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1 Introduction to perinatal HIV

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Contents

Objectives

When you have completed this unit you should be able to:

Introduction to HIV

1-1 What is HIV?

HIV, the human immunodeficiency virus, is a virus which infects people for life and causes a severe clinical condition called AIDS. HIV infects cells of the immune system, particularly lymphocytes. HIV infection can be spread from one person to another.

HIV causes AIDS.

HIV infection is a relatively new condition which was first identified in Paris in 1983. Since then it has spread to almost every country in the world and by 2006 over 40 million people worldwide were infected. The number of HIV infected people dropped to 34 million in 2010. In 26 countries the prevalence of HIV decreased by 50% from 2001 to 2012.

In South Africa the prevalence of HIV in the age group 15 to 49 years was 19% in 2019 while the prevalence of HIV in pregnant women attending public health antenatal clinics remained between 28 and 31% from 2004 through to 2017. Presently 95% of pregnant women living with HIV (WLWH) are on antiretroviral (ARV) treatment. As a result of ARV treatment the annual number of perinatally infected children over the same time period declined by 80% from 70,000 to 13,000. The National Committee for Confidential Enquiries into Maternal Deaths (NCCEMD) reported a 52% reduction in maternal deaths caused by HIV from 2011 to 2016 due to the roll out of ARV treatment.

Note
Two types of HIV are recognised, HIV1 and HIV2. Most infection in southern Africa is caused by HIV1, which has many subtypes (clades). The important subtype in Africa is subtype C, while subtype A is common in West Africa and B is the most common subtype in the developed world.

HIV probably appeared in humans in the 1950s. It was first transmitted to humans by chimpanzees in central Africa. From here it rapidly spread to all parts of the world, especially the USA, Europe, Asia and other parts of Africa.

1-2 What is a virus?

Viruses are extremely small, very simple organisms which can only exist and multiply by invading and taking control of a plant or animal cell (the host cell). Viruses are responsible for many diseases. Unlike bacteria, they are not killed by antibiotics. Viruses may be divided into many different groups. HIV belongs to a group of viruses known as retroviruses.

1-3 What are retroviruses?

They are a group of viruses which are unique in nature as they have a special enzyme which enables them to introduce their own genes into the nucleus of the host cell. The host cell is then instructed to produce millions of new copies of the virus. These copies are released into the bloodstream where they can infect other cells. Retroviruses usually cause long periods of silent infection before signs of disease appear.

Note
Retroviruses contain an RNA genetic code. The enzyme reverse transcriptase allows HIV to make DNA copies of its RNA. The DNA copy is then inserted into the DNA of the nucleus in the host cell. This enables the virus to take over control of the host cell and instruct the host cell to produce huge numbers of new HIV. Only retroviruses have this ability to make a DNA copy of their RNA code. Retroviruses are common and some cause cancers in animals and humans.

HIV is a retrovirus.

1-4 What is AIDS?

AIDS stands for the Acquired Immune Deficiency Syndrome. This is a severe illness caused by advanced HIV infection and may present in many different ways. The symptoms and signs of AIDS are usually due to secondary infections with a number of different organisms. Some secondary infections are due to uncommon organisms not normally seen in HIV-negative people. AIDS is a slow, progressive, incurable disease which is fatal unless correctly treated with ARV drugs. AIDS was first recognised in the USA in 1981. The following year it was diagnosed in Africa.

AIDS is a severe illness caused by HIV infection. There is a widespread epidemic of AIDS in Africa.

Most cases of AIDS occur in Africa. The spread of the HIV epidemic is greatest in southern Africa. In 2019, it is estimated that 7.5 million adults and children were living with HIV in South Africa.

About 7.5 million South Africans are living with HIV.

1-5 Can you have silent HIV infection?

Yes. A person is usually infected with HIV for many years before developing symptoms and signs of the virus. Therefore, most people living with HIV are clinically well and have a ‘silent’ or hidden infection.

The spread of HIV

1-6 How can you become infected with HIV?

The virus may be transmitted from one person to another by:

  1. Unprotected sexual intercourse (horizontal transmission).
  2. Crossing from a mother to her fetus or newborn infant (vertical transmission).
  3. Using syringes, needles, or blades which are soiled with HIV-infected blood. They may be shared by intravenous drug abusers or not correctly cleaned and then reused by health workers.
  4. Accidental needle-stick injuries in healthcare workers.
  5. A blood transfusion with HIV-infected blood or other HIV-infected blood products such as factor VIII in haemophiliacs. This is extremely rare in South Africa as all blood products are screened for HIV.

