PROGRAM GOALS AND OBJECTIVES

Upon completion of this continuing education self-study module, the learner is expected to demonstrate enhanced understanding of HIV/AIDS. Enhanced understanding will be measured by satisfaction of the following objectives, as evidenced by a score of at least 80% on a post-test:

• Discuss legal and ethical responsibilities of caregivers with regard to the testing and confidentiality of HIV test results
• Describe the ways in which HIV infection can be transmitted and identify populations that have an increased incidence related to risk factors and behaviors
• Describe pathophysiological changes which occur with HIV/AIDS including susceptibility for opportunistic infections
• Identify new treatment options which have emerged in the management of HIV/AIDS, including at least two classes of drugs utilized to combat or delay HIV progression to AIDS
• Identify barrier requirements recommended by the CDC & OSHA for health care providers
• Describe emerging chemoprophylactic measures which may be taken after an exposure has occurred
• Identify diverse needs of HIV/AIDS patients including educational, cultural, psychosocial, legal and physical

EPIDEMIOLOGY & TRANSMISSION

 The cumulative number of people with AIDS reported to the CDC through 2002 Nearly 62% (311,381) of the cases reported by that time had died. HIV infection was the 8th leading cause of death overall in the US at that time, and the number one cause of death for individuals age 25 to 44 years old.

There have been no recent new discoveries regarding the transmission of the virus over the last few years. We still know the virus to be readily transmitted through blood semen, vaginal secretions breast milk and via the placenta. The HIV virus has been found in saliva, although transmission of the virus via this route has not been clearly documented and proven.

The demographic picture of HIV/AIDS has changed dramatically since its discovery nearly 20 years ago. Less than half of AIDS cases now are represented by homosexual or bisexual men, the first affected population identified. The fastest growing group of individuals infected by HIV today are minority women.  IV drug abuse accounts for nearly 1/3 of the newly diagnosed cases. Heterosexual transmission accounts for nearly 11% of adult AIDS cases now. New legislation in Florida recognizes the increase in HIV/AIDS infection among women and children.

The diagnosis of HIV infection is made by EL1SA testing which has been confirmed by Western Blot or other equivalent testing methods such as the immunofluorescent antibody test (IFA) or synthetic peptide testing.

Often, and particularly initially after exposure, test results are indeterminate. The indeterminate results may often be affected or explained by the presence of other infectious diseases that may be present besides HIV. Indeterminate test results ALWAYS require repeating and correlation with the clinical picture.

The “severity” of HIV infection and measurement of viral progression is measured diagnostically by the CD4 count. The CD4 count is a laboratory measurement of the number of T-lymphocytes.

A measure of the amount of HIV1 RNA in the body is the “viral load”. The viral load serves as a very concise measure of disease progression and the forecast of death (even when CD4 counts have not fallen). Typically, the higher the viral load, the poorer the outcome and the sooner death can be expected. Monitoring of the viral load is becoming standard practice to evaluate the effectiveness of drug therapy in HIV+ patients. It is important to mention that a viral load measurement may be inaccurate within 1 month of receiving a vaccine or with any illness. The viral load should be measured monthly when drugs are being monitored until the therapy is stabilized. Then every three months it is typically re-checked. The viral load is measured in copies per ml and convened to a “log” scale for comparison, because the numbers are so high.

The progression from exposure to the development of full-blown AIDS may be a lengthy process, often undetected or with symptoms attributed to other causes. Typically, within a few weeks after exposure, the infected individual will experience a flu-like illness that will pass quickly. Often lymph node enlargement will occur.

The HIV virus is a retrovirus that contains no DNA material and must synthesize this material from viral RNA with the help of a viral enzyme known as reverse transcriptase. It is this synthesized viral DNA that invades the host cells of infected individuals. The HIV virus when active has a particular attraction to the cells of the immune system, namely the CD4 cells. When patients are in the latency period, the virus is typically harbored in the lymph nodes. The virus is not “dormant,” however, as previously believed. It is still replicating and the viral loads are increasing, even when the CD4 count is not falling. The obvious goal is to decrease the viral load and have the CD4 count remain high.

