Continuing Education Activity

Clinical laboratory personnel performs routine tests to diagnose, treat, and prevent various diseases. Duties included collecting and analyzing blood samples, tissue samples, and bodily fluids. Because of this, laboratory personnel are at increased risk of exposure to Human Immunodeficiency Virus (HIV) and other bloodborne pathogens. Intended for people working in clinical laboratories, this activity addresses the Florida requirement for continuing education in HIV. This activity improves clinical laboratory personnel’s knowledge of HIV etiology, transmission, prevention, and treatment. It also describes the Florida laws related to HIV testing, reporting, and confidentiality. The activity highlights the role of interprofessional teams in reducing the risk of occupational exposure to HIV.

Objectives:

• Describe the human immunodeficiency virus (HIV) structure.
• Outline HIV modes of transmission in the healthcare setting.
• Identify practices that prevent HIV exposure.
• Explain the impact of HIV testing on current Florida laws.

Introduction

HIV is transmitted through exposure to infected blood, semen, vaginal fluid, or breast milk.[1] The virus targets cells with CD4+ receptors, including T-cells.[2] These cells comprise parts of the immune system that allow the body to fend off infections.[3] Infection with HIV triggers T-cell destruction, decreasing cell-mediated immunity, which can lead to various opportunistic infections and cancer.[2] 

From days to weeks after exposure to the virus, early symptoms of HIV infection may include fever, sore throat, enlarged lymph nodes, weight loss, myalgia, or rash. Then, an infected person can become asymptomatic while the virus continues to replicate, and the number of CD4+ T-cells progressively decreases. Once the CD4+ count drops below a certain level, there is a significant increase in risk for infections that can become life-threatening, defining the Acquired Immunodeficiency Syndrome (AIDS) stage of HIV infection. Without treatment, the time from the start of infection to AIDS-related death is estimated to be about 11 years.[4] However, when started early, Antiretroviral treatment (ART) has enabled people with HIV to live with chronic infection as long as those without the disease.[2]

HIV belongs to the retrovirus family with complex genomes and capsid core particles.[5] Retroviruses are positive-sense RNA viruses that can reverse transcribe their genome, inserting it into the host cell.[6] Through reverse transcription, single-stranded viral RNA is transformed into double-stranded DNA, which can incorporate itself into the host cell’s DNA and replicate.[4]

HIV consists of two primary components: the capsid and the genome. The conical capsid encloses the viral RNA genome, giving it shape and protection. The genome carries genetic information.[7]

The capsid protects the genome, transfers the viral genome between cells, and interacts with host factors to further viral replication.[7] The shape of the capsid is elastic; it starts as an immature sphere and transitions into a mature cone.[6]

For the virus to enter a cell, its envelope must fuse with the host cell’s membrane. The viral envelope consists of glycoproteins gp120 and gp41, forming spikes that allow for attachment. These glycoproteins recognize the host cell’s surface receptors CD4+, CCR5, and CXCR4.[4]

Adsorption occurs when HIV binds and enters a cell through fusion. The spikes on the HIV envelope consist of gp120 and gp41. Gp120 binds CD4 receptors and either CCR5 or CXCR4 on the host cell, allowing HIV entry into the cell. Gp41 promotes the fusion of HIV and the host cell membrane. CXCR4 presents on T-cells and many other cells, and CCR5 presents mainly on macrophages.[4]

Every retrovirus encodes three essential structural genes: gag, pol, and env. The gag gene determines the structural core proteins, creating the capsid; pol encodes for enzymes necessary for viral replication, including reverse transcriptase; and env encodes the glycoproteins of the viral envelope. The HIV-1 genome also encodes six other regulatory genes that modulate replication: tat, rev, vif, vpx, vpr, nef.[4][6]

