HUMAN IMMUNODEFIENCY VIRUS (HIV)

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1 HUMAN IMMUNODEFIENCY VIRUS (HIV) What is HIV? HIV stands for human immunodeficiency virus. It is the virus that can lead to acquired immunodeficiency syndrome, or AIDS. Unlike some other viruses, the human body cannot get rid of HIV. That means that once you have HIV, you have it for life. No safe and effective cure currently exists, but scientists are working hard to find one, and remain hopeful. Meanwhile, with proper medical care, HIV can be controlled. Treatment for HIV is often called antiretroviral therapy or ART. It can dramatically prolong the lives of many people infected with HIV and lower their chance of infecting others. Before the introduction of ART in the mid-1990s, people with HIV could progress to AIDS in just a few years. Today, someone diagnosed with HIV and treated before the disease is far advanced can have a nearly normal life expectancy. HIV affects specific cells of the immune system, called CD4 cells, or T cells. Over time, HIV can destroy so many of these cells that the body can t fight off infections and disease. When this happens, HIV infection leads to AIDS. Where did it come from? 1 P a g e Scientists identified a type of chimpanzee in West Africa as the source of HIV infection in humans. They believe that the chimpanzee version of the immunodeficiency virus (called simian immunodeficiency virus, or SIV) most likely was transmitted to humans and mutated into HIV when humans hunted these chimpanzees for meat and came into contact with their infected blood. Studies show that HIV may have jumped from apes to humans as far

2 back as the late 1800s. Over decades, the virus slowly spread across Africa and later into other parts of the world. We know that the virus has existed in the United States since at least the mid- to late 1970s. What are the stages of HIV? HIV disease has a well-documented progression. Untreated, HIV is almost universally fatal because it eventually overwhelms the immune system resulting in acquired immunodeficiency syndrome (AIDS). HIV treatment helps people at all stages of the disease, and treatment can slow or prevent progression from one stage to the next. A person can transmit HIV to others during any of these stages: Acute infection: Within 2 to 4 weeks after infection with HIV, you may feel sick with flu-like symptoms. This is called acute retroviral syndrome (ARS) or primary HIV infection, and it s the body s natural response to the HIV infection. (Not everyone develops ARS, however and some people may have no symptoms.) During this period of infection, large amounts of HIV are being produced in your body. The virus uses important immune system cells called CD4 cells to make copies of itself and destroys these cells in the process. Because of this, the CD4 count can fall quickly. Your ability to spread HIV is highest during this stage because the amount of virus in the blood is very high. Eventually, your immune response will begin to bring the amount of virus in your body back down to a stable level. At this point, your CD4 count will then begin to increase, but it may not return to pre-infection levels. Clinical latency (inactivity or dormancy): This period is sometimes called asymptomatic HIV infection or chronic HIV infection. During this phase, HIV is still active, but reproduces at very low levels. You may not 2 P a g e

3 have any symptoms or get sick during this time. People who are on antiretroviral therapy (ART) may live with clinical latency for several decades. For people who are not on ART, this period can last up to a decade, but some may progress through this phase faster. It is important to remember that you are still able to transmit HIV to others during this phase even if you are treated with ART, although ART greatly reduces the risk. Toward the middle and end of this period, your viral load begins to rise and your CD4 cell count begins to drop. As this happens, you may begin to have symptoms of HIV infection as your immune system becomes too weak to protect you. AIDS (acquired immunodeficiency syndrome): This is the stage of infection that occurs when your immune system is badly damaged and you become vulnerable to infections and infection-related cancers called opportunistic illnesses. When the number of your CD4 cells falls below 200 cells per cubic millimeter of blood (200 cells/mm3), you are considered to have progressed to AIDS. (Normal CD4 counts are between 500 and 1,600 cells/mm3.) You can also be diagnosed with AIDS if you develop one or more opportunistic illnesses, regardless of your CD4 count. Without treatment, people who are diagnosed with AIDS typically survive about 3 years. Once someone has a dangerous opportunistic illness, life expectancy without treatment falls to about 1 year. People with AIDS need medical treatment to prevent death. 3 P a g e

