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Duval County Medical Society CME Portal, September 2019
Date of Release: Sept. 1, 2019
Date Credit Expires: Sept. 1, 2021
Estimated Completion Time: 1 hour
The Duval County Medical Society (DCMS) is proud to provide its members with free continuing medical education (CME) opportunities in subject areas mandated and suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). This month, the DCMS CME Portal includes an article, “An Update on the Epidemiology, Transmission, and Prevention of HIV/AIDS” authored by Ross Jones, MD, MPH, FAAFP, which has been approved for 1 AMA PRA Category 1 credit.TM For a full description of CME requirements for Florida physicians, please visit www.dcmsonline.org.
Ross Jones, MD, MPH, FAAFP, Medical Director, Community Health, UF Health Jacksonville, Clinical Assistant Professor, UF College of Medicine - Jacksonville.
HIV remains an important public health topic in the state of Florida and there is need for continued vigilance on this issue in the areas of epidemiology, transmission risk, and prevention. Physicians should know proper precautions to protect themselves and others against transmission. Accordingly, the state of Florida requires ongoing training for HIV/AIDs among physician providers.
CME Credit Eligibility:
A minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted. If you take your test online, a certificate of credit/completion will be automatically downloaded to your DCMS member profile. If you submit your test by mail, a certificate of credit/completion will be emailed within 4 weeks of submission. If you have any questions, please contact the DCMS at 904-355-6561 or firstname.lastname@example.org.
Ross Jones, MD, MPH, FAAFP reports no significant relations to disclose, financial or otherwise with any commercial supporter or product manufacturer associated with this activity.
Disclosure of Conflicts of Interest:
St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.
Joint Sponsorship Accreditation Statement:
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare designates this educational activity for a maximum of 1 AMA PRA Category 1 credit.TM Physicians should only claim credit commensurate with the extent of their participation in the activity.
The human immunodeficiency virus (HIV) attacks the body’s immune system, leading infected patients to be susceptible to a variety of opportunistic infections. HIV is transmitted through contact with bodily fluids from an infected person including blood, semen, and vaginal secretions. HIV compromises the immune system by destroying the body’s CD4 cells, macrophages, and dendritic cells. These cells are critically important to ward off infections using cell-mediated immunity. Cell-mediated immunity is the body’s primary method to eliminate pathogens without the use of antibodies. Once the CD4 cells are depleted and the immune system is compromised, the risk for opportunistic infections such as toxoplasmosis and certain cancers dramatically increases.
Nationwide, 1.1 million people are living with HIV infection.1 Currently, more than 135,000 residents of Florida are estimated to be living with HIV infection.2 In 2017, almost 5,000 Floridians were diagnosed with HIV. Florida has the highest rate of HIV infection in the United States with 22.9 new cases per 100,000.2,3
In the state of Florida, males were much more likely to be diagnosed with HIV (M: 78% vs. F: 22%).2 Also in Florida, most cases were diagnosed in patients between the ages of 20-29 (30%), followed by those 30-35 (27%) and then those 50+ (22%).2 From 2013-2017, the biggest increase in HIV diagnoses rate was seen in those 30-39 and above the age of 50.2
Similar to national trends, the majority of patients living with HIV in Florida identified as African American or Black.2,3 This racial category represented 42 percent of cases in Florida compared to 44 percent of cases nationally.2,3 Hispanics and Caucasians/Whites are the next most represented ethnic groups.2 From 2008 to 2017, the rates of HIV infection decreased for both African American/Black and Caucasians/Whites ethnic groups.2 In contrast, during the same time period, the HIV infection rate among Hispanics increased by 24 percent.2
Among exposure types, men who have sex with men (MSM) accounted for the highest number of cases and represents 78 percent of diagnoses in men.2 The next most common exposure types in men are heterosexual contact (16%), and intravenous drug use (IDU) (3%).2 In the female cohort, heterosexual contact (91%) was the most prevalent exposure type followed by IDU (9%).2
The risk of HIV transmission can be significantly reduced using several different methods. Abstinence is the only 100 percent effective method to prevent HIV infection. Other methods that can be utilized to reduce the risk of HIV infection include using barrier aids such as condoms during every sexual encounter, reducing the number of sexual partners, avoiding high risk sexual behaviors such as receptive anal sex. Additionally, early testing and treatment of high-risk individuals and their partners for sexually transmitted infections such as gonorrhea and syphilis would reduce the risk of contracting HIV by preventing transmission through open sores or non-healed lesions. Pre- and post-exposure prophylaxis are the two modalities currently recommended for use in reduction of HIV infection.