HIV, while a deadly virus, is quite delicate and has a short life span.  What it lacks in power, it apparently makes up for in volume. The half-life of HIV in plasma is only approximately 6 hours.  However, an estimated 10 billion viral paticles are produced and cleared daily. This rapid turnover often results in mutations of the virus as more genetic variants develop. A rapidly changing genetic makeup is one of the reasons why resistance to drugs develops quite rapidly and would explain why drugs once ineffective suddenly become effective again. For this reason, multi-drug therapy has become the best approach in decreasing the viral load and forestalling the development of full-blown AIDS, thus prolonging the lives of HIV+ patients.

Once infected, CD4 cells have an estimated half-life of two days.  CD4 cells cannot be replaced in two day’s time. The newly produced CD4 cells are also less effective or specialized in fighting off many of the opportunistic infections that the cells they are replacing were. One emerging reason for this finding is that antigens (like immunity to . diseases which was acquired from vaccinations) attached to the original CD4 cells are also destroyed and not replaced.

The terms HIV+ and AIDS are not one in the same and should not be used interchangeably when referring to patient diagnosis. HTV+ status exists from the moment of diagnostically confirmed laboratory analysis till death. AIDS diagnosis can only be appropriately made when specific criteria has been met, namely a decrease of the CD4 count below 200 per mm of blood, or when systemic manifestations or opportunistic infections have occurred in the presence ofHIV+ status.

The CDC diagnostic criteria for AIDS is noted in the following chart:

CRITERIA FOR THE DIAGNOSIS OF AIDS

I. All patients with a CD4 count of 200 or less
II. Evidence of HIV infection and any one of the following:

• Thrush
• Bacillary angiomatosis
• Oral hairy leukoplakia
• Peripheral neuropathy
• Vulvovaginal candidiasis that is persistent and poorly responsive to tx.
• Shingles of more than one dermatome or more than two episodes
• Listeriosis
• Idiopathic thrombocytopenia
• Fatigue, night sweats, unintentional weight loss greater than one month
• Cervical dysplasia or carcinoma in situ

III. Evidence of HIV infection and any one of the following:

• Bronchial candidiasis
• Esophageal candidiasis
• Coccidiomycosis
• CMV disease in sites other than the liver, spleen & lymph nodes
• Invasive cervical cancer
• Cytomegalovirus retinitis
• HIV encephalopathy
• Histoplasmosis
• Kaposi's sarcoma
• Herpes simplex ulcers, bronchitis, pneumonia
• Burkett's lymphoma
• Primary brain lymphoma
• Pneumocystis pneumonia
• Recurrent pneumonia
• Mycobacterium infection
• Progressive multifocal leukoencephalopathy
• Salmonella septicemia that is recurrent
• Toxoplasmosis

Wasting syndromes

The average survival time from the development of full-blown AIDS to death is approximately two years. New therapies incorporating multiple-drug regimes have significantly delayed the time period seen from contracting the virus to the diagnosis of AIDS.  However, the average time from initial infection to the development of opportunistic infections is approximately ten years.

HIV infection that has progressed from the silent to symptomatic phase is referred to as AIDS-related complex or ARC. This phase marks the point at which the replacement of CD4 cells can no longer keep up with the rate of destruction by HIV. The immunologic decline often progresses rapidly with CD4 counts falling and the decline of the immune system as a defense for disease and infection. "Opportunistic" infections are those which occur easily during this vulnerable period.  Normally the body would not have difficulty fighting them off.

So What’s New With HIV/AIDS:  The Latest Legal Revisions

When examining the legal issues that surround HIV/AIDS care delivery, a debate arises over the greater concern...that of public health or individual rights. The rights of individuals have taken precedence in the legislation enacted so far, over the concern of the public health risks. In part, this position has been seen in the legislation as a result of discrimination against HIV/AIDS patients.

