2010

Human Immunodeficiency Virus

Retrovirus Lentiviruses: produce acute cytocidal infection followed by a slowly developing multisystem disease Bovine immunodeficiency virus Simian immunodeficiency virus Human immunodeficiency virus type 1 and type 2 Oncoviruses: associated with the activation of certain cell genes leading to tumor development Human T cell leu emia virus type ! and !! Spumavirus: have not been associated with any specific disease "#$ virus "everse transciptase : catalyses the reverse transcription of the "#$ genome into a %#$ copy& the resulting %#$ is called the provirus' (rovirus can integrate into host %#$ and remain dormant for wee s& months or even years without being e)pressed i'e' it remains latent H!* is never truly latent& continuous virus production in lymphoid tissues in the apparent disappearance virus in the blood' reverse transcriptase ma es errors relatively fre+uently and does not have a proof,reading mechanism to chec for errors& resulted the emergence of H!* mutants ' high level of viral replication -around 1./ to 1.1. viral particles produced per day0 rapid turn over of the virus -half,life of free virus 1 2 hr0 high fre+uency of the spontaneous appearance of mutations -2 ) 1.3 base pairs per replicative cycle0& create an opportunity for large number of genetically distinct stains or +uasispecies of H!* to be generated a cylindrical eccentric nucleoid or core nucleoid contains H!* genome& composed of two identical single,stranded "#$' 4ncoded in the "#$ genome are the entire complement of genes of the virus' These genes code for structural proteins and the regulatory proteins involved in the regulation of viral gene e)pression' "#$ genome is associated with a basic nucleic acid binding proteins p5 and the reverse transcriptase The core antigen (26 encloses the nucleoid components& completing the nucleocapsid structure (17 antigen encircles the viral core and lines the inner surface of the envelope of the virus Surface of H!* manifest e)ternal nob,li e structure formed by the envelope glycoprotein gp12.' The transmembrane protein gp61 anchors the e)ternal gp12. to the viral envelope8 it has both e)ternal and internal domains' The membrane lipid layer is derived from the host cell

Characteristic of HIV

Structure of HIV

membrane.

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Viral genome

The long terminal repeat -LT"0: - 4nclosing the entire genome& located at either end of the viral genome - provide sites for integration of the %#$ provirus formed by reverse transcription into the host,cell genome and for regulator proteins -eg: tat& rev& nef0 to control the rate of viral replication and termination' There are 2 important genes: env, gag and pol gag gene , coding for the viral core cleaved into 6 smaller products: p17& p26& p7 and p5' , constitute the core protein structure of the virus , encodes protease& reverse transcriptase -p99:p310 and endonuclease -p210'

pol gene

protease acting specifically to cleave gag and pol precursor polypeptides into functionally active proteins' reverse transcriptase re+uiring "#$,dependent %#$ polymerase that is responsible for replicating the "#$ genome' endonuclease important in proviral integration' env gene , encodes a glycosylated polypeptide precursor -gp19.0 that is processed to form the e)terior glycoprotein -gp12.0 and the transmembrane glycoprotein -gp610'

regulatory genes are also present: tat gene -p19:p160: coding for a strong positive transcriptional activator& i'e transactivator of viral "#$ synthesis' Splicing activities nef gene -p23,270: codes for a wea negative transcriptional

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modulator& ;<%6 down regulation' rev gene -p150 : codes for a protein that regulates viral "#$ processing vif gene -p220: codes for a virion infectivity factor& delta vif virus vpu gene -p190: codes for a protein that assists in viral particle release& only in H!*,1 vpx gene -p190: involved in viral infectivity& only inH!*,2

HIV-1 Peptides Gag Pol Env

(500 aa, 50 peptides) (1003 aa, 100 peptides)

(856 aa, 80 peptides) Nef (205 aa, 20 peptides)

, The surface envelope,protein is a 12., d protein -gp12.0 that includes both variable and conserved domains' Tropism for <%6 cells is the result of high,affinity interaction between gp12. and the <%6 surface glycoprotein' , The gp12. glycoprotein contains 3 hypervariable regions -*1:*2& *2& *6 and *30 interspersed between 3,conserved regions -<1 to <30' %isulfide,lin ed loops form the *1:*2& *2 and *6 regions' , *2 is the main principal neutrali=ing domain of the virus' !t is also the primary determinant of macrophage tropism' - Two type of H!*: non,syncytium,inducing -#S!0 and syncytium,inducing -S!0 - 4arly acute infection& macrophage,tropic viruses or non,syncytia,inducing viruses predominate' $s disease progresses& T cell,tropic viruses or syncytia,inducing viruses predominate'

