NURS 330 - Schedule for 4/28/14 HIV Lecture – Disly Juarez, MPH Return and Review Quiz Group Activity Distribute Study Guide for 5/5/14 Mid-term In-Class Assignment

The State of the HIV/AIDS Epidemic County of Los Angeles Department of Public Health Division of HIV and STD Programs Disly Juarez, MPH Health Educator djuarezmunoz@ph.lacounty.gov 2 2

MYTHS AND FACTS ABOUT HIV/AIDS

Video: Myths/Facts about HIV

Myth/Fact? HIV is the same as AIDS

Human Immunodeficiency Virus Acquired ImmunoDeficiency Syndrome HIV vs AIDS HIV AIDS What it stands for Human Immunodeficiency Virus Acquired ImmunoDeficiency Syndrome What it is A virus: an agent that replicates inside a living cell A syndrome: a collection of multiple symptoms or characteristics that often occur together How it is diagnosed A test that shows HIV antibodies or antigens in a person’s blood or saliva HIV positive test A T- Cell count of < 200 -OR- 1 or more opportunistic infections

AIDS Criteria (CDC) OR YES HIV positive test AND a T-Cell count of <200 or 14% (healthy T-Cell count ranges from 800-1200) OR HIV positive test AND one or more opportunistic infections (OIs)/certain cancers If the T-Cell count goes up, or the opportunistic infection goes away, does the person still have AIDS? YES

HIV & the Immune System Over time HIV can lead to AIDS HIV attacks the T cells (aka CD4 cells) weakening the immune system Over time HIV can lead to AIDS

Special Characteristics of HIV Weakens and compromises the immune system HIV replicates in large quantities Ability to mutate (change itself) very quickly

HIV only affects gay men and drug users Myth/Fact? HIV only affects gay men and drug users

with HIV (including AIDS) in LAC Estimated Number of Persons Living with HIV and AIDS in LAC at End of 2013 Estimate ~ 60,050 persons living with HIV (including AIDS) in LAC 13,250 1,500 3,200 9,500 3,200 16,155 50,550 We estimate that over 60,000 persons were living with HIV in Los Angeles County at the end of 2013. Nearly 10,000 of whom are unaware of their infection.   The footnotes: 1. The CDC estimates 15.8% of PLWH are unaware of their infection. 2. The number reported here includes (1) half of our pending lab notifications and (2) half of our coded cases, that we believe represent real cases of HIV, but have not yet reported as a case in our registry by name. Estimate ~ 61,700 living with HIV & AIDS in LAC 25,895 (1) CDC estimates 15.8% of persons with HIV are unaware of their infection. (2) Reported cases includes half of 3,500 lab reports pending investigation and half of 3,300 cases reported to us only by code likely to result in unduplicated named cases. Source: LAC Division of HIV and STD Programs, reported as of 12/31/13. 11

Impact on Los Angeles County LA County is second only to NYC among US metropolitan areas in cumulative number of reported AIDS cases Only 4 states (CA, TX, NY, FL) have reported more AIDS cases than LAC 42% of all California AIDS cases are reported from LAC in 2010

Persons living with HIV Infection from HIV/AIDS Annual Surveillance Summary Jurisdiction No. living with HIV/AIDS U.S. (50 states) 872,990* California 117,695** LA County 45,474 *** *Reported as of 2011, CDC. HIV Surveillance Report, Volume 23(1), February 28, 2013 ** Reported as of 12/31/12, California Office of AIDS, HIV/AIDS Surveillance Section. *** Report as of 12/31/12, LAC Division of HIV/STD Programs

Transmission Category for Persons Living with HIV/AIDS as of December 31, 2012 by Gender in Los Angeles County Male (n=40,315) Female (n=5,159) * Persons with an undetermined transmission category are assigned a risk factor using multiple imputation (MI) methods. Other risks include hemophilia or coagulation disorder, transfusion recipient, perinatal exposure and confirmed other risk. ** Data are provisional due to reporting delay Source: HIV/AIDS Surveillance Summary, data as of December 2012.

Persons Living with HIV/AIDS in LAC per 100,000 population Persons Living with HIV/AIDS in LAC per 100,000 population* by Race/Ethnicity *Sometimes called “Prevalence Rate”; it is really a proportion. Source: HIV/AIDS Surveillance Summary, data as of 12/31/2012.

