Viral particle features include an outer envelope with special “docking proteins,” known as gp41 and gp120, that assist in finding a host (Fig. 21-1). Inside, the virus has two protein coatings and the genetic material along with the enzymes reverse transcriptase (RT) and integrase. The first challenge is for the HIV particle to get inside a host cell. HIV accomplishes this task by first finding a way into the host’s bloodstream. Once in the blood, HIV “hijacks” certain cells. One of the cells that it hijacks is the CD4 T-cell, also known as the CD4 cell, helper/inducer T-cell, or T4-cell (Kaufman, 2011) (see Chapter 19). This cell directs immune system defenses and regulates the activity of all immune system cells. If HIV successfully enters a CD4 T-cell, it can then create more virus particles.

FIG. 21-1 The human immune deficiency virus (HIV).

Virus-host interactions are needed for disease development. When a person is infected with HIV, the virus randomly “bumps” into many cells. The docking proteins on the outside of the virus try to find special receptors on a host cell that will allow the virus to bind and then enter the cell. The CD4+ T-cell has receptors on its surface known as CD4, CCR5, and CXCR4 (Fig. 21-2). Proteins on the HIV particle surface, known as gp120 and gp41, recognize these receptors on the CD4+ T-cell. For the virus to enter this cell, both the gp120 and the gp41 must bind to the receptors. The gp120 first binds to the primary CD4 receptor, which changes its shape and allows the gp41 to bind to one of the co-receptors (either the CCR5 receptor or the CXCR4 receptor). This attachment allows the virus to then enter the CD4+ T-cell (Fig. 21-3). Viral binding to the CD4 receptor and to either of the co-receptors is needed to enter the cell. (The new drug class known as entry inhibitors works here to block the receptor and prevent the interaction needed for entry of HIV into the CD4+ T-cell.)

FIG. 21-2 The CD4+ T-lymphocyte receptors for the HIV “docking” proteins.

FIG. 21-3 The successful interaction of the HIV “docking” proteins with the CD4+ T-lymphocyte receptors.

Viruses, like human cells, have genetic material. After entering a host cell, HIV must get its genetic material into the host cell’s DNA. HIV belongs to a family of viruses called retroviruses. The genetic material of the human cell is double-stranded DNA (ds-DNA). The genetic material of HIV is single-stranded ribonucleic acid (RNA) (ss-RNA). To infect and take over a human cell, the genetic material must be the same. HIV overcomes this problem by bringing along an enzyme at the time of infection, reverse transcriptase (RT). RT takes HIV’s ss-RNA and converts it into ds-DNA, which makes the viral genetic material the same as human DNA. (The drug classes known as nucleoside analog reverse transcriptase inhibitors [NRTIs] and non-nucleoside reverse transcriptase inhibitors [NNRTIs] work here to inhibit HIV reverse transcriptase.) Then HIV must get its DNA into the nucleus of the CD4+ T-cell and place it within the human DNA. HIV also brings an enzyme called integrase. This enzyme allows the viral ds-DNA to be inserted into the host ds-DNA, which completes the infection of the CD4+ T-cell. (The drug class known as integrase inhibitors works here to prevent viral DNA from integrating into the cell’s normal human DNA.)

HIV particles are made within the infected CD4+ T-cell, using all the metabolic machinery of the host. The new virus particle is made in the form of one long protein strand. The strand is clipped, using chemical enzyme scissors called HIV protease, into several small functional pieces. These pieces are formed into a new finished viral particle. (The drug class known as protease inhibitors works here to inhibit HIV protease.) Once the new virus particle is finished, it fuses with the infected cell’s membrane and then buds off in search of another CD4+ T-cell to infect (Fig. 21-4).

FIG. 21-4 The life cycle of the HIV and sites of action for anti-HIV therapy.

