Lina Del Balso BscN

1. Lina Del Balso BscN Nurse Clinician Immunodeficiency Clinic Montreal Chest/Royal Victoria Hospital

2. DO YOU KNOW THE CORRECT ANSWERS? HIV infection has become a chronic illness. TRUE However, it differs from other chronic illnesses by the following key points: The potential resistance of virus to HAART which leads to TX failure and the potential for transmitting a resistant strain, stigma, disclosure issues, facial lipoatrophy makes it easy to identify someone. A mosquito bite carries the potential for transmitting HIV infection. FALSE The HIV virus does not live in an insect. The mosquito will digest the blood from the first person before biting another person. The insect first injects salvia before drawing up the blood. There have been no documented HIV transmission cases in regions infested with mosquitoes. HIV infection can be cured with the anti-retroviral treatments now available. FALSE   Treatments only control viral replication and preserve the immune system. No cure is available.

3. 4. I wear gloves when drawing bloods and/or performing invasive procedures only when the person seems to be at risk. Either way, if I sustain an injury, the gloves will not offer me any protection. FALSE.Do not judge the person, only the behavior!!! Gloves will offer you protection by blocking the needle bore and reducing the amount of blood you are exposed to. Therefore, wear gloves!!! 5.Why should I pass an HIV test when I’m pregnant? Either way, if I’m HIV positive so will my baby. FALSE.Vertical transmission is 15-30%. With AZT alone the risk is  8% if given IV during labour and po for 6 weeks to the infant. With triple therapy and a controlled viral load of <50 copies risk is  0-2%. Since May 1997 0% transmission rate in treated mothers and infants noted at Ste. Justine. Hepatitis B has a 15-90% vertical transmission without TX and  20% with immunoglobulin TX. Hepatitis C has 5% vertical transmission and 14% if co-infected with HIV.

4. 6. I can catch HIV from sharing the same utensils and toilet seat of an infected person. FALSE.There is no risk in becoming infected with HIV with causal contact such as dry kissing, hand shaking, sharing the same bathroom, utensils etc. 7. I am working on a surgical ward and it is extremely busy and I sustain a needle stick injury. It’s my fault for not being careful. I don’t need to go to the emergency department because we are short staffed and besides, what are the chances of an HIV patient being admitted to a cardiovascular unit for heart surgery. FALSE.HIV patients are not immune to other diseases especially with the metabolic complications associated with HAART. HIV patients are not admitted to a specific department. Always scan your environment; you will be surprised where used needles can be found! Remember, it is not your fault!! A needle stick injury is a medical emergency and if assessed to be necessary, PEP needs to be started ideally within in 2 hours of the injury. It still can be initiated 36 hours-72 hours after. Risk of HIV transmission is 0.1-3% and AZT decreases the transmission rate by 81%. Recommended to have 3 class HAART.

5. 8. The Hepatitis B virus can survive for 1 week-1 month on surfaces while still maintaining its virulence. TRUE.It is potentially infectious if an entry point exists such as a cut. 9. The HIV virus can survive in a syringe for days- 1 month. TRUE. Always scan your environment; bedside, bed linen, parks, gardens. Always discard your used needles in the appropriate bins. 10. I am taking an oral contraceptive. Am I at more risk for acquiring STDS? TRUE.Oral contraceptives do not protect you from STDs including HIV or Hepatitis B or C. In JANAC 2002, a study showed that the use of oral contraceptives without condom use, increased the risks of acquiring STDS due to the changes in the vaginal lining that were noted with pill use.

