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							    Lina Del Balso BscN


 Nurse Clinician Immunodeficiency
Clinic Montreal Chest/Royal Victoria
              Hospital
        DO YOU KNOW THE CORRECT ANSWERS?
1.   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.

2.   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.

3.   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.
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.
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.
  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.
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.
             Principles of Transmission
1.   Need a source – Don’t judge the person – judge the
     fluid (ex. blood, semen, etc.)

2. Need a transmission – Mother to infant, sex, injecting
     activity.

3. Need a host – Remember that anyone is a potential
     host – No one’s immune – challenge with teenagers.

4. Need an appropriate route of entry – break in skin,
     disruption of mucosa, etc.

5. Need sufficient virus – semen, vaginal fluid, blood,
     breast milk, urine, saliva, tears.
                    Risk categories
1. No risk – No potential for transmission, no
    documented cases (ex. kissing without blood)

2. Negligible risk – Potential for transmission but no
    evidence.
      a. Fellatio- receiving – oral sex.
      b. Receiving cunnilingus – licking of clitoris and/or in
         vagina.
      c. Anilingus – licking anus – performing + receiving.
         However, sufficient to transmit other STI’s and
         intestinal parasites.
      d. Fingering anal + vagina.
      e. Fisting.
      f. Docking.
                       Risk categories
       3. Low risk – Potential for transmission with evidence under
          certain conditions.
       a. Wet kissing – if mouth sores, blood.
       b. 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.
       c. Cunnilingus – liking clitoris and/or in or around vulva – if
          performing during menses or not. If with barrier protection
          then – negligible risk.
       d. Penile vaginal intercourse with condom.
       e. Penile anal intercourse with condom.

4.   High risk
       a. Penile vaginal intercourse without condom
       b. Penile anal intercourse without condom
       c. Sharing used sex toys
            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
Body Fluids known to transmit HIV
• Blood

• Semen, vaginal secretions

• Bloody body fluids

• Breast milk
       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
       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
        Hand washing is essential!


• Before and after patient contact

• After glove removal

• When contamination with potentially infective
  materials occurs
GLOVES     must   always  be    used
whenever in contact with blood,
secretions and other body fluids and
tissues
• 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
Use gowns when clothing is
likely to be contaminated

Don’t wander with gown on!
   Masks, goggles and face shields



• Wear for splashes

• Routinely    wear     protection     for   airway
  manipulations, endoscopic or dental procedures

• N95 masks for suspected TB cases
     In Occupational Settings


• Needle sticks


• Mucosal contamination (0.03 - 0.09%)


• Contamination of non intact skin
          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 %
        NEVER RECAP NEEDLES!


• Dispose of needles / sharp objects immediately
  after use in sharps container

• Safe needle devices / needless systems
      Post Exposure Prophylaxis

• First aid for any needle sticks, mucous
 (eyes, mouth) and cutaneous exposures
• 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
                                 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.
3 types of HIV testing available 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
         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.
         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 %
            Sexual Transmission



• HIV  is in presence of other STD’s

• Spermicides on condoms can weaken the body’s
  mucosal surfaces and  risk of transmission
                                  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.
                      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.
                            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.
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?
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.
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, Bacterial sinusitis/pneumonia.
 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.
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.
The Vulnerable Population : Persons at Risk
 •   Young gay men
 •   Women
 •   IVDU
 •   Homeless
 •   Endemic countries/refugees
 •   Older adults
 •   Psychiatric/psychological disorders
 •   Aboriginals
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
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”
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
The Vulnerable Population : Persons at Risk



      Knowledge alone does not = safer practices

                  What’s going on?
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
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
            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.
    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
              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