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HIV subtypes
Type: Genomic organi ation !"btype: Envelope se#"ences

2 types: H!*,1 and H!*,2' The types of H!* are defined by the >enomic organisation: vpu is a uni+ue gene of H!*,1 and vpx is a uni+ue gene for H!*,2' H!*,2 crossed reacted with the gag core protein p26 of H!*,1' The amino acid homology of env and pol is low' H!*,1 can be divided into 2 main groups: >roup ? -ma@or0 and O -outlier0'

Virus H!*,1 >roup ? >roup O

Subtype

$& B& <& %& A1&A2& >& H& B C 3 subtypes

H!*,1 group # -#ew& non,?& non,O0 limited distribution in <ameroonian patients H!*,2 , $& B& <& %& 4& A& >

genetic changes in H!* recombinant viruses could result in altered biologic properties that affect the pathologic features& and conse+uences of H!* infection' "ecombinant strains of H!* are becoming identified throughout the world as different subtypes and strains of H!* spread to new regions and new hosts'

Circulating Recombinant Form (CRF) : about 40

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Re!erence strain $)2*0 ,bNG .al1/3 1*$2032 5,1310 -&P10 $N/* G;-6& 16G32111 T=-&061 G%18 (%)(1/1 16$)-1:*1 ;318 11T3.)>2081 .,!,,/001

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HIV-1 subtype in Malaysia :

ased on R! gene

<"A.1D$4 E 7.'2F B subtype E /'5F < subtype E 1'.F

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H subtype E 1'.F G"As E 1/'/F HIV Co-receptors 1' <,< chemo ine receptor <<",3 , e)pressed by monocytes and lymphocytes , mediates entry of non,syncytium,inducing -#S!0& monocytotropic stains of H!* , ccr3delta22& resistant to H!* infections 2' <,H,< chemo ine receptor <H<",6 -fusin0 , e)pressed only on T lymphocytes , mediates entry of syncytium,inducing -S!0& T,cell tropic strains 2' <<",2 and <<",2 chemo ine receptors , mediates H!*,1 entry on circumstances Viral variation in HIV infection ? early after H!* infection& most patients harbor #S! virus , #S! virus grows relatively slowly& does not induce fusion of T cells -syncytium formation0 in vitro& grows e+ually well in monocytes and lymphocytes' , #S! stains are called "3 strains& use only the <<",3 co,receptor later H!* infection& a highly cytopathic& S! variant appeared' , S! virus grows more rapidly than #S!& characteri=ed by the ability to grow in T,cell lines -T,cell tropism0' , emergence of S! variants is associated with rapid decline in <%6I lymphocytes& progress more rapidly to $!%S and S! isolate is a significant independent ris factor for disease progression and death' , S! isolates utili=e <H<",6 -fusin0 co,receptor and also referred as H6 strains , S! isolates are not inhibited by "$#T4S& ?!(,1 alpha or beta %uotropic "3:H6 viruses , use both <<",3 and <H<",6 co,receptors& infect monocytes and <%6I lymphocytes& intermediate forms in the evolution' Step 1 "eceptor binding& H!*,1Js surface glycoprotein gp12. interacts with high affinity receptor& <%6& leading to a conformational change in gp12.& permitting interaction with 1 of 2 cellular coreceptors for H!*& <H<"6& or <<"38 Step 2 ?embrane fusion and cellular entry of the viral core& as interactions of gp12. with <%6 and coreceptor& lead to e)posure of fusogenic domains in the transmembrane portion of gp618 Step 2 Gncoating and reverse transcription of genomic "#$ into %#$8 Step 6 #uclear upta e of viral %#$8 Step 3 the integration of resulting %#$ copy into the host,cell chromosome as a (rovirus Step 9 Transcription& regulated by constitutive host,cell transcription and virally encoded tat protein

"ife cycle of HIV

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Step 7 "#$ processing and nuclear e)port of processed viral "#$& - e)pression of distinct species of viral m"#$s is controlled by the H!*,1 rev protein' - the level of rev present in an infected cell determines the preferential production of either the unspliced or singly spliced "#$s that provide viral "#$ genomes or encode essential structural or en=ymatic proteins -i'e'& gag, pol& and env0& or the multiply spliced m"#$s that encode the viral regulatory gene products -i'e'& tat, rev& and nef0' !n circumstances in which the amount of rev present in an infected cell is limiting& such as the early stages of viral infection only the multiply spliced m"#$ transcripts are available in the cytoplasm for the translation of viral proteins' , Once a sufficient level of rev accumulates& the singly spliced and unspliced H!*,1 "#$s appear in the cytoplasm& and the synthesis of viral structural proteins can proceed' Step / translation of viral ?"#$ into proteins8 Step 5 $ssembly of viral proteins and genomic "#$8 Step 1. Budding of immature viral particles& ac+uire viral env proteins as they bud through the host,cell membrane' The viral gag and gag,polyproteins are cleaved by viral protease during or shortly after budding& generating mature infectious virions'

