Race and ethnicity, by themselves, are not risk factors for HIV infection. However, the CDC studies have concluded that even though HIV testing rates are higher for African Americans than for other racial and ethnic groups African Americans are more likely to face challenges associated with risk for HIV infection, including the following.

African American women are most likely to be infected with HIV as a result of sex with men. They may not be aware of their male partners' possible risks for HIV infection, such as unprotected sex with multiple partners, bisexuality, or injection drug use. In a study of HIV-infected persons, 34% of African American men who have sex with men (MSM) reported having had sex with women, even though only 6% of African American women reported having had sex with a bisexual man.

Not knowing one's HIV serostatus is risky for African American men and their partners. In a recent study of MSM in 5 cities participating in CDC's National HIV Behavioral Surveillance, 46% of the African Americans were HIV-positive, compared with 21% of the whites and 17% of the Hispanics. The study also showed that of the participating MSM who tested positive for HIV, 64% of the African American men, 18% of the Hispanic men, 11% of the white men, and 6% of multiracial/other men were unaware of their HIV infection.

Injection drug use is the second leading cause of HIV infection for African American women and the third leading cause of HIV infection for African American men. In addition to being at risk from sharing needles, casual and chronic substance users are more likely to engage in high-risk behaviors, such as unprotected sex, when they are under the influence of drugs or alcohol. Drug use can also affect treatment success. A recent study of HIV-infected women found that women who used drugs, compared with women who did not, were less likely to take their antiretroviral medicines exactly as prescribed.

The highest rates of sexually transmitted diseases (STDs) are those for African Americans. In 2003, African Americans were about 19 times as likely as whites to have gonorrhea and about 6 times as likely to have syphilis. Partly because of physical changes caused by STDs, including genital lesions that can serve as an entry point for HIV, the presence of certain STDs can increase one's chances of contracting HIV 3- to 5-fold. Similarly, a person who has both HIV and certain STDs has a greater chance of spreading HIV to others.

Studies show that a significant number of African American MSM identify themselves as heterosexual. As a result, they may not relate to prevention messages crafted for men who identify themselves as homosexual.

In 1999, nearly 1 in 4 African Americans were living in poverty. Studies have found an association between higher AIDS incidence and lower income. The socioeconomic problems associated with poverty, including limited access to high-quality health care and HIV prevention education, directly or indirectly increase HIV risk.

The CDC's HIV mission is to prevent HIV infection and reduce the incidence of HIV-related illness and death, in collaboration with community, state, national, and international partners. CDC's programs work to improve treatment, care, and support for persons living with HIV and to help build capacity and infrastructure to address the HIV/AIDS pandemic.

The CDC has concluded that there are many benefits to early knowledge of HIV infection, including early entry into treatment to prevent illnesses that arise from a weakened immune system, treatment of other conditions like substance abuse and sexually transmitted diseases, and access to social services and medical treatments, when appropriate. HIV-infected persons in care are now living longer than before thanks to new highly effective treatments.

About 40% of HIV-infected persons first find out that they have HIV less than 1 year before AIDS diagnosis. On average, it takes 10 years after HIV infection for symptoms of AIDS to appear. People who have their first HIV test close to getting an AIDS diagnosis have been infected and not known it, possibly for many years, potentially passing the infection to their partners. Early diagnosis of HIV enables infected persons and those close to them to take steps to prevent transmission.

If a person with HIV is tested, learns of his or her status, and has access to appropriate treatments, the amount of virus in the body can be reduced, which may decrease the risk for transmission to partners. This reduction of HIV transmission is most clearly seen in reducing transmission of HIV from mother to child by treating pregnant women who are HIV positive.

Advancing HIV Prevention

To reduce further the incidence of HIV, CDC announced a new initiative, Advancing HIV Prevention (AHP). This initiative comprises 4 strategies: making HIV testing a routine part of medical care, implementing new models for diagnosing HIV infections outside medical settings, preventing new infections by working with HIV-infected persons and their partners, and further decreasing perinatal HIV transmission.

1. Incorporate HIV testing as a routine part of care in traditional medical settings. CDC will issue recommendations strongly encouraging all health care providers to include HIV testing, when indicated, as part of routine medical care, like other routine medical tests by:

• Promoting removal of real and perceived barriers to routine testing, including "de-coupling" HIV tests in the medical setting from extensive, pre-test prevention counseling. In some jurisdictions, statutory requirements, e.g. for pretest counseling, can serve as barriers to testing.
• Working with professional medical associations and others to promote adoption of the recommendations. CDC will work with public and private payors to promote appropriate reimbursement incentives.

2. Implement new models for diagnosing HIV infections outside medical settings. Some persons infected with HIV do not have access to traditional medical settings. CDC will create new program models to increase HIV testing in high-prevalence, non-medical settings by:

• Encouraging the use of the HIV rapid test.
• Funding pilot projects, aimed at identifying the most effective models for HIV diagnosis and referral for medical and preventive care which CDC grantees can employ outside traditional medical settings.
• Taking steps to assure that funding is used to support such models through CDC grant programs to health departments and community-based organizations.

3. Prevent new infections by working with people diagnosed with HIV and their partners. CDC will promote preventive and treatment services within and outside traditional medical settings by:

• Working with HRSA to reach those who have been diagnosed with HIV but who are not receiving ongoing treatment and preventive care services
• Conducting demonstration projects through health departments to provide prevention case management and counseling for people living with HIV.
• CDC will standardize new procedures for prevention interventions and evaluation activities to assure that such measures are both appropriate and effective. In accordance with these new procedures, CDC will broadly implement prevention services for people living with HIV through health departments and community-based organizations by refocusing CDC funding on activities with proven effectiveness.
• CDC will assure that requirements related to partner notification in grant guidance are fully met so that this recognized technique of infection control is optimally employed. Additionally, CDC will pilot new approaches to partner notification, including offering rapid HIV testing to partners and using peers to conduct appropriate partner notification, prevention counseling, and referral.

4. Further decrease mother-to-child HIV transmission. Treatment of pregnant women and their infants can substantially reduce the number of babies born with HIV infection. Such interventions are most effective when the HIV status of the pregnant woman is known as early as possible in pregnancy -and if not known-when the baby can be tested at the time of birth. CDC will:

• Promote screening of every pregnant woman for HIV, using the "opt-out" approach. Make prenatal HIV screening a routine part of medical care.
• Promote screening of newborns whose mothers HIV status is not known.

Someone might have HIV and still feel perfectly healthy. The CDC recommends that the only way to know for sure if they are infected or not is to be tested.

Of new cases, a disproportionate number are in persons who do not know they are infected. The CDC reports that each year at publicly funded testing sites, 27,000-30,000 HIV test results are positive. Of those who test positive at CDC-funded public testing sites, 31% do not return for their results.

To reduce barriers to early diagnosis of HIV infection and increase access to treatment and prevention services, the CDC announced a new initiative, "Advancing HIV Prevention: New Strategies for a Changing Epidemic" (AHP) This multifaceted program stresses the importance of routinely offering HIV testing as part of the medical visit and expands on the 1993 recommendations for testing inpatients and outpatients in acute-care hospital settings Additionally, AHP stresses the importance of using rapid HIV tests to facilitate access to early diagnosis in high prevalence areas, for high-risk individuals, and for women during labor and delivery who have not previously been tested and in nontraditional testing settings.

Rapid HIV tests can play an important role in HIV prevention activities and expand access to testing in both clinical and nonclinical settings. They can help overcome some of the barriers to early diagnosis and improve linkage to care of infected persons. This paper will review the operating and performance characteristics, quality assurance (QA) and laboratory requirements for currently available rapid HIV tests, and counseling implications.

A rapid test is a screening test that produces very quick results, in approximately 20-60 minutes. Rapid tests use blood or oral fluid to look for the presence of antibodies to HIV. As is true for all screening tests, a reactive rapid HIV test result must be confirmed with a follow-up confirmatory test before a final diagnosis of infection can be made. These tests have similar accuracy rates as traditional EIA screening tests.

Four rapid HIV tests have been approved by the US Food and Drug Administration (FDA):

1. OraQuick® (and its newer version OraQuick® Advance) Rapid HIV-1/2 Antibody Test (OraSure Technologies, Inc., Bethlehem, PA);
2. Reveal™ (and its newer version Reveal™ G2) Rapid HIV-1 Antibody Test (MedMira, Halifax, Nova Scotia);
3. Uni-Gold Recombigen® HIV Test (Trinity BioTech, Bray, Ireland);
4. and Multispot HIV-1/HIV-2 Rapid Test (Bio-Rad Laboratories, Redmond, WA).

