PENGGUNAAN SALBUTAMOL (ALBUTEROL) DALAM TERAPI ASMA

Gunawan S.Kep

Kata asma berasal dari bahasa Yunani “asthma” yang berarti shttp://www.blogger.com/post-edit.g?blogID=7078148517813616616&postID=3510343273714831931
Edit postingukar bernafas. Asma termasuk salah satu penyakit yang memiliki angka kejadian yang relatif tinggi di Indonesia. Oleh karena itu, kata ”asma” tentu sudah tidak terdengar asing lagi bagi sebagian besar masyarakat. Penyakit asma bisa bisa muncul kapan saja dan bisa diderita oleh siapa saja tanpa pandang bulu, mulai dari anak-anak sampai orang dewasa, baik wanita maupun laki-laki. Saat kambuh, panderita akan mengalami sesak nafas sehingga aktivitas sehari-hari, seperti sekolah maupun kerja, bisa terganggu. Selain mengganggu aktivitas, penyakit ini bahkan bisa menyebabkan kematian bila tidak ditangani secara cepat dan tepat. Namun jika penyakit ini dikendalikan, kematian dapat dicegah dan penderita asma tak perlu mengalami serangan lagi atau gejalanya berkurang. Untuk dapat mengetahui bagaimana cara pencegahan dan pengobatan yang tepat untuk asma, maka penderita perlu mengenal lebih jauh tentang asma terlebih dahulu.

Asma adalah penyakit yang disebabkan karena adanya inflamasi (peradangan) kronis pada saluran pernafasan, yang belum diketahui secara pasti penyebabnya. Beberapa faktor yang dapat memicu terjadinya asma antara lain adalah: infeksi saluran pernafasan, alergen (debu, bulu hewan, serbuk sari, dll), kondisi lingkungan (udara dingin, asap rokok), stress, olahraga berat, obat (aspirin, NSAIDs, β-blocker). Adanya peradangan membuat saluran pernafasan menjadi sangat sensitif terhadap rangsangan dan mudah mengalami penyempitan. Penyempitan ini menyebabkan udara yang masuk dan keluar saluran pernafasan terhalang sehingga penderita menjadi sesak. Selain itu, serangan asma juga sering disertai dengan serangan batuk, nafas pendek, rasa sesak di dada. Pada asma yang sudah parah biasanya juga ditandai dengan wheezing atau “mengi”, terutama pada malam hari. Penyempitan saluran nafas pada asma bersifat reversible dan serangan biasanya berlangsung beberapa menit sampai beberapa jam.

Kelainan utama penyakit asma adalah peradangan saluran nafas, sehingga pengelolaan/pengobatannya bukan hanya ditujukan untuk menghilangkan gejala sesak nafas semata, tetapi juga berbagai tujuan berikut yaitu, agar penderita mempunyai fungsi paru mendekati normal dan gejala asmanya menghilang atau minimal. Tujuan lainnya adalah agar serangan asma minimal, pemakaian obat untuk serangan sesak berkurang, dan tidak ditemukan efek samping obat.

Secara umum, ada 2 cara untuk mengatasi asma yaitu dengan terapi non-farmakologis (tanpa obat) dan terapi farmakologis (dengan obat). Terapi non farmakologis dapat dilakukan dengan menghindari faktor-faktor resiko yang dapat menimbulkan asma serta dengan melakukan olahraga ringan seperti renang.

Adapun untuk terapi farmakologis, ada dua jenis obat yang biasa digunakan yaitu quick-relief dan long-term control. Kedua jenis obat tersebut memiliki cara kerja yang berbeda. Obat-obat quick-relief, misal bronkodilator, bekerja dengan merelaksasi otot-otot di saluran nafas sehingga saluran nafas yang semula menyempit akan melebar kembali dan penderita mampu bernafas dengan lega. Dengan demikian, obat-obat ini lebih efektif digunakan saat serangan asma terjadi. Adapun obat-obat long-term relievers digunakan untuk mencegah timbulnya serangan asma dengan mengatasi peradangan di saluran pernafasan agar tidak semakin memburuk, antara lain dengan mengurangi udem. Contoh obat yang termasuk long-term relievers ini adalah kortikosteroid.