One might argue that given the lethal nature of diagnosis and the increase in incidence that concern regarding the general population would take priority. It has not, particularly in Florida, where new legislation was enacted in 1998, which further protects the rights of individuals with HIV/AIDS and those individuals being tested for the virus. Despite the absence of a preventative vaccination and the minimal impact that educational efforts have had on the spread of the virus (except among the initially identified group of homosexual/bisexual males), the rights of individuals have, in the legislature, taken precedence over the concerns for public health.

HIV/AIDS, while transmissible and at the present time incurable, is not considered as a highly contagious threat to the general public (like communicable diseases such as measles, Rubella, Polio, TB) because most ordinary interactions pose no threat of infection to the general population. The mechanisms of infection have been clearly identified and the risk for infection has been associated with identifiable behaviors among specific at-risk or high-risk groups (namely unprotected sexual activity, IV drug use, receiving blood or blood products, and via transmission from an infected mother to her child). Casual contact (mechanisms which easily and often rapidly facilitate the spread of the previously noted communicable diseases) has not been shown as a route of transmission for HIV.

Complete confidentiality is mandated regarding HIV test results. Consent to test must be obtained first. Testing for HIV without consent may result in fines and disciplinary actions being taken against healthcare professionals. Release of test results without consent of the patient or explicit court order is not permitted. A subpoena alone is not sufficient to release information. Even when knowing the results would impact the care of other exposed individuals, release without patient consent is illegal.

As of July 1,1998, there have been some new and important exceptions made to the disclosure with consent only requirement in Florida.  One such change is that a mother's HIV test results can be entered into the child's medical record by health care professionals.  Another change allows medical professionals to conduct subsequent testing without consent to monitor treatment and prognosis when a previous HIV test has been performed.

In the past, when HIV testing was performed, the legislation had specific mandates regarding counseling before obtaining the test. Counseling is no longer mandatory, but is left to the discretion of the medical professional.

Disclosure of test results in the past had to be made face-to-face. This is also no longer required. Disclosure can now be made by phone or by mail. By dissolving this requirement "home testing kits” which have been marketed directly to consumers may be marketed more aggressively. Viewed initially as an answer to expand testing of at-risk individuals, the concept is not without drawbacks. Without adequate understanding of the “window period,” in which an individual may be infected but not test positive, unsafe sexual practices may take place. Counseling before HIV testing in the past stressed this fact. The validity and reliability of the home testing kits is not as high as the laboratory tests. Some studies have indicated that as many as 10% of HIV+ patients are "missed" and diagnosed negative, while the number of false positives has ranged from 5-10%. One company has already recalled their testing products and discontinued the service as a result of inaccuracy. More companies will probably be seen marketing their products in Florida, expanding the need for nurses to provide clear information and to continue to teach and encourage safe sex practices, regardless of which testing method a patient has used.

CHANGES IN THE TREATMENT OF HIV/AIDS

While no cure or vaccine has been developed to date, tremendous strides have been made through pharmacotherapy to extend the life of the HTV+ patient and forestall the conversion to ARC or full-blown AIDS. Many patients with HIV are living with the virus while remaining relatively healthy.

The most recent recommendations employ AZT (3' azido-3' deoxythymidine) (Retrovir, ZDV).  The first of the nucleoside analogue reverse transcriptase inhibitors works to inhibit reverse transcriptase activity and "binds" to the viral RNA, interfering with replication.  AZT was the first anti-viral drug for HIV/AIDS introduced in 1987 that interferes with the cellular processes of HIV infection. This "binding ' function of AZT, unfortunately does not only target cells which have been infected with HIV. Other cells of the body, particularly those in bone marrow, are adversely affected, and serious side effects may occur including anemia.  AZT is metabolized in the liver, therefore care must be taken with coexistent disorders, illnesses and medications. Recommended dosing is 600 mg daily as a divided dose, either BID or TID. Estimated annual cost: $2,748.  Some patients taking AZT complain of headaches, syncope, nausea, vomiting and diarrhea.