There is no evidence that HIV can be spread by mosquitoes, lice or bed bugs. In Africa, HIV is most commonly spread by sexual intercourse, especially when there are multiple sex partners.

In Africa, HIV is mostly spread by sexual intercourse.

1-7 Can an HIV-infected person who is well transmit the virus?

Yes. HIV is frequently transmitted by people who appear to be clinically well but are infected with HIV. This is the great danger of HIV infection as most infectious people do not know that they have been infected. They are also unaware that they may transmit HIV to another person.

1-8 How may you become infected during sexual intercourse?

By contact with infected body fluids which contain large amounts of HIV, such as:

  1. Vaginal discharge and cervical secretions
  2. Semen
  3. Blood

The spread of HIV between adults by sexual intercourse is called horizontal transmission.

1-9 Can you become infected with HIV during normal social contact?

No. Family and friends of a person living with HIV do not become infected except by sexual contact. HIV is not transmitted by close social contact such as touching, holding hands, hugging and social kissing. HIV is also not spread by coughing, sneezing, swimming pools, toilet seats, sharing cooking and eating utensils or by changing a nappy. However, any bleeding, such as nose bleeds, may spread HIV if the blood comes in contact with broken skin or mucosal surfaces.

1-10 What forms of sexual contact may transmit HIV?

In Africa HIV is almost always transmitted by penetrative sexual intercourse. However all forms of oral sexual contact (mouth to vagina or mouth to penis) can also result in infection, although the risk is less. Deep kissing may possibly transmit HIV, especially if mouth ulcers are present. HIV is not present in urine or stool while very little is present in saliva. HIV cannot penetrate intact skin but may infect open sores, cuts and abrasions, or mucous membranes. The thin, friable rectal mucosa is easily damaged during anal intercourse and, thereby, increases the risk of infection. Men who have been circumcised have a lower risk of being infected through sexual intercourse.

Note
The inner surface of the foreskin is easily crossed by HIV infected lymphocytes. Therefore removal of the foreskin is partially protective against men acquiring HIV infection.

1-11 Is HIV very infectious?

In comparison to other viral illnesses such as hepatitis B, HIV is not very infectious, and repeated exposure to large amounts of virus is usually needed for transmission. People with early and advanced HIV infection are most infectious. Other sexually transmitted diseases and abrasions of the vaginal and cervical epithelium increase the risk of infection. The highest risk of sexual transmission for both men and women is during anal intercourse. Patients on ARV treatment are less infectious.

Within weeks of becoming infected, when HIV levels in the blood are very high, people with multiple partners may infect many people.

Diagnosing HIV infection

1-12 How is HIV infection diagnosed?

Usually a blood test is used to screen people for antibodies to HIV and HIV antigens (proteins). Antibodies are produced by the immune system to protect the body against invading organisms, such as viruses. Unfortunately they offer little protection to HIV. The presence of HIV antibodies in an adult, or child older than 18 months, indicates HIV infection.

A number of antibody tests are available to diagnose HIV infection.

Combined antibody antigen tests have become the standard laboratory test to detect HIV infection. It is a highly accurate test and is used to screen for HIV infection and for confirming a clinical suspicion of HIV infection. From the time of infection it takes between 14 to 21 days for the test to become positive. Two positive tests, using kits from two different manufacturers on the same blood sample, are needed before a definite diagnosis of HIV infection is made. This is done to make sure that an error has not been made. The antigen included in the combined tests is a HIV protein called the p24 antigen.

Rapid tests have been developed to detect HIV antibodies in blood, urine and saliva. The new generation of rapid tests detecting both antibodies and antigens are very accurate and in many places have replaced laboratory tests for screening and confirming HIV infection. Two rapid tests using kits from different manufacturers should be used to diagnose HIV infection. The great benefit of the rapid test is that it can be done on site to give same day results. If the rapid test is negative it is very unlikely that the person has HIV infection. Two positive rapid tests indicate HIV infection. If the first rapid test is positive but the second negative, blood must be taken for laboratory testing.

Two positive laboratory or rapid tests are needed to diagnose HIV infection.

Viral tests, which do not rely on HIV antibodies, can also be used to diagnose HIV infection:

  1. DNA from the HIV can be detected, using the polymerase chain reaction (PCR) test. This is a very accurate, but more expensive, test which is used in special circumstances to confirm or exclude infection. For example, in infants where the mother’s HIV antibodies may remain for up to 18 months and thereby give a positive result in an infant who is not HIV infected. The PCR test is accurate in infants from six weeks after delivery if they have not been breastfed, or in infants who have been breastfed following complete weaning for six weeks. A positive test indicates that the individual is infected with HIV.
  2. The virus can be cultured. This is very expensive.

