Florida HIV/AIDS

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This fulfills the continuing education requirement of Florida HIV/AIDS for the state of Florida.  

An estimated 1.2 million Americans are living with HIV. As many as 1 in 7 of them do not even know they are infected. The others utilize the healthcare system in a variety of ways, from testing and treatment regimens to hospitalizations for symptoms and opportunistic infections. Healthcare professionals in nearly every setting have the potential to encounter patients with HIV as the disease can affect patients of any age or stage of life (4). Proper understanding of HIV is important in order to provide high-quality and holistic care to these patients. For nurses practicing in the state of Florida, it is also important to understand the laws, statutes, and regulations regarding testing, treatment, reporting, and confidentiality related to Florida HIV and AIDS within the state.  

Introduction   

An estimated 1.2 million Americans are living with HIV. As many as 1 in 7 of them do not even know they are infected. The others utilize the healthcare system in a variety of ways, from testing and treatment regimens to hospitalizations for symptoms and opportunistic infections. Healthcare professionals in nearly every setting have the potential to encounter patients with HIV as the disease can affect patients of any age or stage of life (4). Proper understanding of HIV is important in order to provide high-quality and holistic care to these patients. For nurses practicing in the state of Florida, it is also important to understand the Florida HIV/AIDS laws, statutes, and regulations regarding testing, treatment, reporting, and confidentiality related to HIV and AIDS within the state.  

Today, approximately 1.2 million people in the United States are living with HIV, though 1 in 7 people don’t know it. Rates of infection are not equal across demographic groups, and certain factors may increase a person’s risk (7). Patient information to consider when determining someone’s risk includes:   

• Age: As of 2018, the age group with the highest incidence of new HIV diagnoses is 25-34 years or approximately 36% of new infections. Ages 13-24 are next, though the numbers in this age range are coming down in recent years. From there, the risk seems to decrease as people age, with the 55 years and older group accounting for only around 10% of new diagnoses each year (7).   
• Race/Ethnicity: Currently, the highest rate of new infections is in African Americans, at approximately 45%. This is incredibly high when you consider that African Americans only make up 13% of the general population. This is followed by Hispanic/Latinos at 22% of new infections and people of multiple races at 19% (6).   
• Gender: Men are disproportionately affected by HIV, accounting for five times the amount of new infections as females each year. This data refers to the sex of someone at birth. When looking at the transgender population, there is a nearly equal rate of new infections among those who have transitioned male-to-female and female-to-male. Together, transgender people account for 2% of new cases in 2018 (6).   
• Sexual Orientation: Gay and bisexual men remain the population most at risk of HIV, accounting for around 69% of all new infections in 2018 and 86% of all males diagnosed. Similar racial and ethnic disparities affecting all people with HIV still existed among gay and bisexual men (6).   
• Location: Different areas of the country are affected at different rates for a variety of factors, including population density, racial distribution, and access to healthcare. The southern states are unmistakably more affected than other regions, with anywhere from 13-45 people per 100,000 having a diagnosis of HIV. California, Nevada, New York, and DC all having similar rates of infection as the southern states and are among the highest in the country. The Midwest and Pacific Northwest are next most affected, with 9-13 people per 100,000. The Northeast and Northwest have the lowest rates nationally at just up to 5 people per 100,000 (6).  

Transmission 

Perhaps the most elusive part of this virus for many years was how it spreads. We now know that HIV is spread only through certain bodily fluids. An accurate understanding of HIV transmission is important for healthcare professionals to provide proper education to their patients, reduce misconceptions and stigmas, and prevent transmission and protect themselves and other patients (8).  

Bodily fluids that can transmit the virus include:   

• Blood  
• Semen and pre-seminal fluid  
• Rectal fluid  
• Vaginal fluid  
• Breastmilk  
• Fluids that may contain blood such as amniotic fluid, pleural fluid, pericardial fluid, and cerebrospinal fluid   

If one of these fluids comes in contact with a mucous membrane such as the mouth, vagina, rectum, etc., or damaged tissue such as open wounds, or is directly injected into the bloodstream, then transmission of HIV is possible (8).  

