Nurse Continuing Education CEU Contact Hours AIDS HIV UPDATE

HIV (human immunodeficiency virus) is the virus that causes AIDS. This virus is passed from one person to another through blood-to-blood and sexual contact. In addition, infected pregnant women can pass HIV to their baby during pregnancy or delivery, as well as through breast-feeding. People with HIV have what is called HIV infection. Most of these people will develop AIDS as a result of their HIV infection.

These are additional body fluids that may transmit the virus that health care workers may come into contact with:

AIDS stands for acquired immunodeficiency syndrome. An HIV-infected person receives a diagnosis of AIDS after developing one of the CDC-defined AIDS indicator illnesses. An HIV-positive person who has not had any serious illnesses also can receive an AIDS diagnosis on the basis of certain blood tests (CD4+ counts).

A positive HIV test result does not mean that a person has AIDS. A diagnosis of AIDS is made by a physician using certain clinical criteria (e.g., AIDS indicator illnesses).

Infection with HIV can weaken the immune system to the point that it has difficulty fighting off certain infections. These types of infections are known as "opportunistic" infections because they take the opportunity a weakened immune system gives to cause illness.

Many of the infections that cause problems or may be life-threatening for people with AIDS are usually controlled by a healthy immune system. The immune system of a person with AIDS is weakened to the point that medical intervention may be necessary to prevent or treat serious illness.

Today there are medical treatments that can slow down the rate at which HIV weakens the immune system. There are other treatments that can prevent or cure some of the illnesses associated with AIDS. As with other diseases, early detection offers more options for treatment and preventative care.

We do not know. Scientists have different theories about the origin of HIV, but none have been proven. The earliest known case of HIV was from a blood sample collected in 1959 from a man in Kinshasha, Democratic Republic of Congo. (How he became infected is not known.) Genetic analysis of this blood sample suggests that HIV-1 may have stemmed from a single virus in the late 1940s or early 1950s.

We do know that the virus has existed in the United States since at least the mid- to late 1970s. From 1979-1981 rare types of pneumonia, cancer, and other illnesses were being reported by doctors in Los Angeles and New York among a number of gay male patients. These were conditions not usually found in people with healthy immune systems.

In 1982 public health officials began to use the term "acquired immunodeficiency syndrome," or AIDS, to describe the occurrences of opportunistic infections, Kaposi's sarcoma, and Pneumocystis carinii pneumonia in previously healthy men. Formal tracking (surveillance) of AIDS cases began that year in the United States.

The cause of AIDS is a virus that scientists isolated in 1983. The virus was at first named HTLV-III/LAV (human T-cell lymphotropic virus-type III/lymphadenopathy- associated virus) by an international scientific committee. This name was later changed to HIV (human immunodeficiency virus).

AIDS cases and annual rates per 100,000 population, by area and age group, reported through June 1999, United States

Since 1992, scientists have estimated that about half the people with HIV develop AIDS within 10 years after becoming infected. This time varies greatly from person to person and can depend on many factors, including a person's health status and their health-related behaviors.

Today there are medical treatments that can slow down the rate at which HIV weakens the immune system. There are other treatments that can prevent or cure some of the illnesses associated with AIDS, though the treatments do not cure AIDS itself. As with other diseases, early detection offers more options for treatment and preventative health care.

The only way to determine for sure whether you are infected is to be tested for HIV infection. You cannot rely on symptoms to know whether or not you are infected with HIV. Many people who are infected with HIV do not have any symptoms at all for many years.

However, no one should assume they are infected if they have any of these symptoms. Each of these symptoms can be related to other illnesses. Again, the only way to determine whether you are infected is to be tested for HIV infection.

Similarly, you cannot rely on symptoms to establish that a person has AIDS. The symptoms of AIDS are similar to the symptoms of many other illnesses. AIDS is a medical diagnosis made by a doctor based on specific criteria established by the CDC.

A rapid test for detecting antibody to HIV is a screening test that produces very quick results, usually in 5 to 30 minutes. In comparison, results from the commonly used HIV antibody screening test, the EIA (enzyme immunoassay), are not available for 1-2 weeks.

The availability of rapid HIV tests may differ from one place to another. The rapid HIV test is considered to be just as accurate as the EIA.