4 How can I tell if I m infected with HIV? The only way to know if you are infected with HIV is to be tested. You cannot rely on symptoms to know whether you have HIV. Many people who are infected with HIV do not have any symptoms at all for 10 years or more. Some people who are infected with HIV report having flu-like symptoms (often described as the worst flu ever ) 2 to 4 weeks after exposure. Symptoms can include: o o o o Fever Enlarged lymph nodes Sore throat Rash These symptoms can last anywhere from a few days to several weeks. During this time, HIV infection may not show up on an HIV test, but people who have it are highly infectious and can spread the infection to others. However, you should not assume you have HIV if you have any of these symptoms. Each of these symptoms can be caused by other illnesses. Again, the only way to determine whether you are infected is to be tested for HIV infection. For information on where to find an HIV testing site, o o o Visit National HIV and STD Testing Resources and enter your ZIP code. Text your ZIP code to KNOWIT (566948), and you will receive a text back with a testing site near you. Call 800-CDC-INFO ( ) to ask for free testing sites in your area. These resources are confidential. You can also ask your health care provider to give you an HIV test. 4 P a g e

5 Two types of home testing kits are available in most drugstores or pharmacies: one involves pricking your finger for a blood sample, sending the sample to a laboratory, and then phoning in for results. The other involves getting a swab of fluid from your mouth, using the kit to test it, and reading the results in 20 minutes. Confidential counseling and referrals for treatment are available with both kinds of home tests. If you test positive for HIV, you should see your doctor as soon as possible to begin treatment. Is there a cure for HIV? For most people, the answer is no. Most reports of a cure involve HIV-infected people who needed treatment for a cancer that would have killed them otherwise. But these treatments are very risky, even life-threatening, and are used only when the HIV-infected people would have died without them. Antiretroviral therapy (ART), however, can dramatically prolong the lives of many people infected with HIV and lower their chance of infecting others. It is important that people get tested for HIV and know that they are infected early so that medical care and treatment have the greatest effect. BASIC STATISTICS HIV and AIDS remain a persistent problem for the United States and countries around the world. While great progress has been made in preventing and treating HIV, there is still much to do. The questions in this section provide a broad overview of the effects of HIV and AIDS in the United States and globally. About 50,000 people get infected with HIV each year. In 2010, there were around 47,500 new HIV infections in the United States. About 1.1 million people in the United States were living with HIV at the end of 2010, the most recent year this information was available. Of those 5 P a g e

6 people, about 16% do not know they are infected. In the United States, about 15,500 people with AIDS died in HIV disease remains a significant cause of death for certain populations. To date, more than 635,000 individuals with AIDS in the United States have died. HIV is largely an urban disease, with most cases occurring in metropolitan areas with 500,000 or more people. The South has the highest number of individuals living with HIV, but when you take population size into account, the Northeast has the highest rate of persons living with new HIV infections. (Rates are the number of cases of disease per 100,000 people. Rates allow comparisons between two groups of different sizes.) HIV disease continues to be a serious health issue for parts of the world. Worldwide, there were about 2.5 million new cases of HIV in About 34 million people are living with HIV around the world. In 2011, there were about 17 million deaths in persons with AIDS, and nearly 30 million people with AIDS have died worldwide since the epidemic began. Even though Sub-Saharan Africa bears the biggest burden of HIV/AIDS, countries in South and Southeast Asia, Eastern Europe and Central Asia, and those in Latin America are significantly affected by HIV and AIDS. CDC estimates the number of people living with HIV (called prevalence) by using a scientific model. This model helps CDC estimate the number of new HIV infections and how many people are infected but don t know it. HIV prevalence is the number of people living with HIV infection at a given time, such as at the end of a given year. If we look at HIV infection by race and ethnicity, we see that African Americans are most affected by HIV. In 2010, African Americans made up only 12% of the US population, but had 44% of all new HIV infections. Additionally, Hispanic/Latinos are also strongly affected. 6 P a g e

7 They make up 17% of the US population, but had 21% of all new HIV infections. If we look at HIV infections by how people got the virus (transmission category), we see that men who have sex with men (MSM) are most at risk. In 2010, MSM had 63% of all new HIV infections, even though they made up only around 2% of the population. Individuals infected through heterosexual sex made up 25% of all new HIV infections in P a g e

8 Combining those two views allows us to see the most affected populations, by race and by risk factor. Figure1: Estimated New HIV Infections in the United States, 2010, for the Most Affected Subpopulations 8 P a g e

9 There are also variations by age. Young people, aged are especially affected by HIV. They comprised 16% of the US population, but accounted for 26% of all new HIV infections in All young people are not equally at risk, however. Young MSM, for example, accounted for 72% of all new infections in people aged 13-24, and young, African American MSM are even more severely affected. TRANSMISSION Only certain fluids blood, semen (cum), pre-seminal fluid (pre-cum), rectal fluids, vaginal fluids, and breast milk from an HIV-infected person can transmit HIV. These fluids must come in contact with a mucous membrane or damaged tissue or be directly injected into the bloodstream (from a needle or syringe) for transmission to possibly occur. Mucous membranes can be found inside the rectum, the vagina, the opening of the penis, and the mouth. In the United States, HIV is spread mainly by: Having unprotected sex (sex without a condom) with someone who has HIV. Anal sex is the highest-risk sexual behavior. Receptive anal sex (bottoming) is riskier than insertive anal sex (topping). Vaginal sex is the second highest-risk sexual behavior. Having multiple sex partners or having other sexually transmitted infections can increase the risk of infection through sex. Sharing needles, syringes, rinse water, or other equipment (works) used to prepare injection drugs with someone who has HIV. 9 P a g e