Once a person is diagnosed with HIV/AIDS, they will die soon Myth/Fact? Once a person is diagnosed with HIV/AIDS, they will die soon

HIV Spectrum of Disease Exposure No infection Asymptomatic Infection Window period* Asymptomatic Initial Symptoms Lasts a few weeks Mild flu-like symptoms: Fever Muscle aches Swollen glands Asymptomatic Period 8 - 11 years (Average progression, may vary depending on the person) HIV Illness Symptoms include: Night sweats Fevers Fatigue Diarrhea Swollen lymph nodes Oral and vaginal candidiasis PID Pap Smear positive for HPV AIDS T-Cells <200 1 or more OIs (PCP, KS, TB, CMV, Candidiasis, etc.) Wasting syndrome HIV-related dementia *Window Period: average time it takes the body to produce antibodies; usually 2 - 12 weeks, up to 6 months - 1 year (rare)

Common Opportunistic Infections Pneumocystis Carinii Pneumonia (PCP) CMV Infection HIV Wasting Syndrome Candidiasis (oral, esophageal, vaginal) Kaposi’s Sarcoma Tuberculosis HIV - Related Dementia Cervical Cancer

Casual contact CANNOT put you at risk for HIV Myth/Fact? Casual contact CANNOT put you at risk for HIV

You CANNOT get HIV from… Breathing Drinking fountains Coughing Telephones Sneezing Toilet seats Kissing Pools/Tubs Hugging Mosquito bite Shaking hands Giving/donating blood in US Sharing food or drinks

HIV Transmission Semen, Pre-cum Vaginal Secretions Breast Milk Blood Infected Body Fluids 1 2 3 4 Semen, Pre-cum Vaginal Secretions Breast Milk Blood HIV is NOT transmitted by urine, feces, saliva, sweat, tears or giving/donating blood.

HIV Transmission Unprotected Sex 1 2 3 Anal Vaginal Oral

HIV Transmission Insulin, hormone, vitamin shots Injection Drug Use Exchanging Infected Blood : 1 2 3 4 Insulin, hormone, vitamin shots Injection Drug Use Piercing/ Tattooing Acu-puncture Sharing needles for any purpose

HIV Transmission Mother To Child Transmission during pregnancy (in uterus) during birth process (delivery) breastfeeding (through breast milk/blood) *Perinatal transmission can be significantly reduced to less than 2% with proper care

TIME FOR AN ACTIVITY  “The Spectrum of Risk”

Having another STD puts a person at greater risk for contracting HIV Myth/Fact? Having another STD puts a person at greater risk for contracting HIV

STD infection increases risk of contracting HIV (susceptibility) STDs and HIV STD infection increases risk of contracting HIV (susceptibility) STDs cause breaks in the skin on and surrounding the penis, vagina and anus, which provides a perfect entry way for HIV STDs increase the concentration of “infection fighting” CD4 cells in genital secretions, a favorite target of HIV -

STDs and HIV STD infection increases risk of passing HIV to a partner (infectiousness) HIV+ men who are also infected with an STD have much more HIV in their semen than HIV+ men without an STD + HIV+ individuals who are also infected with an STD have more HIV in their genital secretions ? ? ?

Myth/Fact? HIV testing is unnecessary because I would know if my lover or I had it

HIV TEST HIV Antibody test Accuracy of the test Types of tests Looks for antibodies Accuracy of the test 99.9% Types of tests Standard test – results will be known in 1 week Rapid test – results will be known in 20-40mins

HIV TEST - Uni-Gold Recombigen HIV- results will be known in 10 min. Other Test - Uni-Gold Recombigen HIV- results will be known in 10 min. - Reveal G3 Rapid HIV-1 results will be known in 3 minutes - Multispot HIV 1/HIV-2- results will be known in 15 mi. - Clearview HIV 1/2 Stat-Pak - results will be known in 15 mi. - Clearview Complete HIV 1/2- results will be known in 15 mi. - Insti HIV-1- results in as little as 60 seconds FDA has, for the first time, approved an over-the-counter HIV Rapid test (Oraquick) for home use.  Test settings Anonymous Confidential

HIV TEST Informed Consent 12 yrs of age or older Benefits of Testing…….. Where to test? Private medical doctor County clinic Community-based organizations www.hivla.org 1-800-367-AIDS (2437)

A person who is HIV positive must tell partners their status Myth/Fact? A person who is HIV positive must tell partners their status

What are the differences between ethical and legal aspects?

