1
Human Immunodeficiency Virus HIV)

v HIV and Its Transmission

Research has revealed a great deal of valuable medical, scientific, and public health information about the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). The ways in which HIV can be transmitted have been clearly identified. Unfortunately, false information or statements that are not supported by scientific findings continue to be shared widely through the Internet or popular press. Therefore, the Centers for Disease Control and Prevention (CDC) has prepared this fact sheet to correct a few misperceptions about HIV.

How HIV Is Transmitted

HIV is spread by sexual contact with an infected person, by sharing needles and/or syringes (primarily for drug injection) with someone who is infected, or, less commonly (and now very rarely in countries where blood is screened for HIV antibodies), through transfusions of infected blood or blood clotting factors. Babies born to HIV-infected women may become infected before or during birth or through breast-feeding after birth.

HIV in the Environment

Scientists and medical authorities agree that HIV does not survive well in the environment, making the possibility of environmental transmission remote. HIV is found in varying concentrations or amounts in blood, semen, vaginal fluid breast milk, saliva, and tears. To obtain data on the survival of HIV, laboratory studies have required the use of artificially high concentrations of laboratory-grown virus. Although these unnatural concentrations of HIV can be kept alive for days or even weeks under precisely controlled and limited laboratory conditions, CDC studies have shown that drying of even these high concentrations of HIV reduces the amount of infectious virus by 90 to 99 percent within several hours. Since the HIV concentrations used in laboratory studies are much higher than those actually found in blood or other specimens, drying of HIV-infected human blood or other body fluids reduces the theoretical risk of environmental transmission to that which has been observed–essentially zero. Incorrect interpretation of conclusions drawn from laboratory studies have unnecessarily alarmed some people.

Households

Although HIV has been transmitted between family members in a household setting, this type of transmission is very rare. These transmissions are believed to have resulted from contact between skin or mucous membranes and infected blood. To prevent even such rare occurrences, precautions should be taken in all settings including the home to prevent exposures to the blood of persons who are HIV infected, at risk for HIV infection, or whose infection and risk status are unknown. For example,

Businesses and Other Settings

There is no known risk of HIV transmission to co-workers, clients, or consumers from contact in industries such as food-service establishments (see information on survival of HIV in the environment). Food-service workers known to be infected with HIV need not be restricted from work unless they have other infections or illnesses (such as diarrhea or hepatitis A) for which any food-service worker, regardless of HIV infection status, should be restricted. CDC recommends that all food-service workers follow recommended standards and practices of good personal hygiene and food sanitation.

Kissing

Casual contact through closed-mouth or social kissing is not a risk for transmission of HIV. Because of the potential for contact with blood during French or open-mouth kissing, CDC recommends against engaging in this activity with a person known to be infected. However, the risk of acquiring HIV during open-mouth kissing is believed to be very low. CDC has investigated only one case of HIV infection that may be attributed to contact with blood during open-mouth kissing.

Biting

In 1997, CDC published findings from a state health department investigation of an incident that suggested blood-to-blood transmission of HIV by a human bite. There have been other reports in the medical literature in which HIV appeared to have been transmitted by a bite. Severe trauma with extensive tissue tearing and damage and presence of blood were reported in each of these instances. Biting is not a common way of transmitting HIV. In fact, there are numerous reports of bites that did not result in HIV infection.

Saliva, Tears, and Sweat

HIV has been found in saliva and tears in very low quantities from some AIDS patients. It is important to understand that finding a small amount of HIV in a body fluid does not necessarily mean that HIV can be transmitted by that body fluid. HIV has not been recovered from the sweat of HIV-infected persons. Contact with saliva, tears, or sweat has never been shown to result in transmission of HIV.

Insects

From the onset of the HIV epidemic, there has been concern about transmission of the virus by biting and bloodsucking insects. However, studies conducted by researchers at CDC and elsewhere have shown no evidence of HIV transmission through insects—even in areas where there are many cases of AIDS and large populations of insects such as mosquitoes. Lack of such outbreaks, despite intense efforts to detect them, supports the conclusion that HIV is not transmitted by insects.

Effectiveness of Condoms

Condoms are classified as medical devices and are regulated by the Food and Drug Administration (FDA). Condom manufacturers in the United States test each latex condom for defects, including holes, before it is packaged. The proper and consistent use of latex or polyurethane (a type of plastic) condoms when engaging in sexual intercourse–vaginal, anal, or oral–can greatly reduce a person's risk of acquiring or transmitting sexually transmitted diseases, including HIV infection.

v Human Immunodeficiency Virus Type 2

In 1984, 3 years after the first reports of a disease that was to become known as AIDS, researchers discovered the primary causative viral agent, the human immunodeficiency virus 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. Studies of the natural history of HIV-2 are limited, but to date comparisons with HIV-1 show some similarities while suggesting differences. Both HIV-1 and HIV-2 have the same modes of transmission and are associated with similar opportunistic infections and AIDS. In persons infected with HIV-2, immunodeficiency seems to develop more slowly and to be milder. Compared with persons infected with HIV-1, those with HIV-2 are less infectious early in the course of infection. As the disease advances, HIV-2 infectiousness seems to increase; however, compared with HIV-1, the duration of this increased infectiousness is shorter. HIV-1 and HIV-2 also differ in geographic patterns of infection; the United States has few reported cases.

Which countries have a high prevalence of HIV-2 infection?

HIV-2 infections are predominantly found in Africa. West African nations with a prevalence of HIV-2 of more than 1% in the general population are Cape Verde, Côte d'Ivoire (Ivory Coast), Gambia, Guinea-Bissau, Mali, Mauritania Nigeria, and Sierra Leone. Other West African countries reporting HIV-2 are Benin, Burkina Faso, Ghana, Guinea, Liberia Niger, São Tomé, Senegal, and Togo. Angola and Mozambique are other African nations where the prevalence of HIV-2 is more than 1%.

What is known about HIV-2 in the United States?

The first case of HIV-2 infection in the United States was diagnosed in 1987. Since then, the Centers for Disease Control and Prevention (CDC) has worked with state and local health departments to collect demographic, clinical, and laboratory data on persons with HIV-2 infection.

Who should be tested for HIV-2?

Because epidemiologic data indicate that the prevalence of HIV-2 in the United States is very low, CDC does not recommend routine HIV-2 testing at U.S. HIV counseling and test sites or in settings other than blood centers. However when HIV testing is to be performed, tests for antibodies to both HIV-1 and HIV-2 should be obtained if demographic or behavioral information suggests that HIV-2 infection might be present.

Persons at risk for HIV-2 infection include

Are blood donors tested for HIV-2?

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 to both viruses. This testing has demonstrated that HIV-2 infection in blood donors is extremely rare. All donations detected with either HIV-1 or HIV-2 are excluded from any clinical use, and donors are deferred from further donations.

Is the clinical treatment of HIV-2 different from that of HIV-1?

Little is known about the best approach to the clinical treatment and care of patients infected with HIV-2. Given the slower development of immunodeficiency and the limited clinical experience with HIV-2, it is unclear whether antiretroviral therapy significantly slows progression. Not all of the drugs used to treat HIV-1 infection are as effective against HIV-2. In vitro (laboratory) studies suggest that nucleoside analogs are active against HIV-2, though not as active as against HIV-1. Protease inhibitors should be active against HIV-2. However, non-nucleoside reverse transcriptase inhibitors (NNRTIs) are not active against HIV-2. Whether any potential benefits would outweigh the possible adverse effects of treatment is unknown.

What is known about HIV-2 infection in children?

HIV-2 infection in children is rare. Compared with HIV-1, HIV-2 seems to be less transmissible from an infected mother to her child. However, cases of transmission from an infected woman to her fetus or newborn have been reported among women who had primary HIV-2 infection during their pregnancy.

How should physicians and patients decide whether to start treatment for HIV-2?

Physicians caring for patients with HIV-2 infection should decide whether to initiate antiretroviral therapy after discussing with their patients what is known, what is not known, and the possible adverse effects of treatment.

What can be done to control the spread of HIV-2?

Continued surveillance is needed to monitor HIV-2 in the U.S. population because the possibility for further spread of HIV-2 exists, especially among injecting drug users and people with multiple sex partners. Programs aimed at preventing the transmission of HIV-1 also can help to prevent and control the spread of HIV-2.

2.

Epidemiology and Natural History of HIV Infection

v Introduction

The successful introduction and spread of the human immunodeficiency virus (HIV) into the global human population has occurred for many reasons. The discovery and wide spread use of penicillin and other antibiotics meant that there was treatment and cure for most sexually transmitted diseases. The existence of these new drugs changed how people perceived risks associated with sexual activity. Soldiers in World War II increasingly used prophylactics and the subsequent development of hormonal contraceptives hastened the pace of change in sexual practices, as prevention of pregnancy became a real possibility. Lifestyles also were changing: people were moving into regions that were previously uninhabited by man and long distance travel became easier and was much more common, allowing for more social migration and sexual mixing. Although the virus may have first been introduced to humans earlier in the 20th century (most likely contracted from infected animals), it was in the 1970s that wider dissemination occurred.

For industrialized countries, the first evidence of the AIDS epidemic was among groups of individuals who shared a common exposure risk. In the United States, sexually active homosexual men were among the first to present with manifestations of HIV disease, followed by recipients of blood or blood products, then injection drug users, and ultimately children of mothers at risk.

Women have represented an increasing proportion of reported AIDS cases in the United States, accounting for 23% of adult cases from July 1998-June 1999. (CDC, 1999) Eighty percent of AIDS cases in women are in African Americans and Hispanics, as compared to 61% of cases in men.

In developing countries, the AIDS epidemic manifested itself quite differently, both because the signs and symptoms were harder to identify due to other competing causes of morbidity and mortality and because the epidemic did not seem to be limited to high-risk groups and, instead, was more generalized. Worldwide, women now represent 43% of all adults living with HIV and AIDS (Table 1-1, next page) and this proportion had been steadily increasing over time. (UNAIDS, 1998) This chapter reviews the epidemiology of HIV/AIDS: beginning with how HIV is transmitted and the variables involved; the natural history of HIV infection in women, both without treatment and in the era of highly active antiretroviral therapy (HAART); and concludes with future issues regarding the HIV/AIDS epidemic.

Source: UNAIDS and WHO (2001), AIDS Epidemic Update: December 2001 (Geneva, 2001), p. 3.

Notes: * The proportion of adults (15 to 49 years of age) living with HIV/AIDS in 2000, using 2001 population number. ** Hetero (heterosexual transmission), IDU (transmission through infecting drug use), MSM (sexual transmission among men who have sex with men).

v HIV Transmission

Epidemiological studies have demonstrated that HIV is transmitted by three primary routes: sexual, parenteral (blood-born), and perinatal. Virtually all cases of HIV transmission can be attributed to these exposure categories.

Transmission rates from the infected host to the uninfected recipient vary by both mode of transmission and the specific circumstances. Since HIV is a relatively large virus, has a short half-life in vitro, and can only live in primates, HIV cannot be transmitted from causal (i.e. hugging or shaking hands) or surface (i.e. toilet seats) contact or from insect bites.

Modes of Transmission

Sexual transmission of HIV from an infected partner to an uninfected partner can occur through male-to-female, female-to-male, male-to-male, and female-to-female sexual contact. Worldwide, sexual transmission of HIV is the predominant mode of transmission. (Quinn, 1996) Among U.S. women with AIDS, sexual transmission constitutes 40% of reported cases as of June 1999. (CDC, 1999) This 40% is probably an underestimate when you take into consideration that a large proportion of the women with AIDS who report no identifiable risk (an additional 15% of AIDS cases in women) are actually also infected via sexual transmission. While receptive rectal and vaginal intercourse appear to present the greatest risk of infection (approximately 0.13% and 0.10.2%, respectively, per episode), insertive intercourse (both rectal and vaginal) have also been associated with HIV infection (approximately 0.06% and 0.1%, respectively, per episode). (Vittinghoff, 1999; Mastro, 1996) In addition, there have been a few case reports of male-to-male transmission from receptive oral intercourse with an HIV-infected male partner (approximately 0.04% per contact) and female-to-female transmission from oral-vaginal, oral-anal, and digital intercourse. (Marmor, 1986; Monini, 1996; Monzon, 1987; Perry, 1989; Rich, 1993; Sabatini, 1983). Parenteral transmission of HIV has occurred in recipients of blood and blood products, either through transfusion (estimated 95% risk of infection from transfusion of a single unit of HIV-infected whole blood (CDC, 1998)) or clotting factors, in intravenous or injection drug users through the sharing of needles (approximately 0.67% risk per exposure (Kaplan, 1992)), and in healthcare workers through needle sticks (approximately 0.4% risk per exposure, depending on the size and location of the inoculum (Tokar, 1993)) and less commonly mucous membrane exposure. (Hessol, 1989) Among cumulatively reported AIDS cases in U.S. women through June 1999, 42% had injection drug use as their exposure risk and 3% receipt of blood, blood products, or tissue. (CDC, 1999) Parenteral transmission patterns vary by geographic region due to social and economic factors. For instance, in regions where the prevalence of HIV infection is higher, the risk of occupational or nosocomial transmission of HIV is increased over regions where there is lower prevalence. (Consten, 1995) The transmission risk is therefore related to the prevalence of HIV in the population as well as the frequency of exposure to infected body fluids and organs and the method of exposure. (Fraser, 1995) In addition, many developing countries that have a high prevalence of HIV infection also lack the resources to implement universal precautions adequately (Gilks, 1998) and may experience a greater amount of transfusion-associated HIV transmission due to a lack of HIV antibody screening in some areas, a higher residual risk of contamination in blood supplies despite antibody screening (McFarland, 1997), and high rates of transfusion in some groups of patients.

Factors Facilitating Transmission

Transmission of HIV infection can be influenced by several factors, including characteristics of the HIV-infected host, the recipient, and the quantity and infectivity of the virus. A summary of factors affecting sexual transmission of HIV is presented in Table 1-2.

Infectiousness of the Host

There is an association between the quantity of virus transmitted and the risk of HIV infection. (Roques, 1993) Several studies have found that HIV-infected persons may be more likely to transmit the infection when viral replication is high, both during the initial stage of infection (Palasanthiran, 1993) and at more advanced stages of HIV disease. (Laga 1989) People with high blood viral load are more likely to transmit HIV to recipients of blood, their sexual partners, and their offspring. (Vernazza, 1999; Quinn, 2000) HIV has been quantified in semen (Coombs, 1998; Speck, 1999; Vernazza, 1997) and detected in female genital secretions (Ghys, 1997; Mostad, 1998), and virus in these locations may facilitate transmission. However, the association between infectivity and disease stage is not absolute; HIV-infected women may transmit virus to a first-born child while not to a second-born child (deNartubim 1991), and temporal studies of semen from HIV-infected men demonstrate waxing and waning viral titers over time. (Krieger, 1991; Tindall, 1992) Factors that decrease viral titers, including anti-retroviral therapy, may decrease but not eliminate the risk of HIV transmission. (Hamed, 1993) Zidovudine has been shown to reduce vertical transmission from mothers to their fetus even when administered late in pregnancy or during labor. (CDC, 1998) (See Chapter VII on HIV and Reproduction) Individuals receiving antiretroviral therapy have also shown reduced transmission rates of HIV to their sex partners. (Musicco, 1994) Several studies have suggested that anti-retroviral treatment reduces detection of HIV in female genital secretions (Cu Uvin,1998) and the concentration of HIV in semen. (Gilliam, 1997; Gupta, 1997) Providers counseling patients on treatment should be clear that precautions to prevent transmission of the virus should be maintained since not all treatment reduce infectiousness and transmissions have been reported among individuals with undetectable HIV RNA levels. (The European Collaborative Study Group, 1999) Factors which increase the risk of exposure to blood, such as genital ulcer disease (Cameron, 1989; Plummer, 1991), trauma during sexual contact (Marmor, 1986), and menstruation of an HIV-infected woman during sexual contact (The European Collaborative Study Group, 1992; Nair, 1993; St. Louis, 1993) may all increase the risk of transmission.

