1. OBJECTIVES
A. Understand of the
epidemiology, history and transmission patterns for HIV and AIDS.
B. Understand the testing procedure and counseling for HIV.
C. Understand your Right to Know as a funeral director.
D. Learn who has the Right to Know, according to the Florida
law.
E. Understand the importance of universal precautions.
2. DEFINITION
Acquired Immune Deficiency
(AIDS) is the final stage of infection with human immunodeficiency virus
(HIV). AIDS is a complex illness, which
interferes with the body's immune system in a number of ways, particularly that
portion responsible for cello mediated immunity and tumor suppression. Thus, the disease attacks the body's immune system,
leaving a person vulnerable to otherwise rare life-threatening infections,
cancers and other conditions.
The definition of AIDS has
changed several times since surveillance began in the early 1980's. Originally a case definition which included
only the most common clinical conditions associated with late-stage disease,
the AIDS definition was then expanded to include more recently recognized
entities such as lymphomas, wasting syndrome and dementia. At the end of 1992 the AIDS definition was
changed once again, in order to recognize the importance of CD4+ T-cell
monitoring in staging and managing the disease, and the important contributions
made to HIV-related morbidity by cervical carcinoma and recurrent bacterial,
fungal and mycobacterial infections.
3. HISTORY
HIV infection is now widely
viewed as a continuum of disease ranging from asymptomatic to full-blown
AIDS. In the past, the diagnosis of
"AIDS has required the presence of one or more clinical conditions. Since the definition has changed to include
allow those infected persons with CD4+ counts less than 200, it is now possible
for a person to have AIDS yet be asymptomatic.
The change in the case definition is expected to increase reporting of
drug users (who have increased rates of bacterial infections and TB) and women
to the ranks of those with "official AIDS".
HIV affects almost every
organ system. Its impact on an
individual patient is unpredictable and its manifestations protean. Some people infected with HIV remain
relatively healthy for many years before the symptoms of HIV appear. It may take up to ten years or longer for
symptoms of HIV to appear in some HIV-infected individuals. The symptoms sometimes associated with HIV
are similar to those of many common diseases.
They include fever, fatigue, night sweats, weight loss, swollen glands,
dry cough, and diarrhea. But in HIV
infected individuals these unexplained symptoms do not go away.
At this time it is not clear
why some people develop symptoms faster than others infected with the
virus. Some think that certain
cofactors such as stress, poor nutrition, alcohol or drug abuse and certain
sexually transmitted diseases, such as syphilis, may trigger the virus to start
replicating itself and weaken the immune system. Intensive investigation has, however, not yet demonstrated any
consistent relationship between any of these factors and development of
clinical disease.
Persons living with AIDS are
likely to develop a variety of serious infections caused by fungi, viruses and
parasites normally found in the environment but not normally causing
disease. These infections, because they
seize the opportunity presented by a disabled immune response, are called
opportunistic infections.
4. IMMUNOPATHOGENESIS
HIV is a member of the
lentivirus subgroup of retroviruses, which characteristically have a long
latency period between infection and clinical illness. After entering the body through infected
blood, semen, or vaginal secretions, HIV usually attacks T-lymphocytes carrying
the "CD4" marker. These CD4+
cells (also known as "T-4 cells" or "T-helper cells") are
crucial to an effective immune response.
Not only are they central to cellular immunity, but they also play an
important facilitating role in humoral immunity. Because the CD4+ cell count is currently the best predictor of
clinical manifestations of HIV, the progress of the chronic infection is now
tracked by following the slow fall of patients' CD4+ cell counts over several
years.
HIV, like all viruses, must
seek out, infect and command cells of the host organism to reproduce. Unfortunately, the special targets of HIV
are the CD4+ lymphocytes, macrophages and certain brain cells. As HIV takes over the CD4+ cells, it alters
their growth and reproduction through a complicated process that eventually
causes the infected CD4+ cells to be destroyed. The ration of CD4+ cells to CD8+ ("T-8" or
"suppressor") cells then falls (In healthy people, the CD4+CD8+ ratio
is an indication of HIV disease progression.
As a result of this process, defects in the immune system begin to
occur. The CD4+ cells are not as
responsive to identifying antigens.
Macrophages become less responsive.
