Transcript ROUTES of TRANSMISSION

Blood Borne Pathogens
Peter DalPra LADC, LCS
The Starfish Man
One morning at dawn, a young boy went for a walk on
the beach. Up ahead, he noticed an old man stooping
down to pick up starfish and fling them into the sea.
Finally, catching up with the old man, the boy asked
him what he was doing. The old man answered that the
stranded starfish would die unless they were returned
to the water. “But the beach goes on for miles and there
are millions of starfish,” protested the boy. “How can
what you’re doing make any difference?” The old man
looked at the starfish in his hand and then threw it to
safety in the waves. “It makes a difference to this one.”
he said.
HIV stands for “human
immunodeficiency virus.”
AIDS stands for “acquired
immunodeficiency syndrome.”
An individual can have HIV without
receiving an AIDS diagnosis; however,
the opposite is not true. A person
cannot have AIDS without infection by
HIV.
•Experts
from the Centers for Disease
Control, the U.S. National Institute of
Allergy and Infectious Diseases, and the
World Health Organization are currently
presenting the following regarding the
origin of HIV: about 100 years ago in
Africa, an ancestor of HIV, which is known
as simian immunodeficiency virus or SIM,
evolved into a form that jumped from
monkeys to humans. Humans hunted these
chimpanzees for meat and had physical
contact with their infected blood.
•our immune system is the system that fights off
infection or disease
•when the immune system becomes deficient or
is unable to work correctly syndromes can occur
•a syndrome is a collection of symptoms and
signs of disease –AIDS is a syndrome because it
is a complex illness with a wide range of
complications and symptoms
•AIDS is the final stage of HIV infection
where the risk of complications for an
opportunistic infection are the greatest.
AIDS is defined by the CDC as having a T-Cell
count of less than 200 in the blood stream,
and the onset of opportunistic infections. As
a reference, a person who does not have
HIV/AIDS has a normal T-cell count between
800 and 1,200.
THE HIV QUIZ
•
•
•
•
•
•
•
•
•
•
1. HIV Infection and AIDS are the same thing
2. The body produces antibodies to HIV
3. You need to protect yourself from HIV
4. HIV can be spread through sex
5. HIV can be spread by sharing needles
6. You can get HIV from a bug bite
7. Sharing needles with friends is safe
8. Latex condoms provide foolproof protection
9. It’s important to use a water-based lubricant with latex condoms
10. Natural condoms protect against HIV just as well as latex
condoms do.
• 11. Alcohol and other drugs can increase your risk of becoming
infected with HIV
Global summary of the AIDS epidemic 
2014
Number of people
living with HIV
Total
Adults
Women
Children (<15 years)
People newly
infected
with HIV in 2014
Total
Adults
Children (<15 years)
AIDS deaths in 2014
Total
Adults
Children (<15 years)
36.9 million [34.3 million – 41.4
million]
34.3 million [31.8 million – 38.5
million]
17.4 million [16.1 million – 20.0
million]
2.6 million [2.4 million – 2.8 million]
2.0 million [1.9 million – 2.2 million]
1.8 million [1.7 million – 2.0 million]
220 000 [190 000 – 260 000]
1.2 million [980 000 – 1.6 million]
1.0 million [760 000 – 1.8 million]
150 000 [140 000 – 170 000]
•the rates of HIV infections remains
steady at about 50,000 per year
•the most prominent route of
transmission of HIV is male to male
sexual contact
•injection drug users make up 11% of
the possible modes of transmission.
•Anybody can get HIV: HIV does not
discriminate based on age, sexual orientation,
gender identification, marital status ethnicity,
socioeconomic status, or drugs of choice
PLWHA in NH
as of December 31, 2011
HIV: 516
AIDS: 656
Total: 1,172
ROUTES of TRANSMISSION
• Exposure to blood, semen, vaginal
secrections, rectal fluids, mothers milk.
• Exposure through anal,vaginal, and oral
sex.
• Exposure through the sharing of drug
injection equipment.
So, should you be worried about HIV?
Use this checklist to find out.
• Have you ever shared needles for any reason?
• If you are a male, have you ever had sex with a man?
• Have you ever had sex with someone you think might be
infected?
• Have you ever had a sexually transmitted disease?
• Have you ever had sex with someone who might answer yes
to any of the above?
Have you had vaginal, anal, or oral sex
with:
• Someone who has HIV infection
• Someone who injects drugs
• Someone who has an STI (sexually transmitted
•
•
•
•
infection)
A male who has sex with other males
Anonymous partners or sex workers
Anyone who has had sex with someone with the
above risk factors; or
Anyone whose risks for HIV infection you don’t
know?
