H IV / aids: a comprehensive review

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H

IV / AIDS:


A COMPREHENSIVE

REVIEW
Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.

Abstract

As a result of advanced treatment options and increased access to care, the number of people diagnosed with HIV is decreasing. With proper diagnosis and treatment, people can live symptom-free for a significant length of time. Advances in testing and treatment options have improved the care and management of HIV. Comprehensive prevention strategies and widespread education are important in ensuring that the spread of the disease is minimized. The management of HIV in infected individuals is complex and must be assessed on a case-by-case basis. This article will provide comprehensive review for the primary care provider, in identifying and treating patients with HIV.


Continuing Nursing Education Course Director & Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.



Continuing Education Credit Designation

This educational activity is credited for 4.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Pharmacology content is 2 hours.

Statement of Learning Need

Different therapies and strategies can have differing effects on patients and its imperative that nurses have an understanding of HIV and AIDS disease progression, treatment options and the adverse affects of antiretroviral drugs is imperative in disease management.



Course Purpose

To provide nursing professionals with knowledge HIV and AIDS disease progression, treatments and complications.



Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Director Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.



Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC



Release Date: 4/15/2016 Termination Date: 12/31/2016

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

  1. The most common strain of HIV-1 infecting most patients today is believed to have been transmitted by:




  1. Humans in Africa

  2. Cameroon chimps to humans

  3. Insects to humans

  4. West African parrots




  1. True or False. In both confidential and anonymous testing, the patient is required to give informed consent.




  1. True

  2. False



  1. In 2011, there were __________children worldwide who tested positive for HIV.





  1. 1.5 million

  2. 2.5 million

  3. 3.3 million

  4. None of the above




  1. Post-test counseling regarding partner notification allows patients to:




  1. notify their partners themselves

  2. use a free-standing partner notification service

  3. have their name and identifying information kept confidential

  4. All of the above




  1. True or False. Latex and polyurethane condoms are an ineffective means of preventing the transmission of HIV when used correctly.




  1. True

  2. False

Introduction

Human Immunodeficiency Virus (HIV) has affected individuals worldwide since it first caused rare illnesses in a select group of individuals in 1980.1 HIV was first identified in 1983 and quickly spread, eventually becoming a worldwide pandemic. Approximately forty million people worldwide are living with HIV, with one million of those residing in the United States. The disease has had a significant impact on Africa, with the numbers peaking at 2.3 million in 2010. By 1983, HIV was discovered as the cause of a number of rare cases of Kaposi’s sarcoma and pneumocystis pneumonia in otherwise healthy individuals.2 In the first decade, the disease spread rapidly, destroying the immune systems of those infected.

Healthcare providers must understand the signs and symptoms of infection, as well as the various stages of HIV infection. Proper treatment can prevent the infection from progressing beyond the asymptomatic stage. Therefore, providers must work closely with patients to develop a treatment plan that minimizes progression. Different therapies and strategies can have differing effects on patients and an understanding of the adverse affects of antiretroviral drugs is imperative in disease management. Appropriate treatment and management of HIV is necessary to prevent the infection from causing irreversible effects on the patient.8 With the development of antiretroviral therapy and advancements in HIV management and care, the virus is now easily managed and can remain a chronic condition for more than ten years.6 However, the virus is complex and impacts each patient differently. Therefore, it is necessary for providers to work closely with patients to develop a treatment plan that will address the individual patient’s needs and minimize the progression of the virus.
Overview

Since it was first discovered, HIV has become a worldwide pandemic.3 Approximately forty million people worldwide are living with HIV, with one million of those residing in the United States.4 Initially, HIV was considered a homosexual disease, but it was soon discovered to be a virus that infected anyone, regardless of race, sexual orientation, or socioeconomic status.5 HIV attacks, and eventually destroys, the immune system. During the early stages of infection, individuals can live symptom free.6 Progression of the disease varies by patient and can be impacted by a variety of factors. In the stage of the infection known as HIV, patients often exhibit few symptoms. When the disease transitions to Acquired Immune Deficiency Syndrome (AIDS) the patient often experiences an increase in symptoms and severity of the disease and presents with one or more opportunistic infections.7

Origin

When HIV emerged in the early 1980’s scientists began trying to determine its origins. After years of research, scientists traced the virus to chimpanzees in Africa.9 These chimpanzees were infected with simian immunodeficiency virus (SIV), which is a retrovirus similar to HIV.9 While HIV did not spread significantly into the human population until the 1980’s, evidence shows that SIV may have infected humans as early as 1884.10 While there are no documented cases of HIV from that time period, scientists did discover a documented case of HIV posthumously in a fifteen-year-old black male who died in 1968.11 There are various theories as to why the virus did not spread in earlier populations, but there is no definitive answer as to why. Regardless, something caused the virus to spread in the 1980’s, resulting in the pandemic that has affected society for the past thirty years.