Both the rapid test and the EIA look for the presence of antibodies to HIV. As is true for all screening tests (including the EIA), a reactive rapid HIV test result must be confirmed before a diagnosis of infection can be given.

Using rapid HIV tests to provide results on the day of testing can increase the number of persons who learn their HIV status and also reduce the field efforts necessary to locate and counsel HIV-positive persons who do not return. But providing the result of a single rapid test also has disadvantages, because some reactive test results will be false positives. For counseling and testing programs, the first step in deciding whether to use rapid HIV tests is to determine the potential effects, such as the number of persons who would receive results and the number of false-positive test results at their testing site. These effects can be estimated from the test site's history of the number of persons tested, the number who have tested positive, and the percentage of persons who currently return to receive their HIV test results.

The standard screening test for antibody to HIV is the enzyme immunoasssay (EIA), which is widely used in the United States and around the world. This test requires serum or plasma, so a blood specimen must be drawn from a vein. Because EIA requires specialized equipment, the specimen must be sent to a laboratory, and test results are usually available several days to several weeks later. A negative screening test means a person is not infected with HIV, and does not require further testing. However, a diagnosis of HIV infection cannot be based on a reactive screening test alone. Thus, a reactive EIA is repeated, and repeatedly reactive EIA results are confirmed by a supplemental HIV antibody test --Western blot or immunofluorescence assay (IFA).

Until now, testing required two visits. During the first visit, a client receives pretest counseling, and blood is drawn for HIV testing. During the second visit, test results are communicated to the client, additional counseling is provided, and clients who need them are given referrals for additional services.

A rapid test for detecting antibody to HIV is a screening test that produces very quick results, usually in 5 to 30 minutes. Only one rapid HIV test is licensed by the Food and Drug Administration (FDA) for use in the United States.

The rapid HIV test is easier to use and produces results more quickly than the EIA does. The sensitivity and specificity of the rapid HIV test are just as good as those of the EIA.

Rapid HIV testing is suitable for testing any person who would be eligible for HIV testing by EIA. However, the availability of rapid HIV tests may differ from one place to another.

Yes. The individual kit is more costly then the per-test cost of the EIA. EIA testing was designed for the automated processing of tests in batches (usually using a plate that can process 96 specimens at one time.) However, an analysis done in 1996 by Dr. Paul Farnham and his colleagues at CDC indicated that rapid HIV testing is more cost-effective than the current EIA-based system, because of the number of persons who actually learn their results. In other words, although EIA is less expensive, it is a waste of money to perform lab tests if the person tested never learns the test result, if two clinic visits are required to get test results, or if the clinic has to send field staff to locate people for test results. Since an EIA does not yield immediate results, most people must make a second visit to learn their results. Experience at publicly funded testing sites has shown that many persons (26% of those who tested positive for HIV and 33% of those who tested negative in 1996) do not return for their test results.

Are rapid HIV tests more accurate or less accurate than EIAs?

The rapid HIV test is just as accurate as an EIA. As is true of all screening tests (including the EIA), a reactive rapid HIV test result must be confirmed. Studies in countries where more than one type of rapid HIV test is available show that specific combinations of two or more different rapid HIV tests can provide results as reliable as those from an EIA and Western blot or IFA, the combination that is currently used in the United States. A second rapid HIV test for persons whose first rapid HIV test is reactive could significantly improve the predictive value of rapid HIV testing.

Predictive value is the calculated probability that a test result predicts whether a person is truly infected. This calculation produces a number that counselors can use in explaining HIV test results to their clients. For example, a higher predictive value means that a reactive test is more likely to indicate the person is truly infected.

If a person receives a negative rapid HIV test result, is a confirmatory test needed?

A negative antibody test result, whether it is from a rapid HIV test or an EIA, does not require a confirmatory test. However, a person may have been tested too soon, before antibodies developed. The average time between infection and the development of detectable antibodies is 25 days.

Does a negative rapid HIV test result mean that a person has nothing to worry about?

Not necessarily. For most people who are tested, a negative HIV antibody test result does mean that they are not infected. However, in some cases a person may have been tested too soon (before antibodies have developed, which requires an average of 25 days). That is why it is important to assess specific risk behaviors during counseling, and discuss ways to change risky behaviors.

