- Email: [email protected]
Fifteen years later: The changing face of the AIDS epidemic
ifteen years after the M M W R ' s first d e s c r i p t i o n of the n e w illness w e c a m e to k n o w as a c q u i r e d i m m u n o d e f i c i e n c y s y n d r o m e (AIDS), w e h a v e l e a r n e d m u c h , w a t c h e d the e p i d e m i c evolve, a n d s u c c e e d e d in p r o l o n g i n g life a n d m i n i m i z i n g s y m p toms, b u t AIDS r e m a i n s incurable. This i s s u e of "The M M W R File" c o n t a i n s our sixth u p d a t e on publications in M M W R c o n c e r n i n g the h u m a n immunodeficiency virus (HIV) and AIDS, 1-23 covering the period from S e p t e m b e r 1994 t h r o u g h M a r c h 1996. The p u b l i c a t i o n s highlight the latest statistics, share r e s e a r c h a b o u t those at risk for HIV, a n d d i s s e m i n a t e n e w g u i d e l i n e s for clinicians.
F
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The statistical picture In 1995 t h e half million mark w a s r e a c h e d for t h e U n i t e d States. As of October 31, a total of 501,310 p e r s o n s w i t h AIDS h a d b e e n reported to the C e n t e r s for Disease Control a n d P r e v e n t i o n (CDC); of these, 311,381 (62%) h a d died. Nearly half of the cases h a d b e e n reported s i n c e 1993.14 In 1994, the m o s t r e c e n t year for w h i c h data are available, 80,691 c a s e s of AIDS were reported to CDC, a p p r o x i m a t e l y a 3% i n c r e a s e over 1993 after a c c o u n t i n g for the e x p a n d e d case definition i m p l e m e n t e d in 1993. 4 A n e s t i m a t e d 55,000 to 60,000 U.S. r e s i d e n t s died of HIV infection. HIV infection w a s the e i g h t h l e a d i n g c a u s e of d e a t h overall. A m o n g those a g e d 25 to 44 years, HIV i n f e c t i o n w a s the l e a d i n g c a u s e of death. In 1994 HIV i n f e c t i o n m o v e d from fifth to fourth a m o n g l e a d i n g c a u s e s of years of potential life lost before a g e 65. In 1992 there were a n e s t i m a t e d 80,000 HIV-infected w o m e n of c h i l d b e a r i n g age; w h e n t h e s e w o m e n die, as predicted, later d u r i n g t h e
Men~~
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White Women . . . ' , 1990 t992 1994
Year
Figure 1 Death rates from HIV infection among persons aged 25 to 44 years, by sex, race, and year--United States, 1982 to 1984. Death rates are listed per 100,000 population. Statistics reflect the national vital statistics based on underlying cause of death, using final data for 1982 to 1992 and provisional data for 1993 and 1994. Data were unavailable for races other than black and white. From CDC. MMWR 1996;45:124.
1990s, t h e y will leave 125,000 to 150,000 o r p h a n e d children. 17 Worldwide, 18 million adults a n d 1.5 million child r e n h a v e b e e n i n f e c t e d w i t h HIV, a n d there are 4.5 million cases of AIDS, a c c o r d i n g to World Health O r g a n i z a t i o n e s t i m a t e s . 14
The changing face of MDS Highlights from the Morbidity & Mortality Weekly Report, published by the U.S. Public Health Services Centers for Disease Control and Prevention. J Emerg Nurs 1996;22:343-6. Copyright 9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + 0 18/62/74105
Fifteen years ago, AIDS w a s t h o u g h t to be a gay m e n ' s disease. Today this erroneous c o n c e p t of the d i s e a s e has b e e n corrected. As w e have learned that AIDS is t r a n s m i t t e d b y t h e e x c h a n g e of infected blood or body fluids, w e h a v e w a t c h e d n e w risk groups emerge.
