The first rule of preventing the virus from entering the body is: don’t. Don’t share contaminated needles. Don’t be pricked by a needle. Don’t engage in unprotected sex. Don’t breastfeed if you are infected.

The second rule of prevention is barriers. Gloves should be worn by any person with a risk of exposure to HIV-potential fluids. Exposure might include open skin lesions on a patient/client or handling blood, items soiled by blood or other HIV-possible fluids. Gloves should be disposed of, hands washed and new gloves donned before a new client/patient is seen. Face masks and protective eyewear may be appropriate in certain circumstances. If ungloved hands touch any HIV-potential fluid, the hands should be immediately and thoroughly washed.

The third rule is sterilization or disposal. Instruments coming into contact with HIV-potential fluids should either be one-use and immediately disposed of with proper care after use or be sterilized after each use. All surfaces and equipment in the room should be disinfected after each use; these include “…chairs, mirrors, counter tops, drawer handles, …and light handles.” Disposable items and articles soiled with blood require special disposal such as that accorded infectious waste. Used needles should be placed in a puncture-resistant container dedicated solely to this purpose. Needles should not be bent or recapped first; the latter is a frequent cause of puncture injuries. Blood spills require prompt cleaning with sodium hypochlorite or other disinfectant solution.

Breach of infection control procedures resulting in possible exposure to HIV optimally should be verified by rapid HIV testing of the source. Reevaluation of the situation should occur 72 hours after possible infection.

If infection is indicated, the infectee should receive a four week regimen of antiretroviral agents. This course should begin within hours of possible infection. Many persons do not complete the full term of the drugs, some because of substantial side effects. A quarter of the patients experienced nausea and a fifth reported fatigue. Administering this regimen during pregnancy is an additional concern. Optimally, the primary physician should consult with one experienced in infectious diseases and/or antiretroviral agents but regime initiation should not be delayed to do so.

Along with the antiretroviral course (and even if it is refused), the infectee should be offered counseling and evaluation. Follow up testing should occur at 6 weeks, 12 weeks and 24 weeks.

If the regimen is accepted, the infectee should be reviewed for drug toxicity at 2 weeks after possible infection.

Clinical management includes infection control procedures, discussed in Chapter 2, to prevent direct contact with HIV-possible fluids. Used needles should be placed in puncture-resistant containers located at the point of use. Used needles should not be manipulated or re-sheathed. (Needle-stick injury is the primary cause of occupational HIV infection so especial care should be exercised. ) Hand washing and barriers such as gloves, masks, goggles and face shields, as appropriate to the situation, are important components of control.

Clinical management begins with the taking of an initial history, the initial physical examination, appropriate lab tests, confirmation of HIV infection, and the establishment of a staging classification using the CDC or WHO models. Staging may be used to determine eligibility for treatment with antiretroviral drugs.

Two major classification systems for HIV are in use: the U.S. Centers for Disease Control and Prevention (CDC) classification system (1993) and the World Health Organization (WHO) Clinical Staging and Disease Classification System (2005). The CDC relies on CD4 counts while the WHO concentrates on clinical manifestations.

The continuation of clinical management includes formulating a service plan, implementing the plan, coordinating, monitoring, follow up, reassessment, conferencing, crisis intervention and, eventually, case closure.

The service plan may embrace a variety of disciplines to optimize care, including nursing, counseling, social support, and client education.

Clinical case management is not a top-down procedure. The decisions do not flow from up above with automatic acceptance from the client below, Rather, clinical case management should involve the consent and participation of the client.

Clinical case management can be divided into comprehensive case management (CoCM) and supportive case management (SCM). The comprehensive model is proactive, helping a client with complex needs, a long-term horizon and a commitment to assist in the process. SCM addresses immediate, short-term needs, perhaps for a client who is not willing to put forth the level of participation required by CoCM or one who is finished with CoCM but still needs a maintenance level of care. Repetitions of crises or problems in SCM should lead to encouragement of the client to enter CoCM.

Prevention of HIV may start early. Each district school board in Florida is authorized by law to offer age-appropriate education on the subject, emphasizing sexual abstinence as the way to avoid problems. State Universities and community college must develop “comprehensive” policies for instruction on HIV and AIDS, including education on the subject during freshman orientation and information in the student handbook.