Salbutamol merupakan salah satu bronkodilator yang paling aman dan paling efektif. Tidak salah jika obat ini banyak digunakan untuk pengobatan asma. Selain untuk membuka saluran pernafasan yang menyempit, obat ini juga efektif untuk mencegah timbulnya exercise-induced broncospasm (penyempitan saluran pernafasan akibat olahraga). Saat ini, salbutamol telah banyak beredar di pasaran dengan berbagai merk dagang, antara lain: Asmacare, Bronchosal, Buventol Easyhaler, Glisend, Ventolin, Venasma, Volmax, dll. Selain itu, salbutamol juga telah tersedia dalam berbagai bentuk sediaan mulai dari sediaan oral (tablet, sirup, kapsul), inhalasi aerosol, inhalasi cair sampai injeksi. Adapun dosis yang dianjurkan adalah sebagai berikut:

Sediaan oral

Anak <> : 200 mcg/kg BB diminum 4 kali sehari

· Anak 2-6 tahun : 1-2 mg 3-4 kali sehari

· Anak 6-12 tahun : 2 mg diminum 3-4 kali sehari

· Dewasa : 4 mg diminum 3-4 kali sehari, dosis maksimal 1 kali minum sebesar 8 mg

Catatan : dosis awal untuk usia lanjut dan penderita yang sensitif sebesar 2 mg

Ø Inhalasi aerosol

• Anak : 100 mcg (1 hisapan) dan dapat dinaikkan menjadi 200 mcg (2 hisapan) bila perlu.
• Dewasa : 100-200 mcg (1-2 hisapan), 3-4 kali sehari

Ø Inhalasi cair

• Dewasa dan anak >18 bulan : 2,5 mg diberikan sampai 4 kali sehari atau 5 kali bila perlu.
• Catatan : manfaat terapi ini pada anak <>

Ø Injeksi subkutan atau intramuscular

• Dosis : 500 mcg diulang tiap 4 jam bila perlu

Ø Injeksi intravena lambat

• Dosis : 250 mcg, diulang bila perlu

Sediaan inhalasi cair banyak digunakan di rumah sakit untuk mengatasi asma akut yang berat, sedangkan injeksi digunakan untuk mengatasi penyempitan saluran nafas yang berat. Bentuk sediaan lain, seperti tablet, sirup dan kapsul digunakan untuk penderita asma yang tidak dapat menggunakan cara inhalasi. Dari berbagai bentuk sediaan yang ada, pemberian salbutamol dalam bentuk inhalasi aerosol cenderung lebih disukai karena selain efeknya yang cepat, efek samping yang ditimbulkan lebih kecil jika dibandingkan sediaan oral seperti tablet. Bentuk sediaan ini cukup efektif untuk mengatasi serangan asma ringan sampai sedang, dan pada dosis yang dianjurkan, efeknya mampu bertahan selama 3-5 jam. Beberapa keuntungan penggunaan salbutamol dalam bentuk inhalasi aerosol, antara lain:

v Efek obat akan lebih cepat terasa karena obat yang disemprotkan/dihisap langsung masuk ke saluran nafas.

v Karena langsung masuk ke saluran nafas, dosis obat yang dibutuhkan lebih kecil jika dibandingkan dengan sediaan oral.

v Efek samping yang ditimbulkan lebih kecil dibandingkan sediaan oral karena dosis yang digunakan juga lebih kecil.

Namun demikian, penggunaan inhalasi aerosol ini juga memiliki kelemahan yaitu ada kemungkinan obat tertinggal di mulut dan gigi sehingga dosis obat yang masuk ke saluran nafas menjadi lebih sedikit dari dosis yang seharusnya. Untuk memperbaiki penyampaian obat ke saluran nafas, maka bisa digunakan alat yang disebut spacer (penghubung ujung alat dengan mulut).

Sangat penting untuk mengetahui bagaimana cara penggunaan inhalasi aerosol yang benar. Mengapa? Karena cara pakai yang salah bisa berakibat kegagalan terapi. Cara yang benar adalah dengan menghisapnya secara perlahan dan menahan nafas selama 10 detik sesudahnya.