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In 1994 HIV i n f e c t i o n w a s t h e l e a d i n g c a u s e of d e a t h for all m e n a g e d 25 to 44 years. It w a s t h e t h i r d l e a d i n g c a u s e of d e a t h for all w o m e n , t h e l e a d i n g c a u s e for b l a c k w o m e n , a n d fifth for w h i t e w o m e n . T h e d e a t h r a t e for w h i t e m e n in this a g e g r o u p r e m a i n e d u n c h a n g e d , b u t it i n c r e a s e d for w h i t e w o m e n a n d b l a c k s of b o t h g e n d e r s (Figure 1). It is t h o u g h t t h a t racial d i f f e r e n c e s in d e a t h r a t e s reflect social, e c o n o m i c , b e h a v i o r a l , a n d other d i s p a r i t i e s t h a t affect HIV t r a n s m i s s i o n risk. 17
Zidovudine has been found to reduce the risk of transmission when a d m i n i s t e r e d to w o m e n during pregnancy and delivery and afterward to t h e i r n e w b o r n s . A l s o , breastfeeding can be avoided. Women, blacks, H i s p a n i c s , a n d r e s i d e n t s of t h e South a n d N o r t h e a s t a c c o u n t e d for higher p e r c e n t a g e s of reported c a s e s during 1994 than in 1993. Rates of reported AIDS c a s e s are six t i m e s higher for blacks a n d three t i m e s higher for Hispanics. A m o n g women, 77% of c a s e s occurred a m o n g black a n d Hispanic women; rates of AIDS c a s e s w e r e 16 times higher in black w o m e n a n d 7 t i m e s higher in Hispanic women. Cases a m o n g those reporting injecting-drug u s e a n d c a s e s attributed to heterosexual transmission increased. The n u m b e r of c a s e s reported in children i n c r e a s e d b y 8%; 92% w e r e infected during perinatal transmission. The largest decline in t h e proportion of reported c a s e s occurred a m o n g homosexuaffbisexual m e n (Figures 2 a n d 3). 4, 5, 14
Treatment and transmission Syringe exchange programs A p p r o x i m a t e l y one t h i r d of a d u l t AIDS c a s e s are a s s o c i a t e d w i t h i n j e c t i n g - d r u g use. This is t h e risk factor m o s t f r e q u e n t l y a s s o c } a t e d w i t h h e t e r o s e x u a l a n d p e r i n a t a l t r a n s m i s s i o n of HIV in t h e U n i t e d States. S y r i n g e e x c h a n g e p r o g r a m s h a v e d e v e l o p e d a s o n e m e a n s of m i t i g a t i n g t h i s risk. In 1995 t h e N a t i o n a l A c a d e m y of S c i e n c e s r e v i e w e d r e s e a r c h on syringe exchange programs and concluded that such p r o g r a m s are a n effective s t r a t e g y to p r e v e n t infect i o u s d i s e a s e . A p p r o x i m a t e l y 8,000,000 s y r i n g e s w e r e e x c h a n g e d in 1994.12, 24
344 Volume 22, Number 4
Percentage of persons with AIDS by HIV exposure category 44.9 MSM
5.6 MSM + IDU
0.8 Hemophilia 10.1 Heterosexu contact 1
.2 No risk reported nsfusion recipient
Perinatal tra 27.3 IDU
Figure 2 Percentage of persons with AIDS, by HIV exposure category, United States, for the period 1993 to October 1995. IDU, Injecting drug use; MSM, men who have sex with men. From CDC. MMWR 1995; 44:850.
Guidelines for the prevention of opportunistic infections This r e p o r t 23 e x c e r p t s clinical r e c o m m e n d a t i o n s from a longer d o c u m e n t 25 i s s u e d b y t h e U.S. Public H e a l t h Service a n d t h e Infectious Diseases Society of America. For e a c h of 17 opportunistic diseases, information is provided on p r e v e n t i n g exposure, p r e v e n t i n g t h e first e p i s o d e of disease, a n d p r e v e n t i n g d i s e a s e recurrence. T h e r e c o m m e n d a t i o n s are c o d e d according to the s t r e n g t h of t h e r e c o m m e n d a t i o n a n d the quality of the supportive scientific evidence. A n o t h e r set of guidelines u p d a t e r e c o m m e n d a t i o n s for Pneumocystis carinii p n e u m o n i a prophylaxis in children. 21
Revised pediatric classification system K n o w l e d g e a b o u t HIV in c h i l d r e n y o u n g e r t h a n 13 y e a r s of a g e is r e f l e c t e d in a n e w classification syst e m a d o p t e d in 1994. 20 Similar to t h e n e w a d u l t classification s y s t e m a d o p t e d in 1993, t h r e e p a r a m e t e r s are c o n s i d e r e d : i n f e c t i o n s t a t u s , clinical status, a n d i m m u n o l o g i c s t a t u s . D e t e r m i n i n g infection s t a t u s is m o r e c o m p l i c a t e d t h a n in t h e adult. In children born to HIV-infected m o t h e r s , m a t e r n a l anti-HIV IgG antib o d y c r o s s e s t h e p l a c e n t a to t h e fetus; t h u s virtually all t h e s e c h i l d r e n are H I V - a n t i b o d y p o s i t i v e at birth. Only 15% to 30% are actually infected; in t h e rest, t h e a n t i b o d y d i s a p p e a r s at s o m e p o i n t b e t w e e n 6 a n d 18 m o n t h s of age.
