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HIV: Where Are We Now?
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Answer Sheet: HIV: Where Are We Now?
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Read the course material and enter your test answers on the one-page answer sheet included with this book. You earn course credit for every test answer sheet with at least 80% correct answers. We notify failing students within 7 days and give them an opportunity to take a new test. There is no charge for a retest. To claim your credits, return your answers by: • Taking the test online (only if you have not purchased the coursebook separately, you will need to provide credit card information at the time you submit your test online for scoring). • Writing your answers on the one-page answer sheet included with this book, then fax or mail them to: Access Continuing Education (ACE) P.O. Box 14585 Albany, NY 12212 Phone: 518-209-9540 Fax: 518-514-1103 If you downloaded this coursebook from the Internet and are faxing/mailing your test answer sheet please include your credit card information for payment. Answer sheets received without payment will not be processed. We grade all tests in a timely manner; so if you do not receive your certificate within five days, please send an email to [email protected] There is no time limit for return of your answer sheet. Completion dates are taken from the test answer sheet envelope postmark or the finish date recorded in the computer when you do an online exam, and must be in the licensing cycle you wish to use the credits. If you are dissatisfied with the course for any reason, please return the printed materials within 30 days of purchase and we will refund your full tuition. Shipping charges are nonrefundable. If someone else would like to use this material after you are done, he or she may register with us and take advantage of the “sharing discount” workbook tuition charge. Courses downloaded from the Internet can be shared at the same tuition rate as currently available on our website. Please call us if you need an extra answer sheet or download one from our website. There is no “sharing discount” for online exams. The author and ACE have made every effort to include information in this course that is factual and conforms to accepted standards of care. This course is not to be used as a sole reference for treatment decisions. It is your responsibility to understand your legal obligations and license requirements when treating patients. ACE is not responsible for the misuse of information presented in this course. The material in this course cannot be reproduced or transmitted in any way without the written consent of ACE. Table of Contents
The looped red ribbon became the universal symbol of AIDS awareness.   Courtesy of the National Institutes of Health. Judy K. Shaw, PhD, ANP-c
Ms. Shaw is an Adult Nurse Practitioner who has over 13 years of experience providing primary care to HIV/AIDS patients, conducting HIV research, Teaching and developing HIV courses. She has published on the topic of HIV/AIDS, including text books and continuing education programs. Ms. Shaw completed the New York State Department of Health, AIDS Institute, Nicholas A. Rango HIV Clinical Scholar Fellowship (Albany Medical Center, 1997-1999). She is a graduate of The Sage Colleges having received her BS in Nursing, MS in Nursing Education and completed the Adult Nurse Practitioner program. Objectives
Upon completion of this course the learner will be able to: • Discuss the rates of HIV infection in the US and globally. • Identify the routes of transmission and means of prevention. • Describe how antiretroviral medication works. • Discuss case studies, including risk factors for HIV infection. • Describe select research areas that show promise for the prevention, treatment or management Overview/Background
HIV/AIDS continues to be one of the most challenging Public Health problems that we have encountered. Identified less than a mere three decades ago, it’s estimated that someone somewhere in the world is infected with the virus every 15 seconds. At the end of 2009, 33.3 million [31.4 million–35.3 million] people were estimated to be living with HIV, up slightly from 32.8 million [30.9 million–34.7 million] in 2008. This is in large part due to more people living longer as access to antiretroviral therapy increases (UNAIDS, 2010) . In the US, HIV has changed from being a disease thought to infect only men who have sex with men (MSM) and injection drug users (IDU) to a disease known to infect people of all races, ages, genders, and socioeconomic status. Few people today have not been touched by HIV/AIDS in some way. Although millions of dollars have been spent in the US and other countries annually, HIV prevalence continues to increase. In 2009, there were an estimated 56,000 new cases of HIV/AIDS in the U.S. In addition, CDC estimates that about 25% of people infected aren’t yet aware that they have