AZT is not without drawbacks. Therapy is expensive, has side effects as noted and resistance is common, with nearly all patients developing some resistance to the drug after one year.

Other newer nucleoside analogs include:  Lamivudine (Epivir, 3TC), Ddl (Videx), ddC (Hivid), and d4t (Zent). Resistance develops rapidly with each of these drugs, however it often enhances the effectiveness of other drugs, even those which had previously been ineffective or to which resistance has developed. The average annual expense for each of these newer drugs is approximately S2.600. Combination of drugs in therapy is obviously preferred. Side effects include mild headache, GI disturbances, insomnia, and fatigue. In pediatric patients, pancreatitis has been reported also. Of a special interest, studies have shown that 3TC (Epivir) also has activity against the hepatitis B virus.

The noneucleoside reverse transcriptase inhibitors (NNRTI's) block DNA activity by binding to the enzyme reverse transcriptase.  Two drugs in this category are Nevirapine (Viramune) and Delavirdine (Rescriptor).  Resistance is common, therefore use with other drugs.  In particular, the nucleoside analogue reverse transcriptase inhibitors affords the most effective therapy. Rash is a common side effect of these two drugs, and is more pronounced with Nevirapine.  Titrated dosing for the first two weeks is often seen (200mg QD for the first two weeks, followed by the full dose of 400 mg QD thereafter). The recommended dose for Delavirdine is 400 mg TID. Annual cost is about $2,976.

Protease inhibitors are a group of drugs that block the conversion of viral protein toTWA, thus interfering with the replication of the virus. Protease inhibitors include Saquinavir (Invirase), Ritonavir (Norvir), Indinavir (Crixivan) and Nelfinavir (Viracept). Each of these drugs are highly expensive (ranging from $5,400 to $7,416 per year), have side effects (mostly GI-related), and are given in varying dosage schedules. Elevation of Lipids and accelerated atherosclerosis has also been reported. Some patients have also developed new onset hyperglycemia and diabetes or developed poor glycemic control if already diagnosed as diabetic and on established blood sugar monitoring and treatment plans.

To varying extent, these drugs affect a mechanism in the liver known as the Cytochrome P-450 enzyme system. The Cytochrome P-450 system is responsible for the metabolism of many drugs including: astemizole (Hismanal), rifamycins (rifambin and rifabutin), isapride (propulsid), triazolam (Halcion), midazoalm (Versed), and other antiarrhythmics, analgesics, calcium channel blockers, GI and psychotropic medications.

A careful review of a patient’s medications and use of OTC or herbal/home remedies requiring hepatic clearance through the Cytochrome P-450 system must be done when the drugs are prescribed to avoid drug-drug interactions.

When the replication is interfered with, viral load decreases, the number of CD4 cells destroyed is reduced, and the immune system is more effective in fighting off invading pathogens. The main goal of therapy in HIV+ patients is decreasing the viral load, maintaining or having an increase in the CD4 count and the prevention of opportunistic infections.

While the new anti-viral drugs, such as AZT and protease inhibitors are highly effective for some HIV/AIDS patients, they are not as effective for others. The side effects experienced with these drugs vary tremendously and often affect compliance with the rigid dosing requirements to achieve optimal results.

Monitoring of the viral load is essential with drug therapy and an increasing viral load indicates treatment failure or drug resistance, thus signaling a need for modification in treatment or the need to screen for other illnesses or infections which may be present. Remember, HIV/AIDS does not occur as a sole entity, patients may also have blood disorders, cancers, or chronic conditions which take their toll on the immune system too.

The biggest success using antiviral drugs has been seen when a triple-drug therapy approach is used aggressively with newly diagnosed HIV infection, combining AZT, nucleoside drugs and a protease inhibitor. Numerous studies have shown that this approach, while not a "cure" offers improved prognosis. Patients placed on the triple-drug therapy have shown undetectable plasma viral load levels, negative lymph node tissue biopsies, and negative viral cultures. Proviral DNA still remains in the cells, and when antiviral therapies are stopped, replication of the virus begins again.