Effects of HIV infection are related to the new genetic instructions that now direct CD4+ T-cells to change their role in immune system defenses. The new role is to be an “HIV factory.” The immune system is made weaker by removing some CD4+ T-cells from circulation, and the most important cell in the immune system becomes an HIV factory. Up to 10 billion virus particles are made daily. In early HIV infection, the immune system can still attack and destroy most of the newly created virus particles. With time, however, the number of HIV particles overwhelms the immune system. Gradually, CD4+ T-cell counts fall, viral numbers (viral load) rise, and without treatment, the patient eventually dies of opportunistic infections or cancer.

Everyone who has AIDS has HIV infection; however, not everyone who has HIV infection has AIDS. The distinction rests with the number of CD4+ T-cells the patient has and whether any opportunistic infections have occurred. A healthy adult usually has at least 800 to 1000 of these cells per cubic millimeter (mm³) of blood. The number of CD4+ T-cells is reduced in the person with HIV disease.

About 50% to 90% of people who are first infected with HIV develop an acute infection within 4 weeks. Manifestations of this acute HIV infection can be fever, night sweats, chills, headache, and muscle aches. All of these problems can be caused by exposure to almost any virus (e.g., influenza)—not just to HIV. Many people with this acute HIV infection also have a rash and a sore throat, which is often confused with mononucleosis and viral meningitis. With time, these symptoms cease and the person feels well again. Actually, a “war is going on” in the body between HIV and the immune system.

As time passes, with more CD4+ T-cells infected and taken out of service, this cell count drops to below normal levels and those that remain may not function normally. Poor CD4+ T-cell function as a result of HIV infection leads to these immune system abnormalities:

• Lymphocytopenia (decreased numbers of lymphocytes)

• Increased production of incomplete and nonfunctional antibodies

• Abnormally functioning macrophages

As the CD4+ T-cell level drops, the patient is at risk for bacterial, fungal, and viral infections, as well as opportunistic cancers. Opportunistic infections are those caused by organisms that are present as part of the body’s normal environment and are kept in check by normal immune function. They occur because of the profound immunosuppression in the person with AIDS. These infections may result from a newly acquired infection or reactivation of an old infection.

A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm³ or an opportunistic infection. Once AIDS is diagnosed, even if the patient’s cell count goes higher than 200 cells/mm³ or the infection is successfully treated, the AIDS diagnosis remains and the patient never reverts to being just HIV positive.

HIV Classification

The Centers for Disease Control and Prevention (CDC), in a 1993 definition, classified HIV infection by correlating clinical conditions with three ranges of CD4+ T-cell counts. This classification was replaced in 2008 by defining four stages of the disease. In this new definition, laboratory confirmation of HIV infection (by enzyme-linked immunosorbent assay [ELISA] and Western blot analysis) plus CD4+ T-lymphocyte count or percentage and the presence or absence of the 26 AIDS-defining conditions (Table 21-1) determine the classification (CDC, 2008). The person with HIV infection can transmit the virus to others at all stages of disease, but the recently infected person with a high viral load and those at end stage without drug therapy can be particularly infectious.

• Stage 1 CDC Case Definition describes any patient with confirmed HIV infection and a CD4+ T-cell count of greater than 500 cells/mm³ or a CD4+ T-cell percentage of 29% or greater. A person at this stage has no AIDS-defining illnesses.

• Stage 2 CDC Case Definition describes any patient with a confirmed HIV infection and a CD4+ T-cell count between 200 and 499 cells/mm³ or a CD4+ T-cell percentage between 14% and 28%. A person at this stage has no AIDS-defining illnesses.

• Stage 3 CDC Case Definition describes any patient with a confirmed HIV infection and a CD4+ T-cell count of less than 200 cells/mm³ or a CD4+ T-cell percentage of less than 14%. A person who has higher CD4+ T-cell counts or percentages but who also has a documented AIDS-defining illness meets the requirements of Stage 3 CDC Case Definition.

• Stage 4 CDC Case Definition is used to describe any patient with a confirmed HIV infection, but no information regarding CD4+ T-cell counts, CD4+ T-cell percentages, and AIDS-defining illnesses is available.