Royce RA, Sena A, Cates W Jr, Cohen MS. Current concepts: sexual transmission of HIV. N Engl J Med. 1997;336:1072-1078. Copyright 1997. Massachusetts Medical Society. All rights reserved.

Susceptibility of the Recipient

Similarly, characteristics of the uninfected individual may increase the likelihood of infection for a given exposure to HIV. Specifically, inflammation or disruption of the genital or rectal mucosa (which can occur with sexually transmitted diseases and trauma), and lack of circumcision in heterosexual men may increase the risk of infection. (Cameron, 1989; Moses, 1994; Quinn, 2000) Sex during menstruation may increase womens risk of acquiring HIV infection (Lazzarin, 1991) as may bleeding during sexual intercourse. (Seidlin, 1993) In women, both uclerative and non-uclerative sexually transmitted diseases have been shown to be risk factors for getting infected with HIV. (Laga, 1993; Plummer, 1991) Cervical ectopy has been identified as a risk factor for acquisition of HIV infection in some (Nicolosi, 1994; Plourde, 1994) but not all (Mati, 1994) studies that have evaluated this condition. There is also some evidence that changes in the vaginal flora, as characterized by bacterial vaginosis, may facilitate acquisition of HIV. (Sewankambo, 1997) Non-barrier contraceptive methods have also been investigated in association with risk of HIV transmission but the results are inconclusive. The most frequently studied methods of contraception have been oral contraceptives, injectable hormones, intrauterine devices, and nonoxynol-9. (Daly, 1994; Plummer, 1998) (See Chapter III on Prevention) Traditional vaginal agents, used in African women for sexual enhancement and self-treatment of vaginal symptoms, has also been investigated as a potential cofactor for HIV transmission. (Dallabetta, 1995) For many of these studies, limitations of the study design preclude any definitive conclusions.

Viral Properties

Several viral factors have been proposed to play a role in the transmissibility of HIV. These include phenotypic characteristics (e.g., envelope proteins required for transmission), genetic factors that control the replicative capacity and fitness of the virus, and resistance to antiviral drugs. (Vernazza, 1999) Envelope sequences can define viral quasispecies that have been phenotypically arranged according to their ability to induce syncytia formation in infected T-cells. (Paxton, 1998) It appears that the most commonly transmitted phenotype is the non-syncytia-inducing (NSI), M-tropic viral strain, which is frequently found in those who have been recently infected. During the course of HIV infection the development of a more cytopathic, syncytia-inducing (SI), T-tropic viral phenotype can be found and this is often a precursor to the development of AIDS. While some researchers have suggested that NSI isolates of HIV are preferentially transmitted (Roos, 1992), others have not been able to show preferential transmission of this isolate. (Albert, 1995) Envelope sequences can also be used to define viral subtypes, or clades, and these subtypes may also influence the transmissibility of HIV. The distribution of HIV subtypes differ according to geographic region, with A, C, D, and E predominant in sub-Saharan Africa and Asia and B predominant in the United States, the Caribbean, South America, and Western Europe. (Hu, 1996) In one study, subtype E is reported to have greater tropism for Langerhans cells than subtype B (Soto-Ramirez, 1996) and may have a greater per contact transmissibility.

v Natural History and HIV Disease Progression

The natural history of HIV infection in adults has been extensively documented in the medical literature. The impact of gender on the manifestations and progression of HIV-disease is still being investigated. Concerns about gender-based differences in the course of HIV infection were expressed early in the epidemic. In most industrialized countries, women tended to have lower income, be un- or under-insured for health care, know less about HIV, more likely to be Black or Hispanic, and to have a personal or partner history of injection drug or cocaine use. Women also appeared to have more rapid progression of illness than men and to present with a different constellation of opportunistic conditions than men. When sophisticated statistical methods were applied that controlled for the tendency of women to receive less care and to present with more advanced disease, gender-based differences in HIV disease course appeared to lessen. More recently, however, with better measures of viral activity and infirmity, the issue of gender-based differences in rate of disease course and virologic parameters has again been raised. These new observations have prompted active research into the impact of gender, hormones and demographic factors on the outcome of HIV infection.

Staging

HIV can cause a wide range of symptoms and clinical conditions that reflect varying level of immunological injury and different predisposing factors. Certain conditions tend to occur in association with each other and at specific CD4 cell counts. Staging systems for HIV-disease facilitate clinical evaluation and planning therapeutic interventions, help determine the individual level of infirmity, and give prognostic information. Untreated HIV infection is a chronic illness that progresses through characteristic clinical stages that can be used to describe infirmity.

Several groups have produced organized staging systems to facilitate clinical evaluation and planning therapeutic interventions. In industrialized countries, the most widely used system for classifying HIV infection and AIDS in adults and adolescents was published by the United States Centers for Disease Control in 1993. (CDC, 1992) The case definition (Table 2-3) begins first with confirmation of HIV infection either via serologic testing (combination of a screening method such as enzyme immunoassay and more specific confirmatory test such as Western blot), or direct detection of HIV in patient tissue by viral culture, antigen detection or other test such as polymerase chain reaction (PCR). The definition of each stage of illness is then based on two types of information: peripheral blood CD4 cell counts and clinical manifestations. CD4 cell counts are placed in three strata, ranging from relatively normal (gt; 500 cells/mm³) to severe CD4 depletion (lt; 200 cells/mm³).

Developing World

The CDC criteria require diagnostic testing and case confirmation methods that may not be available in developing countries, so several other sets of criteria have been proposed for these regions. Since lymphocyte subset quantitation is not widely available in many countries, the Global Program on AIDS of the World Health Organization (W.H.O.) proposed a clinically based staging system that is more broadly applicable than the CDC system. (W.H.O., 1993) The system uses clinical historical data, laboratory measures (optional) and

indices of physical activity to assess level of infirmity to establish four strata that are summarized in Table 2-4. Laboratory measures include a single assessment absolute CD4 cell count, with the option of replacing this test with total lymphocyte count, each of which are placed in three strata. CD4 cell count is a better prognostic indicator than total lymphocyte count, but the two results correlate well. (Brettle, 1993)

Clinical history and functional measures are placed in four categories that range from asymptomatic to severe disease. In general, when compared with the CDC stages, the W.H.O. system requires less diagnostic test data and fewer direct observations. The definition includes broader categories for conditions that may vary by region (e.g., disseminated infections with endemic mycoses which are common in South East Asian AIDS patients but not in the United States or Europe). The inclusion of performance scale measures permits quantitative clinical assessment that is not dependent on laboratory resources.

Untreated Natural History

Primary or Acute Infection

Acute HIV infection is a transient symptomatic illness that can be identified in 40-90% of cases of new HIV infection. It is characterized by a high rate of HIV replication, high titers of virus in blood and lymphoid organs (up to several million copies of HIV RNA per mm³ of plasma), and initiation of an HIV-specific immune response. The amount of virus present in blood and tissues begins to fall after appearance of cytotoxic (killer) lymphocytes that specifically react with HIV antigens; the vigor of this response varies among individuals and is associated with subsequent rate of disease progression. (Cao, 1995) A pool of persistently infected CD4 cells (latent reservoirs) emerges early in the course of HIV infection and persists indefinitely. (Chun, 1998) Symptoms have been identified from 5-30 days after a recognized exposure to HIV. (Schacker, 1998) The signs and symptoms of acute HIV infection are not specific; fever, fatigue, rash, headache, lymphadenopathy, pharyngitis, mild gastrointestinal upset, night sweats, aseptic meningitis and oral ulcerations are most frequently reported. Because the clinical signs of acute HIV infection resemble those of many acute viral illnesses, the correct diagnosis is often missed. Because early treatment at the time of acute infection may be especially beneficial (See Chapter IV on Primary Medical Care), early suspicion of and evaluation for HIV infection should be encouraged. (Kahn, 1998)

Established Infection

Regardless of whether the syndrome of acute HIV infection is recognized or not, after the HIV-specific immunological response begins to control the intensity of viremia, a so-called viral set-point is established, which varies by individual. With exceedingly rare exceptions, the immunological response to HIV does not eliminate infection, but rather establishes a steady state between viral replication and elimination. (Henrad, 1995) A variable level of viremia is attained, which can be measured via quantification of the number of copies of HIV RNA present in blood (viral load). Although the viral load within the first 120 days of HIV infection is not of prognostic value (Schacker, 1998), in most patients a relatively stable viral load is attained after recovery from acute infection, and this viral set point is highly predictive of the rate of future progression of illness, at least as determined in studies that were largely focused on men. In the case of a high viral load set point (i.e. values ranging up from 40,000 copies per mm³) more rapid decline in CD4 cell counts and more rapid occurrence of Clinical Class B and C conditions will occur. Some individuals have viral load set points that are low (below 500 copies per mm³), which indicates a better prognosis; no evidence of progression (CD4 cell depletion or HIV-diseases) is seen for long periods of time in a small subset of patients (see section on long-term progression, below). The viral set point is likely influenced by several factors such as presence of other infections at the time of HIV exposure, genetic characteristics (particularly the type of HIV binding receptors present on lymphocytes) viral characteristics, age and perhaps gender (see below). (Kahn, 1998) During the period of clinical stability acute illnesses and other events that can stimulate the immune system, such as influenza, herpes simplex outbreaks, and tuberculosis as well as routine vaccinations, have been demonstrated to result in 10-1000 fold increases in viral load; these increases are transient and most often resolve within two months. (Stanley, 1996; Staprans, 1995) Thus, determination of viral load for prognostic purposes should not be done during or shortly after an acute illness.

Time Course

In most studies of seroconverters, (persons for whom the date of the HIV infection can be estimated), 5060% of adults will be diagnosed with an AIDS-defining condition within 10 years of infection (for the pre-HAART treatment era). Forty-eight percent of seroconverters die (due to any cause) after 10 years of infection. Increasing age is the factor most consistently associated with rate of progression and death in most groups of patients studied to date. (Alioum, 1998; UK Register of HIV Seroconverters Steering Committee, 1998; Pezzott, 1999; Prins, 1999) Date of infection also influences time from infection to an AIDS diagnosis, at least in some locations, demonstrating that even in the pre-HAART era, improvements in treatment resulted in tangible benefits. (Webber, 1998)

Laboratory Indicators and Predictors

A large number of laboratory tests have been evaluated as prognostic indicators in HIV infection. For the most part the tests can be divided into three groups: A. measures of HIV replication, B. measures of immune function and C. measures of inflammation. Group A is specific to HIV infection, Group B, when indicating severe CD4 cell depletion is relatively specific to HIV infection and Group C are generally not specific to HIV infection. Table 2-5, on the following page, summarizes these laboratory measures, outcomes, their advantages and disadvantages. HIV RNA quantitation performed on fresh or fresh-frozen plasma or serum, is a powerful and accurate prognostic indicator in HIV infection and is uniquely useful in determining response to antiretroviral therapy. (Saag, 1996) In general the best measures of prognosis and staging include combinations of HIV RNA level, CD4 cell count and perhaps lymphocyte function (cytotoxic lymphocyte response to HIV). (Spijkerman, 1997; Vlahov, 1998)

Long-Term Non-Progressors

In untreated adults the median time from HIV infection to AIDS in developed countries is 8- 10 years. However, approximately 8-15% of HIV infected persons (most studies focus on men) remain symptom free for much longer periods of time, a phenomenon that has been named long-term survival (LTS). Among these individuals who remain clinically stable without treatment for 5-8 years, two groups can be discerned, those who have stable CD4 cell counts and those who have low CD4 cell counts, but no AIDS defining conditions. (Schrager 1994) Several factors have been found to be associated with long-term survival including host characteristics such as the presence of specific anti-HIV cytotoxic lympho- cyte responses, and viral characteristics such as defective genes and gene products. (Kirchhoff, 1995) LTS patients tend to have consistently lower levels of HIV RNA after the period of acute infection suggesting better control of viral replication. (Vesanen, 1996) For example viral growth in peripheral mononuclear cells taken from LTS was markedly less than in PBMCs taken from healthy HIV-uninfected donors. (Cao, 1995)

Gender Effects

In general the predictors of the rate of HIV-disease progression and survival among women are the same as in men. CD4 cell count depletion and higher HIV RNA level are strong predictors of progression and survival in women. (Anastos 1996b) Several recent reports, however, describe gender-based differences in HIV RNA level and in rate of CD4 cell depletion; women had HIV RNA levels that were 30-50% lower than men who had comparable CD4 cell counts. (Bush, 1996; Evans, 1997; Farzadegan, 1998) Similar results occurred when analysis was restricted to seroconverters or when HIV culture was used to quantify viremia rather than RNA assays. ()Lyles, 1998; Sterling, 1999) Intuitively, lower levels of circulating HIV RNA, which suggest lower steady state level of viremia, should be associ- ated with better outcome. However, the findings of several recent studies suggest that the lower HIV RNA level does not provide benefit to women. Women experienced more rapid CD4 cell depletion and faster progression to AIDS and death than men at similar HIV-RNA levels, even when race and age were taken into consideration. (Anastos, 1999a; Farzadegan 1998) Determination of the effect of gender on the rate of progression, time until occurrence of an AIDS defining condition and death is a complicated process. Unless the date of HIV infection can be established, duration of infection becomes a significant unknown factor in studies. In addition, particularly in developed countries, HIV-infected women and men differ by more than just their gender. Women tend to have lower income, be members of minority ethnic groups, have been born in Africa, have used injection drugs or cocaine, or to have a sexual partner who has done so, all of which are risk factors for poor health in general. In most studies women have shorter duration of infection prior to AIDS and death than men, but these differences tend to disappear when CD4 cell count and drug use are taken into consideration. (Alioum, 1998; UK Register of HIV Seronconverters Steering Committee, 1998; Pezzotti, 1999; Santoro-Lopes 1998) Several studies have reported an excess proportion of infections or deaths due to bacterial infection, often pneumonia (Feldman, 1999), among women compared with men. (Melnich, 1994; Weisser, 1998) A summary of factors that influence disease progression is shown in Table 2-6.