This aggressive therapy called Highly Aggressive Antiretroviral Therapy (HAART) is successful in stopping the virus, but not in eliminating it. It is crucial to stress, even when aggressive antiretroviral therapy is begun after initial infection (as early as 10 days after signs and symptoms of acute infection occur), the virus is present in lymphoid tissue and has established a pool of latent infected cells, which persist and can replicate when medication is stopped.

Noncompliance or intolerance to HAART presents a problem, as resistance to drugs will develop more easily and reduce the treatment options. This phenomenon has resulted in what is known as Multidrug resistant (MDR) HIV.

OPPORTUNISTIC INFECTIONS AND CO-EXISTENT ILLNESSESS/DISORDERS

Opportunistic infection incidence has risen sharply, despite public health efforts, advanced technology and treatments and patient education. As seen on the chart describing the AIDS diagnosis criteria, numerous infections and diseases are seen among the HIV+ patient. The most frequently diagnosed opportunistic infection seen among HIV/AIDS patients is Pneumosystis carinii.  Bactrim remains the number one drug of choice for treatment and PCP prophylaxis. Opportunistic infections are often seen as developing in a "chain-reaction,” with one infection facilitating the development, progression or contraction of another. Such an example would be the increased incidence of contracting Herpes or human papilloma virus (HPV) and subsequently developing cervical neoplasms.

Cryptococcoses is an environmentally-acquired fungal infection. It is also the most life-threatening infection associated with HIV/AIDS. The fungus is transmitted by the respiratory route through droplet or spore inhalation. When isolated in the pulmonary tissue, the patient often may be asymptomatic. Cryptococcoses can also lodge in many areas of the body. Cryptococcal Meningitis develops when the fungus settles in the CSF. Some signs and symptoms of cryptococcal infection are non-specific: fever, malaise, N/V, and H/A. Others symptoms are more severe including altered mental status, photophobia, stiff neck, visual disturbances, and cranial nerve palsies.

Cryptosporidium is a protozoa which targets the gastrointestinal tract, often resulting in intense and profuse diarrhea. Transmission is primarily through contaminated water, however it can also occur with food, from animals to humans and from humans to humans. It is diagnosed through stool examination, O&P studies and Acid-fast stains. Other protozoans commonly affecting the HIV+/AIDS patient include Isospora and microsporidium.

Cytomegalovirus is a viral infection which may invade the adrenals, lungs, liver, biliary tract, pancreas and brain In the brain, infection may lead to blindness and can be life-threatening.

Candidiasis (yeast infection) occurs in 9 out of 10 AIDS patients. Candida is most commonly found in the mouth and the vagina, however, skin folds and other warm, moist areas are also sites where a yeast infection may develop.

Oral Candida (thrush) is a thick white coating in the mouth that can be scrapped off often leaving raw open tissue which bleeds. This diagnostic finding is important and helps to differentiate oral Candida from oral hairy leukoplakia, which is caused by the Epstein-Barr Virus.  In oral hairy leukoplakia, the white oral coating cannot be scrapped off. While both of these oral infections are uncomfortable for the HIV+ patient the presence of oral hairy leukoplakia is a more grim sign of probate prognosis. Most patients who develop oral hairy leukoplakia have been seen to develop full-blown AIDS within 30 months tune.

Other bacterial infestations which can be serious or life-threatening to the HIV+/AIDS patient include shigella, vibrio, salmonella, and campylobater. Careful attention must be paid to food preparation, hand washing and personal hygiene to decrease the chances or these pathogens invading.

Many HIV/AIDS patients experience GI disorders, including malnutrition, cachexia, chronic diarrhea, Cytomegalovirus colitis, and hepatobiliary disease. These may be as a direct result of infection or as a result of underlying disease or a response to medications (many of the drugs used with HIV are metabolized in the liver). HIV also aggravates underlying Hepatitis infections, often "speeding up" the process of cirrhosis.

