Contact Hours: 3
This online independent study activity is credited for 3 contact hours at completion.
Course Purpose
To provide healthcare professionals with knowledge of HIV and AIDS, common antiretroviral medications, transmission prevention, and CDC recommendations for pre-and post-exposure prophylaxis.
Overview
Being a healthcare provider is not limited to nurses and physicians. According to the Center for Disease Control (CDC), a healthcare provider is anyone who has the potential of being exposed to HIV through blood and body fluids, equipment, or surfaces. Treatment of HIV and AIDS is ever-evolving with new medications. This learning topic provides an overview of HIV as described by the CDC, it’s history and stages, common antiretroviral medications that are currently used for pre-exposure and post-exposure prophylaxis, and CDC recommendations for the healthcare provider should exposure to HIV occur.
Objectives
Upon completion of the independent study, the learner will be able to:
- Define HIV through a timeline of HIV identification in the United States.
- Describe Modes of HIV transmission.
- Describe common antiretroviral medications used to treat HIV.
- Identify post-exposure prophylaxis recommendations for healthcare providers as described by the Center for Disease Control.
Policy Statement
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Disclosures
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Approximately 1.1 million people in the United States have human immunodeficiency virus (HIV) and approximately 15% of them do not know that they have the virus. It is estimated that approximately 40% of new HIV infections are transmitted by persons who are unaware that they have the disease.¹ Human immunodeficiency virus (HIV) is a virus that is spread through blood and body fluids, such as breast milk, semen, and vaginal fluids. The virus attacks the body’s immune system, specifically the CD4 cells. These cells are often called CD4+ T cells and are white blood cells that fight infection. The average range for CD4 count in a normal, healthy immune system is 500-1600 cells/millimeter (cells/mm³) of blood. When HIV enters and infects a CD4 cell, it begins to replicate, producing thousands of copies of the virus. The copies then enter and infect other CD4 cells and continue to replicate themselves and enter and infect other CD4 cells. The infected CD4 cells do not work appropriately and die early. The loss of CD4 cells results in a weakened immune system, making it harder for the body to remain healthy. Once the CD4 count falls below 200 cells/mm³, one is considered to have acquired immune deficiency syndrome (AIDS)³. AIDS is the most advanced form of infection caused by HIV, where the body has difficulty fighting infections and cancers. It can take 2-10 years, or longer for one diagnosed with HIV to develop AIDS when he or she does not take any antiretroviral medications. Most often, one with HIV will not develop AIDS if he or she begins antiretroviral medications soon after becoming infected. There is currently no cure for HIV, however if persons with HIV take their antiretroviral medications as prescribed, the amount of HIV in their blood (viral load) can become undetectable. Having undetectable levels of HIV will increase one’s life span, and one will effectively have no risk in transferring HIV to someone else through sexual contact. With correct medication adherence, one with HIV can live nearly if one who is not infected with HIV.
Human Immunodeficiency Virus (HIV) is believed to have originated in Kinshasa, in the Dominican Republic of Congo during the 1920s when it was transferred to hunters from chimpanzees. There was sporadic documentation of signs and symptoms related to the disease during early the 1970s, however, it is suggested that the current HIV epidemic began in the late 1970s. By the 1980s, between 100,000 and 300,000 were likely already infected. The following is a timeline of the evolution of HIV within the United States. ⁶
- In 1981 five gay men in Los Angeles were found to have a rare lung disease called Pneumocystis carinii pneumonia (PCP); a fungal lung infection that most often affects those who are immunosuppressed. By December, PCP was found in people who injected intravenous drugs. Pneumocystis carinii is now called Pneumocystis jirovecii, however the abbreviation PCP is still used to refer to the disease. The symptoms of PCP include:
- Cough
- Fever
- Chills
- Shortness of Breath
- Fatigue
- Chest pain
- In 1982 there were cases of immune-deficiency among sexually active gay men and the syndrome was named gay-related immune deficiency. The immune deficiency was also found in hemophiliacs, and later in the year the Center for Disease Control (CDC) termed the advanced form of the disease Acquired Immune Deficiency Syndrome (AIDS).
- In 1983 AIDS was found to be passed to heterosexual women from men infected with the disease. During this year, children were also found to be afflicted with AIDS, and it was concluded that the transfer of AIDS to children likely occurred from mothers during or shortly after birth. AIDS was also identified to be transferred in blood and body secretions, and transfer through social contact, water, food, surfaces, and air was ruled out. As a result, the center for disease control (CDC) was able to submit recommendations for disease prevention in health care professionals. International surveillance was also instituted by the World Health Organization (WHO).
- In 1984 the National Cancer Institute identified the retrovirus HTLV-III as the cause of AIDS. A blood test was also created to screen for the virus, and CDC recommended avoiding intravenous drug use and sharing of needles. Amsterdam was the first to initiate a needle and syringe exchange program to help reduce the rate of AIDS infections.
- In 1985 the Food and Drug Administration (FDA) licensed enzyme-linked immunosorbent assay (ELISA) testing. The test uses chemicals and components of the immune system to detect immune responses in the body. The availability of the test allowed blood banks to screen the blood supply for HIV infection. The United States Public Health Service also made recommendations for the prevention of mother-child transmissions of the virus.
- In 1986 the International Committee on the Taxonomy of viruses officially called the virus that causes AIDS human immunodeficiency virus (HIV).
- In 1987 the FDA approved the first antiretroviral drug zidovudine (AZT) to treat HIV. AZT belongs to a group of drugs known as nucleoside reverse transcriptase inhibitors (NRTIs) and is only active against HIV when the virus is replicating into viral DNA. The FDA also approved the western blot blood test, which is a more specific HIV antibody test than the ELISA test. During this year, the WHO also confirmed that HIV could be passed from mother to infant in breast milk.
- In 1988 the World Health Organization declared December 1st world AIDS day.
- In 1989 the Center for Disease control released guidelines to prevent Pneumocystis carinii pneumonia (PCP).