Kontraindikasi dari obat ini adalah untuk penderita yang hipersensitif terhadap salbutamol maupun salah satu bahan yang terkandung di dalamnya. Adapun efek samping yang mungkin timbul karena pamakaian salbutamol, antara lain: gangguan sistem saraf (gelisah, gemetar, pusing, sakit kepala, kejang, insomnia); nyeri dada; mual, muntah; diare; anorexia; mulut kering; iritasi tenggorokan; batuk; gatal; dan ruam pada kulit (skin rush). Untuk penderita asma yang disertai dengan penyakit lainnya seperti: hipertiroidisme, diabetes mellitus, gangguan jantung termasuk insufisiensi miokard maupun hipertensi, perlu adanya pengawasan yang lebih ketat karena penggunaan salbutamol bisa memperparah keadaan dan meningkatkan resiko efek samping. Pengawasan juga perlu dilakukan pada penderita asma yang sedang hamil dan menyusui karena salbutamol dapat menembus sawar plasenta. Untuk meminimalkan efek samping maka untuk wanita hamil, sediaan inhalasi aeorosol bisa dijadikan pilihan pertama. Penggunaan salbutamol dalam bentuk sediaan oral pada usia lanjut sebaiknya dihindari mengingat efek samping yang mungkin muncul.

Beberapa hal penting yang perlu diketahui oleh para pengguna salbutamol untuk mengatasi asma, adalah sebagai berikut:

v Sebaiknya tidak menggunakan obat ini jika memiliki riwayat alergi terhadap salbutamol atau bahan-bahan lain yang terkandung di dalamnya.

v Untuk sediaan oral, sebaiknya diminum 1 jam sebelum atau 2 jam sesudah makan.

v Telan tablet salbutamol dan jangan memecah maupun mengunyahnya.

v Untuk sediaan inhalasi, kocok dulu sebelum digunakan dan buang 4 semprotan pertama jika menggunakan inhaler baru atau inhaler yang sudah tidak terpakai selama lebih dari 2 minggu.

v Sebaiknya berkumur setiap kali sehabis mengkonsumsi salbutamol supaya tenggorokan dan mulut tidak kering.

v Jika dibutuhkan lebih dari 1 hisapan dalam sekali pemakaian, maka beri jarak waktu minimal 1 menit untuk setiap hisapan.

v Simpan obat pada suhu kamar agar stabil (aerosol: 15-25^o C; inhalasi cair: 2-25^o C dan sirup: 2-30^o C)

v Jika ada dosis yang terlewat, segera minum salbutamol yang terlewat. Namun jika waktu yang ada hampir mendekati waktu pengonsumsian selanjutnya, lewati pengonsumsian yang tertinggal kemudian lanjutkan mengkonsumsi salbutamol seperti biasa. Jangan pernah mengkonsumsi 2 dosis dalam sekali pemakaian.

v Obat-obat golongan beta blocker, seperti: propanolol, metoprolol, atenolol, dll bisa menurunkan efek salbutamol.

v Penggunaan salbutamol dosis tinggi bersamaan dengan kortikosteroid dosis tinggi akan meningkatkan resiko hipokalemia.

v Asetazolamid, diuretik kuat dan thiazida dosis tinggi akan meningkatkan resiko hipokalemia jika diberikan bersamaan dengan salbutamol dosis tinggi pula.

v Penggunaan salbutamol bersama dengan obat golongan MAO-inhibitor (misal: isocarboxazid, phenelzine) bisa menimbulkan reaksi yang serius. Hindari pemakaian obat-obat golongan ini 2 minggu sebelum, selama maupun sesudah konsumsi salbutamol.

Asma merupakan penyakit yang membutuhkan terapi jangka panjang sehingga perlu dilakukan monitoring terhadap perkembangannya secara terus-menerus untuk melihat apakah obat yang diberikan cocok atau tidak. Ada kalanya asma tidak cukup diatasi hanya dengan satu macam obat saja, sehingga perlu penambahan obat (kombinasi obat). Maka dari itu, pengetahuan akan salah satu jenis obat saja tidak cukup karena masih banyak obat selain salbutamol yang tentu saja memiliki kelebihan dan kekurangannya masing-masing.

Agar tujuan terapi tercapai, maka penderita asma dianjurkan tetap proaktif dan semangat dalam mengatasi penyakitnya. Pengendalian asma yang tepat akan mampu meningkatkan kualitas hidup penderita asma sehingga bisa menjalani hidupnya secara menyenangkan. Dan satu hal yang perlu diingat: jangan biarkan asma mengendalikan hidup Anda, tetapi Andalah yang harus mengendalikan asma.