10 Less commonly, HIV may be spread by: Being born to an infected mother. HIV can be passed from mother to child during pregnancy, birth, or breastfeeding. Being stuck with an HIV-contaminated needle or other sharp object. This is a risk mainly for health care workers. Receiving blood transfusions, blood products, or organ/tissue transplants that are contaminated with HIV. This risk is extremely small because of rigorous testing of the US blood supply and donated organs and tissues. Eating food that has been pre-chewed by an HIV-infected person. The contamination occurs when infected blood from a caregiver s mouth mixes with food while chewing, and is very rare. Being bitten by a person with HIV. Each of the very small number of documented cases has involved severe trauma with extensive tissue damage and the presence of blood. There is no risk of transmission if the skin is not broken. Oral sex using the mouth to stimulate the penis, vagina, or anus (fellatio, cunnilingus, and rimming). Giving fellatio (mouth to penis oral sex) and having the person ejaculate (cum) in your mouth is riskier than other types of oral sex. Contact between broken skin, wounds, or mucous membranes and HIVinfected blood or blood-contaminated body fluids. These reports have also been extremely rare. Deep, open-mouth kissing if the person with HIV has sores or bleeding gums and blood is exchanged. HIV is not spread through saliva. Transmission through kissing alone is extremely rare. 10 P a g e

11 HIV does not survive long outside the human body (such as on surfaces), and it cannot reproduce. It is not spread by: 11 P a g e Air or water. Insects, including mosquitoes or ticks. Saliva, tears, or sweat. There is no documented case of HIV being transmitted by spitting. Casual contact like shaking hands or sharing dishes. Closed-mouth or social kissing Toilet seats. Having a sexually transmitted infection (STI) can increase the risk of getting or spreading HIV. If you are HIV-negative but have an STI, you are at least 2 to 5 times as likely to get HIV if you have unprotected sex with someone who has HIV. There are two ways that having an STI can increase the likelihood of getting HIV. If the STI causes irritation of the skin (e.g., from syphilis, herpes, or human papillomavirus), breaks or sores may make it easier for HIV to enter the body during sexual contact. Even STIs that cause no breaks or open sores (e.g., chlamydia, gonorrhea, trichomoniasis) can increase your risk by causing inflammation that increases the number of cells that can serve as targets for HIV. If you are HIV-positive and also infected with another STI, you are 3 to 5 times as likely as other HIV-infected people to spread HIV through sexual contact. This appears to happen because there is an increased concentration of HIV in the semen and genital fluids of HIV-positive people who also are infected with another STI. The HIV superinfection is a new strain of HIV that can replace the original strain or remain along with the original strain. The effects of superinfection differ from person to person. For some people, superinfection may cause them to get sicker faster because they become infected with a new strain of the virus that is resistant to the medicines they are currently taking to treat their original HIV infection. Research suggests that the kind of superinfection where a person becomes infected with a new strain of HIV that is hard to treat is rare, less than 4%.

12 The risk of health care workers being exposed to HIV on the job (occupational exposure) is very low, especially if they use protective practices and personal protective equipment to prevent HIV and other blood-borne infections. 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; however, even this risk is small. Scientists estimate that the risk of HIV infection from being stuck with a needle used on an HIV-infected person is less than 1%. Although HIV risk factors and routes of transmission apply to everyone equally, some people are at higher risk because of where they live and who their sex partners are. The percentage of people living with HIV (prevalence) is higher in major metropolitan areas, so people who live there are more likely to encounter an HIV-positive person among their possible sex partners. In the same way, because the prevalence of HIV is higher among gay and bisexual men and among black and Latino men and women, members of these groups are more likely to encounter partners who are living with HIV. 12 P a g e