TABLE 21-1 CENTERS FOR DISEASE CONTROL AND PREVENTION CLASSIFICATION OF AIDS-DEFINING CONDITIONS IN ADULTS

• Candidiasis of bronchi, trachea, or lungs

• Candidiasis of esophagus

• Cervical cancer, invasive

• Coccidioidomycosis, disseminated or extrapulmonary

• Cryptococcosis, extrapulmonary

• Cryptosporidiosis, chronic intestinal (>1 month’s duration)

• Cytomegalovirus disease (other than liver, spleen, or nodes)

• Cytomegalovirus retinitis (with loss of vision)

• Encephalopathy, HIV related

• Herpes simplex: chronic ulcers (>1 month’s duration) or bronchitis, pneumonitis, or esophagitis

• Histoplasmosis, disseminated or extrapulmonary

• Isosporiasis, chronic intestinal (>1 month’s duration)

• Kaposi sarcoma

• Lymphoid interstitial pneumonia or pulmonary lymphoid hyperplasia complex

• Lymphoma, Burkitt (or equivalent term)

• Lymphoma, immunoblastic (or equivalent term)

• Lymphoma, primary, of brain

• Mycobacterium avium complex or Mycobacterium kansasii, disseminated or extrapulmonary

• Mycobacterium tuberculosis of any site, pulmonary, disseminated, or extrapulmonary

• Mycobacterium, other species or unidentified species, disseminated or extrapulmonary

• Pneumocystis jirovecii pneumonia

• Pneumonia, recurrent (two instances within 12 months)

• Progressive multifocal leukoencephalopathy

• Salmonella septicemia, recurrent

• Toxoplasmosis of brain

• Wasting syndrome attributed to HIV

Centers for Disease Control and Prevention. (2008). Recommendations and reports: Appendix A—AIDS-defining conditions. Morbidity and Mortality Weekly Report, 57(RR-10), 9.

HIV Progression

The time from the beginning of HIV infection to development of AIDS ranges from months to years. The range depends on how HIV was acquired, personal factors, and interventions. For people who have been transfused with HIV-contaminated blood, for example, AIDS often develops quickly. For those who become HIV positive as a result of a single sexual encounter, the period is much longer before progression to AIDS. Other personal factors that may influence progression to AIDS include frequency of re-exposure to HIV, presence of other sexually transmitted diseases (STDs), nutritional status, and stress.

Genetic/Genomic Considerations

About 1% of people with HIV infection are long-term nonprogressors (LTNPs), sometimes called “elite controllers.” These people have been infected with HIV (as measured by ELISA) for at least 10 years and have remained asymptomatic, with CD4+ T-cell counts within the normal range and a viral load that is either undetectable or very low.

A genetic difference for this population is that their CCR5/CXCR4 co-receptors on the CD4+ T-cells are abnormal and nonfunctional. Most LTNPs have mutations in both pairs of the co-receptors’ gene alleles. The mutation creates a defective receptor called delta32. This defective receptor does not bind to the HIV docking proteins. Cells with this defective receptor successfully resist the entrance of HIV. People who have only one mutated co-receptor gene allele have fewer normal co-receptors. Although these people can be infected with HIV, disease progression is slow compared with that in people who have normal co-receptor gene alleles.

Incidence/Prevalence

Since the beginning of the epidemic in the United States, more than 1.2 million cases of HIV/AIDS have been diagnosed, and more than 617,025 people have died of AIDS. Currently, more than 600,000 people in the United States are living with HIV/AIDS (CDC, 2011). This number is less than the total number of people in the United States estimated to be infected with HIV (1.1 million to 1.8 million). Worldwide, about 40 to 60 million people are currently infected with HIV, at least 30 million deaths from AIDS have occurred, and 33 million people are living with AIDS (WHO, 2010).

AIDS hits hardest among people between 21 and 44 years of age. The loss of productivity and wage-earning power among this group devastates the patient and strains the insurance and health care industry.

