Guidelines 2016 – STDs: HIV/AIDS
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Since its original description in 1981, we have achieved substantial advances in our scientific understanding of acquired immune deficiency syndrome (AIDS). In addition, the identification of human immunodeficiency virus (HIV), a cytopathic retrovirus, and the necessary diagnostic serology testing for HIV have essentially laid the foundation for therapies that have continually and dramatically been the cornerstone for diagnosing HIV and AIDS. Information on HIV/AIDS is ever evolving and changing. Because our role as clinicians in ambulatory settings is to identify, educate, and refer persons at high risk for the disease, the purpose of this guideline is to serve as a reference in those three areas only. Because AIDS has become the leading cause of death among young women, it has become increasingly important that women’s health care clinicians keep up to date on current information by consulting professional journals and attending seminars on the subject. Developing an appropriate professional network of health care providers specializing in HIV/AIDS care is critical.
I. DEFINITION
AIDS is the commonly used acronym for acquired immune deficiency syndrome, which is the name for a complex of health problems first reported in 1981. This spectrum of disease can begin with a brief acute retroviral syndrome subsequent to exposure that then morphs into the chronic, often
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clinically latent, illness that will, without treatment in time, progress to a life-threatening immunodeficiency disease known as AIDS. If untreated, the time between infection with the virus and AIDS varies from a few months to many years, the median being 11 years.
II. ETIOLOGY
AIDS is caused by HIV; infection is mainly by sexual contact (anal, vaginal, oral); contaminated blood and blood products, including needle and syringe sharing; contaminated semen used for artificial insemination; intrauterine acquisition (baby of a woman with AIDS); and, rarely, breast milk. Most cases in the United States continue to be HIV-1; HIV-2 infection is endemic in West Africa and is increasing in some European countries.
III. HISTORY
A. Depending on the span of time from the point of seroconversion, the patient may present with a host of subtle-to-obvious presentations:
1. Unexplained rapid weight loss (> 10%)
2. Extreme fatigue; unexplained, increasing tiredness
3. Chronic diarrhea (> 1 month)
4. Persistent dry cough, shortness of breath, dyspnea on exertion
5. Prolonged fever, soaking night sweats, shaking chills
6. Loss of appetite
7. Skin rash: erythematous, purple or pink, flat or raised lesions on skin or under skin and inside mouth, nose, eyelids, anus
8. Changes in neurologic and/or cognitive function
9. Unexplained dementia
10. Localized and/or generalized lymphadenopathy
11. Episodic and/or chronic herpes simplex
12. Recurrent herpes zoster
13. Generalized pruritic dermatitis
14. Oral and pharyngeal candidiasis; fungal infection of nails
15. Persistent muscle pain
16. Fear of exposure to AIDS through sexual partner or high-risk behaviors or work-related accident (needlestick, contact with infected blood)
17. Chronic sinusitis
18. History of abnormal Pap smears
19. Persistent vulvar, vaginal, and anal condylomata
20. Seeking evaluation and treatment for STIs
21. Seeking preexposure prophylaxis (PrEP)
22. Seeking postexposure prophylaxis
B. Additional information to be considered
1. Sexual history
a. Homosexual encounters; anal penetration
b. Use of condoms, other methods of contraception, anal inter- course as contraception
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c. High-risk partners
d. High-risk sexual practices
e. History of traumatic rape
f. History of previous STI
g. History of survivor sex
h. Contact with prostitute
i. Multiple partners or a partner with multiple partners
j. Unprotected sexual encounters with an uncircumcised male partner
k. Unprotected sexual encounters with a previously incarcerated male
2. Use of injectable drugs by self or partner; other substance abuse history
3. High-risk occupation
4. History of blood transfusions or recipient of blood products, particularly from 1980 to 1985
5. Duration and frequency of any presenting symptoms
6. Reason for fear of exposure to HIV/AIDS
7. Gynecologic history
a. Recurrent STIs, vaginitis, vaginosis
b. Widespread molluscum contagiosum, 100 or more lesions
c. Infected with several STIs concurrently (may include gonor- rhea, syphilis, Chlamydia)
d. Rapidly progressing cervical dysplasia
e. Papillomavirus on Pap smear
f. Recurrent, recalcitrant vaginal candidiasis
g. External condyloma unresponsive to treatment
h. Existing pregnancy
i. Anal discharge
j. Pelvic, abdominal pain
8. Travel outside the United States, especially to West Africa or to European countries with known cases of HIV-2
9. Vaccination history
10. Past experiences with PrEP or postexposure prophylaxis
IV. PHYSICAL EXAMINATION
As appropriate to presenting complaint; gynecologic examination: testing for all STIs, Pap smear and wet mount or culture for Trichomonas vaginalis
V. LABORATORY EXAMINATION
A. Per protocol for presenting complaint, symptoms, risk status, or exposure
B. HIV testing if indicated or requested; if setting offers testing, resources must be in place for both pretest and posttest counseling for positive or negative results and follow-up; retest as needed
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C. The CDC recommends HIV testing for all persons seeking evaluation for STIs; consider rapid testing if the patients are unlikely to return for results.