13 WHO S AT RISK FOR HIV? In the United States, HIV is spread mainly by having anal or vaginal sex without a condom or by sharing drug-use equipment with an infected person. Substance use can contribute to these risks indirectly because alcohol and other drugs can lower people s inhibitions and make them less likely to use condoms. Substance Use Substance use, abuse, and dependence been closely associated with HIV infection since the beginning of the epidemic. Although injection drug use (IDU) is a direct route of transmission, drinking, smoking, ingesting, or inhaling drugs such as alcohol, crack cocaine, methamphetamine ( meth ), and amyl nitrite ( poppers ) are also associated with increased risk for HIV infection. These substances may increase HIV risk by reducing users inhibitions to engage in risky sexual behavior. Substance use and addiction are public health concerns for many reasons. In addition to increasing the risk of HIV transmission, substance use can affect people s overall health and make them more susceptible to HIV infection and, in those already infected with HIV, substance use can hasten disease progression and negatively affect adherence to treatment. Vulnerable Populations People who live in poverty. People who live in disadvantaged neighborhoods are more likely to have high rates of alcohol and illicit drug use. Gay and bisexual men. Alcohol and drug use among gay and bisexual men can be a reaction to homophobia, discrimination, or violence they experienced because of their sexual orientation and can contribute to other mental health 13 P a g e

14 problems. Compared with the general population, gay and bisexual men o o o Are more likely to use alcohol and drugs. Are more likely to continue heavy drinking later in life. Have higher rates of substance abuse. People with a mental illness. The coexistence of substance use and mental health disorders is common and is linked to poor impulse control and greater risk-taking and sensationseeking behaviors. People with a history of abuse. People who have experienced sexual, physical, or emotional abuse are more likely to overuse drugs and alcohol and practice risky sexual behaviors. Prevention Challenges A number of factors contribute to the spread of HIV infection among substance users: Sexual risk factors. Substance use can decrease inhibitions and increase sexual risk factors for HIV transmission, including not using a condom. Stigma and discrimination associated with substance use. Often, drug use is viewed as a criminal activity rather than a medical issue that requires counseling and rehabilitation. Stigma may prevent users from seeking HIV testing, care, and treatment. Differences among people who abuse drugs and alcohol. Racial, ethnic, and gender differences, as well as differences in geographic location (urban vs. rural, region of the country), access to drug and alcohol treatment and HIV testing and counseling, and socioeconomic 14 P a g e

15 and cultural issues should be considered when developing and implementing prevention programs. Complex health and social needs. People who use drugs often have other complex health and social needs, including a need for treatment for substance abuse and mental disorders. Comprehensive prevention strategies, including case management, are needed. Effects on HIV treatment adherence. No adherence can lead to medication-resistant viral strains. Because they fear dangerous side effects or dislike following a regimen that interrupts their drug-using activities, many HIV-infected substance users are less willing to start antiviral therapy than non substance users, according to research. Commonly Used Substances Alcohol Excessive alcohol consumption, notably binge drinking, is associated with multiple adverse health and social consequences and is sometimes linked to other drug use. Alcohol use can be an important risk factor for HIV infection because it is linked to less frequent use of condoms and to multiple sexual partners. Crack Cocaine Crack cocaine s short-lived high and addictiveness can create a compulsive cycle in which users quickly exhaust their resources and turn to other ways to get the drug, including trading sex for drugs or money, which increases HIV infection risk. African Americans account for the majority of people who use crack cocaine. Compared to nonusers, crack cocaine users reported A greater number of recent and lifetime sexual partners. Infrequent condom use. 15 P a g e

16 Heightened sexual pleasure. Using more than one substance. Being less responsive to HIV prevention programs, according to recent studies. Methamphetamine Meth use is associated with increased HIV risk and has become a public health threat in recent years because, like alcohol and other substances, it is linked to high-risk sexual activity with nonsteady partners under the influence. In addition, It is highly addictive and can be injected. It tends to dry out the skin on the penis and mucosal tissues in the anus and the vagina, which may lead to small tears and cuts during sex where the HIV can enter the body. Some gay and bisexual men combine meth with erectile dysfunction drugs that are also associated with unprotected anal sex. The largest numbers of meth users are white males. According to one study, gay and bisexual men report using meth and other stimulants at rates approximately 9 times as high as the general population. Inhalants Like meth, use of amyl nitrite ( poppers ) has also been associated with increased HIV risk. Nitrite inhalants have long been linked to risky sexual behaviors, illegal drug use, and sexually transmitted infections among gay and bisexual men and have recently been linked to increased use among adolescents because inhalants: Enhance sexual pleasure. Aid anal sex by increasing sensitivity and relaxing the sphincter, which may lead to more unprotected sex. 16 P a g e