Most AIDS cases in North America occur among men who have had sex with other men (MSM) (53%) or individuals of either gender who have used injection drugs (16%) (CDC, 2011). The changing demographics of the infection indicate that the perception that HIV/AIDS is only a problem for homosexual white men is false (Kirton, 2011).

Cultural Awareness

Most new HIV infections reported in the United States occur in racial and ethnic minority groups, particularly among Blacks/African Americans and Hispanics (CDC, 2011) (Fig. 21-5). These two groups show an increasing trend in HIV infection compared with a leveling off among white people. Factors that may increase the incidence of HIV infection and progression to AIDS among minority groups include:

• Fear of or lack of faith in the U.S. health care system

• Poverty and limited access to high-cost drugs

• Homophobia leading to increased bisexual activity among men of color

• Health beliefs about HIV treatment

FIG. 21-5 Estimates of annual new HIV infections in the United States by ethnicity and race.

Considerations for Older Adults

Infection with HIV can occur at any age. Assess the older patient for risk behaviors, including a sexual and drug use history (Tangredi et al., 2008). Age-related decline in immune function increases the likelihood that the older adult will develop the infection after an HIV exposure. In the older woman, thinning of vaginal tissue as a result of decreased estrogen may increase susceptibility to all sexually transmitted diseases, including HIV infection. Cognitive deficits appear to occur earlier in the older adult with HIV (Vance, 2010).

Women’s Health Considerations

Women are the fastest growing group with HIV infection and AIDS. In North America, about 16% of people with HIV infection are women. Twenty-five percent of newly diagnosed cases are women. In less affluent countries, 50% of cases occur in women (WHO, 2010). Risk factors are sexual exposure (75%) and injection drug use (25%). Strategies specifically targeted to reducing sexual exposures of HIV to women may help prevent an increase in HIV infection in that group. Women with HIV infection have a poorer outcome with shorter mean survival time than that of men. This outcome may be the result of late diagnosis and social or economic factors that reduce access to medical care.

Gynecologic problems, especially persistent or recurrent vaginal candidiasis, may be the first signs of HIV infection in women. Other common problems include genital herpes, pelvic inflammatory disease, other sexually transmitted diseases (STDs), and cervical dysplasia or cancer.

Most women with HIV are of childbearing age. The effect of HIV on pregnancy outcomes includes higher incidence of premature delivery, low-birth-weight infants, and transmission of the disease to the infant. Appropriate antiretroviral drug therapy during pregnancy reduces the risk for transmitting the infection to the infant. (See the discussion on p. 363 in the Perinatal Transmission section.)

AIDS is a disease with a high mortality rate. The fatality rate is at least 60% for adults and, to date, there is no cure (WHO, 2010). Thus a major focus for health care in North America and worldwide is prevention of HIV infection. For those infected with HIV, drug therapy slows disease progression and, to be effective, it must be taken as prescribed for the rest of the patient’s life.

Health Promotion and Maintenance

HIV has been found in most body fluids of infected patients, including blood, semen, vaginal secretions, breast milk, amniotic fluid, urine, feces, saliva, tears, cerebrospinal fluid, lymph nodes, cervical cells, corneal tissue, and brain tissue. The fluids with the highest concentrations of HIV are the semen and the blood. It is also present in vaginal fluids and breast milk. Thus HIV is transmitted most often in these three ways:

• Sexual: genital, anal, or oral sexual contact with exposure of mucous membranes to infected semen or vaginal secretions

• Parenteral: sharing of needles or equipment contaminated with infected blood or receiving contaminated blood products

• Perinatal: from the placenta, from contact with maternal blood and body fluids during birth, or from breast milk from an infected mother to child

Teach everyone about the transmission routes and ways to reduce their exposure (discussed next). Also stress that HIV is not transmitted by casual contact in the home, school, or workplace. Sharing household utensils, towels and linens, and toilet facilities does not transmit HIV. In addition, HIV is not spread by mosquitoes or other insects.