- In 1990 the United States put into effect the Americans with Disabilities Act (ADA). The act prohibits discrimination against persons with HIV and disabilities.
- In 1993 the Center for Disease Control included recurrent pneumonia, invasive cervical cancer, and tuberculosis to the list of indicators of AIDS.
- In 1994 the FDA approved the first oral test not requiring blood to detect HIV.
- In 1995 the FDA approved saquinavir, the first protease inhibitor. The use of the medication resulted in approximately 60% reduction of AIDS related hospitalizations and deaths.
- In 1996 the FDA approved the first HIV home testing kit and HIV urine test.
- In 1997 the FDA approved Combivir; a combination drug within a single tablet. This made it easier for people with HIV to take their medications.
- In 2001 major drug companies began producing generic forms of HIV medications, making them more accessible in developing countries.
- In 2002 the FDA approved the first rapid HIV test which provides result within 20 minutes.
- In 2006 male circumcision was found to reduce the risk of female to male HIV transmission by as much as 60%.
- In 2011 early initiation of antiretroviral therapy was found to reduce the risk of HIV transmission by 96%. Antiretroviral therapy uses two or more drugs to treat HIV. Antiretroviral drugs are beneficial because they:
- Stop the virus from multiplying in the blood
- Increases the CD4 count, thereby improving the immune system function
- Slows down the progression of HIV to AIDS
- Prevents transmission of the disease
- Stops the virus from replicating in the blood
- In 2015 the World Health Organization created new guidelines for everyone living with HIV to receive antiretroviral treatment regardless of the CD4 count.
There are three stages in HIV infection. ⁷ Antiretroviral therapy (ART) can be used by those with HIV during each of the three stages of the disease. Taking medications as prescribed can slow the or prevent the progression of HIV, and having an undetectable viral load reduces the risk of HIV transmission to an HIV negative person. To be considered as having an undetectable viral load and significantly reduced risk of HIV transference, a person with HIV must have an undetectable viral load via blood laboratory draws consistently for six months or more.
- Stage One: Acute HIV infection
One may experience flu like symptoms within 2-4 weeks after HIV infection. These symptoms include fever, fatigue, sore throat, headache, sores in mouth, rash, and swollen lymph nodes. These symptoms are the body’s natural response to infection, however many people in stage one may not experience any symptoms at all. Although they may not experience symptoms, they are still contagious because there is a large amount of virus in their blood. Because one may be asymptomatic in this stage, the only way of determining HIV infection is through blood tests.
- Stage Two: Clinical Latency
Stage two is often called chronic or asymptomatic HIV infection. During this phase, the production of HIV is at low levels, and as a result one with HIV may not exhibit any symptoms. They are, however, still able to transmit the disease to others. One infected with HIV can remain in this stage for 10 years or more without the use of medications, but there is a possibility of someone progressing through stage two faster. When an individual with HIV is taking antiretroviral medications as prescribed, they may stay in stage two for decades, and even slow the production of HIV to a point that it is undetectable in the blood. An HIV positive person with undetectable levels of HIV poses virtually no risk of transmitting the disease during sex. When the production of HIV increases and the viral load goes up, one may begin to exhibit symptoms related to HIV. As the viral load goes up, the CD4 count will begin to decline, signifying the end of stage two and the entrance of stage three.
- Stage Three: Acquired Immune Deficiency Syndrome
AIDS is the most severe phase HIV. People with AIDS have compromised immune systems, and as a result are at higher risks for opportunistic infections and cancers. Common symptoms of AIDS include fever, chills, swollen lymph nodes, weight loss, weakness, and night sweats. AIDS is diagnosed when the CD4 count falls below 200 cells/mm³ or when opportunistic diseases and cancers such as pneumocystis carinii pneumonia or Kaposi sarcoma develop. Without antiretroviral treatment, a person with AIDS will typically survive 3 years. During this time, they can have a high viral load and be very infectious.
Opportunistic infections are infections that occur more frequently in people with weakened immune systems such as in HIV and AIDS. ⁹ Opportunistic infections are less common now than in the 1980s and 1990s because better medications and treatments are available. Although medications and treatments have greatly improved, many people with HIV still develop opportunistic infections because they may not know they are HIV positive, may not have a treatment regimen, or their treatment regimen may not be effective in keeping HIV levels low enough for the immune system to fight off infections. The following is a list of opportunistic infections listed by the CDC⁹:
| Candidiasis of bronchi, trachea, esophagus, or lungs | This illness is caused by infection with a common (and usually harmless) type of fungus called Candida. Candidiasis, or infection with Candida, can affect the skin, nails, and mucous membranes throughout the body. Persons with HIV infection often have trouble with Candida, especially in the mouth and vagina. However, candidiasis is only considered an OI when it infects the esophagus (swallowing tube) or lower respiratory tract, such as the trachea and bronchi (breathing tube), or deeper lung tissue. |
| Invasive cervical cancer | This is a cancer that starts within the cervix, which is the lower part of the uterus at the top of the vagina, and then spreads (becomes invasive) to other parts of the body. This cancer can be prevented by having your care provider perform regular examinations of the cervix. |
| Coccidioidomycosis | This illness is caused by the fungus Coccidioides immitis. It most acquired by inhaling fungal spores, which can lead to a pneumonia that is sometimes called desert fever, San Joaquin Valley fever, or valley fever. The disease is especially common in hot, dry regions of the southwestern United States, Central America, and South America. |
| Cryptococcosis | This illness is caused by infection with the fungus Cryptococcus neoformans. The fungus typically enters the body through the lungs and can cause pneumonia. It can also spread to the brain, causing swelling of the brain. It can infect any part of the body, but (after the brain and lungs) infections of skin, bones, or urinary tract are most common. |
| Cryptosporidiosis, chronic intestinal (greater than one month’s duration) | This diarrheal disease is caused by the protozoan parasite Cryptosporidium. Symptoms include abdominal cramps and severe, chronic, watery diarrhea. |
