HIV/AIDS: Etiology and Oral Manifestations

The following standards are mandated by the Occupational Safety and Health Administration (OSHA).

The enforcement procedures are used to inspect any employer where employees' jobs involve potential exposure to blood and other potentially infectious materials (OPIM).

Occupational groups that have been widely recognized as having potential exposure to bloodborne pathogens such as HIV/HBV/HCV include, but are not limited to:

dental care workers,
law enforcement personnel,
fire fighting personnel,
ambulance personnel, and
other emergency response and public service employees.

While HBV and HIV are specifically identified in the standard, "Bloodborne Pathogens" include any pathogen present in human blood or other potentially infectious materials (OPIM) that can infect and cause disease in people exposed to the pathogen. Bloodborne pathogens may also include HCV, Hepatitis D, malaria, syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections, relapsing fever, Creutzfeldt-Jakob disease, adult T-cell leukemia/lymphoma (caused by HTLV-I), HTLV-I associated myelopathy, diseases associated with HTLV-II, and viral hemorrhagic fever.

According to the CDC, HCV infection is the most common chronic bloodborne infection in the United States. HCV is a viral infection of the liver transmitted primarily by exposure to blood. HCV will be covered in more detail later in this course.

Each employer must develop an Exposure Control Plan. The plan requires the employer to identify those tasks and procedures in which occupational exposure may occur. It also requires the employer to identify the individuals who will receive the training, protective equipment, vaccination, and other benefits of the standard.

This Exposure Control Plan shall contain at least the following elements:

Those job classifications and tasks in which employees have the potential for or documented occupational exposures. The exposure determination shall have been made without taking into consideration the use of personal protective clothing or equipment. It is important to include those employees who are required or expected to administer first aid.
The schedule and method of implementation in a manner appropriate to the circumstances of the particular workplace.

Case Study #5

The HIV coordinator was used to having staff and patients walk into her office with questions. However, the day Julie showed up crying at her door she was slightly surprised. She did not know Julie well, but did not expect that she would be the type to cry unless something was very wrong. She escorted her into the office, closed the door, and asked what had happened. Julie explained that she delivers supplies to different locations within the hospital including the autopsy room. She always wears protective footgear, gloves, and eyeglasses. The day after she restocked supplies in the autopsy suite, someone told her that the procedure that day was on a patient with HIV. She became very upset, and demanded to know why she was not warned before entering the room. She was afraid that she may have contracted HIV from the air or from walking in any blood or tissue left on the floor (although she did not remember anything visible to her at the time). Her worst worry was taking something home to infect her husband and children. By the time the whole story unfolded, she was sobbing.

The coordinator explained the routes of HIV infection, and the probability of infection even with a needle stick. She reassured her that HIV could not be spread by aerosolized particles or from stepping on blood or tissue when wearing shoes. She discussed the limited viability of HIV outside the body. She complimented her on using universal precautions while she worked, and assured her than doing so would provide adequate protection. Julie felt much more reassured about her own health when she left, and confident that she had not exposed her family to the virus.

Universal precautions, as defined by CDC, are designed to prevent transmission of bloodborne pathogens in healthcare and other settings. Under universal precautions, blood/OPIM of all patients should always be considered potentially infectious for HIV and other pathogens.

Standard Precautions is a newer definition that hospitals and other healthcare settings are moving toward. Standard Precautions include all recommendations made for Universal Precautions plus body substance isolation (BSI) when OPIM is present.

Bodily fluids that have been recognized as OPIM and linked to the transmission of HIV, HBV and HCV, and to which Standard Precautions and Universal Precautions apply are: blood, semen, blood products, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid, and specimens with concentrated HIV, HBV and HCV viruses.

Although the terms are not interchangeable, most people are more familiar with the term Universal Precautions. For this course, the term Standard Precautions will be used, although there may be some settings (like daycare) where body substance isolation may not be needed.

Universal and Standard Precautions involve the use of protective barriers to reduce the risk of exposure of the employee's skin or mucous membranes to blood and OPIM. It is also recommended that all dental care workers take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices. Both Universal and Standard Precautions apply to blood and OPIM listed above.

Gloves, masks, protective eyewear and chin-length plastic face shields are examples of personal protective equipment (PPE). PPE shall be provided and worn by employees in all instances where they will or may come into contact with blood or OPIM. This includes, but is not limited to dentistry, phlebotomy or processing of any bodily fluid specimen, and postmortem (after death) procedures.