Pre-exposure prophylaxis (PrEP) involves the use of antiretroviral medications prior to sexual activities to reduce the risk of HIV transmission. Use of daily PreP has been shown to reduce the risk of HIV transmission by over 90 percent.4 PreP should be offered to patients at a high risk for HIV infection. Patients in this high group include:
The preferred regimen for PreP is daily use of a pill containing tenofovir and emtricitabine.4 Patients should be counseled on the importance of medication compliance to avoid the development of resistance. Additionally, the provider should see patient at least every three months to monitor for any complications from the medications and to ensure the patient is not positive for HIV infection or any other STI.
Nonoccupational post-exposure prophylaxis (nPEP) is the use of antiretroviral drugs after a patient has been potentially exposed to HIV. nPEP should be offered within 72 hours to patients that have a potential significant exposure to HIV, such as exposure to bodily fluids of a person known to be HIV positive.5 Patients should be prescribed a 28-day course of 3-drug antiretroviral regimen. The preferred regimen is once daily enofovir disoproxil fumarate with emtricitabine combined with twice daily raltegravir or dolutegravir twice daily.5 Patients should be tested for HIV prior to the start of nPEP and should also be counseled on risk reduction techniques to prevent the transmission of HIV.5
The Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Services Task Force recommend screening for HIV at least once for most adults.6,7 The CDC recommends repeated screening for some individuals based on risk factors.6 Testing for HIV usually involves one of three different types of testing- antibody tests, antigen/antibody tests, and nucleic acid tests.
Antibody tests, also known as enzyme-linked immunosorbent assay (ELISA) tests, look for antibodies against HIV in a patient’s blood, saliva, or urine.7 Most rapid tests currently in use are antibody tests. An antibody test can generally detect HIV two to eight weeks after initial infection.7,8
Antigen/Antibody tests detect the presence of both HIV antibodies and an HIV antigen, p24, in a patient’s blood. The CDC recommends this test for initial HIV screening.6 Typically, antigen/antibody tests are able to detect HIV several weeks earlier than antibody testing. There is a rapid version of this test that can yield results in 20 minutes.
Nucleic acid testing detects HIV in the blood. Nucleic acid testing can identify HIV infection the earliest among the three tests.8 However, this test is the most expensive and is not routinely used for screening.
Once HIV diagnosis is confirmed, a patient should be referred to an HIV specialist. Initial workup should include a thorough history, comprehensive physical, and laboratory evaluations.8 These initial evaluations will act as a baseline for symptoms and other clinical markers. Baseline laboratory evaluations should include the following:10
The results from these laboratory evaluations can aid in staging HIV infection and in the selection of the appropriate antiretroviral therapy (ART).
These visits can also provide time for a patient to be counseled on the natural history of the illness, methods to prevent transmission of the virus, and the benefits of antiretroviral therapy to slow the progression of the HIV and to decrease risk of transmission.10 The patient should also undergo a psychosocial evaluation including domestic violence screenings to ensure that proper supports are in place for successful treatment of HIV infection.8,10 Additionally, the patient should be referred to the appropriate agency if any psychosocial barriers are identified during screening.
Most national and international organizations support starting ART regardless of the CD4 count of the patients. Numerous studies have shown that ART has improved the morbidity and mortality associated with HIV infection.8,10 ART has also been shown to reduce the risk of transmission among patients with chronic HIV infection. However, some concerns remain about the possible long-term complications from ART such as metabolic complications from protease inhibitors. On balance, the benefits of ART, including decreased disease progression and complication rates, outweigh these potential side effects.