| Cytomegalovirus diseases (particularly retinitis) (CMV) | This virus can infect multiple parts of the body and cause pneumonia, gastroenteritis (especially abdominal pain caused by infection of the colon), encephalitis (infection) of the brain, and sight-threatening retinitis (infection of the retina at the back of eye). People with CMV retinitis have difficulty with vision that worsens over time. CMV retinitis is a medical emergency because it can cause blindness if not treated promptly. |
| Encephalopathy, HIV-related | This brain disorder is a result of HIV infection. It can occur as part of acute HIV infection or can result from chronic HIV infection. Its exact cause is unknown, but it is thought to be related to infection of the brain with HIV and the resulting inflammation. |
| Herpes simplex (HSV): chronic ulcer(s) (greater than one month’s duration); or bronchitis, pneumonitis, or esophagitis | Herpes simplex virus (HSV) is a common virus that for most people never causes any major problems. HSV is usually acquired sexually or from an infected mother during birth. In most people with healthy immune systems, HSV is usually latent (inactive). However, stress, trauma, other infections, or suppression of the immune system, (such as by HIV), can reactivate the latent virus and symptoms can return. HSV can cause painful cold sores (sometime called fever blisters) in or around the mouth, or painful ulcers on or around the genitals or anus. In people with severely damaged immune systems, HSV can also cause infection of the bronchus (breathing tube), pneumonia (infection of the lungs), and esophagitis (infection of the esophagus, or swallowing tube). |
| Histoplasmosis | This illness is caused by the fungus Histoplasma capsulatum. Histoplasma most often infects the lungs and produces symptoms that are like those of influenza or pneumonia. People with severely damaged immune systems can get a serious form of the disease called progressive disseminated histoplasmosis. This form of histoplasmosis can last a long time and involves organs other than the lungs. |
| Isosporiasis, chronic intestinal (greater than one month’s duration) | This infection is caused by the parasite Isospora belli, which can enter the body through contaminated food or water. Symptoms include diarrhea, fever, headache, abdominal pain, vomiting, and weight loss. |
| Kaposi’s Sarcoma (KS) | This cancer, also known as KS, is caused by a virus called Kaposi’s sarcoma herpesvirus (KSHV) or human herpesvirus 8 (HHV-8). KS causes small blood vessels, called capillaries, to grow abnormally. Because capillaries are located throughout the body, KS can occur anywhere. KS appears as firm pink or purple spots on the skin that can be raised or flat. KS can be life-threatening when it affects organs inside the body, such the lung, lymph nodes, or intestines. |
| Lymphoma, multiple forms | Lymphoma refers to cancer of the lymph nodes and other lymphoid tissues in the body. There are many kinds of lymphomas. Some types, such as non-Hodgkin lymphoma and Hodgkin lymphoma, are associated with HIV infection. |
| Tuberculosis (TB) | Tuberculosis (TB) infection is caused by the bacteria Mycobacterium tuberculosis. TB can be spread through the air when a person with active TB coughs, sneezes, or speaks. Breathing in the bacteria can lead to infection in the lungs. Symptoms of TB in the lungs include cough, tiredness, weight loss, fever, and night sweats. Although the disease usually occurs in the lungs, it may also affect other parts of the body, most often the larynx, lymph nodes, brain, kidneys, or bones. |
| Mycobacterium Avium Complex (MAC) or Mycobacterium Kansasii, disseminated or extrapulmonary. | MAC is caused by infection with different types of mycobacterium: Mycobacterium avium, Mycobacterium intracellulare, or Mycobacterium kansasii. These mycobacteria live in our environment, including in soil and dust particles. They rarely cause problems for persons with healthy immune systems. In people with severely damaged immune systems, infections with these bacteria spread throughout the body and can be life-threatening. |
| Pneumocystis Carinii Pneumonia (PCP) | This lung infection, also called PCP, is caused by a fungus, which used to be called Pneumocystis carinii, but now is named Pneumocystis jirovecii. PCP occurs in people with weakened immune systems, including people with HIV. The first signs of infection are difficulty breathing, high fever, and dry cough. |
| Pneumonia, recurrent | Pneumonia is an infection in one or both lungs. Many germs, including bacteria, viruses, and fungi can cause pneumonia, with symptoms such as a cough (with mucous), fever, chills, and trouble breathing. In people with immune systems severely damaged by HIV, one of the most common and life-threatening causes of pneumonia is infection with the bacteria Streptococcus pneumoniae, also called Pneumococcus. There are now effective vaccines that can prevent infection with Streptococcus pneumoniae and all persons with HIV infection should be vaccinated. |
| Progressive multifocal leukoencephalopathy | This rare brain and spinal cord disease are caused by the JC (John Cunningham) virus. It is seen almost exclusively in persons whose immune systems have been severely damaged by HIV. Symptoms may include loss of muscle control, paralysis, blindness, speech problems, and an altered mental state. This disease often progresses rapidly and may be fatal. |
| Salmonella septicemia, recurrent | Salmonella are a kind of bacteria that typically enter the body through ingestion of contaminated food or water. Infection with salmonella (called salmonellosis) can affect anyone and usually causes a self-limited illness with nausea, vomiting, and diarrhea. Salmonella septicemia is a severe form of infection in which the bacteria circulate through the whole body and exceeds the immune system’s ability to control it. |
| Toxoplasmosis of brain | This infection, often called toxo, is caused by the parasite Toxoplasma gondii. The parasite is carried by warm-blooded animals including cats, rodents, and birds and is excreted by these animals in their feces. Humans can become infected with it by inhaling dust or eating food contaminated with the parasite. Toxoplasma can also occur in commercial meats, especially red meats, and pork, but rarely poultry. Infection with toxo can occur in the lungs, retina of the eye, heart, pancreas, liver, colon, testes, and brain. Although cats can transmit toxoplasmosis, litter boxes can be changed safely by wearing gloves and washing hands thoroughly with soap and water afterwards. All raw red meats that have not been frozen for at least 24 hours should be cooked through to an internal temperature of at least 150oF. |
| Wasting syndrome due to HIV | Wasting is defined as the involuntary loss of more than 10% of one’s body weight while having experienced diarrhea or weakness and fever for more than 30 days. Wasting refers to the loss of muscle mass, although part of the weight loss may also be due to loss of fat. |