Natural History in HAART Era

Industrialized Countries

In countries that are able to provide highly affective antiretroviral treatments (HAART), HIV-associated morbidity and mortality have declined significantly. (Michales, 1998; Miller, 1999a; Miller 1999b; Palella, 1998; Pezotti, 1999) (See Primary Medical Care in Chapter IV for more information). These population findings, based on regional surveillance systems, were preceded by a multitude of clinical trials that demonstrated clinical and virologic benefits of HAART. (Bartlett, 1996; Collier, 1996; Deeks, 1997; Hammer, 1997) Despite the promise and documented benefits of HAART clinical progression continues to occur among recipients, particularly among persons who received antiretroviral treatment prior to initiation of HAART. (Ledergerber, 1999) Viral resistance to HAART components can occur via several mechanisms, which for the most part involve mutation of viral target proteins. (Richman, 1996; Schapiro, 1999) The emergence of antiretroviral resistance is a function of several factors: prior treatment, pre-treatment level of viremia drug levels (adherence to medication regimens, bioavailability of medications, adequate dosing) and specifics of the regimen. (Guilick, 1998; Ledergerber, 1999; Shafer, 1998) Multiple daily doses, side effects and in some cases, dietary restrictions aggravate the problem of achieving optimal drug levels since protease inhibitor agents are relatively poorly bioavailable. Suppression of viral replication and prevention of resistance are directly related to level of antiretroviral drug. Persistent viral replication provides opportunity of occurrence of resistance mutations, and selective pressure to support continued presence of such mutants. (Condra, 1998; Feinberg, 1997; Wong, 1997) Besides clinical treatment failure, emergence of antiretroviral resistance is now associated with transmission of resistant virus to previously uninfected persons, a finding that could portend significant limits to the effectiveness of these treatments in populations over long periods of time. (Boden, 1999; Brodine, 1999; Yerly, 1999)

Developing Countries

The high cost of antiretroviral drugs and the need for clinical and laboratory services for monitoring response to and efficacy of these treatments has greatly restricted provision of HAART in the developing world. Thus the reductions in morbidity and gains in survival in HIV patients that have been demonstrated in many industrialized countries do not extend to developing countries in which the majority of HIV cases worldwide occur. A consensus statement regarding provision of these therapies has been released based on meetings held in Dakar and Abidjan during 1997. The key recommendations of conference participants include: efforts must be made to expand provision of ART, ART only makes sense in the setting of effective AIDS control programs, funding must be sustained to provide uninterrupted treatment and continuity of care, care providers must be trained in use of the treatments and basic patient rights resources for assessment of efficacy and tolerance must be available, sentinel monitoring for resistance pattern determination should be available, 3-drug combination regimens should be used when possible, treatment of pregnant women to prevent perinatal transmission must be a priority, and new drug development should focus on less costly medications. (International AIDS Society, 1999)

v Future Issues

Global Impact

The HIV/AIDS epidemic continues to spread without full control in any country. Over forty million people have been infected worldwide. By the end of 1998, the United Nations Program on AIDS (UNAIDS) estimated that 33.4 million people were living with HIV, a figure which includes 13.8 million adult women (UNAIDS, 1998) (Table 1-1, page 2). In 1998 it is estimated that 5.8 million new HIV infections occurred of with 2.1 million of these occurring in women. After steady increases of the prevalence of disease among women during the 1990s, currently 43% of all persons over the age of 15 years living with HIV are women. Globally, AIDS is now the fourth leading cause of mortality; 2.5 million deaths have been attributable to AIDS, of which 900,000 occurred in women. The notable improvements in AIDS mortality reported in North America and Europe, in association with the introduction of highly active combination antiretroviral therapies, do not extend to most of the worlds cases which occur in regions in which this expensive type of treatment is not available. More than 95% of HIV-infected people live in the developing world, most in Sub-Saharan Africa. Seventy percent of infections that occurred during 1998 took place in this epicenter. The region has also experienced 83% of all AIDS deaths. Unfortunately prior projections of the epidemic course in Southern Africa underestimated the incidence of infection by half. (Balter, 1998) Improved data have revealed that the prevalence rates in southern Africa are staggering: 20-26% of adults (aged 15-49 years) are infected; in some regions 20-50% of pregnant women are infected and are likely to transmit infection to 1/3 of their offspring. The declining mortality rate, and population growth taking place in other regions cannot be extended to Sub-Saharan Africa, due to the extent of AIDS mortality. (Bongaarts 1998) AIDS has now surpassed malaria as the leading cause of death in this region. (Balter, 1999) Life expectancy will fall from 64 to 47 years by 2015. AIDS will cost, on an average, 17 years of life expectancy in the 9 Sub-Saharan countries with a > 10% prevalence of HIV infection among adults. The child mortality rates in this region are also elevated by AIDS; rates are approximately double that expected without the HIV epidemic. (UNAIDS, 1998) Within one year 2,400 Zimbabweans will succumb to AIDS per week, many in the prime of life, many leaving dependent children as orphans (up to 1 in 5 children are likely to become orphans). The United States Surgeon General, David Satcher, notes that the progress of decades of work immunizing children, controlling diseases, and improving nutrition is being negated by HIV. (Satcher, 1999) In Asia, the epidemic has a mixed pattern that includes countries with slow growth in HIV prevalence, countries with some success in control efforts and regions that appear to be experiencing explosive epidemics. Currently 7 million Asians are infected with HIV. Rapidly accelerating epidemics are possible in China, Cambodia, Vietnam and India. While urban areas were initially of greatest concern in many countries, recent information has revealed very active epidemics in specific rural areas (up to 2% of the general population), which are hosts to large proportions of the regions population.

Containing the Epidemic

Control of the HIV epidemic should be a worldwide health priority. Complex interactions of social, economic and cultural factors have preceded AIDS with epidemics of other sexually transmitted diseases, and now hinder control of HIV itself. Global disparities in economic status have limited efforts to control sexually transmitted diseases that are much simpler to diagnose and treat than HIV. The effect of limited monetary resources are compounded by stigmatization of HIV and sexually transmitted diseases that effect willingness to seek care, social support of afflicted individuals and health policy decision making. Traditional cultural values regarding the role of women also tends to intensify the problems. Lack of acceptance of the right of women to make decisions about child bearing and work outside the home limit options for individuals who wish to reduce risk of infection via sexual exposures. Economic independence is a crucial factor enabling women to make some decisions themselves. The options for employment outside of sex work, for divorced or widowed women, in many societies are quite restricted. These fundamental values may directly conflict with efforts to empower women to avoid risk of HIV and other sexually transmitted diseases.

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116. Phoolchareon, W. HIV/AIDS prevention in Thailand: success and challenges. Science, 280: 1873-1874, 1998.
117. Planella, T, Cortes, M, Martinez-Bru, C, et al. The predictive value of several markers in the progression to acquired immunodeficiency syndrome. Clin Chem Lab Med, 36:169-173, 1998.
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v HIV/AIDS Among U.S. Women

HIV infection among U.S. women has increased significantly over the last decade, especially in communities of color. CDC estimates that, in the United States, between 120,000 and 160,000 adult and adolescent females are living with HIV infection, including those with AIDS.

Heterosexual 

Contact Now Is Greatest Risk for Women 

Sex with drug users plays large role In 1999 most women(40%)reported with AIDS were infected through heterosexual exposure to HIV, injection drug use accounted for 27%. In addition to the direct risks associated with drug injection (sharing needles), drug use also is fueling the heterosexual spread of the epidemic. A large proportion of women infected heterosexually were infected through sex with an injection drug user. Reducing the toll of the epidemic among women will require efforts to combat substance abuse, in addition to reducing HIV risk behaviors.

Many HIV/AIDS cases among women in the United States are initially reported without risk information, suggesting that women may be unaware of their partners' risk factors or that healthcare providers are not documenting their risk. Historically, more than two-thirds of AIDS cases among women initially reported without identified risk were later reclassified as heterosexual transmission, and just over one-fourth were attributed to injection drug use.

Prevention Needs of Women 

v HIV/AIDS Among African Americans

In the United States, the impact of HIV and AIDS in the African American community has been devastating. Through December 1999, CDC had received reports of 733,374 AIDS cases - of those, 272,881 cases occurred among African Americans. Representing only an estimated 12% of the total U.S. population, African Americans make up almost 37% of all AIDS cases reported in this country.

In 1999, more African Americans were reported with AIDS than any other racial/ethnic group

21,900 cases were reported among African Americans, representing nearly half (47%) of the 46,400 AIDS cases reported that year.

Prevention Efforts Must Focus on High-Risk Behaviors

Adult/Adolescent Men. Among African American men with AIDS, men who have sex with men (MSM) represent the largest proportion (37%) of reported cases since the epidemic began. The second most common exposure category for African American men is injection drug use (34%), and heterosexual exposure accounts for 8% of cumulative cases.

Adult/Adolescent Women. Among African American women, injection drug use has accounted for 42% of all AIDS case reports since the epidemic began, with 38% due to heterosexual contact.

Interrelated Prevention Challenges in African American Communities

Looking at select seroprevalence studies among high-risk populations gives an even clearer picture of why the epidemic continues to spread in communities of color. The data suggest that three interrelated issues play a role–the continued health disparities between economic classes, the challenges related to controlling substance abuse, and the intersection of substance abuse with the epidemic of HIV and other sexually transmitted diseases (STDs).

Substance abuse is fueling the sexual spread of HIV in the United States, especially in minority communities with high rates of STDs. Studies of HIV prevalence among patients in drug treatment centers and STD clinics find the rates of HIV infection among African Americans to be significantly higher than those among whites. Sharing needles and trading sex for drugs are two ways that substance abuse can lead to HIV and other STD transmission, putting sex partners and children of drug users at risk as well. Comprehensive programs for drug users must provide the information, skills and support necessary to reduce both injection-related and sexual risks. At the same time, HIV prevention and treatment substance abuse prevention, and sexually transmitted disease treatment and prevention services must be better integrated to take advantage of the multiple opportunities for intervention. Prevention efforts must be improved and sustained for young gay men. In a sample of young men who have sex with men (ages 15-22) in seven urban areas, researchers found that, overall, 7% were infected with HIV (range, 2%-12%). A significantly higher percentage of African American MSM (14%) than white MSM (3%) were infected. It is clear that the public sector alone cannot successfully combat HIV and AIDS in the African American community. Overcoming the current barriers to HIV prevention and treatment requires that local leaders acknowledge the severity of the continuing epidemic among African Americans and play an even greater role in combating HIV/AIDS in their own communities. Additionally, HIV prevention strategies known to be effective (both behavioral and biomedical) must be available and accessible for all populations at risk.

v HIV/AIDS Among Hispanics in the United States

The United States has a large and growing Hispanic population that is heavily affected by the HIV/AIDS epidemics. In 1999, Hispanics represented 13% of the U.S. population (including residents of Puerto Rico), but accounted for 19% of the total number of new U.S. AIDS cases reported that year (9,021 of 46,400 cases). The AIDS incidence rate per 100,000 population (the number of new cases of a disease that occur during a specific time period) among Hispanics in 1999 was 25.6, almost 3 times the rate for whites (7.6) but lower than the rate for African Americans (66.0).

Hispanics in the United States include a diverse mixture of ethnic groups and cultures. As shown in the chart at left, HIV exposure risks for U.S.-born Hispanics and Hispanics born in other countries vary greatly¹, indicating a need for specifically targeted prevention efforts.

Historical Trends in AIDS Cases Among U.S. Hispanics

Between 1992 and 1998, the number of persons living with AIDS increased in all groups, as a result of the 1993 expanded AIDS case definition and, more recently, improved survival among those who have benefited from the new combination drug therapies. During that 6-year period, the characteristics of persons living with AIDS were changing reflecting an expansion of the epidemic, particularly in minority populations. In 1992, 17% of those estimated to be living with AIDS were Hispanic, while in 1998, 19% were Hispanic. In comparison, non-Hispanic whites represented 49% of people estimated to be living with AIDS in 1992, but only 39% in 1998.

Proportion of U.S. AIDS Cases Reported in 1999 Among Selected Hispanics by Exposure Category and Place of Birth

U.S. Mexico Puerto Rico MSM 31% 50% 14% IDU 20% 7% 40% Heterosexual 13% 12% 25% From the beginning of the epidemic through December 1999, 107,867 Hispanic men have been reported with AIDS in the United States. Of these cases, men who have sex with men (MSM) represent 43%, injection drug users (IDUs) account for 36%, and 6% of cases were due to heterosexual contact. About 7% of cases were among Hispanic men who both had sex with men and injected drugs. Among men born in Puerto Rico, however, injection drug use accounts for a significantly higher proportion of cases than male-male sex.

Building Better Prevention Programs for Hispanics

While race and ethnicity alone are not risk factors for HIV infection, underlying social and economic conditions (such as language or cultural diversity, higher rates of poverty and substance abuse, or limited access to healthcare) may increase the risk for infection in some Hispanic American communities.

Epidemiology and Natural History of HIV Infection

v HIV/AIDS Among America's Youth

In the United States, HIV-related death has the greatest impact on young and middle-aged adults, particularly racial and ethnic minorities. In 1998, HIV was the fifth leading cause of death for Americans between the ages of 25 and 44. Among African American men in this age group, HIV infection has been the leading cause of death since 1991. In 1998 among black women 25-44 years old, HIV infection was the third leading cause of death. Many of these young adults likely were infected in their teens and twenties. It has been estimated that at least half of all new HIV infections in the United States are among people under 25, and the majority of young people are infected sexually.

Scientists believe that cases of HIV infection diagnosed among 13- to 24-year-olds are indicative of overall trends in HIV incidence (the number of new infections in a given time period, usually a year) because this age group has more recently initiated high-risk behaviors. Females made up nearly half (49%) of HIV cases in this age group reported from the 32 areas with confidential HIV reporting for adults and adolescents in 1999-and in young people between the ages of 13 and 19, a much greater proportion of HIV infections was reported among females (64%) than among males (36%). Cumulatively, young African Americans are

Improving HIV Prevention for Young People

CDC research has shown that early, clear communications between parents and young people about sex is an important step in helping adolescents adopt and maintain protective sexual behaviors. In addition, a wide range of activities must be implemented in communities to reduce the toll HIV infection and AIDS takes on young Americans.

v Healthcare Workers with HIV/AIDS

Of the adults reported with AIDS in the United States through June 30, 2000, 22,618 had been employed in health care. These cases represented 5.1 percent of the 445,380 AIDS cases reported to CDC for whom occupational information was known (information on employment in the healthcare setting was missing for 299,723 reported AIDS cases).

3.
HIV Testing  

v Overview for HIV Antibody Testing

Concerning HIV antibody testing remember: Counseling and early diagnosis are important to help prevent the spread of HIV.