(rimary H!* infection is associated with e)tensive virus replication and widespread dissemination of the virus' #pidemiology , 2..2& adults and children Living with H!*:$!%S : 6. million , $nnual #ew !nfections of H!* in $dults and <hildren: 3 million , <umulative #umber of <hildren Orphaned by $!%S: 16 million , Over 16&... #ew H!* !nfections a %ay in 2..1 ? ?ore than 53F are in developing countries' ? 2... are in children under 13 years of age' ? $bout 12&... are in adults& of whom:
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? ? $athogenesis of HIV infection

almost 3.F are women about 3.F are 13, to 26,year,olds

%ynamics of HIV-1 infection

, depletion of <%6 lymphocytes , Se+uestration of uninfected <%6 cells by H!*,infected cells with syncytia formation' , Turn over if H!* in plasma: 9 hours , Turn over of H!* infected T cells: 1'3 days , (roduction of new H!*: 1. 1.,12 :day , (roduction of new T cells: 1. 1. : day , Semen : separated into 3cc seminal fluid& about 1 million KB< and 1.. million sperm' Aree virus can be isolated in seminal fluid and KB< but sperm is not infected $rimary infections ? 4stimated up to 1. billion -1.1.0 particles are produced and cleared daily in an infected individual ? $bout half of the circulating virus being replaced with newly produced virions each day ? Half,life of H!*,1 in the plasma is about 1,2 days& half,life of infectious virions is on the order of minutes Second phase of decay ? !nvolve the more gradual loss of long,lived infected macrophages& activated latently infected lymphocytes& average half,life 9,12 months ? On initiation of potent H$$"T& number of infected mononuclear cells in lymph nodes decreases with half,life about 1 day ? *irus in the blood is directly lin ed to virus production that is lin ed to <%6 cells

S#R&"&'IC !#S!S !& %#!#C! HIV I()#C!I&(

"$R%&%'IC(& )I *%)
HIV /ntibody

Serological 0indo0

HIV R(/ HIV p +- /ntigen 1* +* ,* -* .*

%ays

Infection
1 M2$2 ush2 // 133+ 42 2 4ac5son2 !ransfusion2133.

!ests for detection of antibodies to HIV Before testing& consent from patient to the test and pretest counseling is necessary' 4!$ whole virus lysate antigens recombinant protein antigens chemically synthesi=ed antigens

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supplemental tests ($ -particle agglutination0 <onfirmatory test western blot -Line,immunoassay0

Screening $rocedures "e+uire 2 blood samples ta en on different occasions Screening test 4!$ #egative : no H!* infection (ositive "epeat 4!$

Supplemental tests

(article agglutination test -($0

<onfirmation test Kestern blot Clinical Specimens: a0 Blood , gold standard b0 Saliva , alternative specimen H!* rapid tests: The sensitivity and specificity of all these rapid tests are as good as conventional 4!$' (refer by patients& counseling and testing in one visit& cost,effective'

*iagnosis o! HIV In!ection in e+borns

? #early all infants born to H!*,infected mothers passively ac+uire maternal antibody and& antibody will remain positive until age 1/ months regardless of whether they are infected' ? %efinitive diagnosis of H!* infection in early infancy re+uires: nucleic acid amplification -e'g'& polymerase chain reaction L(<"M0 or viral culture' H!* infection is diagnosed by two positive assays -(<" or viral culture0 on two separate specimens' !nfant H!* testing should be done as soon after birth as possible so appropriate treatment interventions can be implemented +uic ly' G??<: (<" +uantitative assay

Routes of transmissio n

1' contaminated blood and blood products' 2' se) , through both heterose)ual and homose)ual activities' 2' Sharing of needle -!*%G0& accidental contamination of needles and other in@ected products' 6' vertical transmission

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$erinatal HIV !ransmission

Can occur:

N during pregnancy -intrauterine0& 23F,,6.F N during labor and delivery -intrapartum0& 9.F,,73F N after delivery through breast,feeding -postpartum0' N !n a randomi=ed trial of formula feeding versus breast, feeding&
appro)imately 66F of H!* infection was attributed to breast,feeding Ris5 factors are associated 0ith perinatal HIV transmission immunologically or clinically advanced H!* disease in the mother high plasma viral load maternal in@ection,drug use during pregnancy