Scenarios where transmission is possible include:   

• Vaginal or anal sex with someone who has HIV (condoms and appropriate treatment with antivirals reduce this risk)  
• Sharing needles or syringes with someone who has HIV  
• Mother-to-child transmission during pregnancy, delivery, or breastfeeding (appropriate treatment during pregnancy, c-section delivery, and alternative feeding methods reduce this risk)  
• Receiving a transfusion of infected blood or blood products (this is very rare now because of screening processes for blood donations)  
• Oral sex with someone who has HIV (though this is very rare)  
• A healthcare worker receiving a needle stick with a dirty sharp (risk of transmission is very low in this scenario)  

HIV cannot be transmitted via:   

• Saliva  
• Sputum  
• Feces  
• Urine  
• Vomit  
• Sweat  
• Mucous   
• Kissing  
• Sharing food or drink  

Reducing Transmission & Infection Control 

Patient education about risk and protection against HIV, testing, and what to do if exposed should be standard practice for healthcare professionals in nearly all healthcare settings. Primary care should include risk screenings and patient education routinely to ideally help prevent infections from even occurring or catch those that have occurred early on in the disease process (8).  

 Strategies include:   

• Identifying those most at risk, including gay or bisexual men, minority patients, and those using drugs by injection  
• Ensure patients are aware of and have access to protective measures such as condoms and clean needle exchange programs  
• Provide routine screening blood work for anyone with risk factors or desiring testing  
• Providing access to PrEP medications where indicated (discussed further below)  
• Staying up to date on current CDC recommendations and HIV developments  
• Maintaining a nonjudgmental demeanor when discussing HIV with patients to welcome open discussion (8)   

For patients with a repeated or frequent high risk of HIV exposure, such as those with an HIV+ partner or those routinely using IV drugs, pre-exposure prophylaxis (PrEP) may be a good choice to reduce the risk of them contracting the virus. When used correctly, PrEP is 99% effective at preventing infection from high-risk sexual activity and 74% effective at preventing infection from injectable drug use. Depending on the type of exposure risk (anal sex, vaginal sex, needle sharing, etc.), PrEP needs to be taken anywhere from 7-21 days before it reaches its maximum effectiveness. Most insurances, including Medicaid programs, cover PrEP at least in part. There are also federal and state assistance programs available to make PrEP available to as many people who need it as possible. Some side effects are commonly reported, primarily GI symptoms, headaches, and fatigue (8).   

For those who have a confirmed diagnosis of HIV, the focus should be promoting interventions that will prevent further transmission. One of the biggest determinants for transmission is the infected person’s viral load. Individuals being treated for HIV can have their viral load measured to ensure viral replication is being controlled as intended. A viral load lower than 20-40 copies per milliliter of blood is considered undetectable, meaning the virus is not transmissible to others. Even for those not receiving treatment, there are methods to reduce transmission (8).  

Methods of infection control for healthcare professionals include:  

• Universal precautions when handling any bodily fluids  
• Eyewear when at risk for fluid splashing  
• Careful and proper handling of sharps  
• Facilities having a standard plan in place for potential exposures  

If exposure or needlestick do occur for healthcare professionals, the patient would ideally submit to testing for HIV to determine if the staff member is even at any risk. If the HIV status of the patient is unknown or confirmed to be positive, four weeks of post-exposure prophylaxis (PEP) may be advised within 72 hours of exposure (8).

Florida HIV/AIDS Treatment

 When HIV is appropriately treated, advancement from HIV to AIDS can be significantly reduced, and quality and longevity of life maximized. In 2018, the CDC estimated around 65% of all US citizens living with HIV were virally suppressed, and 85% of those receiving regular HIV-related care were considered virally suppressed. However, an estimated13% of all HIV cases do not know they are infected. Appropriate medical care and keeping viral loads undetectable is one of the single most effective methods of preventing transmission (4, 5).   

For those receiving treatment, a multifaceted and individualized approach can reduce a person’s viral load, reduce the risk of transmission, reduce the likelihood of developing AIDS, and preserve the immune system. Regardless of how early someone receives treatment, there is no cure for HIV, and an infected person will be infected for life. All individuals diagnosed with HIV (even asymptomatic people, infants, and children) should receive antiretroviral therapy (ART) as quickly as possible after a diagnosis of HIV is made.  