Nursing Safety Priority

Action Alert

Teach all people, regardless of age, gender, ethnicity, or sexual orientation, that they are susceptible to HIV infection.

Sexual Transmission

The CDC describes the ABC safer sex methods as A, abstinence; B, be faithful; and C, condoms (CDC, 2009b). Abstinence and mutually monogamous sex with a noninfected partner are the only absolutely safe methods of preventing HIV infection from sexual contact. Many forms of sexual expression can spread HIV infection if one partner is infected. The risk for becoming infected from a partner who is HIV positive is always present, although some sexual practices are more risky than others. The virus concentrates most heavily in blood and seminal fluid, although it is also present in vaginal secretions. Thus risk differs by gender, sexual act, and the viral load of the infected partner.

Gender affects HIV transmission. HIV is most easily transmitted when infected body fluids come into contact with mucous membranes or nonintact skin. The vagina has much more mucous membrane than does the penis. Thus HIV, like all other sexually transmitted diseases (STDs), is more easily transmitted from infected male to uninfected female than vice versa. Teach women the importance of always either using a vaginal or dental dam or female condom, or having their male partners use a condom.

Sexual acts or practices that permit infected seminal fluid to come into contact with mucous membranes or nonintact skin are the most risky for sexual transmission of HIV. The practice with the highest risk is anal intercourse. In anal intercourse, the risk increases when the penis and seminal fluid of an infected person come into contact with the mucous membranes of the uninfected partner’s rectum. Anal intercourse in which the semen depositor (inserting or active partner) is infected is a very risky sexual practice regardless of whether the semen receiver (receiving partner) is male or female. Anal intercourse not only allows seminal fluid to make contact with the mucous membranes of the rectum but also tears the mucous membranes, making infection more likely. Teach patients who engage in anal intercourse that the safer sex practice is for the semen depositor to wear a condom during this act.

Viral load, or the amount of virus present in blood and other body fluids, affects transmission. The higher the blood level of HIV (viremia), the greater the risk for sexual and perinatal transmission. Current highly active antiretroviral therapy (HAART) has caused the viral load of some infected patients to drop below detectable levels. Although there is less virus in seminal or vaginal fluids of people receiving HAART, the risk for transmission still exists (Kirton, 2011).

Safer sex practices are those that reduce the risk for nonintact skin or mucous membranes coming in contact with infected body fluids and blood. Teach everyone the importance of consistently using these safer sex practices:

• A latex or polyurethane condom for genital and anal intercourse (Chart 21-1)

• A condom or latex barrier (dental dam) over the genitals or anus during oral-genital or oral-anal sexual contact

• Latex gloves for finger or hand contact with the vagina or rectum

Chart 21-1

Patient and Family Education

Preparing for Self-Management: Condom Use to Prevent Sexually Transmitted Diseases

• Use latex or polyurethane condoms rather than natural membrane condoms.

• Store condoms in a cool, dry place.

• Do not use condoms that were in damaged packages or those that show signs of age, such as those that are brittle, sticky, or discolored.

• Handle condoms carefully to avoid puncturing them.

• Put a condom on before making any genital contact.

• Hold the tip of the condom and unroll it onto the erect penis, making sure that no air is trapped in the tip. Leave space at the tip to collect semen.

• Use adequate lubrication. Use water-based lubricants only. Petroleum or oil-based lubricants such as petroleum jelly, cooking oil, shortening, and lotions can damage the condom.

• Replace a broken condom immediately. If ejaculation occurs after the condom breaks, there may be some protection in the immediate use of a spermicide.

• After ejaculation, the condom must remain on until the penis is withdrawn. While the penis is still erect, hold the condom against the base of the penis while withdrawing.

• Never reuse condoms.

From Centers for Disease Control. (1988). Condoms for prevention of sexually transmitted diseases. Morbidity and Mortality Weekly Report, 37(9), 133-137.

A promising area of research for prevention of sexual transmission is the use of vaginal gels that contain an antiretroviral agent (tenofovir or raltegravir). Early results indicate that if the gel is used before and after intercourse, new infections among women can be reduced by as much as 50% (Abdool Karim et al., 2010).

