HIV Infection:
Administrative Aspects
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 Navys 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
Reference
-
SECNAVINST 5300.30
Revised by CDR James C. Pile, MC, USNR, Infectious Disease Department, National
Naval Medical Center, Bethesda, MD (1999).
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Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
20372-5300
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