Classes and Available Medications for ART (1)

Nucleoside reverse transcriptase inhibitors (NRTIs): these inhibit the transcription of viral RNA to DNA  

• Abacavir (Ziagen)  
• Emtricitabine (Emtriva)  
• Lamivudine (Epivir)  
• Tenofovir disoproxil fumerate (Viread)  
• Zidovudine (Retrovir)  

Non-nucleoside reverse transcriptase inhibitors (NNRTIs): these inhibit the transcription of viral RNA to DNA  

• Doravirine (Pifeltro)  
• Efavirenz (Sustiva)  
• Etravirine (Intelence)  
• Nevirapine (Viramune, Viramune XR)  
• Rilpivirine (Edurant)  

Protease inhibitors: inhibit the final step of viral budding  

• Atazanavir (Reyataz)  
• Darunavir (Prezista)  
• Fosamprenavir (Lexiva)  
• Ritonavir (Norvir)  
• Saquinavir (Invirase)  
• Tipranavir (Apitvus)  

Fusion inhibitors: prevent the virus from fusing with CD4-T cells  

• Enfuvirtide (Fuzeon)  

Integrase strand transfer inhibitors (INSTIs): these stop HIV from inserting its DNA into cells  

• Dolutegravir (Tivicay)  
• Raltegravir (Isentress, Isentress HD)  

Chemokine receptor antagonists (CCR5 antagonists): prevent the virus from binding to CD4-T cells  

• Maraviroc (Selzentry)  

Entry inhibitors: prevent the virus from binding to and entering cells  

• Ibalizumab-uiyk (Trogarzo) (1)  

Florida HIV/AIDS Laws

The Omnibus AIDS Act is based on the premise that illness can be best controlled through public knowledge. If the public is aware of potential illness, and ways to avoid contracting and transmitting illness, that is the best method of prevention and further spread (2). The state of Florida became one of the first states with high rates of HIV infection within their population to enact legislation surrounding the AIDS epidemic. This necessitates the need for strict Florida HIV/AIDs laws and regulations.  Transmission of HIV, as aforementioned, occurs through direct contact with virus-containing body fluids. Activities by which transmission involves such as sexual activity, needle stick, blood transfusion, or mother to baby, the government cannot regulate. Therefore, the governmental response to a disease epidemic must rely primarily upon the education of the public and its cooperation with their educational efforts and recommendations (2).  

Protocols and Procedures for Testing in Florida HIV/AIDS

Healthcare providers performing HIV tests must have advanced procedures in place regarding patient consent, testing samples, and informing patients of their results (2). The informed consent requirement based on the Omnibus act allows the patient to control when and where an HIV test can occur (2).  

Health care providers must: (2) 

1. Disclose that they, as the healthcare provider, are required by law to report the patient‘s name to the local county health department if the HIV test results as positive. 
2. Alert the patient that they may secure an HIV test at a testing site that performs anonymous testing, which the provider is required to make available. 
3. Explain that the information identifying the patient and the results of the test are confidential and protected. 

The rule that parental consent is required before medical diagnosis or treatment of a minor does not apply when sexually transmitted diseases are involved (2). Florida HIV/AIDS laws expressly forbid telling parents information relating to the minor‘s consultation, examination, or treatment for an STD such as an HIV infection, either directly or indirectly (2). The state of Florida does not require providers to have the patient sign a written document authorizing the test. The health care provider is only responsible for entering a note within the patient’s medical record that the test was explained and verbal consent was obtained (2).  

Exceptions to Informed Consent Requirements by HCP’s (2) 

Pregnancy: in 2005, the Florida HIV/AIDS statute was amended to establish the system of “opt out“ testing. In this system, pregnant women are advised that the HCP will conduct an HIV test. However, they have a right of refusal. If an objection is present, it is required in writing to be placed within the patient‘s medical record. The rule 64D-2.004, FAC, also requires to repeat testing procedures at 28-32 weeks gestation for all STD‘s including HIV (2).  

Emergencies: A provider can test without consent in a medical emergency only if the provider documents it within the medical record that the results are medically necessary to provide appropriate treatment to the patient if they are unable to consent. This is based on §381.004(3)(h)3, FS. 

Therapeutic Privilege: Therapeutic Privilege bypasses informed consent requirements when the provider‘s medical record documents that obtaining informed consent would be detrimental to the health of a patient suffering from an acute illness and that the test results are necessary for medical diagnostic purposes to provide appropriate treatment to the patient. This is based on §381.004(3)(h)4, FS.  

Sexually Transmissible Diseases: The state law of Florida permit HIV testing for HIV on specific subjects such as convicted prostitutes (§796.08, F.S.), inmates prior to release (§945.355, FS), and cadavers over which a medical examiner has asserted authority(§381.004(3)(h)1.c) without the consent of the subject.  