Even though B-cells are more active they produce fewer specific humoral
antibodies and lose their responsiveness to ordinary signals. This B-cell defect is thought to be
responsible for the greater susceptibility of HIV-infected individuals to
serious infection with encapsulated organisms such as pneumococcus and
Hemophilus influenza.
The virus sheds its protein
coat and enters the CD4+ cell, it uses a reverse transcriptase enzyme to
replicate its own genetic information, RNA (ribonucleic acid) into DNA
(deoxyribonucleic acid), which is then incorporated into the host cell's
genome. The infected host cello now is
capable of producing new viral particles that eventually lyse and destroy the
infected CD4+ cell, releasing free virus to begin the process anew.
The viral coat (protein
envelope) of HIV mutates frequently over time.
This characteristic, called antigenic drift, helps the virus to evade
antibody detection because the immune system only recognizes a previously
encountered surface form. At least 100
variants of HIV have been isolated. Its
mutation rate is estimated to be 100 to 1,000 times greater than the influenza
virus. In addition, HIV has been found to develop resistance to Zidovudine
("ZDV" also known as "AZT") after several months of
administration. The problem of antigenic
variation and mutation is one of the principal challenges in the development of
effective vaccines and therapies.
5. EPIDEMIOLOGY
The first case of what we
now call AIDS was reported in 1981. By
the end of that year 316 cases of this newly discovered disease were reported
to the Centers for Disease Control (CDC).
Within five years (1986), the number had risen to 23,000 and by the
spring of 1990, the number of reported cases of AIDS in the U.S. had reached
132,000. As of February 1993, the
cumulative total was over 249,199. AIDS
continues to be the number one public health concern in the country.
The distribution of HIV disease differs in different parts of the
nation and the world. In West Africa,
AIDS is acquired primarily through heterosexual contact. Throughout the United States and Western
Europe, unprotected homosexual sex and contaminated equipment for the injection
of drugs have been the primary means of spread. In San Francisco, AIDS has been diagnosed overwhelmingly in
homosexual and bisexual men, the majority white. In Newark, New Jersey, on the other hand, men and women infected
through drug equipment and women infected heterosexually are responsible for
the majority of cases (most are Black and Puerto Rican). Nationally, homosexual and bisexual men
account for about 59% of the number of reported cases of AIDS. However, that percentage has been decreasing
as more cases associated with drug use and heterosexual activity have been
diagnosed.
6. HIV Prevention
The only way to eliminate
your risk of exposure to HIV is to not have sex, not share needles and not have
a blood transfusion.
When the risk of exposure to
bodily fluids is challenged, universal precautions should always be
observed. This will help reduce the
risk of exposure.
7. Transmission
HIV can be transmitted from
person to person through infected blood, semen or vaginal secretions. Three
conditions must be met before transmission can occur:
- HIV must be in the body fluid.
- It must contain sufficient quantity.
- It must have a means of entry into the bloodstream.
Infected blood, semen and
vaginal secretions contain the highest concentration of HIV. Breast milk has been identified as a
possible source of infection. Urine,
tears, saliva and perspiration, though they may contain minute quantities of
viral material, have never been implicated in the spread of HIV. The three basic modes of transmission are:
- Sexual contact - heterosexual
or homosexual.
- Blood to blood contact
through:
- Transfusion or
transplants of infected blood or organs
- Direct inoculation from
drug paraphernalia
- Needle sticks or scalpel cuts
- Vertical transmission from
infected mother to child.
The virus can be spread from
sexual activity that involves the exchange of infected blood, semen, or vaginal
secretions. Although the statistical
probability of infection from any single act of intercourse is low on the order
of 1%, it is possible to become infected with HIV from just one sexual contact
with an infected person.
Different sexual acts appear
to carry different degrees of risk.
Unprotected anal sex is a very high-risk sexual activity.
The lining of the rectum
contains a large supply of blood vessels, which can easily tear during anal
intercourse, and the rectal mucosa is highly absorptive. Small tears thus might allow virus in
infected semen to enter directly into the bloodstream. Unprotected vaginal sex is also a high-risk
activity. As with other sexually
transmitted diseases, male-to-female transmission appears to be more efficient
than female-to-male, perhaps because small abrasions or lesions in the vagina
can allow infected cells or free virus in seminal fluid to enter directly into
the bloodstream.
