H.I.V.

DR AZAM MUSHTAQ
MBBS, DTCD, FCPS
ASSISTANT PROFESSOR CHEST DEPTT NISHTAR HOSPITIAL MULTAN.

WHAT IS HIV??
Human Immunodeficiency Virus A unique type of virus (a retrovirus) Invades the helper T cells (CD4 cells) in the body of

the host (defense mechanism of a person)

Threatening a global epidemic. Preventable, managable but not curable.

OTHER NAMES FOR HIV

Former names of the virus include:

Human T cell lymphotrophic virus (HTLV-III) Lymphadenopathy associated virus (LAV) AIDS associated retrovirus (ARV)

WHAT IS AIDS ???

Acquired Immunodeficiency Syndrome HIV is the virus that causes AIDS Disease limits the bodys ability to fight infection

due to markedly reduced helper T cells.

Patients have a very weak immune system (defense

mechanism)
Patients predisposed to multiple opportunistic

infections leading to death.

AIDS (definition)
Opportunistic infections and malignancies that

rarely occur in the absence of severe immunodeficiency (eg, Pneumocystis pneumonia, central nervous system lymphoma). Persons with positive HIV serology who have ever had a CD4 lymphocyte count below 200 cells/mcL or a CD4 lymphocyte percentage below 14% are considered to have AIDS.

THE VIRAL GENOME

Icosahedral (20 sided), enveloped virus of the

lentivirus subfamily of retroviruses. Retroviruses transcribe RNA to DNA.

Two viral strands of RNA found in core surrounded by protein outer coat.

Outer envelope contains a lipid matrix within which specific viral glycoproteins are imbedded. These knob-like structures responsible for binding to target cell.

Modes of HIV/AIDS Transmission

Through Bodily Fluids

Blood products Semen Vaginal fluids

IntraVenous Drug Abuse

Sharing Needles Without sterilization Increases the chances of

contracting HIV

Unsterilized blades

Through Sex
Unprotected Intercourse
Oral Anal

Mother-to-Baby
Before Birth During Birth

Myths about transmission

NATURAL COURSE OF HIV/AIDS

Stage 1 - Primary
Short, flu-like illness

- occurs one to six weeks after infection

Mild symptoms
Infected person can

infect other people

Stage 2 - Asymptomatic
Lasts for an average of ten years

This stage is free from symptoms

There may be swollen glands The level of HIV in the blood drops to low

levels
HIV antibodies are detectable in the blood

Stage 3 - Symptomatic

The immune system deteriorates Opportunistic infections and cancers start to

appear.

Stage 4 - HIV AIDS

The immune system

weakens too much as CD4 cells decrease in number.

Opportunistic Infections associated with AIDS

CD4<500
Bacterial infections
Tuberculosis (TB) Herpes Simplex Herpes Zoster Vaginal candidiasis Hairy leukoplakia Kaposis sarcoma

Opportunistic Infections associated with AIDS

CD4<200 Pneumocystic carinii Toxoplasmosis Cryptococcosis Coccidiodomycosis Cryptosporiosis Non hodgkins lymphoma

CD4 <50 Disseminated mycobacterium avium complex (MAC) infection Histoplasmosis CMV retinitis CNS lymphoma Progressive multifocal leukoencephalopathy HIV dementia

TB & HIV CO-INFECTION

TB is the most common opportunistic infection in HIV and

the first cause of mortality in HIV infected patients (1030%) 10 million patients co-infected in the world. Immunosuppression induced by HIV modifies the clinical presentation of TB :
1. 2. 3.

Subnormal clinical and roentgen presentation High rate of MDR/XDR High rate of treatment failure and relapse (5% vs < 1% in HIV)

Testing Options for HIV

Anonymous Testing
No name is used Unique identifying number Results issued only to test recipient

23659874515
Anonymous

Blood Detection Tests

HIV enzyme-linked immunosorbent assay (ELISA) Western blot Screening test for HIV Sensitivity > 99.9% Confirmatory test Speicificity > 99.9% (when combined with ELIZA) Screening test for HIV Simple to perform Predictor of HIV progression Risk of opportunistic infections and AIDS when <200

HIV rapid antibody test Absolute CD4 lymphocyte count

HIV viral load tests

Best test for diagnosis of acute HIV infection Correlates with disease progression and response to HAART

Urine Testing

Urine Western Blot As sensitive as testing blood Safe way to screen for HIV Can cause false positives in certain people at high risk for HIV

Oral Testing
Orasure The only FDA approved HIV antibody. As accurate as blood testing Draws blood-derived fluids from the gum tissue. NOT A SALIVA TEST!