Although there is evidence that HIV may have infected humans as early as 1884, the sub-type of the virus that currently infects individuals has been traced to a more recent time period. Research shows that HIV most likely spread to humans at three different points in history, one for each subtype of HIV-1 (M, N, and O).12 The most common strain of HIV-1, the type that infects most patients today, is believed to have transmitted by the Cameroon chimps to humans in the period shortly before 1931.10 This conclusion was made after extensive research, which examined the virus in samples of infected tissue that was collected over the past three decades. Upon examination of these samples, it was determined that an ancestral form of HIV started to spread in the human population approximately 75 years ago.13 Therefore, it is assumed that the transmission from chimpanzees to humans occurred shortly before that.

History

In June of 1981, the Centers for Disease Control and Prevention (CDC) reported on five individual cases of a rare lung infection, Pneumocystis carinii pneumonia (PCP)14 All five individuals were homosexual men living in Los Angeles, and each patient had been healthy prior to the onset of infection. Upon further examination, it was determined that all five men were experiencing other illnesses as well.14 When the CDC report was released, other doctors submitted reports of similar cases nationwide. In all cases, patients had been previously healthy and were presenting with similar infections.2 Among the infections were reports of a rare form of cancer, Kaposi’s sarcoma.1,5 A task force was formed to study the incidence of infections and determine common causes among the patients.3 In 1981, there were 270 cases reported, with 121 deaths.15 By 1982, there were a total of 452 reported cases from 23 states.15

In the two years following the first reported cases, various initiatives were established to assist with the identification, management and care of the unknown disease. Initially, the disease was thought to be specific to homosexual men.5 In fact, in the beginning, many individuals referred to the disease as GRID (Homosexual-Related Immune Deficiency).16 While the virus was originally thought to be a disease only affecting homosexual men, it was soon discovered in other individuals, especially those who had received blood transfusions.17,18 In 1982, the term Acquired Immune Deficiency Syndrome (AIDS) was used to define the syndrome that was affecting individuals throughout the country.19 Care centers were established to help the tens of thousands of patients who were infected with the disease.16

By 1983, the CDC was able to identify the specific transmission modes of the disease as through sexual contact and exposure to blood and blood-borne pathogens.20 The CDC also discovered that the disease had infected homosexual men, women with male partners, infants and injection drug users.15 As a result, a public statement was released warning individuals to refrain from activities that would put them in contact with the disease.20 Scientists in France identified the specific virus strain suspected to be causing AIDS as Lymphadenopathy Associated Virus (LAV),21 while scientists in the United States identified the virus as the retrovirus HTLV-III.22 After comparing the findings, it was determined that the two strains were almost identical. It was also determined that they were most likely the cause of AIDS.10
In 1985, the viral strain became known as Human Immunodeficiency Virus and was identified as the cause of AIDS.10 As a result, the CDC redefined the AIDS clinical definition to include HIV as the cause of the infection. AIDS was determined to be an end result of HIV infection.3 While the disease is considered to have started in 1980, it is now understood that it must have originated years earlier as an individual can live for many years with HIV before progressing to the stage of AIDS.13

In the years following the discovery of HIV, significant research focused on identifying the origin and causes of the virus, developing treatment, and attempting to find a cure.23 In the late 1980’s and throughout the 1990’s, when the virus reached its peak, numerous organizations were founded to address the needs of those living with HIV and to help prevent the spread of the infection.3 During this time, the stigma associated with the virus impacted how people viewed and interacted with HIV positive individuals and educational campaigns aimed at eliminating the stigma were introduced.16 Social service and case management programs were developed to address non-HIV issues in patients and training for healthcare providers focused on the effective treatment and management of the virus.16

In the thirty years since the first reported case of AIDS, the disease has spread and swelled to significant numbers.10 HIV has impacted individuals throughout the world and has resulted in a worldwide pandemic which required myriad initiatives to help infected individuals live with the disease and also to minimize the spread of the infection. However, by the early 2000’s, public knowledge of the virus had increased. Due to educational programming and patient treatment strategies, the number of new cases began to decrease.24 In addition, HIV positive individuals began to live longer and remained relatively symptom-free for extended periods of time.6 HIV treatment strategies evolved and a multi-faceted approach to disease management became standard protocol for working with positive patients.25
Epidemiology