Because HIV consists of two RNA molecules, genetic mutations are likely, as point mutations can occur on either molecule. The high frequency of mutations allows the virus to escape from the body’s immune system.[4][5] There are two genetically different strains of HIV: HIV-1 and HIV-2. HIV-1 makes up most infections worldwide, and HIV-2 is primarily restricted to Western Africa. HIV-1 has been divided into groups M, N, O, and P. The M group dominates the HIV pandemic. Thus, this group has been further divided into nine subtypes A-D, F-H, J, and K. Subtype B predominates in North America.[8]

Issues of Concern

Modes of Transmission

Occupational Exposures

HIV transmission occurs through direct exposure to infected blood or secretions. This can happen in an occupational setting through accidental needlesticks or cuts with a sharp object.[4] Developing HIV after a needlestick injury is uncommon, and studies have revealed that the risk of transmission is 0.3%. This can be higher if the patient has a high viral titer or if there is exposure to a large quantity of infected blood. Additionally, the transmission may occur by infected blood splashing onto mucosal surfaces.[9]

Potentially Infectious Body Fluids

Exposure to blood or other bodily fluids, including vaginal secretions, semen, CSF, peritoneal fluid, pleural fluid, and amniotic fluid, can expose healthcare workers to bloodborne pathogens like HIV.[10]

Risk Factors Associated with Increased HIV Infection

Following established recommendations and protocols is necessary to decrease the risk of occupational exposure to HIV infection. Factors associated with increased risk include:

• Lack of universal precautions
• Failure to follow safety protocol
• Use of sharp devices without safety features
• Exposure to a higher quantity of blood or large-bore needle[9]

Practices that Prevent HIV Exposure

Overview

There is no vaccine for HIV. However, prevention of HIV exposure is the best way to prevent transmission in the healthcare setting. Among healthcare laboratory personnel, bloodborne viruses are responsible for most laboratory-acquired infections. Education, training, and biosafety protocols should be in place to reduce the potential risk of disease transmission.[11]

Engineering Controls

Engineering controls are tools made to remove equipment from the workplace that may be contaminated.[10] Proper use of safety-engineered devices reduces the risk of accidental exposure to HIV, including:

• Dispose of sharps in sharps containers 
• Avoid recapping used needles
• Use shields and retractable needles
• Use plastic blood tubes instead of glass[12][13][14]

Exposure prevention is critical to preventing transmitting HIV and other bloodborne pathogens.

Sharps

Sharp injuries may result from needles, scalpels, razors, or lancets. All sharps must be disposed of in a specified, puncture-proof container.[10][12]

Work Practice Controls

These controls reduce exposure to bloodborne pathogens.[10][15] When an exposure risk is identified,

• Wear gloves when there is direct contact with blood and bodily fluid.
• Wear masks, eyeglasses, and waterproof gowns during procedures where blood splashing may occur.
• Do not perform mouth pipetting.
• Avoid contact with mucosal surfaces, such as eating, drinking, smoking, applying lip balm, or handling contact lenses.

Handwashing

Proper hand hygiene is one of the most effective ways to control infection and prevent disease transmission after exposure. CDC guidelines recommend handwashing with soap and water for 20 seconds or using an alcohol hand rub with 60% alcohol. Hand hygiene should occur after touching a patient, cleaning a soiled site, contacting bodily fluids, and touching contaminated surfaces.[10]

Personal Protective Equipment (PPE)

PPE is essential in the laboratory. It protects healthcare workers from potential exposure by creating a physical barrier. Basic PPE includes masks, gowns or coats, gloves, and face shields.[10]

Gloves

Healthcare workers must wear gloves when encountering bodily fluids, collecting blood or fluids, and contacting contaminated surfaces. Gloves must be changed when there is a tear, damage, or contamination. They must also be changed before leaving the work area and between patient encounters.

Disinfection

HIV can persist on dry surfaces for more than seven days.[16] The organic materials should be removed from the surface before cleaning. There are disinfectant solutions that are effective against HIV. Most commonly, UV-LED light, 70% ethyl alcohol, or sodium hypochlorite (household bleach) can inactivate HIV on surfaces.[17][18] Reading the product's label is important to ensure activity against HIV.