Infection
• If HIV-infected, at first you
may have• No symptoms
•
•
•
•
•
•
•
Later, you may haveFever
Fatigue
Diarrhea
Skin Rashes
Night sweats
Loss of appetite
• Swollen lymph glands
• Significant weight loss
• Lack of resistance to
•
•
•
•
infection
Furry white spots in mouth
Dry cough or shortness of
breath
Memory or movement
difficulties
Red or purplish spots on
the body
– American Red Cross
Infection
• Having any of these signs
or symptoms may indicate
symptomatic HIV infection
or AIDS. Only a doctor can
tell you what your signs or
symptoms mean.

American Red Cross
•HIV testing tells a person if they have been
infected by HIV. Most tests are “antibody” tests
that look for the antibodies that the body would
have created in response to infection. Antibodies
are proteins produced by the immune system to
fight off a specific germ. Seroconversion is the
process of going from having no antibodies in
one’s blood (a seronegative result) to having
detectable antibodies (a seropositive result).
99% of the cases of seroconversion occur within
6 months.
•Antigen tests require a blood sample and look
for the HIV-specific antigens; antigen tests can
test a person within 1-3 weeks of infection. PCR
test is a polymerase chain reaction test, which
detects the genetic material of HIV itself and can
identify HIV within 2-3 weeks of infection.
•Babies are tested using a special PCR test that
does not pick up the mother’s antibodies; the
special PCR test is able to determine if the baby
has HIV.
•A viral load test will measure how quickly the
virus is multiplying and the strength of the
immune system
Without sufficient numbers of CD4 cells,
the immune system is unable to function
effectively-the onset of
immunodeficiency.
When AIDS develops, the body becomes
vulnerable to rare malignancies and to
serious infection from organisms that
usually pose no threat to people.
When to Treat??
• If symptomatic, regardless of CD4 or VLSymptomatic means having one of the
following “AIDS Defining Conditions”
• PCP
• Toxoplasmosis of brain
• Karposi’s Sarcoma
• Invasive Cervical Cancer
When to Treat (con’t)
• CD4 <200
• If CD4 is between 200 and 350 and
VL>55k, careful observation is warranted
Primary Goals
• Reduce Viral Load
• Preserve Immune Function
Time
• Often substance abusers fail to recognize symptoms of
disease and seek Tx only when they become acutely ill
or emergent, thus prolonging the time they spread the
conditions to others
• HIV or HEP C may be asymptomatic for many years (HIV
10 years), (HEP C 20 years) so many partners may be
infected
• “Processing time” (denial, etc)
Why are our Clients at Greater Risk?
• Substance abuse damages health and nutrition,
•
•
•
•
increasing susceptibility to HIV infection of progression.
They are more likely to engage in drug related activities
like needle-sharing or trading sex for drugs.
Because of impaired judgment, sexual disinhibition
associated with SA or having blackouts, they are more
likely to engage in risky behaviors.
Increased possibility of unsafe sex through improper use
of condoms.
Social networks of substance abusers may overlap those
of individuals who have TB or STD’s.
OK, So what do they want from
us?
• We as counselors working with HIV+
clients hold a paramount position. By
playing a role in our client’s recovery,
we’re helping them in their process of
developing a positive identity both as a
recovering substance abuser and a person
living with HIV.
WHY SUBSTANCE MISUSE WORKERS MUST
BECOME INVOLVED IN HIV DISEASE
PREVENTION
• Several other intercurrent epidemics—tuberculosis, STDs, hepatitis
•
A,B,&C, are closely connected with substance abusers and their
behaviors. Each of these infectious diseases may act as a cofactor
in disease progression among HIV+ substance abusers.
Substance misuse workers enjoy an advantaged position for doing
HIV disease prevention:
– Established skills in treating and preventing the problem of substance
abuse and behavioral relapse;
– Positive credibility with many substance abusers at risk for HIV
disease;
– Compassion for the problems of chemically dependent persons and
ability to model the difficult changes required; and
– Therapeutic relationships with clients in treatment, who already
expressed an interest in and initiated changes in their lifestyle.
HARM REDUCTION:
•A rumor persists on the street that alcohol is a
disinfectant and therefore, dipping one’s needle in beer is
sufficient. Seventy percent rubbing (isopropyl) alcohol
does destroy HIV in less than a minute, however 3.2%
beer will have no effect. Soaking the equipment for 20
minutes in 70% alcohol is thought to be better insurance.