Testing for HIV antibody is highly accurate. A repeatedly reactive screening test followed by a positive confirmatory test is necessary before a person is considered seropositive. Antibodies generally appear within 3 months after infection with HIV, but may take up to 6 months in some persons. Testing is recommended at 3 months and again at 6 months after exposure. An HIV-2 enzyme immunoassay or EIA was licensed by the US Food and Drug Administration in 1990. The Food and Drug Administration mandated that by June 1, 1992, U.S. blood centers must begin testing all blood donations for antibodies to HIV-2. Some blood banks and plasma centers began testing potential donors for HIV-2 prior to that date. The HIV-2 EIA should be available from your private physician or through state and local health departments. HIV-2 testing is indicated in persons with epidemiologic risk factors for HIV-2 infection. These include 1. sex and needle-sharing partners of West Africans, 2. persons who have received blood transfusions in West Africa, 3. children born to HIV-2-infected mothers, 4. persons with conditions suggestive of HIV infection (such as an AIDS-associated opportunistic disease) for whom HIV-1 testing is not positive, and 5. persons whose blood specimens are reactive on HIV-1 EIA testing and exhibit certain unusual indeterminate patterns on HIV-1 western blot.>

v Rapid HIV Tests: Questions/Answers  

General Questions

What has been the routine test for HIV antibody testing?

The standard screening test for antibody to HIV is the enzyme immunoasssay (EIA), which is widely used in the United States and around the world. This test requires serum or plasma, so a blood specimen must be drawn from a vein. Because EIA requires specialized equipment, the specimen must be sent to a laboratory, and test results are usually available several days to several weeks later. A negative screening test means a person is not infected with HIV, and does not require further testing. However, a diagnosis of HIV infection cannot be based on a reactive screening test alone. Thus a reactive EIA is repeated, and repeatedly reactive EIA results are confirmed by a supplemental HIV antibody test–Western blot or immunofluorescence assay (IFA).

What is rapid HIV testing?

A rapid test for detecting antibody to HIV is a screening test that produces very quick results, usually in 5 to 30 minutes. Only one rapid HIV test is licensed by the Food and Drug Administration (FDA) for use in the United States.

What is the difference between a rapid HIV test and an EIA?

The rapid HIV test is easier to use and produces results more quickly than the EIA does. The sensitivity and specificity of the rapid HIV test are just as good as those of the EIA.

What rapid HIV tests are available?

Currently, only one rapid HIV test is licensed by the FDA.

Will other rapid HIV tests be available in the future?

Several other rapid HIV tests are being used in many other countries. Still others, including one for use with oral fluids, are being developed. The new generation of rapid HIV tests may be quicker and easier to use.

Who can be tested with a rapid HIV test?

Rapid HIV testing is suitable for testing any person who would be eligible for HIV testing by EIA. However, the availability of rapid HIV tests may differ from one place to another. (See the list of resources at the end of these questions and answers.)

Does the rapid HIV test cost more than the EIA?

Yes. The individual kit is more costly then the per-test cost of the EIA. EIA testing was designed for the automated processing of tests in batches (usually using a plate that can process 96 specimens at one time.) However, an analysis done in 1996 by Dr. Paul Farnham and his colleagues at CDC indicated that rapid HIV testing is more cost-effective than the current EIA-based system, because of the number of persons who actually learn their results. In other words although EIA is less expensive, it is a waste of money to perform lab tests if the person tested never learns the test result, if two clinic visits are required to get test results, or if the clinic has to send field staff to locate people for test results. Since an EIA does not yield immediate results, most people must make a second visit to learn their results. Experience at publicly funded testing sites has shown that many persons (26% of those who tested positive for HIV and 33% of those who tested negative in 1996) do not return for their test results.

Can I expect to see rapid HIV testing in most clinics and doctors' offices soon?

Probably. It is difficult to know how soon this will take place.

Are rapid HIV tests more accurate or less accurate than EIAs?

The rapid HIV test is just as accurate as an EIA. As is true of all screening tests (including the EIA), a reactive rapid HIV test result must be confirmed. Studies in countries where more than one type of rapid HIV test is available show that specific combinations of two or more different rapid HIV tests can provide results as reliable as those from an EIA and Western blot or IFA, the combination that is currently used in the United States. A second rapid HIV test for persons whose first rapid HIV test is reactive could significantly improve the predictive value of rapid HIV testing.

What is predictive value?

Predictive value is the calculated probability that a test result predicts whether a person is truly infected. This calculation produces a number that counselors can use in explaining HIV test results to their clients. For example, a higher predictive value means that a reactive test is more likely to indicate the person is truly infected.

If a person receives a negative rapid HIV test result, is a confirmatory test needed?

A negative antibody test result, whether it is from a rapid HIV test or an EIA, does not require a confirmatory test. However, a person may have been tested too soon, before antibodies developed. The average time between infection and the development of detectable antibodies is 25 days.

Does a negative rapid HIV test result mean that a person has nothing to worry about?

Not necessarily. For most people who are tested, a negative HIV antibody test result does mean that they are not infected. However, in some cases a person may have been tested too soon (before antibodies have developed, which requires an average of 25 days). That is why it is important to assess specific risk behaviors during counseling, and discuss ways to change risky behaviors.

What is a reactive HIV test result?

The term reactive is used to describe a test that has detected the presence of antibodies to HIV. It is recommended that all reactive tests be repeated immediately, by using the same test. Repeatedly reactive tests are then further confirmed, by using a different test on the same blood specimen.

After a reactive rapid HIV test result, how long does a person have to wait for the confirmatory test result?

The confirmatory tests are usually sent to a laboratory for processing; results are generally available in 1 to 2 weeks.

v Questions–Technical, Counseling, and Implementation

What is the cost of a rapid HIV test?

Prices may be different in different parts of the country. The test kit usually costs $6 to $10, which is more expensive than an EIA. However, the EIA requires expensive equipment and rapid HIV tests do not. Additional costs such as a laboratory or a laboratory technician's time for conducting the tests should also be considered. Rapid HIV tests are simpler to perform and require fewer specialized skills than does an EIA.

If a confirmatory test is still needed, what is the advantage to sexually transmitted disease (STD) clinics of using rapid HIV testing?

The advantage to the clinic is that more people will receive their test results without expensive field visits. Most of the clients at all U.S. publicly funded testing sites, including STD clinics, test negative for HIV. For these persons (approximately 2.1 million in 1996), the need to make a second visit would be eliminated. Of all testing sites, STD clinics have had the lowest proportion of persons who return for HIV test results. Thus, rapid HIV tests have the potential to greatly increase the number of persons who learn their results. In addition, persons who test HIV-positive by the rapid HIV test can be advised immediately of their screening test result, and counseled about the need to take precautions to prevent the possibility of transmitting HIV. These persons of course need to return for their confirmatory test result.

What is the advantage to clients of using rapid HIV testing?

Interviews with persons being tested indicate that most persons prefer rapid HIV testing, and most persons who receive a positive HIV screening test result return on their own to learn the confirmed result (unlike the situation with current testing, in which many persons learn their test results only as a result of outreach). This also means that persons who are truly HIV-positive will learn of their infection sooner. This may help prevent infections that might otherwise have occurred between the time the person was tested and the time the person received results (sometimes as long as several weeks.)

Will people who have progressed to the late stages of AIDS continue to test positive on the rapid HIV tests?

Yes. The progression of HIV disease rarely affects the detection of HIV antibody.

Can rapid HIV tests be performed on infants?

The result of any HIV antibody test performed on an infant less than 15 months of age may reflect the mother's HIV status, because the antibodies are transferred from the mother to the baby. Until these antibodies disappear, only specific virus detection tests can determine the infection status of an infant.

Can clinic staff batch rapid HIV tests?

Yes. Batching, or collecting several specimens before testing all of them at the same time, can be done. This process can save money for a busy clinic, because fewer control test kits are required. However, accumulating a sufficient number of tests for a batch can result in excessive waiting time for the client, reducing the main benefit of the rapid HIV test: rapid results.

How long does the rapid HIV test take after the lab receives the specimen?

The rapid HIV test usually takes 15 to 30 minutes. The waiting time depends on how many clients are being tested and whether the clinic is testing individual samples or batching them. Counseling can be performed while the test is being done.

HIV Testing

What type of training will be available for HIV counselors at sites that use rapid HIV tests?

CDC is developing new guidance and training for counselors. (See the list of resources at the end of these questions and answers.)

Are educational materials (e.g., handouts, videos) available for the clinics that want to use rapid HIV tests?

CDC will assist counselors and others who plan to develop such products. The manufacturers of rapid HIV tests usually have such materials as well.

Would telephoning clients to provide the results of a positive confirmatory HIV test be acceptable?

Current CDC counseling and testing guidelines state that positive HIV results should be communicated by personal contact. Whether this personal contact is established by phone or in person is a decision to be made at the local level.

What does the counselor tell a client who has a reactive rapid HIV test?

One of the more challenging counseling issues is how to communicate reactive rapid HIV test results to clients without the benefit of a same-day confirmatory test result. Counselors should be able to discuss with the client the likelihood of whether the rapid HIV test result means the client has HIV infection. This discussion should be based on the prevalence of HIV among persons tested at that clinic coupled with an assessment of the client's risk behaviors. In clinics that usually experience a high prevalence of HIV infection among their clients, a reactive rapid HIV test result is more likely to represent a true infection, especially in persons who report risk behaviors for HIV. Any person whose rapid HIV test is reactive should be counseled about the need to take precautions to prevent any possibility of transmitting HIV infection until their infection status has been determined by a confirmatory 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?

Partner notification and referral services should not be initiated until the reactive rapid HIV test result has been confirmed.

Should a physician prescribe antiretroviral treatment for a pregnant woman on the basis of rapid HIV test results (per the PHS Guidelines)?

A negative rapid HIV test of course means that antiretroviral treatment is not necessary. Deciding what to do about therapy when the rapid HIV test is reactive is more complicated. If the circumstances are not urgent, it would be preferable to wait for the confirmatory test result. In other circumstances (such as a rapid HIV test result for a woman in labor, for whom no other result is available), physicians should base decisions about antiretroviral treatment on the predictive value of the preliminary rapid HIV test results and an assessment of the mother's HIV risk.

Are confirmatory tests necessary for a rapid HIV test result to be considered a diagnosis of HIV infection?

As is true of current EIA antibody procedure, an initial reactive rapid HIV test result should be confirmed by Western blot or IFA. For persons who test positive by confirmatory testing, CDC and the Association of State and Territorial Public Health Laboratory Directors recommend that the test sequence be repeated, by using a different sample, to be absolutely certain of the results.

Resources

For information on referrals to counseling and testing sites, contact

CDC National AIDS Hotline (English) 800-342-2437 (Spanish) 800-344-7432 (TTY) 800-243-7889 CDC Educator/Trainer Network — HIV Prevention Counseling Trainers and Counselors/p>

Sheila Cort Isoke, MPH CDC, National Center for HIV, STD, and TB Prevention (telephone) 404-639-0962 (fax) 404-639-0944 (e-mail) shc1@cdc.gov CDC-sponsored training for performing HIV testing

National Laboratory Training Network (telephone) 770-488-7811 CDC Division of HIV/AIDS Prevention Internet Homepage http://www.cdc.gov/nchstp/hiv–aids/dhap.htm<

v Understanding Viral Load

Introduction

Measurements of HIV- RNA blood levels (viral load) are increasingly being used by healthcare providers to determine when to start antiretroviral therapy and when to change current therapies. This test has become very important in the management of HIV infection because studies have shown that the level of virus in the blood is a predictor of disease progression. In other words, people with high levels of HIV-RNA in their blood, are more likely to rapidly progress to AIDS than people with low levels of the virus.

What is viral load and how is it measured?

Viral load or viral burden is the quantity of HIV-RNA (HIV virus) that is in the blood. RNA is the genetic material of HIV that contains the information needed to make more virus. Viral load tests measure the amount of HIV-RNA in a small amount of blood (one milliliter, ml).

Because the tests do not give exactly the same results, it is important to have the same type of viral load test done each time. This will give the physician a baseline measurement against which changes can be evaluated. Since the results of this test can vary greatly, they should be interpreted in the context of clinical management with an experienced physician.When should viral load be measured?

An Expert Panel for the International AIDS Society-USA (1) has issued guidelines indicating when viral load should be measured. The following is the Panel's timetable for testing: Take two different viral load measurements 2-3 weeks apart to determine a baseline measurement.

What prompts changes in viral load?

Changes in viral load are often reported as logarithmic or log changes. This mathematical term denotes a change in the value of what is being measured by a factor of 10. For example, if the baseline viral load by PCR were 20,000 copies/ml plasma, then a 1 log increase equals a 10-fold (10 times) increase or 200,000 copies/ml plasma. A 2 log increase equals 2,000,000 copies/ml plasma, or a 100-fold increase.

What does an undetectable level mean?

Many individuals now have an undetectable level of virus in their blood after taking combination therapy. Undetectable levels do not mean that the person is cured or no longer infectious. Undetectable levels mean that current tests are not sensitive enough to measure very low levels of virus in the blood, for example less than 400 copies/ml. There are experimental assays used in research which are more sensitive and can detect levels of virus as low as 20 copies/ml but they are not generally available in clinics and doctor's offices. Even if the measurement of virus is less than 20 copies/ml in the blood, HIV may be present and infectious in blood genital secretions (such as semen), lymph nodes, other lymphoid tissues, and elsewhere in the body. There are insufficient data to say that individuals with undetectable levels of virus are no longer infectious or no longer at risk of disease progression in the future. We simply do not know yet what an undetectable level of virus means over the long term. Individuals with undetectable levels of virus still need to be monitored by their healthcare providers regularly and they need to practice risk free behaviors.

Is there still a need to have CD4+ levels monitored?

Even with ongoing monitoring of viral load, it is important to monitor CD4+ levels. CD4+ levels provide information about the status of the immune system. Research has shown that when viral load is lowered, CD4+ levels usually increase. However, research is still ongoing to determine whether the increase in CD4+ levels represent normal, functioning immune cells. CD4+ levels continue to be used as the basis for deciding what type of opportunistic infection prophylaxis a patient should take. Some physicians feel decisions about prophylaxis should be based on the lowest CD4+ level recorded for a person. CD4+ cell levels are also used to measure response to antiretroviral treatment, although most regard viral load as more important indicator. In order to provide the physician with the best possible information about a patient's disease status, it is important to have routine viral load and CD4+ levels measured.

HIV/AIDS

4.
HIV Counseling

v HIV Counseling and Testing-Overview

Historical Perspective

Publicly funded HIV antibody counseling and testing services were initiated in March 1985 to provide an alternative to the donation of blood as a means for high-risk persons to determine their HIV status. At that time, little was known about the prevalence and natural history of HIV infection. Counseling was considered an essential adjunct to HIV testing. The counseling addressed the accuracy and consequences of the test and was designed to help persons interpret the meaning of positive or negative antibody results. HIV counseling was based on the recognition that learning HIV status may be difficult for some clients.