HIV is spread from a person with HIV to a noninfected person through blood, semen, pre-seminal fluid, vaginal fluid, rectal fluid, and breast milk. For transmission to occur, the bodily fluids containing HIV must encounter damaged tissue or mucous membranes or be injected into the blood stream. It is not however, spread through tears, sweat, feces, urine, dry kissing, hugging, or insect bites. ⁷
37, 832 people were diagnosed with HIV in 2018.¹ The number of HIV infections decreased between 2010 and 2017, ⁶ however yearly diagnosis has increased among some groups. For instance, 68 % of those diagnosed were gay or bisexual men, 24% were heterosexuals, and 7% were people who injected drugs. Of the 68% of men considered gay or bisexual, 37% were African American, 27% were Caucasian, 30% were Hispanic, 3% were Asian, 2% were from multiple races, 1% was Native American, and <1% was Pacific Islander. Of the 24% that were heterosexuals, women accounted for 16 % of new HIV diagnoses and men accounted for 7%. The lowest group of new HIV infections occurred in people who injected drugs. Of the 7% in that group, 4% were men and 3% were women. Those between the ages of 25 and 34 were also shown to have the highest incidence of new transmission as shown in the table below¹:
| Age at time of HIV infection | Number of HIV infections |
| 13-24 | 7,807 |
| 25-34 | 13,458 |
| 35-44 | 7,237 |
| 45-54 | 5,377 |
| 55 and Older | 3,862 |
HIV is most often spread by having unprotected anal or vaginal sex with an HIV infected person.¹ Receptive anal sex poses the highest risk because the lining of the rectus is thin and could allow entry of HIV from damaged tissue or mucous membranes. Insertive anal sex is also considered high risk for HIV transmission because HIV can potentially pass through the urethra, the foreskin in an uncircumcised male, open wounds, or scratches on the penis.
HIV can also be transmitted through vaginal sex. HIV can enter a woman during unprotected sex through mucous membranes that line the vagina and cervix. Men are also at risk of getting HIV from an HIV positive woman. Because HIV is in blood and vaginal fluid, it can pass through the urethra, the foreskin of an uncircumcised penis, scratches, cuts, and sores on the penis.
Oral sex involves putting the mouth on the vagina (cunnilingus), penis (fellatio), or anus (anilingus). For the most part, the risk of HIV transmission during oral sex is low. The risk of HIV transmission can be increased during oral sex if the man ejaculates into a mouth with bleeding gums, oral ulcers, or if genital sores or other sexually transmittable diseases are present during any form of oral sex. One can also get a sexually transmitted disease from oral sex. For instance, if anilingus is performed and feces enters the mouth, one is at increased risk for getting hepatitis A, hepatitis B, parasites, and bacterial infections.
HIV can be transmitted through the sharing of needles, syringes, and other injecting equipment. The transmission occurs when blood remains in a previously used needle or syringe. Depending on temperature and other factors, HIV can live in used needles, syringes, or other injecting equipment up to 42 days.
There are other rare cases of HIV transmission besides oral sex. For instance, blood transfusions have low risk of HIV transmission. There was a time in the 1980’s when the risk of HIV transmission through blood transmission was much higher, however the risk was drastically reduced with the implementation of rigorous testing of donated blood, organs, and tissues.
Being bitten by a person who is HIV positive also poses little risk of transmission, however the risks increased if there is extensive tissue damage and blood present at the site. If the skin is not broken, there is no risk for transmission of HIV. Likewise, deep open mouth kissing poses little risk of transmission, unless both people have sores or bleeding gums in their mouths, and blood from the HIV positive person gets into the blood stream of the HIV negative person.
A healthcare professional has little risk of HIV exposure or transmission when protective practices and personal protective equipment (when applicable) are utilized. The main risk that a healthcare professional may face is risk through a needle stick from an HIV contaminated needle, however the risk of transmission is less than 1%.
Transgender women and men are at high risk for getting HIV.² According to the CDC¹, approximately 14% of transgender women have HIV, and the percentage is much higher among black/African American (44%) and Hispanic/Latina (26%) transgender women. An estimated 3% of transgender men also have HIV. ²
Many transgender people face obstacles that make it harder to access HIV services, such as stigma and discrimination, inadequate employment or housing, and limited access to welcoming, supportive health care. Addressing these barriers is essential to the health and well-being of transgender people.
Increasing culturally appropriate, focused HIV testing efforts and care are key to preventing disparities and reducing HIV transmission in transgender communities. Having an early diagnosis and treatment regimen benefits everyone with HIV, and those HIV who take antiretroviral therapy as prescribed and are able stay virally suppressed can live long, healthy lives. They also have little risk of sexually transmitting HIV to partners.
Antiretroviral therapy (ART) reduces the HIV related mortality during all stages of HIV infections and reduces the rate of transmission to others.¹⁰ When taken as prescribed by s healthcare professional, ARTs can effectively suppress the viral load of HIV (sometimes to the point of being undetectable), maintain high levels of CD4, prolong survival by improving AIDS prevention, and reduce the risk of transfer of HIV infection to others.¹⁰ The CDC¹ recommends antiretroviral therapy medications be taken by everyone who is HIV positive, regardless of CD4 count. The plasma HIV RNA viral load should be monitored routinely to ensure appropriate response to antiretroviral therapy. When taken as prescribed, may HIV positive people achieve viral suppression within 6 months. The viral load should be tested within 2-4 weeks of initiation and every 4-8-week intervals until the viral load is undetectable or when the medication regimen is changed because of suboptimal response.³ Once the desired response to antiretroviral therapy is achieved, the viral load should be tested every 3-4 months for continued monitoring. When the viral load is proven to be suppressed for 2 years, the viral load can be tested every 6 months. ³ Occasionally, HIV positive persons with undetectable viral loads may experience a sporadic rise in the tests for viral load. When this occurs, they may need to use transmission prevention strategies such as condoms or pre-exposure prophylaxis until the viral load becomes undetectable again. Often, the viral load will be undetectable on the test.
