours a week.
"My recovery was like being on death row and getting that last minute pardon from the governor," she says.
This so-called "Lazarus Effect," named for the biblical figure who was raised from the dead, has occurred with many AIDS patients who take the triple therapy. "It returns many who were debiliŽtated and dying to relatively healthy and productive life," says Richard Klein, HIV/AIDS coordinaŽtor for the Food arid Drug Administration's Office of Special Health Issues.
In 1997, for the first time since 1990, AIDS fell out of the top 10 causes of death in the United States, dropping from 8th to 14th place, according to the national Centers for Disease Control and Prevention. By 1998, about 16,000 people were still alive who would have died the previous year if AIDS mortality had continued at its former rate. Still, about 40,000 new infections occur yearly.
| 1. | Describe how HIV is transmitted and dispel some of the common misconceptions about how one cannot get HIV. | |
| 2. | Describe the presence and possibility of transmission of HIV in households, foodŽservice establishments, through kissing, biting, saliva, tears, sweat and insects. | |
| 3. | Describe the natural history of HIV infection in adults and the progression of the disease to AIDS. | |
| 4. | Discuss the CDC system for classifying HIV infection and AIDS in adults and adolescents in the U.S. and identify clinical conditions under each of the three categories. | |
| 5. | Define "viral set-point" and indicate its use in predicting the rate of future progression of the illness. | |
| 6. | List various laboratory tests used as indicators of prognosis and/or stage of illness in HIV infection and weigh their advantages and disadvantages. | |
| 7. | List host factors, viral factors, acquired factors and clinical indicators that influence the rate of HIV -disease progression. | |
| 8. | Identify the three primary routes of HIV transmission and indicate the relative risk of infection. | |
| 9. | Discuss the three factors-infectiousness of the host, susceptibility of the recipient and the quantity and infectivity of the virus-that influence the transmission of HIV infection. | |
| 10. | Identify the HIV / AIDS prevention needs of women. | |
| 11. | Address the special challenges posed to the prevention of HIV epidemic in the African American community. | |
| 12. | Describe the epidemiology of HIV/AIDS among Hispanics in the U.S. and compare HIV exposure risks for U.S.-born Hispanics and Hispanics born in their countries. | |
| 13. | Describe the epidemiology of HIV/AIDS among America's youth. | |
| 14. | Describe the standard screening test for antibody to HIV and contrast it with the rapid HIV testing. | |
| 15. | Discuss the various advantages and disadvantages of rapid HIV test as compared to an EIA. | |
| 16. | Understand the importance of measuring HIV-RNA blood levels (viral load.) | |
| 17. | Explain what "undetectable" level of HIV in the blood means. | |
| 18. | List 5 steps for the correct use of condoms. | |
| 19. | Make the connection between sexually transmitted diseases and HIV and explain how other STDs facilitate HIV transmission. | |
| 20. | Point to the new evidence of the effectiveness of STD treatment in HIV prevention. | |
| 21. | Point to statistics showing the effectiveness of condoms in preventing HIV and STDs. | |
| 22. | Discuss the study sponsored by the CDC that quantified the risk of HIV infection associated with oral transmission. | |
| 23. | Describe the prevalence of HIV among men who have sex with men and outline the measures to combat the spread of STDs and HIV in this population group. | |
| 24. | Describe the risk of HI V transmission among women who have sex with women and list 3 specific measures that should be taken to reduce their risk of contracting HIV. | |
| 25. | Discuss the injection drug use and the transmission of HIV and other blood-borne infections. | |
| 26. | Make 3 specific recommendations to drug users who continue to inject to reduce the public and individual health risks. | |
| 27. | Describe the extent of the problem in curbing the transmission of HIV and other blood-borne diseases in the intravenous drug-using (IDU) population. | |
| 28. | Enunciate the 4 basic principles underlying the comprehensive approach to working with IDUs. | |
| 29. | Define universal precautions and list body fluids to which universal precautions apply and those to which they do not apply. | |
| 30. | Discuss precautions that a healthcare worker should take for other body fluids in special settings. | |
| 31. | Describe general guidelines for healthcare workers in the use of protective barriers. | |
| 32. | Discuss why the routine use of gloves for all phlebotomies is not necessary. | |
| 33. | Identify general guidelines in the selection and use of gloves in healthcare settings | |