17 Are commonly found, even in household products. Oral Sex Oral sex involves giving or receiving oral stimulation (i.e., sucking or licking) to the penis (fellatio), the vagina (cunnilingus), or the anus (anilingus). HIV can be transmitted during any of these activities, but the risk is much less than that from anal or vaginal sex. Receiving fellatio, giving or receiving cunnilingus, and giving or receiving anilingus carry little to no risk. The highest oral sex risk is to individuals performing fellatio on an HIV-infected man, with ejaculation. Even though oral sex carries a lower risk of HIV transmission than other sexual activities, the risk is not zero. It s hard to measure the exact risk because most people who practice oral sex also practice other forms of sex during the same encounter. When transmission occurs, it may be the result of oral sex or other, riskier sexual activities, such as anal or vaginal sex. If the person receiving oral sex has HIV, their blood, semen, pre-seminal fluid, or vaginal fluid may contain the virus. If the person performing oral sex has HIV, blood from their mouth may enter the body of the person receiving oral sex through the lining of the urethra (the opening at the tip of the penis), vagina, cervix, or anus, or through cuts and sores. Several factors may increase the risk of HIV transmission through oral sex, including oral ulcers, bleeding gums, genital sores, and the presence of other sexually transmitted infections (STIs). In addition to HIV, other organisms can be transmitted through oral sex with an infected partner, leading to herpes, syphilis, gonorrhea, genital warts (human papillomavirus, or HPV), intestinal parasites (amebiasis), or hepatitis A or B infection. Barrier methods can help lower the risk of getting HIV and other STIs from oral sex. A latex or plastic condom may be used on the penis, and a cut- 17 P a g e

18 open condom or a dental dam can be used between the mouth and the vagina or anus. Racial/Ethnic Groups United States, HIV is spread mainly by having unprotected anal or vaginal sex or by sharing drug-use equipment with an infected person. Although these risk factors are the same for everyone, some racial/ethnic groups are more affected than others, given their percentage of the population. This is because some population groups have higher rates of HIV in their communities, thus raising the risk of new infections with each sexual or drug use encounter. Additionally, a range of social, economic, and demographic factors such as stigma, discrimination, income, education, and geographic region affect their risk for HIV. Blacks/African Americans* have the most severe burden of HIV of all racial/ethnic groups in the United States. Compared with other races and ethnicities, African Americans account for a higher proportion of new HIV infections, those living with HIV, and those ever diagnosed with AIDS. African Americans accounted for an estimated 44% of all new HIV infections among adults and adolescents (aged 13 years or older) in 2010, despite representing only 12% of the US population; considering the smaller size of the African American population in the United States, this represents a population rate that is 8 times that of whites overall. In 2010, men accounted for 70% (14,700) of the estimated 20,900 new HIV infections among all adult and adolescent African Americans. The estimated rate of new HIV infections for African American men (103.6/100,000 population) was 7 times that of white men, twice that of Latino men, and nearly 3 times that of African American women. In 2010, African American gay, bisexual, and other men who have sex with men represented an estimated 72% (10,600) of new infections among all African American men and 36% of an estimated 29,800 new 18 P a g e

19 HIV infections among all gay and bisexual men. More new HIV infections (4,800) occurred among young African American gay and bisexual men (aged 13-24) than any other subgroup of gay and bisexual men. In 2010, African American women accounted for 6,100 (29%) of the estimated new HIV infections among all adult and adolescent African Americans. This number represents a decrease of 21% since Most new HIV infections among African American women (87%; 5,300) are attributed to heterosexual contact. The estimated rate of new HIV infections for African American women (38.1/100,000 population) was 20 times that of white women and almost 5 times that of Hispanic/Latino women. HIV infection is a serious threat to the health of the Hispanic/Latino community. In 2010, Hispanics/Latinos accounted for over one-fifth (21% or 9,800) of all new HIV infections in the United States and 6 dependent areas despite representing about 16% of the total US population. In 2010, Hispanic/Latino men accounted for 87% (8,500) of all estimated new HIV infections among Hispanics/Latinos in the United States. Most (79% or 6,700) of the estimated new HIV infections among Hispanic/Latino men were attributed to male-to-male sexual contact. Among Hispanic/Latino men who have sex with men (MSM), 67% of estimated new HIV infections occurred in those under age 35. Hispanic women/latinas accounted for 14% (1,400) of the estimated new infections among all Hispanics/Latinos in the United States in The estimated rate of new HIV infection among Hispanics/Latinos in the United States in 2010 was more than 3 times as high as that of whites (27.5 vs. 8.7 per 100,000 populations). HIV is a public health issue among the approximately 5.2 million American Indians and Alaska Natives (AI/AN), who represent about 19 P a g e