Traditionally, latex gloves have been used when dealing with blood or OPIM. However, there have been documented cases of people with allergies to latex. In most circumstances, nitrile and vinyl gloves meet the definition of "appropriate" gloves and may be used in place of latex gloves. Employers are required to provide PPE alternatives to employees with latex and other sensitivities.

Engineering and work practice controls must be used in preference to personal protective equipment to minimize or eliminate employee exposure. There are now many safer needle devices available. Since these laws became effective, employers have been required to use needle-less syringes, or syringes that have protective devices built into their use. Employers must include employees in ongoing evaluation of engineering controls and implement appropriate engineering controls whenever feasible. Evaluation and implementation of these controls must be documented in the Exposure Control Plan.

The most common way that infection is spread throughout the dental care system is through hand contact. Indeed, handwashing and hand hygiene are the single most effective means of limiting the spread of infection. Employers must provide handwashing facilities, which are accessible to employees.

According to the Bloodborne Pathogens Standard, handwashing must be performed:

After removal of gloves and/or other protective equipment.
Immediately after hand contact with blood or other infectious materials.
Upon leaving the work area.

It is also recommended that handwashing be performed before and after patient contact and after using restroom facilities.

Proper handwashing technique involves the following:

Using soap, warm (almost hot) water, and good friction, make sure to scrub the top, back, and all sides of the fingers.
Lather well and rinse for at least 10 seconds. When rinsing, begin at the fingertips, so that the dirty water runs down and off the hands from the wrists. It is preferable to use a pump-type of liquid soap instead of bar hand soap.
Dry hands on paper towels. Use the dry paper towels to turn off the faucets (don't touch with clean hands).

These guidelines include the following indications for handwashing and hand antisepsis (CDC, 2002):

When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water.
If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in clinical situations. Alternatively, wash hands with an antimicrobial soap and water in clinical situations.
Decontaminate hands before having direct contact with patients.
Decontaminate hands after contact with a patient's intact skin.
Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled.
Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care.
Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
Decontaminate hands after removing gloves.
Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water.
Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with non-antimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of healthcare workers, they are not a substitute for using an alcohol-based hand rub or antimicrobial soap.
Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if exposure to Bacillus anthracis is suspected or proven. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores.
No recommendations were made regarding the routine use of nonalcohol-based hand rubs for hand hygiene in dental care settings; this remains an unresolved issue.

Hand-hygiene technique recommendations of the guidelines include (CDC, 2002):

When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer's recommendations regarding the volume of product to use.
When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis.
Liquid, bar, leaflet or powdered forms of plain soap are acceptable when washing hands with a non-antimicrobial soap and water. When bar soap is used, soap racks that facilitate drainage and small bars of soap should be used.
Multiple-use cloth towels of the hanging or roll type are not recommended for use in healthcare settings.

Recommendations for other aspects of hand hygiene in the Guidelines include (CDC, 2002):

Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms).
Keep natural nails tips less than 1/4-inch long.
Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin could occur.
Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients.
Change gloves during patient care if moving from a contaminated body site to a clean body site.
No recommendations were made regarding wearing rings in dental care settings; this remains an unresolved issue.

Sharp instruments and disposable items must be properly handled and disposed. Needles are NOT to be recapped, purposely bent or broken, removed from disposable syringes or otherwise manipulated by hand. After they are used, disposable syringes and needles, scalpel blades and other sharp items are to be placed in puncture-resistant, labeled containers for sharps disposal. It is important that these containers be conveniently located, as close as possible to where they will be used. Additionally, it is important to not overfill the sharps containers as placing items into these containers poses risk when the container is overflowing with needles, syringes and other sharp objects.

Housekeeping is important to maintain the work area in a clean and sanitary condition. The employer is required to determine and implement a written schedule for cleaning and disinfection based on the location within the facility or office, type of surface to be cleaned, type of soil present and tasks or procedures being performed. All equipment, environmental and working surfaces must be properly cleaned and disinfected after contact with blood or OPIM.

Potentially contaminated broken glassware must be removed using mechanical means, like a brush and dustpan or vacuum cleaner. Specimens of blood or OPIM must be placed in a closeable, labeled or color-coded leakproof container prior to being stored or transported.