The term "reactive" is used to describe a test that has detected the presence of antibodies to HIV. It is recommended that all reactive tests be repeated immediately, by using the same test. Repeatedly reactive tests are then further confirmed, by using a different test on the same blood specimen.

After a reactive rapid HIV test result, how long does a person have to wait for the confirmatory test result?

The confirmatory tests are usually sent to a laboratory for processing; results are generally available in 1 to 2 weeks.

If a confirmatory test is still needed, what is the advantage to sexually transmitted disease (STD) clinics of using rapid HIV testing?

The advantage to the clinic is that more people will receive their test results without expensive field visits. Most of the clients at all U.S. publicly funded testing sites, including STD clinics, test negative for HIV. For these persons (approximately 2.1 million in 1996), the need to make a second visit would be eliminated. Of all testing sites, STD clinics have had the lowest proportion of persons who return for HIV test results. Thus, rapid HIV tests have the potential to greatly increase the number of persons who learn their results. In addition, persons who test HIV-positive by the rapid HIV test can be advised immediately of their screening test result, and counseled about the need to take precautions to prevent the possibility of transmitting HIV. These persons of course need to return for their confirmatory test result.

What is the advantage to clients of using rapid HIV testing?

Interviews with persons being tested indicate that most persons prefer rapid HIV testing, and most persons who receive a positive HIV screening test result return on their own to learn the confirmed result (unlike the situation with current testing, in which many persons learn their test results only as a result of outreach). This also means that persons who are truly HIV-positive will learn of their infection sooner. This may help prevent infections that might otherwise have occurred between the time the person was tested and the time the person received results (sometimes as long as several weeks.)

Will people who have progressed to the late stages of AIDS continue to test positive on the rapid HIV tests?

Yes. The progression of HIV disease rarely affects the detection of HIV antibody.

The result of any HIV antibody test performed on an infant less than 15 months of age may reflect the mother's HIV status, because the antibodies are transferred from the mother to the baby. Until these antibodies disappear, only specific virus detection tests can determine the infection status of an infant.

Yes. Batching, or collecting several specimens before testing all of them at the same time, can be done. This process can save money for a busy clinic, because fewer control test kits are required. However, accumulating a sufficient number of tests for a batch can result in excessive waiting time for the client, reducing the main benefit of the rapid HIV test: rapid results.

The rapid HIV test usually takes 15 to 30 minutes. The waiting time depends on how many clients are being tested and whether the clinic is testing individual samples or batching them. Counseling can be performed while the test is being done.

One of the more challenging counseling issues is how to communicate reactive rapid HIV test results to clients without the benefit of a same-day confirmatory test result. Counselors should be able to discuss with the client the likelihood of whether the rapid HIV test result means the client has HIV infection. This discussion should be based on the prevalence of HIV among persons tested at that clinic coupled with an assessment of the client's risk behaviors. In clinics that usually experience a high prevalence of HIV infection among their clients, a reactive rapid HIV test result is more likely to represent a true infection, especially in persons who report risk behaviors for HIV. Any person whose rapid HIV test is reactive should be counseled about the need to take precautions to prevent any possibility of transmitting HIV infection until their infection status has been determined by a confirmatory HIV test.

Do you start partner notification and referral services immediately upon receiving a reactive rapid HIV test result, or do you wait for the confirmatory test result?

Partner notification and referral services should not be initiated until the reactive rapid HIV test result has been confirmed.

Should a physician prescribe antiretroviral treatment for a pregnant woman on the basis of rapid HIV test results (per the PHS Guidelines)?

A negative rapid HIV test of course means that antiretroviral treatment is not necessary. Deciding what to do about therapy when the rapid HIV test is reactive is more complicated. If the circumstances are not urgent, it would be preferable to wait for the confirmatory test result. In other circumstances (such as a rapid HIV test result for a woman in labor, for whom no other result is available), physicians should base decisions about antiretroviral treatment on the predictive value of the preliminary rapid HIV test results and an assessment of the mother's HIV risk.

Are confirmatory tests necessary for a rapid HIV test result to be considered a diagnosis of HIV infection?

As is true of current EIA antibody procedure, an initial reactive rapid HIV test result should be confirmed by Western blot or IFA. For persons who test positive by confirmatory testing, CDC and the Association of State and Territorial Public Health Laboratory Directors recommend that the test sequence be repeated, by using a different sample, to be absolutely certain of the results.