20 1.7% of the US population. Compared with other racial/ethnic groups, AI/AN ranked fifth in estimated rates of HIV infection diagnoses in 2011, with lower rates than in blacks/african Americans, Hispanics/Latinos, Native Hawaiians/Other Pacific Islanders, and people reporting multiple races, but higher rates than in Asians and whites. Despite being a rapidly growing population, Asians have experienced stable numbers of new HIV infections in recent years. Overall, Asians continue to account for only a small proportion of new HIV infections in the United States and dependent areas. National estimates show that Native Hawaiians and Other Pacific Islanders (NHOPI) are not greatly affected by HIV. However, current estimates of HIV and AIDS diagnoses among NHOPI may be too low because of race/ethnicity misclassification and may mask the real impact of HIV on this population. Gender In the United States, HIV is spread mainly by having unprotected anal or vaginal sex or by sharing drug-use equipment with an infected person. Although these risk factors are the same for everyone, some gender groups are far more affected than others. Gay, bisexual, and other men who have sex with men, for example, account for the majority of new infections despite making up only 2% of the population. Age In the United States, HIV is spread mainly by having unprotected anal or vaginal sex or by sharing drug-use equipment with an infected person. Although these risk factors are the same for everyone, some groups merit special consideration because of their age. New infections are increasing among young men who have sex with men, especially young, black men, men who have sex with men, for example, despite remaining steady overall. 20 P a g e

21 Youth in the United States account for a substantial number of HIV infections. Gay, bisexual, and other men who have sex with men account for most new infections in the age group 13 to 24; black/african American or Hispanic/Latino gay and bisexual men are especially affected. Continual HIV prevention outreach and education efforts, including programs on abstinence, delaying the initiation of sex, and negotiating safer sex for the spectrum of sexuality among youth homosexual, bisexual, heterosexual, and transgender are urgently needed for a new generation at risk. A growing number of people aged 50 and older in the United States are living with HIV infection. People aged 55 and older accounted for almost one-fifth (19%, 217,000) of the estimated 1.1 million people living with HIV infection in the United States in HIV TESTING At the end of 2009, an estimated 1,148,200 persons aged 13 and older were living with HIV infection in the United States, including 207,600 (18.1%) persons whose infections had not been diagnosed. CDC estimates that approximately 50,000 people are infected with HIV each year. HIV testing is entering a new era in this country as lawmakers, health care and insurance executives, and public health officials are making changes in their respective fields to ensure that more people will know their HIV status an important consideration for maintaining health and reducing the spread of the virus. In September 2006, CDC released Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. These Recommendations advise routine HIV screening of adults, adolescents, and pregnant women in health care settings in the United States. They also recommend reducing barriers to HIV testing. People who are infected with HIV but not aware of it are not able to take advantage of the therapies that can keep them healthy and extend their lives, nor do they have the knowledge to protect their sex or drug-use partners from becoming infected. Knowing whether one is positive or 21 P a g e

22 negative for HIV confers great benefits in healthy decision making. Cohort studies have demonstrated that many infected persons decrease behaviors that help transmit infection to sex or needle-sharing partners once they are aware of their positive HIV status. HIV-infected persons who are unaware of their infection do not reduce risk behaviors. Persons tested for HIV who do not return for test results might even increase their risk for transmitting HIV to partners. Because medical treatment that lowers HIV viral load might also reduce risk for transmission to others, early referral to medical care could prevent HIV transmission in communities while reducing a person's risk for HIV-related illness and death. The most common HIV test is the antibody screening test, which tests for the antibodies that your body makes against HIV, not HIV itself. Antibody tests may be conducted in a lab or as a rapid test at the testing site. They may be performed on blood or oral fluid (not saliva). HIV tests can be administered in community-based organizations and even in mobile clinics by certified personnel. HIV testing in these non-clinical settings offers an effective way to bring HIV testing to the community. This section offers guidance, articles, information on linkage and referral, and reports to aid individuals in non-clinical settings in their HIV testing programs. Blood tests can detect HIV infection sooner after exposure than oral fluid tests because the level of antibody in blood is higher than it is in oral fluid. In addition, most blood-based lab tests find infection sooner after exposure than rapid HIV tests. Newer blood tests can find HIV as soon as 3 weeks after exposure to the virus. In addition to antibody tests, there are several tests now in use that can detect both antibodies and antigens, which are pieces of the virus itself. Because these tests do not have to wait for the body to make an immune response to the virus, they can find infection earlier than tests that only look for antibodies. 22 P a g e