For those who believe they have been exposed to HIV as a result of sexual relations or other types of nonoccupational exposure, the CDC has guidelines for postexposure prophylaxis. The length and type of prophylaxis therapy depend on the nature of the exposure (Chart 21-2).

Chart 21-2 Patient and Family Education

Preparing for Self-Management: Nonoccupational Postexposure Prophylaxis (nPEP) to HIV

Recommendations for nPEP with a substantial risk for HIV exposure is a 28-day course of the preferred regimen of HAART*^†
NNRTI-based	Efavirenz plus either lamivudine or emtricitabine plus either zidovudine or tenofovir
or
PI-based	Lopinavir/ritonavir plus either lamivudine or emtricitabine plus zidovudine
A substantial risk is exposure of any of these:
• Vagina • Rectum • Eye • Mouth	• Other intact mucous membrane • Nonintact skin or mucous membrane
With: • Blood • Semen • Vaginal secretions • Rectal secretions • Breast milk • Any body fluid visibly contaminated with blood When: • The source person is known to be HIV-infected

HAART, Highly active antiretroviral therapy; NNRTI, non-nucleoside reverse transcriptase inhibitor; PI, protease inhibitor.

^* Either when a substantial risk has occurred and more than 72 hours has passed since the exposure or when the exposure is considered to be a negligible risk, nPEP is not recommended.

^† When a substantial risk has occurred and less than 72 hours has passed since the exposure but the HIV-infection status of the source person is not known, nPEP is determined on a case-by-case basis.

Data from Centers for Disease Control and Prevention. (2005). Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States. Morbidity and Mortality Weekly Report, 54(RR-2), 1-27.

Data from Centers for Disease Control and Prevention. (2005). Updated Public Health Service guidelines for the management of health-care worker exposure to HIV and recommendations for postexposure prophylaxis. Morbidity and Mortality Weekly Report, 54(RR-9), 1-22.

Best Practice for Patient Safety & Quality Care: Postexposure Prophylaxis (PEP) for Occupational HIV Exposure *

BASIC PEP†	EXPANDED PEP‡
Small volume (few drops) exposure to mucous membranes or nonintact skin • Source patient is HIV positive, asymptomatic with known low viral load • Source patient is HIV positive, symptomatic or AIDS with high viral load	Large volume (major splash) exposure to mucous membranes or nonintact skin • Source patient is HIV positive, symptomatic or AIDS with high viral load
Large volume (major splash) exposure to mucous membranes or nonintact skin • Source patient is HIV positive, asymptomatic with known low viral load • Optional when source patient is unknown or known with HIV risk factors	Less severe percutaneous injury (solid needle or superficial injury) • Source patient is HIV positive, symptomatic or AIDS with high viral load
Less severe percutaneous injury (solid needle or superficial injury) • Source patient is HIV positive, asymptomatic with known low viral load • Optional when source patient is unknown or known with HIV risk factors	More severe percutaneous injury (large-bore hollow needle, deep punctures, visible blood on the device, needle was in the patient’s artery or vein) • Source patient is HIV positive, asymptomatic with known low viral load • Source patient is HIV positive, symptomatic or AIDS with high viral load

^* When PEP therapy is instituted, the recommended course is 28 days.

^† Basic PEP = Two drugs: (zidovudine plus lamivudine or emtricitabine); or (stavudine plus lamivudine or emtricitabine); or (tenofovir plus lamivudine or emtricitabine).

^‡ Expanded PEP = Three or more drugs: (zidovudine plus lamivudine or emtricitabine plus lopinavir/ritonavir); or (stavudine plus lamivudine or emtricitabine plus lopinavir/ritonavir); or (tenofovir plus lamivudine or emtricitabine plus lopinavir/ritonavir).