D. All pregnant women should have fourth-generation HIV screening as early in pregnancy as possible and encourage screening for women planning a pregnancy (per new CDC guidelines, 2014)
E. Workplace exposures
F. Consider other blood-borne screening including HBV, HCV
G. Consider the time since a possible HIV exposure and obtain HIV RNA in addition to the HIV antibody screening
VI. DIFFERENTIAL DIAGNOSIS
Widely different depending on presenting complaint
VII. TREATMENT
A. General measures
1. Counseling to avoid or minimize high-risk behaviors
a. Give instruction and counseling regarding safer sexual practices to protect self and partner from exchange of body fluids (e.g., by using latex condoms, female condoms, dental dams, Saran Wrap); by avoiding anal intercourse and oral–genital contact; avoiding sharing sex toys such as vibrators and dildos (or clean them with bleach or alcohol)
b. Encourage a decreased number of sexual partners; mutual monogamy; abstinence
c. Discourage use of injectable drugs; if patient is using injectable drugs, stress the need to avoid needle, works, or cooker sharing; offer resources on drug rehabilitation programs
d. Avoid unsafe sexual contact with persons who are injectable drug users or fall into other high-risk groups
e. Stress sexual activities with a partner with HIV/AIDS that do not involve direct passage of body fluids, such as light kissing, caressing, or mutual masturbation
f. Empower women to maintain equal decision-making power in their relationship(s)
g. Specifically review the risks of HIV discordant relationships
h. Avoid sharing razors, toothbrushes, nail files and clippers, and other items that could be contaminated with blood
B. Specific treatment
1. Per guideline for specific presenting complaint
2. Refer those patients falling into high-risk groups for further counseling and appropriate testing and follow up if setting does not offer such services
3. Timely referral (within 72 hours from point of exposure) so postexposure prophylactic therapy can be instituted
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VIII. COMPLICATIONS
A. Opportunistic infections
B. AIDS may be fatal to some of its victims within 2 years of diagnosis.
C. Transmission to unborn child or a child: definitive determination at less than 18 months, usually based on HIV nucleic acid testing
IX. CONSULTATIONS AND REFERRAL
A. All patients falling into high-risk groups in need of testing for presence of HIV virus unless setting offers testing and counseling
B. Referral for all patients testing positive to HIV antibody for appropriate treatment
C. Referral per guideline for all occupational exposures
D. Prompt referral for all patients requesting or requiring PrEP or postexposure prophylaxis
X. FOLLOW-UP
A. Per referral
B. Contraceptive and gynecologic services for women with HIV/AIDS
See Appendix D for self-assessment of AIDS (HIV) risk list, which can be photocopied or adapted for your patients.
See Bibliographies.
Websites: www.cdc.gov/mmwr/pdf/rr/rr5912.pdf; www.cdc.gov/std/treatment/ 2015