Transcript No Slide Title

HIV Update for
EMS 2007
Abigail Gallucci
Director of Education and Outreach
Albany Medical Center’s AIDS Program
Objectives :
Identify HIV Transmission modes
Review Communicable diseases vs. Bloodborne
Pathogen
Review the Epidemiology of the HIV Virus Globally and
in the United States
Review common misconceptions about HIV Medicine
Review needlestick data and prevention methods
CNN Headlines
LONDON, England (CNN) -- HIV and AIDS is considered "the greatest
risk to world health today" by residents of Britain, France and
Germany, according to a survey carried out on behalf of CNN and
TIME.
56 % rated this as the biggest threat
35 % Heart disease
7% Bird Flu
When asked about "the single biggest hindrance to fighting AIDS
globally," 50 percent said it was a lack of education and 25
percent said a lack of commitment from political world leaders.
CNN November 30, 2005
Communicable vs. Bloodborne
Disease
Communicable diseases are:
Diseases that can be transmitted by direct, indirect, airborne or
waterborne contact.
 Bloodborne diseases are:
Diseases that are carried in the blood and are
transmitted by direct contact only
NEEDS A PORTAL OF ENTRY
HIV
Facts about HIV…
HIV is present in:
 Semen
 Vaginal secretions
 Blood
 Breast milk
HIV is spread by:
Vaginal sex
Anal sex
Oral sex
sharing needles for any purpose
25 Years of HIV/AIDS
Number Individuals Infected (Millions)
50
45
40
35
30
25
20
15
1 First cases of unusual immune deficiency are identified
among gay men in USA, and a new deadly disease noticed
2 The first HIV antibody test becomes available
People
living
with HIV
7
3 The World Health Organization launches the
Global Program on AIDS
4 Highly Active Antiretroviral Treatment launched
5 Scientists develop the first treatment regimen
to reduce mother-to-child transmission of HIV
6 UNAIDS is created
4
7 WHO and UNAIDS launch the "3 x 5"
initiative with the goal of reaching
3 million people in developing
world with ART by 2005
10
5
6
Children
orphaned
by AIDS in
sub-Saharan
Africa
3
2
5
1
0
1980
1985
UNAIDS Report on the global AIDS epidemic, 2006
1990
1995
2000
2005
Transmission from HIV mom
to baby in the US:
Down 80% in last 10 years
2000 – 325
1991- 1,760
In 2000 6% of babies born to HIV moms
were positive
In 2004 less than 2%
Neviripine costs less that $ 4.00 a dose and can
be taken once during delivery for mom and once
for baby
What is the current state of
the Epidemic?
Global epidemic vs.
National epidemic
Rapid Scale up in India
Estimated 5.2 million
people living with
HIV/AIDS in India
Outcomes at 24 mos.
for Patients Started on ART
13%
April 2004: Free ART
program started at
8 centers
June 2006: 34,620 pts
on ART at 54 centers
13%
1%
73%
Planned
– 2007: 100,000 pts on ART
– 2011: 300,000 pts on ART
LTFU
Died
Stopped
On ART
Khera A, et al. XVI IAC Toronto, Canada, Aug. 13-18, 2006; Abst. WEPE0096.
An estimated 24.5 million adults and children were living with HIV in sub-Saharan Africa at the end
of 2005.
During that year, an estimated 2 million people died from AIDS. The epidemic has left behind some
12 million orphaned African children.