Clinical Significance

Clinical Management of an HIV Exposure

Exposure

If exposure occurs, a healthcare worker must get emergency care, and first aid should be started. The type of care depends on the route of exposure. If the nose, mouth, face, or skin is exposed, it should be flushed with water. If exposure occurs to the eyes, they should be irrigated with saline, sterile irrigation, or clean water. For needlestick or cut exposure, the site should be washed with soap and water, and wounds must be cleaned.[9]

Healthcare workers should promptly report it to their supervisors upon exposure, and medical evaluation with management should follow.[10]

Evaluation and Treatment

Medical evaluation and decision to treat should occur immediately, and a plan for postexposure prophylaxis should ensure. Follow-up evaluations should occur. The healthcare worker’s health information is kept confidential.[19]

If possible, the CDC recommends testing the source patient with an FDA-approved rapid HIV test. Both third-generation chemiluminescent immunoassays and fourth-generation combination p24antigen-HIV antibody (Ag/Ab) tests allow for rapid and accurate results. 

[See CDC Report, U.S. Public Health Service guidelines for managing occupational exposures to HIV and recommendations for postexposure prophylaxis.]

Postexposure Prophylaxis (PEP)

If possible, the source patient should be tested for HIV. Antiretroviral therapy (ART) must be started as soon as possible, preferably within seventy-two hours of the exposure, and it is continued for four weeks. PEP regimens typically consist of three drugs with low side effects and minimal risk of development of HIV resistance. Expert consultation is suggested.[1] If the primary workup is negative, confirmatory tests should be performed at four- and six months post-exposure.[9]

Care and Treatment of HIV/AIDS Patients

Identifying Risks and Behaviors Associated with HIV/AIDS

HIV can be transmitted through bodily secretions through sexual contact, blood, and pregnancy.[20] Specific risk behaviors can increase the chance of disease transmission, including:

• Injection and non-injection drug use
• Unprotected sex
• Multiple sexual partners
• Exchange of sex for money or drugs
• Use of alcohol or drugs before or during sexual intercourse[21]

HIV cannot be transmitted through casual contact with saliva, such as kissing, spitting, or sharing drinks.[22]

Goals of HIV/AIDS Treatment

Currently, there is no vaccine or cure for HIV, though clinical trials and studies continue to be performed. ART, when started early, has enabled people with HIV to live long lives with chronic infection.[2] The CDC aims to implement a 90-90-90 plan, where 90% of people infected with HIV have been diagnosed, 90% with diagnosed infection are on ART, and 90% of those on ART have decreased viral load.[23]

Antiretroviral Treatment (ART) for Patients Infected With HIV

Individuals should be tested for drug resistance before beginning treatment with ART, allowing physicians to choose the most effective medications.[23] ART should be started immediately, regardless of CD4 cell count or viral load. The World Health Organization (WHO) advises one month of ART with at least three medications as post-exposure prophylaxis.[24]

Benefits of ART

• Better clinical outcomes
• Decrease in viral load and transmission
• Delay in disease progression
• Reduced morbidity and mortality
• Prevention of immune system decline[25]

Limitations of ART

• Daily adherence
• Long-term medication toxicity
• Cost of treatment
• Limited options for those with multiclass resistance[26]

Types of ART Medications

Each medication targets a step in the HIV lifecycle. A combination of different classes is used to treat patients with HIV, including: 

• Fusion inhibitors – enfuvirtide
• Entry inhibitors – maraviroc
• Nucleoside reverse transcriptase inhibitors (NRTI) – zidovudine, lamivudine, abacavir, didanosine
• Nucleotide reverse transcriptase inhibitors (NtRTI) – tenofovir
• Non-nucleoside reverse transcriptase inhibitors (NNRTI) – efavirenz, nevirapine
• Integrase inhibitors – raltegravir
• Protease inhibitors (PI) – ritonavir, darunavir, atazanavir[2]