A positive PCR test in an infant indicates that the infant is infected with HIV.

Note
The DNA-PCR or the total nucleic acid (DNA and RNA) test is used to diagnose HIV infection while the RNA-PCR is used to measure viral load.

The antibody tests may be negative for 2 to 8 weeks and the combined antibody antigen laboratory or rapid screening tests may be negative for 14 to 21 days after infection with HIV. This is known as the window period. During the window period these people are still infectious to others, despite their test being negative. The window period for the PCR test is 3 to 12 days.

Clinical signs of HIV infection

1-13 What acute illness may occur soon after HIV infection?

In response to infection with HIV, the immune system produces antibodies against the virus. Unfortunately these antibodies fail to kill all the HIV and cure the infection. At the time that HIV antibodies appear in the blood (seroconversion) some people develop a flu-like illness which lasts a few days or weeks. This illness starts 2 to 4 weeks after infection with HIV and is called acute seroconversion illness (or acute HIV syndrome). It only occurs in about half of HIV-infected individuals.

The usual signs of acute seroconversion illness are:

  1. Fever
  2. General tiredness
  3. Enlarged lymph nodes
  4. A measles-like rash
  5. Cough or sore throat
  6. Oral or genital ulcers

The above signs and symptoms are similar to those found in glandular fever (infectious mononucleosis).

Note
Some people also develop signs of viral meningitis or encephalitis.

During the first few weeks of HIV infection, large amounts of virus are present in the blood and the person is very infectious to others. HIV is most infectious during the acute seroconversion illness. Combined antibody antigen HIV screening tests may still be negative at this time.

Acute seroconversion illness is often the first sign of HIV infection.

1-14 What is the latent phase of HIV infection?

HIV infection, with or without acute seroconversion illness, is followed by months or years when the person feels well. In adults, this silent, asymptomatic period is usually five to ten years but may last for as long as 15 years before the signs of symptomatic HIV infection appear. In children, the latent phase is much shorter, from a few months to five years. Occasionally, asymptomatic adults living with HIV may also progress rapidly and become symptomatic. Generalised lymphadenopathy is common in the latent phase.

HIV infection can, therefore, be divided into three phases:

  1. Acute seroconversion illness (which only occurs in 50% of people)
  2. The latent, asymptomatic phase when people feel well
  3. Symptomatic HIV infection when people are ill

Patients who have signs and symptoms due to HIV infection following the latent phase are said to have symptomatic HIV infection (HIV illness or HIV disease). Only when they become severely ill is the clinical condition called AIDS.

1-15 What clinical signs suggest an adult has symptomatic HIV infection?

The clinical signs of symptomatic HIV infection are largely due to a wide range of infections and cancers, which occur because of the damaged immune system.

Common clinical signs in adults with symptomatic HIV infection are:

Note
HIV may also cause myelopathy and peripheral neuropathy. Oral hairy leucoplakia is asymptomatic but diagnostic of HIV infection.

HIV infection often presents with weight loss and chronic diarrhoea.

The severity of HIV infection can be graded from 1 to 4 based on clinical symptoms and signs. Grade 4 infection is most severe and is called AIDS.

1-16 What are opportunistic infections?

Opportunistic or HIV-associated infections are infections which usually do not occur in people with a normal functioning immune system. They are severe, repeated or chronic infections with common bacteria and viruses or infections with uncommon organisms. The organisms causing most opportunistic infections in HIV-positive people are:

  1. Common bacteria such as Pneumococcus
  2. Candida (which causes oral, oesophageal and tracheobronchial thrush)
  3. Tuberculosis (TB)
  4. Pneumocystis carinii and jiroveci (a parasite causing pneumonia)
  5. Cytomegalovirus (CMV)
  6. Herpes simplex
  7. Varicella (the chickenpox virus which causes herpes zoster)
  8. Cryptococcus (a fungus which causes meningitis)
  9. Cryptosporidium (causes chronic diarrhoea)

Opportunistic infections are common in HIV-infected people due to their damaged immune systems.

An opportunistic infection, such as tuberculosis, is often the first sign that the patient is infected with HIV. Therefore HIV infection must be suspected and screened for in any person diagnosed with TB or who has severe, chronic, repeated or unusual infections.

1-17 Can AIDS be cured?