This emphasis on education is carried out in Florida’s mandate that 22 professions (including doctors and massage therapists) complete a course on HIV and AIDS as a condition of licensure or re-licensure. A similar course is required for employees of various care facilities. Additionally, the law directs that a program be established to educate the public, including minority populations, about methods of transmission and prevention, distinguishing between the different risks of transmission in social, employment and educational settings. The broad-based program also provides education to health workers and health facility employees, as well as making available consulting and information to state and local agencies and governments, and information to private employers. The Departments of Education, Health, and of Business and Professional Regulation shall establish an interagency agreement to review AIDS education programs in the state.

Mandatory HIV education is required in HIV/AIDS for all staff and prisoners in Florida correctional facilities.

The state of Florida is concerned that HIV-risky behavior may be the result of behavior patterns, such as emotional disturbances, which lessen one’s normal judgment. The San Francisco AIDS Foundation has found a similar issue with black gay and bisexual men; “[t]hese men struggle not only with issues related to HIV, but also with racism, addiction, poverty, homophobia, violence, and marginal housing conditions.” Their idea is that drop in sessions weekly, workshops, social events, leadership training and community development can improve the other problems and lead to a diminished risk-taking re HIV.

Infectious diseases are caused by “viruses, bacteria, parasites, fungi and other microbes.” They are spread to a person by contact—directly from another human or animal, from contaminated food or water, from insects, or from a contaminated environment (ranging from animal droppings to air).

Antibiotics have not eliminated infectious diseases, which remain the leading cause of deaths globally. Infectious diseases are one of the top ten causes of death in the United States (specifically HIV and pneumonia/influenza), accounting for 160,000 fatalities annually. Their annual cost in treatment and lost productivity in the United States is estimated to exceed $120 billion. Even once “under control” diseases, such as tuberculosis, cholera, and diphtheria, are re-emerging. In addition, new diseases have arisen—30 in the last two decades.

Surprisingly, however, much of this large problem can be prevented through methods which are easy and inexpensive: washing hands, barriers, personal hygiene and environmental controls.

Hand washing is “the single most effective technique for preventing the spread of communicable disease” and should be done:

Eating

Handling food

Drinking

Smoking

Handling another person’s medication or food

Assisting another person with feeding or toileting

Using the bathroom

Protective clothing or equipment is used

Handling clean equipment or utensils

Handling contact lenses

Using cosmetics

Eating

Contact with any bodily fluids (including blood, secretions, excretions)

Caring for another person and before moving on to the next person

Blowing nose, sneezing, or coughing

Playing with or handling an animal

Removing jewelry

Washing for 10 to 15 seconds

Washing between the fingers and under the nails

Thoroughly drying

Turning faucets off using paper towels

Washing jewelry with soap and water before putting on again

Gloves must be worn if there is a chance that the wearer will encounter bodily fluids. Vinyl gloves are recommended over latex ones because some people have an allergy to latex. After use, gloves must be removed immediately. The touching of any non-contaminated item or environmental surface post-use must not occur.

Activities with the potential for splashing of bodily fluids call for the caregiver to wear a gown. After use, the gown should be taken off immediately and stored safely for cleaning.

Environmental control measures should be used to minimize the spread of disease. These measures include:

Storing clean clothing, supplies and equipment in areas separate from soiled items

Storing food and handling food, first aid supplies and medications in areas separate from soiled items

Placing soiled disposal items (gloves, paper towels, cover-up sheets, under-pads, etc.) in covered receptacles which use plastic bags. The bags should be sealed and discarded daily. The use of cloth laundry bags should be avoided.

Routinely cleaning and disinfecting surfaces. Just soap and water eliminates dirt and most germs. Using a disinfectant will kill additional germs. Don’t forget to clean door knobs, light switches and the wall areas around toilets.

Establishing a cleaning schedule

Paying special attention to the cleanup of body fluid spills including blood

Secure the area so no one is contaminated and the spill is not spread.

Use a commercially available spill clean up kit.

Wear gloves during the cleanup (double gloves if picking up glass).

Pour an absorbent material over the spill.

Pick up material using a scoop.

Place glass in a special needle-disposal (sharps) container.

Use an absorbent towel to wipe up blood.

Apply a disinfectant to the area.

Place all cleanup materials in a special red bag for incineration.

The Legislature determined that making test results confidential would lead to more people testing for HIV. Generally, a person may not disclose the identity of a person tested or the results of a HIV test. To do so can be a misdemeanor; if done maliciously or for gain, this can be a felony.

