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					                                                                          Oklahoma State Department of Health
                                                                                           01-2009 Reviewed

                           PHN GUIDELINE: HIV ANTIBODY SCREENING


I.     DEFINITIONS:

       A.    HIV      -       Human Immunodeficiency Virus

       B.    AIDS     -       Acquired Immune Deficiency Syndrome

II.    ETIOLOGY/PATHOGENESIS:

       A.    HIV, the virus that can lead to AIDS, is a retrovirus transmitted through the exchange of
             body fluids, primarily semen, blood, and vaginal secretions, usually through intimate
             sexual contact, sharing needles, and vertical transmission between a mother and her
             baby.

       B.    Shortly following infection and prior to seroconversion, many have an acute retroviral
             syndrome and experience flu-like symptoms such as swollen lymph glands, a fever
             and/or rash.

       C.    The acute retroviral syndrome is brief and followed by an asymptomatic period which
             varies from months to years, with an average of ten years. During this period, very little
             virus can be found circulating in blood but HIV is present and continuously replicating
             within the lymphatic system. As with other viruses, HIV must infect a living cell in order to
             replicate. Although several types of cells are infected, HIV has an affinity for T helper
             lymphocyte cells (T4 or CD4 cells), key players in the cell mediated immune response.
             Once infected, a CD4 cell will eventually rupture and die as new virus particles are
             released. As the disease progresses, the immune system becomes increasingly
             impaired because virus numbers continue to increase while CD4 cells slowly decline. At
             some point, most infected persons begin to experience the less severe symptoms of HIV
             infection and, over time, progress to more severe opportunistic diseases and/or rare
             cancers. During this more advanced stage, many infected people are clinically
             diagnosed with AIDS; the diagnosis is based on T4 laboratory tests results and the
             presence of one or more opportunistic infections and/or cancers. In most cases, the
             diseases and/or cancers eventually become life threatening.

III.   CLINICAL FEATURES:

       A.    Signs and Symptoms

             1.       Early HIV infection

                      a.      Acute retroviral syndrome– occurs within two to twelve weeks in 70% of
                              those infected; before antibody test results become positive.
                              1)      Malaise
                              2)      swollen lymph glands
                              3)      fever, sometimes very high
                              4)      rash
                              5)      Oral ulcerations

                      b.      HIV antibody tests-most become “positive” within three months of
                              infection

                              1)      EIA (ELISA) - (enzyme linked immunosorbent assay) A test to
                                      identify HIV antibodies. A “reactive” test will be confirmed by
                                      repeating the EIA and a supplemental test
                              2)      Western blot (WB) – (Supplemental test) – A more specific test
                                      that identifies antibodies to HIV by specific reacting bands


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                                                                         Oklahoma State Department of Health
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                           3)       A “positive” test indicates client is infected with HIV

                                    a)      “Indeterminate” indicates that some, but not all, of the
                                            bands in the WB are reactive.

                                    b)      Because pregnancy can interfere with the WB, if the test
                                            result is indeterminate and the client is pregnant, a more
                                            specific test, Polymerase Chain Reaction (PCR) is done.

            2.     Progressive HIV infection process

                   a.      Asymptomatic period lasting an average of 10 years

                   b.      Initial symptoms include:

                           1)       Persistent Generalized Lymphadenopathy (PGL)
                           2)       Night Sweats
                           3)       Weight loss (wasting syndrome)
                           4)       Fevers
                           5)       Rashes
                           6)       Chronic vaginal yeast infections (hard to treat)
                           7)       Chronic diarrhea

                   c.      Increasingly impaired immune system (marked by decreasing CD4 count
                           and increasing viral load). Cohort studies of adults infected with HIV
                           show that within 17 years after infection, AIDS developed in 87%.

                   d.      Opportunistic infections and/or rare cancers (see Appendix I)
                           (Diagnosis is now AIDS, the end stage of HIV infection)

IV.   DIAGNOSIS:

      A.    HIV INFECTION

            1.     Available to county health departments through OSDH lab

                   a.      Reactive EIA (ELISA) times two AND positive Western Blot

                   b.      Pregnant client will have PCR positive before being diagnosed as HIV
                           infected.

            2.     Other tests available in the private sector

                   a.      Immunofluorescence assay (IFA)-another supplemental antibody test
                           that can be used to resolve an EIA-positive, Western blot-indeterminate
                           sample.

                   b.      Polymerase chain reaction (PCR)

                   c.      Virus culture

                   d.      Rapid test (results within one half hour) from oral swab or fingerstick




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                                                                        Oklahoma State Department of Health
                                                                                         01-2009 Reviewed

     B.    AIDS: A clinical diagnosis of AIDS is based on a “positive” HIV antibody test and the
           1993 CDC case definition:
                                                    3
           1.      Fewer than 200 CD4 cells/mm or a T4 cell percentage of total lymphocytes of
                   less than 14.

           2.      One or more opportunistic infection, designated conditions, and/or rare cancers.

V.   MANAGEMENT PLAN (Screening):

     A.    Provide test decision counseling

     B.    Assist client in assessing personal risk of HIV infection

           1.      TB clients: assist the client in assessing his/her perception of risk for co-infection
                   with HIV

           2.      Maternity clients:

                   a. Ensure client understands risk of vertical transmission before or during birth,
                      and following birth through breastfeeding
                   b. Obtain specimen on first prenatal visit

     C.    Ensure serology specimen for the HIV antibody test is obtained, labeled correctly and
           sent to OSDH Public Health Laboratory.

