HIV INFECTION AND ACQUIRED IMMUNODEFICIENCY SYNDROME AIDS HIV EXPOSURE

HIV INFECTION AND ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) HIV EXPOSURE, PERINATAL REPORTING INFORMATION • Reporting requirement: ORC Section 3701.24 B (effective 2-12-04) and OAC 3701-312 (effective 2-12-04). PERSONS REQUIRED TO REPORT • Any attending health care provider shall report promptly every case of AIDS, every ARC, and every confirmed positive HIV test, every HIV infection, and every CD4 + T lymphocyte count below two hundred cells per microliter or a CD4 + T lymphocyte percentage of less than fourteen when an HIV infection has not been ruled out as the cause to the department of health on forms and in a manner prescribed by the director. In each county the director shall designate the health commissioner of a health district in the county to receive the reports. Every health care provider attending a newborn infant or child born to an HIV infected mother shall report promptly every case of such perinatal exposure to HIV and any subsequent test results on every such exposed newborn infant or child until such time that either an HIV infection or a seroeversion status that is negative is confirmed. In an institutional or health care facility setting, a designated agent, including, but not limited to, an infection control practitioner, may make the report for the attending health care provider. Laboratories shall report confirmed positive HIV tests and a CD4 + T lymphocyte count below two hundred cells per microliter or a CD4 + T lymphocyte percentage of less than fourteen when an HIV infection has not been ruled out as the cause shall be reported by the person in charge of the laboratory performing the test. If a second laboratory is used for additional or confirmatory testing, the person in charge of the laboratory first receiving the specimen shall report the confirmed positive test. Test results to be reported: • • • 1. Two or more reactive EIA tests followed by a positive Western Blot or positive immunofluorescence assay. 2. A positive culture of HIV. 3. A positive reaction to an HIV antigen test (p24 antigen). 4. Identification of HIV by polymerase chain reaction (PCR) or nucleic acid probe. Reporting Forms 1. Laboratories report using the four-copy laboratory report form (3833.11) used for syphilis and other infectious diseases or other format that contains the same information. 2. Physicians report on the “Adult/Adolescence HIV/AIDS Confidential Case Report Form” (CDC 50.42A) for patients age 13 years or older; Pediatric HIV/AIDS Confidential Case report Form (CDC 50.42B) for patients less than 13 years of age. • Reports should be mailed in an envelope marked "Confidential" and submitted to the designated health department in each county: ODH-IDCM HIVAIDS Page 1/Section 3 Revised 1/2009 County Cuyahoga Franklin Hamilton Jefferson Lucas Mahoning Montgomery Stark Summit All other Counties • Designated Health Department Cleveland Department of Public Health Columbus Public Health Cincinnati City Health District Steubenville City Health Department Toledo/Lucas County Health Department Youngstown City Health District Combined General Health District of Montgomery Canton City Health Department Akron City Health Department County Health Department Health Departments forward the case reports to the ODH HIV/AIDS Surveillance Program: Ohio Department of Health 246 North High Street Columbus, OH 43215 ATTN: HIV/AIDS Surveillance Program Key Reporting Information Demographic Date of Birth/Death Gender Ethnicity Race Residence at Diagnosis HIV/AIDS Mode of Transmission (Risk) Laboratory Test name Test Date Test Result Test Parameter Clinical and Treatment AIDS Indicator Diseases Date of Diagnosis Treatment information Agent Human immunodeficiency virus (HIV), a retrovirus. Two strains are known, HIV-1 and HIV-2. ODH-IDCM HIVAIDS Page 2/Section 3 Revised 1/2009 REVISED SURVEILLANCE CASE DEFINITION FOR HIV INFECTION* This revised definition of HIV infection, which applies to any HIV (e.g. HIV-1 or HIV-2), is intended for public health surveillance only. It incorporates the reporting criteria for HIV infection and AIDS into a single case definition. The revised criteria for HIV infection update the definition of HIV infection implemented in 1993; the revised HIV criteria apply to AIDS-defining conditions for adults and children, which require laboratory evidence of HIV. This definition is not presented as a guide to clinical diagnosis or for other uses. I. In adults, adolescents, or children aged greater than or equal to 18 months**, a reportable case of HIV infection must meet at least one of the following criteria: Laboratory Criteria • Positive result on a screening test for HIV antibody (e.g., repeatedly reactive enzyme immunoassay), followed by a positive result on a confirmatory (sensitive and more specific) test for HIV antibody (e.g. Western blot or immunofluorescence antibody test) or • Positive result or report of a detectable quantity on any of the following HIV virologic (non-antibody) tests: o HIV nucleic acid (DNA or RNA) detection (e.g., DNA polymerase chain reaction [PCR] or plasma HIV-1 RNA)*** o HIV p24 antigen test, including neutralization assay o HIV isolation (viral culture) OR Clinical or Other Criteria (if the above laboratory criteria are not met) • Diagnosis of HIV infection, based on the laboratory criteria above, that is documented in a medical record by a physician or • Conditions that meet criteria included in the case definition for AIDS. II. In a child aged less than 18 months, a reportable case of HIV infection must meet at least one of the following criteria: Laboratory Criteria Definitive • Positive results on two separate specimens (excluding cord blood) using one or more of the following HIV virologic (non-antibody) tests: o HIV nucleic acid (DNA or RNA) detection o HIV p24 antigen test, including neutralization assay, in a child greater than or equal to 1 month of age o HIV isolation (viral culture) or ODH-IDCM HIVAIDS Page 3/Section 3 Revised 1/2009 Presumptive A child who does not meet the criteria for definitive HIV infection but who has: • Positive results on only one specimen (excluding cord blood) using the above HIV virologic tests and no subsequent negative HIV virologic or negative HIV antibody tests OR Clinical or Other Criteria (if the above definitive or presumptive laboratory criteria are not met) • Diagnosis of HIV infection, based on the laboratory criteria above, that is documented in a medical record by a physician or • Conditions that meet criteria included in the 1987 pediatric surveillance case definition for AIDS. III. A child aged less than 18 months born to an HIV-infected mother will be categorized for surveillance purposes as "not infected with HIV" if the child does not meet the criteria for HIV infection but meets the following criteria: Laboratory Criteria Definitive • At least two negative HIV antibody tests from separate specimens obtained at greater than or equal to 6 months of age or • At least two negative HIV virologic tests* from separate specimens, both of which were performed at greater than or equal to 1 month of age and one of which was performed at greater than or equal to 4 months of age AND No other laboratory or clinical evidence of HIV infection (i.e. has not had any positive virologic tests, if performed, and has not had an AIDS-defining condition). or Presumptive A child who does not meet the above criteria for definitive "not infected" status but who has: • One negative EIA HIV antibody test performed at greater than or equal to 6 months of age and NO positive HIV virologic tests, if performed or • One negative HIV virologic test* performed at greater than or equal to 4 months of age and NO positive HIV virologic tests, if performed or • One positive HIV virologic test with at least two subsequent negative virologic tests****, at least one of which is at greater than or equal to 4 months of age; or negative HIV antibody test results, at least one of which is at greater than or equal to 6 months of age AND ODH-IDCM HIVAIDS Page 4/Section 3 Revised 1/2009 No other laboratory or clinical evidence of HIV infection (i.e., has not had any positive virologic tests, if performed, and has not had an AIDS-defining condition). OR Clinical or Other Criteria (if the above definitive or presumptive laboratory criteria are not met) • Determined by a physician to be "not infected", and a physician has noted the results of the preceding HIV diagnostic tests in the medical record AND NO other laboratory or clinical evidence of HIV infection (i.e. has not had any positive virologic tests, if performed, and has not had an AIDS-defining condition). IV. A child aged less than 18 months born to an HIV-infected mother will be categorized as having perinatal exposure to HIV infection if the child does not meet the criteria for HIV infection (II) or the criteria for "not infected with HIV" (III). SPECIAL INFORMATION AIDS Related Complex (ARC) is a reportable condition under Ohio law, however it is an outdated concept and reports are not sought. The surveillance definition used in Ohio in the late 1980s is provided below for reference purposes. ARC will be defined in a person having at least three of the following clinical signs or symptoms lasting three or more months, and unexplained by other illnesses or conditions: a. Fever: 100OF, intermittent or continuous b. Weight loss: 10 percent or 15 lbs. c. Lymphadenopathy: persistent involvement of 2 extra-inguinal node-bearing areas d. Diarrhea: intermittent or continuous e. Fatigue: to the point of decreased physical or mental function f. Night