There are numerous exceptions, though, to the rule. These people can be told of a test and of the identity of the subject:

The subject of the test

The legally authorized representative of the subject

Anyone the subject or the legally authorized representative authorizes in writing

Anyone who has received significant exposure to the subject’s HIV-possible fluids

Employer of the significantly exposed person as necessary to file a worker’s compensation claim or other disability claim

The health care provider (positive preliminary test only; may be told identity and any test result if has need to know or when dealing with a human body part from a deceased person)

The doctor caring for the subject

Other doctors the doctor may need to consult to reach a diagnosis

Health facility staff committees when conducting evaluation and review

Those authorized by court order after a hearing demonstrating compelling need which cannot be otherwise met. (The subject has a right to participate in the hearing. This is not a public hearing unless the subject agrees otherwise or the court finds a public hearing is necessary in the public interest and for the proper administration of justice.)

Department of Health

County health department (positive result only)

Insurers

Child agencies involved with test subject

Adult custodian, adult relative or adult responsible for welfare of a child subject

Developmentally disabled agencies involved with test subject

Sheriff or correctional officers responsible for the care of the subject if subject is an inmate

Disclosing test results must be accompanied by a written statement prohibiting further disclosure without the subject’s specific written consent and noting a general authorization from the subject is not sufficient for re-disclosure of this information.

Violating confidentiality provisions can be a misdemeanor. Disclosing maliciously or for monetary gain that a person has HIV or AIDS to a person not on the list of confidentiality exceptions may be a felony.

HIV testing in Florida generally requires the informed consent of the person being tested. Prior to consent, the subject must be told of the confidentiality of the subject’s identity and of the test’s results to the limits imposed by law, of the disclosure of positive results and the subject’s identity to the county health department, and of the whereabouts and hours of anonymous testing sites. This consent need not be written or signed by the client but the medical record must be noted that the explanations were given and consent received. Prior to the test, a post-test visit should be scheduled for discussing test results and for counseling.

There are numerous exceptions to the general rule. In the following circumstances, a test subject does not need to give consent in order to have a HIV test administered:

the subject is not competent to consent or a minor and has a legal guardian consent on subject’s behalf

in an emergency when the subject is unable to consent and the test is necessary for diagnosis

the attending physician determines obtaining informed consent would be detrimental to the patient and the test is needed for the medical diagnosis of acute illness

the subject is dead and the medical examiner is performing an autopsy

the subject is dead and others had significant exposure to HIV-possible fluids while providing emergency medical assistance or care. Requires documentation by a licensed physician that significant exposure occurred and the test is necessary to determine a course of treatment. Such personnel must be tested themselves or provide a negative test taken within 6 months prior to the significant exposure.

when federal law requires STD testing

donated blood, plasma, organ, skin and other human tissue in certain circumstances

pregnant woman (though woman must be told of the test and of her right to refuse it)

infant in hospital when parent cannot be reached and test is medically indicated

subsequent testing of previously diagnosed HIV-positive subject to monitor clinical progress

upon the request of a victim of sexual battery in which the subject is the perpetrator

court order

epidemiological research

when personnel have received significant exposure to HIV-possible fluids (if such personnel have a vial of voluntarily obtained blood from the subject and the subject cannot be found, the vial can be tested without the subject’s consent. Reasonable, documented attempts must be made to locate the subject and obtain consent.) Such personnel must be tested themselves or provide a negative test taken within 6 months prior to the significant exposure.

personnel providing emergency medical treatment to subject outside a hospital during which significant exposure to HIV-possible fluid occurs. Consent should be requested. A licensed physician must document there has been a significant exposure and that the test is medically necessary to determine a course of treatment. Such personnel must be tested themselves or provide a negative test taken within 6 months prior to the significant exposure. The present test must be performed during the course of the medical emergency; outside of that time frame and if the subject will not consent, a court order for the test must be sought.

if the subject has been convicted or prostitution or of procuring others to commit prostitution

an inmate

The person ordering the test (or that person’s designee) must make “all reasonable efforts” to tell the subject what the results of the test are. When the test results are positive, notification includes 3 things: information on medical and support services, the importance of notifying possibly-exposed partners, and preventing further transmission of HIV. Only the last item is necessary when the notification involves a negative test result.