Over the past thirty years, HIV has become a worldwide pandemic. Since the epidemic began, approximately sixty million people worldwide have contracted the disease.26 Currently, there are approximately forty million people living with HIV. Of those, one million reside in the United States.4 Approximately 3 million of the current HIV cases are in individuals under the age of fifteen.27 Since 1995, HIV has been one of the leading causes of death in persons age 25 – 44.28 The total number of deaths since the virus was first reported total approximately thirty million worldwide.26

Global Impact

While the epidemic has had a significant impact on the United States, its impact has been even greater worldwide, with the most significant numbers occurring in Sub-Saharan Africa.26 More than two-thirds of the reported cases of HIV are in individuals living in Sub-Saharan Africa.29 Since the disease began spreading, it has utterly devastated the country, with the number of reported cases peaking at 2.3 million.30 Due to the lack of adequate care and prevention measures, the transmission rate of HIV in Sub-Saharan Africa is greater than in other areas.26

The World Health Organization (WHO) monitors the disease on a global scale, and reports are issued annually which provide detailed statistics on the number of reported case globally and by nation. According to the WHO, 34.0 million (31.4–35.9 million) people globally were living with HIV at the end of 2011. An estimated 0.8% of adults aged 15-49 years worldwide are living with HIV, although the burden of the epidemic continues to vary considerably between countries and regions. Sub-Saharan Africa remains most severely affected, with nearly 1 in every 20 adults (4.9%) living with HIV and accounting for 69% of the people living with HIV worldwide.29

While HIV has affected individuals on a global scale, the disease is most prevalent in Sub-Saharan Africa, where 69% of the population is currently HIV positive.26 HIV is currently the leading cause of death in Africa. This region has the highest percentage of children who are HIV positive, which is 94%. In nine countries in this region, at least 10% or more of the population is HIV positive, and all of the nations in the region have generalized HIV epidemics.31 The highest numbers of people worldwide who are HIV positive reside in South Africa, and Swaziland has the highest overall prevalence rate, which is 26%. The remaining HIV cases are spread throughout the world, with a high concentration of cases in low and middle-income countries.32

International and national organizations responding to the HIV epidemic support health team efforts to provide education and health aid to high risk areas; examples include the U.S. Peace Corps (http://www.peacecorps.gov/learn/whatvol/hivaids/) as well as other Africa and interurban intiatives (http://oaa.dc.gov/release/oaa-launches-health-education-initiative-team-think-eat-act-move-africa).




HIV Prevalence & Incidence by Region3

Region

Total No. (%) Living with HIV in 2011

Newly Infected in 2011

Adult Prevalence Rate 2011

Global Total

34.0 million (100%)

2.5 million

0.8%

Sub-Saharan Africa

23.5 million (69%)

1.8 million

4.9%

South/South-East Asia

4.0 million (12%)

280,000

0.3%

Eastern Europe/Central Asia

1.4 million (4%)


140,000

1.0%

Latin America

1.4 million (4%)

86,000

0.4%

North America

1.4 million (4%)

51,000

0.6%

Western/Central Europe

900,000 (3%)

30,000

0.2%

East Asia

830,000 (2%)

89,000

0.1%

Middle East/North Africa

300,000 (1%)

37,000

0.2%

Caribbean

230,000 (0.7%)

13,000

1.0%

Oceania


53,000 (0.2%)

2,900

0.3%

Since 2001, the number of new HIV infections has decreased by more than 20%.26 In low and middle-income countries, the rate of infection has declined by more than 50%.30 However, even with a decline, there are still new cases reported each year, and the risk of infection in low and middle-income countries is still high. In 2011, there were 2.5 million new infections reported, and 1.8 million of the infections were in Sub-Saharan Africa.32


Young people between the ages of 15 – 24 make up approximately 40% of the new HIV cases worldwide.32 Young women are two times more likely to test positive for HIV than men of the same age.26 The virus also significantly impacts children under the age of fifteen. In 2011, there were 3.3 million children worldwide who tested positive for HIV.33 There are many international health organizations, such as UNICEF, World Camp for Kids, Save the Children, and others supporting volunteer efforts for children with HIV infections and AIDS.