Attitude and Stigma Associated with HIV/AIDS

Introduction to HIV/AIDS Stigma

HIV/AIDS stigma remains a barrier to accessing medical care, prevention, and therapy. Manifestation of stigma varies between cultures, societal beliefs, and group norms. Structural violence (racism, sexism, poverty) coupled with a pre-existing stigma against high-risk groups (injection drug users, sex workers, men who have sex with men) enhances the power stigma has on the HIV/AIDS epidemic, ultimately leading to decreased diagnosis, treatment, and care. Stigma arises from a convergence of labeling, stereotyping, separating, and discriminating.[27]

Counteracting HIV/AIDS Stigma

• Understand how HIV is transmitted and who can become infected
• Advocate for laws and policies to end the stigma against men who have sex with men, sex workers, injection drug users, and migrants.
• Support organizations rallying to end discrimination against people infected with HIV
• Assist families and communities of those infected or affected
• Learn about legal consequences and policy actions
• Support routine HIV testing[27]

Other Issues

Current Florida law on AIDS and its Impact on HIV Testing

Legislative Intent

The Florida legislature designs laws regarding HIV and other sexually transmitted diseases to provide patients with privacy, confidentiality, and dignity.

Informed Consent

Informed consent for HIV testing must include an explanation to the patient regarding confidentiality, mandatory reporting, and opportunity for anonymous testing. Florida statutes maintain that in a healthcare setting, a patient must be notified of a planned HIV test, and they have the right to refuse the test, which will be documented in the patient’s chart. A legal guardian may provide informed consent if a person is incompetent, incapacitated, or a legal minor.

Confidentiality

Information regarding a person’s HIV status must be kept confidential, except when:

• The patient gives consent
• Given for statistical purposes and excluding identifying information
• Made to mandatory reporting to medical personnel, state agencies, or mandated court jurisdiction
• Disclosed during a medical emergency, only sharing relevant information for the patient’s care

If confidentiality is violated, the person commits a misdemeanor of the first degree, which is punishable by a fine of up to $1,000 and up to one year in prison. Any person who spreads information about an individual with HIV or another sexually transmitted disease for monetary gain or with malicious intent commits a felony in the third degree. This is punishable by a fine of up to $5,000 or imprisonment of up to five years.

Reporting Results

The Florida Department of Health will keep information confidential and private. The diagnosis of HIV or AIDS must be reported to the Florida Department of Health within two weeks of the positive test result. Any positive HIV or AIDS results must be reported using the system developed by the CDC or an equivalent system to ensure confidentiality. The Department of Health may fine anyone who fails to report HIV or AIDS up to $500 for each offense, and a regulatory agency will be informed of the violation.

[See Florida State Statutes, Title XXIX Public Health, Chapter 381 Public Health: General Provisions]

Preliminary and Confirmatory Testing

In 2014, the CDC updated testing guidelines. They recommend screening with an HIV-1/2 antigen/antibody test. If it is non-reactive, no further testing is required. If it is reactive, an HIV-1/HIV-2 antibody differentiation test is recommended. If the differentiation test is non-reactive or indeterminate, then a qualitative HIV-1 RNA test is suggested to confirm the results.[28]

Enhancing Healthcare Team Outcomes

Healthcare workers should work together to recognize workplace hazards, including exposure to HIV. Together, they can develop protocols to mitigate these threats and create programs to promote health and safety in the laboratory. 

Though training and understanding HIV prevention is critical to avoid transmission, accidents and exposure to bloodborne pathogens will occur. Knowledge of exposure, treatment, and postexposure prophylaxis is of vital importance. By using safety-engineered medical devices, the number of needlestick injuries has decreased.[29] [Level 1]

Nurses, technicians, and phlebotomists collect and screen tissues and blood samples. Laboratory personnel ensures safe testing and handling of these products. Physicians, pharmacists, and advanced care providers work in the coordination of care and information. Communication throughout the levels of the healthcare team is critical for patient care and healthcare workers’ safety. Coordinating care amongst all interprofessional team members can improve health and safety measures.