DAFTAR PUSTAKA

Anonim, 2000, informatorium Obat Nasional Indonesia, Departemen Kesehatan Republik Indonesia, Jakarta.

Anonim, 2006, MIMS Petunjuk Konsultasi, Ed. Ke-6, 70-76, PT. InfoMaster, Jakarta

Dipiro, J.T., 1997, Pharmacotherapy “A Pathophysiologyc Approach“, 3^rd Ed., Appleton & Lange Stamford, Connecticut

Katzung, B.G., 2001, Farmakologi Dasar & Klinik, Ed.I, Salemba Medika, Jakarta

Lacy, Charles F.; Armstrong, Lora I.; Goldman, Morton P., 2003, Drug Information Handbook, 11^th Ed., 45-46, Lexi-Comp Inc., Canada

Paul, Les and Nagle, Becky, 2002, The Essential Medication Guidebook To Healthy Aging, 99-104, Ballantine Books, New York

Expanded HIV Testing in Nursing Care: Implementing the CDC Recommendations CE www.medscape.com Bernard M. Branson, MD Disclosures

The findings and conclusions described in this article are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention. On September 22, 2006 the Centers for Disease Control and Prevention (CDC) published recommendations for a major change in the approach to testing for HIV infection in the United States: expanded screening in healthcare settings with streamlined procedures for consent and pretest information,[1] available at http://www.cdc.gov/mmwr/PDF/rr/rr5514.pdf. The CDC's specific recommendations for healthcare settings, outlined in Table 1, included: expanded HIV screening for patients regardless of risk; revisions to procedures for separate, written informed consent; indications for diagnostic testing; and decreased emphasis on prevention counseling. Table 1. Summary: CDC Recommendations for HIV Testing of Adults and Adolescents in Healthcare Settings Screening All persons aged 13-64, regardless of risk, should receive routine, voluntary screening for HIV in all healthcare settings in which the prevalence of undiagnosed HIV infection is at least 0.1%. All patients initiating treatment for TB should be screened for HIV. All patients seeking treatment for STDs should be screened for HIV each time they seek such treatment. Healthcare providers should encourage patients and their prospective sex partners to be tested before initiating a new sexual relationship. Repeat HIV screening should be performed for patients with known risk at least annually. Persons likely to be at high risk include injection-drug users and their sex partners, persons who exchange sex for money or drugs, sex partners of HIV-infected persons, and men who have sex with men (MSM) or heterosexual persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test. This type of screening, known as opt-out testing, is carried out after notifying the patient that an HIV test will be performed and that the patient may elect to decline or defer testing. Thus, consent is inferred unless the patient declines testing. Opt-out testing is sometimes referred to as "routine testing," but the two are not synonymous. In opt-out testing, patients are notified that an HIV test is a routine part of the encounter and as such there is no requirement for formalized counseling or separate written informed consent. Patients must specifically decline testing, either orally or in writing, to be exempt from having an HIV test. Routine testing, on the other hand, is the routine offer of an HIV test, followed by whatever protocol is required in that setting or state. Rationale for the CDC's Revised Recommendations The impetus for the revised recommendations came from several observations. First, effective treatment with highly active antiretroviral therapy (HAART) has substantially changed the risk-benefit ratio associated with HIV testing, transforming AIDS from a fatal disease to a highly treatable chronic condition: A 25-year-old, HIV-infected person who is receiving care in the 21st century can expect to live another 38.9 years, only 12 years less than the estimated life expectancy of an uninfected counterpart.[2]Second, persons who know they are infected with HIV are 3.5 times less likely to transmit HIV to uninfected partners than persons unaware of their infection.[3] Thus, increasing the number of HIV-infected persons who know they are infected could lead to a considerable reduction in new infections. Third, technical advances in testing methods (including rapid HIV tests) have made HIV testing more feasible in a variety of healthcare venues.