Since that time, public awareness about HIV infection has increased, and the reliability and predictive value of the HIV test have been proven. Investigations have demonstrated the benefit of early antiviral and prophylactic treatment for HIV infected persons. These HIV counseling standards and guidelines are the result of increased knowledge about HIV prevention and experience with HIV counseling. 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. Goals of HIV Counseling, Testing, and Referral Services

The current goals of HIV counseling are as follows: provide a convenient opportunity for persons to learn their current serostatus; allow such persons to receive prevention counseling to help initiate behavior change to prevent the transmission or acquisition of HIV; help persons obtain referrals to receive additional medical-care, preventive, psycho social, and other needed services; provide prevention services and referrals for sex and needle sharing partners of HIV- infected persons.

Objectives of HIV Counseling, Testing, and Referral Services

1. Identify persons who are unaware, uninformed, misin-formed, 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 infection 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 HIV 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 of HIV Counseling, Testing, and Referral Services

v HIV Prevention Case Management

HIV Prevention Case Management (PCM) is a one-on-one client service designed to assist both uninfected persons and those living with HIV. PCM provides intensive, individualized support and prevention counseling to assist persons to remain seronegative or to reduce the risk for HIV transmission to others by those who are seropositive. PCM is intended for persons who are having or who are likely to have difficulty initiating and sustaining safer behavior. The client's participation is always voluntary, and services are provided with the client's informed consent.

Staff Characteristics of the Prevention Case Manager

	Includes specific, measurable, realistic, and time-phased program objectives.
	Assures that all services in the plan conform to agency policies and local, State, and Federal laws (for example, confidentiality of information).
	Assures the development of a written, formal PCM protocol for service delivery.
	Provides for the development of specific, measurable, realistic, and time-phased objectives in each client's case plan.
	Provides for regular meetings with each client to assess changing needs, monitor progress, and revise the service plan accordingly.
	Assures that each case manager negotiates a risk reduction plan with the client, referring to the plan at each session in order to assess progress.
	Assures the development and use of a comprehensive HIV risk assessment instrument to assess the behavioral variables influencing the client's risk taking.
	Assures the development and use of a comprehensive psychosocial assessment instrument to assess psychosocial and medical service needs of the client as well as financial resources, language preferences, barriers to accessing these services, etc.
	Assures that prevention case managers and their supervisors meet frequently for case presentations and supervision.
	Defines collaboration with other local service providers through memoranda of agreement and regular meetings between agencies to facilitate access to other social and health services as well as to discuss and coordinate treatment plans for individual clients.
	Assures that the memoranda of understanding among agencies are periodically updated, accurately reflecting collaborative activities.
	Assures that the assessment of progress in meeting the case plan is communicated to the client for review and comment.
	Assures that case records include documentation that acknowledges voluntary client participation and mutually satisfactory case plans.
	Assures that an updated written or computerized database of service referrals and a system for documenting successful referrals are maintained.
	Assures that regularly scheduled staff meetings are held to discuss challenges, successes, and barriers encountered by case managers; adequate time must be allocated for staff to share concerns, frustrations, grief, and other emotions experienced through the close work with persons at risk or with persons living with HIV.

	Staff training in established PCM protocols, agency policies, and referral mechanisms.
	Periodic training addressing the local services available for client referral.
	Skills training to improve the HIV risk reduction counseling provided to clients.
	Training that addresses how to effectively intervene with clients who are in extreme states, such as persons who are combative, in emotional crisis, mentally ill, or under the influence of drugs and/or alcohol.

– Establish and/or improve the client's understanding of his/her HIV risk;

– Assess the client's readiness to adopt safer behaviors by identifying behavior changes the client has already implemented; and

– Negotiate a realistic and incremental plan for reducing risk.

	Assure the client that test results and other information he or she provides will remain confidential.
	Discuss anonymous testing options.
	Provide client-centered counseling to:
	Discuss clients history of HIV testing and results.
	Involve the client in an assessment to determine his or her behaviors which result in a risk of acquiring HIV infection.
	Tailor the counseling session to the behaviors, circumstances, and special needs of the client. Assist the client in recognizing those behaviors which put him or her at risk for HIV.
	Identify steps already taken by the client to reduce risk and provide positive reinforcement.
	Identify barriers/obstacles to the client's previous efforts to reduce risk.
	Determine one or two behavioral changes the client may be willing to make to reduce risk.
	Discuss the steps necessary to implement these changes.
	Address any difficulties the client anticipates in taking these steps.
	Respond to the client's concerns.
	Provide the client with necessary referrals and a written copy of the risk reduction plan (this plan should not include any personal identifiers).
	For clients who cannot read, a verbal summary should be provided. – Assist the client to arrive at an appropriate decision concerning HIV testing. – Obtain informed consent from the client prior to testing.
	Establish a plan with the client to receive test results.

	Document the risk assessment in the client's record for use during subsequent care.
	Document the risk reduction plan in the client's record.
	Ensure that the client understands the risks and benefits of knowing his or her HIV infection status.
	Discuss the client's expectations of test results.
	Discuss the client's plan to cope while waiting for test results.
	Explore with the client support systems that may be available.
	Ensure that the client understands what will happen during his or her visit to receive test results.
	Discuss the client's responsibility to disclose HIV infection status to sex/needle sharing partners.

	Discuss what the virus is and how it is transmitted.
	Assist the client to comprehend transmission of HIVand the delay between infection and development of a positive test
	Discuss what the test results mean and how they are used in medical management.

Discuss need for retest.

- Abstain from sex and injecting street drugs; enroll in a drug treatment program.

- Use condoms to prevent STDs and HIV transmission.

- Modify sexual practices to low or no risk behaviors.

- Limit the number of sex partners

. - Disinfect drug injecting equipment and avoid sharing paraphernalia.

- Limit the use of alcohol and other drugs.

- Obtain early diagnosis and treatment for STDs, when appropriate.

	Review risk reduction options with the client, for example:
	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:
	Explain authorized disclosures and antidiscrimination protection.

- Assess the client's readiness to receive HIV test results;

- Interpret the result for the client, based on his or her risk for HIV infection;

- Ensure that the client understands what the result means and address immediate emotional concerns; and

- Renegotiate or reinforce the existing plan for reducing risk considering the client's HIV status.

	Review available documentation including the risk assessment, prior to meeting with the client.
	Assure the client that test results and other information he or she provides will remain confidential.
	Provide HIV positive test results only by personal contact, assuring a confidential environment.
	Provide counseling at the time results are given to:
	Discuss with the client the need to appropriately disclose HIV status.
	Assess the client's need for subsequent counseling or medical services.
	Develop a plan to access necessary resources and appropriate referrals.
	For use during subsequent clinical care, document test results, risk reduction plan, and identified need for any resources and referrals in the client's chart.
	Ensure that confidentially tested HIV infected clients who do not return for results and counseling are provided appropriate follow-up. Document all follow-up. Exhaustive efforts should be made to ensure that confidentially tested HIV infected clients are offered their HIV test results and counseling.

– Limitations of test (i.e., time lag between infection and development of antibodies); and

	Ensure that the client understands what the test result means including:
	Identify any steps already taken by the client to reduce risk and provide positive reinforcement.
	Encourage the client to continue avoiding risk behaviors.
	Determine one or two behavioral changes the client may be willing to make to reduce risk and discuss steps to implement these changes.
	Assist the client in building skills to negotiate risk reduction activities with current or potential partners through discussion and role plays.
	Offer referral for further assistance in avoiding risk behaviors and maintaining low-risk behaviors.
	Discuss his/her need and ability to help partners realize they are also at risk for HIV infection.
	Reinforce the importance of discussing risk reduction measures with potential partners; identify any difficulties the client perceives.
	Advise client about importance of early STD detection and treatment to reduce HIV risk.
	Advise client to refrain from donating blood, plasma, and organs.
	Advise client on access to other prevention and treatment services (i.e., drug treatment, psychosocial support etc.)

– Identify necessary referrals and assist the client with contacting them, and

– Provide the client with written referral information.

	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.
	Ensure that the client understands what the test result means.
	Assess the client's immediate needs for medical, preventive, and psychosocial support. (e.g., financial personal, and other)
	Make the client aware of the need for additional medical evaluation and the availability of treatment.
	Establish a plan for continuing medical care and psychological support, including a subsequent prevention counseling session if necessary. As part of the plan, the counselor should:
	Reassess the client's risk for transmitting HIV infection.
	Help facilitate behavior change and/or reinforce behaviors that minimize or eliminate risk of transmission.
	Discuss with the client access and availability to ongoing prevention services including psychosocial and support services.
	Discuss with the client the responsibility to assure that sex and/or needle-sharing partners are counseled about their exposure to HIV and the need for them to seek medical evaluation.
	Assist the client in developing a plan which ensures that all partners are counseled about their exposure to HIV.
	Discuss how the client will notify other persons of his or her HIV status including future sex and needle-sharing partners, healthcare providers, and dental providers.
	Discuss with the client his or her specific plans for the next few days and ensure that the client has access to support systems during this time.
	Advise client to refrain from donating blood, plasma, and organs.

	Clients whose results are HIV positive may have specific medical questions.
	Considering the complexity of medical questions, responses should be left to clinicians to whom the client is referred, or to counselors or case managers with specific expertise in this area.
	Some clients may be at very high risk of transmitting the virus to others. Sites are encouraged to provide either on-site or through referral, additional prevention counseling (individual, couple, group, or peer), as appropriate to the needs of these clients. Counselors should appreciate the complexity of reproductive decision-making for HIV-infected women and must be familiar with the most recent Public Health Service recommendations on antiretroviral therapy to prevent vertical transmission.

– a biologic false positive test, or

– a truly positive test from a recent infection in which antibodies have not yet fully developed.

– arrange psychological referral to assist the client with coping while resolving the indeterminate test result,

– provide a hotline telephone number(s) as a referral option, and

– provide a subsequent counseling session or follow-up telephone call.

	Explain that the test result is inconclusive and may represent either:
	Schedule a repeat test approximately 6 weeks after the date of this inconclusive test.
	Emphasize that the client must take the same risk reduction precautions as persons testing HIV positive until the indeterminate finding is resolved.
	Assess the client's concerns and anxieties during the waiting period. If necessary,

	Assess the reasons the client requests repeat testing or continues risk behaviors.
	Emphasize that repeated testing for HIV will not prevent infection if the client continues to engage in risk behaviors.
	Arrange the specific services to meet the client's needs.
	Document all counseling activities, negotiated plans, and referrals in the client's record.

	Review previous risk assessment and risk reduction plan with client.
	Proceed with HIV counseling as outlined in the Section, HIV Prevention Counseling.
	Provide alternative counseling options (e.g. referral to community based group or individual counseling) to the client to further help him or her understand his or her recidivist risk behavior(s) and modify the behaviors accordingly.
	Acknowledge incremental behavior changes, reinforce those which have reduced risk, and document in the client's chart.
	Identify obstacles which the client encountered in adopting safe behaviors.
	Explain potentially negative impact of HIV reinfection or exposure to other STDs.

	Explain the continued risk of infecting sex and needle sharing partners
	> Negotiate a plan with the client to prevent HIV transmission.
	Identify resources and alternative counseling options to ensure that the client implements this plan and to reinforce the importance of practicing safer behaviors to protect himself or herself and others.
	Reinforce the importance of informing partners and making risk-reduction decisions with partners.
	Ensure that the client understands the adverse impact of STDs and drug use upon immune function.

	Arrange a repeat test approximately 6 weeks from the date of this current test;
	Assess the client's concerns and level of anxiety during the waiting period. If necessary, arrange psychological referral to assist the client in coping;
	Consider persons to be negative for antibodies to HIV if their Western Blot test results continue to be consistently indeterminate for at least 6 months in the absence of any known risk behaviors, clinical symptoms, or other findings (2);
	Encourage the client to follow guidelines outlined in the Notification of HIV Results and Prevention Counseling Section.

	Counsel the client on modes of HIV transmission and behaviors that place persons at risk for HIV;
	Counsel the client on unwarranted fears;
	Arrange referral for additional counseling for clients who continue to exhibit unfounded anxiety about HIV.

- For clients with no acknowledged risk for HIV, repeat the test.

- For clients with behavioral risk for HIV, arrange for medical referral and repeat test, if necessary.

	Assess why the client doubts the accuracy of the test results;
	Explain the process of multiple tests to confirm a positive result;
	Assist the client in recognizing behaviors that lead to HIV infection

– Any client who may be in need of support to maintain safer behaviors,

– HIV negative clients who continue to engage in risk behavior,

– HIV negative clients who continue to test but are without risk,

– HIV positive clients who continue to engage in risk behaviors, and

– HIV positive clients with additional medical, social, or psychological needs.

	Provide appropriate referral resources for:
	Provide the client with a written list of referrals including telephone numbers, addresses, hours of operation and services provided.
	Document referrals in the client's record.
	Referrals made during the initial HIV prevention counseling session should be followed-up during the test notification/prevention counseling session.

Guidelines __________________________________

	The counselor should: Offer referral to case management provider, if one is available;
	Seek feedback from the client about preferences for referrals, the accessibility of the referral, and the client's intention to follow through with the referral;
	Provide the client with relevant details about referral sites, e.g., the name of a specific contact person.

Special Note

Any HIV positive or negative client who continues to engage in risk behaviors should know where and how to access STD 11 examination and treatment services.

v Partner Notification for Preventing (HIV) Infection

Partner notification, a component of sexually transmitted disease (STD) control programs for many years , is a means to identify and target risk-reduction education to individuals at high risk for contracting or transmitting HIV infection. When applied to HIV infection, the term partner includes not only sex partners but also intravenous drug users who share needles. Partner notification for HIV infection or acquired immunodeficiency syndrome (AIDS), as for all STDs, is highly confidential and depends upon the voluntary cooperation of the patient. CDC currently recommends the following: 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 should use confidential procedures to assure that the partners are notified. Two complementary notification processes can be used to identify partners, patient referral and provider referral.

With patient referral, HIV-infected patients choose to inform their own partners directly of their risk of infection. Trained health department personnel can help instruct patients how to inform sex and needle- sharing partners sensitively about their potential risk for infection. With provider referral, infected patients request assistance in notifying some or all of their partners; they voluntarily provide names, descriptions, and addresses so that the notification process can be carried out by trained health department staff. This process is designed to protect the anonymity of patients; their names are never revealed to sex or needle-sharing partners. When the partner-notification model is applied to the control of HIV infection, certain differences must be considered. The incubation period for HIV is long; therefore, sex partners or needle-sharing partners from months or years earlier may potentially have been the sources of infection. Partner notification for patients with hepatitis B, which has an epidemiologic pattern similar to that of HIV infection, has proven difficult because of the prolonged period of infectivity, the large number of anonymous sex partners among many homosexual men, and the inaccessibility of the intravenous drug-using population.

The assurance of confidentiality and protection against discrimination, which are critical in dealing with any STD have become legal issues in the case of HIV infection. These issues may influence the success of programs based on patient referral alone. Confidentiality is essential to ensure that individuals at risk continue to seek counseling, testing, or partner-notification services.