WORKPLACE EXPOSURE AND RELATED FACTORS

The HIV epidemic has resulted in a dramatic revision in healthcare delivery and education. Federal regulatory agencies, particularly OSHA, have enhanced the rights of healthcare workers to be provided with measures to protect themselves from workplace-acquired pathogens. Healthcare workers have the right to a safe workplace with adequate access to protective equipment.

HIV/AIDS presents legal, social and moral dilemmas for healthcare professionals. Care must be taken to protect the implicit legal rights of patients while protecting the safety of healthcare workers. To this end, the CDC has devised and revised numerous standards that govern how patient care is delivered and what measures should be taken in terms of barriers to blood born pathogen exposure.

The mainstay of reducing HIV/AIDS exposure risk among health care workers has focused on the education of healthcare professionals regarding strict adherence to protective guidelines and precautions with ALL patients, regardless of positive HIV status or presence of risk factors.

It must be clearly stated that the risk for acquiring HIV in the workplace is low (less than 1%) even when an exposure has occurred.

After exposure, counseling and monitoring of the individual must be offered, but at this point, healthcare workers acquire the rights of patients and may refuse to be tested or to share their results. If testing is elected, it should be done at baseline (as soon after exposure as possible), at 6 weeks, 12 weeks, and at 6 months. The healthcare worker has legal rights not to be discriminated against, regardless of their diagnosis.

ADDITIONAL ASPECTS AND CONCERNS FOR PROVIDING HOLISTIC CARE TO HIV/AIDS PATIENTS

Nutrition is a significant yet often under-emphasized concern for the HIV/AIDS patient. The demand for nutrients is high in a system struggling to manufacture CD4 cells in the face of increasing viral loads while fighting off opportunistic infections. Not to mention, many other treatments employed in HTV/AIDS management contribute to the problems of nutritional deficits by decreasing appetite, or by causing distressing GI side effects, namely N/V/D. Opportunistic infections such as thrush or oral lesions may also make eating a painful experience for the patient. Careful attention must be paid to the maintenance of weight, adequate intake of nutrients, and fluid balance. HIV+/AIDS patients often experience weight loss that has been termed "wasting syndrome.”  Strategies to make eating more palatable or tolerable should also be employed. Studies have indicated that HIV/AIDS patients benefit from vitamin supplements. Even in patients consuming well-balanced meals, levels of thiamine, riboflavin, B-12 and folate are deficient and they are often associated with higher incidence immunological changes.

The HIV/AIDS patient is also more vulnerable to food-borne pathogens. Care should be taken in the handling and preparation of food including:

• All shellfish and meats should be thoroughly cooked.
• "Leftovers" should be thoroughly heated and eaten within two days or discarded.
• Careful attention should be paid to the selection of fresh fruits and vegetables. Those that are bruised or contain broken peelings or skin should not be eaten. All fruits and vegetables should be washed thoroughly under running water, even if they are to be cooked.
• Pay close attention to expiration and "best if used by" dates. Discard food that has passed this date, regardless of how it "looks" or "smells."
• Raw eggs, or mixtures (batters) containing raw eggs should never be eaten.
• When preparing food, hand washing, is imperative, as is the maintenance of clean cooking surfaces and eating utensils.

Mental Health issues such as depression, anxiety, social support and isolation must be addressed when caring for the HIV+/AIDS patient. Much research has been done regarding the mind-body connection and the impact of a positive emotional state on the patient's prognosis. It is important to assess the social-support network available to the patient. This educational packet closes with a number of local (Broward County, FL) agencies which can be of assistance to the HIV/AIDS patient.

There are also many "web sites" for those individuals who "surf the net.”  Site addresses must be typed in exactly as they appear (including letter case, punctuation marks and underline spaces) or they will not work.