In some circumstances, the subject may have departed the test venue before the results come back (hospital emergency room or detention facility, for example.) In that case, telling the county health department satisfies the notification requirement. A blood donor whose HIV test is positive shall be notified by certified letter; the chance to discuss this by phone or in person is offered. If the person does not respond within 30 days, the actual test results and other required information are sent to the donor by certified mail.

A practitioner regulated by the Division of Medial Quality Assurance of the Department of Health may (but is not required to) notify the subject’s partner without the subject’s consent if the following 4 conditions are met:

the HIV-positive patient tells the practitioner the identity of the partner

the practitioner recommends notification of the partner including advice to refrain from dangerous activity which might transmit the virus

patient refuses notification

practitioner informs patient the practitioner intends to notify the patient’s partner

Each county shall provide these services:

Voluntary, anonymous and confidential HIV testing program

Counseling

Notice of partner-notification services

County HIV testing programs must register with the Department of Health and re-register annually. The directors must have AIDS/HIV counseling experience. The medical care must be supervised by a licensed physician. Laboratory procedures must be done in a licensed laboratory.

Pre-testing counseling must be offered at the testing program. The following points should then be covered: the meaning of a HIV test, medical indications for such a test, the possibility of false results (whether positive or negative), the possible need of a second (confirmatory) test, the possible impact (social, medical, economic) of a positive result, and the need to eliminate behavior which entails a high risk of contracting HIV.

Before any positive results are given to the patient, a confirmatory test must be provided.

Post-test, in-person counseling must be offered at the testing program. This should cover the same points as the pre-testing counseling except the possible false results issue may be omitted. This post-test counseling can only be offered by specially trained counselors, alert to the possibility of suicidal behavior and able to offer the patient referrals to further appropriate health and social services.

No HIV test may be required for:

Admission to any facility or to purchase any service or product which is licensed by the Agency of Health Care Administration, the Department of Health, or the Department of Business and Professional Regulation

Hiring, promotion or continued employment (unless the absence of HIV is a bona fide occupational qualification for the job)

Other employment decisions. (Employee status or discharge cannot be based upon a HIV test unless the absence of HIV is a bona fide occupational qualification for the job.)

Life insurance

Health insurance

Disability insurance

To prove that the absence of HIV is a bona fide occupational requirement for a job, the employer must demonstrate 2 things:

The HIV test is necessary either to determine if the employee can reasonably perform the job’s duties or to determine if an employee will present a significant risk of passing HIV to other persons in the course of normal work, and

There exists no way to reasonably accommodate a HIV-positive person in the job.

A person who has HIV may not be discriminated against (if otherwise qualified) in:

Housing

Public accommodations

Governmental services

A licensed health care professional or health worker who treats or provides care to HIV-positive persons cannot be discriminated against in employment issues because of those patients.

A person discriminated against in violation of these laws may sue for $1,000 or the actual damages suffered (whichever is greater) for each occurrence. If the discrimination was intentional or reckless, the thousand dollars becomes $5,000. Additionally, the victim may recover reasonable attorney’s fees and other relief the court deems appropriate.

A parent or grandparent’s shared parental responsibility, custody or visitation rights cannot be denied by a court solely because of the parent’s or grandparent’s HIV status. The court can however issue conditions designed to prevent the transmission of HIV to the child.

It is a crime in Florida for a person who has HIV and knows it to:

donate “blood, plasma, skin, organ, or other human tissue donation” if the person has been informed such donations may transmit the disease; this is a felony. (Any person who fails to test that which is destined for a transfusion or transplant is guilty of a misdemeanor.)

have sexual intercourse with another person if the subject person has been informed sexual activity may transmit the disease, unless the sexual partner is informed the subject person is HIV-positive and consents to the sexual intercourse.

There are 14 crimes (including prostitution) which if a HIV-positive person is convicted of committing a second (or subsequent) time will also make that person guilty of criminal transmission of HIV. Actual infection need not occur. This may also trigger a term of “community quarantine community control” imposed by the court. A HIV-positive person who commits prostitution (or offers to commit) or who procures another to commit has also committed criminal transmission of HIV, a felony.

The Department of Health can petition the court to order a person to be isolated from the general public if it is probable that otherwise the person would spread HIV/AIDS, such quarantine continuing until the likelihood of danger to the public health ceases or becomes insignificant. The Department may ask for detention of the person before a hearing can be held; the detainee has the right to a bail hearing within 24 hours and to habeas corpus.

Violating the laws about confidentiality is a misdemeanor.