| According to Gerberding and Schecter, a particular study reviewing needle stick
exposures among surgical staff at Grady Memorial Hospital in Atlanta from 1988 to 1989 led
to the observation that a higher perceived caseload of at-risk HIV-infected persons among
surgeons at a hospital such as San Francisco General Hospital may likely lead to fewer
exposures compared with a hospital with a lower perceived risk, such as Grady Memorial. The message should be that if all patients are considered potentially HIV infected, safer techniques will then be practiced. Experience has shown that care is always taken with documented HIV-infected patients but not with those unsuspected of being infected; this latter group, course, represents the greatest risk.
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Screening With these demographics in mind, the following populations should be screened for HIV : persons with sexually transmitted diseases, past or present injecting drug use (regardless of how long ago), and persons who consider themselves at risk. A large percentage of people who present to be tested on their own volition may have a risk factor they do not readily admit to, and adequate counseling should be provided. Other groups include selected women of childbearing age who use injecting drugs, engage in commercial sex, live in a community with a high prevalence of HIV infection, or have at-risk sex partners. |
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| This last group should be emphasized among physicians and counselors because it represents a significant risk category that is often not considered. Certain medical conditions that can suggest HIV infection or cause complications as a result of infection, such as tuberculosis or hepatitis B, should prompt consideration for screening. Finally, for reasons that will be discussed shortly, all pregnant women should be screened. | |||
| According to assessments by Hammer and Gulick and their associates, the benefits of
HIV testing are more relevant now than ever before, mainly because of the development of
potent antiretroviral agents called protease inhibitors. Since their first use in late
1995, these agents, in combination with reverse transcriptase inhibitors (RTIs), have made
a greater impact on halting the progression of AIDS than any other intervention since the
beginning of the epidemic. Although these drugs have led to a clinical response at
all stages of disease, their success is more profound and longer-lasting when applied in
the earlier stages, thus making timely diagnosis all the more crucial.
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| HIV testing also provides the opportunity for patient
education, particularly if the test result is negative. It allows for contact notification
to reduce spread of the disease and permit early recognition of infection in others.
Testing also enables persons to enter into health care management planning and thus reduce
medical complications and address social problems that may have magnified the clinical
problems.
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| One area that has made such a great impact in preventing infection that established guidelines are strongly recommended is that involving infected pregnant women. The ACTG 076 study found that providing zidovudine to HIV-1 infected pregnant women and their newborns reduces the risk of vertical transmission threefold, from 25% to 8%, which is a significant change. |
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| According to a 1994 MMWR report, this has led to at least one state requirement to request HIV-1 antibody testing for all pregnant women. |
| In situations where the woman is found to be HIV positive, oral zidovudine in a dosage of 100 mg 5 times a day is initiated at 14 to 34 weeks of gestation and continued throughout the pregnancy. Shorter courses are being studies in developing countries. Although five-times-a-day dosing is not routinely used in nonpregnant patients at the present time, it was standard practice at the time the study was done; whether the latest twice-daily and thrice-daily dosing regimens would accomplish the same effect is presently being investigated. During labor, intravenous zidovudine in a 1-hour loading dose of 2 mg/kg of body weight is given, followed by a continuous infusion of 1 mg/kg of body weight per hour until delivery. |
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| Oral administration of zidovudine syrup at 2 mg/kg of body weight per dose every 6 hours is given to the newborn, beginning 8 to 12 hours after birth and continuing for 6 weeks. | ||
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