The person who wants to get high is not going to wait
that long nor will they typically have that strength of
alcohol readily available. (Hatcher, A., 2010)
•Bleach destroys other disease organisms as well as HIV
and therefore provides the least expensive yet effective
means for cleaning drug works. (Hatcher, A., 2010)
•Needle exchange programs across the
US have been effective for infectious
disease containment. This has been a
controversial procedure that some equate
with endorsing drug use –but in fact,
addicts have gone back to agencies
where they got needles to get treatment
when ready to tackle sobriety.
•Nonoxynal-9 has been shown to increase
risk for HIV due to micro-tears caused by
the spermicide.
•Latex condoms, when used consistently and
correctly, are highly effective in preventing the
sexual transmission of HIV.
•HIV infection is, by far, the most deadly STD, and
considerably more scientific evidence exists
regarding condom effectiveness for prevention of
HIV infection than for other STDs. The body of
research on the effectiveness of latex condoms in
preventing sexual transmission of HIV is both
comprehensive and conclusive. The ability of
latex condoms to prevent transmission of HIV has
been scientifically established in “real-life”
studies of sexually active couples as well as in
laboratory studies. (CDC)
KEY RISK ISSUES TO BE
PERSONALIZED
• “Personalizing risk” is a way of helping an
individual develop attitudes that support
difficult behavior change. The objective of
personalizing is to have the individual
believe that HIV infection risks are
important to her/his health concerns and
to accept that her/his personal behaviors
are directly connected to both real risk and
risk reduction.
Coming to Terms
• Supervision
• Listen to your internal messages of fatigue,
•
•
•
powerlessness, elation, rejection, hunger,
sadness, and dread
We don’t expect a HIV+ substance abuser to
embark on a therapeutic journey alone, neither
should we expect to accompany them on this
journey alone.
Understand (and believe) that their journey is
also our own.
Ralph Rynes, PhD
STD’s
Sexually Transmitted Diseases
• CHLAMYDIA:
– Most common sexually transmitted
disease in the United States. Four
million men and women are infected
each year. Symptoms appear from 1-4
weeks. Can cause Pelvic Inflammatory
Disease (PID). Can be cured with
Antibiotics.
STD’s
Sexually Transmitted Diseases
• GONORRHEA:
– Two million men and women are
infected each year, most under the age
of twenty-five. Symptoms develop
within 3-4 days but 60-80% do not
show symptoms. If left untreated it can
cause infertility, skin and heart
problems as well as PID. Can be cured
with Antibiotics.
STD’s
Sexually Transmitted Diseases
• SYPHILIS:
– Fourth most commonly reported STD.
The first symptom is a small painless
sore (white patches may appear in the
mouth and throat). Serious illness can
still happen years after chancre has
healed itself without medical treatment.
Have a blood test done if you have any
questions. Can be treated with
Penicillin.
STD’s
Sexually Transmitted Diseases
• HERPES:
– HSV-2 is the virus that causes genital
herpes. Symptoms usually appear
between 2-20 days after infection. Small
red bumps or sores appear at the site of
the infection. These bumps may develop
into blisters or painful open sores. Over
a period of days the sores crust over and
then heal. About one in six in the US
have genital herpes. There is no cure for
herpes but, ongoing research is
searching for a cure.
STD’s
Sexually Transmitted Diseases
• GENITAL WARTS:
– Are caused by the Human Papilloma
Virus (HPV). Contracted only through
vaginal, anal, or oral sex with an
infected partner. One in ten sexually
active Americans has Genital Warts.
There is no cure however vaccine is now
available. Studies have shown that
women who’ve had genital warts may
be at greater risk for getting cervical
cancer.
TB, Substance
Abuse and HIV
disease hang out
together and are a
bad influence on
one another.
TUBERCULOSIS, HIV DISEASE AND
SUBSTANCE ABUSE: A LETHAL CONNECTION
• The association between the behaviors of
substance abusers and HIV disease have been
well documented. During the 1990’s we became
challenged by a new factor in this deadly
equation. Tuberculosis cases, previously a leading
cause of death in the US, has been on a decline
since the 1950’s. However, since 1984, we have
begun to see the emergence of TB as a major
public health concern with dramatic implications
for individuals with HIV disease and substance
abuse treatment staff.