[4] Finally, efforts focused on changing behavior in the large, uninfected population have been insufficient to stem the spread of HIV. More than 1 million Americans are estimated to be living with HIV, nearly a quarter of whom remain undiagnosed,[5] and at least 40,000 new infections occur each year. The Critical Role of Nursing Of the demonstration projects designed to explore alternative models for HIV screening, those that are nursing-driven have proven most effective. Using existing nursing staff to obtain consent, provide pre- and post-test information, and perform point-of-care HIV testing has several advantages over using supplemental HIV counseling and testing staff to provide these services. First, it allows HIV testing to be offered 24 hours a day, 7 days per week without hiring additional personnel. In comparison studies,[6] a nursing-driven program allowed many more HIV tests to be performed than in programs with a limited number of supplemental staff dedicated to conducting HIV counseling and testing. In 15 months, nurses were able to test nearly 6400 patients and identify 65 new HIV infections in an Oakland emergency department (ED). During the same time period, counselor-based models tested 1700 patients and found 13 new HIV infections in a comparable Los Angeles ED; and in New York, supplemental staff was able to test only 1300 patients and discover 19 patients with previously-undiagnosed HIV infection. Late Diagnosis of HIV and Implications for Survival Several studies now document that many HIV-infected patients make numerous healthcare visits in acute care, managed care, and primary care settings but are not tested for HIV until late in the course of their disease -- too late to derive optimal benefit from antiretroviral therapy.[7-9] Data from domestic HIV surveillance consistently indicate that 40% of patients receive an AIDS diagnosis within 1 year of their first positive HIV test. Taking into account the natural history of HIV infection, this means that an average of 7 to 9 years elapse before diagnosis for these late testers, during which they may unknowingly transmit HIV and fail to receive effective therapy. Earlier diagnosis and therapy confer distinct survival advantages. Mean survival when HIV is detected with a CD4 count of 320/mcL is estimated to be 24.2 years, compared with 13 years when treatment is initiated at a CD4 count of 87/mcL. Median survival after AIDS diagnosis has increased from 1.6 years in the absence of treatment to 14.9 years in the era of HAART.[10] Diagnostic Testing vs Opt-out Screening To be sure, diagnostic testing for HIV infection, especially acute HIV infection, remains a stalwart of good clinical care. The CDC recommendations regarding such diagnostic testing are shown in Table 2. Table 2. Summary: CDC Recommendations for HIV Testing of Adults and Adolescents in Healthcare Settings Diagnostic Testing All patients with signs or symptoms consistent with HIV infection or an opportunistic illness characteristic of AIDS should be tested for HIV. Clinicians should maintain a high level of suspicion for acute HIV infection in all patients who have a compatible clinical syndrome and who report recent high-risk behavior. When acute retroviral infection is a possibility, an RNA test should be performed in conjunction with an HIV antibody test. Further, as shown in Table 3, healthcare settings -- doctors' offices, hospitals, emergency departments, and community clinics -- account for more than 75% of the estimated 16-22 million HIV tests performed annually in the United States, and for nearly two thirds of all HIV diagnoses.[11] Table 3. Source of HIV Tests and Positive Tests, United States, 2002 HIV Tests* HIV+ Tests** Private doctor/HMO 44% 17% Hospital, ED, Outpatient 22% 27% Community clinic (public) 9% 21% HIV counseling/testing 5% 9% Correctional facility 0.6% 5% STD clinic 0.1% 6% Drug treatment clinic 0.7% 2% Sources: * National Health Interview Survey, 2002;[11] **Supplement to HIV/AIDS Surveillance, 2000-2003, CDC unpublished data Because HIV testing has traditionally been based on risk (either explicitly or implicitly), clinicians often do not consider the diagnosis of HIV infection until patients present with symptoms of immunodeficiency. As seen in the Figure, those tested less than 1 year before an AIDS diagnosis do so much more commonly because of illness than those who are diagnosed earlier in the course of HIV infection. Late testers, compared with those tested early, tend more often to be younger, heterosexual, less educated, and African American or Hispanic.[11] Figure. Percentage of late and early testers, by reason for testing -- 16 sites, US 2000-2003. Source: CDC. Late versus early testing of HIV -- 16 sites, United States, 2000-2003. MMWR. 2003;52:581-586. Of the 40,000 persons who acquire HIV infection each year, an estimated 40% to will experience symptoms of acute HIV infection,[12-14] and 50% to 90% of these patients will seek medical care. In general, patients present with the symptoms of viral illness shown in Table 4 and, of those diagnosed with acute HIV, 50% of patients are seen at least 3 times before the diagnosis of acute HIV infection is established. Table 4. Clinical Manifestations of Acute HIV Infection, 101 Seroconverters, HIVNET Cohort, 1995-98 Symptom Percentage Median Duration Days (IQR) Any symptom 85% Fatigue 56% 9 (5-29) Fever 55% 5 (4-10) Pharyngitis 43% 7 (5-10) Lymphadenopathy 36% 7 (4-14) Rash 16% 8 (6-14) Source: Celum CL, et al.