HIV testing and counseling for pregnant women HIV s t a t u s h a s i m p o r t a n t i m p l i c a t i o n s for p r e g n a n t w o m e n a n d for w o m e n d e c i d i n g w h e t h e r to b e c o m e
Danis/JOURNAL OF EMERGENCYNURSING
Percentage of women with AIDS, by HIV exposure category Heterosexual contact
41 IDU
53 Partner with unknown risk factor r _ F
z rar[ner recewed contaminated blood/blood products
Contaminated blood/blood products Figure 3 Percentage of women with AIDS, by HIV exposure category, 1994. IDU, Injecting drug use; MSM, men who
p r e g n a n t . HIV c a n b e t r a n s m i t t e d from a n i n f e c t e d w o m a n to her fetus or n e w b o r n d u r i n g p r e g n a n c y , d u r i n g labor a n d delivery, a n d d u r i n g t h e p o s t p a r t u m period until the d i s c o n t i n u a t i o n of b r e a s t f e e d i n g . With k n o w l e d g e of HIV status, p r e v e n t i v e i n t e r v e n t i o n s c a n b e initiated. For example, z i d o v u d i n e h a s b e e n found to r e d u c e the risk of t r a n s m i s s i o n w h e n a d m i n i s t e r e d to w o m e n d u r i n g p r e g n a n c y a n d delivery a n d afterward to their n e w b o r n s . Also, b r e a s t f e e d i n g c a n b e avoided. W o m e n m a y k n o w their o w n risk factors b u t n o t t h o s e of their sexual partners. A n i n c r e a s i n g proportion of p e r i n a t a l t r a n s m i s s i o n s h a s b e e n a t t r i b u t e d to w o m e n w h o w e r e n o t a w a r e that their p a r t n e r h a d k n o w n HIV risk factors. For this r e a s o n a n d b e c a u s e of t h e health i m p l i c a t i o n s for m o t h e r s a n d their n e w borns, t h e U.S. Public Health Service is n e w r e c o m m e n d i n g routine HIV c o u n s e l i n g a n d voluntary t e s t i n g for all p r e g n a n t w o m e n . 22
HIV seroconversion in health care workers In a r e t r o s p e c t i v e c a s e - c o n t r o l study, 15 31 health care workers w i t h HIV i n f e c t i o n related to a p e r c u t a n e o u s e x p o s u r e to HIV-infected blood w e r e c o m p a r e d w i t h 679 control h e a l t h care workers w i t h similar e x p o s u r e b u t w h o did n o t c o n t r a c t t h e virus. T h e i n f e c t e d workers w e r e from t h e U n i t e d S t a t e s (23), F r a n c e (5), a n d the U n i t e d K i n g d o m (3). Factors f o u n d to b e a s s o c i a t e d w i t h HIV t r a n s m i s s i o n i n c l u d e d d e e p injuries, devices visibly c o n t a m i n a t e d
have sex with men. From CDC. MMWR 1995;44:81-4.
w i t h blood, p r o c e d u r e s involving needle insertion directly into a vein or artery, a n d terminal illness in the source patient. Postexposure administration of zidovud i n e was found to r e d u c e the likelihood of infection. Additional information a b o u t H1V a n d AIDS is available from the National AIDS Hotline, (800) 3422437. Another excellent resource is a r e c e n t issue of Nursing Clinics of North America devoted entirely to HIV infection. 26
References 1. CDC. AIDS among racial/ethnic minorities--United States, 1993. MMWR 1994;43:644-7, 653-5. 2. CDC. World AIDS Day--December 1, 1994. MMWR 1994; 43:825. 3. CDC. Update: trends in AIDS diagnosis and reporting under the expanded surveillance definition for adolescents and adults--United States, 1993. MMWR 1994;43:826-31. 4. CDC. Update: acquired immunodeficiency syndrome-United States, 1994. MMWR 1995;44:64-7. 5. CDC. Update: AIDS among women--United States, 1994. MMWR 1995;44:81-4. 6. CDC. Trends in sexual risk behavior among high school students--United States, 1990, 1991, and 1993. MMWR 1995;44:124-5, 131-2. 7. CDC. HIV counseling and testing--United States, 1993. MMWR 1995;44:169-74. 8. CDC. Co-incidence of HIV/AIDS and tuberculosis-Chicago, 1982-1993. MMWR 1995;44:227-31. 9. CDC. Update: trends in AIDS among men who have sex with men--United States, 1989-1994. MMWR 1995;44:401-4.