ART should be started as soon as it is feasible. Selection of the regimen for ART consists of many factors including cost, safety, clinical markers, childbearing potential, and resistance testing. In general, the ART regimen for treatment naïve patients would consist of two nucleoside reverse transcriptase inhibitors alongside another antiretroviral agent, such as either an integrase transfer inhibitor, a non-nucleoside reverse transcriptase inhibitor or a protease inhibitor with a pharmacokinetic booster such as ritonavir or cobicistat.8,10 For more detailed information on ART, the U.S. Department of Health and Human Services publishes clinical guidelines for specific patient populations.
Transmission of HIV between patients and healthcare providers is an important issue. Overall, the risk of acquiring HIV infection through occupational exposure is low. In the U.S., there has only been 58 confirmed cases of occupationally acquired HIV infection.11 Only one of those cases has occurred since 2000.11 The risk of HIV transmission depends on the exposure type. Most of the confirmed cases involved percutaneous inoculation from hollow bore needles.12 Studies have shown the risk of HIV infection after a needle stick to be 0.33 percent.11 The risk of mucosal exposure is even lower at 0.09 percent.11 There have been no confirmed cases from exposure to intact skin.11 It should also be noted that transmission of HIV from HIV positive healthcare providers to patients is exceedingly rare. There has only been one confirmed case in the U.S.13
Despite the low risk of HIV transmission in occupational settings, providers and healthcare organizations must remain vigilant in their infection control policies and use of universal precautions. The Occupational Safety and Health Administration (OSHA) requires healthcare organizations to have detailed policies about occupational exposure to HIV and other infectious diseases.14 The policy should be easily accessible to employees and readily implemented by the department of employee health and emergency departments of those institutions. The most comprehensive of these plans includes educating employees of the risk of blood borne pathogens such as HIV and methods to reduce those risks including prevention of occupational exposures.
Preventing occupational exposures is the most important strategy to reduce the risk of HIV transmission. Providers should assume that all blood and bodily fluids are potentially infectious. One of the most readily available safeguards is following universal precautions. According to the CDC, these infection control precautions should be followed at all times:14
Providers should use needles with safety devices to avoid needle stick injuries. Proper disposal of sharps, such as used syringes or other sharp instruments, can reduce the risk of injections and occupational HIV transmission.
If a healthcare provider is exposed, several steps must be taken to reduce the risk of transmission. The first step for an exposure is to clean the affected area. For skin exposure, the areas must be cleaned with soap and water. Puncture wounds should by cleaned with antiseptics such as alcohol-based cleansers or chlorohexidine.14 The exposure should be documented. Documentation should include clinical information about the source patient and the provider that has been exposed such as viral load, method of exposure, and time and date of the exposure. Risk factors and results of other testing such as Hepatitis B or Hepatitis C should be included in the information.13 Post exposure prophylaxis (PEP) should also be offered to any employee with exposure to a source patient with known or suspected HIV.
The CDC has produced guidelines that provide clear direction on which regimen should be used for PEP based on the type of exposure.15 Several national and international organization suggest PEP should be started as soon as possible after exposure, ideally within 2-72 hours of exposure.15 According to the CDC guidelines, most HIV exposures can be treated with a four week, two-drug regimen. However, some high-risk situations may require a three-drug regimen. Providers receiving PEP should be monitored for drug toxicity. Monitoring should include a complete blood count and complete metabolic panel at baseline, at two weeks of therapy, and at four weeks of therapy.
Codified in 1988, Florida’s Omnibus AIDS Act contains most laws that concern diagnoses, testing, and disclosure for HIV and AIDS in the state.16 This piece of legislation requires every licensed healthcare provider in the state to undergo mandatory education on HIV/AIDS. Additionally, this law requires healthcare facilities and other institutions, such as colleges and universities, to educate their work force on HIV/AIDS.
