1. Spectrum of HIV Disease
ACUTE STAGE Flu like symptoms – 1 to 2 weeks ASYMPTOMATIC PERIOD No physical symptoms – 8 to 11 years HIV ILLNESS Night sweats, fatigue, diarrhea, fever, yeast infections, swollen lymph nodes AIDS Opportunistic Infections, CD4<200 1

2. 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 minutes Test settings Anonymous Confidential 2

3. HIV Diagnosis (Testing)
Antibody tests
EIA (or ELISA)
Western Blot
Rapid Tests
OraQuick Advance *
Unigold *
Clearview Stat Pak & Stat Pak Complete *
* These tests are “waived” under CLIA
Most commonly used HIV tests look for antibodies to HIV.
Antibodies usually form within 2-12 weeks after infection but sometimes not until 6 months.
ELISA (or EIA) stands for Enzyme linked Immunosorbent Assay. HIV antibodies in the test serum are detected using an antibody sandwich capture technique. Essentially, HIV antibodies, if present, in the test serum are ‘sandwiched’ between HIV antigen, which is fixed to the test well, and to ‘enzymes’ that are added to the test well following addition of the test serum. The test well is washed thoroughly to remove any unbound enzyme. A color reagent is then added to the well. Any bound enzyme will catalyze a change in color in this reagent. The presence of HIV antibodies is thus inferred from the change in color.
Western Blot: HIV antibodies in the test serum are detected by reacting to a variety of viral proteins. The viral proteins are initially separated into bands according to their molecular weight on an electrophoresis gel. These proteins are then transferred or ‘blotted’ to nitrocellulose paper. The paper is then incubated with the patient’s serum. HIV antibodies to specific HIV proteins bind to the nitrocellulose paper at precisely the point to which the target protein migrated. Bound antibodies are detected by colorimetric techniques.
The standard of care for US testing is to have the HIV + result with EIA confirmed with another EIA and the Western Blot.
FDA approved rapid tests are all % sensitive and 97-99% specific
They need to be confirmed with EIA and Western blot before they are considered to be more than just “Preliminary.” Research is being conducted to determine if one rapid test can be used to confirm the results of another brand.
A test “waived” under CLIA basically allows a test to be performed in settings other than a laboratory if quality assurance guidance is met and the test is performed by qualified personnel. 3

4. HIV Diagnosis (Testing)
Other tests
p24 antigen test
Viral load tests
Proviral DNA
PCR RNA
Home kits
p24 is a protein from the core of HIV and is found during the early stages of HIV infection. It peaks along with viral load and is detectable before the antibody response is triggered. For this reason it is used to test blood for transfusion. Once the antibody response is triggered, p24 is often not detectable because of complexing with HIV antibodies.
Viral Load tests are not commonly used for HIV screening except in the adult film industry or screening the blood supply where detecting early infection is critical to stopping an outbreak.
Proviral DNA tests, proviral DNA is formed during the process of reverse transcription, when viral RNA is converted into DNA just prior to insertion into the T cell’s *or other infected cell’s) nuclear DNA. Laboratory methods use Polymerase Chain Reaction method for amplification. Proviral DNA tests may actually detect HIV infection at lower levels than PCR RNA tests.
PCR RNA test viral RNA is extracted from the patient's plasma and is treated with reverse transcriptase so that the RNA of the virus is transcribed into DNA. The polymerase chain reaction (PCR) is then applied, using two primers thought to be unique to the virus's genome. After the PCR amplification process is complete, the resulting amplified segments bind to specific oligonucleotides bound to the vessel wall and are then made visible with a probe bound to an enzyme. The amount of virus in the sample can be quantified with sufficient accuracy to detect three-fold changes
Home kits involve collecting a sample and mailing it to a laboratory and getting results by phone or mail No rapid tests are FDA approved for home use as of yet. 4

5. HIV TEST Informed Consent 12 yrs of age or older
Benefits of Testing……..
Where to test?
Private medical doctor
County clinic
Community-based organizations 5

6. 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. 6

7. 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. 7

8. 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. 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 8

9. PREVENTION Abstinence Safer Sex Needle use Harm reduction
“It is not who we are but what we do that puts us at risk for HIV infection”
Abstinence
Safer Sex
Male Condom (Activity)
Female Condom
Dental Dams
Needle use
Not Sharing Needles
Cleaning Needles (3x3x3 Method)
Needle Exchange
Harm reduction 9

10. PREVENTION Universal Precautions
“Infection control measures that reduce the risk of transmission of blood-born germs from patients to health care workers”
Wash hands thoroughly
Wear latex gloves
Use masks and eye protection
Wear a gown
Carefully handling and disposing of sharp instruments during and after use. 10

11. PREVENTION POST–EXPOSURE PROPHYLAXIS (PEP)
Exposure to HIV within the prior 72 hours
Approve for 13 yrs of age or older
For more information call
PRE-EXPOSURE PROPHYLAXIS (PREP)
It refers to anti-HIV medication used daily or before
sexual encounters
Start prior to potential exposure
Prep should never be seen as the first line of defense against HIV
BREAST FEEDING
It is recommended that HIV+ women do not breastfeed
Infants. 11

12. 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). 12

13. TREATMENT What are Anti-retrovirals (ARVs) ?
HIV Critical Issues 2011
TREATMENT
What are Anti-retrovirals (ARVs) ?
Drugs that interrupt HIV replication & preserve immune system.
When to start ARVs?:
There are severe symptoms of HIV infection or
diagnosis of AIDS with a CD4 count of < 350 cells/mm3
Patient has CD4 count less than 500 /mm3
Recommended for pregnant women who otherwise do not meet criteria to halt vertical transmission
Regardless of CD4 count, treatment is recommended for all pregnant patients, and patients with HIV-associated nephropathy (a kidney disorder) or those who need treatment for hepatitis B.
Treatment is considered optional for patients with CD4 counts over 500. 13 13

14. Current classes of Anti-HIV medications
HIV Critical Issues 2011
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 14 14

15. Who Pays For Treatment? HMO insurance Medi-Cal Medicare Part D ADAP
Shared cost 15

16. Recent Advancements Immune based therapies Maturation inhibitors
Multi-class Combination Products
Gene Therapy
Vaccine 16

17. Treatment as Prevention
Science Magazine named 'HIV Treatment as Prevention' as the breakthrough of 2011
The HIV Prevention Trials Network (HPTN)
052 study of 1,700 sero-discordant couples reported that ARVs reduced the risk of heterosexual transmission by 96%. 17

18. Complementary Therapy
General Health Maintenance
Psychological Well-Being
Spiritual Well-Being
Social Well-Being 18

19. For More Information Contact
Jason Dawson, MPH