Partner-notification data from several states reveal a high seroprevalence rate, ranging from 11% to 39%, among persons identified as sex or needle-sharing partners, many of whom are themselves engaging in high-risk behavior. By identifying such individuals, the partner-notification process can target risk-reduction messages to those at greatest risk of acquiring or transmitting infection. Thus, partner notification provides both primary and secondary prevention of HIV infection. Notification of unsuspecting partners is especially important because it enables persons who may not have been reached through other AIDS education programs to receive risk-reduction education. For example, the partner-notification process can identify female and male partners of intravenous drug users or female partners of bisexual males who may have been exposed to HIV infection but who may be unaware of their risk. Partner-notification activities targeted toward women of childbearing age contribute additionally by potentially preventing the perinatal transmission of HIV. Homosexual men who voluntarily request counseling and HIV testing may be at lower risk for infection than those who have refused testing. Through the partner-notification process, these high-risk partners who otherwise might not request risk-reduction education can receive counseling. Also, counseling of partners provides an opportunity to offer other beneficial services to those at risk, including drug treatment, STD treatment, tuberculosis testing and treatment, adult immunizations, psychosocial support services, and contraceptive counseling. The type of partner-notification services provided by different health departments will depend on local resources and the number of seropositive persons identified. In San Francisco, which has high rates of infection among homosexual men, provider referral for all partners of homosexual men was not thought to be feasible because of the excessive cost and personnel required. However, the San Francisco Health Department did notify heterosexual sex partners of AIDS patients and received excellent cooperation from both patients and named partners.

Terms

ABSTINENCE: Refraining from participating in something. When talking about HIV, abstinence refers to not engaging in sexual intercourse or injecting drugs.

AIDS: The acronym for acquired immunodeficiency syndrome. AIDS can affect the immune and central nervous systems and can result in neurological problems, infections, or cancers. It is caused by HIV.

Anal Sex: A type of sexual intercourse in which a man's penis enters his partner's anus.

Anonymous: Without any identification. The term is used in regard to HIV testing when the persons ordering and performing the test do not maintain a record of the name or identity of the person whose blood they are testing.

Antibodies: Proteins that are manufactured by the immune system in response to foreign substances. Antibody Test: A laboratory procedure which detects antibodies to specific microorganisms. An HIV antibody test determines if a person's body has produced antibodies to HIV but does not detect the virus itself.

Antidiscrimination Protection: Provisions of laws that impose penalties for discrimination because of a person's HIV infection or perceived risk of infection.

ANTIVIRAL: Pertaining to something that inhibits the actions of a virus. Antiviral therapy refers to a treatment that works against the virus itself.

ANUS: The opening of the body through which feces or bowel movements pass. The anus is the part of the body which is penetrated during anal sex.

APPROPRIATE DISCLOSURE: Notifying specific people of a client's HIV risks or infection to other people because of their risk of exposure or their ability to provide medical assistance or support.

ASYMPTOMATIC: Being infected but having no symptoms of infection.

BISEXUAL: A person whose sex partners are both men and women. A bisexual can be a man or a woman.

CD4 TESTING: A laboratory blood test that counts a subset of white blood cells as an aid to determining immune function. Certain counts are indications for starting medications for persons with HIV infection.

CLIENT: A person to whom professional services are rendered.

CLIENT-CENTERED APPROACH: Refers to counseling conducted in an interactive manner responsive to individual client needs. Avoids a preconceived set of points to be made by the counselor and encourages the client to do most of the talking. Focuses on developing goals with the client rather than simply providing information or imposing counselor goals.

CONDOM: Commonly called rubbers, condoms are sheaths that fit over a man's penis or into a woman's vagina to prevent semen from entering the partner's body after ejaculation. Condoms also prevent a man's penis from coming in contact with his partner's body fluids.

CONFIDENTIAL: Kept private. In regard to HIV testing, it means that the results of a test are known only to the person who is being tested and the immediate group of people who provide care and prevention services for that person.

COUNSELING: Helping people plan actions that will benefit themselves or others. Unless designated as group counseling or couple counseling, the word is used here to describe one-on-one discussions.

DISCORDANT: Conflicting. Used to describe the circumstances in which one partner is infected with HIV and the other is not.

EIA: See ELISA.

EARLY INTERVENTION: The set of medical, preventive and psychosocial services provided to persons upon diagnosis of HIV infection. Involves monitoring indicators of immune function as signals to provide interventions to delay the onset of illness, psychosocial support, and measures to prevent transmission.

ELISA: Acronym for enzyme-linked immunosorbent assay. The laboratory test most commonly used to screen for antibodies to HIV. See Positive Test.

FALSE-NEGATIVE: A negative test result for a person who is actually infected.

FALSE-POSITIVE: A positive test result for a person who is actually not infected.

HETEROSEXUAL: A person whose sex partners are exclusively persons of the opposite sex.

HIV: Human immunodeficiency virus; the virus that causes AIDS.

HOMOSEXUAL: A person whose sex partners are exclusively members of the same sex. A homosexual man is called a gay man. A homosexual woman is called a lesbian.

IMMUNE STATUS: The state of the body's natural ability to fight diseases.

IMMUNE SYSTEM: The body's mechanism to identify and fight off infections and other foreign substances.

INJECTED DRUGS: Drugs that are introduced directly into a person's body or bloodstream through a needle. These include cocaine, crack, heroin, and steroids.

INDETERMINATE: Not determined one way or another. Inconclusive test results; the laboratory is unable to state whether antibody is present or not.

INTERVENTION: An action taken to change an outcome.

MASTURBATION: Stimulating a man's penis or a woman's clitoris. MONOGAMOUS: Having an exclusive sexual relationship with only one partner. Mutual monogamy means neither partner has sex with other people.

MORBIDITY: Illness or disease.

MORTALITY: Death.

NEGOTIATED RISK

REDUCTION PLAN: Discussions that result in identifying the steps that a client thinks he or she will take to reduce the chances of acquiring HIV. The counselor's role is to assist the client in developing a realistic plan.

OUTREACH SERVICES: Usually refers to services provided outside the walls of an agency. An outreach worker might go to a client's home or neighborhood.

PARENTERAL: Taken into the body through intravenous or intramuscular injection.

PHLEBOTOMY: Collecting a blood sample for laboratory testing by inserting a needle into a person's vein.

POSITIVE REINFORCEMENT: Acknowledging healthy behaviors or intentions through some mechanism that indicates approval intended to be perceived as rewarding.

POSITIVE TEST: For HIV, a sample of blood that is reactive on an initial ELISA test, repeatedly reactive on a second

ELISA run on the same specimen, and confirmed positive on Western blot or other supplemental test. PREVALENCE: The total number of persons in a given population with a disease or condition at a given point in time.

PREVENTION COUNSELING: Counseling which is designed to facilitate the client's perception of risk, identify behavior changes that the client has already implemented and barriers to the client's previous efforts to reduce risk, and to assist the client in developing a plan to reduce risk regardless of whether or not he or she takes the test. Prevention counseling that takes place prior to HIV testing should prepare the client for receiving and managing his or her test results.

PROBLEM-SOLVING TECHNIQUES: A process by which a counselor tries to discover the basis of barriers indicated by some verbal or nonverbal communication from the client. After the barriers have been identified, possible solutions are discussed.

PROPHYLACTIC TREATMENT: Medications given to help prevent infection or its consequences.

PROBLEM-SOLVING TECHNIQUES: A process by which a counselor tries to discover the basis of barriers indicated by some verbal or nonverbal communication from the client. After the barriers have been identified, possible solutions are discussed.

PROPHYLACTIC TREATMENT: Medications given to help prevent infection or its consequences. RETROVIRUS: One of a group of RNA viruses. HIV is a retrovirus.

RISK ASSESSMENT: Used in this document, risk assessment is that portion of a client-centered discussion that encourages the client to identify and acknowledge his or her personal risk for acquiring HIV.

SENSITIVITY: The probability that a test will be positive when infection is present.

SPECIFICITY: The probability that a test will be negative when the infection is not present.

SPERMICIDE: A substance that kills sperm.

TRIAGE ASSESSMENT: The process that determines whether someone should be referred to counseling. Triage assessment facilitates prevention counseling services for those persons at increased risk for HIV.

WESTERN BLOT: A laboratory test that detects specific antibodies to components of a virus. Often used to confirm HIV antibodies in specimens found repeatedly reactive using the ELISA test for HIV antibodies.

5.
Sex and HIV Prevention

v Prevention and Treatment of Sexually Transmitted Diseases as an HIV Prevention Strategy

The interconnectedness of HIV and other sexually transmitted diseases (STDs) grows increasingly apparent as biomedical and behavioral scientists learn more about people's susceptibility and risks. CDC is applying new research to the prevention of all major STDs, including HIV infection, and is working to ensure communities have the information they need to design, implement, and evaluate comprehensive approaches to HIV and STD prevention.

The Parallel Epidemics of HIV Infection and Other STDs

Globally, an estimated 333 million new cases of curable STDs occur each year among adults, according to 1995 estimates by the World Health Organization. STDs in the United States have reached epidemic proportions with an estimated 12 million new cases each year. Of these, 3 million occur among teenagers, 13 to 19 years old. STDs are the most common reportable diseases in the United States.

The sexual spread of HIV in the United States has paralleled that of other STDs. For example, the geographic distribution of heterosexual HIV transmission closely parallels that of other STDs. Most of the health districts with the highest syphilis and gonorrhea rates in the United States are concentrated in the South, the same part of the nation with the highest HIV prevalence among childbearing women. Researchers have long recognized that the risk behaviors which place individuals at risk for other STDs also increase a person's risk of becoming infected with HIV. STD surveillance can provide important indications of where HIV infection may spread, and where efforts to promote safer sexual behaviors should be targeted.

Other STDs Facilitate HIV Transmission

There is now strong evidence that other STDs increase the risk of HIV transmission and, conversely, that STD treatment reduces the spread of HIV.

Epidemiological studies: Studies have repeatedly demonstrated that people are 2-5 times more likely to become infected with HIV when other STDs are present. Biological studies: Biological studies suggest both increased susceptibility to HIV infection and increased likelihood of infecting other people when other STDs are present. a) Increased susceptibility–STDs that cause genital lesions can create a portal of entry for HIV. And even without lesions, STDs increase the number of HIV target cells (CD4 cells) in cervical secretions, thereby likely increasing HIV susceptibility in women. b) Increased infectiousness–Studies have demonstrated that co-infection with HIV and other STDs results both in more shedding of HIV and in greater concentrations of HIV being shed. For example, in African studies, co-infection with gonorrhea and HIV more than doubles the proportion of HIV-infected individuals with HIV RNA detectable in genital secretions. Furthermore, the median concentration of HIV RNA in semen is dramatically increased in co-infected men compared with men infected with HIV alone.

New Evidence of the Effectiveness of STD Treatment in HIV Prevention

Intervention studies: New evidence indicates that STD detection and treatment can substantially reduce HIV transmission. For example: a) STD treatment reduces the prevalence and magnitude of HIV shedding–Treatment of gonorrhea in HIV-infected men resulted in a reduction in the number of men who shed HIV, as well as a lower concentration of HIV shed. With STD treatment, the level of shedding among co-infected men returns to the level seen in men who are not co-infected.

b) STD treatment reduces the spread of HIV infection in communities– A community-level, randomized trial in a rural African community in Tanzania demonstrated a 42% decrease in new, heterosexually transmitted HIV infections in communities with improved STD treatment. An ongoing study in Uganda is further exploring the impact of mass STD treatment in slowing the spread of HIV. These studies will be critical in more clearly defining the role STD treatment can play in HIV prevention efforts in the developing world and in industrialized nations.

v Condoms and Their Use in Preventing HIV Infection and Other STDs

With nearly 1 million Americans infected with HIV, most of them through sexual transmission, and an estimated 15 million cases of other sexually transmitted diseases (STDs) occurring each year in the United States, effective strategies for preventing these diseases are critical. Refraining from having sexual intercourse with an infected partner is the best way to prevent transmission of HIV and other STDs. But for those who have sexual intercourse, latex condoms are highly effective when used consistently and correctly.

Condoms are effective in preventing HIV and other STDs

The correct and consistent use of latex condoms during sexual intercourse- vaginal, anal, or oral-can greatly reduce a person' s risk of acquiring or transmitting most STDs, including HIV infection, gonorrhea, chlamydia, trichomonas human papilloma virus infection (HPV), and hepatitis B. Protecting yourself and others against STDs is important because many of these diseases have serious complications. Protecting yourself and others against HIV is important because it is life threatening and has no cure.

Laboratory studies show that latex condoms are effective barriers to HIV and other STDs. In addition, several studies provide compelling evidence that latex condoms are highly effective in protecting against HIV infection when used for every act of intercourse. This protection is most evident from studies of couples in which one member is infected with HIV and the other is not, i.e., discordant couples. 

In a 2-year study of discordant couples in Europe, among 124 couples who reported consistent use of latex condoms none of the uninfected partners became infected. In contrast, among the 121 couples who used condoms inconsistently, 12 (10%) of the uninfected partners became infected. In another study, among a group of 134 discordant couples who did not use condoms at all or did not use them consistently, 16 partners (12%) became infected. This contrasts markedly with infections occurring in only 3 partners (2%) of the 171 couples in this study who reported consistently using condoms over the 2-year period. Similarly, in a recent study among discordant couples in Haiti, 1 of 42 uninfected partners (2%) became infected with consistent condom use and 19 of 135 who used condoms inconsistently (14%) became infected. 

Condoms are classified as medical devices and are regulated by the Food and Drug Administration (FDA). Every latex condom manufactured in the United States is tested for defects before it is packaged. During the manufacturing process, condoms are double-dipped in latex and tested electronically for holes. Several studies clearly show that condom breakage rates in this country are less than 2%. Most of the breakage and slippage likely is due to incorrect use rather than poor condom quality. Using oil-based lubricants can weaken latex, causing the condom to break. In addition, condoms can be weakened by exposure to heat or sunlight or by age, or they can be torn by teeth or fingernails. Studies also indicate that condoms slip off the penis in about 1-5% of acts of vaginal intercourse and slip down (but not off) about 3-13% of the time. 

Some persons have expressed concern about studies that report higher failure rates among couples using condoms for pregnancy prevention. Analysis of these studies indicates that the large range of efficacy rates is related to incorrect or inconsistent use. In fact, latex condoms are highly effective for pregnancy prevention, but only when they are used properly. Research indicates that only 30-60% of men who claim to use condoms for contraception actually use them for every act of intercourse. Further, even people who use condoms every time may not use them correctly from start to finish. Incorrect use contributes to the possibility that the condom could leak at the base or break.

Condoms must be used consistently and correctly to provide maximum protection

As mentioned previously, the primary reason that condoms sometimes fail to prevent HIV/STD infection or pregnancy is incorrect or inconsistent use, not failure of the condom itself. Consistent use means using a condom with each act of intercourse. Correct condom use includes all of the following steps: 

	Use a new condom for each act of vaginal, anal, or oral intercourse. Water-based lubricants
	Use the condom throughout sex–from start to finish.
	Put on the condom as soon as erection occurs and before any vaginal, anal, or oral contact with the penis. Hold the tip of the condom and unroll it onto the erect penis, leaving space at the tip of the condom, yet ensuring that no air is trapped in the condom' s tip.
	Adequate lubrication is important to prevent condom breakage, but use only water-based lubricants, such as glycerine or lubricating jellies (which can be purchased at any pharmacy). Do not use oil-based lubricants such as petroleum jelly, cold cream, hand lotion, or baby oil, which can weaken the condom.

