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HIV Update for EMS 2007

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

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HIV Update for EMS 2007

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  1. HIV Update for EMS 2007 Abigail Gallucci Director of Education and Outreach Albany Medical Center’s AIDS Program

  2. 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

  3. 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

  4. 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

  5. HIV

  6. Facts about HIV… HIV is spread by: • Vaginal sex • Anal sex • Oral sex • sharing needles for any purpose HIV is present in: • Semen • Vaginal secretions • Blood • Breast milk

  7. 6 4 7 2 1 3 25 Years of HIV/AIDS People living with HIV 50 1 First cases of unusual immune deficiency are identified among gay men in USA, and a new deadly disease noticed 45 2 The first HIV antibody test becomes available 40 3 The World Health Organization launches the Global Program on AIDS 35 4 Highly Active Antiretroviral Treatment launched 30 5 Scientists develop the first treatment regimen to reduce mother-to-child transmission of HIV 5 Children orphaned by AIDS in sub-Saharan Africa Number Individuals Infected (Millions) 25 6 UNAIDS is created 20 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 15 10 5 0 2005 1980 1985 1990 1995 2000 UNAIDS Report on the global AIDS epidemic, 2006

  8. 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 CDC 2003

  9. What is the current state of the Epidemic?Global epidemic vs. National epidemic

  10. Rapid Scale up in India Outcomes at 24 mos. for Patients Started on ART • Estimated 5.2 million people living with HIV/AIDS in India • April 2004: Free ART program started at 8 centers • June 2006: 34,620 pts on ART at 54 centers • Planned • 2007: 100,000 pts on ART • 2011: 300,000 pts on ART at 250 centers Khera A, et al. XVI IAC Toronto, Canada, Aug. 13-18, 2006; Abst. WEPE0096.

  11. 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.

  12. Estimated number of adults and children newly infected with HIV during 2005 Eastern Europe & Central Asia 270 000 [140 000 – 610 000] Western & Central Europe 22 000 [15 000 – 39 000] North America 43 000 [15 000 – 120 000] East Asia 140 000 [42 000 – 390 000] North Africa & Middle East 67 000 [35 000 – 200 000] Caribbean 30 000 [17 000 – 71 000] South & South-East Asia 990 000 [480 000 – 2.4 million] Sub-Saharan Africa 3.2 million [2.8 – 3.9 million] Latin America 200 000 [130 000 – 360 000] Oceania 8200 [2400 – 25 000] Total: 4.9 (4.3 – 6.6) million World Health Organization / UNAIDS 2005

  13. Estimated adult and child deaths from AIDS during 2005 Western & Central Europe 12 000 [<15 000] Eastern Europe & Central Asia 62 000 [39 000 – 91 000] North America 18 000 [9000 – 30 000] East Asia 41 000 [20 000 – 68 000] North Africa & Middle East 58 000 [25 000 – 145 000] Caribbean 24 000 [16 000 – 40 000] South & South-East Asia 480 000 [290 000 – 740 000] Sub-Saharan Africa 2.4 million [2.1 – 2.7 million] Latin America 66 000 [52 000 – 86 000] Oceania 3600 [1700 – 8200] Total: 3.1 (2.8 – 3.6) million World Health Organization / UNAIDS 2005

  14. Children (<15 years) estimated to be living with HIV as of end 2005 Eastern Europe & Central Asia 7 800 [5 300 – 14 000] Western & Central Europe 5 300 [4 200 – 6 800] North America 9 000 [4 600 – 14 200] East Asia 5 000 [1 900 – 14 000] North Africa & Middle East 37 000 [12 000 – 130 000] Caribbean 17 000 [9 900 – 34 000] South & South-East Asia 130 000 [73 000 – 250 000] Sub-Saharan Africa 2.1 million [1.8 – 2.5 million] Latin America 50 000 [35 000 – 91 000] Oceania 3 300 [1 000 - 13 000] Total: 2.3 (2.1 – 2.8) million World Health Organization / UNAIDS 2005

  15. 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 Campsmith M, et al. XVI IAC Toronto, Canada, Aug. 13-18, 2006; Abst. MOPE0551

  16. 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.

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. HIV in NY 166,814 Cumulative AIDS cases as of December 2004

  23. Comparison of Risk Distribution for Cumulative AIDS Cases in United States and New York State United States New York (n=807,075) (n=149,079) Adult Risk MSM 46 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 Percent Percent Reported through Nov. 2002 NYSDOH_BHAE

  24. 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.

  25. FI Fuzeon Approved Antiretrovirals Between ’87 and ’95, 4 antiretrovials were launched. Since ’95, 24 new products have been introduced. Atripla Combivir Epzicom Viread Epivir Rescriptor Hivid Ziagen Truvada Viramune Sustiva Emtriva Trizivir Zerit Retrovir Videx ‘04 ‘05 ‘06 ’93 ’87 ’88 ’89 ’90 ’91 ’92 ’94 ’95 ’96 ’97 ’98 ’99 ‘00 ’01 ‘02 ‘03 Aptivus RTI Invirase Viracept Kaletra Reyataz NNRTI Prezista Fortovase Agenerase PI Norvir Lexiva Crixivan

  26. 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

  27. Updated DHHS Guidelines: When to Treat • * Severe symptoms = unexplained fever or diarrhea > 2-4 wks, oral candidiasis, or > 10% unexplained weight loss. DHHS guidelines. http://AIDSinfo.nih.gov. Accessed November 11, 2004.

  28. 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

  29. 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

  30. 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 !!

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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%

  36. 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

  37. Animal Studies of PEP:Prevention of SIV in macaques with Tenofovir (PMPA) Initiation / duration% Protected 24h / 28d 100% 48h / 28d 50% 72h / 28d 50% 24h / 10d 75% 24h / 3d 0 Tsai et al, J Virol, 1998;72:4265

  38. 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

  39. 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?

  40. 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.

  41. Typical Course of Primary HIV HIV RNA 1 mil HIV RNA 100,000 + HIV-1 Antibodies _ 10,000 Ab P24 + 1,000 Exposure 100 Symptoms 10 0 20 30 40 50 Days

  42. 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

  43. Universal Regimen ZDV 3TC + Tenofovir Basic Regimen ZDV 3TC Expanded Regimen Basic + indinavir or nelfinavir or efavirenz or abacavir Antiretroviral RegimensNYSDOH CDC (Combivir) (Combivir)

  44. 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.

  45. 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.

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