[13] One study, based on national ambulatory medical care surveys, estimated that the prevalence of acute HIV infection was 0.5% to 0.7% among ambulatory patients who sought care for fever or rash.[15] In persons with a negative or indeterminate HIV antibody test, acute HIV infection can be diagnosed by detecting HIV RNA in plasma. Although the long-term benefit of HAART during acute HIV infection has not been established conclusively,[16] identifying primary HIV infection can reduce the spread of HIV that might otherwise occur during the acute phase of HIV disease. Advances in HIV Testing Technology Techniques for detecting HIV infection are now substantially easier and less expensive, with a more rapid turnaround time for test results. Conventional testing, the enzyme immunoassay screening test followed by a confirmatory Western blot, required the resources of a high-complexity laboratory and several days or weeks for completion. Because of the lag between initiation of testing and the availability of results, up to one-third of HIV-infected patients never received their test results. Since 2002, 6 rapid HIV tests have been approved by the Food and Drug Administration, including 4 commercial products that are CLIA-waived, require only saliva or a drop of blood with no specialized equipment, and yield results in 10-20 minutes with a sensitivity of 99.6% to 100% and a specificity of 99.7% to 100%.[4] A positive test result still requires confirmation, but a negative test is regarded as conclusive. Thus, for practical purposes, a rapid HIV test can be done in virtually any medical or non-medical setting and provide preliminary results at the time of testing with low cost and high accuracy. The CDC's recent recommendations regarding test results are shown in Table 5. The CDC Web page on rapid HIV testing is quite useful and includes descriptions of the rapid HIV tests approved by the FDA, how the tests can be implemented in different settings, and research on the effectiveness and possible uses of the tests; this information can be found at http://www.cdc.gov/hiv/rapid_testing. Table 5. Summary: CDC Recommendations for HIV Testing of Adults and Adolescents in Healthcare Settings Test Results HIV test results should be provided to patients in the same manner as results of other diagnostic or screening tests. HIV test results should be provided confidentially and by personal contact. HIV test results may be provided by telephone. Positive or negative HIV test results should be documented in the patient's confidential medical record and should be readily available to all healthcare providers involved in the patient's clinical management. Cost-Effectiveness Analyses of costs and effectiveness concluded that expanded HIV screening is as cost-effective as other routinely recommended interventions (such as mammography and PAP testing) when the prevalence of HIV exceeds 0.1%.[17,18] The CDC recommends screening in all healthcare settings where HIV prevalence exceeds this 0.1% threshold. Because most clinicians do not know the prevalence of undiagnosed HIV infection in their practice setting, they should initiate screening to determine its potential yield. If screening identifies less than 1 new infection per 1000 patients screened, continued universal screening is not warranted; targeted screening for patients at increased risk for HIV should be conducted. Prevention Counseling Counseling with testing has been a longstanding HIV prevention strategy, but studies have not demonstrated whether it reduces the rate of HIV acquisition. A meta-analysis of 27 studies found that HIV-negative persons failed to modify behavior as a result of counseling with HIV testing.[19] However, patients at 4 sexually transmitted disease (STD) clinics who received theory-based, carefully structured prevention counseling from well-trained counselors showed an increase in condom use and a 30% decrease in the incidence of STDs at 6 months; a 20% decrease was still evident after 12 months.