Like conventional HIV enzyme immunoassays (EIAs), rapid HIV tests are screening tests that require confirmation if reactive. Though each of these rapid HIV tests has unique characteristics, they share many common features, including how the tests work, the use of external controls, and other requirements such as the product information sheets that are provided to patients.

The price for the FDA-approved rapid HIV test kits range from $14 to $25. Costs for multidose external control vials range from $20 to $26.25.

CDC has also established the African American Working Group to focus on the urgent issue of HIV/AIDS in African Americans. The working group will develop a comprehensive response to guide CDC's efforts to increase and strengthen HIV/AIDS prevention and intervention activities directed toward African Americans. Already, CDC is engaged in a wide range of activities to involve community leaders in the African American community and to decrease the incidence of HIV/AIDS in African Americans. For example, CDC will:

• Funds demonstration projects evaluating rapid HIV testing in historically black colleges and universities
• Conducts epidemiologic research focused on African Americans.

Prevention

The CDC recommendations for preventing the spread of HIV are:

• Don't share needles and syringes used to inject drugs, steroids, vitamins, or for tattooing or body piercing. Also, don't share equipment ("works") used to prepare drugs to be injected. Many people have been infected with HIV, hepatitis, and other germs this way. Germs from an infected person can stay in a needle and then be injected directly into the next person who uses the needle.
• The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual intercourse, or to be in a longterm mutually monogamous relationship with a partner who has been tested and you know is uninfected.
• For persons whose sexual behaviors place them at risk for STDs, correct and consistent use of the male latex condom can reduce the risk of STD transmission. However, no protective method is 100 percent effective, and condom use cannot guarantee absolute protection against any STD. The more sex partners one has, the greater the chances are of getting HIV or other diseases passed through sex.
• Condoms lubricated with spermicides are no more effective than other lubricated condoms in protecting against the transmission of HIV and other STDs. In order to achieve the protective effect of condoms, they must be used correctly and consistently. Incorrect use can lead to condom slippage or breakage, thus diminishing their protective effect. Inconsistent use, e.g., failure to use condoms with every act of intercourse, can lead to STD transmission because transmission can occur with a single act of intercourse.
• Don't share razors or toothbrushes because of the possibility of contact with blood.

If a women believes that they are pregnant or think they might be soon, it is recommended that they talk to a doctor or their local health department about being tested for HIV. Drug treatments are available to help and reduce the chance of passing HIV to the baby if they have it.

Highly Active Antiretroviral Therapy (HAART)

Anti-HIV (also called antiretroviral) medications are used to control the reproduction of the virus and to slow the progression of HIV-related disease. Highly Active Antiretroviral Therapy (HAART) is the recommended treatment for HIV infection. HAART combines three or more anti-HIV medications in a daily regimen. How many pills will needed and how often they are taken depends on what medications the doctor chooses.

Anti-HIV medications do not cure HIV infection, and individuals taking these medications can still transmit HIV to others. Anti-HIV medications approved by the U.S. Food and Drug Administration (FDA) fall into four classes:

Each HAART regimen is tailored to the individual patient - there is no one "best" regimen. The individual and their doctor will decide which medications are right. For people taking HAART for the first time, the USFDA recommended regimens are:

• Sustiva + (Epivir or Emtriva) + (Retrovir or Viread)
• Kaletra + (Epivir or Emtriva) + Retrovir

Some people may benefit from a different regimen. Recommended alternative regimens are:

• Sustiva + (Epivir or Emtriva) + (Ziagen or Videx or Zerit)
• Viramune + (Epivir or Emtriva) + (Retrovir or Zerit or Videx or Ziagen or Viread)
• Reyataz + (Epivir or Emtriva) + (Retrovir or Zerit or Ziagen or Videx) or (Viread + low dose Norvir)
• Lexiva + (Epivir or Emtriva) + (Retrovir or Zerit or Ziagen or Viread or Videx)
• Lexiva + low dose Norvir + (Epivir or Emtriva) + (Retrovir or Zerit or Ziagen or Viread or Videx)
• Crixivan + low dose Norvir + (Epivir + Emtriva) + (Retrovir or Zerit or Ziagen or Viread or Videx)
• Kaletra + (Epivir or Emtriva) + (Zerit or Ziagen or Viread or Videx)
• Viracept + (Epivir or Emtriva) + (Retrovir or Zerit or Ziagen or Viread or Videx)
• Invirase + low dose Norvir + (Epivir or Emtriva) + (Retrovir or Zerit or Ziagen or Viread or Videx)

In general, taking only one or two drugs is not recommended because any decrease in viral load is almost always temporary without three or more drugs. The exception is the recommendation for pregnant women, who may take Retrovir alone or with other drugs to reduce the risk of passing HIV to their infants. If you are pregnant or considering becoming pregnant, there are additional treatment considerations.

The person may experience negative side effects (drug toxicity) when they take HIV drugs. Some of these side effects are serious, even life-threatening; the person may have to change drugs due to intolerable side effects. The person and their doctor or pharmacist should discuss the side effects of each medication. Possible side effects of HAART include:

• Liver problems
• Diabetes o abnormal fat distribution (lipodystrophy syndrome)
• High cholesterol o increased bleeding in patients with hemophilia
• Decreased bone density o skin rash o pancreatitis (inflammation of the pancreas)
• Nerve problems Side effects that may seem minor, such as fever, nausea, and fatigue, can mean there are serious problems. Always discuss any side effects you are having with your docto

It is recommended that a person's viral load be tested 2 to 8 weeks after they start treatment, then every 3 to 4 months throughout treatment to make sure the drugs are still working. HIV treatment should reduce the viral load to the point at which it is undetectable. An undetectable viral load does not mean that the HIV infection is gone; it simply means that the test is not sensitive enough to detect the small amount of HIV left in the blood.

If the viral load is still detectable within 4 to 6 months after starting treatment, the person and their doctor should discuss how well the person has adhered to the. Missing medication doses is the most common reason for treatment failure and development of drug resistance. The doctor should do a drug resistance test, which will determine if the HIV in the person's body has mutated into a strain that the current treatment regimen can't control.

How fast or how much the viral load decreases depends on factors other than the treatment regimen. These factors include the baseline viral load and CD4 count, whether the person has taken HIV drugs before, whether they have HIV-related medical conditions, and how closely they have followed (adhered to) the treatment.

CD4 counts also indicate how well the treatment regimen is working. The person's CD4 count should be tested every 3 to 6 months throughout their treatment. HIV treatment should increase the CD4 count or at least keep it from going down.

There are several reasons why the person's treatment regimen may need to change. Two of the most important reasons are drug toxicity and regimen failure.

• Drug toxicity means that your treatment regimen creates side effects that make it difficult for you to take the drugs.
• Regimen failure means that the drugs are not working well enough.

Regimen failure occurs when the anti-HIV medications you are taking do not adequately control the infection. Factors that may cause regimen failure include:

• Poor health before starting the treatment regimen
• Poor adherence to the regimen (not taking medications exactly as instructed by your doctor, including missing doses)
• Previous anti-HIV treatment and/or drug resistance
• Alcohol or drug abuse
• Medication side effects, medication toxicity, or interactions with other medications
• Medication poorly absorbed by the body
• Medical conditions or illnesses other than HIV infection

There are three types of regimen failure

1. Virologic failure: Regimens should lower the amount of HIV in the blood to undetectable levels. Virologic failure has occurred if HIV can still be detected in the blood 48 weeks after starting treatment, or if it is detected again after treatment had previously lowered the viral load to undetectable.
2. Immunologic failure: An effective regimen should increase the number of CD4 cells in the blood or at least prevent the number from going down. Immunologic failure has occurred if the CD4 count decreases below a baseline measurement or does not increase above the baseline count within the first year of therapy.
3. Clinical failure: Clinical failure has occurred if the person experience's an HIV-related infection or a decline in physical health despite at least 3 months of anti-HIV treatment.

Virologic failure is the most common kind of regimen failure. People with virologic failure who do not switch to a more effective drug regimen usually progress to immunologic failure within about 3 years. Immunologic failure may be followed by clinical failure.

Consumer-controlled test kits (popularly known as "home testing kits") were first licensed in 1997. Although home HIV tests are sometimes advertised through the Internet, currently only the "Home Access HIV-1 Test System" is approved by the Food and Drug Administration. The Department of Health and Human Services has allowed the manufacturer to greater than 99.9% accurate.