the virus because they have never been tested, or have been tested but did not return for the results (Hill et al., 2008; CDC, 2008). Efforts to develop a vaccine against HIV have been unsuccessful. For now, the only sure way to prevent infection during sexual activity is abstinence. Barrier use reduces the risk of infection, but is not considered completely effective. The introduction of needle exchange programs have also helped to reduce the number of new infections among IDU. The introduction and continued use of universal precautions in healthcare facilities helps to prevent healthcare workers from exposure. Although these programs may been effective to some degree in preventing the increased number of infections, until an effective vaccine is developed eliminating risky behaviors is the only real method to avoid infection. The purpose of this course is to discuss HIV prevention, routes of infection and medical management in order to increase HIV awareness and provide information to help protect you and the people you care for. "The science is clear, HIV prevention can and does save lives…it is estimated that prevention efforts have averted more than 350,000 HIV infections in the U.S. and…saved more than $125 billion dollars in health care costs” (CDC, 2008).  Epidemiology
Rates of HIV infection remained at about 40,000/year until 2006 when the CDC reported 56,000 new cases. This increased incidence of new infections sparked an interest among scientists, medical providers and the media. CDC responded by saying that the increase was primarily due to improved reporting techniques, not an actual significant increase in new infections. They also warned that up to 25% of people currently infected with HIV are not aware of their status because they have not been tested, or have been tested and have not returned for test results. In September 2006 CDC changed their recommendations for HIV testing among adults and adolescents. The revised guidelines emphasized four major foci: (1) the importance of HIV testing for all patients between the ages of 13 and 64; (2) the need to streamline the pre and post test criteria for HIV testing; (3) advised making HIV testing a routine part of medical care; and (4) stressed the importance of early detection and linkage into specialty care. In the US, the largest numbers of HIV infection continue to be among men who have sex with men (MSM). Globally, there are an estimated 32 million people infected with HIV/AIDS. About one-half of all cases of HIV are among women. The burden of HIV/AIDS is greatest among the poor. In some countries, as many as one out of every four people are infected. Besides being a risk factor for infection poverty is a hindrance to prevention efforts; in many areas HIV testing is not available, in others, there is no medication available to those who are infected. Unprotected heterosexual sex is a common route of transmission, along with prostitution and intravenous drug use. Routes of HIV Transmission
HIV can be transmitted by the exchange of blood or body fluids from someone who is infected. The most common routes of transmission are: Other behaviors that could result in HIV transmission include unprotected oral sex, maternal/fetal transmission, and tattoos and piercing without sterilization of instruments. HIV can’t be transmitted by mosquitoes, toilet seats, eating utensils, or casual contact with someone who is infected. For transmission to occur there must be contact with the virus via damaged skin or a break in the mucous membrane. Not every exposure to HIV results in infection, but any exposure can result in infection.
In the US, donated blood has been tested for HIV since 1985. However, as a warning for travelers, not all countries screen donated blood for HIV. Therefore, in the US HIV infections that result from blood transfusions are rare but still occur. HIV prevention programs focus on both abstinence and barrier use. Still, after years of prevention messages and millions of dollars, people continue to engage in high risk behaviors. In fact, there is evidence that many adolescents have “tuned out” prevention messages and inconsistently use barriers when having sex. Table 1. Estimation of New HIV Cases in the U.S. 2006 (Hall, 2008)
Route Percentage
Clinical Management of HIV
