Infectious Diseases

sec_arr Human Immunodeficiency Virus, Acquired Immunodeficiency Syndrome
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Human Immunodeficiency Virus

General Description: An infection of the immune system with the human immunodeficiency virus, detected on a serologic test. More than 90% of untreated HIV infections progress to AIDS within 20 years, manifested by secondary opportunistic infections, cancers, and multi-organ failure. The initial HIV infection may present as a non-specific viral syndrome similar to mononucleosis. Treatment of HIV infection with multiple antiviral medications (highly active antiretroviral therapy or HAART) can restore immune system functioning. HAART has substantially reduced the progression of the HIV infection to AIDS and its associated high mortality rate. HAART may cause a broad range of gastrointestinal, hematologic, metabolic, and neuropsychiatric side effects which require close monitoring by the treating physician to optimize the regimen and minimize associated side effects. Post-exposure prophylaxis taken for the prevention of HIV is generally well tolerated, however the LEO taking the 4-week course of therapy should be monitored for side effects.

Mode of Transmission: Commonly, person-to-person spread through sexual activity, sharing contaminated injection equipment, maternal-to-fetal transmission. Particular LEO activities of concern would include penetrating injuries during contraband searches, broken skin with potential exposure to blood-borne pathogens, and first-responder rescue duties.

Saliva and urine are NOT considered infectious unless contaminated with blood. Transfusion of blood and blood products contaminated with HIV has been substantially reduced by screening of the blood supply.

Laboratory experiments suggest that HIV infectivity decreases approximately tenfold every 9 hours when it is exposed to drying conditions. However, other experiments suggest that in a cool, humid climate, viable HIV may persist for up to 6 weeks within a syringe. Dried blood at the tip of a discarded needle probably carries a very low risk of HIV transmission, but the liquid contents within a needle could contain infectious HIV for a long period of time.

Efficiency of Transmission/Attack Rate: In health care providers, the risk of infection with HIV virus after exposure to HIV-infected blood through needlestick or other sharps is less than 0.5%. The risk to health care workers after mucous membrane exposure has been estimated at 0.09%; the risk after exposure to non-intact skin is thought to be even less.

Period of Communicability: Persists throughout the life of the infected individual; related to concentration of virus in blood (viral load).

Effect on LEO Fitness for Duty: HIV Associated Neurocognitive Disorders (HAND), manifest as impairment of memory, concentration, attention and motor skills that cannot be explained by other conditions.11 Comprehensive neuropsychological testing performed in research environments have categorized HAND as asymptomatic neurocognitive impairment, with no symptomatic or observable functional impairment (ANI); mild neurocognitive disorder, with at least mild symptomatic or functional impairment (MND); and HIV-associated dementia, with impairment in activities of daily living (HAD). HAART has significantly reduced the prevalence of severe neurological deficits in those with HIV. However, a substantial number of patients taking HAART still have neuropsychological test results categorized as ANI or MND.

Five screening tools were reviewed(Joska citation).It is the consensus of the Task Group that if an HIV-positive LEO has been observed to have a deterioration in job performance, a fitness-for-duty evaluation should include a screening neurocognitive test for HAND, such as the Montreal Cognitive Assessment (MoCA).[ref: Joska JA, Witten J, Thomas KG, et al. A comparison of five brief screening tools for HIV-associated neurocognitive disorders in the USA and South Africa. AIDS Behav. 2016;20(8):1621-31. doi: 10.1007/s10461-016-1316-y. PMID: 26860536; PMCID: PMC5771655.]

HIV-positive LEO and Defensive Tactics Training

The potential for the LEO or recruit to sustain bleeding injuries exists in both the training facility and the routine work environment. Portals of entry for bloodborne pathogens are abrasions, other wounds, mucous membranes, or conjunctiva. However, the absolute risk of transmission is unknown in the absence of ongoing serosurveillance. Decontamination of training facility equipment should be performed on a routine basis (see Appendix A).

Based on the likelihood of: 1) the LEO bleeding; and 2) the person being exposed having non-intact skin or a mucous membrane exposure; the Task Group has stratified risk of transmission into the following three categories. This list is meant to be exemplary only and is not intended to be a complete list of possible activities that can be considered.

Category I: Activities with no risk of bloodborne virus transmission:

• Motor vehicle operation
• Interviewing a non-violent, compliant subject
• Searching a non-violent, compliant subject

Category II: Activities where bloodborne virus transmission is theoretically possible, but unlikely:

• Physical training
• Administering first aid
• Use of duty weapons
• Exposure to chemical agents – e.g., oleo-capsicum (OC) and/or orthocholorobenzal-malonotrite (CS)

Category III: Activities where there is definite risk of bloodborne virus transmission:

• Defensive tactics training
• Handcuffing
• Restraining subjects
• Administering first aid to violent subjects
• Administering first aid to subjects having a seizure

Each risk assessment should be individualized. The evaluating physician may consider reviewing the viral load thresholds for work restrictions cited in the 2021 updated Management of healthcare personnel living with hepatitis B, hepatitis C, or human immunodeficiency virus in US healthcare institutions.8

Although there are no studies to support which activities can be performed at specific viral load, it is the consensus of the Task Group is that the LEO with HIV could safely perform all essential job tasks with a viral load of <200 copies/mL. Viral loads above 200 copies/ml are considered virologic failure. The LEO should be monitored on a periodic basis (e.g., every 6 months), to confirm that the HIV RNA remains below 200 copies/ml. Test results should be presented to the police physician for review.

