HIV Infection: Administrative Aspects

Department of the Navy
Bureau of Medicine and Surgery

Notification of Command

A command generally learns of a newly diagnosed, human immunodeficiency virus (HIV) seropositive individual when the commanding officer receives a letter of notification from BUMED, informing him or her of the individual. The letter instructs the commanding officer to direct the seropositive service member to one of the Navy’s 3 comprehensive HIV evaluation units, where the individual will undergo a thorough 2-week initial visit that entails intensive education and psychosocial support in addition to clinical evaluation. The units are located at the Naval Medical Center San Diego, National Naval Medical Center (Bethesda), and Naval Medical Center Portsmouth.

On occasion, positive HIV serology results of an active duty member will be obtained by an ordering physician before a letter of notification has been sent by BUMED. This may occur when an HIV test has been ordered based on clinical suspicion, or when a patient has requested an HIV test. (The latter situation should always be honored, as an individual may be in a high-risk group and unwilling to say so; although many of these individuals will seek testing outside the military system). When positive serology on an active duty member does become available before the BUMED notification has been sent, it is appropriate to refer the individual directly to one of the HIV evaluation centers. Those numbers are included at the end of this chapter. Of note, positive HIV serology consists initially of a positive enzyme-linked immunosorbent assay (ELISA), followed by a positive confirmatory test, the Western blot. A positive ELISA will not be communicated to the ordering physician unless confirmed by a Western blot.

Clinical Suspicion of Infection

On other occasions, an active duty member will be suspected of being HIV infected, or of being in the process of seroconverting. If an individual is suspected of being HIV infected or in the process of seroconverting, HIV serology and an HIV viral load should be ordered (see accompanying chapter on clinical aspects of HIV), but should not be sent to an HIV evaluation center until positive HIV serology has been obtained. As an aside, should a dependent be found to be HIV +, he or she is not mandated to be seen at one of the evaluation centers, but should be encouraged to do so.

Notification of Service Member

The notification of HIV positivity in a service member is the responsibility of the commanding officer. In many circumstances this may be facilitated by the presence of the medical officer at the time of notification. Alternatively, it may be helpful for the medical officer to counsel the individual immediately after notification, as there will generally be questions best answered by a physician. In many situations involvement of the chaplain is desirable as well. Timing of notification is often important. In most circumstances a delay of a day or two in notification is not of major importance, and it makes good sense to wait until Monday morning rather than Friday afternoon to tell an individual of their status, for example.

The needs and desires of a newly diagnosed, HIV seropositive individual are variable. In general, however, it is important to communicate the basic concept that being positive for HIV does not equate to having AIDS, and that most individuals will enjoy a lengthy period of health after diagnosis. In the current era of highly active antiretroviral therapy, HIV infection has become a chronic illness analogous to diabetes mellitus or hypertension for many if not most patients, and it is reasonable to explain this circumstance. The importance of the initial evaluation at one of the HIV evaluation centers should be stressed, and service members should be informed that this will, in general, be a very positive experience in a highly supportive environment.

The individual should be counseled that although he or she will not be eligible to for future service in deployable billets, HIV positive status is not grounds for discrimination or punitive action. He or she should further be counseled that state-of-the-art treatment is available through the Navy for the duration of the infection. The service member should be assessed for suicidal ideation at the time of initial notification, and then as indicated before formal evaluation takes place at one of the evaluation centers. Emergent psychiatric referral, although seldom necessary, should be made as needed.

Finally, the importance of empathy on the part of the medical officer, the chaplain, and the commanding officer cannot be overstressed. Notification that one is HIV positive is likely to be one of the most stressful events an individual will ever experience, and some basic understanding and support from the previously mentioned "key players" may go a long way toward modulating some of the trauma of the situation.

Service Member Disposition

HIV seropositive, active duty members may remain on active duty if they do not experience opportunistic infections, or otherwise show evidence of advanced or rapidly progressing immunologic deterioration. When a service member is required to leave active duty because of their HIV disease, the Physical Evaluation Board and their HIV physician are both involved in determining disposition. They understand the service member and examine each situation on a case to case basis. In general, however, a CD4+ count of less than 200 or a major opportunistic infection would be grounds for medical retirement. As already mentioned, HIV + active duty are not deployable, and are required to be stationed within reasonable driving distance of an internist. The HIV + service member is required to undergo a week long re-evaluation at one of the 3 HIV sites every 6 months, at which time, a clinical assessment as well as an educational update is performed. HIV + active duty members may reenlist and be promoted, but enlisted members may not be commissioned as officers.

More information may be found in SECNAVINST 5300.30.

Telephone Numbers of Navy HIV Evaluation Centers

• National Naval Medical Center, Bethesda, MD: (301) 295-6400

• Naval Medical Center Portsmouth, Portsmouth, VA: (757) 953-5179 or 5182

1. SECNAVINST 5300.30