The only practice that is 100% effective in preventing the transmission of HIV is abstinence. ¹ Abstinence occurs when one chooses to refrain from having oral, vaginal, and anal sex. Although the risk of getting HIV from oral sex is extremely low, there is a risk that is present. The risk for transmission during oral sex occurs when a man ejaculates into a partner’s mouth which has oral ulcers or bleeding gums, or when oral sex is performed in the presence of genital sores or other sexually transmitted diseases. Although the risk of transmission during oral sex is small, the risk of transmissions be further reduced with the use of a condom, which also reduces the risk of contracting sexually transmitted diseases such as gonorrhea of the throat and hepatitis. Condom use during vaginal and anal sex are also effective in reducing the risk of transmission of HIV.
Female and male condoms are available. The female condom is a thin pouch that is made up of synthetic latex that is called nitrile. It is worn by a woman in her vagina during sex and is comparable to the male condom in preventing HIV, sexually transmitted diseases, and pregnancy. The male condom is a thin layer of latex, polyisoprene, polyurethane, or natural membrane that is worn over the penis during sex. Like the female condom, latex is the most effective in preventing HIV transmission, sexually transmitted diseases, and pregnancy. For those who are allergic to latex, polyisoprene that is made of synthetic rubber, or polyurethane that is made of plastic are good options, but they are more prone to breaking than the latex condom. Natural membrane condoms have small pores and do not prevent the transmission of HIV or other sexually transmitted diseases. Water based and silicone lubricants can be used with a male condom, but oil-based lubricants such as Vaseline should not be used, because it can break down the lining of the latex condom, rendering it ineffective. Oil based lubricants can be used with the female condom without decreasing the effectiveness of the condom.
Pre-exposure prophylaxis (PrEP) are antiretroviral medications that are used by those who are HIV negative and have an increased risk of exposure to HIV through sexual activity or injectable drug use.¹⁰ When taken daily as prescribed, PrEPs greatly reduce the risk of HIV transmission through sexual contact by 99% and through injectable drug use by 74%. When the prescribed medications are not taken consistently, their efficacy in reducing the risk of HIV transmission greatly diminishes. They do require time for efficacy to build up in the system; pre-exposure prophylaxis reaches maximum protection from HIV at 7 days for receptive anal sex and 21 days for receptive vaginal sex and injectable drug use. There is no data available for insertive anal or vaginal sex efficacy¹. Pre-exposure prophylaxis medications must be taken daily for the duration of risk of HIV transmission. They can be stopped when the risk for HIV transmission decreases as a result in lifestyle changes, inability to PrEPs on a daily basis and another form of protection such as condoms is established, or when one has side effects to the medication that hinder its use. Side effects such as renal insufficiency and nausea have been documented with use of PrEPs, however the side effects have also been documented to diminish over time.¹⁰ An HIV test should be completed to confirm a negative HIV test prior to prescribing PrEP because resistant HIV can develop by administering PrEPs to one who is already HIV positive. The estimated creatine clearance should also be evaluated to confirm that it is ≥60 mL/minute prior to initiating therapy.³ Pre-exposure prophylaxis medications do not prevent the transmission of sexually transmitted diseases, in which case condom use is recommended. Pre-exposure prophylaxis medications also have not been shown to interfere with hormone therapy of transgender individuals and can be taken at the same time. Currently, Truvada is the only medication that is approved as a pre-exposure prophylactic to prevent the transmission of HIV. It is a combination drug that consists of tenofovir and emtricitabine and is commonly used in conjunction with other medications to treat HIV infection. Truvada works by blocking an enzyme called reverse transcriptase, HIV uses to copy its genetic material and reproduce.
Post-exposure prophylaxis (PEP) are antiretroviral medications that should be used by those who think they have been exposed to HIV through sex or injectable drug use.⁸ These medications are used to prevent HIV transmission and should be initiated within 72 hours of the possible exposure. They should be taken for 28 days; the frequency of medication use (daily or twice daily) is at the discretion of the prescribing provider⁸. Examples of recommended post-exposure prophylaxis regimens includes medications consisting of a dual nucleoside reverse transcriptase inhibitor (NRTI) backbone plus an integrase strand transfer inhibitor (INSTI), a protease inhibitor (boosted with ritonavir), or a non-nucleoside reverse transcriptase inhibitor.