sweats: intermittent or continuous g. Established central or peripheral neurologic deficit h. Idiopathic thrombocytopenic purpura (ITP) i. Oral candidiasis AND a positive serologic test for identification of antibodies to HIV. V. * Draft revised surveillance criteria for HIV infection were approved and recommended by the membership of the Council of State and Territorial Epidemiologists (CSTE) at the 1998 annual meeting (11). Draft versions of these criteria were previously reviewed by state HIV/AIDS surveillance staffs, CDC, CSTE, and laboratory experts. In addition, the pediatric criteria were reviewed by an expert panel of consultants. [External Pediatric Consultants: C. Hanson, M. Kaiser, S. Paul, G. Scott, and P. Thomas. CDC staff: J. ODH-IDCM HIVAIDS Page 5/Section 3 Revised 1/2009 Bertolli, K. Dominguez, M. Kalish, M.L. Lindegren, M. Rogers, C. Schable, R.J. Simonds, and J. Ward] ** Children aged greater than or equal to 18 months but less than 13 years are categorized as "not infected with HIV" if they meet the criteria in III. *** In adults, adolescents, and children infected by other than perinatal exposure, plasma viral RNA nucleic acid tests should NOT be used in lieu of licensed HIV screening tests (e.g. repeatedly reactive enzyme immunoassay). In addition, a negative (i.e. undetectable) plasma HIV-1 RNA test result does not rule out the diagnosis of HIV infection. **** HIV nucleic acid (DNA or RNA) detection tests are the virologic methods of choice to exclude infection in children aged less than 18 months. Although HIV culture can be used for this purpose, it is more complex and expensive to perform and is less well standardized than nucleic acid detection tests. The use of p24 antigen testing to exclude infection in children aged less than 18 months is not recommended because of its lack of sensitivity. Surveillance case definitions for acquired immunodeficiency syndrome and human immunodeficiency virus infection have been published and revised in:1. CDC. 1999 Revised Surveillance Case Definition for HIV Infection. MMWR 1999:48(No RR-13). 1. CDC. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 1992;41(No. RR-17). 2. CDC. 1994 revised classification system for Human Immunodeficiency Virus infection in children less than 13 years of age. MMWR 1994;43(No. RR-12). 3. CDC. Classification system for human Y-lymphotropic virus type III/lymphadenopathyassociated virus infections. MMWR 1987;35:334-9. 4. CDC. Classification system for human immunodeficiency virus (HIV) infection in children under 13 years of age. MMWR 1987;36:225-30,235. SIGNS AND SYMPTOMS In 50-80% of new cases of HIV, the patient will develop “acute retroviral syndrome.” This occurs 1-3 weeks after exposure and is characterized by a mononucleosis-like syndrome consisting of fever, lymphadenopathy, pharyngitis, rash, myalgias, and sometimes diarrhea, headache, nausea and vomiting. At this time HIV infection can often only be suspected because antibody tests for the HIV virus may sometimes be negative at this very early stage. Patients with known or suspected acute retroviral syndrome should be immediately referred to an HIV/AIDS specialist. Unfortunately, in many cases of HIV, the acute retroviral syndrome is misinterpreted as a simple cold or flu for which the patient does not seek medical attention or in which a health care provider fails to consider the diagnosis. The acute retroviral syndrome resolves without treatment, so many people with HIV have no recognizable symptoms up to ten years. In patients who do have symptoms of HIV, they are nonspecific, such as lymphadenopathy, anorexia, unexplained weight loss, chronic diarrhea, night sweats, fever and fatigue. Alternatively, patients can present with neurologic problems. Progression of immunosuppression is indicated by decreasing CD4 levels. Severe immunosuppression or certain opportunistic infections result in a diagnosis of AIDS. DIAGNOSIS Diagnosis is based on laboratory evidence of HIV infection. The least expensive and most commonly ODH-IDCM HIVAIDS Page 6/Section 3 Revised 1/2009 used tests detect antibodies to HIV. A positive finding is based on repeatedly reactive findings on an EIA or IFA with confirmation by IFA or Western blot. Tests are now available for use on blood, oral fluid and urine. Antigen capture and nucleic acid amplification tests are also widely available. EPIDEMIOLOGY Source HIV has been found in blood and blood products, semen, vaginal secretions, breast milk, saliva and tears. Evidence suggests that saliva and tears are not implicated in transmission of the virus. Occurrence Disease caused by HIV was first recognized in the United States in 1981; however HIV, the causative agent, was not identified until 1983. Every state in the United States and every county in Ohio has reported AIDS cases. Persons at risk for