At present AIDS is a severe, chronic illness which cannot be cured and has a slowly progressive and fatal outcome without the correct management. However, treatment with ARV drugs can prevent the progression of the disease and improve the quality of life for decades. Without treatment, most AIDS patients will die within 2 years of the onset of the clinical illness. While the amount of virus in the body can be drastically reduced by ARV drugs, some virus unfortunately remains hidden in the lymphocytes. The aim of HIV management is to keep the person well for as long as possible.

Preventing HIV infection

1-18 How can HIV infection be avoided?

HIV infection can be avoided by:

The ‘ABC’ of preventing HIV infection is Abstinence, Be faithful to one HIV-negative partner only, and always use a Condom when having sexual intercourse. Delaying the start of sexual activity and then reducing the number of sexual partners is most important. Having more than one sex partner at a time is dangerous. The only way the HIV epidemic will be controlled is by reducing the number of new infections by practising safe sex and by preventing perinatal mother to child transmission of HIV.

Every effort must be made to reduce the number of new HIV infections.

1-19 Do other sexually transmitted diseases increase the risk of HIV infection?

Yes. The presence of other sexually transmitted diseases increases the risk of HIV infection, especially if these other diseases cause ulcers or mucosal damage. Treatment of these sexually transmitted diseases reduces the risk of the sexual spread of HIV.

1-20 Which sexually transmitted diseases may increase the risk of infection with HIV?

Important examples are:

The risk of HIV infection is highest if ulcers are present, as in syphilis, chancroid and herpes.

1-21 Are HIV-infected people always infectious to others?

Yes, although the risk of infection varies widely between individuals. HIV is most infectious in the first weeks of the infection and again in seriously ill people when the signs of AIDS develop. At these times there are large amounts of HIV in the blood (a high viral load). The risk of infection is less during the latent period when smaller amounts of HIV are present in the blood. However, most HIV is still spread during the latent period when many people are unaware that they are infected. It is therefore very important that all sexually active adults know their HIV status.

People who are asymptomatic and on ARV treatment with an undetectable viral load have the lowest risk of spreading HIV.

Patients with a high viral load are most infectious.

1-22 Is HIV equally common in men and women?

No. During heterosexual intercourse HIV is more infectious to women than to men as HIV-infected semen may remain in the vagina for many hours. Therefore, in most countries where sexual transmission is common, HIV infection is more frequent in women. During 2018 in South Africa 62.7% of adults living with HIV were women. In the age group 15 to 24 years 69,000 of new infections were women and 28,000 men. Therefore young women are 3 times more likely to acquire HIV than their male counterparts.

1-23 How does HIV damage the immune system?

HIV invades and destroys the immune system by damaging the CD4 lymphocytes. These special cells are produced by the thymus and control the functions of the immune system. CD4 lymphocytes are also called helper lymphocytes as they assist other types of lymphocytes. A normally functioning immune system prevents severe infections and the development of malignancies. HIV infection causes a fall in the number of CD4 lymphocytes with the result that the immune system cannot function normally. As a result, the risk of infection and cancer increases.

The CD4 count is a very important way of determining the immunological stage of the HIV infection, by measuring the amount of damage that has been done to the immune system.

Note
Normally the CD4 count in adults is well above 500 cells/µl (usually about 1000 cells/µl). Signs of AIDS usually appear when the count falls below 200. A CD4 count is needed to assess the amount of suppression of the immune system.

The body also responds by producing antibodies to the HIV. Unfortunately, the antibodies cannot kill all the virus, which is able to hide inside cells.

HIV damages the immune system by attacking and destroying the CD4 lymphocytes.

1-24 How does HIV multiply in human cells?

HIV is a retrovirus which infects human CD4 lymphocytes. Retroviruses invade the nucleus of lymphocytes and instruct these ‘host’ cells to produce more copies of the virus. HIV therefore ‘hijacks’ the host cell and converts it into a factory which produces millions of new viruses. Antiretroviral drugs act by stopping the multiplication of HIV in lymphocytes.

Managing HIV infection

1-25 What drugs can be used to treat HIV infection?

There are a number of drugs used for antiretroviral treatment (ART) which can reduce the amount of HIV in the body and, thereby, slow the progression to AIDS and improve the clinical signs of AIDS. At present none of these drugs can cure AIDS. They are called antiretroviral (ARV) drugs. It is best to use at least three of these drugs together. Combination therapy is more effective and helps to avoid drug resistance.

There are four groups of ARV drugs. They block the function of enzymes needed for the multiplication of HIV.