Early Identification of HIV Infection One of the most important factors that influence patient outcomes is early identification of HIV infection. Too often patients present to the clinic or emergency department with complaints of symptoms consistent with any viral illness. The most common symptoms of HIV infection include fever, headache, rash, fatigue, anorexia, pharyngitis, lymphadenopathy, nausea, vomiting, and diarrhea. If HIV is not suspected or considered in the differential diagnosis, the patient will be sent home with the usual instructions: rest, drink plenty of fluids, and take Tylenol as needed for fever. After about one week symptoms may resolve with no further treatment, and the patient can resume their normal activities of daily life. If these activities include unprotected sex or intravenous drug use, new cases of HIV infection will occur. The importance of taking a complete assessment for HIV risk factors can’t be overemphasized. Patients don’t usually volunteer personal information unless asked. Someone coming in for a symptomatic illness may not think to tell you about a recent divorce or change in relationship. They will focus on the current problem. A person who is newly infected with HIV can live eight to ten years with no distinct symptoms of the illness. They may have a cold more often than their co-workers or take longer to recover from an infection, but overall they continue to look healthy until one day they become very sick and eventually a diagnosis of HIV infection is made. Patients who are diagnosed at later stages of the disease usually have Acquired Immune Deficiency Syndrome or AIDS. This is a condition caused by HIV which involves symptoms consistent with severe suppression of the immune system. Patients with AIDS are at risk for developing opportunistic infections. These infections are caused by pathogens that are ubiquitous in the environment and only cause illness when the immune system is too compromised to prevent infection. Table 2. Opportunistic Infections Correlated with CD4 Count Less than 200 cells/mm3

Two markers are monitored to determine the prognosis of the patient with HIV. The first, the T
lymphocytes or CD4 count
is a marker of the prognosis of the patient. This provides a rough estimate of
the condition of the immune system. Lower values are indicative of more severe immune suppression. In
clinical practice, these values are used to determine the need for antiretroviral therapy and prophylaxis
against opportunistic infections. Usual normal laboratory values for CD4 counts range from 350- 1200 cells/mm3. When someone reaches 200 cells/mm3 their classification changes from HIV to AIDS. There are other illnesses that are considered to be AIDS defining and also change a person’s status from HIV to AIDS. These include, but are not limited to: • Candidiasis of the lungs, esophagus or trachea The second marker is the HIV viral load (VL).This value is an estimation of the number of copies of HIV
in the body. Since it is estimated rather than an actual number, it may vary from day to day and/or from
morning to night. Patients should be reassured if this happens.
The decision to initiate ART is based on a number of factors. While there are recommendations for the use of ART meant to guide treatment, patients should be evaluated personally before making the decision when to treat and what to treat with. In many instances, these decisions will be based not only on medical facts, but also on mental health and socioeconomic variables. The most efficacious treatment will not be effective if the person is not adherent with dosing directions. Missing doses of ART can lead to viral resistance, not only to the one medication missed, but also to other ART medications in the same or other classes of drugs. This phenomenon is known as “cross resistance.” Prior to beginning any ART, patients should be educated about the medication, possible adverse side effects, the importance of adherence, and potential drug-drug or drug-food interactions. Whenever possible, regimens should be chosen to best meet the needs of the individual. Classes of Antiretroviral Medication There are currently five classes of antiretroviral medications. Each class of drugs works to interrupt viral replication at a distinct step in the process. The use of combination therapy has been shown to be more effective at controlling the virus than mono (one medication) or dual therapy (two medications). Combination therapy increases the sites where drugs can interrupt the viral replication cycle and effectively lower the viral load. The five classes of ART are: • Nucleoside/Nucleotide Reverse Transcriptase Inhibitors • Non-Nucleoside Reverse Transcriptase Inhibitors There is no known cure for HIV at this time. A person with an undetectable viral load still has HIV and can still spread the virus. They are not cured, but they are less likely to infect someone following exposure than someone with a large viral load. Like other viruses, HIV needs to replicate inside another cell. It has proteins on its surface that are attracted to receptors on the outside of the CD4 cell’s surface. When the two surfaces meet, they bind which allows entry of the RNA from the HIV to enter the CD4 cell. This is the point where fusion and entry inhibitors attempt to interrupt the replication process by preventing the two cells from binding together. Table 3. Fusion/Entry Inhibitors

Generic Name

Brand Name
Date of FDA
Approval