Other antiretroviral drug combinations may be prescribed in specific cases, such as when one is exposed to a person who has drug resistant HIV. Post-exposure prophylaxis medications can be associated with severe side effects, and for this reason they should not be used when there is a negligible risk for HIV transmission. ⁸
| Nucleoside reverse transcriptase inhibitor (NRTI) | Work by targeting the structure of reverse transcriptase to inhibit enzyme activity. By inhibiting the enzymatic activity necessary for reverse transcription, NNRTIs successfully interfere with a one of the steps of the HIV life cycle and prevent the virus from being able to reproduce. |
| Integrase strand transfer inhibitor (INSTI) | Block the action of integrase, a viral enzyme of the human immunodeficiency virus Type 1 (HIV-1), that is involved in integrating viral DNA into the host chromosome. Integration of the viral DNA into the host DNA is necessary for viral replication. |
| Protease inhibitor (PI) | Block activation of an HIV enzyme called protease. The protease enzyme is involved in the synthesis of new viral particles, which can lead to the spread of HIV to uninfected cells. |
| Non-nucleoside reverse transcriptase inhibitor (NNRTI) | Bind to and block HIV reverse transcriptase that HIV uses to convert its RNA into DNA. Blocking reverse transcriptase and reverse transcription prevents HIV from replicating. |
| Fusion Inhibitor (FI) | Drugs that prevent HIV from entering the cells. |
| chemokine (C-C motif) receptor antagonist (CCR5) | Drugs that block the CCR5 coreceptor, preventing HIV from attaching to and entering the white blood cell. For this reason, doctors refer to CCR5 antagonists as entry inhibitors. |
| Medication Name | Dose | Classification | Side Effects | Benefits |
| Abacavir (Ziagen®; ABC) | ABC: 600 mg daily (available as a 300 mg tablet) Also available as component of fixed dose combination Epzicom®, dosed daily (300mg 3TC + 600mg ABC) Trizivir®, dosed twice daily (150mg 3TC + 300mg ABC + 300mg AZT | Nucleoside Reverse Transcriptase Inhibitor (NRTI) | Potential for life-threatening ABC hypersensitivity reaction (rash, fever, nausea, vomiting, diarrhea, abdominal pain, malaise, respiratory symptoms) in patients with HLA-B*5701; requires patient testing prior to use which may not be available nor practical prior to initiating PEP | Can be taken on an empty stomach |
| Atazanavir (Reyataz®; ATV) | ATV: 300 mg + RTV: 100 mg once daily (Preferred dosing for PEP^) ATV: 400 mg once daily without RTV (Alternative dosing- may not be used in combination with TDF) (available as 100, 150, 300, and 200 mg capsules) | Protease Inhibitor (PI) | Indirect hyperbilirubinemia and jaundice common Skin rash Nephrolithiasis Potential for serious or life-threatening drug interactions that may affect dosing. Absorption depends on low pH; Caution when co-administered with H2 Antagonists, antacids, and proton pump inhibitors PR interval prolongation Caution in patients with underlying conduction defects or on concomitant medications that can cause PR prolongation Must be given with food | Tolerated well |
| Darunavir (Prezista®; DRV) | DRV: 800 mg once daily + RTV: 100 mg once daily (Preferred dosing for PEP) DRV: 600 mg twice daily + RTV: 100 mg twice daily (Alternative dosing) | PI | Rash (DRV has sulfonamide moiety) Diarrhea, nausea, headache Hepatotoxicity Potential for serious or life-threatening drug interactions that may affect dosing Must be given with food and with RTV | Tolerated well |
| Efavirenz (Sustiva®; EFV) | EFV: 600 mg daily (available as 50, 200 mg capsules and 600 mg tablets) Also available as component of fixed dose combination Atripla®, dosed daily (200mg FTC + 300mg TDF + 600mg EFV) | Nonnucleoside Reverse Transcriptase Inhibitor (NNRTI) | Rash Neuropsychiatric side effects (e.g., dizziness, somnolence, insomnia, or abnormal dreaming) common; severe psychiatric symptoms possible (dosing before bedtime might minimize these side effects); use with caution in shift workers Do not use during pregnancy; Teratogen in nonhuman primates Potential for serious or life-threatening drug interactions that may affect dosing May cause false-positive results with some cannabinoid and benzodiazepine screening assays Take on an empty stomach | |
| Elvitegravir (EVG) | Available as a component of fixed dose combination Stribild™, dosed daily (150mg EVG + 150mg cobicistat + 300mg TDF + 200mg FTC) | Integrase Strand Transfer Inhibitor (INSTI) | Available as a component of fixed-dose Diarrhea, nausea, headache Nephrotoxicity; should not be administered to individuals with acute or chronic kidney injury or those with eGFR<70 Cobicistat is a pharmacokinetic enhancer to increase EVG exposures, has no antiviral activity, but is a potent CYP3A inhibitor Potential for serious or life-threatening drug interactions Must be given with food | Well tolerated Available as a complete regimen dosed once per day |
| Emtricitabine (Emtriva™; FTC) | 200 mg once daily (available as 200 mg capsule) Also available as component of fixed dose combination Atripla®, dosed daily (200mg FTC + 300mg TDF + 600mg EFV) Complera™, dosed daily (25mg RPV+ 300mg TDF + 200mg FTC) Stribild™, dosed daily (150mg EVG + 150mg cobicistat + 300mg TDF + 200mg FTC) Truvada™, dosed daily (200mg FTC + 300mg TDF) | NRTI | Rash perhaps more frequent than with 3TC Hyperpigmentation/skin discoloration If the PEP recipient has chronic hepatitis B, withdrawal of this drug may cause an acute hepatitis exacerbation | Well tolerated Minimal toxicity Minimal drug interactions Take without regard for food |
| Enfuvirtide (Fuzeon™; T20) | T20: 90 mg (1 ml) twice daily by subcutaneous injection (available as Single dose vial, reconstituted to 90 mg/ml) | Fusion Inhibitor (FI) | Local injection site reactions occur in almost 100% of patients Never studied among antiretroviralnaïve or HIV negative patients False-positive EIA HIV antibody tests might result from formation of antiT20 antibodies that cross-react with anti-gp41 antibodies Twice-daily injection | |
| Etravirine (Intelence®; ETR) | 200 mg twice daily (available as 100mg and 200mg tablets) | NNRTI | Rash (including SJS) and hypersensitivity (sometimes with organ dysfunction, including hepatic failure) Nausea Potential for serious or life-threatening drug interactions that may affect dosing Must be given with food | Well tolerated and has not had the same frequency of CNS side effects reported as EFV |