The Home Access HIV-1 Test System can be found at most local drug stores. It is not a true home test, but a home collection kit. The testing procedure involves pricking a finger with a special device, placing drops of blood on a specially treated card, and then mailing the card in to be tested at a licensed laboratory. Customers are given an identification number to use when phoning in for the results. Callers may speak to a counselor before taking the test, while waiting for the test result, and when the results are given. All individuals receiving a positive test result are provided referrals for a follow-up confirmatory test, as well as information and resources on treatment and support services.

HIV/AIDS Dietetic Practice Group finds that keeping its members current on information related to HIV/AIDS, Hepatitis C and other infectious diseases is crucial to clinical care. The dietetic practice group provides information, research and networking with leaders in this field for those who have made a career change to HIV-related care or occasionally see an HIV-positive patient or would like to become more informed on the role of nutrition in Infectious Disease. Members are active in public policy, advocacy and clinical practice management. (To join the HIV/AIDS DPG, you must be a member of the American Dietetic Association).

The goals of the HIV/AIDS Dietetic Practice Group are:

1. To support and expand a network of dietetics professionals and share information and experiences on the nutritional management of HIV/AIDS, Hepatitis C and other infectious diseases.

2. To create and disseminate a comprehensive quarterly publication that provides nutrition information to members, allied health professionals, and primary care providers in the field of HIV/AIDS management through a variety of communication channels.

3. To inform members of current research in HIV/AIDS nutrition, and to provide support for their participation in research projects through networking and a competitive research grant.

4. To advocate through public policy and education for the integration of nutrition into HIV disease management.

The position of the American Dietetic Association and Dietitians of Canada: Nutrition intervention in the care of persons with human immunodeficiency virus infection is as follows:

The ADA's position paper reports that as new treatment modalities continue to emerge, and the population's experience of the disease changes and becomes more complex health practitioners must work with clients to plan for and respond to these changes. Additional support for research is required to identify the best practices to accomplish appropriate outcomes in health status, quality of life, and disease management. Education for health care practitioners should be a continuous process that integrates research and best practices for clinical and other nutrition-related interventions. In addition, dietetics professionals should have adequate and continuous training in HIV-specific issues to ensure the availability and appropriateness of HIV-targeted and nutrition-related services. Practical issues such as food insecurity and reimbursement for nutrition-related services also need to be addressed to ensure effective and timely interventions for all people living with HIV infection. Collaboration between stakeholders to address education, research, adherence, and advocacy needs can leverage available time and funds.

Nutrition and HIV Disease Interaction

The role of food and nutrition security in maintaining the family unit, preserving livelihood strategies, and prolonging life is an important component in developing countries, in which the very survival of family members and community infrastructure is dependent on passing indigenous survival-related knowledge to future generations. In developing, transitional, and developed countries, poor nutritional status can be related to psychosocial and economic issues. Lack of education, food access, economic support, and access to health care services may increase the risk of malnutrition.

Achieving optimal nutritional status is a challenge for anyone living with HIV. The Committee on World Food Security's 2001 paper, "The Impact of HIV/AIDS on Food Security," states: "All dimensions of food security-availability, stability, access and use of food-are affected where the prevalence of HIV/AIDS is high". As such, the nutritional issues facing HIV-affected populations challenges the development and implementation of resolutions to the problem of world hunger and malnutrition. Many people with AIDS face hunger and multiple barriers to food and nutrition security. Coupled with their HIV status and the disease's complications, some people are facing economic insecurity, social isolation and stigmatization, incarceration or other institutionalization, inadequate cooking skills and facilities, limited food availability and dietary diversity, substance use, and coinfections and other illnesses, including mental illness and disabilities. Food represents more than a vehicle to deliver nutrients, and having food security includes being able to access food with dignity.

Safe access to appropriate food in an acceptable environment is an important part of improving and maintaining physical and emotional health. Discussing and resolving barriers to food security is an essential step in improving health status. The American Dietetic Association's (ADA) papers on domestic and global food and nutrition security exhort dietetics professionals to build food and nutrition security through competent and collaborative practice as a part of the health care team as well as client advocacy ). In an effort to reduce the incidence of hunger 50% by 2015, both the United States and Canada signed a final declaration of the World Food Summit to work collaboratively with 182 other countries.

The effects of HIV and its complications on nutritional status and the effect of nutritional status on HIV disease progression have been explored. A well-nourished HIV-positive person with a controlled viral load is more likely to be able to withstand the effects of HIV infection. However, macronutrient and micronutrient needs may increase significantly with one or a combination of these interrelated factors: a high viral load associated with a decline in immune function, ineffective treatment regimens, viral resistance, and/or active secondary infections. Men, women, and children have specific nutrition considerations that must be addressed with the patient's sex and age in mind. Men, women, and children with HIV/AIDS are at risk for compromised nutritional status, although the type and severity of malnutrition may vary from macronutrient and micronutrient deficits to altered nutrient metabolism.

Nutritional status, specifically the maintenance of weight and crucial body-protein stores (body cell mass), affects a person's ability to survive HIV disease. With a loss of body cell mass to a level of 54% of the expected value based on height, death is likely to occur in HIV-infected patients regardless of the presence or absence of infectious complications. Because metabolism of nutrients and medications occurs primarily in the body cell mass compartment (composed mostly of organ and muscle tissues), knowledge and preservation of these body tissues may support the efficacy of medication therapies. It is likely that there are a combination of mechanisms for weight and protein losses, including a loss of appetite and increased use associated with inflammatory responses. Negative nitrogen balance and weight losses are correlated. It is expected that 80% to 90% of weight loss during acute events is accounted for by protein losses, whereas less protein is lost during the starvation process. During critical events, both nutrition and other medical therapy strategies are required to achieve disease management goals, including the preservation of crucial body cell mass stores. Diets high in both calories and protein may be required to improve the body's response to the challenge of symptomatic HIV infection.

Starvation-style malnutrition can result from malabsorption of nutrients. Malabsorption-particularly fat malabsorption-seems to occur throughout the disease process and is not always accompanied by diarrhea or other typical symptoms. Villous atrophy, intestinal cell maturation defects, increased gut permeability, autonomic neuropathy, and gastrointestinal pathogens have all been documented with malabsorption throughout the disease. It has also been suggested that activation of gut immunity and the inflammation that results can contribute to malabsorption.

Infectious disease can lead to a cascade of events such as anorexia, diarrhea, and an inflammatory response causing a preferential loss of nitrogen stores, even early in the disease process and during asymptomatic phases. The cascade of events that occurs as part of the inflammatory and immune response to infection is dependent on the severity of the infection and may include the preferential and rapid loss of lean body mass. Seminal research examining cortisol levels and immune function suggests that psychological stress, as an inducer of the physiologic stress response, may contribute to metabolic alterations and subsequently to lean tissue losses. Although of interest, empirical evidence has not yet accrued to support this hypothesis. The loss of lean tissue central to body metabolism may be present throughout the disease process, regardless of weight maintenance, suggesting that weight is not a good early indicator of declining nutritional status. Differences in sex seen in HIV infection have suggested that a large proportion of the weight loss in female patients may come from the fat compartments. Fat tissue losses can also alter metabolic stability.

In addition to nutrition and disease interaction, the health care professional must consider the nutritional interactions with treatment regimens. It is apparent that the efficacy of antiretroviral and other medications is important to nutritional status maintenance. There are currently four classes of antiretroviral medications: nucleoside reverse transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, protease inhibitors, and fusion inhibitors. Lifelong pharmacotherapy with combinations of these medications may be required for continuous disease management and presents challenges to nutrition status maintenance by introducing potential interactions with food, body metabolism, and side effects. Potential side effects may be reduced in incidence or severity with nutrition status maintenance and strategies aimed at symptom management. Nutrients and nutritional status can affect medication absorption, use, elimination, and tolerance. Developing meal plans to support medication regimens may include meal timing, macronutrient and micronutrient modulation, and symptom management strategies. Nonnutrient therapies may be required to manage nutrition-related adverse effects of treatment, including exercise and medications.

Metabolic abnormalities, including changes in organ or other tissue function, leading to altered utilization, storage, and excretion of nutrients, may occur as a result of immune dysfunction, medication side effects, infection, or alterations in the hormonal milieu, or through the effects of HIV itself in adults and children. Since the introduction of highly active antiretroviral therapy (HAART), altered patterns of body composition (eg, peripheral loss of fat [lipoatrophy] and central fat deposition [lipohypertrophy]), metabolic abnormalities of elevated blood lipids, altered insulin sensitivity or glucose dysregulation, mitochondrial toxicity, and lactic acidosis have been reported. Some of these problems may have occurred independently and before the use of these therapies. An increase in longevity suggests that both clients and health care professionals will have to address these chronic metabolic and physical alterations as a part of routine health care provision.