In respect to HIV testing, the law requires that healthcare providers have the necessary procedures in place to obtain “informed consent,” to confirm positive test results prior to informing the patient, and to notify patients using “all reasonable efforts.” Additionally, The Omnibus AIDS Acts states that testing should be “informed, voluntary, and confidential” (FS 381.004). Prior to obtaining informed consent, providers should ensure that patients have the capacity to make decisions about whether to undergo testing for HIV. This decision should be based on a patient’s cognitive ability, age, and language skills. Under the current law, patients must explicitly agree or consent to have HIV testing done in the majority of cases. Exceptions to informed consents are delineated within the statute and include, but are not confined to, the following circumstances: emergencies, criminal acts, significant exposures, abandoned infants, and judicial authority. Appropriate informed consent for HIV testing should include:16
Documenting informed consent does not require written consent from the patient. Providers must still document in the patient’s medical record that HIV testing was explained and that consent was obtained prior to testing. However, obtaining written consent from patient does provide a practical benefit to some providers as the written document will clearly outline what was explained to the patient.
Failure to obtain informed consent carries many consequences. Licensed healthcare providers may receive disciplinary actions from their licensing bodies including revocation of their licenses. Also, patients may sue providers civilly citing negligence or invasion of privacy.
Requirements for notifying patients of the results of HIV testing are also spelled out under the Omnibus AIDS Act. Providers must “ensure that all reasonable efforts are made to notify test subject of his or her test results” whether positive or negative. Providers are expected to use similar methods that they would use to notify patients of any other serious condition. In addition to notification, providers administering HIV testing should have methods in place to confirm the test subject’s identity and to provide adequate counseling based on the testing results. Minimally, patients with HIV negative results should be counseled on “preventing the transmission of HIV.” HIV positive patients must be counseled on the availability of medical and support services, the importance of notifying partners that may have been exposed, and prevention of the transmission of HIV.
Florida Statute 384.25 requires all HIV testing facilities to report to local health departments all patients with positive HIV results along with patient identifiers. Failing to report positive test results may result in fines and disciplinary actions from licensing bodies. In most cases, the Florida Department of Health requires all positive results to be reported within two weeks (Rule64D-3.029 and Rule 64D-3.030(5). The Florida DOH also requires reporting of CD4 and viral load testing results (Rule 64D-3.029). These rules ensure the most accurate data about current rates are being gathered within the state. However, a patient can undergo anonymous testing where the identity of the test subject is not known and thus cannot be reported to local public health authorities. Moreover, reporting of anonymous HIV testing is forbidden under current Florida law (384.25(3) (b)).
HIV/AIDS remains an important public health issue. While HIV rates have continued to decline, thousands of Floridians are still being diagnosed every year. Similar to other chronic conditions, prevention is paramount. Providers must be vigilant in screening for HIV and using appropriate prevention methods, such as PreP, if they hope to continue to decrease the rate of HIV infections.
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1. Approximately how many people in the United States are living with HIV infection?
a. 100, 000
c. 1 million
d. 2 million
2. What cells are primarily affected by HIV infection?
a. CD4 cells
b. Red blood cells
3. In Florida, which age range had the most number of cases diagnosed for HIV infection?
a. Under 18
4. Which prevention method is 100% effective for HIV transmission?
c. Using condoms
5. PreP reduces the risk of HIV transmission by what percentage?
6. Which is the preferred test for HIV screening?
a. Antibody testing
b. Antibody/antigen testing
c. Nucleic acid testing
7. When should ART be started in HIV positive patients?
a. 1 month after diagnosis
b. When patient has symptoms
c. As soon as feasible
d. When CD4 count is below 200
8. Which exposure type is responsible for the majority of occupationally acquired HIV infections?
a. Percutaneous inoculation with a hollow bore needle
b. Percutaneous inoculation with a solid needle
c. Exposure to intact skin
d. Exposure to mucosal surface
9. What is the name of the Florida law which covers most of the regulations around HIV/AIDs?
a. Affordable Care Act
b. Omnibus AIDS Act
c. Health Insurance Portability and Accountability Act
d. The Stark Law
10. True or False: A provider may be sued civilly for failure to obtain informed consent.