HIV infection include men who have sex with men, intravenous drug users, hemophiliacs who have received non-heat-treated blood products, persons who have had sexual contact with persons with HIV, recipients of blood transfusions or transplanted organs not tested for HIV antibody and unborn and newborn children of mothers with HIV infection. HIV disproportionately affects minorities in Ohio as well as the nation. Mode of Transmission HIV has been isolated from semen, blood, vaginal secretions, breast milk, saliva and tears. Epidemiologic evidence indicates that HIV can be transmitted: from person-to-person through sexual contact; by percutaneous exposure to contaminated blood, including the sharing of contaminated intravenous needles; by transfusion of contaminated blood or blood products; and from an infected pregnant woman to her unborn child. Although HIV has been isolated from saliva and tears, there is no evidence to support transmission of HIV through casual contact such as sharing of food or sharing eating utensils. Transmission has occurred in unusual circumstances of blood-to-blood contact. These situations include an intentional self-inoculation of contaminated blood, a blood-to-blood exposure after a bite resulting in severe tissue damage and suspected transmission through a blood-contaminated toothbrush and razor. No animal or vector borne transmission has been documented. Period of Communicability It appears that once a person is infected with HIV, infection and communicability persist for life. It is unknown when persons with HIV infection are most communicable. Communicability may vary as the body’s viral load fluctuates with the stage of disease. Asymptomatic infected persons can transmit infection to others. Persons in any stage of HIV infection must be presumed infectious. Incubation Period Information from transfusion-associated cases of AIDS suggest an incubation period from infection to symptomatic AIDS ranging from six months to eight years or longer without HIV related treatment. With available treatments, onset of disease may be delayed beyond 10 years. PUBLIC HEALTH MANAGEMENT Case Investigation Cases should be interviewed to identify individuals who have had sexual or needle-sharing contact so that these individuals may be encouraged to seek HIV testing. The Ohio Department of Health’s (ODH's) Partner Counseling and Referral Services (PCRS) provides this interviewing and contact notification for cases reported to ODH. Call the HIV/STD Prevention Program for details and referrals: 614-466-2446 or 614-644-1838. ODH-IDCM HIVAIDS Page 7/Section 3 Revised 1/2009 Treatment Anti-retroviral treatment may significantly slow progression of HIV infection. Prophylactic treatment is available to prevent or decrease the severity of opportunistic infections. An ongoing relationship with a physician is essential for management of HIV infection, and an HIV/AIDS specialist should be consulted for current treatment options. Assistance in accessing medical and social services provided for persons with HIV infection is available from HIV case managers throughout Ohio (call ODH’s HIV Care Services at 614-466-6374 to locate a case manager near the patient). Isolation Isolation is inappropriate, except for protection of patients with severe immunosuppression. However, cases should be counseled about avoiding behaviors that may result in blood or body fluid exposures that could infect others. Contacts Sexual/needle-sharing contacts These individuals should be contacted, informed that they have been named as a contact of someone infected with HIV, encouraged to be tested for HIV, and counseled about avoiding HIV risk behaviors. ODH's Partner Counseling and Referral Services (PCRS) provides this interviewing and contact notification for cases reported to ODH. Call the HIV/STD Prevention Program for details and referrals: 614-466-2446 or 614-644-1838. Occupational exposures In biologically significant exposures, the exposed individuals should be offered testing and, if reported within 48 hours of exposure, offered prophylaxis following OSHA guidelines for HIV exposure. Non-Occupational exposures and post-exposure prophylaxis (PEP) CDC has recently published PEP guidelines. For example, “for persons seeking care ≤ 72 hours after non-occupational exposure to blood, genital secretions, or other potentially infectious body fluids of a person known to be HIV infected, when that exposure represents a substantial risk for transmission, a 28 day course of highly active antiretroviral therapy (HAART) is recommended.” See other details in: CDC. Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV in the United States. MMWR 2005; 54 (No. RR-2): 1-20. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm Physician referral is necessary. ODH-IDCM HIVAIDS Page 8/Section 3 Revised 1/2009