Site address Sponsor/Information

http://www.aegis.com
AIDS Education Global Information System

http://www.204.179.124.69/network
AIDS Treatment Data Network

http://www.thebody.com
A Multimedia AIDS and HIV Resource

http://www.projinf.org
Johns Hopkins AIDS Service

http://cdc.gov/nchstp/hiv_aids/hivinfo.htm
From the Centers for Disease Control

SUMMARY

There is no "cure" in sight for HIV/AIDS. Prototypes of vaccines are being developed, but none are forecasted to be available anytime soon. At best, utilizing multiple antiviral agents to decrease the viral load and keep the CD4 levels high enough to permit the immune system to resist opportunistic infections and the development of full-blown AIDS appears to be a life-extending "band-aid" for many patients.

The healthcare worker must realize that a delicate balance exists legally ethically, and morally when caring for HIV/AIDS patients. Florida statutes have recently reinforced the rights of patients with regard to testing for HIV and the release of this information. Confidentiality is a crucial factor that cannot be stressed enough when caring for patients with HIV/AIDS, or for individuals who have been tested. Violation of the statutes concerning HIV testing and disclosure can result in severe penalties and potential litigation.

At the present time, the best defense a healthcare worker can have against the occupational exposure and contraction of HIV is consistently practicing preventative measures, and treating all patients as if they are potentially carrying the HIV virus. The burden of responsibility for protecting healthcare workers is shared by the employer and the healthcare worker. The facility must make available protective equipment and assure that personnel have been trained in HIV/AIDS-related transmission modes and appropriate preventative measures.

The healthcare worker maintains responsibility for appropriately and consistently using the equipment toorotect themselves not only from contracting HIV/AIDS but to prevent the spread ofnosocomial infections to patients, who, as we stated before, are all potentially infected with HIV. .They certainly do not want a nosocomial infection if they have low CD4 counts and high viral loads! Think about it.... microorganisms travel on a two-way (two handed?) street, and often we forget that patients are much more likely to contract something from us than we are likely to contract HIV from them. Many microorganisms which live on and can be carried on our hands pose little threat to most individuals^ however to the HIV/AIDS patient may result in a lethal opportunistic infection. Lets keen our germs to ourselves and observe universal barrier precautions to prevent acquiring the germs of our patients.

SELECTED REFERENCES

AAHIVM. (2003). Post- and preexposure prophylaxis. HIV Medicine Self-Directed Study Guide. Vol 11. Los Angeles, CA: The American Academy of HIV Medicine;  47.1, 47.2

Buchanan RJ, Wang S, Huang C.  (2002).  Analysis of nursing home residents with human immunodeficiency virus and depression using the minimum data set.  AIDS Patient Care STDS, 16(9):441-455.

Center for Disease Control and Prevention (CDC).  (2002).  Sexually transmitted disease treatment guidelines 2002.   MMWR Recomm Rep 10(RR-6):1-78.

CDC. National Center for HIV, STD and TB Prevention. Divisions of HIV/AIDS Prevention. Available at: http://www.cdc.gov/hiv/stats.htm   Accessed 02/11/05.

Dévieux, JG. Malow, RM, Rosenberg, R., et al.  (2004).  Context and common ground: Cultural adaptation of an intervention for minority HIV-infectred individuals.  Journal of Cultural Diversity, 11; (2):49-58.

Emlet CA & Farkas KJ.  (2002).  Correlates of service utilization among midlife and older adults with HIV/AIDS: the role of age in the equation.  J Aging Health, 14(3):315-335.

Stephenson J.  (2003).  Growing, evolving HIV/AIDS pandemic is producing social and economic fallout.  JAMA, 289(1):31-33.

USDHHS.  (2002).   USPHS/ISDA guidelines for the prevention of opportunistic infections in persons infected with HIV.  Atlanta, GA: USDHHS.

USDHHS.   (2003).  HIV infection and AIDS: An overview.  http://www.niaid.nih.gov/factsheets/hivinf.htm   site accessed 02/11/05.

Ward, EG, Disch, WB, Levy, JA, Schensul, JJ. (2004).  Perception of HIV/AIDS risk among urban low-income senior housing residents. AIDS Education & Prevention, 16; (6):571-589.

Williams AB.  (2002).  Adherence to HIV Regimens: 10 Vital Lessons.  AJN, 101
(6):37-44.

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