Support to reduce or eliminate malnutrition shows the potential to significantly slow progression of disease, decrease its severity, and improve longevity. Individualized care that integrates medical and social services and is delivered by health care professionals with HIV experience, training, and expertise is necessary for optimally managing HIV disease. Dietetics professionals and other health care professionals involved in evaluation and intervention will need to be well versed in issues specific to HIV infection and its treatment as well as sensitive to privacy and disclosure of an HIV diagnosis. The HIV care provider should be comfortable in providing services to people with HIV infection without judgment.

Nutrition plays an essential role in supporting the health and quality of life of people with HIV disease. Nutritional alterations can occur early in HIV infection, thus, nutrition intervention should begin soon after diagnosis. The negative effects of malnutrition are often preventable and are usually not easily reversed.

A complete baseline nutrition assessment should be performed as part of the multidisciplinary care plan development, with regular follow-up as indicated. For optimal care, a dietetics professional should perform nutrition evaluation and follow-up. There are many formats for nutrition evaluation, including the "ABCD" nutrition evaluation of anthropometric, biochemical, clinical, and dietary parameters. The dietetics professional or other qualified clinician may use these assessment parameters in partnership with clients to form the basis for the nutrition care plan.

The AIDS-related wasting syndrome is defined by the CDC as a 10% weight loss from baseline in a 6-month period accompanied by diarrhea or fever for more than 30 days without a known cause. Although the rate of opportunistic infections has decreased in the last few years, the incidence of AIDS-related wasting syndrome according to this AIDS-defining diagnosis seems to have held steady. Malnutrition is not an AIDS-defining diagnosis at this time. Recommendations for a revision to the current CDC definition include time frames for weight loss and body composition alterations, with specific attention to the body cell mass compartment, to identify detrimental wasting of lean tissues that may occur even without weight loss. Anthropometrics are measures of body weight, dimension, and subcutaneous fat stores.

The manifestation of wasting has changed in the HAART era. Clients may experience body composition changes such as lean tissue wasting or lipodystrophy, which are not reflected as weight change and may not be identified in a weight record. Body composition changes characterized as lipodystrophy syndrome may involve fat accumulation in the abdomen, dorsocervical, and breast areas, and subcutaneous fat loss in the limbs and face. Screening and monitoring of wasting, lipodystrophy, and other body changes can be accomplished using measures of body composition, including anthropometrics, bioelectric impedance analysis, computed tomography scans, magnetic resonance imaging, and dual energy x-ray absorptiometry scans. The choice of diagnostic techniques should be appropriate for the problems experienced by the client. Although anthropometrics can provide important insight into nutritional status and alterations in body dimensions and composition, the clinician (includes dietetics professional, physician, nurse or nurse practitioner, physician assistant, and others) should be sensitive to the client's body image and self-esteem. The health care provider and the client should make informed decisions together about the use of anthropometrics to determine problems and monitor treatment.

The clinician should also determine the client's usual physical activity level, which may have an impact on the ability to prevent and treat wasting, alterations in body fat deposition, and other long-term complications of HIV disease and treatment. Limitations in physical activity should be noted, including barriers such as peripheral neuropathy and fatigue. These barriers should be further explored to determine the potential role for nutrition-related problems of anemias, vitamin B-12 alterations, and vitamin B-6 deficiency and toxicity.

Biochemical assessment provides laboratory measurements of serum protein, lipids, and micronutrients. Indicators of disease complications and prognosis include nutrition-related laboratory values such as albumin, transthyretin, hemoglobin, hematocrit, creatinine, urea nitrogen, transferrin, glucose, vitamin B-12, C-reactive protein, and other. For instance, alterations in nutrition-related laboratory values may reflect inflammatory responses rather than purely nutritional compromise. Alterations in micronutrient and macronutrient metabolism such as zinc, iron, selenium, vitamin B-12, carbohydrate, and fat have been reported during asymptomatic and symptomatic disease states. Zinc and albumin may decrease rapidly during the physical stress of infection and quickly increase when an infection is resolved. Iron may be shunted to a storage form during inflammation. Various types of anemias occur with chronic HIV infection and may sometimes include anemias associated with nutrient deficiencies, but more often may reflect anemias of chronic disease and related to medication interactions. Although shifts in nutrient levels may not represent deficiency, other body tissues, such as blood, may be at risk for depletion of shunted nutrients.

Low levels of micronutrients are common because of malabsorption, alterations in metabolism, and accelerated turnover. Regular measures of albumin, transthyretin, hemoglobin, serum iron, total iron-binding capacity, magnesium, vitamin levels, trace elements, cholesterol, C-reactive protein, triglycerides, fasting glucose, CD4 and CD8 immune cells, HIV viral load, renal function, and liver enzyme levels may be useful in assessing nutritional status, depending on the patient's clinical status and disease stage.

Medication therapies, including the types, duration of use, and history of use, should be considered in nutritional status assessments. Some of the potential adverse effects that are related to medications include dyslipidemia, insulin resistance and glucose intolerance, and anemias. Evaluation of potential adverse effects of medications along with risk factors may help in the early identification of disease complications. For instance, a diagnosis of diabetes may alert the clinician to the possibility of an increased risk of neuropathies that can affect physical activity necessary for the maintenance of body composition.

Male and female patients may experience problems associated with medication interactions differently, which may be related to varying hormone and enzyme levels and body composition. For instance, female patients may experience higher increases in blood lipids, whereas the expected differences in ratios between low-density lipoprotein cholesterol and high-density lipoprotein cholesterol disappear between the sexes with antiretroviral therapy. A higher percentage of female patients experience fat accumulation, whereas male patients tend to experience subcutaneous fat losses. In the use of ritonavir- and nelfinavir-containing regimens, male patients may experience more diarrhea, whereas female patients may experience nausea, vomiting, and abdominal pain more frequently than male patients.

Dietary intake assessment examines eating patterns and current diet, and evaluates the factors influencing the client's ability to achieve an adequate diet. Important components of the diet history include evaluation of usual intake, current intake and any perceived changes, ethnic and cultural food preferences and practices, food preparation limitations, food intolerances, and use of macronutrient and/or micronutrient supplements. In addition, potential antiretroviral medication interactions with food, nutrient supplements, other medications, and herbal treatments should be considered in nutritional evaluations. Specific nutrients of interest include, but are not limited to, vitamins A, B-6, B-12, and D; folate; carotenoids; selenium; and zinc.

Psychosocial issues related to nutrition should also be evaluated. It is important to determine how the client is accessing food, including the use of food assistance programs, who is shopping for and preparing meals, how and where meals are prepared; whether there is a history of eating disorders or body image concerns; socioeconomic issues; and housing status. A discussion of the client's lifestyle, living arrangements, cultural practices, and weight- and food-related goals may help the clinician and the client work together to develop an appropriate nutrition care plan. In addition, factors that affect the ability of the individual to seek health care should be evaluated and addressed with the health care team to overcome barriers to achieving and maintaining nutritional status.

Risk factors for disease that affects or is affected by diet and nutritional status should be included in a complete nutrition evaluation. For instance, clients with a family history of renal dialysis, diabetes, and/or heart disease should be evaluated for these disease states on a routine basis. Risk factors such as smoking, alcohol or other drug abuse, age, sex, obesity or underweight, and medication profiles can help to determine the need to monitor for bone mineral density losses, lactic acidosis, and other common complications of chronic HIV disease.

Children living with HIV experience the same nutrition issues as adults who have the disease, but because of the added demands of growth and development, the effects are often more devastating. Inability to achieve a normal weight for height, growth stunting, failure to thrive, malnutrition, impaired cognitive development, and wasting are potential adverse nutrition-related outcomes in pediatric HIV. HIV-positive children are at high nutritional risk and should be referred for ongoing nutrition assessment and counseling. Children are hard-hit by HIV/AIDS worldwide, and the growing numbers of orphans tend to be malnourished and uneducated and to live in poverty. Some children and their families, friends, and school personnel may not know their HIV status, which presents challenges for counseling and intervention for medication interactions and other nutrition-related problems.