Several factors, including temperature and centrifuge speed, can affect test results. Second-generation rapid HIV tests are being developed, and they may be licensed by the FDA in the future.

Interpretation is the same as for any HIV screening test. Negative results from a single rapid HIV test do not require confirmation. Reactive results must be confirmed by a supplemental HIV antibody test. At this time, confirmation is done with Western blot or IFA.

The EIA (enzyme immunoassay) is the standard screening test used to detect the presence of antibodies to HIV. The EIA should be used with a confirmatory test such as the Western blot. Tests that detect other signs of HIV are available for special purposes, such as for additional testing of the blood supply and conducting research. Because some tests are expensive or require sophisticated equipment and specialized training, their use is limited. In addition to the EIA, other tests now available include:

The tests commonly used to detect HIV infection actually look for antibodies produced by your body to fight HIV. Most people will develop detectable antibodies within 3 months after infection, the average being 25 days. In rare cases, it can take up to 6 months. For this reason, the CDC currently recommends testing 6 months after the last possible exposure (unprotected vaginal, anal, or oral sex or sharing needles). It would be extremely rare to take longer than 6 months to develop detectable antibodies. It is important, during the 6 months between exposure and the test, to protect yourself and others from further possible exposures to HIV.

HIV transmission can occur when blood, semen (including pre-seminal fluid, or "pre-cum"), vaginal fluid, or breast milk from an infected person enters the body of an uninfected person.

HIV can enter the body through a vein (e.g., injection drug use), the anus or rectum, the vagina, the penis, the mouth, other mucous membranes (e.g., eyes or inside of the nose), or cuts and sores. Intact, healthy skin is an excellent barrier against HIV and other viruses and bacteria.

These are the most common ways that HIV is transmitted from one person to another:

HIV also can be transmitted through transfusions of infected blood or blood clotting factors. However, since 1985, all donated blood in the United States has been tested for HIV. Therefore, the risk of infection through transfusion of blood or blood products is extremely low. The U.S. blood supply is considered to be among the safest in the world.

Some health-care workers have become infected after being stuck with needles containing HIV-infected blood or, less frequently, after infected blood contact with the worker's open cut or through splashes into the worker's eyes or inside their nose. There has been only one instance of patients being infected by an HIV-infected health care worker. This involved HIV transmission from an infected dentist to six patients.

The risk of health care workers getting HIV on the job is very low, especially if they carefully follow universal precautions (i.e., using protective practices and personal protective equipment to prevent HIV and other blood-borne infections). It is important to remember that casual, everyday contact with an HIV-infected person does not expose health care workers or anyone else to HIV. For health care workers on the job, the main risk of HIV transmission is through accidental injuries from needles and other sharp instruments that may be contaminated with the virus. Even this risk is small, however. Scientists estimate that the risk of infection from a needle jab is less than 1 percent, a figure based on the findings of several studies of health care workers who received punctures from HIV-contaminated needles or were otherwise exposed to HIV-contaminated blood.

HIV is not casually transmitted, so kissing on the cheek is very safe. Even if the other person has the virus, your unbroken skin is a good barrier. No one has become infected from such ordinary social contact as dry kisses, hugs, and handshakes.

Open-mouth kissing is considered a very low-risk activity for the transmission of HIV. However, prolonged open-mouth kissing could damage the mouth or lips and allow HIV to pass from an infected person to a partner and then enter the body through cuts or sores in the mouth. Because of this possible risk, the CDC recommends against open-mouth kissing with an infected partner.

One case suggests that a woman became infected with HIV from her sex partner through exposure to contaminated blood during open-mouth kissing. The July 11, 1997, Morbidity and Mortality Weekly Report contains an article on this case.

Yes, it is possible for you to become infected with HIV through performing oral sex. There have been a few cases of HIV transmission from performing oral sex on a person infected with HIV. While no one knows exactly what the degree of risk is, evidence suggests that the risk is less than that of unprotected anal or vaginal sex.