For individuals with HIV infection, HAART suppresses and but does not result in a sustained virologic response after stopping the medication (in contrast to treatment for hepatitis C). In other words, if the objective is to keep the viral load as low as possible, the individual cannot discontinue the medication.

Reduction of viral load is generally considered to be at steady state at 3-6 months after initiating HAART (highly active antiretroviral therapy). At that time, if the viral load were <200 copies/mL, the LEO could safely perform all essential job tasks without restrictions.

In addition to these categories, the Task Group recommends that persons known to be infected with HIV be excluded from intentional skin breaching or puncturing (e.g., receiving a TASER discharge with darts).

LEO-specific Clinical Studies and Reports:

Abel S, Césaire R, Cales-Quist D, Béra O, Sobesky G, Cabié A. Occupational transmission of human immunodeficiency virus and hepatitis C virus after a punch. Clin Infect Dis. 2000;31(6):1494-5.

Adjei AA, Armah HB, Gbagbo F, et al. Correlates of HIV, HBV, HCV and syphilis infections among prison inmates and officers in Ghana: a national multicenter study. BMC Infect Dis. 2008;8:33.

Alarid L. Risk factors for potential occupational exposure to HIV: a study of correctional officers. J Crim Just. 2009;37(2):114-22.

Bonoli F, Poissonnet CM. Biological hazards among police workers: a hospital-based prevention programme. J Hospital Infec. 2009;72(2):189-90.

Chen GX, Jenkins EL. Potential work-related bloodborne pathogen exposures by industry and occupation in the United States Part I: an emergency department-based surveillance study. Am J Indus Med. 2007;50(3):183-90.

Chen GX, Jenkins EL. Potential work-related exposures to bloodborne pathogens by industry and occupation in the United States Part II: a telephone interview study. Am J Indus Med. 2007;50(4):285-92.

Dunleavy K, Taylor A, Gow J, Cullen B, Roy K. Management of blood and body fluid exposures in police service staff. Occup Med (Lond). 2010;60(7):540-5.

Goldberg RL, Spilberg SW, Weyers SG. Medical Screening Manual for California Law Enforcement. Sacramento: California Commission on Peace Officer Standards and Training (POST), 2015; Chapter VII–Infectious Diseases.

Heiskell L, Tang D. AIDS and hepatitis: what are the risks to police officers? Police: Law Enforcement Mag. 1998;22(1):34-6.

Hoffman RE, Henderson N, O’Keefe K, Wood RC. Occupational exposure to human immunodeficiency virus (HIV)-infected blood in Denver, Colorado, police officers. Am J Epidemiol. 1994;139(9):910-7.

Occupational Medicine Forum. How do you counsel law enforcement officers on bodily fluid exposures? J Occup Environ Med. 2004;46(5):510-3.

Lorentz J, Hill L, Samimi B. Occupational needlestick injuries in a metropolitan police force. Am J Prev Med. 2000;18(2):146-50.

Merchant RC, Nettleton JE, Mayer KH, Becker BM. HIV post-exposure prophylaxis among police and corrections officers. Occup Med (Lond). 2008;58(7):502-5.

Merchant RC, Nettleton JE, Mayer KH, Becker BM. Blood or body fluid exposures and HIV post exposure prophylaxis utilization among first responders. Prehosp Emerg Care. 2009;13(1):6-13.

Pagane J, Chanmugam A, Kirsch T, Kelen GD. New York City police officers incidence of transcutaneous exposures. Occup Med (Lond). 1996;46(4):285-8.

Pearce H. HIV/AIDS and police. J Security Sector Manage. 2008;6(1):1-17.

Pretty IA, Anderson GS, Sweet DJ. Human bites and the risk of human immunodeficiency virus transmission. Am J Forensic Med Pathol. 1999; 20(3):232-9. PMID 10507789

Smith K, DenBesten K, Sha B, et al. HIV exposure in Chicago police: an under-recognized occupational risk group. In: Program and Abstracts of the 36th Annual Meeting of the Infectious Diseases Society of America. Denver, Colo; 1998.

Sonder GJ, Bovée LP, Coutinho RA, Baayen D, Spaargaren J, van den Hoek A. Occupational exposure to bloodborne viruses in the Amsterdam police force, 2000-2003. Am J Prev Med. 2005;28(2):169-74. PMID 15710272