Once the HIV viral capsid enters the cell a viral enzyme called reverse transcriptase is released. The reverse transcriptase enzyme has a major role in transcribing viral RNA into DNA, the genetic material found in human cells. It is at this point in the replication cycle that nucleoside/ nucleotide and non-nucleoside reverse transcriptase inhibitors work to interrupt the viral replication cycle. Table 4. Nucleoside/Nucleotide Reverse Transcriptase Inhibitors
Non-Nucleoside Reverse Transcriptase Inhibitors
Delavirdine Rescriptor 1997 Efavirenz Sustiva 1998 Etravirine Intelence 2008 Once the viral RNA is transcribed into DNA the genetic material is transported into the nucleus of the CD4 cell. After this happens, the viral enzyme integrase facilitates insertion into the DNA of the CD4 cell so that when the cell replicates it makes viral cells instead of CD4 cells. In fact, the CD4 cell which previously helped to protect the body from invasion with harmful organisms is turned into a “viral factory.” It is during this process that the integrase inhibitor attempts to interrupt the viral replication cycle. The class of integrase inhibitors is one of the newer classes of ART. Table 6. Integrase Inhibitor
Generic Name
Brand Name
Date of FDA Approval
Viral assembly begins when long strings of proteins are cut into smaller pieces by the protease enzyme and assembled into HIV structural elements and enzymes. When this process is complete, they bud off of the CD4 cell to become new virons. After maturation, these virons can infect new CD4 cells and continue the process of immune suppression. Protease inhibitors target this portion of the process to attempt to interrupt the viral replication cycle. Table 7. Protease Inhibitors
Generic Name
Brand Name
Date of FDA Approval
Much research has been conducted in order to understand which medications have the most efficacy in different circumstances. As a result of these studies, CDC and other Infectious Disease organizations have made recommendation on when to begin ART and what order to use the drugs that are available. Again, these recommendations are simply guidelines, not solid rules, and the unique needs of each patient should be assessed prior to beginning or switching medications. Table 8. CDC Recommended Antiretroviral Regimens for Treatment Naïve Patients (2009)
• Non Nucleoside Reverse Transcriptase Inhibitor + 2 Nucleoside/nucleotide Reverse • One Protease Inhibitor (preferably boosted with ritonavir) + 2 Nucleoside/nucleotide • One Integrase Inhibitor + 2 Nucleoside/nucleotide Reverse Transcriptase Inhibitors The viral load is used to monitor the effectiveness of ART. Once on effective antiretroviral therapy, the
HIV viral load (VL) should be “undetectable.” This value is determined by the type of test used by the
laboratory. The most common values considered to be undetectable can vary from 4 to 400 copies. CD4
and VL laboratory tests are monitored carefully by the provider and should be checked every three to six
months.
If the HIV viral load becomes detectable a discussion should be held with the patient to determine if all ART is being taken appropriately at the correct dose and time interval. The most common reason for the development of viral resistance is non-adherence. If the patient is non-adherent it is important to stress the importance of taking ART properly. Studies have shown that drug resistance can develop if less than 95% of ART is taken correctly. On occasion, the virus will naturally mutate to detectable levels. In either case a HIV genotype should be ordered to determine if genetic mutations have occurred, and another ART regimen should be initiated if needed based on these results. Adherence to ART is important on two levels, for the patient who is HIV infected, non-adherence can lead to drug resistance and greatly increase the possibility of death. Drug resistant HIV viruses are transmitted to newly infected patients from source patients. A person who is newly diagnosed with HIV/AIDS can have few if any choices for effective ART, increasing the possibility of a poor prognosis. The development of multidrug resistant strains of HIV is a real concern in the field of medicine and Public Health. Case Study 1
Maria is a 38 year old Hispanic female recently diagnosed with HIV. She reported that she was probably infected by her boyfriend, Juan, with whom she had lived for the past 10 years. She claimed they were in a monogamous relationship, and so did not worry about using condoms. Juan had a drug problem before she met him, and had relapsed several times while they were living together. His drug of choice is heroin. Juan was diagnosed with HIV last year after being hospitalized with pneumonia. He was prescribed ART but he never really recovered fully from being ill and he died two months ago. After his death, Maria decided to be tested for HIV. Maria’s PCP explained that her CD4 count was 300/mm3, and VL was 32,000 copies. Based on the CDC recommendations she encouraged Maria to start ART. However, before deciding what medications she should order, a genotype would be needed to check for viral mutations that could result in drug resistance. At her next appointment, the PCP discussed the GT results which indicated probable resistance to several nucleoside reverse transcriptase inhibitors and one protease inhibitor. Based on the results they decided on ART. The PCP carefully explained the dosing, dietary restrictions, and possible adverse side effects. She explained that Maria’s CD4 and VL would be checked in one month to determine if the medications were effective, and if so would be checked every three months to monitor for any resistance development. She also emphasized the importance of adherence to all ART. Maria continued to do very well and her VL remained undetectable. 