Posted December 29, 2009
Don Kurtyka is a family nurse practitioner who is director of HIV services at Tampa General Hospital in Tampa, Fla. He is an assistant clinical professor at the University of South Florida College of Medicine in Tampa and also practices in the Specialty Care Center operated by the Hillsborough County Health Department in Tampa. He is a member of the speaker bureaus for Gilead Sciences, GlaxoSmithKline, Bristol Myers Squibb, Tibotec Therapeutics and VircoLab.
Objectives: The purpose of this article is to educate nurse practitioners about HIV infection in 2010. After reading this article, the nurse practitioner should be able to:
Describe the epidemiology of HIV/AIDS, and describe HIV testing guidelines.
Explain various approaches to HIV prevention.
Describe medications used in the treatment of HIV infection.
Identify when to start ARV therapy, and state potential complications of ARV therapy.
As we approach the third decade of treating patients with HIV infection, we can celebrate several accomplishments. We have transitioned a terminal disease into a manageable chronic illness for many patients. This article summarizes key treatment issues and new developments to assist NPs caring for HIV-infected patients as we begin 2010.
Globally, more than 30 million people are living with HIV infection.1Accurate tracking of new HIV infections is essential to prevention efforts. Unfortunately, monitoring has been difficult because many HIV infections are not diagnosed until years after they occur. For many years, the Centers for Disease Control and Prevention (CDC) estimated that approximately 40,000 new cases of HIV infection were acquired annually in the United States. Using a new assay technology, the CDC can now differentiate between newly acquired infections and longstanding infections. When the CDC used the new methodology to reexamine data from 2006, 31% of cases were reclassified as recent infections. Using statistical extrapolation, the CDC raised the 2006 estimate of new infections from 40,000 to 56,300.2
Table 1 provides data about the population of newly infected people. The most severe impact is evident among men who have sex with men (MSM) and black people. These new estimates confirm that blacks are more severely and disproportionately affected by HIV than any other racial or ethnic group in the United States.
CDC analyses show that HIV incidence among blacks has held steady at an unacceptably high level since the early 1990s (except for a brief fluctuation in the late 1990s).
Although race itself is not a risk factor for HIV infection, a range of issues contribute to the disproportionate HIV risk among blacks in the United States: poverty, stigma, higher rates of other sexually transmitted infections and drug use. In 2008, an estimated 1 in 29 black men in Miami-Dade County, Fla., was infected with HIV.3These findings illustrate the need to expand access to HIV testing and other proven interventions and to continue working to identify new interventions to address the evolving needs of diverse populations at risk for HIV infection.
The U.S. Department of Health and Human Services (DHHS) published updated HIV testing recommendations in September 2006. They are intended for all public and private healthcare settings. The recommendations encompass the following:
HIV screening is recommended after notification. Screening should not be performed if the patient declines (opt-out screening).
High-risk patients should be screened annually.
General consent for medical care should be sufficient to encompass HIV testing consent.
Prevention counseling should not be required for HIV testing or screening programs.
These same principles should be incorporated into prenatal screening.
Collectively, these actions should increase HIV screening, foster earlier detection of HIV infection, identify people with unrecognized HIV infection (allowing them to link to clinical and prevention services), and further reduce perinatal transmission of HIV.4
Many states have revised their HIV testing procedures since the release of the 2006 HIV testing guidelines, but testing laws and policies still vary widely. State policies are listed on the State HIV Testing Laws Compendium Web site managed by the National HIV/AIDS Consultation Center for current information about each state (www.nccc.ucsf.edu/StateLaws/).5