Condoms and latex sheets

	Ongoing studies show that both HIV prevalence (the proportion of people living with HIV in a population) and risk behaviors remain high among young MSM. In a sample of MSM 15-22 years old in seven urban counties, CDC researchers found that, overall, 7% already were infected with HIV. Higher percentages of African Americans (14%) and Hispanics (7%) were infected than were whites (3%).
	In the 32 states with confidential HIV reporting, data show that substantial numbers of MSM still are being infected, especially young men. In 1999, 46% of reported HIV infections among adolescent males aged 13-19 and 51% of cases among men aged 20-24 were attributed to male-to-male sexual contact.
	Research among gay and bisexual men suggests that some individuals are now less concerned about becoming infected than in the past and may be inclined to take more risks. This is backed up by reported increases in gonorrhea among gay men in several large U.S. cities between 1993 and 1996. Despite medical advances, HIV remains a serious usually fatal disease that requires complex, costly, and difficult treatment regimens that do not work for everyone. As better treatment options are developed, we must not lose sight of the fact that preventing HIV infection in the first place precludes the need for people to undergo these difficult and expensive therapies.

Although female-to-female transmission of HIV apparently is rare, female sexual contact should be considered a possible means of transmission among WSW. These women need to know:  

	that exposure of a mucous membrane, such as the mouth, (especially nonintact tissue) to vaginal secretions and menstrual blood is potentially infectious, particularly during early and late-stage HIV infection when the amount of virus in the blood is expected to be highest.
	that condoms should be used consistently and correctly each and every time for sexual contact with men or when using sex toys. Sex toys should not be shared. No barrier methods for use during oral sex have been evaluated as effective or approved by the FDA. However, women can use dental dams, cut-open condoms, or plastic wrap to help protect themselves from contact with body fluids during oral sex.
	their own and their partner's HIV status. This knowledge can help uninfected women begin and maintain behavioral changes that reduce their risk of becoming infected. For women who are found to be infected, it can assist in getting early treatment and avoiding infecting others.

Health professionals also need to remember:  

	that sexual identity does not necessarily predict behavior, and that women who identify as lesbian may be at risk for HIV through unprotected sex with men.
	that prevention interventions targeting WSW must address behaviors that put WSW at risk for HIV infection including injection drug use and unprotected vaginal-penile intercourse.

References

	substance abuse treatment to reduce or eliminate drug injection;
	the use of sterile syringes to reduce the spread of blood-borne infections;
	the use of new, ideally, sterile water and equipment to prepare drugs; and
	adequate disinfection of the injection site by drug users to prevent local infection and endocarditis.

	The pathogen involved
	The type of exposure
	The amount of blood involved in the exposure
	The amount of virus in the patient's blood at the time of exposure

1. Immediately following an exposure to blood:

	Wash needlesticks and cuts with soap and water u Flush splashes to the nose, mouth, or skin with water
	Irrigate eyes with clean water, saline, or sterile irrigants No scientific evidence shows that using antiseptics or squeezing the wound will reduce the risk of transmission of a bloodborne pathogen. Using a caustic agent such as bleach is not recommended.

2. Following any blood exposure you should:

Report the exposure to the department (e.g., occupational health, infection control) responsible for managing exposures. Prompt reporting is essential because, in some cases, postexposure treatment may be recommended and it should be started as soon as possible. Discuss the possible risks of acquiring HBV, HCV, and HIV and the need for postexposure treatment with the provider managing your exposure. You should have already received hepatitis B vaccine, which is extremely safe and effective in preventing HBV infection.

The risk after exposure of the skin to HlV-infected blood is estimated to be less than 0.1%. A small amount of blood on intact skin probably poses no risk at all. There have been no documented cases of HIV transmission due to an exposure involving a small amount of blood on intact skin (a few drops of blood on skin for a short period of time). The risk may be higher if the skin is dam-aged (for example, by a recent cut) or if the contact involves a large area of skin or is prolonged (for example, being covered in blood for hours).

	Whether the source individual is positive for hepatitis B surface antigen.
	Whether you have been vaccinated.
	Whether the vaccine provided you immunity. HCV There is no vaccine against hepatitis C, and no treatment after an exposure that will prevent infection. Immune globulin is not recommended. For these reasons, following recommended infection control practices is imperative.

	A community planning process to ensure efforts are directed to communities at greatest risk
	Epidemiologic and behavioral surveillance to effectively guide prevention efforts
	Voluntary HIV counseling, testing, referral, and partner counseling to provide a pathway to needed prevention and treatment services
	Health education and risk-reduction activities, including individual-, group-, and community-level programs to provide the skills and support necessary for reducing risks
	Accessible diagnosis and treatment of other sexually transmitted diseases to decrease risk of HIV transmission
	School-based prevention efforts for youth to provide young people the skills and support they need to keep from initiating risky behaviors and to adopt healthy ones
	Public information programs to ensure that knowledge and awareness of how to prevent HIV remain high
	Training and quality assurance to provide those implementing programs needed skills
	Laboratory support to keep pace with diagnostic and testing services and related research efforts
	HIV prevention capacity-building activities to support organizations in expanding their abilities to implement effective programs
	An HIV prevention technical assistance assessment and plan to ensure that programs keep pace with prevention technologies
	Evaluation of major program activities, interventions, and servicesto ensure efforts are effective

Partner counseling. CDC considers voluntary, confidential notification of potentially exposed partners to be an essential component of a comprehensive HIV prevention program. Partner counseling is a primary prevention service with the following objectives:  

	To provide prevention information to people who are at very high risk of becoming HIV infected, but who may be unaware of or misunderstand their risks
	To assist these individuals in obtaining HIV prevention counseling and voluntary testing, and referral
	To provide access to partners who are already infected to prevention and treatment services that can improve their health and quality of life

Partner counseling services can be provided in both anonymous and confidential testing sites. For areas lacking the resources to perform partner counseling services themselves, CDC recommends they provide the necessary training to conduct these services for physicians or hospitals that provide HIV counseling and testing.

Preventing the spread of HIV through injection drug use requires a comprehensive approach that incorporates several basic principles:  

	ensure coordination and collaboration among all providers of services to IDUs, their sex partners, and their children,
	ensure coverage, access to, and quality of interventions,
	recognize and overcome stigma associated with injection drug use, and
	tailor services and programs to the diverse populations and characteristics of IDUs.

Strategies for prevention should include:

	preventing initiation of drug injection,
	using community outreach programs to reach drug users on the streets
	improving access to high quality substance abuse treatment programs,
	instituting HIV prevention programs in jails and prisons,
	providing healthcare for HIV-infected IDUs, and
	making HIV risk-reduction counseling and testing available for IDUs and their sex partners.

	Between 1992 and 1997, perinatally acquired AIDS cases declined 66% in the United States.
	A study conducted in four states (Michigan, New Jersey, Louisiana, and South Carolina) found that the proportion of pregnant women voluntarily tested for HIV increased from 68% in 1993 to 79% in 1996. The percentage of women offered AZT increased from 27% in 1993 to 85% in 1996. However, the study also found that 15% of HIV-infected pregnant women in these states did not receive prenatal care and therefore could not be offered this intervention.
	Among women in CDC's Perinatal AIDS Collaborative Transmission Study (PACTS), AZT use increased following the publication of PHS guidelines, and the rate of perinatal transmission dropped from 21% to 11%. The PACTS study includes women from four cities -New York City, Newark, Atlanta, and Baltimore.
	Prenatal care that includes HIV counseling and testing and AZT treatment for infected mothers and their children saves lives and resources. Without intervention, a 25% mother-to-infant transmission rate would result in the birth of an estimated 1,750 HIV-infected infants annually in the United States, with lifetime medical costs of $282 million.
	The estimated annual cost of perinatal prevention in the United States is $67.6 million. This investment prevents 656 HIV infections and saves $105.6 million in medical care costs alone a net cost-savings of $38.1 million annually.

Perinatal HIV prevention activities must help ensure that all HIV-infected women are reached early in pregnancy with prenatal care and with the opportunity to learn their HIV status. If infected, they should be offered preventive therapy to improve the chances that their children will be born free of infection and to ensure quality HIV care and treatment for mothers and their babies. Achieving this goal will required increased access to and use of prenatal care.

Women who use drugs during pregnancy are the least likely to get prenatal care. Increased efforts are needed at all levels (community, state, national) to integrate substance abuse and HIV prevention activities and assist pregnant women in accessing needed services to improve their own health and the health of their babies.

	high-risk drug use–sharing blood-contaminated syringes and injection paraphernalia such as water, cookers, and cottons
	high-risk sex–unprotected sex, sex with many partners, failure to treat STDs

	most drug users cannot stop using without it
	treatment prevents transmission because it helps users reduce drug- and sex-related risk behaviors
	it has major positive effects on a user's life
	treatment is cost effective
	providers can reach IDUs with other messages and interventions during treatment
	society benefits from reduced drug use and associated crime

	it reaches IDUs who don't participate in conventional service systems
	it provides services in settings that are familiar to IDUs
	outreach interventions help create a culture of risk reduction in the community, which helps to reinforce prevention messages
	peers, who are often used in community out-reach, are likely to be trusted by IDUs
	it's relatively low cost

	the U.S. Public Health Service and other agencies and institutions recommend consistent, one-time only use of sterile syringes obtained from a reliable source as a central risk reduction strategy for IDUs who cannot or will not stop injecting
	the use of a sterile syringe every time helps ensure that IDUs who continue to inject will not acquire or transmit infection
	existing laws, regulations, and public and pharmacists' attitudes hamper IDUs' ability to btain and safely dispose of syringes and therefore promote multiperson use of syringes access to sterile syringes does not increase drug use or attract new people to drug use
	ensuring access to sterile syringes involves working with pharmacists; addressing existing syringe laws and regulations; and syringe exchange programs

	many IDUs are in jail or prison because of their drug use
	inmates have disproportionately high rates of HIV infection, STDs, and hepatitis
	high-risk sex and drug-use behavior occurs in jails and prisons
	interventions benefit inmates and the communities to which almost all will return

	IDUs are an important source of sexual transmission of HIV and hepatitis B
	high-risk drug use and sex behaviors are often linked

	they allow IDUs to find out whether they are infected with HIV
	they allow infected IDUs access to counseling and medical care and other services
	they help infected IDUs inform sex and drug-use partners
	they help public health officials follow the chains of transmission and reach those at high risk
	they help uninfected but high-risk IDUs reduce their risk behaviors

	they can help infected IDUs reduce high-risk drug and sex behaviors
	IDUs should have access to comprehensive and quality health care HIV disease management is complex and long-term, requiring close monitoring infected
	IDUs who receive substance abuse treatment and other health services are more likely to comply with medication regimens

	preventing first use of alcohol, marijuana, inhalants, and other drugs among youth can
	reduce the risk that they will go on to use injection drugs
	preventing injection drug use eliminates injection-related blood-borne virus transmission
	preventing alcohol and drug use and associated crime and injuries benefits society

	While the number of AIDS cases is declining, the number of people living with HIV infection is growing. This increased prevalence of HIV in the population means that even more prevention efforts are needed, not fewer. For individuals at risk, increased prevalence means that each risk behavior carries an increased risk for infection. This makes the danger of relaxing preventive behaviors greater than ever.
	Past prevention efforts have resulted in behavior change for many individuals and have helped slow the epidemic overall. However, many studies find that high-risk behaviors, especially unprotected sex, are continuing at far too high a rate. This is true even for some people who have been counseled and tested for HIV, including those found to be infected.
	The long-term effectiveness of HAART is unknown. Further, HIV may develop resistance to these drugs. The powerful treatments are complicated and involve taking large numbers of pills. Even the most motivated patients may forget to take all their medications or skip doses. Some patients have been known to take drug holidays, completely stopping their medications for a number of days or weeks. These drug treatments are less effective when treatment schedules are not followed. Diversions from the prescribed treatment regimen increase the possibility of drug resistance developing, which would greatly narrow future treatment options for those infected with a drug-resistant strain of HIV. And, if the development of drug-resistance is coupled with a relaxation in preventive behaviors resistant strains could be transmitted to others and spread widely.
	Research among gay and bisexual men suggests that some individuals are less concerned about becoming infected than in the past and may be inclined to take more risks. This may be equally true in other groups at risk who might believe they no longer need to use condoms because protease inhibitors are so effective in treating HIV disease. The truth is, despite medical advances, HIV remains a serious and usually fatal disease that requires complex, costly, and difficult treatment regimens. These treatments don't work for everyone. Sometimes when they do work, they have unpleasant or intolerable side effects. Some people can't take them because the interaction with their other drugs causes serious problems. Still others find it extremely difficult to maintain the drug treatment schedules. As we continue working to develop better treatment options, we must not lose sight of the fact that preventing HIV infectionin the first place precludes the need for people to follow these difficult regimens.

Until recently, AIDS cases provided a reliable picture of trends in the HIV epidemic. Before highly effective treatments were available, researchers could take into account the time between HIV infection and progression to AIDS and estimate where and how many new infections were occurring based on observed cases of disease. Today, trends in AIDS cases and deaths may provide a valuable measure of groups for whom highly effective treatment is not available or has not succeeded. However, they no longer tell us enough about where and how many new infections are occurring - information critical for addressing the increasing need for prevention and treatment services. To allow the U.S. to target programs and resources most effectively, we must be able to keep pace with where the epidemic is going. This means we need to improve our ability to track early HIV infections, before they progress to AIDS.

	Many studies indicate that prevention programs can contribute to changes in personal behavior that reduce risks of infection, and these changes are sustained over time. A 1997 scientific consensus conference sponsored by the National Institutes of Health that reviewed existing data on the effectiveness of HIV behavioral interventions concluded that behavioral interventions to reduce risk for HIV/AIDS are effective and should be disseminated widely.
	Comprehensive school-based HIV and sex education programs have been shown to delay the initiation of sexual intercourse, reduce the frequency of intercourse, reduce the number of sex partners, or increase the use of condoms or other contraceptives.
	Efforts to reduce risks of injection drug users through policy changes also have been evaluated and found to be very effective. For example, both New York and Connecticut reported significant reductions in the sharing of drug injection equipment after implementation of programs and policies that increased access to sterile injection equipment.
	Perinatal prevention programs that identify and treat pregnant women who are HIV infected have shown dramatic success in reducing HIV transmission to their babies.
	Screening the blood supply for HIV and heat-treating blood products for the treatment of hemophilia have nearly eliminated HIV transmission through these early transmission routes.
	Postexposure prophylaxis for healthcare workers has shown some success in reducing HIV transmission rates among those with occupational exposure to HIV-infected blood.
	Numerous HIV prevention programs have been shown to be cost-effective when compared against the resources required to treat and deliver HIV medical care to a person over the remaining years of their life. With the rising costs of lifetime treatment of HIV, effective prevention has become even more cost effective. New CDC estimates find that if only 1,255 infections are prevented each year, CDC's federally funded HIV prevention efforts in the United States are cost effective. If only 3,995 infections are prevented, our nation's investment in HIV prevention has actually saved money.