  1. Nucleoside and nucleotide reverse transcriptase inhibitors (‘nucs’), such as tenofovir (TDF), zidovudine (AZT), lamivudine (3TC) and emtricitabine (FTC). These drugs stop HIV from infecting cells.
  2. Non-nucleoside reverse transcriptase inhibitors (‘non-nucs’), such as nevirapine (NVP) and efavirenz (EFV). They also stop HIV from infecting cells.
  3. Protease inhibitors (‘PIs’), such as ritonavir and lopinavir. These drugs prevent the HIV-infected cell from releasing new viruses.
  4. Integrase inhibitors, such as raltegravir (RAL) and dolutegravir (DTG) that block integrase, a viral enzyme that inserts the viral genetic messages into the DNA of the host cell.

DTG in combination with two other ARVs is used as the first line treatment for all newly diagnosed HIV infections. It is also used if HIV acquires resistance to other drugs.

Note
Other nucleoside reverse transcriptase inhibitors include didanosine (ddi) and stavudine (d4T), while other protease inhibitors include indinavir, saquinavir and nelfinavir. The two groups of reverse transcriptase inhibitors act differently in preventing HIV infection of cells.

ARV drugs can be used to treat a patient with severe HIV infection (ARV treatment) or to prevent infection with HIV (ARV prophylaxis):

  1. TLD is a single pill fixed dose combination of TDF (tenofovir), 3TC (lamivudine) and DTG (dolutegravir) used as first line treatment for all newly diagnosed people living with HIV.
  2. Until recently TDF, FTC and EFV (Odimune, Tribuss, Atroiza and Atripla) as a single pill fixed dose combination (FDC) regimen was most commonly used. Many people living with HIV that commenced treatment prior to TLD roll out will still be on FDC.
  3. NVP syrup is given to infants postpartum and during breastfeeding to prevent infection.

TLD is a single pill fixed dose combination of TDF (tenofovir), 3TC (lamivudine) and DTG (dolutegravir) used as first line treatment for all newly diagnosed people living with HIV.

1-26 Which nucleoside and nucleotide reverse transcriptase inhibitors are commonly used?

Zidovudine (also called AZT) was the first ARV drug available. It is effective when used prophylactically during pregnancy and labour to reduce the risk of transmission of HIV from mother to infant. It can also be given to the newborn infant after delivery. When used alone for a short period it is uncommon for HIV to become resistant to AZT. AZT is well absorbed orally and crosses the placenta well. It increases the fetus’s ability to resist infection from HIV. AZT needs to be taken twice a day.

Note
AZT is presently used in combination with 3TC and DTG for people who defaulted treatment with FDC and at that time did not have a viral load that was lower than detectable (LDL) or whose viral load is unknown.

3TC, FTC and TDF are commonly used and have the same mechanism of action as AZT. TDF and FDC are available as a combination drug known as Truvada. Common side effects of these drugs are shown in Table 1-1.

Note
AZT, 3TC and FTC are nucleoside analogues. This means that it mimics a natural nucleoside. Nucleosides are linked together to form DNA. When reverse transcriptase produces DNA, AZT is incorporated in preference to a natural nucleoside. The resulting DNA is not correctly formed and HIV cannot be produced. TDF is a nucleotide analogue that has a similar action.

Table 1-1 Common side-effects of AZT, 3TC, FTC and TDF

AZT 3TC and FTC TDF
Headache Headache Vomiting and diarrhoea
Malaise (feeling tired) Nausea Peripheral neuropathy
Muscle pains Diarrhoea Osteoporosis
Nausea and vomiting Pancreatitis Lipodystrophy
Bone marrow suppression resulting in anaemia and neutropenia Skin hyperpigmentation Lactic acidosis
  Anaemia Renal failure

1-27 Which non-nucleotide reverse transcriptase inhibitors are commonly used?

NVP is a potent and rapidly acting antiretroviral drug, which is very useful in reducing the risk of HIV transmission from mother to infant during labour and delivery. It is absorbed orally and crosses the placenta very well. A single dose is given to the mothers newly diagnosed to be HIV positive during labour. NVP has few adverse effects when used as a single dose. However, resistance develops rapidly when NVP is used as a single dose. Therefore, NVP always is used with Truvada (a combination of TDF and FTC) to prevent resistance developing.

Prophylactic NVP is very useful in reducing the risk of mother-to-child transmission during labour and delivery for newly diagnosed mothers who are not yet on antiretroviral treatment.

EFV is also a non-nucleoside reverse transcriptase inhibitor and commonly used together with TDF and FTC as a single FDC tablet taken once daily. EFV is also used with AZT and 3TC as HAART when there are contra-indications to the use of TDF.

Common side effects of these drugs are shown in Table 1-2.