Blood, semen, pre-seminal fluid, and vaginal fluid all may contain the virus. Cells in the mucous lining of the mouth may carry HIV into the lymph nodes or the bloodstream. The risk increases

Research has shown the effectiveness of latex condoms used on the penis to prevent the transmission of HIV. Condoms are not risk-free, but they greatly reduce your risk of becoming HIV-infected if your partner has the virus.

Yes, it is possible for you to become infected with HIV through receiving oral sex. If your partner has HIV, blood from their mouth may enter the urethra (the opening at the tip of the penis), the vagina, the anus, or directly into the body through small cuts or open sores. While no one knows exactly what the degree of risk is, evidence suggests that the risk is less than that of unprotected anal or vaginal sex.

Research has shown the effectiveness of latex condoms used on the penis for preventing the transmission of HIV. Condoms are not risk-free, but they greatly reduce your risk of becoming HIV-infected if your partner has the virus.

This study, one component of a primary and recent HIV infection study called the Options Project, is funded by the Centers for Disease Control and Prevention (CDC) at the University of California, San Francisco. The purpose of this particular study was to ascertain the extent of HIV transmitted by oral sex among men who have sex with men who were identified with HIV within 12 months of becoming infected.

Question: Hasn’t oral sex already been identified as a
method of transmitting HIV?

Answer : Yes. However, this is the most definitive study to date. Earlier studies have been published. (See a bibliography at the end of these questions/answers.)

Question: What is the risk of HIV transmission from
oral sex?

Answer : The likelihood of transmission of HIV from an infected person to an uninfected person varies significantly depending on the type of exposure or contact involved. The risk of becoming infected with HIV through unprotected (without a condom) oral sex is lower than that of unprotected anal or vaginal sex. However, even a lower risk activity can become an important way people get infected if it is done often enough. The Options Project found that 7.8% (8 of 102) of recently infected men who have sex with men in San Francisco were probably infected through oral sex. Most of these men believed that the risk was minimal or non-existent.

Question: What are the exact ways that HIV was transmitted in this study?

Answer : Nearly half (3 of 8) of these cases reported oral problems, including occasional bleeding gums. Almost all (7 of 8) of these men reported to have had oral contact with pre-semen or semen.

Question: How do you know if the study participants were telling the truth about their sexual history?

Answer : Oral transmission of HIV is very difficult to single out as the only way that HIV is transmitted because few people engage exclusively in oral sex. A number of specific questions were asked by a trained evaluator. The participants’ risk behaviors were assessed by using clinical interviews, counselor intervention, epidemiologic interview, partner interview when possible, and final disposition of transmission risk. Of the 8 cases, 4 reported protected anal intercourse, without the condom breaking, with persons who were either HIV infected or had an unknown serostatus. Men in this study who reported that they were uncertain if the condom was used properly were eliminated from this study.

Question: Was this a surprise finding?

Answer : Yes and No. The percentage of recently infected men enrolled in this study who were probably infected through oral sex (8%) was higher than many researchers had thought likely or found in other studies. More media attention appeared to be placed on this particular study, probably because of the higher number of study participants. There appears to be evidence that higher risk activities (anal sex) among men who have sex with men is decreasing while lower risk activities (oral sex) among these men is increasing. Oral sex has always been considered a lower risk activity but is certainly not risk free.

Yes, it is possible to become infected with HIV through vaginal intercourse. In fact, it is the most common way the virus is transmitted in much of the world. HIV can be found in the blood, semen, pre-seminal fluid, or vaginal fluid of a person infected with the virus. The lining of the vagina can tear and possibly allow HIV to enter the body. Direct absorption of HIV through the mucous membranes that line the vagina also is a possibility.

The male may be at less risk for HIV transmission than the female through vaginal intercourse. However, HIV can enter the body of the male through his urethra (the opening at the tip of the penis) or through small cuts or open sores on the penis.

Risk for HIV infection increases if you or a partner has a sexually transmitted disease (STD).

If you choose to have vaginal intercourse, use a latex condom to help protect both you and your partner from the risk of HIV and other STDs. Studies have shown that latex condoms are very effective, though not perfect, in preventing HIV transmission when used correctly and consistently. If either partner is allergic to latex, plastic (polyurethane) condoms for either the male or female can be used.