23 CDC recommends that individuals aged get tested at least once in their lifetimes and those with risk factors get tested more frequently. A general rule for those with risk factors is to get tested at least annually. Additionally, CDC has recently reported that gay and bisexual men may benefit from getting an HIV test more often, perhaps every 3-6 months. This section highlights information for healthcare providers who may be administering HIV tests. Follow-up diagnostic testing is performed if the first test result is positive. HIV tests are generally very accurate, but follow-up testing allows you and your health care provider to be sure the diagnosis is right. If your first test is a rapid test, and it is positive, you will be directed to a medical setting to get follow-up testing. If your first test that required a lab for analysis is positive, the lab will conduct follow-up testing, usually on the same blood specimen as the first test. Follow-up tests include: an antibody differentiation test, which distinguishes HIV-1 from HIV-2; a Western blot or indirect immunofluorescenceassay, which detect antibodies an HIV-1 nucleic acid test, which looks for virus directly. CDC is drafting revised laboratory HIV diagnostic guidelines due to evidence that many persons infected with HIV at the time of testing are not detected by current testing strategies. The proposed testing process recommends Initial screening with a sensitive HIV antigen/antibody test. If reactive, the initial test is followed by a differentiation test that distinguishes HIV-1 from HIV-2. If the differentiation test is negative or indeterminate, HIV-1 nucleic acid testing, which looks specifically for components of HIV, is performed to identify new infections. 23 P a g e

24 LIVING WITH HIV Today, an estimated 1.1 million people are living with HIV in the United States. Thanks to better treatments, people with HIV are now living longer and with a better quality of life than ever before. If you are living with HIV, it s important to make choices that keep you healthy and protect others. It s very important for you to take your HIV medicines exactly as directed. Not taking medications correctly may lower the level of immune system defenders called CD4 cells and cause the level of virus in your blood (viral load) to go up. The medicines then become less effective when taken. Some people report not feeling well as a reason for stopping their medication or not taking it as prescribed. Tell your doctor if your medicines are making you sick. He or she may be able to help you deal with side effects so you can feel better. Don t just stop taking your medicines, because your health depends on it. Be sure that your partner or partners know that you have HIV. Then they will know it s important to use condoms for all sexual activity and to be tested often for HIV. Health departments offer Partner Services to help you tell your partners about their exposure. Partner Services provides many free services to people with HIV or other STDs and their partners. Through Partner Services, health department staff help find sex or drug-injection partners to let them know of their risk of being exposed to HIV or another sexually transmitted disease (STD) and provide them with testing, counseling, and referrals for other services. Partner Services will not reveal your name unless you want to work with them to tell your partners. HIV is spread through body fluids such as blood, semen (cum), vaginal fluids, and breast milk. In the United States, HIV is most commonly passed from one person to another through unprotected anal or vaginal sex and through sharing needles or other drug equipment. In addition, a mother can pass HIV to her baby during pregnancy, during labor, through breastfeeding, or if by pre-chewing her baby s food. 24 P a g e

25 Viral load can range from undetectable levels of 40 to 75 copies per milliliter of blood to millions of copies. The higher your viral load, the greater the risk of spreading HIV to others. Protect your partners by keeping yourself healthy. Take all of your medicines and get tested and treated for other STDs. If you have HIV plus another STD or hepatitis, you are 3 to 5 times more likely to spread HIV than if you only have HIV. Your viral load goes up and your CD4 count goes down when you have an STD. Although having a low viral load greatly decreases your chance of spreading HIV, some risk remains, even when your viral load is lower than 3,500 copies per milliliter. You can avoid spreading the virus to others by making sure they do not come into contact with your body fluids. Abstinence (not having sex) is the best way to prevent the spread of HIV infection and some other STDs. If abstinence is not possible, use condoms whenever you have sex vaginal, anal, or oral. Do not share drug equipment. Blood can get into needles, syringes, and other equipment. If the blood has HIV in it, the infection can be spread to the next user. Do not share items that may have your blood on them, such as razors or toothbrushes. Treatment Although there is no cure for HIV infection, there are treatment options that can help people living with HIV experience long and productive lives. CDC and other government agencies continue to work on a variety of treatmentrelated activities, including: HIV/AIDS clinical research and drug trials; vaccine research; development of treatment guidelines and best practices; and 25 P a g e

26 creating and implementing treatment-related prevention strategies that can help stop new infections. PREVENTION RESEARCH Guided by the National HIV/AIDS Strategy for the United States, CDC provides national leadership and support for the implementation of a highimpact prevention approach to reducing new HIV infections by using combinations of scientifically proven, cost-effective, and scalable interventions and prevention strategies directed towards the most vulnerable populations in the US who are most affected by, or at greatest risk for, HIV infection. Find out more about how the Division of HIV/AIDS Prevention s funded programs and interventions. CDC provides national leadership for HIV prevention research, including the development and evaluation of HIV biomedical and behavioral interventions to prevent HIV transmission and reduce HIV disease progression in the United States and internationally. CDC s research efforts also include identifying those scientifically proven, cost-effective, and scalable interventions and prevention strategies to be implemented as part of a highimpact prevention approach for maximal impact on the HIV epidemic. There are also demonstration projects that test and measure the effects of program changes in real-world situations and ongoing research conducted by the Division of HIV/AIDS Prevention (DHAP) with a comprehensive program of behavioral, clinical, epidemiological, laboratory, and prevention research. Through this ongoing research, DHAP monitors many facets of the trends in HIV in the United States. The data guide decisions that ensure HIV prevention funds are directed to those populations most affected by the disease. 26 P a g e