Table 1-2 Common side-effects of NVP and EFV

NVP¹ EFV
Skin rash, that could be severe and life threatening (Stevens Johnson syndrome) Dizziness/drowsiness
Hepatoxicity (liver damage) that could be severe and life threatening Insomnia (unable to sleep)
  Abnormal dreams
  Psychiatric symptoms
  Skin rash²
  Hepatotoxicity²

¹Side effects do not occur if used as a single dose ²Frequency of these side effects much lower compared with NVP

1.28 Which integrase inhibitor is commonly used?

DTG is the commonly used integrase inhibitor. DTG in combination with TDF and 3TC as a single TLD tablet is the first line treatment for people living with HIV. Compared to EFV, DTG has:

Common side effects of DTG are shown in Table 1-3.

Table 1-3 Common side-effects of DTG

DTG
Nausea and vomiting
Abdominal pain
Headache
Insomnia (therefore take tablet in morning)
Weight gain
Slight increase risk of neural tube defect in early pregnancies

1-29 Is a vaccine available to prevent HIV infection?

Unfortunately not. An effective vaccine against HIV is the only way that the HIV epidemic will be controlled. Many studies are being conducted in an attempt to produce an HIV vaccine. However it may be years before an effective HIV vaccine is available.

1-30 What drugs are commonly used to prevent opportunistic infections?

  1. Co-trimoxazole (Bactrim, Septran or Purbac) is currently used in patients with HIV infection to prevent opportunistic infections with Pneumocystis, Toxoplasma and some common bacteria. It is very effective but must be taken regularly. It is used with advanced disease when the CD4 count is 200 cells/μl or less and with stage 3 and 4 disease.
  2. Isoniazid (INH) is used for preventive therapy (IPT) for 6 months to prevent tuberculosis. IPT for healthy pregnant women living with HIV is postponed to start 12 weeks postpartum.

1-31 What is the general management of women living with HIV?

The general management of adults with HIV infection consists of the following:

Except for the use of ARV drugs, the general management of HIV infection is not expensive and makes a big difference to the quality of the patient’s life. Whenever possible, patients should not be admitted to hospital, but managed at home with the support of the community and primary healthcare services. Patients with AIDS should never be abandoned. Progress to AIDS cannot be prevented with diet alone.

Accidental HIV infection

1-32 Are nurses and doctors at risk of infection when caring for HIV-positive women?

Yes, as body fluids, especially vaginal discharge and cervical secretions, blood, amniotic fluid, breast milk and semen may contain large amounts of HIV. Healthcare workers can become infected by HIV via the following routes:

1-33 How can healthcare workers reduce the risk of HIV infection?

By adopting standard (universal) precautions. This means that all body fluids should be regarded as potentially infectious in all patients. Precautions should always be taken to prevent exposure to infectious body fluids.

1-34 What are the standard precautions to prevent HIV infection when caring for patients?

All patients should be regarded as being potentially HIV positive. Therefore, general precautions should be taken with all patients. These precautions are especially important in patients known to be HIV positive.

Standard precautions should be adopted when managing all patients.

1-35 How should sharps be handled?

Always use a sharps container for the disposal of lancets or needles.

1-36 What is the risk of HIV infection after an accidental needle-stick injury?

The overall risk without antiretroviral prophylaxis is 1 in 300. Therefore, of every 300 healthcare workers who prick or cut themselves with an instrument covered with HIV-positive blood, one person will become infected with HIV. With the correct use of antiretroviral prophylaxis this risk is reduced by 80%. The risk of infection is greatest if:

  1. The wound is deep.
  2. The person is stuck with a hollow needle.
  3. The patient has AIDS or has recently been infected with HIV (high viral load).
  4. Antiretroviral prophylaxis is not given or is given incorrectly.

The risk of infection without antiretroviral prophylaxis after a splash of HIV-infected blood into the mouth or eye, or contamination of a cut or skin abrasion, is less than 1 in 1000.

1-37 What prophylaxis should be given to a healthcare worker exposed accidentally to HIV?

Healthcare workers may be accidentally exposed to HIV by needle-stick injuries or splashes of infected body fluid into the eyes or mouth, or onto broken skin. The risk of infection is greatest with a cut or needle-stick injury. Every effort must be made to start antiretroviral prophylaxis within 2 hours of exposure. Start treatment as soon as possible. Treatment is probably not effective if the delay is greater than 72 hours.

Prophylaxis is strongly recommended with mucosal splashes if the patient is sick with AIDS. Prophylaxis is not indicated after exposure to uncontaminated, non-infectious body fluids.