1. What risk factors did Maria have for HIV? 2. Why do you think she may not have been tested until after Juan died? 3. Why is it important for Maria to be adherent with her medications? Maria was at risk for HIV because her sexual partner had a past IV drug habit and had relapsed several times during their relationship. Even if Maria did not use drugs herself, having unprotected sex with Juan placed her at risk for infection. Many partners of sick individuals delay HIV testing until after their partners have died. This is not a good thing to do, since early detection and treatment is usually related to a better prognosis. The main reasons why someone waits to be tested is denial, not feeling capable of coping with a diagnosis of HIV while caring for a dying partner, or not wanting their partner to know they are infected. It is important for Maria to be adherent to her medication regimen to avoid resistance development, especially since she was infected with a strain of virus that already had several mutations. Theoretically, it could be difficult in the future for an effective regimen to be identified depending on the number and type of mutations present. HIV Select Issues
Studies have shown that the mucosal surface of the male foreskin contains a greater number of HIV target cells (known as Langerhans cells) than the skin along the penile shaft. The foreskin is also more sensitive and fragile and more easily torn during sexual activity, again increasing the risk of HIV entry with exposure. During male circumcision, the foreskin or the prepuce of the penis is removed. Results of studies in Africa and Asia have shown promising results. Overall, male circumcision has reduced HIV infection rates by 44 - 71% in areas where the circumcision rate for men is less than 20%. Following male circumcision, there were also reductions in rates of genital ulcer disease, chlamydia and penile cancer (Weiss et al., 2006). CDC is currently reviewing data in order to make recommendations on circumcision for men living in the U.S. Preliminary data has shown decreased rates of HIV transmission during penile-vaginal sex (more common in Africa/Asia), but not penile-anal sex (more common in US). Additionally, more US males were circumcised as infants than in many other countries bringing into question the cost effectiveness and risk ratio of the surgical procedure as an adult. Regardless of future recommendations, it is important to stress the fact that circumcision should not be considered an effective barrier to HIV infection, but rather used in conjunction with other barriers or abstinence (CDC, 2010). There continues to be much interest and research in the development of a vaccine for HIV. In the past decade, numerous vaccines have been trialed to some extent in the US and in developing countries with limited success. Scientists have learned valuable information from the trials, but to date, no effective vaccine has been developed. The process of HIV vaccine development has been difficult in many ways. First, the virus mutates rapidly, making it a sort of “moving target.” Next, clinical trials are expected to be conducted safely without placing participants at unnecessary risk. With the HIV vaccine, failure could lead to infection with an incurable disease. Finally, there are ethical issues related to developing countries and the benefit and risk of trialing the vaccine. There is no cure and no approved HIV vaccine today, but hopefully the future will hold both. Future research may include gene therapy to mitigate target cells and receptor cells on the surface of the CD4 cells of the immune system. The use of a vaginal cream or gel to prevent HIV infection in women has been a consideration for several years. This year, there was finally a report from a clinical trial using a tenofovir gel in South Africa that showed a 54% reduction in HIV infection among women in the study who were adherent with the gel application. Lower, but still improved rates of infection were reported for women with lower adherence rates. This was a breakthrough in prevention and may prove to be a safe and cost effective method of HIV prevention in years to come, especially in populations where condom use is infrequent. Gel application allows women to protect themselves when their partners refuse to use barriers in a way that is not obvious. The number of new cases of HIV