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10. CDC. HIV t r a n s m i s s i o n in a dialysis c e n t e r - - C o l u m b i a , 1991-1993. M M W R 1995;44:404-5, 411-2. 11. CDC. Update: HIV-2 infection a m o n g blood a n d p l a s m a d o n o r s - - U n i t e d States, J u n e 1992-June 1995. MMWR 1995; 44:603-6. 12. CDC. Syringe e x c h a n g e p r o g r a m s - - U n i t e d States, 1994-1995. MMWR 1995;44:684-5, 691. 13. CDC. HIV risk p r a c t i c e s of male i n j e c t i n g - d r u g users w h o h a v e sex w i t h m e n - - D a l l a s , Denver, a n d Long Beach, 1991-1994. MMWR 1995;44:767-9. 14. CDC. First 500,000 AIDS c a s e s - - U n i t e d States, 1995. MMWR 1995;44:849-53. 15. CDC. Case-control s t u d y of HIV s e r o c o n v e r s i o n in h e a l t h - c a r e workers after p e r c u t a n e o u s e x p o s u r e to HIVi n f e c t e d b l o o d - - F r a n c e , U n i t e d Kingdom, a n d U n i t e d States, J a n u a r y 1988-August 1994. MMWR 1995;44:929-33. 16. CDC. Surveillance of t u b e r c u l o s i s a n d AIDS co-morbidity--Florida, 1981-1993. M M W R 1996;45:38-41. 17. CDC. Update: mortality a t t r i b u t a b l e to HIV infection a m o n g p e r s o n s a g e d 25-44 y e a r s - - U n i t e d States, 1994. M M W R 1996;45:121-5. 18. CDC. C o n t i n u e d sexual risk b e h a v i o r a m o n g HIVseropositive, d r u g - u s i n g m e n - - A t l a n t a ; Washington, D.C.; a n d San Juan, Puerto Rico, 1993. M M W R 1996;45:151-2. 19. CDC. Persistent lack of detectable HIV-1 antibody in a person with HIV infection--Utah, 1995. MMWR 1996;45:181-5.
20. CDC. 1994 R e v i s e d classification s y s t e m for h u m a n i m m u n o d e f i c i e n c y virus i n f e c t i o n in c h i l d r e n less t h a n 13 years of age: official authorized a d d e n d a - - h u m a n immunodeficiency virus infection codes a n d official guidelines for c o d i n g a n d r e p o r t i n g ICD-9-CM. M M W R 1994;43(RR-12): 1-19. 21. CDC. 1995 Revised guidelines for prophylaxis a g a i n s t Pneumocystis carinii p n e u m o n i a for children infected w i t h or perinatally e x p o s e d to h u m a n i m m u n o d e f i c i e n c y virus. MMWR 1995;44(RR-4):1-11. 22. CDC. U.S. Public H e a l t h Service r e c o m m e n d a t i o n s for h u m a n i m m u n o d e f i c i e n c y v i r u s c o u n s e l i n g a n d voluntary t e s t i n g for p r e g n a n t w o m e n . M M W R 1995;44(RR-7): 1-15. 23. CDC. USPHS/IDSA guidelines for t h e p r e v e n t i o n of opportunistic infections in p e r s o n s infected w i t h h u m a n i m m u n o d e f i c i e n c y virus: a summary. MMWR 1995;44(RR-8): 1-34. 24. N e r m a n d J, Vlahov D, M o s e s LE, editors. P r e v e n t i n g HIV transmission: t h e role of sterile n e e d l e s a n d bleach. Washington, DC: National A c a d e m y Press, 1995. 25. USPHS/IDSA guidelines for t h e p r e v e n t i o n of opport u n i s t i c infections in p e r s o n s i n f e c t e d w i t h h u m a n i m m u n odeficiency virus. Clin Infect Dis 1995;21(suppl 1):1-43. 26. HIV infection a n d perinatally t r a n s m i t t e d HIV infection (entire issue). Nurs Clin North A m 1996;31:1-258.