Either of two possible post-exposure regimen can be used:

  1. One TLD tablet taken immediately then daily for 28 days.
  2. One tablet of Truvada (tenofovir/emtricitabine (300mg/200mg) plus one tablet each of atazanavir (300mg) and ritonavir (100mg) should be taken immediately followed by all three tablets daily for 28 days. This regiment is also recommended for women in the first 6 weeks of pregnancy or women not on contraception and planning a pregnancy.

The adverse effects of nausea, vomiting, diarrhoea and tiredness are common. Therefore both drug options are best taken with food and an anti-emetic can be taken a half an hour before taking the tablets to reduce nausea.

Always acquaint yourself with the local post-exposure prophylaxis (PEP) protocol.

1-38 What is the correct procedure after a needle-stick injury?

After a needle-stick injury the following procedure should be followed:

  1. Do not panic. Encourage bleeding from the puncture site and wash with soap and water. The mouth or eyes should immediately be washed with water after a blood splash.
  2. Notify the correct hospital authority. Every hospital and clinic must have a clear management policy for accidental HIV exposure. This should be available to all staff. Everyone must know who the person to contact is, should accidental HIV exposure occur.
  3. Start prophylactic antiretroviral management with TLD or Truvadia, atazanavir and ritonavir as soon as possible. These drugs must be readily available in all hospitals and clinics both day and night. All the drugs are taken once a day.
  4. Obtain consent and collect blood samples from the patient for HIV and hepatitis C screening. If the healthcare worker has not been immunised also include a hepatitis B test. If consent is refused, assume that the patient is HIV positive. If the patient is under anaesthetic blood samples can be drawn, as provision is made for screening on consent forms for surgery. The patient must be informed when awake.
  5. An HIV test need only be performed on the healthcare worker if the patient tests positive. A test for hepatitis B must always be done. This is to make sure that the healthcare worker is not already HIV positive and to test for immunity against hepatitis B. If the healthcare worker is HIV and hepatitis B positive, prophylaxis is not indicated.
  6. Notify the laboratory that two urgent HIV tests are needed for screening. The screening test must be done as soon as possible. For medico legal purposes all screening must be laboratory tests and not rapid tests.
  7. If the HIV test on the patient’s blood is negative stop the antiretroviral prophylaxis. If the test is positive, continue for 28 days.
  8. Serum creatinine tests must be done at baseline and again at 2 weeks. At the 2 week follow-up visit enquire about well-being and side effects as well as assessing adherence.
  9. Repeat the HIV test on the healthcare worker after six weeks to determine whether or not they have become HIV positive. If the test is negative, repeat after another 3 and 6 months.
  10. The efficacy of combined oral contraceptives is reduced by atazanavir/ritonavir. The healthcare worker must practice safe sex by using condoms until the HIV test at 6 months is negative.
  11. Counselling and ongoing psychosocial support must be given for all healthcare workers exposed to HIV-contaminated blood.

All hospitals and clinics must keep emergency packs of prophylactic antiretrovirals for staff with accidental exposure to HIV.

Case study 1

During a public lecture at a social club, the speaker says that HIV infection in Africa is usually acquired by heterosexual intercourse. He also says that HIV infection is commoner in women. During question time a member of the public asks whether HIV is also spread by kissing. Another member of the audience asks if HIV infection is the same as having AIDS, and whether people who are HIV positive but well can be infectious to others.

1. Do you agree that HIV infection in Africa is usually acquired by heterosexual intercourse?

Yes. Heterosexual intercourse is the most common method of spreading HIV in Africa. However, the vertical spread from mother to infant is also very important. Homosexual intercourse and the use of contaminated needles are other important methods of spread in some communities.

2. Why is HIV infection commoner in women in Africa?

Because HIV is usually spread by unprotected heterosexual intercourse. As semen may remain in the vagina for some time after intercourse, women have a greater chance than men of being infected.

3. Can HIV be spread by kissing?

Probably not. HIV cannot be acquired by non-sexual contact such as social kissing, holding hands, hugging and sharing cooking and eating utensils.

4. Is HIV infection the same as having AIDS?

No. The difference commonly causes confusion among members of the public. Most people living with HIV remain well for years before they become seriously sick with the illness called AIDS. Therefore, it is very common to have HIV infection without AIDS. With time, however, these people with asymptomatic HIV infection will become sick.

5. Can people who do not have AIDS transmit HIV to others?

Yes. Everyone with HIV infection is infectious to others even if they are clinically well. Patients on ARV treatment are less infectious than patients not receiving treatment.