| Fosamprenair (Lexiva®; FOSAPV) | FOSAPV: 1400 mg daily + RTV: 100 mg once daily (Preferred dosing for PEP) FOSAPV: 1400 mg twice daily without RTV (Alternative dosing) (available as 700 mg tablets) | PI | Diarrhea, nausea, vomiting, headache, skin rash (FOSAPV has sulfonamide moiety) Potential for serious or life-threatening drug interactions that may affect dosing Oral contraceptives decrease FOSAPV concentrations Take with food if given with RTV | Well tolerated |
| Lamivudine (Epivir®; 3TC) | 3TC: 300 mg once daily (Preferred dosing for PEP) 3TC: 150 mg twice daily (Alternative dosing) (available as a 150 or 300 mg tablet) Also available as component of fixed dose combination generic lamivudine/zidovudine, dosed twice daily (150mg 3TC + 300mg AZT) (300mg 3TC + 600mg ABC) Trizivir®, dosed twice daily (150mg 3TC + 300mg ABC + 300mg AZT) Combivir®, dosed twice daily (150mg 3TC + 300mg AZT) Epzicom®, dosed daily | NRTI | If the PEP recipient has chronic hepatitis B, withdrawal of this drug may cause an acute hepatitis exacerbation | Well tolerated Minimal toxicity Minimal drug interactions Take without regard for food |
| Lopinavir/ritonavir (Kaletra®; LPV/RTV) | Kaletra®: 400/100 mg = 2 tablets twice daily (Preferred dosing for PEP) Kaletra®: 800/200 mg = 4 tablets once daily (Alternative dosing) (available as 200/50 mg tablets) | PI | GI intolerance, nausea, vomiting, diarrhea is common PR and QT interval prolongation have been reported. Use with caution in patients at risk of cardiac conduction abnormalities or receiving other drugs with similar effect. Potential for serious or life-threatening drug interactions that may affect dosing | Take without regard to food |
| Maraviroc (Selzentry®; MVC) | MVC: 300 mg twice daily (dose may need adjustment by expert consultant if on concomitant CYP3A inducers) (available as 150 and 300 mg tablets) | CCR5 Coreceptor Antagonist | Abdominal pain, cough, dizziness, musculoskeletal symptoms, pyrexia, rash, orthostatic hypotension Hepatotoxicity which may present with an allergic reaction including rash. Requires HIV tropism testing of source virus before treatment to ensure CCR5 tropic virus and efficacy, which may not be available nor practical prior to initiating PEP Potential for serious or life-threatening drug interactions that may affect dosing Dose adjustments for MVC required when given with potent CYP3A inhibitors or inducers | Well tolerated |
| Raltegravir (Isentress®; RAL) | 400 mg twice daily (available as 400 mg tablet) | INSTI | Insomnia, nausea, fatigue, headache, severe skin, and hypersensitivity reactions have been reported | Well tolerated Minimal drug interactions Take without regard for food |
| Rilpivirine (Edurant™; RPV) | 25 mg once daily (available as 25mg tablets) Also available as component of fixed dose combination Complera™, dosed daily (25mg RPV + 300mg TDF + 300mg FTC) | NNRTI | Depression, insomnia, rash, hypersensitivity, headache Potential for serious or life-threatening drug interactions that may affect dosing Caution when co-administered with H2 antagonists and antacids Coadministration with proton pump inhibitors is contraindicated Use RPV with caution when co-administered with a drug having a known risk of torsade’s de pointes. Must be given with food | Well tolerated and fewer rashes and fewer discontinuations for CNS adverse effects compared to EFV Available as a complete regimen dosed once per day |
| Saquinavir (Invirase®; SQV) | SQV: 1,000 mg + RTV: 100 mg twice daily (Preferred dosing for PEP) (available as 500 mg tablets) | PI | GI intolerance, nausea, diarrhea, headache Pretreatment ECG recommended SQV/r is not recommended for patients with any of the following conditions: (1) congenital or acquired QT prolongation; (2) pretreatment ECG >450 msec; (3) on concomitant therapy with other drugs that prolong QT interval; (4) complete AV block without implanted pacemakers; (5) risk of complete AV block. PR and QT interval prolongations, torsade’s de pointes have been reported Potential for serious or life-threatening drug interactions that may affect dosing | Well-tolerated, although GI events commonMust be given with food |
| Stavudine (Zerit®; d4T) | d4T: 40 mg twice daily if body weight is >60 kg d4T: 30 mg twice daily if body weight is <60 kg (available as 15, 20, 30, and 40 mg tablets) | NRTI | GI side effects include diarrhea and nausea Hepatotoxicity, neurologic symptoms (e.g. peripheral neuropathy), and pancreatitis | Take without regard for food |
| Tenofovir DF (Viread®; TDF) | 300 mg once daily (available as 300 mg tablet) Also available as component of fixed dose combination Atripla®, dosed daily (200mg FTC+ 300mg TDF + 600mg EFV) Complera™, dosed daily (25mg RPV + 300mg TDF + 200mg FTC) Stribild™, dosed daily (150mg EVG + 150mg cobicistat + 300mg TDF + 200mg FTC) Truvada™, dosed daily (200m | NRTI | Asthenia, headache, diarrhea, nausea, vomiting Nephrotoxicity If the PEP recipient has chronic hepatitis B, withdrawal of this drug may cause an acute hepatitis exacerbation Drug interactions | Well tolerated Take without regard for food |
| Zidovudine (Retrovir®; ZDV; AZT) | AZT: 300 mg twice daily (available as 100 mg capsule or 300 mg tablet) Also available as component of fixed dose combination generic lamivudine/zidovudine, dosed twice daily (150mg 3TC + 300mg AZT) Combivir®, dosed twice daily (150mg 3TC + 300mg AZT) Trizivir®, dosed twice daily (150 mg 3TC 300mg ABC + 300mg AZT) | NRTI | Side effects (especially nausea, vomiting, headache, insomnia, and fatigue) common and might result in low adherence Anemia and neutropenia | Take without regard for food |
A healthcare provider is anyone who works in the healthcare setting and is at risk for exposure to infectious materials such as blood, body fluids, tissue, contaminated equipment and medical supplies, and contaminated surfaces.⁸ The types of exposure that can place a healthcare provider at risk to HIV transmission include needle sticks, cuts from sharp objects, exposed nonintact skin that is chapped, cut, or has dermatitis that comes into contact with blood, body fluids, or tissues of an infected person. Cerebral spinal fluid, amniotic fluid, peritoneal fluid, synovial fluid, pericardial fluid, and pleural fluid all pose a potential risk of HIV infection. Unless visibly bloody, feces, urine, sputum, vomitus, tears and sweat are not considered infection.