Estimated number of adults and children
newly infected with HIV during 2005
North America
43 000
[15 000 – 120 000]
Caribbean
30 000
[17 000 – 71 000]
Western & Central
Europe
Eastern Europe
& Central Asia
[15 000 – 39 000]
[140 000 – 610 000]
22 000
270 000
North Africa & Middle East
67 000
[35 000 – 200 000]
Latin America
200 000
[130 000 – 360 000]
Sub-Saharan Africa
3.2 million
[2.8 – 3.9 million]
East Asia
140 000
[42 000 – 390 000]
South
& South-East Asia
990 000
[480 000 – 2.4 million]
Oceania
8200
[2400 – 25 000]
Total: 4.9 (4.3 – 6.6) million
World Health Organization / UNAIDS 2005
Estimated adult and child deaths
from AIDS during 2005
North America
18 000
[9000 – 30 000]
Caribbean
24 000
[16 000 – 40 000]
Latin America
66 000
[52 000 – 86 000]
Western & Central
Europe
Eastern Europe
& Central Asia
[<15 000]
[39 000 – 91 000]
12 000
62 000
North Africa & Middle East
58 000
[25 000 – 145 000]
Sub-Saharan Africa
2.4 million
[2.1 – 2.7 million]
East Asia
41 000
[20 000 – 68 000]
South
& South-East Asia
480 000
[290 000 – 740 000]
Oceania
3600
[1700 – 8200]
Total: 3.1 (2.8 – 3.6) million
World Health Organization / UNAIDS 2005
Children (<15 years) estimated to be living
with HIV as of end 2005
North America
9 000
[4 600 – 14 200]
Caribbean
Western & Central
Europe
5 300
[4 200 – 6 800]
Eastern Europe
& Central Asia
7 800
[5 300 – 14 000]
North Africa & Middle East
17 000
[9 900 – 34 000]
Latin America
50 000
[35 000 – 91 000]
37 000
[12 000 – 130 000]
Sub-Saharan Africa
2.1 million
[1.8 – 2.5 million]
East Asia
5 000
[1 900 – 14 000]
South
& South-East Asia
130 000
[73 000 – 250 000]
Oceania
3 300
[1 000 - 13 000]
Total: 2.3 (2.1 – 2.8) million
World Health Organization / UNAIDS 2005
Epidemiology of HIV in US
462,164 people living with HIV/AIDS
in 33 states at end of 2004
– Demographic data indicate most are men,
black/white, 30-59 years of age and MSM
Sexual contact is the main risk factor
for transmission for both men and
women
– Women: 71% heterosexual; 27% IDU.
Blacks: 48% of HIV infected,
but only 13% population
HIV higher in cities with population
>500,000 (0.33%) vs. smaller cities
(0.14%) and non-metro areas
(0.094%)
Overall prevalence of HIV increased
17% 2001 to 2004
Gender
Female
Male
28%
72%
Race
White
Black
Hispanic
34%
48%
17%
Age
<13
13-29
30-44
45-59
>60
1%
10%
49%
35%
5%
Risk Factors
MSM
IDU
Heterosexual
60%
19%
13%
Campsmith M, et al. XVI IAC Toronto, Canada, Aug. 13-18, 2006; Abst.
MOPE0551
USA Surveillance
2004-2005 CDC data showed that Black MSM
have the highest rate of both HIV (46%) and
undiagnosed infection (67%).
African Americans account for 13% of the US
population, but 48% of all AIDS cases diagnosed
since the epidemic began.
During 2002-2003 African American Women’s
HIV/AIDS rates were 19% higher than white
females.
HIV and Youth
Are they at risk?
Why so much attention to HIV/AIDS
education?
What is the percentage of those new HIV
Infections found in youth?
Controversy
AIDS is NOT Over for Youth
50% - new HIV infections among youth 13-24
20,000 - HIV infections annually- US youth
2/3 - HIV+ youth contract HIV sexually
3/4 - HIV+ youth are racial/ethnic minorities
1/3 + - HIV+ people have not been tested
80% - HIV+ gay youth unaware of infection
CDC 2003
Adolescents and HIV
Among 13- to 19-year olds
– 37% were females, in contrast;
– 16% of AIDS cases across all age groups
were females
Ratio of male: female AIDS cases
– 1.5:1 in 13- to 19 year olds
– 5:5:1 in adults 20 years old and older
CDC 2003
Adolescent Sexuality:
Historical Trends
Younger age at fertility/puberty
– Rising economic status: better health/care
– US since 1900: menarche from 15 yrs to 12.5 yrs
Younger age at first experience
– Sexualization of youth in media/society
– Less social stigma for “extra-marital” sex
Older age at marriage
– US since 1890: interval from puberty to marriage
increased from 7 to 12 years
Misconceptions about HIV/AIDS
I am cured
HIV/AIDS is a death
sentence
I have an
undetectable viral
load, so I can not
transmit
I exhibit no
symptoms, so I must
be fine
HIV is not found in
the older population
HIV is a gay, IV drug
abusing disease
HIV in NY
166,814
Cumulative AIDS cases
as of December 2004
Comparison of Risk Distribution
for Cumulative AIDS Cases
in United States and New York State
Adult Risk
MSM
United States
New York
(n=807,075)
(n=149,079)
Percent
46
Percent
30
IDU
25
41
MSM/ID
6
3
Hemophilia
1
0.5
Heterosexual
11
10
Blood Products
1
0.5
Other/U
10
15
TOTAL
100
100
Reported through Nov. 2002
NYSDOH_BHAE
Disease Progression
 Increasing Concern for Non-AIDS related Morbidity
and Mortality
 Lifestyle can speed up HIV disease
 SMOKING
 Drug Use
 Pts. can live increasingly long lives, if they are adherent
to their meds. Most patients do have problems after about
10 years.