Case study 2

A blood donor has a routine HIV test which is negative. A few weeks later she has unprotected sexual intercourse with a stranger. After three weeks she develops a fever, a mild cough and a generalised pink rash. On examination, her doctor notes that she has enlarged lymph nodes in her neck and axilla, and small ulcers on her throat. He diagnoses infectious mononucleosis and prescribes oral penicillin. She recovers rapidly. Six months later, when she again asks to donate blood, it is found that she is HIV positive.

1. What is the correct diagnosis of her illness?

Acute seroconversion illness. This occurs 2 to 4 weeks after HIV infection in about 50% of individuals. It is often misdiagnosed as acute infectious mononucleosis (glandular fever) as both conditions present with fever, sore throat, rash and lymphadenopathy.

2. How could she have avoided HIV infection?

By abstaining from sexual intercourse or by using a condom.

3. Can a person become infected with HIV by donating blood?

No. There is no risk in donating blood. However, one can become infected by receiving blood donated by someone who is infected with HIV. All donated blood in South Africa is screened for HIV.

4. For how long can this woman expect to remain well?

She will probably remain well for five to ten years. However, the latent phase of HIV infection may last as long as 15 years. According the South African guidelines for the management of HIV infected people she need to commenced on lifelong ARV treatment to keep her healthy and prevent her from developing AIDS.

Case study 3

A young man presents with shortness of breath and a chronic cough. During the past few months he has noticed an unexplained weight loss. On examination he has oral thrush and generalised lymphadenopathy. A chest X-ray shows pneumonia with a cavity in one lung. The HIV rapid test is positive. Recently he was treated for syphilis.

1. What is the diagnosis?

Symptomatic HIV infection complicated by tuberculosis (TB). HIV infection commonly presents with a history of weight loss, cough and shortness of breath.

2. Is TB common in HIV-positive people?

Yes. It may be the first sign that the patient has symptomatic HIV disease.

3. Why has the patient got oral thrush?

Thrush is an infection caused by the fungus Candida. It is common in young infants but rare in adults. Thrush is one of the opportunistic infections which complicate HIV infection.

4. Why do patients living with HIV commonly have opportunistic infections?

Because HIV damages the CD4 lymphocytes which play an important role in the immune system. Thrush, therefore, takes this opportunity of infecting the mouth and pharynx. Some opportunistic infections, such as Pneumocystis and CMV, may also cause pneumonia which often presents with cough and shortness of breath.

5. How can syphilis increase the risk of becoming infected with HIV?

Often more than one sexually transmitted disease occurs in a patient. Syphilis causes genital ulcers that increase the risk of HIV infecting the person.

6. Can AIDS be treated?

AIDS can be treated with a combination of ARV drugs. While the signs and symptoms of AIDS may disappear while on treatment, HIV infection cannot be cured. A vaccine holds the only hope of ending the HIV epidemic.

Case study 4

After collecting capillary blood for haemoglobin measurement from the finger of an antenatal patient, a nurse accidentally pricks her finger with the lancet while cleaning up. A sharps container is not available in the antenatal ward. She only informs the management the following day. Blood from the patient and the nurse is then sent urgently to the laboratory and the HIV test on the patient is positive. A 4 weeks course of TLD is started but she stops after a week as the medication makes her feel nauseous and tired.

1. What basic mistake was made by the nurse?

There was no sharps container in the nursery. After collecting a blood sample, the needle or lancet must immediately be placed in a special sharps container. It is extremely dangerous to place the used needle or lancet on the bed or work top, as staff commonly prick themselves while tidying up afterwards.

2. When should she have informed the management?

Immediately. As soon as any staff member is pricked with a blood-stained needle or lancet, the management must be informed so that the procedure of testing the patient’s and staff member’s blood and starting prophylactic ARV drugs can begin without delay. Every hospital and clinic must have a clear list of instructions as to the correct procedure after a needle-stick injury.

3. Was the correct medication given?

Yes. A course of TLD is used for needle-stick injuries. However, the risk of HIV infection is increased if the treatment is not started within a few hours of the needle-stick injury.

4. What is the risk of her becoming infected with HIV?

Without treatment the risk is about 1 in 300. This risk is greatly reduced if the correct prophylactic treatment is started as soon as possible, preferably within 2 hours.

5. Does it matter that the prophylactic treatment was only taken for a week?

Yes. To be as effective as possible the treatment must be taken for 28 days. Unfortunately the ARV agents do have adverse effects such as lethargy and nausea. As a result the full course of treatment is often not taken. Counseling regarding side effects of the drugs and measures to reduce side effects must always be given.

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