| 34. | Evaluate the risk healthcare workers face of getting HIV on the job. | |
| 35. | Evaluate the risk of patients in a dentist's or doctor's office of getting HIV. | |
| 36. | Review the effectiveness of HIV prevention programs targeted toward changing personal behaviors, sexual education, intravenous drug users, HIV -infected pregnant women, blood banks and healthcare workers. | |
| 37. | Recount the dramatic success of protease inhibitors in the treatment of patients infected with HIV. | |
| 38. | Answer specific questions of people living with HIV/AIDS, including progression to AIDS, opportunistic infections, antiretroviral drug therapy and safe sexual behavior. | |
| 1 | Human Immunodeficiency Virus (HIV) | |||
| HIV and Its Transmission | ||||
| How HIV Is Transmitted | ||||
| HIV in the Environment | ||||
| Households | ||||
| Businesses and Other Settings | ||||
| Kissing | ||||
| Biting | ||||
| Saliva, Tears, and Sweat | ||||
| Insects | ||||
| 2 | Epidemiology and Natural History of HIV Infection | |||
| Introduction | ||||
| HIV Transmission | ||||
| Modes of Transmission | ||||
| Factors Facilitating Transmission | ||||
| Infectiousness of the Host | ||||
| Susceptibility of the Recipient | ||||
| Viral Properties | ||||
| Natural History and HIV Disease Progression | ||||
| Staging | ||||
| Untreated Natural History | ||||
| Primary or Acute Infection | ||||
| Established Infection | ||||
| Time Course | ||||
| Laboratory Indicators and Predictors | ||||
| Long-Term Non-Progressors | ||||
| Gender Effects | ||||
| Natural History in HAART Era | ||||
| Industrialized Countries | ||||
| References | ||||
| HIV/AIDS Among U.S. Women | ||||
| Heterosexual Contact Now Is Greatest Risk for Women | ||||
| Prevention Needs of Women | ||||
| HIV/AIDS Among African Americans | ||||
| Prevention Efforts Must Focus on High-Risk Behaviors | ||||
| Interrelated Prevention Challenges in African American Communities | ||||
| HIV/AIDS Among Hispanics in the United States | ||||
| Historical Trends in AIDS Cases Among U.S. Hispanics | ||||
| Building Better Prevention Programs for Hispanics | ||||
| HIV/AIDS Among America's Youth | ||||
| Improving HIV Prevention for Young People | ||||
| Healthcare Workers with HIV/AIDS | ||||
| 3 | HIV Testing | |||
| Overview for HIV Antibody Testing | ||||
| Rapid HIV Test: Questions/Answers | ||||
| General Questions | ||||
| What has been the routine test for HIV antibody testing? | ||||
| What is rapid HIV testing? | ||||
| What is the difference between a rapid HIV test and an EIA? | ||||
| What rapid HIV tests be available in the future? | ||||
| Will other rapid HIV tests be available in the future? | ||||
| Who can be tested with a rapid HIV test? | ||||
| Does the rapid HIV test cost more than the EIA? | ||||
| Can I expect to see rapid HIV testing in most clinics and doctors' offices soon? | ||||
| Are rapid HIV tests more accurate or less accurate than EIAs? | ||||
| What is predictive value? | ||||
| Does a negative rapid HIV test result mean that a person has nothing to worry about? | ||||
| What is "reactive" HIV test result? | ||||
| After a reactive rapid HIV test result, how long does a person have to wait for the confirmatory test result? | ||||
| Questions-Technical, Counseling, and Implementation | ||||
| What is the cost of rapid HIV test? | ||||
| If a confirmatory test is still needed, what is the advantage to sexually transmitted disease (STD) clinics of using rapid HIV testing? | ||||
| What is the advantage to clients of using rapid HIV Testing? | ||||
| Will people who have progressed to the late stages of AID continue to test positive on the rapid HIV test? | ||||
| Can rapid HIV tests be performed on infants? | ||||
| Can clinic staff batch rapid HIV tests? | ||||
| How long does the rapid HIV test take after the lab receives the specimen? | ||||
| What type of training will be available for HIV counselors at sites that use rapid HIV tests? | ||||
| Are educational materials (e.g., handouts, videos) available for the clinics that want to use rapid HIV tests? | ||||
| Would telephoning clients to provide the results of a positive confirmatory HIV test be acceptable? | ||||
| What does the counselor tell a client who has a reactive rapid HIV test? | ||||
| Do you start partner notification and referral services immediately upon receiving a reactive rapid HIV test result, or do you wait for the confirmatory test result? | ||||
| Should a physician prescribe antiretroviral treatment for a pregnant woman on the basis of rapid HIV test results (per the PHS Guidelines)? | ||||
| Are confirmatory tests necessary for a rapid HIV test result to be considered a diagnosis of HIV infection? | ||||
| Resources | ||||
| Understanding Viral Load | ||||
| What is viral load and how is it measured? | ||||
| When should viral load be measured? | ||||
| What prompts changes in viral load? | ||||