Chemical germicides and disinfectants used at recommended dilutions must be used to decontaminate spills of blood and other body fluids. Consult the Environmental Protection Agency (EPA) lists of registered sterilants, tuberculocidal disinfectants, and antimicrobials with HIV efficacy claims for verification that the disinfectant used is appropriate. The lists are available from the National Antimicrobial Information Network at (800) 447-6349 or http://www.metrokc.gov/health/locations/index.htm.

Laundry that is or may be soiled with blood or OPIM, and/or may contain contaminated sharps, must be treated as though contaminated. Contaminated laundry must be bagged at the location where it was used, and shall not be sorted or rinsed in patient-care areas. It must be placed and transported in bags that are labeled or color-coded (red-bagged).

Laundry workers must wear protective gloves and other appropriate personal protective clothing when handling potentially contaminated laundry. All contaminated laundry must be cleaned or laundered so that any infectious agents are destroyed.

Waste disposal procedures must be carefully followed. All infectious waste must be placed in closeable, leakproof containers or bags that are color-coded (red-bagged) or labeled to prevent leakage during handling, storage and transport. Disposal of waste shall be in accordance with federal, state and local regulations.

Tags or labels must be used as a means to prevent accidental injury or illness to employees who are exposed to hazardous or potentially hazardous conditions, equipment or operations which are out of the ordinary, unexpected or not readily apparent. Tags must be used until the identified hazard is eliminated or the hazardous operation is completed.

All required tags must have the following:

Tags must contain a signal word or symbol and a major message. The signal word shall be "BIOHAZARD", or the biological hazard symbol. The major message must indicate the specific hazardous condition or the instruction to be communicated to the employee.
The signal word must be readable at a minimum of five feet or such greater distance as warranted by the hazard.
The tag's major message must be presented in either pictographs, written text, or both.
The signal word and the major message must be understandable to all employees who may be exposed to the identified hazard.
All employees will be informed as to the meaning of the various tags used throughout the workplace and what special precautions are necessary.

Personal activities such as eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in laboratories and other work areas where blood or OPIM are present.

Food and drink must not be stored in refrigerators, freezers or cabinets where blood or OPIM are stored, or in other areas of possible contamination.

All new dental workers or dental workers being transferred into jobs involving tasks or activities with potential exposure to blood/OPIM shall receive training in the Bloodborne Pathogen Standard at the time of initial assignment to the tasks where occupational exposure may occur. This training will include information on the hazards associated with blood/OPIM, the protective measures to be taken to minimize the risk of occupational exposure, and information on the appropriate actions to take if an exposure occurs.

Retraining is required annually, or when changes in procedures or tasks affecting occupational exposure occur. As previously mentioned, the limited information in this section does not qualify for the full training.

All dental workers whose jobs involve participation in tasks or activities with exposure to blood/OPIM shall be offered the start of the Hepatitis B vaccination series within 10 working days of employment and/or new assignment. The vaccine will be provided free of charge. Serologic testing after vaccination (to ensure that the shots were effective) is recommended for all persons with occupational exposures.

HIV, HBV and HCV are not transmitted by water. Any bloodborne pathogen introduced into a water source would be greatly diluted, making it noninfectious. One study found that HIV did survive in wastewater for up to 12 hours. However, the transmissibility of HIV in this situation is profoundly unlikely. There has never been a documented case of HIV transmission due to wastewater exposure.

The CDC states that the risk of infection for HIV, HBV or HCV in the healthcare setting varies from case by case.

Factors influencing the risk of infection from occupational exposure are:

Whether the exposure was from a hollow-bore needle or other sharp instrument;
To intact skin or mucus membranes (such as the eyes, nose, mouth);
The amount of blood that was involved and
The amount of virus present in the source's blood

The risk of HIV infection to a healthcare worker through a needlestick is less than 1%. Approximately 1 in 300 exposures through a needle or sharp instrument result in infection. The risks of HIV infection through splashes of blood to the eyes, nose or mouth is even smaller - approximately 1 in 1,000. There have been no reports of HIV transmission from blood contact with intact skin. There is a theoretical risk of blood contact to an area of skin that is damaged, or from a large area of skin covered in blood for a long period of time. In 2001, the CDC reported 56 documented cases and 138 possible cases of occupational exposure to HIV since reporting started in 1985.