Nutrition assessment includes regular growth monitoring of height, weight, and head circumference with comparison to growth standards for age and sex. Additional anthropometry that may be helpful for serial measure comparisons includes thigh circumference and mid-upper arm circumference. Other aspects of nutrition assessment include dietary intake, psychosocial and environmental variables, physical activity, dental health, oral-motor feeding skills, and medical data (eg, clinical symptoms, comorbidities, nutrition-related laboratory values, viral load, and histories of medication and infections). In addition to the standard assessment, the clinician should address the following issues with nutritional implications in the pediatric population: Perinatal factors in infants, including nutritional status of the mother, exposure to drugs or alcohol, and birth weight.

The caregiver's choice of feeding method: HIV-positive mothers should be made aware of the risks and benefits of different infant feeding options, including the risk of transmission of HIV through breastfeeding. Mothers who can provide replacement feeding that is acceptable, feasible, affordable, sustainable, and safe are advised to do so. When these criteria cannot be met through family or community resources, particularly in resource-limited settings, women are advised to exclusively breastfeed.

• Inadequate nutritional intake because of limited food selectivity, poor appetite, nausea, vomiting, diarrhea, or malabsorption.
• Developmental and oral motor feeding skills delays or regression because of HIV encephalopathy or other reasons.
• Increased nutrient needs to achieve catch-up growth.
• Disordered eating patterns.
• Caregiver health and support system.
• Any distortions in the feeding relationship between caregiver and child.
• The food and economic security of the caregiver and child.

The relationship between clinician and client is important in working together to identify nutrition goals and to develop a nutrition care plan that supports those goals. The nutrition care plan is an important part of the health care plan, and the dietetics professional should work cooperatively with the client and other members of the multidisciplinary care team to ensure that nutrition goals are congruent with other elements of the health care plan. The nutrition care plan should work in harmony with the client's complete physical, mental, spiritual, and emotional health goals. AIDS is a complex disease, and its treatment requires specialized knowledge in many areas, including nutrition.

Nutrition counseling can improve health outcomes and is an integral part of HIV care at any stage of the disease, from helping newly infected people to stay healthy to assisting people taking antiretroviral drugs to manage their therapy, to allowing people with end-stage AIDS to die with dignity. However, there are many potential barriers to the effectiveness of nutrition education and counseling interventions. Care providers need to work with their clients to develop creative ways to overcome barriers caused by cultural identity, linguistic preference, distrust, cognitive dysfunction, or limited literary skills. Dietetics professionals and other clinicians may find that they need to be prepared for clients from different and overlapping backgrounds, including refugees and immigrants, gay and transgender people, intravenous drug users, and heterosexual couples and their children. Clinicians should consider these elements when providing counseling and developing materials. Clients facing special challenges should be given opportunities for frequent nutrition counseling follow-up, linked to the multidisciplinary team.

Partnering with and supporting clients to develop goals and improve their health and nutrition requires care providers to develop education and counseling skills. There are many theories and methods available, and the care provider must use counseling styles that they are comfortable with but that are appropriate for their client's individual needs. Regardless of the methods used, all education and counseling should be free from value judgments and conducted in an atmosphere of trust and respect, with an emphasis on building rapport and partnership. These elements are essential to successful nutrition education and counseling in all practice areas, but are especially important when working with people living with HIV/AIDS who may be experiencing stigma and discrimination. Personal counseling should always be kept confidential, and care providers should become good listeners and allow the clients to direct the outcomes of the sessions. Some of the methods that may be incorporated into nutrition counseling include motivational interviewing, problem solving, cognitive behavior theory, and personal coaching.

An example of a method often used as a framework for nutrition counseling is the stages-of-change model, which identifies six stages that individuals go through when changing behavior: precontemplation, contemplation, preparation, action, maintenance, and termination. When using this model, care providers should recognize that change is a process for clients and that the process is repetitive, not linear. A client may enter the counseling process at any point in the stages of change model, and then may move to any other stage, and can be at different stages of change for different goals and behaviors. Care providers should be prepared to support self-efficacy for change when the client is in precontemplation and contemplation phases; to support behavior change when the client is in preparation, action, and maintenance phases; and to respond with flexible counseling skills and a dynamic care plan.

Both nutrient and nonnutrient supplementation have been popular in the treatment of HIV infection for a variety of purposes. Supplements may emphasize calories, protein, fats, and micronutrients. Calorie-containing supplements may be required for patients with volume intolerances, extraordinary macronutrient needs, or other barriers to adequate intake to restore and maintain nutritional status. Calories are required to maintain weight, and additional dietary protein may be required to improve body cell mass. Dietetics professionals and other clinicians should keep in mind the potential for toxicities and interactions with prescribed medications when evaluating the potential benefit of nutrient and other supplementation. In general, the goals for nutrient intake should address the provision of food first and recognize that additional intake in pill or other refined forms should be viewed as supplementation beyond dietary intake. Nutrient and nonnutrient substances in foods act synergistically to improve utilization in many cases.

Supplementation based on levels described in the Dietary Reference Intakes, while staying below the known upper limits of safety, seems prudent in the absence of sufficient evidence. Specific nutrient and nonnutrient supplementation designed to address a deficiency or overcome an alteration in absorption or utilization of endogenous and exogenous nutrients should be monitored routinely, as with any other medication therapy.

Dietetics professionals should have a good understanding of both the potential benefits and the problems that may be associated with the use of vitamin and mineral supplements. For instance, although there is a lack of case-controlled study evidence, case reports of high-dose intravenous regimens that include B vitamins and L-carnitine or oral vitamin C, B-complex, and L-carnitine or coenzyme Q supplementation along with the discontinuation of antiretroviral medications have suggested a need for this type of research.

Nutrient supplementation has been suggested in resource-limited settings to reduce the rate of mother-to-child transmission of HIV. Although single nutrients were initially explored, recent research suggests a role for multiple nutrient interventions. For instance, children with HIV infection who received multivitamin intervention were compared with those receiving vitamin A alone. The multivitamin group showed a better effect on diarrhea than the groups receiving vitamin A alone or no micronutrient supplementation.

In developed countries, specialized nutrition support has been explored to determine health impact. Restoration of intestinal function and immune cell counts was improved in severely malnourished children receiving complete nutrition support through total parenteral nutrition and enteral nutrition. Enteral nutrition showed even better results than parenteral nutrition for survival, weight gain, and improvement of CD4 cell counts. The study investigators noted that such intervention should take place before terminal stages.

Nutrition-related side effects have been shown to correlate negatively with quality-of-life measures in people infected with HIV. Nutrition-related symptoms and side effects could have a significant effect on dietary intake and antiretroviral therapy adherence. Symptoms that may affect nutritional status may include nausea, vomiting, diarrhea, anorexia, pain, chewing/swallowing difficulties, taste changes, and others. Providing specific strategies to support clients through these challenges is an important part of nutrition therapy. Dietary strategies are the topic of many consumer guidelines and patient education publications.

Nonnutrient therapies are recommended both to improve nutritional status and to augment HIV-related therapies. Risk-vs-benefit analysis should be conducted before the use of these adjunctive therapies, with careful attention to potential interactions with antiretroviral and other medications. Supplemental nutrients, herbs, and other medications may be processed by and otherwise affect the pathways that are used by antiretroviral medications. These substances may decrease or increase levels of antiretroviral medications and can also decrease or increase expected levels of the supplemental nutrients, herbs, or other medications. This can lead to a decreased level of and efficacy of the medications and/or increased toxicities. Examples of potential interactions of supplements with medications include the reduction of drug efficacy during the concomitant use of St. John's Wort, garlic, and Echinacea with protease inhibitors and/or nonnucleoside reverse transcriptase inhibitor antiretroviral drugs. Other potentially interacting herbal substances include ginseng, melatonin, milk thistle, geniposide, and skullcap.

There are many other issues related to HIV disease and side effects of medication therapy that may require nutrition intervention. With the development of HAART, life spans are increasing and people with HIV are facing new sets of challenges. Lipodystrophy has emerged as a complex issue in HIV care. Body composition and serum levels of total and free testosterone should be monitored regularly for changes that indicate a decrease in lean body mass. Dietetics professionals and other clinicians may also wish to discuss the psychosocial impact of lipodystrophy with the client. Some clients may consider stopping treatment because of body image issues. Nutrition interventions should support the client's medication treatment goals while reducing any negative nutrition-related health impacts of the disease and the medication regimens. Coinfections, such as hepatitis C infection, may require specific attention to organ systems and the potential for additional therapies to interact with nutritional status, food, and other medications.