27 POLICIES AND PROGRAMS Law impacts nearly every aspect of our lives. Laws and explicit policies can be viewed as structural interventions for achieving HIV prevention goals. Given the importance of law in HIV prevention work, the Division of HIV/AIDS Prevention (DHAP) has implemented public health law research methods to systematically collect and assess statutory and regulatory frameworks across a range of legal domains to help determine whether these legal frameworks act as barriers or facilitators to effective HIV prevention environments. DHAP has focused on the public health implications of state statutes and regulations across key HIV prevention topic areas, such as HIV testing, Medicaid reimbursement for routine HIV screening, laboratory reporting of CD4 and viral load data for HIV surveillance purposes, and criminalization of potential HIV exposure. Laws and policies are structural interventions that can be facilitators or barriers to effective HIV prevention and care activities. Examples of these laws and policies include: 48 states plus D.C. now have HIV testing laws that are consistent with CDC s 2006 recommendations, nearly twice as many as when the recommendations were released. 22 states have Medicaid programs that reimburse for routine HIV screening in all settings and populations. 36 states plus D.C. require reporting of all CD4 and viral load laboratory data to HIV surveillance programs. The Centers for Disease Control and Prevention (CDC) estimates that 1,178,350 Americans are living with HIV; of those, approximately 240,000 are unaware of their HIV-positive status. Increasing the number of persons who are aware of their status is a critical strategy for preventing HIV infections. As of 2008, over half a million African Americans are estimated to be infected with HIV, with 21.4% undiagnosed. To increase awareness 27 P a g e

28 of HIV status, CDC established the Expanded Testing Initiative (ETI), under which three programs have been launched. In 2007, CDC implemented PS Expanded and Integrated Human Immunodeficiency Virus (HIV) Testing for Populations Disproportionately Affected by HIV, Primarily African American. It was followed by PS : Expanded Human Immunodeficiency Virus (HIV) Testing for Disproportionately Affected Populations ( ), which in turn was incorporated into PS : Comprehensive Human Immunodeficiency Virus (HIV) Prevention Programs for Health Departments ( ). Overall, ETI is aimed at (1) significantly increasing the number of persons tested in jurisdictions with a high rate of HIV among disproportionately affected populations and (2) supporting implementation of the Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. GUIDELINES AND RECOMMENDATIONS The Centers for Disease Control and Prevention and other federal government agencies have issued several guidelines and recommendations about the prevention, screening, diagnosis, treatment, and management of HIV infection and HIV-related diseases in the United States and dependent areas. These guidelines and recommendations are intended for clinicians, public health professionals, program managers in clinical and non-clinical settings, persons at risk for HIV infection, and the general public. Implementation of guidelines and recommendations should also consider other standards, best practices, regulations, policies, and laws articulated by state and local government jurisdictions, public health authorities, health systems, and public and private sector programs and insurers that provide or cover costs of health services. HIV screening and testing guidance continues to evolve with changes in testing technology and methods to reach persons who can benefit from 28 P a g e

29 these services. Currently, CDC is updating recommendations for HIV testing outside of healthcare facilities and diagnostic HIV testing in laboratories in collaboration with federal and non-federal partner organizations. 29 P a g e

30 REFERENCES Centers for Disease Control and Prevention (CDC). (2013). HIV in the United States: At A Glance. Retrieved May 12, 2014, from Centers for Disease Control and Prevention (CDC). (2013). HIV Among African Americans. Retrieved May 12, 2014, from Centers for Disease Control and Prevention (CDC). (2013). HIV Among African American Gay and Bisexual Men. Retrieved May 12, 2014, from Centers for Disease Control and Prevention (CDC). (2013). HIV Among Native Hawaiians and Other Pacific Islanders in the United States and Dependent Areas. Retrieved May 12, 2014, from Centers for Disease Control and Prevention (CDC). (2013). HIV Among Asians in the United States and Dependent Areas. Retrieved May 12, 2014, from Centers for Disease Control and Prevention (CDC). (2013). HIV and Risk Behaviors. Retrieved May 12, 2014, from AIDS Update 2014: An Annual Overview of Acquired Immune Deficiency Syndrome, 23/e by Stine. (2014). 30 P a g e