Reviewers A c k n o w l e d g m e n t The Journal of Emergency Nursing gratefully a c k n o w l e d g e s t h e time, effort, expertise, a n d advice d o n a t e d by the following reviewers of this issue's content: June Andrea Mary Bailey Audrey Brighenti Terese B r u g m a n Robert Cadigan Laura Criddle Joni H e n t z e n Daniels Dianne Danis Karen Fenicchia Patricia Geary Karen H a d a d
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Volume 22, N u m b e r 4
Maryfran McGonagle H u g h e s Jill J o n e s Nigel Keep Cathi Koneru J a n e Koziol-McLain Diane Lapsley Marge Letitia Chris Lewis Dixie Link J u d y Lombardi Karen M a r s h
Kay McClain Mathilda Merker Annie O'Connor Karen O'Neil Mary O'Shields J u d i t h Patrizzi J e a n Proehl A n n e Turner
F
Death rates from HIV infection 180
t
16o
I / 4#
140
2-
120
Black
100
j~,
80
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60 s d
2O
/
/
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~.~
~
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~ ~ ~ ,"~ " " . . . . . . . . . 1982 1984 1986 1988
The statistical picture In 1995 t h e half million mark w a s r e a c h e d for t h e U n i t e d States. As of October 31, a total of 501,310 p e r s o n s w i t h AIDS h a d b e e n reported to the C e n t e r s for Disease Control a n d P r e v e n t i o n (CDC); of these, 311,381 (62%) h a d died. Nearly half of the cases h a d b e e n reported s i n c e 1993.14 In 1994, the m o s t r e c e n t year for w h i c h data are available, 80,691 c a s e s of AIDS were reported to CDC, a p p r o x i m a t e l y a 3% i n c r e a s e over 1993 after a c c o u n t i n g for the e x p a n d e d case definition i m p l e m e n t e d in 1993. 4 A n e s t i m a t e d 55,000 to 60,000 U.S. r e s i d e n t s died of HIV infection. HIV infection w a s the e i g h t h l e a d i n g c a u s e of d e a t h overall. A m o n g those a g e d 25 to 44 years, HIV i n f e c t i o n w a s the l e a d i n g c a u s e of death. In 1994 HIV i n f e c t i o n m o v e d from fifth to fourth a m o n g l e a d i n g c a u s e s of years of potential life lost before a g e 65. In 1992 there were a n e s t i m a t e d 80,000 HIV-infected w o m e n of c h i l d b e a r i n g age; w h e n t h e s e w o m e n die, as predicted, later d u r i n g t h e
Men~~
/ "~
40
0
I
~,~ ,.,"* ~
.......
Black Women
White Women . . . ' , 1990 t992 1994
Year
Figure 1 Death rates from HIV infection among persons aged 25 to 44 years, by sex, race, and year--United States, 1982 to 1984. Death rates are listed per 100,000 population. Statistics reflect the national vital statistics based on underlying cause of death, using final data for 1982 to 1992 and provisional data for 1993 and 1994. Data were unavailable for races other than black and white. From CDC. MMWR 1996;45:124.
1990s, t h e y will leave 125,000 to 150,000 o r p h a n e d children. 17 Worldwide, 18 million adults a n d 1.5 million child r e n h a v e b e e n i n f e c t e d w i t h HIV, a n d there are 4.5 million cases of AIDS, a c c o r d i n g to World Health O r g a n i z a t i o n e s t i m a t e s . 14
The changing face of MDS Highlights from the Morbidity & Mortality Weekly Report, published by the U.S. Public Health Services Centers for Disease Control and Prevention. J Emerg Nurs 1996;22:343-6. Copyright 9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + 0 18/62/74105
Fifteen years ago, AIDS w a s t h o u g h t to be a gay m e n ' s disease. Today this erroneous c o n c e p t of the d i s e a s e has b e e n corrected. As w e have learned that AIDS is t r a n s m i t t e d b y t h e e x c h a n g e of infected blood or body fluids, w e h a v e w a t c h e d n e w risk groups emerge.
