1. April 27, 2015 – NURS 330 Turn in info for Group Project: – Group Name -and- – Names of Group Members Guest Lecture: HIV/AIDS – Amber Wilburn, PhD, LA County Public Health Review 4/13/15 In-Class Assignment Review Mid-term and Extra Credit

2. 2 County of Los Angeles Department of Public Health Division of HIV and STD Programs Amber Wilburn, PhD Health Educator amwilburn@ph.lacounty.gov The State of the HIV/AIDS Epidemic

3. MYTHS AND FACTS ABOUT HIV/AIDS 3

4. Myth/Fact? HIV is the same as AIDS 4

5. HIV vs AIDS 5 HIVAIDS 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

6. AIDS Criteria (CDC) 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 6 If the T-Cell count goes up, or the opportunistic infection goes away, does the person still have AIDS?

7. Special Characteristics of HIV  Weakens and compromises the immune system  HIV replicates in large quantities  Ability to mutate (change itself) very quickly 7

8. Myth/Fact? HIV only affects gay men and drug users 8

9. 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 9

10. Myth/Fact? Once a person is diagnosed with HIV/AIDS, they will die soon 10

11. 11 HIV Spectrum of Disease Exposure No infection Asymptomatic Initial Symptoms Lasts a few weeks Mild flu-like symptoms: Fever Muscle aches Swollen glands Infection Window period* Asymptomatic *Window Period: average time it takes the body to produce antibodies; usually 2 - 12 weeks, up to 6 months - 1 year (rare) 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

12. Common Opportunistic Infections  Pneumocystis Jiroveci Pneumonia (PJP)  Formerly Pneumocystis Carinii Pneumonia (PCP)  CMV Infection  HIV Wasting Syndrome  Candidiasis (oral, esophageal, vaginal)  Kaposi’s Sarcoma  Tuberculosis  HIV - Related Dementia  Cervical Cancer 12

13. Myth/Fact? Casual contact CANNOT put you at risk for HIV 13

14. You CANNOT get HIV from… Breathing Coughing Sneezing Kissing Hugging Shaking hands Sharing food or drinks Drinking fountains Telephones Toilet seats Pools/Tubs Mosquito bite Giving/donating blood in US 14

15. HIV Transmission HIV is NOT transmitted by urine, feces, saliva, sweat, tears or giving/donating blood. 15 132 4 Infected Body Fluids

16. HIV Transmission 16 132 Unprotected Sex

17. HIV Transmission 17 Piercing/ Tattooing Insulin, hormone, vitamin shots Acu- puncture 132 4 Exchanging Infected Blood Sharing needles for any purpose

18. 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 18

19. TIME FOR AN ACTIVITY “The Spectrum of Risk” 19

20. Myth/Fact? Having another STD puts a person at greater risk for contracting HIV 20

21. 21 STDs and HIV STDs increase the concentration of “infection fighting” CD4 cells in genital secretions, a favorite target of HIV STDs cause breaks in the skin on and surrounding the penis, vagina and anus, which provides a perfect entry way for HIV STD infection increases risk of contracting HIV (susceptibility) -

22. HIV+ individuals who are also infected with an STD have more HIV in their genital secretions STDs and HIV 22 HIV+ men who are also infected with an STD have much more HIV in their semen than HIV+ men without an STD STD infection increases risk of passing HIV to a partner (infectiousness) + ? ??

23. Myth/Fact? HIV testing is unnecessary because I would know if my lover or I had it 23

24. HIV TEST HIV Antibody test  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 24

25. HIV TEST 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 25

26. 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) 26

27. Myth/Fact? A person who is HIV positive must tell partners their status 27

28. What are the differences between ethical and legal aspects? 28

29. 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. 29

30. 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. 30

31. 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 31 FEDERAL ANTI-DISCRIMINATION LAWS

32. PREVENTION 32 It is not who we are but what we do that puts us at risk for HIV infection

33. The Prevention “Toolbox” 1.Abstinence 2.Safer Sex Male Condom (Activity) Female Condom Dental Dams 3.Safer Needle Use Not Sharing Needles Cleaning Needles (3x3x3 Method) Needle Exchange 4.Harm Reduction 33

34. 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? – Monogamous relationship – Using barriers (Safer Sex) 34

35. PREVENTION: The Female Condom The female condom Needle exchange

36. 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. 36

37. TREATMENT 37

38. 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). 38

39. 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. 39

40. When to start anti-HIV medications? 2 schools of thought: 1.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 2.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. 40

41. Current classes of Anti-HIV medications  Entry inhibitors  Fusion inhibitors  Non-Nucleoside Reverse Transcriptase Inhibitors (NRTIs)  Nucleoside Reverse Transcriptase Inhibitors (NRTIs)  Protease Inhibitors  Integrase inhibitors 41

42. Who Pays For Treatment?  HMO insurance  Medi-Cal  Medicare Part D  ADAP  Shared cost 42

43. Complementary Therapy  General Health Maintenance  Psychological Well-Being  Spiritual Well-Being  Social Well-Being 43

44. Treatment as Prevention  What is ‘Treatment as Prevention’?  The use of antiretroviral drugs (ARVs)in HIV-positive individuals to reduce the risk of transmitting the virus to others  How does ‘Treatment as Prevention’ work?  Consistent use of ARVs lowers an HIV positive person’s viral load. Less virus in the body means less virus to be transmitted. In general, people who have a suppressed viral load (<200 copies/ml) are much less likely to transmit HIV to sex and/or needle sharing partners Large international study of serodiscordant couples showed ART for the HIV infected partner reduced HIV transmission by 96% (Cohen et al, NEJM 2011) 44

45. PEP vs. PrEP PEPPrEP What it stands for What it is Use of 2-3 ARVs AFTER HIV exposure Use of 2 ARVs taken BEFORE HIV exposure Who it’s for HIV negative person exposed to HIV during a single event HIV negative person engaging in high risk activities who may be unable to use other prevention methods When to take it Within 72 hours after exposure and for 28 days thereafter 7 days before an exposure and daily until risk goes away Where to get it Emergency rooms, Intensive care units, Primary doctor In LAC: Oasis Clinic and LA LGBT Center Doctor, certain clinics where PrEP studies are being done 45

46. Recent Advancements  Maturation inhibitors  Multi-class Combination Products  Immune based therapies  Gene Therapy  Vaccine 46

47. QUESTIONS? 47

48. For More Information, Contact: http://publichealth.lacounty.gov/dhsp/ Amber Wilburn, PhD amwilburn@ph.lacounty.gov 213-351-8094