| What does an "undetectable" level mean? | ||||
| Is there still a need to have CD4+ levels monitored? | ||||
| 4 | Sex and HIV Prevention | |||
| Prevention and Treatment of Sexually Transmitted Diseases as an HIV | ||||
| Prevention Strategy | ||||
| The Parallel Epidemics of HIV Infection and Other STDs | ||||
| Other STDs Facilitate HIV Transmission | ||||
| New Evidence of the Effectiveness of STD Treatment in HIV Prevention | ||||
| Condoms and Their Use in Preventing HIV Infection and Other STDs | ||||
| Condoms are effective in preventing HIV and other STDs | ||||
| Condoms must be used consistently and correctly to provide maximum protection | ||||
| Condoms users have product options | ||||
| Education about condom efficacy does not promote sexual activity | ||||
| Prevention is cost-effective | ||||
| Primary HIV Infection Associate with Oral Transmission | ||||
| What is the risk of HIV transmission from oral sex? | ||||
| What are the exact ways that HIV was transmitted in this study? | ||||
| How do you know if the study participants were telling the truth about their sexual history? | ||||
| Was this a surprise finding? | ||||
| What can be done to prevent HIV? | ||||
| Bibliography | ||||
| HIV Prevention Among Men who Have Sex with Men (MSM) | ||||
| Continuing Risk Among Young MSM | ||||
| Need to Combat Other STDs | ||||
| Prevention Services Must Reach Both Uninfected and Infected | ||||
| Women Who Have Sex With Women (WSW) | ||||
| What do surveillance tools tell us about transmission between women? | ||||
| What do investigations of female-to-female transmission show? | ||||
| What are the behaviors that place WSW at risk of HIV infection? | ||||
| What can WSW do to reduce their risk of contracting HIV? | ||||
| References | ||||
| 5 | IDUs and HIV | |||
| Injection Drug Use and the Transmission of HIV and Other Blood-Borne Infections | ||||
| Critical Importance of Prevention and Treatment of Drug Dependence | ||||
| HIV Risks Associated With Drug Injection | ||||
| Recommendations to Drug Users Who Continue to Inject | ||||
| References | ||||
| 6 | Universal Precautions | |||
| Universal Precautions for Prevention of Transmission of HIV, HBV, and Other | ||||
| Blood borne Pathogens in Healthcare Settings | ||||
| Introduction | ||||
| Body Fluids to Which Universal Precautions Apply | ||||
| Body Fluids to Which Universal Precautions Do Not Apply | ||||
| Precautions for Other Body Fluids in Special Settings | ||||
| Use of Protective Barriers | ||||
| Glove Use for Phlebotomy | ||||
| Selection of Gloves | ||||
| Waste Management | ||||
| References | ||||
| 7 | Occupational Exposures to Blood | |||
| Introduction | ||||
| Are healthcare workers at risk of getting HIV on the job? | ||||
| How can occupational exposures be prevented? | ||||
| If An Exposure Occurs | ||||
| What should I do if I am exposed to the blood of a patient? | ||||
| Risk of Infection After Exposure | ||||
| What is the risk of infection after an occupational exposure? | ||||
| How many healthcare workers have been infected with bloodborne pathogens? | ||||
| Treatment for the Exposure | ||||
| Is vaccine or treatment available to prevent infections with bloodborne pathogens? | ||||
| What about exposures to blood from an individual whose infection status is unknown? | ||||
| What specific drugs are recommended for post exposure treatment? | ||||
| How soon after exposure to a bloodborne pathogen should treatment start? | ||||
| Has the FDA approved these drugs to prevent bloodborne pathogen infection following an occupational exposure? | ||||
| What is known about the safety and side effects of these drugs? | ||||
| Can pregnant healthcare workers take the drugs recommended for post exposure treatment? | ||||
| Follow-Up After An Exposure | ||||
| What follow-up should be done after an exposure | ||||
| What precautions should be taken during the follow-up period? | ||||
| Are patients in a dentist's or doctor's office at risk of getting HIV? | ||||
| 8 | Antiretroviral Therapy | |||
| Attacking AIDS with a 'Cocktail' Therapy Drug Combo Sends Deaths Plummeting | ||||
| A "One-Two Punch" | ||||
| Regimen has drawbacks | ||||
| AIDS-related illnesses | ||||
| Pregnant women and children | ||||
| In the future | ||||
| 9 | Living with HIV/AIDS | |||
| What is HIV and haw did I get it? | ||||
| What is the difference between HIV and AIDS? | ||||
| How can I stay healthy longer? | ||||
| What can I expect when I go to the doctor? | ||||
| What is the treatment for HIV or AIDS? | ||||
| What are some of the other diseases I could get? | ||||
| How do I protect other people from my HIV? | ||||
| Family Planning and Pregnancy | ||||
| Is there any special advice for women with HIV? | ||||
| What if I become pregnant? | ||||
| Where can I find help in fighting HIV? | ||||
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