6. 11. Uncircumcised men are more prone to HIV infection than circumcised men. TRUE.Foreskin contains large concentrations of cell types that HIV targets. In addition, the foreskin provides an environment for survival of bacteria and viruses and may be susceptible to tears, scratches and abrasions, which may  the likelihood of contracting HIV. Studies in sub-Saharan Africa show this. 12. It is not necessary to practice safer sex since there are new HIV treatments available. FALSE.It is always important to protect yourself because the treatments are not a cure! In 1996 in Quebec, 1 adult in 500 became infected and in Montreal, 1/200 became infected. In 2005, it was estimated that 800 to 1,500 individuals are newly infected each year in the Montreal region. Increase syphilis rates of been noted in gay community. For patients already infected, it is important for them to protect themselves because STDS could affect the immune system and increase the viral load and potentially trigger the progression of HIV from asymptomatic seropositive state to illness. Infection affects the immune response and may activate cells that HIV targets. Infection with new strains may produce illness at varying rates and result in development of premature resistance to HAART. In addition, co-infection is harder to TX, i.e. Hepatitis. C and HIV.

7. Principles of Transmission Need a source – Don’t judge the person – judge the fluid (ex. blood, semen, etc.) Need a transmission – Mother to infant, sex, injecting activity. Need a host – Remember that anyone is a potential host – No one’s immune – challenge with teenagers. Need an appropriate route of entry – break in skin, disruption of mucosa, etc. Need sufficient virus – semen, vaginal fluid, blood, breast milk, urine, saliva, tears.

8. Risk categories No risk – No potential for transmission, no documented cases (ex. kissing without blood) Negligible risk – Potential for transmission but no evidence. Fellatio- receiving – oral sex. Receiving cunnilingus – licking of clitoris and/or in vagina. Anilingus – licking anus – performing + receiving. However, sufficient to transmit other STI’s and intestinal parasites. Fingering anal + vagina. Fisting. Docking.

9. Riskcategories 3. Low risk – Potential for transmission with evidence under certain conditions. Wet kissing – if mouth sores, blood. Performing fellatio (oral sex) without condom + receiving semen and/or pre-ejaculate in mouth. Pre-ejaculate and semen has HIV but healthy mouth is hostile to HIV because the enzyme in saliva inhibits HIV. Wait 30 minutes – 2hours after brushing teeth or flossing before sexual activity. Cunnilingus – liking clitoris and/or in or around vulva – if performing during menses or not. If with barrier protection then – negligible risk. Penile vaginal intercourse with condom. Penile anal intercourse with condom. 4. High risk Penile vaginal intercourse without condom Penile anal intercourse without condom Sharing used sex toys

10. Transmission of HIV • HIV does not survive well in the environment • No transmission has been documented from exposure on surfaces • Viable HIV has been found in syringes  1 month

11. Body Fluids known to transmit HIV • Blood • Semen, vaginal secretions • Bloody body fluids • Breast milk

12. Fluids likely to pose a risk • Inflammatory fluids (pericardial, synovial, peritoneal, pleural, exudate) • Saliva, urine, tears and sweat are non infectious unless contaminated with blood

13. Body Substance Precaution • BSP is based on anticipated contact with body fluids and tissues, regardless of diagnosis • Use of gloves, protective clothing and other barriers as needed to prevent direct contact with all body fluids • BSP has shown at least a 50% reduction in mucotaneous exposure frequency

14. Hand washing is essential! • Before and after patient contact • After glove removal • When contamination with potentially infective materials occurs

15. GLOVES must always be used whenever in contact with blood, secretions and other body fluids and tissues

16. Use of double gloving with invasive surgical procedures or prolonged contact with blood • Own skin integrity • Use of gloves  blood to other side by 50% in hollow bore and 85% for suture needles

17. Use gowns when clothing is likely to be contaminated Don’t wander with gown on!

18. Masks, goggles and face shields • Wear for splashes • Routinely wear protection for airway manipulations, endoscopic or dental procedures • N95 masks for suspected TB cases

19. In Occupational Settings • Needle sticks • Mucosal contamination (0.03 - 0.09%) • Contamination of non intact skin

20. Percutaneous Exposure • Needle stick injuries is most frequent cause of HIV infection in occupational exposure • HIV : 0.32 % • Hep B : 6 - 30 % • Hep C : 3 %