August 1996
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JOURNAL OF EMERGENCY NURSING/Danis
In 1994 HIV i n f e c t i o n w a s t h e l e a d i n g c a u s e of d e a t h for all m e n a g e d 25 to 44 years. It w a s t h e t h i r d l e a d i n g c a u s e of d e a t h for all w o m e n , t h e l e a d i n g c a u s e for b l a c k w o m e n , a n d fifth for w h i t e w o m e n . T h e d e a t h r a t e for w h i t e m e n in this a g e g r o u p r e m a i n e d u n c h a n g e d , b u t it i n c r e a s e d for w h i t e w o m e n a n d b l a c k s of b o t h g e n d e r s (Figure 1). It is t h o u g h t t h a t racial d i f f e r e n c e s in d e a t h r a t e s reflect social, e c o n o m i c , b e h a v i o r a l , a n d other d i s p a r i t i e s t h a t affect HIV t r a n s m i s s i o n risk. 17
Zidovudine has been found to reduce the risk of transmission when a d m i n i s t e r e d to w o m e n during pregnancy and delivery and afterward to t h e i r n e w b o r n s . A l s o , breastfeeding can be avoided. Women, blacks, H i s p a n i c s , a n d r e s i d e n t s of t h e South a n d N o r t h e a s t a c c o u n t e d for higher p e r c e n t a g e s of reported c a s e s during 1994 than in 1993. Rates of reported AIDS c a s e s are six t i m e s higher for blacks a n d three t i m e s higher for Hispanics. A m o n g women, 77% of c a s e s occurred a m o n g black a n d Hispanic women; rates of AIDS c a s e s w e r e 16 times higher in black w o m e n a n d 7 t i m e s higher in Hispanic women. Cases a m o n g those reporting injecting-drug u s e a n d c a s e s attributed to heterosexual transmission increased. The n u m b e r of c a s e s reported in children i n c r e a s e d b y 8%; 92% w e r e infected during perinatal transmission. The largest decline in t h e proportion of reported c a s e s occurred a m o n g homosexuaffbisexual m e n (Figures 2 a n d 3). 4, 5, 14
Treatment and transmission Syringe exchange programs A p p r o x i m a t e l y one t h i r d of a d u l t AIDS c a s e s are a s s o c i a t e d w i t h i n j e c t i n g - d r u g use. This is t h e risk factor m o s t f r e q u e n t l y a s s o c } a t e d w i t h h e t e r o s e x u a l a n d p e r i n a t a l t r a n s m i s s i o n of HIV in t h e U n i t e d States. S y r i n g e e x c h a n g e p r o g r a m s h a v e d e v e l o p e d a s o n e m e a n s of m i t i g a t i n g t h i s risk. In 1995 t h e N a t i o n a l A c a d e m y of S c i e n c e s r e v i e w e d r e s e a r c h on syringe exchange programs and concluded that such p r o g r a m s are a n effective s t r a t e g y to p r e v e n t infect i o u s d i s e a s e . A p p r o x i m a t e l y 8,000,000 s y r i n g e s w e r e e x c h a n g e d in 1994.12, 24
344 Volume 22, Number 4
Percentage of persons with AIDS by HIV exposure category 44.9 MSM
5.6 MSM + IDU
0.8 Hemophilia 10.1 Heterosexu contact 1
.2 No risk reported nsfusion recipient
Perinatal tra 27.3 IDU
Figure 2 Percentage of persons with AIDS, by HIV exposure category, United States, for the period 1993 to October 1995. IDU, Injecting drug use; MSM, men who have sex with men. From CDC. MMWR 1995; 44:850.
Guidelines for the prevention of opportunistic infections This r e p o r t 23 e x c e r p t s clinical r e c o m m e n d a t i o n s from a longer d o c u m e n t 25 i s s u e d b y t h e U.S. Public H e a l t h Service a n d t h e Infectious Diseases Society of America. For e a c h of 17 opportunistic diseases, information is provided on p r e v e n t i n g exposure, p r e v e n t i n g t h e first e p i s o d e of disease, a n d p r e v e n t i n g d i s e a s e recurrence. T h e r e c o m m e n d a t i o n s are c o d e d according to the s t r e n g t h of t h e r e c o m m e n d a t i o n a n d the quality of the supportive scientific evidence. A n o t h e r set of guidelines u p d a t e r e c o m m e n d a t i o n s for Pneumocystis carinii p n e u m o n i a prophylaxis in children. 21
Revised pediatric classification system K n o w l e d g e a b o u t HIV in c h i l d r e n y o u n g e r t h a n 13 y e a r s of a g e is r e f l e c t e d in a n e w classification syst e m a d o p t e d in 1994. 20 Similar to t h e n e w a d u l t classification s y s t e m a d o p t e d in 1993, t h r e e p a r a m e t e r s are c o n s i d e r e d : i n f e c t i o n s t a t u s , clinical status, a n d i m m u n o l o g i c s t a t u s . D e t e r m i n i n g infection s t a t u s is m o r e c o m p l i c a t e d t h a n in t h e adult. In children born to HIV-infected m o t h e r s , m a t e r n a l anti-HIV IgG antib o d y c r o s s e s t h e p l a c e n t a to t h e fetus; t h u s virtually all t h e s e c h i l d r e n are H I V - a n t i b o d y p o s i t i v e at birth. Only 15% to 30% are actually infected; in t h e rest, t h e a n t i b o d y d i s a p p e a r s at s o m e p o i n t b e t w e e n 6 a n d 18 m o n t h s of age.