	People with HIV risk behaviors need an array of prevention messages, skills, and support to help them reduce sexual and drug-related risks. Drug injectors, for example, not only need strategies to help them stop using drugs or sharing needles, but also need to learn ways to protect themselves from sexual transmission if their partner has ever injected drugs and may have shared needles.
	Substance use is a major problem in this country, and the intersection of substance use and sexual HIV transmission cannot be overlooked. Ideally, everyone who abuses any drug (including alcohol) should be offered counseling and treatment to help them stop using drugs and prevent HIV infection. HIV prevention interventions for the vast majority of substance users who are not in treatment also must address the sexual risks that are common among people who use drugs, including crack cocaine, marijuana, and alcohol.
	Each and every generation of young people needs comprehensive, sustained health information and interventions that help them develop life-long skills for avoiding behaviors that could lead to HIV infection. Such comprehensive programs should include the involvement of parents as well as educators. The most effective programs start at an early age and are designed to encourage the adoption of healthy behaviors, such as exercising and eating a healthy diet, and to prevent the initiation of unhealthy ones, such as drug use, excessive alcohol consumption, smoking, and premature sexual activity, before they start.
	Scientific studies show that treatment of other sexually transmitted diseases can greatly reduce the risk of transmitting and acquiring HIV.

	Primary HIVprevention means keeping people from becoming infected with HIV in the first place. Interventions must focus not only on uninfected populations - there also is a major role for preventing further infections by focusing on infected individuals and helping them develop skills for reducing the risk of infecting others.
	Secondary HIV prevention means keeping people who already are HIV-infected safe and healthy by helping them avoid opportunistic infections and stopping the infection from progressing to AIDS.
	In all prevention efforts, there is a growing need to address the link between HIV treatment and prevention. In some cases, such as preventing perinatal transmission to infants by providing antiretroviral drugs to the mother treatment is prevention. We also know that the treatment of other STDs can greatly reduce a person's risk for sexually acquired HIV infection. And, scientists even now are exploring the possibility that combination drug therapies may reduce infectivity. With the lines between prevention and treatment beginning to fade, ongoing services for people who are HIV positive must balance medical advances with the behavioral and social support needed to preserve their quality of life and prevent the spread of infection.
	We must maintain a focus on behavioral strategies. Even a vaccine doesn't stop a disease unless people use it – and in the case of HIV, a vaccine is unlikely to confer 100% lifelong immunity. Because no medical advance can succeed on its own, people must adapt their behaviors to work in tandem with it. To do this, they need several things:
	Access to prevention services and new medical treatments. For example, pregnant women who may not know they are infected with HIV cannot reduce the risk of transmission to their children unless they first get prenatal care that includes routine HIV counseling and voluntary testing. Those found to be infected then must have access to antiretroviral drugs.
	Assistance in developing skills to use new medical treatments. HAART, for example, involves complex treatment regimens and may require the development of compliance-related skills. For example, people may need to learn how to deal with side effects, what drug interactions might occur, how to lessen the risk of developing drug resistance or how to cope with complicated schedules.
	Support and encouragement from family, friends, care providers, and the community at large will help people make and sustain behavioral changes in their lives.

	Tuberculosis (TB) is caused by a germ called Mycobacterium tuberculosis.
	TB is spread through the air. You need to have close contact with a person who has TB to get it.
	Get tested for TB as soon as possible after learning you have HIV. Go to your doctor or your health department for a skin test for TB. n You can take medicines to prevent and to treat TB.

Your symptoms depend on where in your body the TB germs are growing. TB germs usually grow in the lungs. TB in the lungs may cause:  

	bad cough that lasts longer than 3 weeks
	pain in the chest
	coughing up blood or phlegm from deep inside the lungs

Other symptoms are:  

	weakness or fatigue
	weight loss
	no appetite
	chills
	fever
	sweating at night

Does TB affect only the lungs?

	What is HIV and how did I get it?
	What is the difference between HIV and AIDS?/li>
	How can I stay healthy longer?/li>
	How do I protect other people from my HIV?/li>
	Where can I find help in fighting HIV?

	Make sure you have a doctor who knows how to treat HIV.
	Follow your doctor's instructions. Keep your appointments. Your doctor may prescribe medicine for you. Take the medicine just the way he or she tells you to because taking only some of your medicine gives your HIV infection more chance to fight back. If you get sick from your medicine, call your doctor for advice–don't change how you take your medicine on your own or because of advice from friends.
	Get immunizations (shots) to prevent infections such as pneumonia and flu.Your doctor will tell you when to get these shots.
	If you smoke or if you use drugs not prescribed by your doctor, quit.
	Eat healthy foods. This will help keep you strong, keep your energy and weight up, and help your body protect itself.
	Exercise regularly to stay strong and fit.

	Get enough sleep and rest.
	Take time to relax. Many people find prayer or meditation, along with exercise and rest, helps them cope with the stress of having HIV infection or AIDS.

	MAC (mycobacterium avium [my-ko-bak-TEER-i-um a-VEE-i-um] complex)
	CMV (cytomegalovirus [si-to-MEG-eh-lo-vi-res])
	TB (tuberculosis [too-burr-qu-LO-sis])
	toxo (toxoplasmosis [tok-so-plaz-MO-sis])
	crypto (cryptosporidiosis [krip-to-spo-rid-e-O-sis])

	breathing problems
	mouth problems, such as thrush (white spots), sores, change in taste,
	dryness, trouble swallowing, or loose teeth
	fever for more than two days
	weight loss
	poor vision or floaters(moving lines or spots in your vision)
	diarrhea

	Don't have unprotected sex–sex without a condom. Abstinence–not having sex–is the best way to protect other people. If you have sex, use a new latex condom (rubber) each and every time.
	If you use a lubricant, use a water-based lubricant. You should not use new petroleum-based jelly, cold cream baby oil, or other oils because they can weaken a condom and it may break.
	If you are allergic to latex, you can use polyurethane (a type of plastic) condoms.
	If male condoms are not available, use female condoms.
	If you choose to use a spermicide (a cream, foam, or gel used to kill sperm) use it as the instructions say. You can use condoms with or without spermicide.
	For oral sex, use protection such as a condom, dental dam (a square piece of latex used by dentists), or plastic food wrap. Do not reuse these items.
	Keep sex toys for your own use only and don't use someone else's sex toys.
	Don't share drug needles or drug works. In many places there are needle exchange programs. Use them. Better yet seek help if you inject drugs.You can fight HIV much better if you don't have a drug habit.
	Tell people you've had sex with that you have HIV. This will not be easy, but it will help them get the help they need. Your local public health department may help you find these people and tell them they have been exposed to HIV. If they have HIV, this may help them get care and avoid spreading HIV to others.
	If a woman you had sex with is pregnant, even if you are not the father, it is very important that you tell her you have HIV. If she has HIV, she needs to get early medical care for her own health and to protect her baby.
	Don't donate blood, plasma, or organs.
	Keep razors or toothbrushes for your own use only and don't use someone else's razor or toothbrush. HIV can be spread through fresh blood on such items.

	What birth control methods are best for me?
	Will HIV cause problems for me during pregnancy or delivery?
	Will my baby have HIV?
	Will treatment for my HIV infection cause problems for my baby?
	If I am pregnant and want an abortion, where can I go for it? What if they won't help me because I have HIV?
	If I choose to get pregnant, what medical and community programs and support groups can help me and my baby?

	answers to your questions about HIV and AIDS
	doctors, insurance, and help in making healthcare decisions
	food, housing, and transportation
	planning to meet financial and daily needs
	support groups for you and your loved ones
	home nursing care
	help in legal matters, including Americans with Disabilities Act (ADA) claims
	confidential help in applying for Social Security disability benefits

You also can get information on these things from the CDC National AIDS Hotline at (800) 342-2437. Many people living with HIV feel better if they can talk with other people who also have HIV. Here are some ways to find others with HIV:  

	Contact your local AIDS service organization. Look under AIDS or Social Service Organizations in the yellow pages of your telephone book.
	Contact a local hospital, church, or American Red Cross chapter for referrals.
	Read HIV newsletters or magazines.
	Join support groups or Internet forums.
	Volunteer to help others with HIV.
	Be an HIV educator or public speaker, or work on a newsletter.
	Attend social events to meet other people who have HIV.

Thousands of people are living with HIV, and AIDS, today. Many are leading full, happy, and productive lives. You can too if you work with your doctor and others and take the steps outlined in this booklet to stay healthy.

v Safe Food and Water: A Guide for People With HIV Infection

	Cook all meat and poultry until they are no longer pink in the middle. If you use a meat thermometer, the temperature inside the meat or poultry should be over 165° F. Fish should be cooked until it is flaky, not rubbery.
	After handling raw meat, poultry, and fish, wash your hands well with soap and water before you touch any other food.
	Thoroughly wash cutting boards, cooking utensils, and countertops with soap and hot water after they have had contact with raw meat, poultry, or fish.
	Do not let uncooked meat, poultry, or fish or their juices touch other food or each other.
	Do not let meat, poultry, or fish sit at room temperature for more than a few minutes. Keep them in the refrigerator until you are ready to cook them.
	Eat or drink only pasteurized milk or dairy products.

	Don't drink water straight from lakes, rivers, streams, or springs.
	Because you cannot be sure if your tap water is safe, you may wish to avoid tap water, including water or ice from a refrigerator ice-maker, which is made with tap water. Always check with the local health department and water utility to see if they have issued any special notices for people with HIV about tap water.
	You may also wish to boil or filter your water, or to drink bottled water. Processed carbonated (bubbly) drinks in cans or bottles should be safe, but drinks made at a fountain might not be because they are made with tap water. If you choose to boil or filter your water or to drink only bottled water, do this all the time, not just at home. Boiling is the best way to kill germs in your water. Heat your water at a rolling boil for 1 minute. After the boiled water cools, put it in a clean bottle or pitcher with a lid and store it in the refrigerator. Use the water for drinking, cooking, or making ice. Water bottles and ice trays should be cleaned with soap and water before use. Don't touch the inside of them after cleaning. If you can, clean your water bottles and ice trays yourself.

	Read food labels carefully. Be sure that all dairy products that you purchase have been pasteurized. Do not buy any food that contains raw or undercooked meat or eggs if it is meant to be eaten raw. Be sure that the sell by date has not passed.
	Put packaged meat, poultry, or fish in separate plastic bags to prevent their juices from dripping onto other groceries or each other.
	Check the package that the food comes in to make sure that it isn't damaged.
	Do not buy food that has been displayed in unsafe or unclean conditions.Examples include meat that is allowed to sit without refrigeration or cooked shrimp that is displayed with raw shrimp.
	After shopping, put all cold and frozen foods into your refrigerator or freezer as soon as you can. Do not leave food sitting in the car. Keeping cold or frozen food out of refrigeration for even a couple of hours can give germs a chance to grow.

Yes. Like grocery stores, restaurants follow guidelines for cleanliness and good hygiene set by the health department. However, you should follow these general rules in restaurants:  

	Order all food well done. If meat is served pink or bloody, send it back to the kitchen for more cooking. Fish should be flaky, not rubbery, when you cut it.
	Order fried eggs cooked on both sides. Avoid eggs that are sunny-side up. Scrambled eggs should be cooked until they are not runny. Do not order foods that may contain raw eggs, such as Caesar salad or hollandaise sauce. If you aren't sure about the ingredients in a dish, ask your waiter before you order.
	Do not order any raw or lightly steamed fish or shellfish, such as oysters, clams, mussels, sushi, or sashimi. All fish should be cooked until done.

Should I take special measures with food and water in other countries?

Yes. Not all countries have high standards of food hygiene. You need to take special care abroad, particularly in developing countries. Follow these rules when in other countries:  

	Do not eat uncooked fruits and vegetables unless you can peel them. Avoid salads.
	Eat cooked foods while they are still hot.
	Boil all water before drinking it. Use only ice made from boiled water. Drink only canned or bottled drinks or beverages made with boiled water.
	Steaming-hot foods, fruits you peel yourself, bottled and canned processed drinks, and hot coffee or tea should be safe.

Talk with your healthcare provider about other advice on travel abroad.

v Caring for Someone with AIDS at Home

The most common ways HIV is spread are:  

	By having unprotected anal, vaginal, or oral sex with one who is infected with HIV
	By sharing needles or syringes (works) with someone who is infected with HIV
	From mothers to their babies before the baby is born, during birth, or through breast-feeding. Taking the drug AZT during pregnancy can reduce the chances of infecting the baby by two-thirds, but will not prevent all babies from becoming infected with HIV.

Earlier in the AIDS epidemic some people became infected through blood transfusions, blood products (such as clotting factors given to people with hemophilia), or organ or tissue transplants. This has been very rare in the United States since 1985, when the test for HIV was licensed. Since then, all donated blood and donors of organs or tissue are tested for HIV. Health care workers, such as nurses, risk getting infected if they are stuck with a needle containing infected blood or splashed with infected blood in the eyes, nose, mouth, or on open cuts or sores. In a few cases, a person sharing a house with a person with HIV infection or taking care of a person with AIDS has become infected themselves. These infections may have been caused by sharing a razor, getting blood from the infected person into open cuts or sores, or some other way of having contact with blood from the infected person. If you are taking care of a person with HIV infection, carefully follow the steps on protecting yourself from infection discussed later.

How HIV is Not Spread

Watch for any changes in health or the way the child acts. If you notice anything unusual for that child, let the doctor know. For a child with AIDS, little problems can become big problems very quickly. Watch for breathing problems, fever, unusual sleepiness, diarrhea, or changes in how much they eat. Talk to the child's doctor about what else to look for and when to report it.

	Talk to the doctor before the child gets any immunizations (including oral polio vaccine) or booster shots. Some vaccines could make the child sick. No child with HIV or anyone in the household should ever take oral polio vaccine.
	Stuffed and furry toys can hold dirt and might hide germs that can make the child sick. Plastic and washable toys are better. If the child has any stuffed toys, wash them in a washing machine often and keep them as clean as possible.
	Keep the child away from litter boxes and sandboxes that a pet or other animal might have been in.
	Ask the child's doctor what to do about pets that might be in the house.
	Try to keep the child from getting infectious diseases, especially chickenpox. If the child with HIV infection gets near somebody with chickenpox, tell the child's doctor right away. Chickenpox can kill a child with AIDS.
	Bandage any cuts or scrapes quickly and completely after washing with soap and warm water. Use gloves if the child is bleeding.
	Taking care of a child who is sick is very hard for people who love that child. You will need help and emotional support. You are not alone. There are people who can help you get through this.