21. NEVER RECAP NEEDLES! • Dispose of needles / sharp objects immediately after use in sharps container • Safe needle devices / needless systems

22. Post Exposure Prophylaxis • First aid for any needle sticks, mucous (eyes, mouth) and cutaneous exposures

23. Seek immediate medical attention (Hospital ER) • Assess need for prophylaxis • PEP only effective if started  36 h, ideal if within 2 hours of exposure • PEP consists usually of 3 drugs – 2 classes given for 4 weeks (PEP can cost $600-$1,150) • Condom use during PEP • 6 month window period • Initial test done then repeated 6 weeks, 12 weeks, 6 months • Monitor for signs and symptoms of primo infection

24. HIV Testing Can be done by your G.P., local CLSC or STD clinics HIV testing is voluntary – consent, counselling, confidentiality. Pre-test counselling – discussed. Risk reduction discussed. Post-test counselling : Results given only in person. Reactions to HIV result – disclosure, confidentiality, Review and identify high risk behaviour. If HIV test + ,ELISA test confirmed with Western Blot at LSPQ , notification of partners – support system offered at CLSC Metro. HIV is being declared to public Health for surveillance since 2001.

25. 3 types of HIV testingavailable in Canada a) nominal – name based HIV testing - can be done at numerous locations - person ordered the test knows the identity of the person - name of person is used and demographics - If HIV test is + physician is obligated by law to notify public health b) non-nominal / non-identifying HIV testing - similar to nominal except HIV test is ordered using a code or initials of the person c) Anonymous testing - available at specialized clinics ex. : CLSC metro - identity of person is not known - code is used – only person being tested knows the code. Physician and lab do not know to whom the code belongs - age, gender, HIV related risk factors and ethnicity may be collected depending on province or territory - not recorded in medical record. Only if person gives consent – not necessarily reported to public health

26. Vertical Transmission • HIV • 15 - 30 % in untreated mothers •  to 8 % when treated • Hepatitis B • 15 - 90 % (20% when treated) • Breastfeeding • 8 % not recommended in North America but recommended in Africa for 1st 6 months – low risk. If mixed with cow milk then intestinal lining is disrupted and risk increases.

27. Risk of HIV transmission in unprotected sexual relations • Vaginal 0.1 - 2 % HIV 25 - 40 % Hep. B • Anal 0.1 - 3 % HIV 25 - 40 % Hep. B • Oral Sex (receptive) 0.1 %

28. Sexual Transmission • HIV  is in presence of other STD’s • Spermicides on condoms can weaken the body’s mucosal surfaces and  risk of transmission

29. References • The Aids Knowledge Base. Preventing HIV Infection in Health Care Settings. HIVinsite 1999 Edition • Dufresne, Serge. La transmission du VIH et des hépatites: Mythes et réalités. Huitième symposium sur les aspects cliniques de l’infection par le VIH. 2001 • Thibodeau, Pierre G. Les prophylaxies post-exposition. Huitième symposium sur les aspects cliniques de l’infection par le VIH. 2001 • Guide to HIV/AIDS Therapy – 10th Edition. 2001. • Portrait des infections transmissibles sexuellement et par le sang (ITSS), de l’hépatite C, de l’infection par le VIH et du sida au Québec. Décembre 2003. • HIV and AIDS in Canada – Surveillance Report to December 31, 2004. April 2005. • HIV Transmission : Guidelines for Assessing Risk. 2005.

30. References (cont.) HIV/AIDS Epi Updates. May 2005. The Global Challenges of the HIV/AIDS Pandemic. JAIDS. 2000. Factors Affecting Adherence to Antiretroviral Therapy in People Living With HIV/AIDS. JAIDS. 2003. Factors That Influence the Medication Decision Making of Persons With HIV/AIDS : A Taxonomic Exploration. JAIDS. 2003. Stigma and HIV : Does the Social Response Affect the Natural Course of the Epidemic? JAIDS. 2003. HIV : Associated Transmission Risks in Older Adults – An Integrative Review of Literature. JAIDS. 2004. Treatment of Hepatitis C Virus in the Coinfected Patient. JAIDS. 2003.