The risk of getting HBV from a needlestick or cut is between 6-30%, unless the person exposed has been vaccinated to hepatitis B. There are only a few studies regarding the risk of getting HCV from occupational exposure. The risk of getting HCV from a needlestick or cut is between 2-3%. The risk of getting HBV or HCV from a blood splash to the eyes, nose or mouth is possible but believed to be very small. As of 1999, about 800 healthcare workers a year are reported to be infected with HBV following occupational exposure. There are no exact estimates on how many healthcare workers contract HCV from an occupational exposure. To put this in perspective, the risk of a healthcare worker contracting HCV from an accidental needlestick is 20-40% greater than their risk of contracting HIV.

It is important to follow the protocol of your employer. The CDC recommends that as soon as safely possible, wash the affected area(s).

Wash the wound and surrounding skin with soap and water. Flush mucous membranes with water. Antiseptics are not contraindicated, but do not apply caustic agents (e.g., bleach) or inject antiseptics or disinfectants into the wound.

Application of antiseptics should not be a substitute for washing. It is recommended that any potentially contaminated clothing be removed as soon as possible. It is also recommended that you familiarize yourself with existing protocols and the location of emergency eyewash or showers and other stations within your facility.

If the exposure is to the eyes, nose or mouth, flush them continuously with water, saline or sterile irrigants for at least five minutes. The risk of contracting HIV through this type of exposure is estimated to be 0.09%.

Wash the exposed area with soap and clean water. Do not "milk" or squeeze the wound. There is no evidence that shows using antiseptics (like hydrogen peroxide) will reduce the risk of transmission for any bloodborne pathogens. In the event that the wound needs suturing, emergency treatment should be obtained. The risk of contracting HIV from this type of exposure is estimated to be 0.3%.

Exposure to saliva is not considered substantial unless there is visible contamination with blood. Wash the area with soap and water, and cover with a sterile dressing as appropriate. All bites should be evaluated by a healthcare professional.

Exposure to urine, feces, vomit or sputum is not considered substantial unless the fluid is visibly contaminated with blood. Follow normal procedures for cleaning these fluids.

Follow the protocol of your employer. The following general guidelines taken from the CDC are not meant to replace an existing protocol. After cleaning the exposed area as recommended above, report the exposure to the department or individual at your workplace that is responsible for managing exposure.

A written report must include:

The date and time of exposure.
Details of the procedure being performed when the exposure took place. Include where it occurred, what was taking place at the time, what sharp devices were involved, and how the sharp device was being used at the time of the incident.
Details of the exposure. Include the type of fluid, amount of blood in the fluid, severity of exposure (depth of penetration, estimated volume of material, duration of contact); and the condition of skin or mucosa at the time of contact (e.g., intact, chapped, abraded)
Details of exposure source. Include HIV status if known, stage of disease, history of antiretroviral therapy, and viral load.
Details of counseling, postexposure management, and follow-up.

Obtain medical evaluation as soon as possible. Discuss with a healthcare professional the extent of the exposure, prophylaxis/prevention of other bloodborne pathogens, the need for a tetanus shot and other care.

Post-exposure prophylaxis (PEP) provides anti-HIV medications to someone who has had a substantial exposure, usually to blood. PEP has been the standard of care for occupationally-exposed dental care workers with substantial exposures since 1996.

As of December 1996, CDC had received reports of 52 documented cases and 111 possible cases of occupationally acquired HIV infection among Health Care Workers in the United States. 90% of these cases were due to direct contact with infected blood.

A national toll-free hotline at (888) 448-4911 is available to help with counseling and treatment recommendations for health care workers with occupational exposure to bloodborne pathogens. The National Clinicians' Post-Exposure Prophylaxis Hot Line (PEPline) is staffed 24 hours a day by trained physicians. The hotline merges the National HIV Telephone Consultation Service and the University of California/San Francisco General Hospital Epidemiology and Prevention Interventions Center Needlestick Hotline.

The CDC released postexposure recommendations in the May 1998 issue of Morbidity and Mortality Weekly Report.

Animal models suggest that cellular HIV infection happens within 2 days of exposure to HIV. Virus in blood is detectable within 5 days. Therefore, PEP should be started as soon as possible, optimally within 2 hours, preferably within 24 hours of the exposure or as soon as possible and continued for 28 days. However, PEP for HIV does not provide prevention of other bloodborne diseases, like HBV or HCV.