Sexually transmitted
diseases (STD) such as syphilis, herpes, or chancroid leave open sores,
facilitating easy access by the virus to the bloodstream. Women may be at a greater risk because of
the painless sores of syphilis can go undetected inside the vagina. There can be no doubt that HIV can be
transmitted heterosexually to and from males and females, and that clinically
apparent STD's, while perhaps facilitating transmission, need not be present
for transmission to occur.
Unprotected oral sex is
considered a less risky activity. If
there is a cut or sore in the mouth, virus from infected semen or vaginal
secretions could possibly enter into the bloodstream.
Blood to blood contact is
the most direct method of transmitting HIV.
Whenever infected blood comes in direct contact with the bloodstream,
the chances of acquiring the virus are extremely high. For this reason, recipients of infected
blood and blood products, which receive large inocula of virus, have been the
most likely infected of all those exposed.
Similarly, those sharing infected drug paraphernalia receive direct
inoculation of the virus.
Before the US blood banking
system began screening blood in May 1985, thousands of hemophiliacs and people
who needed blood transfusions became infected with HIV after receiving infected
donor blood. All donated blood, tissue
and sperm in the US are now screened for HIV before being used. The chances of getting infected in this
manner are rare, although a small risk remains from blood collected from
individuals recently which are in the "window period" where their
test is negative despite infection.
Sharing needles with someone
who is infected is another direct method of passing the virus from on person to
another. This is most common from users
of illegal drugs HIV can also be transmitted by needles used for tattooing, ear
piercing, acupuncture and electrolysis if sterile needles are not used each
time. Numerous studies have shown that
occupational risk to health care workers is reduced when universal precautions
are taken.
8. HIV Testing and Diagnosis
The tests for HIV infection
do not test for the virus; instead it tests for antibody produced by the body's
immune response to infection.
Seroconversion usually takes place between two weeks and six months
after exposure to HIV, 95% of seroconversion takes place within six
months.
HIV testing is usually done
in a series, starting with the basic screening and background check. The methods of testing are changing rapidly
as new developments surface, therefore, what is done today may not be done
tomorrow. In the event there is a
positive test result, the test will be redone to eliminate false positives.
The enzyme-linked
immunosorbent assay (ELISA) screen test is the most common. The ELISA kits are inexpensive and highly
sensitive, causing false positive test results. Though, this is usually the result of another problem, the false
positive test results play a major part in the refusal to be tested.
A physician of choice or the
health clinic can do tests. The test is
confidential and the tested person is the only person who will receive the test
results.
9. Infection Control
Funeral directors or funeral
home staff should assume every body they come in contact with is infected, and
protect themselves from exposure. In
order to do this universal precautions must be observed.
Gloves, face masks, eye
protection, hair coverings, non-absorbent gowns and shoe coverings must be worn
when embalming a body. This will help
reduce the risk of accidental exposure to blood or other infectious bodily
fluids.
Hands should be washed with
an anti microbial soap, immediately after removing gloves. If an employee has open sores on their hands
or any other parts of their body, that may be exposed, that employee should not
handle a body.
The appropriate disinfectant
must be used to disinfect all instruments that are exposed to blood and other
potentially infectious bodily fluids.
All sharps will be placed in
an adequate sharp container. All
biomedical waste will be stored in a red bag and removed from the preproom
every 30 days.
The above mentioned
requirements go hand in hand with the most important method of protecting
yourself, that is OBSERVING UNIVERSAL
PRECAUTIONS.
10. Confidentiality
In the state of Florida all
physicians are required to report all Aids cases, they are not required to
disclose HIV positive results. Medical
information is confidential and the HIV test status is to be known only by the
physician and the individual who is infected.
The individual can disclose the results to anyone they choose. If anyone other than the physician and infected
individual release the test results, they can be punished, sued and even
charged with a misdemeanor.
11. The Funeral Directors Right
To Know
As stated above, it is a
violation of the law in Florida, to disclose the HIV status of an HIV infected
individual. By law, your only right to
know, is if the individual or family members disclose that information. This is why it is so important to observe
universal precautions.
12. Direct Exposure
Direct exposure is when
exposure has occurred to blood or other bodily fluids through a needle stick,
laceration, skin contact, etc.