Yes, it is possible for either sex partner to become infected with HIV during anal sex. HIV can be found in the blood, semen, pre-seminal fluid, or vaginal fluid of a person infected with the virus. In general, the person receiving the semen is at greater risk of getting HIV because the lining of the rectum is thin and may allow the virus to enter the body during anal sex. However, a person who inserts his penis into an infected partner also is at risk because HIV can enter through the urethra (the opening at the tip of the penis) or through small cuts, abrasions, or open sores on the penis.

Having unprotected (without a condom) anal sex is considered to be a very risky behavior. If people choose to have anal sex, they should use a latex condom. Most of the time, condoms work well. However, condoms are more likely to break during anal sex than during vaginal sex. Thus, even with a condom, anal sex can be risky. A person should use a water-based lubricant in addition to the condom to reduce the chances of the condom breaking.

Yes. Having a sexually transmitted disease (STD) can increase a person's risk of becoming infected with HIV, whether the STD causes open sores or breaks in the skin (e.g., syphilis, herpes, chancroid) or does not cause breaks in the skin (e.g., chlamydia, gonorrhea).

If the STD infection causes irritation of the skin, breaks or sores may make it easier for HIV to enter the body during sexual contact. Even when the STD causes no breaks or open sores, the infection can stimulate an immune response in the genital area that can make HIV transmission more likely.

In addition, if an HIV-infected person also is infected with another STD, that person is three to five times more likely than other HIV-infected persons to transmit HIV through sexual contact.

Studies have shown that latex condoms are highly effective in preventing HIV transmission when used consistently and correctly. These studies looked at uninfected people considered to be at very high risk of infection because they were involved in sexual relationships with HIV-infected people. The studies found that even with repeated sexual contact, 98-100 percent of those people who used latex condoms correctly and consistently did not become infected.

At the start of every intravenous injection, blood is introduced into needles and syringes. HIV can be found in the blood of a person infected with the virus. The reuse of a blood-contaminated needle or syringe by another drug injector (sometimes called "direct syringe sharing") carries a high risk of HIV transmission because infected blood can be injected directly into the bloodstream.

In addition, sharing drug equipment (or "works") can be a risk for spreading HIV. Infected blood can be introduced into drug solutions by

"Street sellers" of syringes may repackage used syringes and sell them as sterile syringes. For this reason, people who continue to inject drugs should obtain syringes from reliable sources of sterile syringes, such as pharmacies. It is important to know that sharing a needle or syringe for any use, including skin popping and injecting steroids, can put one at risk for HIV and other blood-borne infections.

The CDC recommends that people who inject drugs should be regularly counseled to

For injection drug users who cannot or will not stop injecting drugs, the following steps may be taken to reduce personal and public health risks:

If new, sterile syringes and other drug preparation and injection equipment are not available, then previously used equipment should be boiled in water or disinfected with bleach before reuse.

A risk of HIV transmission does exist if instruments contaminated with blood are either not sterilized or disinfected or are used inappropriately between clients. CDC recommends that instruments that are intended to penetrate the skin be used once, then disposed of or thoroughly cleaned and sterilized.

Personal service workers who do tattooing or body piercing should be educated about how HIV is transmitted and take precautions to prevent transmission of HIV and other blood-borne infections in their settings. If you are considering getting a tattoo or having your body pierced, ask staff at the establishment what procedures they use to prevent the spread of HIV and other blood-borne infections, such as hepatitis B virus. You also may call the local health department to find out what sterilization procedures are in place in the local area for these types of establishments.

Although HIV transmission is possible in health care settings, it is extremely rare. Medical experts emphasize that the careful practice of infection control procedures, including universal precautions, protects patients as well as health care providers from possible HIV infection in medical and dental offices.

In 1990, the CDC reported on an HIV-infected dentist in Florida who apparently infected some of his patients while doing dental work. Studies of viral DNA sequences linked the dentist to six of his patients who were also HIV-infected. The CDC has as yet been unable to establish how the transmission took place.

Further studies of more than 22,000 patients of 63 health care providers who were HIV-infected have found no further evidence of transmission from provider to patient in health care settings.

There are no documented cases of HIV being transmitted during participation in sports. The very low risk of transmission during sports participation would involve sports with direct body contact in which bleeding might be expected to occur.