HIV testing and counseling for pregnant women HIV s t a t u s h a s i m p o r t a n t i m p l i c a t i o n s for p r e g n a n t w o m e n a n d for w o m e n d e c i d i n g w h e t h e r to b e c o m e
Danis/JOURNAL OF EMERGENCYNURSING
Percentage of women with AIDS, by HIV exposure category Heterosexual contact
41 IDU
53 Partner with unknown risk factor r _ F
z rar[ner recewed contaminated blood/blood products
Contaminated blood/blood products Figure 3 Percentage of women with AIDS, by HIV exposure category, 1994. IDU, Injecting drug use; MSM, men who
p r e g n a n t . HIV c a n b e t r a n s m i t t e d from a n i n f e c t e d w o m a n to her fetus or n e w b o r n d u r i n g p r e g n a n c y , d u r i n g labor a n d delivery, a n d d u r i n g t h e p o s t p a r t u m period until the d i s c o n t i n u a t i o n of b r e a s t f e e d i n g . With k n o w l e d g e of HIV status, p r e v e n t i v e i n t e r v e n t i o n s c a n b e initiated. For example, z i d o v u d i n e h a s b e e n found to r e d u c e the risk of t r a n s m i s s i o n w h e n a d m i n i s t e r e d to w o m e n d u r i n g p r e g n a n c y a n d delivery a n d afterward to their n e w b o r n s . Also, b r e a s t f e e d i n g c a n b e avoided. W o m e n m a y k n o w their o w n risk factors b u t n o t t h o s e of their sexual partners. A n i n c r e a s i n g proportion of p e r i n a t a l t r a n s m i s s i o n s h a s b e e n a t t r i b u t e d to w o m e n w h o w e r e n o t a w a r e that their p a r t n e r h a d k n o w n HIV risk factors. For this r e a s o n a n d b e c a u s e of t h e health i m p l i c a t i o n s for m o t h e r s a n d their n e w borns, t h e U.S. Public Health Service is n e w r e c o m m e n d i n g routine HIV c o u n s e l i n g a n d voluntary t e s t i n g for all p r e g n a n t w o m e n . 22
HIV seroconversion in health care workers In a r e t r o s p e c t i v e c a s e - c o n t r o l study, 15 31 health care workers w i t h HIV i n f e c t i o n related to a p e r c u t a n e o u s e x p o s u r e to HIV-infected blood w e r e c o m p a r e d w i t h 679 control h e a l t h care workers w i t h similar e x p o s u r e b u t w h o did n o t c o n t r a c t t h e virus. T h e i n f e c t e d workers w e r e from t h e U n i t e d S t a t e s (23), F r a n c e (5), a n d the U n i t e d K i n g d o m (3). Factors f o u n d to b e a s s o c i a t e d w i t h HIV t r a n s m i s s i o n i n c l u d e d d e e p injuries, devices visibly c o n t a m i n a t e d
have sex with men. From CDC. MMWR 1995;44:81-4.
w i t h blood, p r o c e d u r e s involving needle insertion directly into a vein or artery, a n d terminal illness in the source patient. Postexposure administration of zidovud i n e was found to r e d u c e the likelihood of infection. Additional information a b o u t H1V a n d AIDS is available from the National AIDS Hotline, (800) 3422437. Another excellent resource is a r e c e n t issue of Nursing Clinics of North America devoted entirely to HIV infection. 26
References 1. CDC. AIDS among racial/ethnic minorities--United States, 1993. MMWR 1994;43:644-7, 653-5. 2. CDC. World AIDS Day--December 1, 1994. MMWR 1994; 43:825. 3. CDC. Update: trends in AIDS diagnosis and reporting under the expanded surveillance definition for adolescents and adults--United States, 1993. MMWR 1994;43:826-31. 4. CDC. Update: acquired immunodeficiency syndrome-United States, 1994. MMWR 1995;44:64-7. 5. CDC. Update: AIDS among women--United States, 1994. MMWR 1995;44:81-4. 6. CDC. Trends in sexual risk behavior among high school students--United States, 1990, 1991, and 1993. MMWR 1995;44:124-5, 131-2. 7. CDC. HIV counseling and testing--United States, 1993. MMWR 1995;44:169-74. 8. CDC. Co-incidence of HIV/AIDS and tuberculosis-Chicago, 1982-1993. MMWR 1995;44:227-31. 9. CDC. Update: trends in AIDS among men who have sex with men--United States, 1989-1994. MMWR 1995;44:401-4.