[20] In practice, this presents a paradox: counseling is viewed as potentially beneficial for disease prevention, but the need to provide counseling is also cited by providers as a major barrier to HIV testing,[21][22] The CDC's recent recommendations regarding pretest information, counseling, and consent in healthcare settings, shown in Table 6, do not advise against counseling, but presume that clinicians will use their judgment to provide or refer patients for counseling, when appropriate, as they would with any clinical test. and scarce financial and human resources often make intensive prevention counseling impractical. Table 6. Summary: CDC Recommendations for HIV Testing of Adults and Adolescents in Healthcare Settings Pretest Information, Counseling and Consent Screening should be voluntary, and should never be performed without the patient's knowledge and understanding that an HIV test will be performed. Patients should be informed orally or in writing that HIV testing will be performed unless they decline (opt-out screening). Providers should discuss and address reasons for declining an HIV test. HIV testing need not be linked explicitly to prevention counseling. Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in healthcare settings. Prevention counseling is desirable for all patients at risk for HIV infection, but might not be appropriate or feasible in all settings. Prevention counseling is strongly encouraged for persons at high risk for HIV in settings in which risk behaviors are assessed routinely (eg, STD clinics) but should not pose a barrier to HIV testing. Consent for HIV screening should be incorporated into the patient's general informed consent for medical care on the same basis as other screening or diagnostic tests. Separate, signed consent forms for HIV testing are not recommended. If a patient declines the HIV test, this decision should be documented in the medical record. Evidence for Adoption of the Revised Recommendations Initial reports from 33 projects presented in abstract form at the December 2007 National HIV Prevention Conference and the February 2008 Conference on Retroviruses and Opportunistic Infections show promising results. As shown in Table 7, 249,374 persons were tested, of whom 2,867 (1.2%) were newly diagnosed with HIV infection. The proportion of patients who tested positive varied considerably across different settings. Table 7. Initial Results from HIV Screening Programs in Healthcare Settings Setting Number of Projects Total Tested Total Positive % Positive Median (range) % positive Emergency Departments 13 64,217 629 0.98% 1.04% (0.27-1.79) Primary Care 5 7233 22 0.30% 0.17% (0.05-0.95) Mixed Venues 5 58,190 926 1.59% 1.95% (0-6.02) Hospital/Ambulatory 4 103,233 963 0.93% 1.35% (0.34-3.67) HIV/STD Clinics 4 5634 85 1.51% 4.61% (0.39-11.41) Prisons 4 10,279 219 2.13% 0.95% (0-3.63) Mental Health Clinic 1 588 23 3.91% Total 249,374 2867 1.15% 0.95% (0-11.41) At the time the CDC's recommendations were issued, laws in numerous states required signed informed consent for HIV testing, and pre- or post-test counseling, or both.[23] Many of these laws, established at a time when no effective therapy for HIV infection existed and when those who tested positive faced an extraordinary fear of contagion, are less relevant now that therapy has become increasingly effective and the stigma associated with HIV infection has been substantially reduced (although not eliminated).[24] Since the recommendations were issued, legislation to remove barriers to opt-out testing has been passed in 14 states (California, Georgia, Illinois, Indiana, Iowa, Louisiana, Maine, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, Rhode Island, and Tennessee)[25] and introduced in 7 others. Several states (eg, Florida and Missouri) have reviewed their state regulations and found no impediments to adopting the recommendations. An updated compendium of state-by-state testing laws can be accessed at: http://www.ucsf.edu/hivcntr/StateLaws/Index.html The 2006 CDC Revised Recommendations provide an opportunity to accelerate domestic HIV prevention efforts through increasing the proportion of individuals who know their HIV status and promoting earlier access to effective treatment. Changing clinical attitudes and practice will be incremental but rewarding, requiring sustained leadership at all levels of society. This activity is supported by an independent educational grant from Gilead. References [ CLOSE WINDOW ] References Branson BM, Handsfield HH, Lampe MA, et al. Revised Recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Morbid Mortal Wkly Rep. 2006;55:1-14. Lohse N, Hansen A-BE, Pedersen G, et al. Survival of Persons with and without HIV Infection in Denmark 1995-2005. Ann Int Med. 2007;146:87-95. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware that they are infected with the virus in the USA. AIDS. 2006;20:1447-1450. Branson BM. State of the art for diagnosis of HIV infection. Clin Infect Dis. 2007;45:S221-225. Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003 [abstract]. Presented at the National HIV Prevention Conference; June 12–15, 2005; Atlanta, Georgia. Telzak EE, Grumm F, Coffey J, et al. Rapid HIV testing in emergency departments -- three U.S. sites, January 2005-March 2006. MMWR. 2007;56:597-601. Klein D, Hurley LB, Merrill D, Quesenberry CP Jr. Review of medical encounters in the 5 years before a diagnosis of HIV-1 infection: implications for early detection. J Acquir Immune Defic Syndr. 2003;32:143-152. Liddicoat RV, Horton NJ, Urban R, Maier E, Christiansen D, Samet JH. Assessing missed opportunities for HIV testing in medical settings. J Gen Intern Med. 2004;19:349-356. Centers for Disease Control and Prevention (CDC). Missed opportunities for earlier diagnosis of HIV infection -- South Carolina, 1997-2005. MMWR Morb Mortal Wkly Rep. 2006;55:1269-1272. Walensky RP, Paltiel AD, Losina E, et al. The survival benefits of AIDS treatment in the United States. J Infect Dis. 2006;194:11-19. CDC. Number of Persons Tested for HIV -- United States, 2002. MMWR 2004;53:1110-1113. Kahn JO, Walker BD. Acute human immunodeficiency virus type 1 infection. N Engl J Med. 1998;339:33-39. Celum CL, Buchbinder SP, Donnell D, et al. Early human immunodeficiency virus (HIV) infection in the HIV Network for Prevention Trials vaccine preparedness cohort: risk behaviors, symptoms, and early plasma and genital tract virus load. J Infect Dis 2001;183:23-35. Weintrob AC, Giner J, Menezes P, et al. Infrequent diagnosis of primary human immunodeficiency virus infection: missed opportunities in acute care settings. Arch Intern Med. 2003;163:2097-2100. Coco A, Kleinhans E. Prevalence of primary HIV infection in symptomatic ambulatory patients. Ann Fam Med. 2005;3:400-404. Smith DE, Walker BD, Cooper DA, Rosenberg ES, Kaldor JM. Is antiretroviral treatment of primary HIV infection clinically justified on the basis of current evidence? AIDS. 2004;18:709-718. Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States -- an analysis of cost-effectiveness. N Engl J Med. 2005;352:586-595. Sanders GD, Bayoumi AM, Sundaram V, Bilir SP, Neukermans CP, Rydazk CE. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med. 2005;352:570-585. Weinhardt LS, Carey MP, Johnson BT, Bickham NL. Effects of HIV counseling and testing on sexual risk behavior: a meta-analytic review of published research, 1985-1997. Am J Public Health. 1999;89:1397-1405. Kamb ML, Fishbein M, Douglas JM Jr, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group. JAMA. 1998; 280:1161-1167. Burke RC, Sepkowitz KA, Bernstein KT, et al. Why don't physicians test for HIV? A review of the US literature. AIDS. 2007;21:1617-1624. Rietmeijer CA. Risk reduction counseling for prevention of sexually transmitted infections: how it works and how to make it work. Sex Transm Infect. 2007;83:2-9. Wolf LE, Donoghoe A, Lane T. Implementing routine HIV testing: the role of state law. PLoS ONE. 2007;2:e1005. Available at: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0001005. Accessed March 26, 2008. Halpern SD, Metkus TS, Fuchs BD, et al. Nonconsented human immunodeficiency virus testing among critically ill patients: intensivists' practices and the influence of state laws. Arch Intern Med. 2007;167:2323-2328. National HIV/AIDS Clinicians' Consultation Center: State HIV testing Laws -- 2008. Available at: http://www.ucsf.edu/hivcntr/StateLaws/Index.html. Accessed March 1, 2008. Go to CE Test Questions » Contents of: Expanded HIV Testing -- Implementing the CDC Recommendations: Guidance for Nurses All sections of this activity are required for credit. Expanded HIV Testing in Nursing Care: Implementing the CDC RecommendationsDr. Bernard M. Branson discusses the rationale for the CDC guidelines on expanded HIV testing and outlines strategies for their implementation by nurses.Bernard M. Branson, MD (Clinical Update, March 28, 2008) HIV Opt-out Testing: The Role of the Nurse: An Expert Interview With Carl Kirton and Lyn C. StevensNurses are often the professionals called upon to make things happen in clinical settings. Learn from these HIV nurse-experts about how to implement an HIV opt-out testing program.Lyn C. Stevens, MS, NP, ACRN; Carl A. Kirton, MA, RN, ACRN, ANP-BC (Expert Interview, March 28, 2008) Implementing a Rapid HIV Testing Program in the Acute Care Setting: Nurses Take the LeadWould you know where to begin if you were charged with implementing an opt-out HIV testing program in a hospital setting? This case illustrates an approach that works.Carl A. Kirton, MA, RN, ACRN, ANP-BC; Lyn C. Stevens, MS, NP, ACRN (Test and Teach Case, March 28, 2008)