If direct exposure occurs
the post-exposure evaluation and follow-up shall be followed. This would consist of medical care, testing
the source of exposure if available, counseling, documenting the route of
exposure, this will all be done by a license physician and all blood work will
be done by an accredited laboratory.
13. Discrimination
It is against the law to
discriminate against an individual because of their HIV status. If a person discloses that they are HIV
positive they are to be given the same treatment as someone who is HIV
negative, and have the same opportunity for advancement in their position.
Remember if someone is HIV
positive, they are legally considered handicapped (disabled). This is why there are severe ramifications
if an HIV infected person is discriminated against.
Discrimination laws do not
go away when an HIV infected individual person dies. If a funeral director refuses to handle a body in which the HIV
status is known to be positive, this funeral director is discriminating and
legal ramifications can be pursued. It
is also illegal to charge a family extra if the HIV status is disclosed to be
positive.
14. Conclusion
It is very easy to stereotype
what an HIV infected person will look like.
People in the health care industry can look for signs, such as sores on
the body, the individual lifestyle (partner), medical history, fever or
diarrhea. The funeral director isn't
always going to be able to count on the typical stereotype to determine the
medical condition of the body being handled.
There are many cases in which the HIV infected person contracted HIV
through a blood transfusion.
This body might not have any
of the obvious signs of being HIV positive, but is. The funeral director will always have access to the cause of
death on the death certificate, but unfortunately this is generally after
handling of the body and embalming.
It is imperative that
universal precautions are observed at all times. This is the funeral directors only method of reducing the risk of
occupational exposure. The risk of
becoming infected through the handling and embalming of bodies is real. The
following is a list of the protective clothing that should be worn when
handling bodies:
-Gloves
-Eye
protection
-Face mask
-Fluid
retardant gowns
-Hair
covering
-Shoe
covering
When the clothing is removed
it should be placed in a red bag that must be available in the preproom. Never re-use the protective clothing.
Question and Answer Sheet
for HIV/AIDS Test. GOOD LUCK!
L.F.D./Exposed Employee Name:
L.F.D. License Number:
Address:
1. It is legal for a funeral
director to refuse to serve a family of an HIV positive individual. TRUE
or FALSE
2. HIV/AIDS can be spread the following ways except:
a)
Sexual intercourse
b) Shaking
hands
c) Sharing
needles
d) Blood
transfusions
3. Who has the right to disclose the HIV positive status of an
individual?
a) A
nurse
b) A
doctor
c) The
infected individual
d) A
minister
4. Which of the following would not be considered discrimination
against a HIV/AIDS infected individual:
a)
Refusal to embalm
b)
Charging extra for handling body
c) Firing
an employee because of HIV status
d) An
unauthorized person disclosing the HIV status
e) None of
these questions apply to the answer
5. The first AIDS case was reported in 1983. TRUE
or FALSE
6. Direct exposure is when there is exposure to which of the
following:
a)
Needle stick
b) Blood
c) Bodily
fluids
d) All
answers apply to the question
7. When into the bloodstream HIV attacks the T-lymphocytes carrying
the T-helper cells (CD4) marker? TRUE or FALSE
8. Unprotected homosexual sex and sharing needles (to satisfy drug
habit) in the U.S. and Western Europe is not a cause of spreading HIV/AIDS.
TRUE or FALSE
9. The following are symptoms associated with HIV:
a)
Diarrhea
b) Fever
c) Weight
loss
d) Swollen
glands
e) All the
answers apply to the question
10. In order for HIV/AIDS to be transmitted,
which has to be a true statement?
a)
Shaking hands with an infected person
b) There
must be direct exposure to the bloodstream
c) Sitting
next to a HIV/AIDS infected person who has a cold
11. The majority of the HIV/AIDS test available,
test for antibody produced by the body's immune response to infection. TRUE
or FALSE
12. The only way to eliminate the risk of HIV/AIDS is to:
a) Use
protective clothing
b) Wash
hands after removing gloves
c) Don’t
have sex
d) Don’t share needles
e) Answers
c and d apply to the question
13. Universal precautions are the only way to
help reduce the risk of occupational
exposure to HIV/AIDS when handling a body or embalming.
TRUE or FALSE