California’s “Willful Exposure” Law (1998) aka “Recalcitrant Behavior”: Willfully exposing another to HIV through unprotected sex 8 years of imprisonment Intention to infect others with HIV through sex To be prosecuted under the law, one would have to do ALL of the following: Have anal or vaginal sex Know that they are HIV + Fail to disclose their HIV status Fail to use a condom Have a specific intent to infect another person Actual knowledge of HIV infection without more evidence of “specific intent” is insufficient for prosecution.

CONFIDENTIALITY LAWS Disclosing a person’s HIV+ status to a third party without the individual’s specific signed consent, is illegal; Penalties and damages for unauthorized disclosure of HIV status is a $5,000-$10,000 fine and/or jail sentence.  

FEDERAL ANTI-DISCRIMINATION LAWS Rehabilitation Act of 1973 and American with Disabilities Act (ADA) 1990 Prohibits discrimination against a person with a disability, including HIV disease or AIDS. infection. This prohibits discrimination with regards to employment, public services, public accommodations, and medical care. Housing Discrimination Care Discrimination A doctor or dentist cannot refuse to treat an HIV+ person California Anti-Discrimination Laws Fair Employment and Housing Act (FEHA) and Unruh Civil Rights Act

that puts us at risk for HIV infection PREVENTION It is not who we are but what we do that puts us at risk for HIV infection

The Prevention “Toolbox” Abstinence Safer Sex Male Condom (Activity) Female Condom Dental Dams Safer Needle Use Not Sharing Needles Cleaning Needles (3x3x3 Method) Needle Exchange Harm Reduction

PREVENTION: Abstinence Abstinence: not having sex of any kind or sharing needles. Not exchanging any bodily fluids is the only 100% sure way to avoid becoming infected with HIV. If one is not going to abstain, what other options do they have?

PREVENTION: Needle use Needle Exchange van in Berkley, CA

PREVENTION: Standard Precautions Infection control measures that reduce the risk of transmission of blood-born germs from patients to health care workers Wash hands thoroughly Wear gloves Use masks and eye protection Wear a gown Carefully handling and disposing of sharp instruments during and after use.

TREATMENT

TREATMENT Goals of HIV/AIDS treatment: Reduce HIV-related morbidity and prolong survival, Improve quality of life, Restore the immune system, Suppress the viral load, and Prevent vertical HIV transmission (mother to child).

TREATMENT What are Anti-retrovirals (ARVs) ? Anti-retrovirals are drugs that interrupt the HIV replication process and help preserve the health of the immune system These drugs must be taken in combinations in order to have a lasting effect. The three drug combination is commonly known as a “triple cocktail” Using a combination of anti-retrovirals creates multiple obstacles to HIV replication. This is designed to keep the virus from replicating freely and reduce the possibility of a mutation.

When to start anti-HIV medications? 2 schools of thought: Treatment should begin if there are severe symptoms of HIV infection or a diagnosis of AIDS with a CD4 count of 350 cells/mm3 or less Starting treatment immediately following diagnosis Because of the complexity of selecting and following a regimen, the severity of the side-effects, and the importance of compliance to prevent resistance, it is extremely important to engage patients in treatment decisions.

Current classes of Anti-HIV medications Nucleoside Reverse Transcriptase Inhibitors (NRTIs) Non-Nucleoside Reverse Transcriptase Inhibitors (NRTIs) Protease Inhibitors Entry inhibitors Fusion inhibitors Integrase inhibitors

Who Pays For Treatment? HMO insurance Medi-Cal Medicare Part D ADAP Shared cost

Complementary Therapy General Health Maintenance Psychological Well-Being Spiritual Well-Being Social Well-Being

Recent advancements Immune based therapies Maturation inhibitors Multi-class Combination Products Gene Therapy Vaccine

QUESTIONS?

For More Information Contact http://publichealth.lacounty.gov/dhsp/ Disly Juarez, MPH djuarezmunoz@ph.lacounty.gov 213-351-8102