HBV PEP for susceptible persons would include administration of hepatitis B immune globulin and HBV vaccine. This should occur as soon as possible and no later than 7 days post-exposure. There are currently no recommendations for HCV exposure.

Because of the frequent advances in treatment, doses and medications are not extensively listed here.

There is a brief "window of opportunity" in which an antiretroviral agent may prevent or inhibit viral replication in the target cells or lymph nodes. Human studies and several animal studies have used zidovudine (ZDV) effectively to reduce the risk of HIV infection by up to 81% with proper use. ZDV is not 100% effective.

Some factors believed to contribute to its failure include:

ZDV resistant strains of HIV,
High viral titer of HIV or large volume of inoculum,
Delayed initiation or inadequate duration of postexposure treatment, and
Host or viral characteristics.

Several antiretroviral agents are available for HIV disease treatment. ZDV is the only agent currently shown to prevent HIV transmission in humans, so it is the first drug of choice. It is often supplemented with a drug called lamivudine (3TC). This one-two punch is very effective against ZDV resistant strains. Another drug, indinavir, can also be given with the other two in cases where large amounts of blood were transferred. This drug can only be taken safely for a short period of time.

Post-exposure prophylaxis can only be obtained from a licensed healthcare provider. Your facility may have recommendations and a chain of command in place for you to obtain PEP. Employers must design a system of written protocols for reporting, evaluation, counseling, treatment, and follow-up after any occupational injury that may have exposed the worker to a bloodborne infection. Access to postexposure care must be available to the workers during all working hours to facilitate a timely administration of PEP. Workers must know the system and how to implement it in advance, so they can act as soon as possible after the exposure.

After evaluation of the exposure route and other risk factors, certain anti-HIV medications may be prescribed.

The specific details about post-exposure management and treatment, see the Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV (2001) available at http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf.

PEP is not as simple as swallowing one pill. The medications must be started within the first 2 hours if possible, and continued for 28 days. Many people experience significant medication side effects.

If a healthcare professional determines that you have sustained an exposure, which puts you at risk, you will be offered antibody testing for HIV, HBV and HCV, and HBV vaccine if needed. The HIV test does not show presence of HIV, rather it looks for antibodies (your body's reaction to HIV). It usually takes your body between two weeks and three months to produce antibodies to HIV. The initial test serves as a baseline; it will show whether you were infected with HIV before the exposure. You will need to retest in order to make sure you have not been infected. In 2001, the CDC recommended retesting at six weeks, 3 and 6 months after exposure. Testing for up to 12 months may be recommended for high risk exposures or when the source is documented to be infected with HIV. You should also discuss the need for a Hepatitis B titer test (if you have been vaccinated for HBV), tests for elevated liver enzymes and other available testing for other bloodborne pathogens.

There are situations where dental care workers and others are not aware of the HIV status of the individual to whose blood they have been exposed. Usually, you cannot force someone to test for HIV and reveal their results to you.

If you experience an occupational substantial exposure to another person's blood or OPIM, you can request HIV testing of the source individual through your employer or local health officer. Before the health officer will issue a health order for HIV testing of the source individual, s/he will first make the determination of whether a substantial exposure occurred, and if the exposure occurred on the job. Depending on the type of exposure and risks involved, the health officer may make the determination that source testing is unnecessary.

In the case of occupationally exposed healthcare workers, if the employer is unable to obtain permission of the source individual, the employer may request assistance from the local health officer provided the request is made within 7 days of the occurrence.

Source testing does not eliminate the need for baseline testing of the exposed individual for HIV, HBV, HCV and liver enzymes. Provision of PEP should also not be contingent upon the results of a source's test. Current wisdom indicates immediate provision of PEP in certain circumstances, with discontinuation of treatment based upon the source's test results.

PEP for occupational exposure is standard, and its effectiveness has been documented. PEP for sexual exposure (assault or consenting) or for needle-sharing is not standard medical practice in many communities.

If your healthcare provider has questions, s/he can call PEPLine, the University of California at San Francisco's hotline for clinicians - 1-888-HIV-4911. This is NOT a hotline for answering basic questions about HIV.

PEP should never be used for primary prevention of HIV. Unlike emergency contraception to prevent pregnancy, there are no good studies to show that PEP works for post-sexual exposure. It is a complicated combination of medicines that sometimes have serious side effects. Advice for counseling and PEP related to sexual assault is found in the Counseling and Testing section of this course.