The public may be concerned about HIV transmission by health care workers. Health care workers should wear gloves when in contact with patients’ mucous membranes or nonintact skin. Infected workers with weeping dermatitis or open lesions should not perform direct care. The CDC guidelines for preventing HIV transmission by health care workers during exposure-prone invasive procedures are listed in Chart 21-4. These include any procedure in which there is a risk for broken skin injury to the health care worker and the worker’s blood is likely to make contact with the patient’s body cavity, subcutaneous tissues, or mucous membranes. The purpose of these guidelines is to reduce the risk for HIV transmission to patients.

Chart 21-4

Best Practice for Patient Safety & Quality Care

Recommendations for Preventing HIV Transmission by Health Care Workers

• Workers should adhere to Standard Precautions.

• Workers with exudative lesions or weeping dermatitis should not perform direct patient care or handle patient care equipment and devices used in invasive procedures.

• Workers must follow guidelines for disinfection and sterilization of reusable equipment used in invasive procedures.

• Workers infected with HIV are not restricted from practice of non–exposure-prone procedures, as long as they comply with Standard Precautions and sterilization and disinfection recommendations.

• Workers should identify exposure-prone procedures by institutions where they are performed.

• Workers who perform exposure-prone procedures should know their HIV antibody status.

• Workers who are infected with HIV should seek advice from an expert review panel before performing exposure-prone procedures to determine under what circumstances they may continue to practice these procedures. These circumstances would include notification of prospective patients of HIV positivity.

Modified from Centers for Disease Control. (1991). Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. Morbidity and Mortality Weekly Report, 40(RR-8), 1-9.

Decision-Making Challenge

Teamwork and Collaboration; Safety

You have just changed jobs and are working in the day-surgery and procedure center of a large hospital. You recognize from your former place of employment one of the gastroenterologists as a patient who is under treatment for HIV disease. He is performing short procedures, including endoscopy and colonoscopy.

1. Should you approach this surgeon with the knowledge you have about his HIV status? Why or why not?

2. Does performing endoscopies or colonoscopies represent an HIV transmission risk from this surgeon to his patients? Explain your choice.

3. What are your responsibilities in this situation?

Testing

Testing for HIV antibodies or other features of the virus is complex, requiring interpretation, counseling, and confidentiality. Testing plays a role in prevention because tests are a way of diagnosing HIV infection before immune changes or symptoms develop. A primary health care focus for testing is to teach those who test positive to modify their behaviors to prevent transmission to others. Therefore all sexually active people should know their HIV status. Chart 21-5 lists additional conditions for which HIV antibody testing is advised.

Chart 21-5

Patient and Family Education

Preparing for Self-Management: CDC Recommendations for HIV Testing

You should be tested for HIV if you fall within one or more of these groups:

• People with sexually transmitted disease

• Injection drug users

• People who consider themselves at risk

• Women of childbearing age with identifiable risks, including:

• Used injection drugs

• Engaged in prostitution

• Had sexual partners who were infected or at risk

• Had contact with men from countries with high HIV prevalence

• People who received a transfusion between 1978 and 1985

• People planning to get married

• People undergoing medical evaluation or treatment for manifestations that may be HIV related

• People admitted to hospitals

• People in correctional institutions such as jails and prisons

• Prostitutes and their customers

CDC, Centers for Disease Control and Prevention.

Modified from Centers for Disease Control. (1987). Public Health Service guidelines for counseling and antibody testing to prevent HIV infection and AIDS. Morbidity and Mortality Weekly Report, 36(31), 509-515.

Pretest and post-test counseling must be performed by personnel trained in HIV issues. These counselors may be nurses, physicians, social workers, health educators, or even lay educators who have specialized training. Counseling helps the patient make an informed decision about testing and provides an opportunity to teach risk-reduction behaviors. Post-test counseling is needed to interpret the results, discuss risk reduction, and provide psychological support and health promotion information for the patient with a positive test result. People who test positive should also be counseled on how to inform sexual partners and those with whom they have shared needles. Testing methods, their accuracy, and indications are presented on pp. 368-369 in the Laboratory Assessment section.