National Impact

To properly track the HIV epidemic in the United States, reporting of the virus has been required throughout the country since shortly after the virus was discovered.24 From 1981 – 1995, the virus spread rapidly, and although antiretroviral treatment helped reduce the number of cases, the virus peaked in the United States in the period from 1993 – 95 (28). By 1989, the number of reported cases in the United States reached 100,000, and by 1995 the numbers had exceeded half a million.28

To accurately measure the impact of the virus in the United States, the CDC collects information about each reported HIV case. This information is compiled into surveillance reports that explain how and where the virus has spread. The reports examine factors such as risk group, age, gender, status, and geographic location to analyze trends in viral spread and progression.
The most recent HIV Surveillance Report, which was released in 2011, provides information on the period from 2008 – 2011. While the report itself is very detailed and includes extensive information on the epidemiology of the virus, the CDC also releases brief reports that summarize the information and provide basic trend information based on risk group. The following is the CDC’s most recent summary of HIV trends from 2008 – 2011.
HIV Incidence (New Infections):
The estimated incidence of HIV has remained stable overall in recent years, at about 50,000 new HIV infections per year. Within the overall estimates, however, some groups are affected more than others. MSM (men who have sex with men) continue to bear the greatest burden of HIV infection, and among races/ethnicities, African Americans continue to be disproportionately affected.
HIV Diagnoses: New Diagnoses (regardless of when infection occurred):
In 2011, an estimated 49,273 people were diagnosed with HIV infection in the United States. In that same year, an estimated 32,052 people were diagnosed with AIDS. Since the epidemic began, an estimated 1,155,792 people in the United States have been diagnosed with AIDS.3

Deaths:

An estimated 15,529 people with an AIDS diagnosis died in 2010, and nearly 636,000 people in the United States with an AIDS diagnosis have died since the epidemic began.3 The deaths of persons with an AIDS diagnosis can be due to any cause — that is, the death may or may not be related to AIDS.

By Risk Group:

Homosexual, bisexual, and other men who have sex with men (MSM) of all races and ethnicities remain the population most profoundly affected by HIV.


  • In 2010, the estimated number of new HIV infections in MSM cohorts was 29,800, a significant 12% increase from the 26,700 new infections with MSM in 2008.

  • Although MSM represent about 4% of the male population in the United States, in 2010, MSM accounted for 78% of new HIV infections among males and 63% of all new infections.2 MSM accounted for 52% of all people living with HIV infection in 2009, the most recent year these data are available.

  • In 2010, white MSM continued to account for the largest number of new HIV infections (11,200), by transmission category, followed closely by black MSM (10,600).

  • The estimated number of new HIV infections was greatest with MSM in the youngest age group. In 2010, the greatest number of new HIV infections (4,800) with MSM occurred in young black/African American MSM aged 13–24. Young black MSM accounted for 45% of new HIV infections among black MSM and 55% of new HIV infections among young MSM overall.

  • Since the epidemic began, almost 300,000 MSM with an AIDS diagnosis have died, including an estimated 6,863 in 2009.

Heterosexuals and injection drug users also continue to be affected by HIV.

  • Heterosexuals accounted for 25% of estimated new HIV infections in 2010 and 27% of people living with HIV infection in 2009.
  • Since the epidemic began, more than 85,000 persons with an AIDS diagnosis, infected through heterosexual sex, have died, including an estimated 4,003 in 2010.


  • New HIV infections among women are primarily attributed to heterosexual contact (84% in 2010) or injection drug use (16% in 2010). Women accounted for 20% of estimated new HIV infections in 2010 and 24% of those living with HIV infection in 2009. The 9,500 new infections among women in 2010 reflect a significant 21% decrease from the 12,000 new infections that occurred among this group in 2008.

  • Injection drug users represented 8% of new HIV infections in 2010 and 16% of those living with HIV in 2009.

  • Since the epidemic began, more than 182,000 injection drug users with an AIDS diagnosis have died, including an estimated 4,218 in 2010.

By Race/Ethnicity:

Blacks/African Americans continue to experience the most severe burden of HIV, compared with other races and ethnicities.



  • Blacks represent approximately 12% of the U.S. population, but accounted for an estimated 44% of new HIV infections in 2010. They also accounted for 44% of people living with HIV infection in 2009.

  • Since the epidemic began, more than 260,800 blacks with an AIDS diagnosis have died, including 7,678 in 2010.

  • Unless the course of the epidemic changes, at some point in their lifetime, an estimated 1 in 16 black men and 1 in 32 black women will be diagnosed with HIV infection.

HIV also disproportionately affects Hispanics/Latinos. Data extracted from literature is included below:
  • Hispanics/Latinos represented 16% of the population but accounted for 21% of new HIV infections in 2010.2 Hispanics/Latinos accounted for 19% of people living with HIV infection in 2009.


  • Disparities persist in the estimated rate of new HIV infections in Hispanics/Latinos. In 2010, the rate of new HIV infections for Latino males was 2.9 times that for white males, and the rate of new infections for Latinas was 4.2 times that for white females.

  • Since the epidemic began, more than an estimated 96,200 Hispanics/Latinos with an AIDS diagnosis have died, including 2,370 in 2010.27




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