Approved Antiretrovirals
Between ’87 and ’95, 4 antiretrovials were launched.
Since ’95, 24 new products have been introduced.
Atripla
Combivir
Hivid
Retrovir
Videx
Epivir
Zerit
Rescriptor
Epzicom
Viread
Ziagen
Viramune
Sustiva Trizivir
Truvada
Emtriva
’87 ’88 ’89 ’90 ’91 ’92 ’93 ’94 ’95 ’96 ’97 ’98 ’99 ‘00 ’01 ‘02 ‘03 ‘04‘05‘06
RTI
NNRTI
PI
FI
Invirase
Viracept Kaletra
Fortovase Agenerase
Aptivus
Reyataz
Prezista
Fuzeon
Norvir
Crixivan
Lexiva
What is Unique about HIV
Treatment?
Adherence of greater than 95% is
necessary to suppress the virus and
avoid resistance
Most medications for HIV have some
level of toxicity or side effects
Patients taking HAART will need to
continue treatment throughout their
lifetime
Updated DHHS Guidelines: When to Treat
Clinical Category
CD4+ Cell
Count
Plasma
HIV-1 RNA
General Guidelines
AIDS-defining
illness
or severe
symptoms*
Any value
Any value
Treat
Asymptomatic
< 200
Any value
Treat
Asymptomatic
200-350
Any value
Treatment should be
offered
following full discussion
of
pros and cons of
treatment.
Asymptomatic
> 350
≥ 100,000
Most clinicians
recommend
deferring therapy, but
some
clinicians will treat.
*Asymptomatic
Severe symptoms = unexplained fever
or diarrhea > 2-4
oral candidiasis, or > 10%
unexplained
weight loss.
> 350
< wks,
100,000
Defer
therapy
DHHS guidelines. http://AIDSinfo.nih.gov. Accessed November 11, 2004.
Early Testing of HIV:

In 2000 among 850,000-950,000 persons
living with HIV in the US, one-quarter
(180,000-280,000) were unaware that they
were infected.*

During 1994-1999, among persons
diagnosed with HIV, 43% were tested late in
the infection (AIDS diagnosed within one year
of HIV diagnosis)

* MMWR Vol. 52, No. 25
Standard Precautions
The number one way to prevent infection:
WASH YOUR HANDS
– Trim nails
– Rings often harbor bacteria
– Hand lotion that contains petroleum interferes with
latex gloves
– Gloves are not a substitute for hand washing
– Cover your mouth when you cough or sneeze and
encourage students to do the same
How do I protect myself from
Bloodborne Diseases ?
Access to gloves
In an accident or situation where no gloves
are available, place another barrier (such
as a paper towel or article of clothing)
between yourself and the blood or body
fluid.
Be aware !!
How do I protect myself from Communicable Diseases ?
Don’t share personal items
Increase ventilation in classrooms. Reduced ventilation is
why more people get sick in the winter
Get an annual TB test if you work in a high risk area
Get the flu shot
Get the Hepatitis B vaccine
Recent Occupational
Epidemiology
HIV
– 57 documented occupational infections in U.S.
health care workers, 138 possible infections
Hepatitis C
– 1-2% of health care workers infected (same as
general population)
Hepatitis B
– 400/year in 1995 compared to 16,000/yr in 1983
U.S. Healthcare Personnel with Documented and
Possible Occupationally Acquired AIDS/HIV
Infection, by Occupation, June 2001*
Documented
Transmission (No.)
Occupation
Dental worker, including dentist
Embalmer/morgue technician
Emergency medical technician/paramedic
Health aide/attendant
Housekeeper/maintenance worker
Laboratory technician, clinical
Laboratory technician, nonclinical
Nurse
Physician, nonsurgical
Physician , surgical
Respiratory therapist
Technician, dialysis
Technician, surgical
Technician/therapist, other than above
Other healthcare occupations
Total
Possible
Transmission ( No.)