infection among people age 50+ has continued to rise steadily since 1997. In addition, due to the effectiveness of ART, the number of people who are living with HIV/AIDS at age 50+ continues to climb. Currently, about one of every five persons with HIV/AIDS in the US is age 50+ (Shah & Mildvan, 2010). The older HIV population has problems that are specific to their age cohort including: • Lack of knowledge of HIV/AIDS risk behaviors • Drug/drug interactions related to multiple medical conditions Care and treatment of this population may need to be modified to assist with these issues. Affordable safe housing, proper nutrition, transportation to and from medical appointments, availability of medications and other issues must be discussed prior to staring ART to assure the best possible outcome. Social support is also very important, and seniors should be encouraged to participate in social activities with family and friends regardless if they choose to disclose their HIV status or not. Many older adults are afraid of the stigma associated with HIV infection and become more isolated at a time when social support is important. HIV education is important, since many older adults choose not to be around loved ones because they fear infecting them with the virus. Older adults who understand HIV transmission and risk factors will be able to continue in relationships without the worry of accidental transmission. Case Study #2
Cathy is a 64 year old woman. Her husband died 4 years ago and she has been very lonely. One day neighbor and friend introduced her to her brother, who recently moved nearby to be closer to family. Ed retired from the military and had traveled all over the world. Several weeks later he invited her out to dinner and a movie. She had not dated since her husband’s death, but felt like it would be ok since it was her friend’s brother. When she got ready to leave for the evening his sister said jokingly, “Be careful, he’s always been a real ladies man.” Her date acted like a gentleman all evening. He opened doors, pulled out her chair, and told non-stop accounts of his exciting life in the military. His last post before retiring was Bangkok. He made it sound beautiful and mysterious. Cathy asked if he ever married and he said no, but he had been in several long-term relationships. He was easy to be with, and soon she was in a serious relationship. 1. Identify clues that Cathy might have been putting herself at risk for HIV/AIDS. 4. In your opinion this your case out of the ordinary or do you think that it is common Cathy may be at risk for HIV infection. Ed has been in the military and traveled to many different countries. Like others their age, ED and Cathy may have limited knowledge of HIV risk factors. Ed has had multiple long term relationships, and may also have had other sexual partners. Thailand has a brisk prostitution trade and a high prevalence of HIV/AIDS. As their relationship progressed, Cathy should have asked about other sexual encounters, STDs, and if he had been tested for HIV. Although Cathy had been in a monogamous relationship, they should go together to be tested for HIV. This case is common, especially among older people. Many are not well informed about the risks associated with HIV/AIDS, and consider barrier use necessary only for protection from contraception (Lindau et al, 2007). HIV/AIDS continues to be a major public health concern in both the US and Globally. Despite millions of dollars spent for HIV/AIDS prevention programs, the number of new cases of infection continues to rise. Vaccines trialed to date have not been effective in preventing infection. Behavioral change and education seem to be the most promising ways to lower infection rates until an effective vaccine or cure is found. ART has slowed the progress of the disease in many cases, allowing people who were once very ill to recover and live productive lives. Currently there are five classes of ART, with more in development. This year there was a report of a vaginal antiviral gel found to be effective in preventing infection during vaginal/penile sex in So. Africa. As more and more research looks into HIV infection and prevention we will hopefully move closer to a cure. CDC recommends that all people age 13-64 be tested at least once in their lifetime as part of their routine medical care, and more often if risk factors for HIV are identified. They estimate that 25% of people in the US infected with HIV are not aware of their status because they have not been tested or were tested and did not return for their results. They further propose that they may be responsible for many of the new infections reported yearly. Early diagnosis and treatment will improve the prognosis of the patient and slow transmission. We as providers are responsible to encourage patients to be tested for HIV and to provide education on risk factors and prevention techniques. HIV is still a real public health threat. New social marketing campaigns are needed to change our old messages and to reach our youth and elderly populations. References