     D.    Provide prevention counseling. Refer to OSDH HIV Counselor for in depth counseling as
           needed.

     E.    Provide test results.

           1.      NEGATIVE test results are given to the client in the routine way. Encourage
                   retesting in 3 months from last exposure if determined to be at higher risk of HIV
                   infection.

           2.       The Disease Intervention Specialist (DIS) will give POSITIVE test results with
                   support by nursing staff. If a Disease Intervention Specialist (DIS) is not
                   available, the nursing staff may give the results. These persons will also:

                   a.       Provide client centered prevention counseling
                   b.       Refer to appropriate resources for additional medical care, financial,
                            housing, and support group services
                   c.       Offer partner notification

           3.      Indeterminate test results are given to the client in the routine way unless the
                   client is pregnant. The non-pregnant client should be encouraged to return to
                   clinic for retesting in 30 days.

                   a.       When WB is “indeterminate” in a pregnant client, the OSDH lab will
                            provide a yellow-stopper tube to the county with instructions for returning
                            it to OSDH
                   b.       The nurse will explain the meaning of “indeterminate” to the client and
                            obtain a second specimen.




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                                                                         Oklahoma State Department of Health
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VI.   MANAGEMENT PLAN (After positive diagnosis):

      With the exception of a few select immunizations, county health departments do not routinely
      provide services for clients infected with HIV. The management plan is determined by the patient
      and the physician he/she has selected and may include:


      A.     Immunizations (according the OSDH Immunization policies)

             1.      Pneumococcal vaccination

             2.      Annual influenza vaccination

             3.      Hepatitis B vaccination

             4.      Others (those who are at increased risk of exposure and have written
                     permission from their physician)

                     a.       Haemophilus influenzae type B (Hib)
                     b.       MMR

      B.     TB (tuberculosis) skin testing is strongly recommended for all HIV positive clients.

      C.     Available Treatment in the Private Sector

             1.      Medications to halt/slow HIV replication.

             2.      Medications used to prevent and treat opportunistic infections

      D.     Other Considerations/Referrals

             1.      Education for client and their families

                     a.       Secondary Prevention

                              1)      Preventing transmission to others
                              2)      Developing/maintaining healthy behaviors (nutrition, exercise,
                                      rest, safer sex practices, etc.)

                     b.       Partner notification

                              1)      Offered by the OSDH Disease Intervention Specialist to all
                                      newly diagnosed HIV infections.

                                      a)       Questions related to programmatic issues call
                                               HIV/STD Epidemiology
                                               (405) 271-4636

                                      b)       To initiate partner notification call the Surveillance and
                                               Analysis Division
                                               Program Manager
                                               (405) 271-4636

                              2)      Handouts on partner notification are available (ODH #P-273,
                                      “Letting Partners Know”)

                     c.       Available resources



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                                                                           Oklahoma State Department of Health
                                                                                            01-2009 Reviewed




               2.      Laboratory tests after diagnosis

                       In the private sector, laboratory tests often begin with repeat HIV antibody testing
                       and screening/baseline studies including TB, syphilis and other STDs, and
                       hepatitis. Other tests such as CBC, viral load, absolute T4 cell numbers, and
                       liver transaminases will be monitored as needed.


               3.      Ongoing assessments by private physician

                       Physical, psychosocial and financial assessments will be made throughout HIV
                       infection.




REFERENCES:

Centers for Disease Control and Prevention. 2006 Guidelines for Treatment of Sexually Transmitted
  Disease, MMWR, August 4, 2006/Vol. 55/No. RR-11.
Muma, Richard D., et al., HIV Manual for Health Care Professionals, Appleton & Lange, Norwalk,
  Connecticut, 1994.
                                         rd
Fan, Hung, et al., The Biology of AIDS, 3 ed., Jones & Bartlett Publishers, Boston, 1994.

Sexually Transmitted Infections and HIV. Clutterbuck, Dan




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Oklahoma State Department of Health
                 01-2009 Reviewed




      HIV Antibody Screening - 6
                                                             Oklahoma State Department of Health
                                                                              01-2009 Reviewed



                   PHN ORDER: HIV ANTIBODY SCREENING


I.   DIAGNOSTIC PROCEDURES/LABORATORY STUDIES

     A.   Specimen collection for EIA (ELISA) and Western Blot (WB) for HIV antibody

          1.     Serum Separator Tube (SST) -- Venipuncture

          2.     Filter Paper (dried blood spot) -- Fingerstick

     B.   Polymerase Chain Reaction (PCR) OSDH Maternity Clinic Clients ONLY

          1.     If the client’s WB is “indeterminate”, the OSDH lab will notify the county
                 and provide a yellow stopper tube and requisition.

          2.     Obtain venous specimen and return to OSDH lab.




                                                                   HIV Antibody Screening - 7
Oklahoma State Department of Health
                 01-2009 Reviewed




      HIV Antibody Screening - 8

				
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