31. CASE STUDY 1 Clarissa is a 40-year-old woman accountant from Burundi, refugee in Canada since September 2005. Social History: Patient was gang raped in refugee camp by military officers. Father and 4 brothers were murdered in 1995-2004. She came to Canada leaving behind several children she cared for. Living at the YMCA until November 2005 when she finally found an apartment. She contracts scabies in infested apartment. Lives alone and is relatively isolated. Has two African friends she met at YMCA. Friends are unaware of HIV status. Medical History: HIV positive since June 2004. Received antiretroviral in Africa but had to stop them because of immigration to Canada. No opportunistic infections. Hepatitis B surface antigen positive. Hepatitis C antibody negative. Negative PPD. Negative Toxo Igm. CD4s 87 9%. Viral load 32, 532 copies. No known allergies.

32. She is very eager to start treatment. She is very knowledgeable of risks of mutations and resistance if medications are not taken properly. She tells you, “I was told in Africa that I could never stop my meds.” She is started on Septra. She also was started on Zithromax 1200mg po once weekly for MAC prophylaxis. Questions 1-Which social issues are very relevant to Clarissa and why do we need to focus on these issues? Remember that you can’t simply treat HIV. Patients are the most important part of the health care team. Need to look at the person as a whole. Immigration status: Clarissa has refugee status. Need to evaluate if she has a lawyer who is familiar with HIV and refugee issues and problems in her country. Need to help Clarissa prepare for her refugee hearing. Need to consider the losses she has experienced and coping with!!! New country with different social structure and rules. Need assistance of social worker, immigration lawyer,nursing. Housing: Infested apartment! Is it liveable? Is it affordable? Furniture expenses. How far is it from medical facility where she is followed? Is it accessible to public transit? Is it in her community?

33. Need assistance of social worker, nursing.  Employment/ Financial:Recent refugee. Has not yet had the time to find an employment. Need to evaluate if medications are covered by refugee status otherwise need to make a request for federal interim program for exemption. Her accounting education is not recognized in Quebec. Need assistance of social worker and pharmacist,nursing. Cultural values:HIV is very taboo in African cultures. Stigma associated with illness. Do not assume she will seek help from newly made friendships. Rape is not spoken about openly. Patients of been known to refuse CLSC assistance because the community members will wonder why is someone going to their home. Patients from same community have been seen hiding from each other at our clinic. Assess cultural values that may hinder compliance and affect their understanding of their illness. Need assistance of nurse and psychologist. Isolation/support:Refugees are isolated. Family support in their country or family members may have been killed. At high risk for depression. Are still morning losses of loved ones killed or left behind. Clarissa lost father and brothers. Has children left behind in Africa. Who is taking care of them? Are their lives at risk from potentially being killed, HIV status of kids? Need assistance of nurse and social worker, community organizations, CLSC.

34. Education/literacy:You need to assess the patient’s education level and literacy level, which can affect their understanding of HIV and the treatments. Clarissa is very knowledgeable of HIV illness and treatment adherence.Referral to community groups. 2- Should Clarissa be started on HAART (Highly Active Antiretroviral Therapy)?Yes. Initiation of HAART is strongly recommended when the CD4 count is <200 and the viral load is >30, 000 copies. Importantly is that the patient is also willing to comply. Genotyping blood sample is recommended given that she was on meds in Africa. 3- What are the opportunistic infections Clarissa is at risk for?Pneumocystis carnii pneumonia (PCP), systemic infections, cryptosporidiosis, cerebral toxoplasmosis, progressive multifocal leukoencephalopathy (PML), peripheral neuropathy, cervical carcinoma. Thrush, Kaposi sarcoma. Herpes zoster, Herpes simplex, Bacterialsinusitis/pneumonia.