CDC. HIV prevalence estimates- United States, 2006. MMWR 2008; 57 (39), 1073- 1076. CDC. HIV and Male circumcision. Downloaded on 9/12/2010 from http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm. Guidelines for the Use of Antiretroviral Agents for HIV-1 Infection in Adults and Adolescents. CDC. (2009). Downloaded from http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf Hall, H., Song, R., Rhodes, P. et al. (2008). Estimation of HIV incidence in the United States. JAMA, 300 (5), 520-529. Lindau ST, Schumm MA, Laumann EO, et al. A study of sexuality and health among older adults in the United States. N Eng J Med 2007;357:762–774. Shah, S. & Mildvan, D. (2010). HIV and aging. Current Infectious Disease Reports, 8 (3), 241-247). UNAIDS. At least 56 countries have either stabilized or achieved significant declines in rates of new HIV infections (2010). Press Release, November 23, 2010. Downloaded on 12/15/10 from http://unaidstoday.org/?p=1673. UNAIDS. A global view of HIV infection (2008) downloaded on 6/28/2010 from http://data.unaids.org/pub/GlobalRepot/2008/GRB_2007_HIVPrevWallMap_GRO8_en.jpg Weiss HA, Thomas SL, Munabi SK, Hayes RJ. (2006). Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sexual Transmission of Infections, 82 (2), 101-9. Course Test
1. What is the best answer related to HIV infection in the US? A. In 2006 the number of new HIV infections increased to 56,000 annually. CDC reported that this was due to better reporting, rather than an actual increase in cases. B. For many years the number of new HIV infections was reported to be 40,000 per C. 25% of people who are infected do not know they are infected, because they have not been tested, or have not returned for test results. 2. All the following are true about global HIV infection EXCEPT:
A. It is a challenging public health problem. B. More than 33 million people are infected globally. C. The increase in the number of people living with HIV infections globally is thought to D. It is estimated that somewhere in the world, someone is infected with the HIV virus 3. In September 2006 CDC changed recommendations for HIV testing among adults and • the importance of HIV testing for all patients between the ages of 13 and 64; • the need to streamline the pre and post test criteria for HIV testing; • advised making HIV testing a routine part of medical care; and • stressed the importance of early detection and linkage into specialty care. 4. HIV can be transmitted by the exchange of blood or body fluids from someone who is infected. The most common routes of transmission include all the following EXCEPT:
A. Unprotected anal or vaginal sex. B. Mosquito 5. In the US, donated blood has been tested for HIV since 1985. However, as a warning for travelers, not all countries screen donated blood for HIV. 6. There are currently five classes of antiretroviral medications with each class of drugs working to interrupt viral replication at a distinct step in the process. All the following are true about
antiretroviral medications EXCEPT:
A. The use of combination therapy has been shown to be more effective at controlling  the virus than mono therapy (one medication). B. The use of combination therapy has been shown to be more effective at controlling the virus than dual therapy (two medications). increases the sites where drugs can interrupt the viral D. None of the antiretroviral medications lower the viral load. • Nucleoside/Nucleotide Reverse Transcriptase Inhibitors • Non-Nucleoside Reverse Transcriptase Inhibitors 8. All the following are true about viral load (VL) EXCEPT:
A. It is used to monitor the effectiveness of ART; once on effective antiretroviral therapy, the HIV viral load should be “undetectable.” B. The value of the viral load is determined by the type of test used by the laboratory. The most common values considered to be undetectable can vary from 4 to 400 copies. CD4 and VL laboratory tests are monitored carefully by the provider and should be checked every three to six months. C. The value of the viral load determines which antiretroviral medication should be used D. If the HIV viral load becomes detectable a discussion should be held with the patient to determine if all ART is being taken appropriately at the correct dose and time interval. The most common reason for the development of viral resistance is non-adherence. 9. There is no cure and no approved HIV vaccine today. 10. In addition to the stigma of HIV and ageism, issues for the older HIV population (age 50+) include all the following EXCEPT:
A. Lack of knowledge of HIV/AIDS risk behaviors including denial of risk. B. Later diagnosis, often with AIDS, a naturally decreasing immune system, and drug/drug interactions related to multiple medical conditions C. Social isolation and financial hardships. D. Higher viral load and non-adherence.

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