Along with lipodystrophy, an increased risk of cardiovascular disease and decreased insulin resistance are important issues with nutrition implications. Increases in blood lipids should be regularly monitored. Increases in risk factors for cardiovascular disease related to antiretroviral therapies are likely to require exercise and lipid-lowering medications in addition to dietary modification. Following a heart-healthy diet and exercise program has been shown to reduce blood lipid levels in HIV-positive patients. Clients require support to attain a healthful body weight and to reduce their intake of saturated fat, trans-fatty acids, salt, and dietary cholesterol. Clients with hypertriglyceridemia would benefit from increasing fiber intake, limiting simple carbohydrates, and avoiding alcohol.

Abnormal glucose tolerance has also been associated with HAART. Clients with insulin resistance may benefit from participation in diabetes education programs that can be integrated into their health care and in which they can learn strategies for regulating their blood glucose through diet and exercise. The potential benefit in the treatment of insulin resistance with oral antidiabetic drugs has been explored with some promising and mixed results. Metformin has shown some promise for the reduction of central fat accumulation, whereas the glitazones are under investigation for their potential to slow or reverse facial and peripheral subcutaneous fat losses. Furthermore, medication support may be indicated to help reduce blood lipid levels and insulin resistance and to increase lean body mass.

Although the causes are still unclear, HIV-positive clients may experience a progressive loss of bone mineral density leading to osteopenia or osteoporosis. Many HIV-positive clients have lower bone mineral density than expected for their age. Clients may have multiple risk factors for loss of bone mineral density, including some or all of the following: low body mass index, a history of weight loss, steroid use, a history of nucleoside reverse transcriptase inhibitor use, and smoking. Bone density should be monitored through the use of routine bone density tests such as dual energy x-ray absorptiometry. Modifiable risk factor reduction may include one or more of the following:

• Maintaining an optimal weight and preventing rapid weight loss;
• Reducing or discontinuing smoking, alcohol, and caffeine consumption;
• Reducing or balancing the consumption of foods and beverages high in phosphoric acid by choosing calcium-rich beverages (eg, milk or fortified soy beverages) instead of high-phosphorous carbonated beverages and eating a variety of protein foods;
• Working with primary care providers to adjust HAART to minimize side effects;
• Engaging in regular weight-bearing or resistance exercise; and
• Eating calcium-rich and vitamin D-fortified foods and supplementing with 500 to 1,200 mg/day calcium.

Vitamin K, vitamin C, and zinc are also important for bone formation and should be included in counseling on an adequate diet.

Nutritional counseling, nutrient supplements, and appetite stimulants have been successful in improving weight status, including fat and lean tissue volumes, for both adults and children. The health care plan also may include medication therapy together with diet strategies to reduce the adverse effects of nutrition-related disease complications. Increased protein intake, weight-bearing exercise, and the use of growth hormones, anabolic steroids, insulin-sensitizing agents, and others have been shown to positively correlate with improved body composition and quality-of-life parameters.

Further support may be indicated to help reduce blood lipid levels, improve insulin sensitivity, and increase lean body mass. Dietetics professionals and other clinicians should be familiar with both nutrient-based and medication treatments for improving nutritional status and nutrient metabolism and storage ranging from exercise and complementary therapies to pharmacologic modulation. Exercise has shown efficacy in improving the restoration of lean tissues and has been recommended as an adjunctive therapy to improve body shape alterations and metabolic alterations such as insulin resistance. Increases in weight-bearing exercise and lean body mass may help to stimulate bone formation and require further study.

Testosterone replacement and anabolic steroids have been explored to assist in the restoration of body weight and body cell mass in addition to improving strength and quality of life. Potential for liver toxicity and changes in lipid profiles exists for anabolic steroid treatment.

Recombinant human growth hormone has been explored in the treatment of wasting and central fat accumulation. Growth hormone has been used at higher doses to recover from HIV-related wasting by restoring body cell mass and at lower doses to reduce central fat accumulation.

Anti-cytokine therapy, such as thalidomide, has been explored for treating tuberculosis and HIV-related wasting. At present, the use of thalidomide is limited by the potential for teratogenicity, peripheral neuropathy, and other adverse effects.

Nutrition is an important element of HIV care. Nutrition interventions can increase quality of life, assist in symptom management, support medication therapy, and improve resistance against infections and complications. Nutrition-related complications in HIV-positive people are prevalent and impact disease progression and risk of mortality. All people infected with HIV should have the benefit of a nutrition care plan that includes both nutrition education and medical nutrition therapy as part of the multidisciplinary care plan. The client should have access to a dietetics professional for assessment and follow-up. Reimbursement for nutrition services is an important step in reducing barriers so that clients can access such care. Good nutrition as an essential part of HIV care can have a positive impact on all aspects of health.

The following forms that can be used as a "Nutrition Screen & Referral Criteria for Adults (18+ Years) with HIV/AIDS" was developed by the HIV/AIDS Dietetic Practice Group (DPG).

The AIDS Information Network defines "Good Nutrition" as getting enough macronutrients and micronutrients. Macronutrients contain calories (energy): proteins, carbohydrates, and fats. They help maintain body weight. Micronutrients include vitamins and minerals. They keep cells working properly, but will not prevent weight loss.

Good nutrition can be a problem for many people with HIV. When the body fights any infection, it uses more energy and the patient needs to eat more than normal. But when one feels sick, they eat less than normal.

Some medications can upset the stomach, and some opportunistic infections can affect the mouth or throat. This makes it difficult to eat. Also, some medications and infections cause diarrhea. With diarrhea, the body actually uses less of what you eat.

With weight lose, they might be losing fat, or they might be losing lean body weight like muscle. If they lose too much lean weight, the body chemistry changes. This condition is called wasting syndrome or cachexia. Wasting can kill.

• First, eat more. Extra muscle weight will help fight HIV. This is very important. Many people want to lose weight, but for people with HIV, it can be dangerous.
• Make sure they eat plenty of protein and starches, with moderate amounts of fat.
• Protein helps build and maintain muscles. Meats, fish, beans, nuts, and seeds are good sources.

Carbohydrates give energy. Complex carbohydrates come from grains, cereals, vegetables, and fruits. They are a "time release" energy source and are a good source of fiber and nutrients. Simple carbohydrates, or sugars give quick energy. Sugars are in fresh or dried fruit, honey, jam, or syrups.

Fat gives extra energy. The patient needs some - but not too much. The "monounsaturated" fats in nuts, seeds, canola and olive oils, and fish are considered "good" fats. The "saturated" fats in butter and animal products are "bad" fats.

A moderate exercise program will help the body turn food into muscle. Take it easy, and work exercise into daily activities.

Drinking enough liquids is very important when the person has HIV. Extra water can reduce the side effects of medications. It can help avoid a dry mouth and constipation. Be aware that drinking tea, coffee, colas, chocolate, or alcohol can actually make a person lose body liquid.

Recommended Daily Allowances

There is a popular misconception that all you have to do to get enough vitamins and minerals is to take a "one-a-day" multivitamin pill. Unfortunately, it's not that easy. The amounts of micronutrients in many of these pills are based on the Recommended Dietary Allowances (RDAs) set by the US government. The problem with the RDAs is that they are not the amounts of micronutrients that are needed by people with HIV. Instead, they are the minimum amounts needed to prevent shortages in healthy people. HIV disease and many AIDS medications can use up some nutrients. One study of people with HIV showed that they needed between 6 and 25 times the RDA of some nutrients! Still, a high potency multivitamin is a good way to get basic micronutrients.

Important Nutrients

There has not been a lot of research on specific nutrients and HIV disease. Also, many nutrients interact with each other. Most nutritionists believe in designing an overall program of supplements.

• People with HIV may benefit from taking supplements of the following vitamins and minerals:
• B Vitamins: Vitamin B-1 (Thiamine), Vitamin B2 (Riboflavin), Vitamin B6 (Pyridoxine), Vitamin B12 (Cobalamin), and Folate (Folic Acid).
• Antioxidants, including beta-carotene (the body breaks down beta-carotene to make Vitamin A), selenium, Vitamin E (Tocopherol), and Vitamin C.
• Magnesium and Zinc

Most vitamins and nutrients appear to be safe as supplements, even at levels higher than the Recommended Dietary Allowances (RDAs). However, some can cause problems at higher doses, including Vitamin A, Vitamin D, copper, iron, niacin, selenium, and zinc.

• A basic program of vitamin and mineral supplementation should be safe. This would include the following, all taken according to directions on the bottle:
• A multiple vitamin/mineral (without extra iron),
• An antioxidant supplement with several different ingredients, and
• A trace element supplement. There are seven essential trace elements: chromium, copper, cobalt, iodine, iron, selenium, and zinc. Some multivitamins also include trace elements.