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10. CDC. HIV t r a n s m i s s i o n in a dialysis c e n t e r - - C o l u m b i a , 1991-1993. M M W R 1995;44:404-5, 411-2. 11. CDC. Update: HIV-2 infection a m o n g blood a n d p l a s m a d o n o r s - - U n i t e d States, J u n e 1992-June 1995. MMWR 1995; 44:603-6. 12. CDC. Syringe e x c h a n g e p r o g r a m s - - U n i t e d States, 1994-1995. MMWR 1995;44:684-5, 691. 13. CDC. HIV risk p r a c t i c e s of male i n j e c t i n g - d r u g users w h o h a v e sex w i t h m e n - - D a l l a s , Denver, a n d Long Beach, 1991-1994. MMWR 1995;44:767-9. 14. CDC. First 500,000 AIDS c a s e s - - U n i t e d States, 1995. MMWR 1995;44:849-53. 15. CDC. Case-control s t u d y of HIV s e r o c o n v e r s i o n in h e a l t h - c a r e workers after p e r c u t a n e o u s e x p o s u r e to HIVi n f e c t e d b l o o d - - F r a n c e , U n i t e d Kingdom, a n d U n i t e d States, J a n u a r y 1988-August 1994. MMWR 1995;44:929-33. 16. CDC. Surveillance of t u b e r c u l o s i s a n d AIDS co-morbidity--Florida, 1981-1993. M M W R 1996;45:38-41. 17. CDC. Update: mortality a t t r i b u t a b l e to HIV infection a m o n g p e r s o n s a g e d 25-44 y e a r s - - U n i t e d States, 1994. M M W R 1996;45:121-5. 18. CDC. C o n t i n u e d sexual risk b e h a v i o r a m o n g HIVseropositive, d r u g - u s i n g m e n - - A t l a n t a ; Washington, D.C.; a n d San Juan, Puerto Rico, 1993. M M W R 1996;45:151-2. 19. CDC. Persistent lack of detectable HIV-1 antibody in a person with HIV infection--Utah, 1995. MMWR 1996;45:181-5.
20. CDC. 1994 R e v i s e d classification s y s t e m for h u m a n i m m u n o d e f i c i e n c y virus i n f e c t i o n in c h i l d r e n less t h a n 13 years of age: official authorized a d d e n d a - - h u m a n immunodeficiency virus infection codes a n d official guidelines for c o d i n g a n d r e p o r t i n g ICD-9-CM. M M W R 1994;43(RR-12): 1-19. 21. CDC. 1995 Revised guidelines for prophylaxis a g a i n s t Pneumocystis carinii p n e u m o n i a for children infected w i t h or perinatally e x p o s e d to h u m a n i m m u n o d e f i c i e n c y virus. MMWR 1995;44(RR-4):1-11. 22. CDC. U.S. Public H e a l t h Service r e c o m m e n d a t i o n s for h u m a n i m m u n o d e f i c i e n c y v i r u s c o u n s e l i n g a n d voluntary t e s t i n g for p r e g n a n t w o m e n . M M W R 1995;44(RR-7): 1-15. 23. CDC. USPHS/IDSA guidelines for t h e p r e v e n t i o n of opportunistic infections in p e r s o n s infected w i t h h u m a n i m m u n o d e f i c i e n c y virus: a summary. MMWR 1995;44(RR-8): 1-34. 24. N e r m a n d J, Vlahov D, M o s e s LE, editors. P r e v e n t i n g HIV transmission: t h e role of sterile n e e d l e s a n d bleach. Washington, DC: National A c a d e m y Press, 1995. 25. USPHS/IDSA guidelines for t h e p r e v e n t i o n of opport u n i s t i c infections in p e r s o n s i n f e c t e d w i t h h u m a n i m m u n odeficiency virus. Clin Infect Dis 1995;21(suppl 1):1-43. 26. HIV infection a n d perinatally t r a n s m i t t e d HIV infection (entire issue). Nurs Clin North A m 1996;31:1-258.
Reviewers A c k n o w l e d g m e n t The Journal of Emergency Nursing gratefully a c k n o w l e d g e s t h e time, effort, expertise, a n d advice d o n a t e d by the following reviewers of this issue's content: June Andrea Mary Bailey Audrey Brighenti Terese B r u g m a n Robert Cadigan Laura Criddle Joni H e n t z e n Daniels Dianne Danis Karen Fenicchia Patricia Geary Karen H a d a d
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Maryfran McGonagle H u g h e s Jill J o n e s Nigel Keep Cathi Koneru J a n e Koziol-McLain Diane Lapsley Marge Letitia Chris Lewis Dixie Link J u d y Lombardi Karen M a r s h
Kay McClain Mathilda Merker Annie O'Connor Karen O'Neil Mary O'Shields J u d i t h Patrizzi J e a n Proehl A n n e Turner