If someone is bleeding, their participation in the sport should be interrupted until the wound stops bleeding and is both antiseptically cleaned and securely bandaged. There is no risk of HIV transmission through sports activities where bleeding does not occur

Can I get HIV from casual contact (shaking hands, hugging, using a toilet, drinking from the same glass, or the sneezing and coughing of an infected person)?

No. HIV is not transmitted by day-to-day contact in the workplace, schools, or social settings. HIV is not transmitted through shaking hands, hugging, or a casual kiss. You cannot become infected from a toilet seat, a drinking fountain, a door knob, dishes, drinking glasses, food, or pets.

A small number of cases of transmission have been reported in which a person became infected with HIV as a result of contact with blood or other body secretions from an HIV-infected person in the household. Although contact with blood and other body substances can occur in households, transmission of HIV is rare in this setting. However, persons infected with HIV and persons providing home care for those who are HIV-infected should be fully educated and trained regarding appropriate infection-control techniques.

HIV is not an airborne or food-borne virus, and it does not live long outside the body. HIV can be found in the blood, semen, or vaginal fluid of an infected person. The three main ways HIV is transmitted are

No. From the start of the HIV epidemic there has been concern about HIV transmission of the virus by biting and bloodsucking insects, such as mosquitoes. However, studies conducted by the CDC and elsewhere have shown no evidence of HIV transmission through mosquitoes or any other insects -- even in areas where there are many cases of AIDS and large populations of mosquitoes. Lack of such outbreaks, despite intense efforts to detect them, supports the conclusion that HIV is not transmitted by insects.

The results of experiments and observations of insect biting behavior indicate that when an insect bites a person, it does not inject its own or a previously bitten person's or animal's blood into the next person bitten. Rather, it injects saliva, which acts as a lubricant so the insect can feed efficiently. Diseases such as yellow fever and malaria are transmitted through the saliva of specific species of mosquitoes. However, HIV lives for only a short time inside an insect and, unlike organisms that are transmitted via insect bites, HIV does not reproduce (and does not survive) in insects. Thus, even if the virus enters a mosquito or another insect, the insect does not become infected and cannot transmit HIV to the next human it bites.

There also is no reason to fear that a mosquito or other insect could transmit HIV from one person to another through HIV-infected blood left on its mouth parts. Several reasons help explain why this is so. First, infected people do not have constantly high levels of HIV in their blood streams. Second, insect mouth parts retain only very small amounts of blood on their surfaces. Finally, scientists who study insects have determined that biting insects normally do not travel from one person to the next immediately after ingesting blood. Rather, they fly to a resting place to digest the blood meal.

In many states no medical professional can perform an HIV test without first obtaining informed consent. Consent includes an explanation of the purpose and limitations of the test, meaning of test results, measures for the prevention of exposure to and transmission of HIV, the benefits of partner notification, the availability of health care services, and confidentiality of test results.

The patient should be pre-test counseled and post test counseled by a Certified HIV Counselor or licensed physician. When a person is incompetent or under the age of majority, informed consent must be obtained from a legal guardian or other authorized person.

HIV-Related Knowledge and Stigma --- United States, 2000

An essential component of efforts to prevent new human immunodeficiency virus (HIV) infections in the United States is the use of voluntary HIV counseling and testing by persons at risk for HIV, especially members of underserved populations (1). To increase the number of persons at risk for HIV who receive voluntary HIV counseling and testing services, barriers to these services must be identified and removed. The stigmatization of persons infected with HIV and the groups most affected by HIV, including men who have sex with men and illicit drug users, is a barrier to testing (2,3). Measuring public attitudes and knowledge about HIV transmission to determine the prevalence and the correlates of stigmatizing attitudes is important for guiding efforts to remove barriers to HIV prevention. This report describes the results of a national public opinion survey conducted through the Internet to measure indicators of HIV-related stigma and knowledge of HIV transmission. The findings indicate that most persons do not have stigmatizing views.

During August--September 2000, Research Triangle Institute conducted an Internet-based, household survey in a sample of 7493 adults aged >18 years. The sample was proportionately selected from a nationally representative panel of approximately 45,000 households. To establish the panel, a sample of U.S. households obtained through random-digit--dialed telephone sampling was offered Internet access and equipment in exchange for participation in weekly surveys. Surveys were conducted using a standard television set connected to the Internet, and responses were entered using a remote control. A module on HIV-related stigma and knowledge of transmission was included in a larger survey on health and aging. This analysis is based on 5641 respondents (75.3%) who answered the question on HIV stigma.