It's very important to for the AIDS patient to protect themselves against infections that can be carried by food or water.

They should wash their hands before preparing food, and keep all of kitchen tools and work areas clean. Wash all fruits and vegetables carefully. They can't eat raw or undercooked eggs or meat, and the juices from raw meat need to be cleaned up quickly. Leftovers should be kept refrigerated and eaten within three days. Always check the expiration date on foods.

To prevent transmission of HIV to healthcare personnel in the workplace, the Centers for Disease Control and Prevention (CDC) offers the following recommendations.

Healthcare personnel should assume that the blood and other body fluids from all patients are potentially infectious. They should therefore follow infection control precautions at all times.

These precautions include:

• The routine use of barriers (such as gloves and/or goggles) when anticipating contact with blood or body fluids
• Washing hands and other skin surfaces immediately after contact with blood or body fluids, and
• The careful handling and disposing of sharp instruments during and after use.

Safety devices have been developed to help prevent needle-stick injuries. If used properly, these types of devices may reduce the risk of exposure to HIV. Many percutaneous injuries are related to sharps disposal. Strategies for safer disposal, including safer design of disposal containers and placement of containers, are being developed.

Although the most important strategy for reducing the risk of occupational HIV transmission is to prevent occupational exposures, plans for postexposure management of health care personnel should be in place. CDC has issued guidelines for the management of HCP exposures to HIV and recommendations for postexposure prophylaxis (PEP).

These guidelines outline a number of considerations in determining whether or not healthcare personnel should receive PEP and in choosing the type of PEP regimen.

• For most HIV exposures that warrant PEP, a basic 4-week, two-drug (there are several options) regimen is recommended.
• For HIV exposures that pose an increased risk of transmission (based on the infection status of the source and the type of exposure), a three-drug regimen may be recommended.

Special circumstances such as a delayed exposure report, unknown source person, pregnancy in the exposed person, resistance of the source virus to antiviral agents, and toxicity of PEP regimens are also discussed in the guidelines.

Occupational exposures should be considered urgent medical concerns.

The CDC has recommended that the following steps be used in the Management of Occupational Blood Exposures:

1. Provide immediate care to the exposure site.

• Wash wounds and skin with soap and water.
• Flush mucous membranes with water.

2. Determine risk associated with exposure by

• Type of fluid (e.g., blood, visibly bloody fluid, other potentially infectious fluid or tissue, and concentrated virus) and
• Type of exposure (i.e., percutaneous injury, mucous membrane or nonintact skin exposure, and bites resulting in blood exposure).

3. Evaluate exposure source.

• Assess the risk of infection using available information.
• Test known sources for HBsAg, anti-HCV, and HIV antibody (consider using rapid testing).
• For unknown sources, assess risk of exposure to HBV, HCV, or HIV infection.
• Do not test discarded needles or syringes for virus contamination.

4. Evaluate the exposed person.

• Assess immune status for HBV infection (i.e., by history of hepatitis B vaccination and vaccine response).

5. Give PEP for exposures posing risk of infection transmission.

• Initiate PEP as soon as possible, preferably within hours of exposure.
• Offer pregnancy testing to all women of childbearing age not known to be pregnant.
• Seek expert consultation if viral resistance is suspected.
• Administer PEP for 4 weeks if tolerated.

6. Perform follow-up testing and provide counseling.

• Advise exposed persons to seek medical evaluation for any acute illness occurring during follow-up.

7. HBV exposures

• Perform follow-up anti-HBs testing in persons who receive hepatitis B vaccine.
• --- Test for anti-HBs 1--2 months after last dose of vaccine.
• --- Anti-HBs response to vaccine cannot be ascertained if HBIG was received in the previous 3--4 months.

8. HCV exposures

• Perform baseline and follow-up testing for anti-HCV and alanine amino- transferase (ALT) 4--6 months after exposures.
• Perform HCV RNA at 4--6 weeks if earlier diagnosis of HCV infection desired.
• Confirm repeatedly reactive anti-HCV enzyme immunoassays (EIAs) with supplemental tests.

9. HIV exposures

• Perform HIV-antibody testing for at least 6 months postexposure (e.g., at baseline, 6 weeks, 3 months, and 6 months).
• Perform HIV antibody testing if illness compatible with an acute retroviral syndrome occurs.
• Advise exposed persons to use precautions to prevent secondary transmission during the follow-up period.
• Evaluate exposed persons taking PEP within 72 hours after exposure and monitor for drug toxicity for at least 2 weeks.

Continued work in the following areas is needed to reduce the risk of occupational HIV transmission to healthcare personnel:

• Administrative efforts. All healthcare organizations should train HCP in infection control procedures and on the importance of reporting occupational exposures. They should develop a system to monitor reporting and management of occupational exposures.

• Develop and promote the use of safety devices. Effective and competitively priced devices engineered to prevent sharps injuries are needed for HCP who frequently come into contact with potentially HIV-infected blood and other body fluids. Proper and consistent use of such safety devices should be evaluated.

• Monitor the effects of PEP. More data are needed on the safety and acceptability of different regimens of PEP, particularly those regimens that include new antiretroviral agents. Furthermore, improved communication prior to treatment about possible side effects and close follow-up of HCP receiving treatment are needed to increase compliance with the PEP.

The number of people living with HIV has never been higher-over 40 million worldwide, including approximately 5 million new infections in 2005, according to UNAIDS. Many nations face rapidly growing epidemics even as HIV/AIDS reduces average life spans.

President Bush promised to lead the fight against global HIV/AIDS in 2003 with the launch of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR/Emergency Plan) - $15 billion to fight HIV/AIDS in more than 120 countries around the world. Bilateral programs include a special emphasis on 15 focus countries in Africa, the Caribbean, and Asia that together account for approximately one-half of the world's 40 million HIV infections.

In fiscal year 2005, the Emergency Plan provided approximately $2.8 billion to the fight, and for fiscal year 2006 the U.S. commitment has grown to over $3.2 billion. President Bush has requested over $4 billion for fiscal year 2007.

This financial commitment is accompanied by ambitious goals. These include supporting the prevention of 7 million new infections, supporting treatment for 2 million HIV-infected people, and supporting care for 10 million peoples infected and affected by HIV/AIDS, including orphans and vulnerable children, in an accountable and sustainable way.

The U.S. Global AIDS Coordinator, Ambassador Randall L. Tobias, was appointed by President Bush and confirmed by the Senate to coordinate and oversee the U.S. global response to HIV/AIDS. Reporting directly to the Secretary of State, the U.S. Global AIDS Coordinator will:

• Lead the U.S. Government's international HIV/AIDS efforts;
• Ensure program and policy coordination among the relevant USG agencies and departments and nongovernmental organizations, avoiding duplication of effort;
• Pursue coordination with other countries and international organizations;
• Resolve policy, program, and funding disputes among the relevant USG agencies and departments;
• Directly approve all activities of the United States relating to combating HIV/AIDS in 15 focus countries; and
• Promote program accountability and monitor progress toward meeting the Emergency Plan's goals.

The U.S. Global AIDS Coordinator is particularly aware of the need for the Emergency Plan's programs to be accountable to both the President of the United States and the Congress. Accordingly, the Global AIDS Coordinator is committed to regular communication and consultation about the Emergency Plan's progress and achievements.

The President's Emergency Plan for AIDS Relief works with a broad range of partners in order to achieve its ambitious goals for HIV/AIDS prevention, treatment, and care. Report 108-599, accompanying H.R. 4818, called upon the Office of the United States Global AIDS Coordinator to submit a report on its achievements in involving such organizations in the Emergency Plan.

In a report to the Congress the US Department of State noted that the President's Emergency Plan has brought unprecedented focus to building the institutional capacity of local organizations - including host governments and community- and faith-based organizations - to plan, implement, and manage HIV/AIDS programs to ensure sustainability. The organizing structure, management, coordination, and leadership provided by capable host governments are essential to an effective, efficient HIV/AIDS response.

Local community- and faith-based organizations remain an underutilized resource for expanding the reach of quality services. They are among the first responders to community needs, with a reach that enables them to deliver effective services for hard-to-reach or underserved populations, such as people living with HIV/AIDS and orphans. Community- and faith-based groups, trained in program management and HIV/AIDS best practices, often design the most culturally appropriate and responsive interventions and have the legitimacy and authority to implement successful programs that deal with normally sensitive subjects. The Emergency Plan has provided technical assistance and infusions of key resources to help host governments and local organizations develop and maintain high-quality services, with training in both HIV/AIDS service provision and improving managerial capacity.