TUBERCULOSIS, HIV DISEASE AND
SUBSTANCE ABUSE: A LETHAL CONNECTION
• The similarities between individuals with
diagnosed AIDS cases and substance abusers
have historically included:
– The medically underserved;
– An over-representation of ethnic and racial minorities;
– Lower socio-economic status; and
– Risky substance abuse and sexual behaviors.
Another similarity; during the early 1990’s the five States
with the highest numbers of diagnosed AIDS cases were
the same five States with the most new TB cases. They
were: New York, California, Florida, Texas, and New
Jersey.
TB TRANSMISSION
• Caused by Mycobacterium
tuberculosis
• Spread through airborne particles
• More easily transmitted in closed
airspaces.
TUBERCULOSIS INFECTION,
NO DISEASE
• Cannot spread to others
• Not considered a TB case
• Positive skin test reaction
• X-ray negative
• No symptoms
• Potential for active disease
PROGRESSION FROM INFECTION
TO DISEASE INCREASED BY
• HIV Infection
• X-ray evidence of old, untreated TB
• Substance abuse, injecting drug use
• Silicosis, diabetes
• Certain therapies
• Certain cancers
• 10% or more underweight
PROBLEMS DIAGNOSING TB
INFECTION IN HIV INFECTION
• False negative TB skin test
– HIV infection may suppress skin test response
– False negative test more likely if person has
AIDS
• 5mm skin test reaction considered
•
significant.
Consider anergy testing if HIV+ with
negative skin test.
CDC Recommendations for TB Prevention in
Substance Abuse Treatment Facilities
• Routinely provide Mantoux tuberculin testing on•
•
•
site for every client.
Refer persons with TB-like symptoms, regardless
of test results, for TB evaluation.
Provide or refer for HIV counseling and testing for
clients and their sex partners.
Follow up all clients referred for TB evaluation
and HIV counseling and testing to make sure they
keep their appointments.
CDC Recommendations for TB Prevention in
Substance Abuse Treatment Facilities
• Ensure compliance with TB medication by providing on-site
directly observed preventive therapy to persons who have
tuberculosis infection but no clinical evidence of disease.
This therapy can be provided on a daily or twice daily basis,
and if possible, should be provided the same time a client is
seen for counseling/treatment
• Provide an ongoing TB screening and prevention program
for workers who have regular contact with persons who
have or are at risk for TB or HIV infection. This includes TB
skin tests for employees at least once a year.
• THINK TB!!! LEARN ABOUT TB!!! EDUCATE ABOUT TB!!!
Hepatitis Education
What You Need to Know About
Hepatitis Viruses
What is Hepatitis
• “Hepatitis” means inflammation of the liver
• There are 3 main types of Hepatitis
– Hepatitis A (HAV)
– Hepatitis B (HBV)
– Hepatitis C (HCV)
• Causes of Hepatitis include:
–
–
–
–
Viruses
Toxins
Genetic Disorders
Bacteria and Parasites
Hepatitis A (HAV)
• Hepatitis A is transmitted through fecal exposure
• HAV can live outside of the body (in feces)
•
•
– Can be transmitted through: food, water,
changing diapers, anal sex, and very rarely IV
use
Proper hand washing and vaccination can
reduce risk of HAV
Vaccination usually happens at 12 months old
Hepatitis B (HBV)
• Hepatitis B is blood borne and it can live
outside the body for at least 7 days
• Highly infectious in sexual fluids (semen
and vaginal)
• Can also transmit through needles, drug
injection equipment, sharing personal
items (tweezers, clippers) and mother to
child
Hepatits B (HBV)
• Symptoms
– Up to 70% of people infected with HBV have
no symptoms
– Jaundice, fatigue, stomach discomfort,
abdominal pain, fever, loss of appetite,
nausea, joint pain
• Prevention methods: vaccines (3 shots),
do not share drug injection equipment or
personal care items, safe sex methods
Hepatitis C (HCV)
• Hepatitis C is highly infectious and
transmitted through blood to blood
contact, lives for at least 16 hours and up
to 4 days outside of the body- studies
have shown it can live up to 63 days in a
syringe
• No vaccine developed
Transmission of HCV
• Transmission:
– Sharing drug injection equipment, personal care
items, tattoo and piercing equipment, drug smoking
equipment (crack pipes)
– Intravenous use ( up to 90% who use IV will be
infected)
– Sexual transmission ( 0-3% chance)
– Mother to child (~4-5% chance)
– Healthcare workers (~2% chance)
– Unidentified ( 10% unknown soruce)
HCV Infection
• Up to 75% of people will become chronically
•
•
•
infected (won’t clear within 6 months)
10% to 25% will progress over 10-40 years and
may lead to serious liver damage, cirrhosis and
cancer
2-4 out of 10 people will clear acute HCV on
their own (won’t progress to chronic infection)
Six different genotypes, most common in USA
are genotypes 1 and 2
HCV Is Not Spread By
• Breast Feeding
• Food or Water
• Sharing eating utensils
• Sneezing
• Hugging
How HCV affects the body
• Hepatitis is inflammation of the liver
• Over 70% of people do not experience any symptoms
• Symptoms include:
–
–
–
–
Jaundice (yellowing of skin and eyes)
Variceal bleeding (dilated blood vessels that bleed)
Hepatic Encephalopathy (altered consciousness, coma)
Carcinoma
– Low platelets
• Can be detected 4-10 weeks after
infection
Healthy Liver
Photo from WebMD
What Does The Liver Do?