---1
---1
2
16
3
24
6
---1
1
2
------57
* http://www.cdc.gov/hiv/pubs/facts.htm#Transmission
6
2
12
15
13
17
---34
12
6
2
3
2
9
4
137
Exposure Risk
Riskiest
– deep parenteral inoculation via hollow needle
– parenteral inoculation with high viral titers
Less Risky
– small volume via non-hollow needle
– mucosal exposure/non-intact skin exposure
Risk not identified
– intact skin exposure
– exposure to urine, saliva, tears, sweat
Immediate Measures
Percutaneous:
– wash needlesticks and cuts with soap and water
– remove foreign materials
Non-intact skin exposure:
– wash with soap and water or antiseptic
Mucous membrane
– flush splashes to the nose, mouth or skin with
water
– irrigate eyes with clean water, sterile saline or
sterile irrigants
HIV, HCV & HBV Exposure and
Seroconversion Risks
Occupational exposure
–
–
–
–
–
–
Average risk after percutaneous exposure 0.3% (3 in 1000)
Estimated risk after mucocutaneous exposure 0.09%
No seroconversion documented prospectively after skin exposure
Risk after exposure to body fluids other than blood not quantified
HCV risk: 1.8% (range 0-7%)
HBV risk: 22 -30% if HBeAg +; 1-6% if HBeAg - for serologic
hepatitis
Sexual exposure
– Estimate of HIV risk from receptive anal intercourse 0.1 to 0.3%
– Estimate of HIV risk from receptive vaginal intercourse 0.08 to
0.2%
Animal Studies of PEP:
Prevention of SIV in macaques with
Tenofovir (PMPA)
24 macaques
- 4 / study arm
IV inoculation of SIV
– 10 X 50% animal infectious dose
Initiation at 24, 48, 72h post exposure
Duration 3,10, 28 days
Tsai et al, J Virol, 1998;72:4265
Animal Studies of PEP:
Prevention of SIV in macaques with
Tenofovir (PMPA)
Initiation / duration
24h / 28d
48h / 28d
72h / 28d
% Protected
100%
50%
50%
24h / 10d
75%
24h / 3d
0
Tsai et al, J Virol, 1998;72:4265
Prevention of Perinatal
Transmission
Risk of perinatal transmission is approximately 25%
Most perinatal HIV transmission occurs at birth
Regimens with prepartum, intrapartum, and postpartum
zidovudine components can reduce perinatal
transmission by two-thirds (PACTG 076)
NYS observational data showed 9.8% transmission
among infants receiving PEP beginning in the first 24-48
hours of life
Stratifying Risk - Source
Assessment
If source is HIV+
– What is viral load/stage of disease?
If HIV status is unknown
– What is history of risk factors?
– Any symptoms of primary HIV infection?
– What is history of testing?
If source is unknown
– What is prevalence where exposure
occurred?
– How long has sharp been environmentally
exposed?
Source Assessment: Addressing
the Window Period
Median time to seroconversion is
estimated at 4 weeks.
If source is HIV- and has no history
of recent (last 3 months) risk
behavior and no symptoms of
primary HIV infection, consider HIV
ruled out.
1 mil
HIV
RNA
100,000
+
_
10,000
Ab
P24 +
1,000
100
Exposure
Symptoms
10
0
20
30
Days
40
50
HIV-1 Antibodies
HIV RNA
Typical Course of Primary HIV
Source Patient HIV Information
Test source patient
– obtain patient consent (required) for testing and for
disclosure of results to exposed employee
– Source needs to be tested for HIV, HBV and HCV
Obtain preexisting HIV test results on source
patient
– obtain patient consent for release of HIV information, or
– contact source patient’s physician for documentation of
results (patient consent not required)
If source patient HIV antibody negative, may stop
PEP unless acute antiretroviral syndrome or
recent HIV infection is suspected
Antiretroviral Regimens
NYSDOH
CDC
Universal Regimen
ZDV
3TC
(Combivir)
+
Tenofovir
Basic Regimen
ZDV
3TC
(Combivir)
Expanded Regimen
Basic +
indinavir or nelfinavir or
efavirenz or abacavir
Recommendations for Occupational PEP
NYSDOH (2003)
Duration of PEP: 4 weeks
HIV Antibody Testing of HCW
– • Baseline
– • 6 weeks post-exposure
– • 12 weeks post-exposure
– • 26 weeks post-exposure
Initiation of PEP: ASAP
No Later than 36 hours after the exposure to
optimize effectiveness.
What would make an EMS call
unique for an HIV patient
HIV patients are more prone to infection
HIV patients are more prone to Metabolic
and lipodystrophy complications
– This in no way makes them unique. They will
present like any other patient.
– HIV Patients do NOT have to disclose their
status.
USA
Since the beginning of the epidemic,
524,060 deaths were reported
through December 2003