The Emergency Plan prioritizes the development of new partnerships with local groups and organizations as a key strategy for increasing access and building sustainability. Review of the U.S. five-year strategy and the annual country operations plan in each country includes an evaluation of efforts to increase the number of indigenous organizations partnering with the Plan. This emphasis has led to impressive results.

Indigenous partners demonstrates represented the following level of importance, in fiscal year 2004:

• More than 1,000 (80 percent) of over 1,200 partners (both prime and subcontractors) were indigenous. This figure is expected to rise in fiscal year 2005.
• More than 47 percent of the Emergency Plan's "prime" partners - organizations with the program and financial management expertise to receive U.S. funds directly - were indigenous. This figure is expected to rise to almost 53 percent in fiscal year 2005.
• More than 83 percent of subpartners receiving support under the management supervision of an eligible prime partner were indigenous. This figure is expected to rise to over 87 percent in fiscal year 2005.

The Emergency Plan is pursuing innovative approaches to strengthening the capacity of local nongovernmental organizations (NGOs). In Botswana, the United States initiated and supported Tebelopele, the largest provider of voluntary counseling and testing, with 16 freestanding sites and four mobile caravans. In fiscal year 2004, Tebelopele was "spun off" to become an independent NGO, with all staff and assets transferred from the U.S. Mission. A U.S. Government-funded partner is working with Tebelopele to expand management capacity and ensure that it succeeds as a sustainable organization.

As part of the longterm plan, faith-based groups are priority local partners. In many focus countries it is important to note that more than 80 percent of citizens participate in religious institutions. In certain nations, upwards of 50 percent of health services are provided through faith-based institutions, making them crucial delivery points for HIV/AIDS information and services. In fiscal year 2004, more than 20 percent of all Emergency Plan partners (including both prime and subcontractors) were faith-based. In fiscal year 2005, planned activities indicate that this proportion will rise to nearly a quarter of all partners.

To support expanded faith-based work, South Africa's Emergency Plan program is developing strategic plans with five faith-based communities for training, other capacity development, and service delivery. Tanzania's program is supporting a national needs assessment within the Islamic community to assess current HIV/AIDS work and next steps, with additional plans under way to support voluntary counseling and testing and prevention of mother-to-child transmission services in 30 dioceses, 13 church denominations, and 20 mosques. The Emergency Plan has launched pilot programs in multiple countries that allow small groups to apply directly to Emergency Plan country teams for rapid approval of small grants in order to get funds quickly to local organizations doing needed work on the ground.

The World Health Organization (WHO) launched a new program "Year of Acceleration of HIV Prevention in the African Region" in 2006. WHO reports that a comprehensive approach to HIV prevention could avert 29 million out of 45 million cumulative new infections - 63 per cent of all new infections - that are projected to occur between 2002 and 2010.

However, with a very few exceptions and despite national and international efforts to stem the pandemic, rates of new HIV infections continued to rise in 2005 in many countries of sub-Saharan Africa, the most affected region in the world.

• Of the 5 million new infections recorded globally in 2005, 3.2 million (64 per cent) were in sub-Saharan Africa.

HIV/AIDS is identified by the United Nations as the single greatest threat to the security and development of much of Africa, making it impossible to attain many of the globally agreed Millennium Development Goals. Without accelerated efforts to prevent its spread, HIV/AIDS will continue to roll back progress and hard won gains and intensify poverty and human suffering in Africa.

Rapidly growing demand for treatment will exceed available human and financial resources. More and more children will be orphaned, outstripping the capacity of families and communities to care for them. Millions more will become infected and die.

• Since the 1980s, the World Health Organization reports that 50 million people in Africa have been infected by HIV and 22 million have died, the majority of them in their most productive years. In Nigeria 20 per cent of those currently living with AIDS are civil servants. Zambia could lose 20 per cent of its workforce by 2020. Mozambique may lose more than 19,000 teachers to AIDS in the years between 2000 - 2010.
• Infant mortality, which fell by half in much of Africa between 1960-1990, is again on the rise in several countries, due to HIV infection and reduced care resulting from parental deaths. A child whose mother dies is 3.3 times more likely to die herself, according to a study in Malawi.
• Similary, life expectancy, once improving, has fallen by more than 15 years in five countries and by six-to-15 years in nine others. A child born today in Zambia can expect to live for only 32 years. In South Africa life expectancy dropped between 1995-2002 from 61.4 years to 51.4 years. Overall, GDP growth drops by one per cent a year in a country where HIV prevalence has reached 8 per cent.
• AIDS deaths undermine Africa's ability to feed itself, leaving children and the elderly to work the land. Agricultural production in Kenya, for example, is projected to drop by 2.4 per cent by 2010. Food insecurity is increasing in Africa, in part because of the impact of HIV/AIDS on agricultural production.
• More than 12 million African children have been orphaned due to AIDS, depriving them of the love, care, and guidance normally offered by parents. Many of them are homeless and impoverished, subject to exploitation and abuse.

WHO's immediate objective is to provide accurate information about HIV and AIDS. A vital step in successfully accelerating HIV prevention is understanding as much as possible about current patterns of HIV transmission in Africa, and about the underlying and contributing factors in the pandemic's spread.

• Women and children currently represent 60 per cent of those infected with HIV in Africa and nearly half of all new infections occur among children and youth between the ages of 15 and 24.
• Women, particularly young women, are at greater physiological risk of HIV infection. Women are twice as likely as men to contract HIV during sex.
• Health care systems are weak in Africa in general. In addition, there is a lack of facilities for treating sexually transmitted infections (STIs) and some STIs increase vulnerability to HIV infection.
• The lack of counseling and services, particularly for young people, constrains effective prevention. Many young people, particularly girls and young women, still do not have the information they need to protect themselves from HIV/AIDS. In some cases, denial of risk can be a significant danger: Despite the fact that South Africa has the largest number of infected people in the world, 66 per cent of South African respondents to a 2005 survey believed that they were unlikely to become infected.
• Cultural and gender factors need to be addressed, including patriarchal attitudes towards women and young girls, early sexual activity and early marriage and multiple sex partners. Engaging in sex with several partners during the same time period, for example, is emerging as a key risk factor for HIV infection, as people are 10-100 times more liable to pass the infection on within a month or so of becoming infected themselves.

WHO identifies one of the major issues as the Gender inequalities that prevent girls from refusing high-risk sex and put them at high risk of rape and sexual exploitation. The prevailing taboos and sensitivities about sex-related matters needs to be overcome, so information is shared more widely and effectively. Men and boys must be involved in ending gender inequities and changing the patterns of male behaviour that put girls and women at risk.

• Economic factors such as drought, globalization, unemployment and growing impoverishment push women and youth toward risky, transactional sex. More options as well as more information are needed.

The global goal of Universal Access to prevention, care and treatment for HIV/AIDS by 2010 will only be attainable if prevention activities are successful. Accelerating prevention will require:

• Urgently tackling these problems, targeting efforts to those most at risk, such as women and marginalized youth, commercial sex workers, and those in highly mobile occupations.
• Identifying the most successful strategies in each country and expanding their reach, or "taking them to scale".
• Improving the availability and quality of health care.
• Increasing the resources available for prevention activities.

Special Assignment - It is recommended that after completing this section that each practitioner use the Internet to research their own state requirements. The issues addressed in Florida will be same that are faced across the US.

Throughout the AIDS epidemic, Florida has consistently ranked third in the nation in the number of reported cases and second in the number of pediatric cases. (Source: Florida Department of Health, 2003).

• The HIV/AIDS epidemic in Florida has disproportionately impacted minorities. An important issue common to all minorities is access to health care, including HIV diagnostic and treatment services. (Source: Florida Department of Health, 2002)

• The Florida Department of Health estimates that 100,000 Floridians (11% of the national total) are living with HIV infection.

• Males account for 76% and
• Females account for 24%. (Source: Florida Department of Health, 2003)

• Of the over 78,000 cumulative HIV cases in Florida,

• 55% are among African Americans,
• 28% are among Caucasians, and
• 17% are among Hispanics (Source: Florida Department of Health, 2003)

The following chart shows a comparison of the adult population in Florida (200 Census) and the to total adult AIDS cases by race/ethnicity.


• HIV/AIDS is the leading cause of death in Florida for both black males and black females. (Source: Florida Department of Health, 2003)

The following chart shows the AIDS rates per 100,000 population reported by county of resident in 2004.



The total new AIDS cases reported each from 1995 to 2004 show a slight increase in the 2004.



Florida Omnibus AIDS Act

In 1988, Florida became one of the first states with hig