35. 4- Why is she started on Septra? Septra is an anti-parasitic drug that protects Clarissa from developing a PCP and toxoplasmosis infection. Septra DS 1 tab po qd is the recommended dose. Clarissa was eligible for a research protocol. She was suppose to start her new regimen, when she fell and fractured her elbow. She was admitted to orthopedics for an oblique fracture of her elbow and surgery, which involved an internal fixation of her elbow. Clarissa’s refugee hearing and new regimen are postponed due to the admission. During her hospitalization, Clarissa’s behavior changes and she starts having delusional thoughts of people wanting to kill her. She has her surgery, gets discharged and is re-admitted 24 hours later for an acute psychosis. She has a CT-scan of the head and is seen by psychiatry service.

36. 5- Why did Clarissa have a CT scan of the head? Ct scan was done to rule out PML, lymphoma and other bacterial or parasitic infections common in Africa. Since her serology was negative for Toxoplasmosis and she was taking her Septra, cerebral Toxo infection was unlikely. CT scan was negative. 6- What do you think was causing Clarissa’s change in behavior? She was diagnosed with Post Traumatic Stress Syndrome. Losses>>>>Coping abilities. Rape, family murdered, new arrival to Canada. Isolated. Fracture caused important refugee hearing to be postponed. New treatment postponed. Stressed that she will be too ill to start new treatment. Pain from fracture, morphine as pain med. NPO for surgery, which was delayed 3 times. 7- Which services would you need to set up for Clarissa upon discharge? Psychosocial services-follow-up with team psychiatrist and psychologist where made. CLSC referral made for assistance with groceries, laundry, scabies treatment, evaluation of home environment, physiotherapy, and wound assessment and pain control. Follow-up with team social worker and lawyer. Referral to community organizations such as Le CRISS.

37. The Vulnerable Population : Persons at Risk • Young gay men • Women • IVDU • Homeless • Endemic countries/refugees • Older adults • Psychiatric/psychological disorders • Aboriginals

38. The Vulnerable Population : Persons at Risk When assessing for risk of HIV transmission, always remember, it’s not the group but the behaviours that are high risk

39. The Vulnerable Population : Persons at Risk • Implications for healthcare professionals • Can’t change groups but you can change behaviours • Persons may not identify themselves as part of a group and may be “missed” • Less stigmatizing and more likely to have individuals tested when focusing on behaviours and not the “label”

40. The Vulnerable Population : Persons at Risk • Unprotected sexual relations/high number of sexual partners • Sharing of needles or kits • Breastfeeding/mother-to-child transmission • Needle stick injuries

41. The Vulnerable Population : Persons at Risk Knowledge alone does not = safer practices What’s going on?

42. The Vulnerable Population : Persons at Risk • Cultural background/health beliefs • Knowledge about HIV • Ability to negotiate/power position in relationship • Self-esteem/self-efficacy • Perceived risk vs immediate gain

43. The Stigma of HIV : A Vicious Cycle Stigma of HIV Fear of disclosure Restricted support system Increased isolation Interrupted / Inadequate healthcare Poor control of HIV Increased risk of transmission New infection of HIV

44. The Stigma of HIV : A Vicious Cycle • At increased risk for poverty • Minimum wage jobs that require no formal education • Poor working conditions • Disclosure for medical coverage Again this leads to inadequate health care where often the only option is welfare.

45. Services for Healthcare Professionals • Consultation SIDA 1-800-363-4814 • Programme National de Mentorat • Unité régionale de Médecine de jour • National AIDS clearinghouse • CANAC/ACIIS • Santé Publique-notification des partenaires (528-2400 x 3840) • HIV/AIDS legal network

46. Useful Websites • www.catie.ca • www.hivmedicationguide.com • www.cmeonhiv.com • www.canac.org • www.aidslaw.ca • www.statcan.ca • Journal of American Nurses in AIDS Care