Criminal Acts: Victims of criminal offenses involving transmission of body fluids may require the person convicted or charged of the offenses to be tested for HIV by requests of a court order (§960.003(2), FS 

Organ and Tissue Donations: Provisions permit testing without informed consent with certain blood and tissue donations (§§381.004 (3), 5 and 9, FS. 

Research: Established epidemiologic research methods that ensure test subject anonymity is expected from informed consent (§381.004(3)(h)8, FS) 

Abandoned Infants: When a physician determines that it is medically indicated that a hospitalized infant have HIV test, but the infant‘s parents or legal guardian cannot be located after reasonable attempts, the test may be performed without consent, with the reason being documented in the medical record and the test result being provided to the parent or guardian once they are located (§381.004(3)(h)13, FS). 

Significant Exposure: the blood source of significant exposure to medical personnel or to others who render emergency medical assistance may be tested without informed consent (§381.004(3)(h)10-12, FS).  

Repeat HIV Testing: Renewed consents agree not required for repeat HIV testing to monitor the clinical progress of a previously diagnosed HIV-positive patient (§§381.004(2)(h)14 and 15, FS.) 

Judicial Authority: a court may order an HIV test to be performed without the individual‘s consent (§381.004(3)(h)7, FS).

Florida HIV/AIDS Confidentiality

If an HIV test was performed on an identifiable individual, and any “HIV test result“ (negative or positive) is specially protected (§381.004(2)(e), FS). The state of Florida defines the definition of an HIV test and an HIV test result explicitly.  An HIV test, as defined by the Florida HIV/AIDS Statutes, is “a test ordered after July 6, 1988, to determine the presence of the antibody or antigen to human immunodeficiency virus or the presence of human immunodeficiency virus infection (2).” An HIV test result as defined by the Florida statutes is “A laboratory report of a human immunodeficiency virus test result entered into a medical record on or after July 6, 1988, or any report or notation in a medical record of a laboratory report of a human immunodeficiency virus test (2).“ 

The results are excluded as an acceptable “HIV test result“ if a patient reports of their HIV– test status from Department of Health anonymous testing sites, from home access HIV test kids, or from any other sources that do not constitute “HIV test results“ unless separately confirmed by the provider through a laboratory report or as a medical record (2) 

Any patient disclosures of an HIV test or positive infection to any persons other than health care providers caring for the patient under the provisions of the Omnibus Act also do not fall within the statute‘s special confidentiality protections.  

Voluntary Partner Notification

The person ordering the HIV test is required to advise their patients with HIV-positive test results of the importance of notifying partners who may have been exposed (2). Practitioners are also advised to tell the patient of the availability of voluntary partner notification services provided by the Department of Health. When notifying partners, county health department staff are required NOT to reveal the original client’s identity. Partner notification makes persons aware of their potential exposure to HIV, providing them with referrals to testing, treatment options, and other services (§381.004(3)(c), FS). Notification services also benefit the community by leading to earlier HIV identification and treatment of previously undiagnosed cases of HIV.  

Florida HIV/AIDS Infection Reporting 

Florida was one of the first states with a high incidence of HIV infection to authorize regulatory procedures requiring physicians and labs to report to local health authorities HIV-positive test results (§384.25, FS). Per Florida HIV/AIDS law, practitioners and clinical labs that fail to report HIV positive test results are subject to a $500 fine along with disciplinary action by their individual licensing boards (§384.25, FS) (2,3) 

The Ryan White CARE Act, which was enacted in 1990 and reauthorized in 2009 as the Ryan White HIV/AIDS Treatment Extension Act, provides funding to urban areas, states, and localities to improve the availability of care for low income, uninsured and under-insured AIDS and HIV-infected patients and their families (2).  

Florida HIV/AIDS infection reporting requirement increases the funding for persons with the illness and enables the HOH to link them to medical support and services in the early stages of infection.  

Under the rules by the DOH of Florida (2,3):  

1. Practitioners must report to their local county health department within two weeks of the HIV-positive diagnosis of all persons, EXCEPT infants born to HIV-positive women, which must be reported the next business day (Rule 64D-3.029, FAC and Rule 64D-3.030(5), FAC.) 
2. Clinical laboratories must report to the local health department HIV test results from blood specimens within three days of diagnosis (Rule 64D-3.029, FAC.) 

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