• The liver converts food into energy
• Filters toxins from the blood (i.e. alcohol)
• Processes medicines and distributes to
body
• Makes substances to keep body healthy
– Proteins
– Fats
– Sugars
• Blood is filtered through the liver
How the Liver is Affected by HCV
• When someone becomes infected with
hepatitis, the liver becomes enlarged and
inflamed
• Liver cells die and scar tissue forms
• Because of this the liver cannot function
properly
• The liver will then shrink and harden
Cirrhosis
Photo from University of
Washington
How to Test for HCV
• Blood test- test for antibodies (not the virus itself)
– Elisa or EIA test
– HCV Rapid Antibody test
– Viral Load test
• Liver Biopsy
• Up to 90% of people infected can be
cured from HCV
Treatment & Management of HCV
• HCV genotype 1
– Pegylated Interferon
– Ribavirin
– HCV inhibitor
• HCV genotype 2
– HCV Inhibitor
– Ribavirin
Other Treatments/ Management
• Some herbal supplements have been
shown to help but no conclusive tests
have been run (always check with your doctor before
taking any medications as interactions may occur)
– Milk Thistle has shown to help promote liver health
Lifestyle Changes
– Exercise
– Health eating
– Reducing risky behavior (safe sex, IV use)
Why is there no vaccine for HCV?
• There are 6 genotypes of HCV
• HCV can mutate during infection (similar
to HIV)
• Could you get a negative result and still be
infected?
– Yes- the test is to test for antibodies, not the
virus itself
– Can take up to 6 months for the antibodies to
show
Can I Give Myself HCV?
• Not unless you are already infected
• Can get it from using/ re-using infected
needles
Alcohol Related Liver Disease
Fatty Liver Disease
Alcoholic Hepatitis
Build up of extra fat in
liver cells
Liver swells and
becomes damaged
Usually no symptoms;
could include fatigue,
weakness, weight loss
Symptoms: loss of
appetite, nausea,
vomiting, abdominal
pain, fever, and jaundice
Almost all heavy drinkers
have fatty liver
Mild: can be reversed
Severe: liver failure and
death
Alcoholic Cirrhosis
Scarring of the liver
Most serious type of liver
disease
10-20% of heavy
drinkers develop
cirrhosis
Resources
• American Liver Foundation. 2014.
www.liverfoundation.org
• Franciscus, Alan. 2009. HCV Training
Workshop Powerpoint. 2009
• Hepatitis C Support Project. 2014.
www.hcvadvocate.org
• Peters, Tim and Company. 2007. Hepatitis
C Virus (HCV) and Liver Disorders.
Workplace Precautions for Chemical
Dependency Program Treatment Staff
• Wash hands thoroughly after contact with any
•
•
body fluids or wastes.
Wear rubber/latex/vinyl gloves when handling
wounds, specimens, organs or other body fluids.
Carefully dispose of:
– Used needles, without recapping, in immediately
accessible puncture-proof needle boxes/sharp bins;
– Trash, waste matter, tissues, dressings, etc., in double,
tear-proof sealed bags;
– Soiled linens in double bags for transport to laundry.
Workplace Precautions for Chemical
Dependency Program Treatment Staff
• Wipe up any spill or accidents
involving body fluids with a
disinfectant such as a 1:10 solution
of bleach: water.
Important
Use these infection control
procedures for all
patients/clients/staff all the time.
Hence the name universal
precautions.
In Closing
• Nikosi Johnson, a South African
native born with HIV, who died at
age 12, said most succinctly at the
International AIDS Conference in
Durban, South Africa:
“Do all you can with what you have
in the time you have in the place you
are”
Ralph Rynes, PhD