N N N N N

preterm delivery breast,feeding #o antiretroviral therapy H!* subtype

Obstetric factors : %elivery O6 hours after the rupture of the fetal membranes8 maternal infection with another se)ually transmitted disease or coinfection with HS*,2 increased ris of H!* transmission8 chorioamnionitis $revention and control healthy lifestyle , single partner for drug addicts , not sharing needle with others in hospital , blood screening premarital screening ;; $#< screening H$$"T

"oute of e)posure and H!* ris !nfection "oute Se)ual intercourse Aemale,to,male transmission ?ale,to,female transmission ?ale,to,male transmission #eedles #eedle stic #eedle sharing Transfusion of infected blood Transmission from mother to infant Kithout $PT treatment Kith $PT treatment <ombination antiretrovial therapy "is of !nfection 1 in 7.. to 1 in 2... 1 in 2.. to 1 in 2... 1 in 1. to 1 in 19.. 1 in 2.. 1 in 13. 53 in 1.. 1 in 2,3 11 in 1. 1 in 3.

?ain factor in H!* transmission: viral burden' !ndividuals with a blood serum viral burden 123.. H!* "#$ copies:mL failed to transmitted H!* to their se)ual partners' The greatest transmission of H!* when blood serum viral burden O3.&... H!* "#$ copies:mL'

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The genotype and phenotypes of the virus may also affect the probability of transmission' H!* clade < found in sub,Saharan $frica may be more infectious than other viral types' <ells concomitantly e)pressing <<"3 and <%6 receptors and %<,S!># -a dendritic cell,specific H!*,1 binding protein that enhances transinfection of T cells0 are most li ely to be infected' $ deletion in a portion of the <<"3 receptor e)erts considerable hereditary resistance to H!* infection' $ppro)imately 1 in 1.. white people has this deletion& no effect on the health of individual' H!* transmission depends on a variety of microenviromental properties: bacterial vaginosis increased ris of H!* ac+uisition' <oinfection with HS*,2 increased ris of H!* transmission' &pportunistic infections Viruses: <?*& Herpes& HB*& H<*& (arvo Mycoses in /I%S , <andidiasis& worldwide& mucosal and disseminated infections , <ryptococcosis& worldwide& mainly meningitis but disseminated infections is common , $spergillosis& Asp fumigatus , Histoplasmosis& worldwide& disseminated infection mainly in "4S& dimorphic fungus , (enicillinosis& mainly in S4 $sia& dimorphic fungus& disseminated infection mainly pulmonary and s in , Sporotrichosis& worldwide& dimorphic fungus& subcutaneous and disseminated infections' acteria , ?ycobacteria species: M. avium, M. intracellulare, M. kansasii, M. malmoense and M. tuberculosis comple) HIV therapy /ntiretroviral drugs 1' #ucleoside and #ucleotide "everse Transcriptase !nhibitors Pidovudine& Stavudine& %idanosine& Lamivudine& $bacavir& Palcitabine& tenofovir #onnucleoside "everse Transcriptase !nhibitors #evirapine& Pdelavirdinem 4faviren= (rotease inhibitors !ndinavir& "itonavir& Sa+uinavir& #elfinavir& $mprenavir 4ntry inhibitors : 4nfuvirtide& T2. !ntegrase inhibitors : S,129.& L,/7./1. <hemo ine receptor inhibitors: <<"3 inhibitors& <H<"6 inhibitors

2' 2' 6' 3' 9'

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H//R! -Highly active antiretroviral therapy0: defined as a regimen containing at least 2 agents' common combination: Stavudine I didanosine I efaviren= Stavudine I didanosine I nelfinavir Pidovudine I lamivudine I efaviren= Pidovudine I lamivudine I nelfinavir Stavudine I didanosine I efaviren= I nelfinavir

$redictors of Virologic )ailure ? prior antiretroviral treatment ? higher baseline:pea viral load level ? lower baseline:nadir <%6I cell count ? specific antiretroviral regimen used ? more missed clinic appointments Complications associated 0ith H//R! 1' Side effects: - hepatoto)icity& lactic acidosis& - increase triglyceride levels& L%L - lipodystrophy - glucose intolerance 2' *irologic nonrespnse: defined as less tha 2'. log 1. drop in H!* "#$ by wee / or a 1'. log 1. rebound from nadir' 2' 4mergence of drug resistance mutants %rug resistance mutations were defined as mutations associated with drug resistance in at least one of the rules,based algorithms'

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