The survey included one question that was considered a proxy indicator for a stigmatizing attitude. Participants were identified who strongly agreed or agreed with the statement "People who got AIDS [acquired immunodeficiency syndrome] through sex or drug use have gotten what they deserve." Although this question addresses only one element of HIV/AIDS stigma, for this report, these answers were considered a "stigmatizing" response. Two questions concerned knowledge about HIV transmission. Persons who responded that it was very unlikely or impossible to become infected through sharing a glass or being coughed or sneezed on were considered informed; those who stated that it was very likely, somewhat likely, or somewhat unlikely were classified as misinformed. Percentage estimates were weighted to provide representative estimates, and confidence intervals (CIs) and p-values were computed using SUDAAN.

Among the 5641 respondents, 40.2% (95% CI=38.8%--41.6%) responded that HIV transmission could occur (i.e., it was very likely, somewhat likely, or somewhat unlikely) through sharing a glass, and 41.1% (CI=39.7%--42.5%) responded that it could occur from being coughed or sneezed on by an HIV-infected person. A total of 18.7% responded that persons who acquired AIDS through sex or drug use have gotten what they deserve. Stigmatizing responses were more common among men (21.5%), whites (20.8%), persons aged >55 years (30.0%), those with only a high school education (22.1%), those with an income <$30,000 (23.4%), and those in poorer health compared with others (23.6%) (Table 1). For both transmission questions, approximately 25% of those who were misinformed gave stigmatizing responses, compared with approximately 14% who were informed (p<0.05).

Reported by: DA Lentine, JC Hersey, VG Iannacchione, GH Laird, K McClamroch, L Thalji, Research Triangle Institute, Research Triangle Park, North Carolina. Prevention Informatics Office, Office of the Director; Behavioral Intervention Research Br, Div of HIV/AIDS Prevention--Intervention Research and Support, National Center for HIV, STD, and TB Prevention, CDC.

The findings in this report suggest that most U.S. adults do not hold stigmatizing views about persons with HIV infection or AIDS. However, a substantial minority gave a response that suggests they may have stigmatizing attitudes about persons with HIV. The smallest proportion of respondents who gave this response was black, the racial/ethnic group with the highest rates of AIDS in the United States. Significantly more of the respondents who were misinformed about HIV transmission gave a stigmatizing response, suggesting that increasing understanding about behaviors related to HIV transmission may result in lower levels of stigmatizing beliefs about infected persons. However, many other factors are probably related to stigma.

Early HIV diagnosis and entry into health care have both individual and societal benefits: improved health and productivity, reduced hospitalization costs, and decreased transmission from persons who do not know their HIV status (1). Because most HIV-infected persons probably will adopt safer sexual behaviors after the diagnosis of HIV infection (4,5), increasing the number of infected persons who know their serostatus is an important prevention goal. However, HIV-infected persons who fear being stigmatized are typically reluctant to acknowledge risk behaviors, avoid seeking prevention information, and may experience real or perceived barriers to prevention and other health-care services (2,3). Therefore, public health measures that encourage access to HIV testing by reducing stigma (e.g., social marketing campaigns targeted to high risk, stigmatized populations; sexuality and cultural sensitivity training for health-care providers; and anonymous testing opportunities) strengthen HIV-prevention efforts.

The findings in this report are subject to at least two limitations. First, the results are based on only one question about stigma, which comprises a range of attitudes, beliefs, and behaviors. Second, the survey did not include persons who do not own a telephone, persons in institutions, the transient or homeless, and those living on military installations. Despite these limitations, the sampling methods eliminated the main bias in earlier Internet samples (i.e., a lack of universal access to the Internet) while preserving the advantages of Internet surveys. In addition, the panel closely matched the overall U.S. population with respect to age, race/ethnicity, sex, education, and income.

Stigma includes prejudice and active discrimination directed toward persons either perceived to be or actually infected with HIV and the social groups and persons with whom they are associated (3). Overcoming stigma is an important step in persons seeking to know their HIV status. Measurements such as those conducted in this study help to direct and assess efforts to overcome these barriers.