There is a risk for HIV transmission to the healthcare provider who is punctured by a needle that is contaminated with HIV blood, however the risk is small at 0.3%.¹ Mucous membrane exposure yields 0.09% chance of transmission.¹ The risk for HIV exposure from nonintact skin is minimally quantifiable, but per the Center for Disease Control, the risk is less than mucous membrane exposure. The HIV transmission risk is increased when the healthcare provider is exposed to large quantities of HIV infected blood from needles that were placed in veins or arteries, or persons with high viral loads, such as in AIDS. The higher the viral load in the blood (even in a needle), the higher the risk for HIV transmission. The risk for HIV transmission also exists when one who is HIV positive has an undetectable viral load. This is because the HIV RNA (plasma viral load) is reflective of what is in the blood, however HIV is still present in infected cells despite treatment with antiretroviral drugs. The risk of transfer is small, but because a risk for HIV transmission exists, post-exposure prophylaxis should be offered to the healthcare provider who has been exposed.
The Center for Disease Control has recommendations for a healthcare provider’s occupational exposure to HIV. The recommendations are as follows¹⁰:
- Begin post-exposure prophylaxis as soon as possible (within 72 hrs.) of HIV exposure. The medications should be taken for four weeks. If after treatment the healthcare provider is found to not have acquired HIV, treatment and consultation can be discontinued.
- Determine the HIV status of the source to determine the need for post-exposure prophylaxis (when possible). It this is not feasible, begin post-exposure prophylaxis immediately.
- Post-exposure treatment regimens should include three different antiretroviral drugs prescribed by a specialist. The recommendation by the CDC for use of three-drug HIV Post-exposure prophylaxis regimens reflects.
- Studies that have demonstrated superior effectiveness of three medication regimens in reducing viral load in those with HIV when compared with two medication regimens.
- Concerns about a HIV source patient’s drug-resistance to medications that are commonly used for postexposure prophylaxis.
- New HIV medications safety and ability to be tolerated.
- The likelihood for better adherence to medication regimens because of fewer side effects.
- Expert consultation is recommended for any person exposed to HIV.
- Close monitoring of the exposed personnel should include counseling, baseline, and follow-up HIV testing, and monitoring for drug toxicity. The follow-up appointments should begin 72 hours after the regimen is began.
- If a newer generation combination HIV p24 antigen-HIV antibody is used for follow-up HIV testing may be completed 4 months after the exposure. If no newer test is available, HIV follow-up testing may be completed at 6 months.
Human immunodeficiency Virus (HIV) poses the risk of transmission through various activities such as sex, drug use, and occupational exposure. Multiple HIV prevention options are available and every healthcare provider who is exposed to or has HIV should learn about all options for the prevention of transmission. The benefits of ongoing treatment include supporting antiretroviral adherence, maintaining decreased viral load, and maintaining an increased CD4 count, which can lower the rates of HIV progression to AIDS, and improving overall health.Should a healthcare provider be exposed to HIV during occupational exposure, they should follow their institution’s recommendations for guidance, which has been set forth by guidelines created by the CDC. The guidelines include timelines and exceptions for testing, treatment regimens, and post-exposure monitoring. Healthcare providers should also take comfort in the low risk of HIV transmission during occupational exposure, as it is 0.3%¹ through needle puncture that is contaminated with HIV blood, and 0.09%¹ through mucous membrane exposure.
- About HIV/AIDS. (2019, December 2). Retrieved from https://www.cdc.gov/hiv/basics/whatishiv.html
- Becasen, J. S., Denard, C. L., Mullins, M. M., Higa, D. H., & Sipe, T. A. (2019). Estimating the prevalence of HIV and sexual behaviors among the US transgender population: A systematic review and meta-analysis, 2006–2017. American Journal of Public Health, 109(1), e1-e8. doi:10.2105/ajph.2018.304727
- Bernard M., B., S. Michele, O., Laura G., W., Berry, B., Barbara G., W., Kelly E., W., … Michael A., P. (2014). Laboratory testing for the diagnosis of HIV infection: Updated recommendations. doi:10.15620/cdc.23447
- Charles Patrick Davis, MD, PhD. (n.d.). ELISA test results, types & procedure risks. Retrieved from https://www.medicinenet.com/elisa_tests/article.htm
- Guidelines for prophylaxis against pneumocystis carinii pneumonia for persons infected with human immunodeficiency virus. (2001, May 2). Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/00001409.htm
- History of HIV and AIDS overview. (2019, October 10). Retrieved from https://www.avert.org/professionals/history-hiv-aids/overview
- HIV basics. (2019, September 25). Retrieved from https://www.cdc.gov/hiv/basics/index.html
- Kuhar, D. T., Henderson, D. K., Struble, K. A., Heneine, W., Thomas, V., Cheever, L. W., … Gomaa, A. (2013). Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for Postexposure prophylaxis. Infection Control & Hospital Epidemiology, 34(9), 875-892. doi:10.1086/672271
- Opportunistic infections | Living with HIV | HIV basics | HIV/AIDS | CDC. (2019, September 26). Retrieved from https://www.cdc.gov/hiv/basics/livingwithhiv/opportunisticinfections.html
- Prescribe PrEP pre-exposure prophylaxis. (n.d.). Retrieved from https://www.cdc.gov/stophivtogether/library/prescribe-hiv-prevention/brochures/cdc-lsht-php-brochure-prep-faq.pdf
- Sabin, C. A., & Lundgren, J. D. (2013). The natural history of HIV infection. Current Opinion in HIV and AIDS, 1. doi:10.1097/coh.0b013e328361fa66
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