Treatment Options

HAART = highly active anti-retroviral treatment

Antiretroviral Drugs (HAART)

Nucleoside Reverse Transcriptase inhibitors AZT (Zidovudine) Non-Nucleoside Transcriptase inhibitors Viramune (Nevirapine)

Protease inhibitors Norvir (Ritonavir)

EFFECTIVENESS OF HAART IN REDUCING MORTALITY

HEALTH CARE FOLLOW UP OF HIV INFECTED PATIENTS

For all HIV-infected individuals:
CD4 counts every 36 months Viral load tests every 36 months and 1 month following a change in therapy PPD

INH for those with positive PPD and normal chest radiograph
RPR or VDRL for syphilis Toxoplasma IgG serology CMV IgG serology

Pneumococcal vaccine
Influenza vaccine in season Hepatitis B vaccine for those who are HBsAb-negative Haemophilus influenzae type b vaccination Papanicolaou smears every 6 months for women

 For HIV-infected individuals with CD4 < 200

cells/mcL:

Pneumocystis jiroveci1 prophylaxis

For HIV-infected individuals with CD4 < 75

cells/mcL:

Mycobacterium avium complex prophylaxis

For HIV-infected individuals with CD4 < 50

cells/mcL:

Consider CMV prophylaxis

PRIMARY PREVENTION: Five ways to protect yourself?

Abstinence Monogamous Relationship Protected Sex Sterile needles New shaving/cutting blades

Abstinence

It is the most effective method of not acquiring

HIV/AIDS. Refraining from unprotected sex: oral, anal, or vaginal. Refraining from intravenous drug use

Monogamous relationship
A mutually monogamous (only one sex

partner) relationship with a person who is not infected with HIV HIV testing before intercourse is necessary to prove your partner is not infected

Protected Sex
Use condoms every time you have

sex Always use latex or polyurethane condom (not a natural skin condom) Always use a latex barrier during oral sex

When Using A Condom Remember To:

Make sure the package is

not expired Make sure to check the package for damages Do not open the package with your teeth for risk of tearing Never use the condom more than once Use water-based rather than oil-based condoms

GLOBAL ESTIMATES 2008

ESCALATING EPIDEMIC !!!

Source: WHO/UNAIDS/UN The Millennium Development Goals Report, 2009, p.32 and WHO.

HIV PREVALENCE IN VARIOUS REGIONS

Sub-Saharan Africa
South/South-East Asia
42%

18% 4% 4% 3% 3% 2% 1% 1%
Total = 39.4 million

Latin America
Eurasia

North America
East Asia Western Europe North Africa/Middle East Caribbean Oceania

< 1%

Source: UNAIDS, AIDS Epidemic Update, December 2004.

NEWLY INFECTED CASES OF HIV IN VARIOUS REGIONS

Sub-Saharan Africa South/South-East Asia East Asia Latin America Eurasia North Africa/Middle East Caribbean North America
63%

18% 6% 5% 4% 2% 1% 1%
Total = 4.9 million

Western Europe <1%

Source: UNAIDS, AIDS Epidemic Update, December 2004

Oceania

<1%

ESTIMATED HIV BURDEN IN PAKISTAN

0.1% of the adult population in Pakistan Total Population (2008) = 180,800,000 People living with HIV/AIDS (2008) = 96,000 Women (aged 15+) with HIV/AIDS (2008) = 27,000 Children with HIV/AIDS (2008) = nd Adult HIV prevalence(%) (2008) = 0.1% AIDS deaths (2008) = 5,100

ESCALATING EPIDEMIC OF HIV IN HIGH RISK GROUPS IN PAKISTAN

20% 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0%

4%

2%

1%

POTENTIAL THREATS IN PAKISTAN

100,000 commercial sex workers with poor safe sex

awareness in three major cities Estimated 60,000 iv drug users in pakistan (1 in 5 infected with HIV) 38,000 homosexuals reported in lahore in 2002 40% of 1.5 million annual blood donors not screened for HIV 20% of blood transfusions come from professional donors with high prevalence of infectious diseases Significantly large number of migrants and refugees.

UNDER-REPORTING
Until September 2004, only 300 cases of full-blown AIDS and another 2300 cases of HIV infection were reported to the National AIDS Control Program. The reasons for under reporting are: Social stigma attached to the infection, Limited surveillance Voluntary counseling and testing systems Lack of knowledge among the general population and health practitioners.

NATIONAL RESPONSE TO HIV/AIDS

Pakistans Federal Ministry of Health initiated

a National AIDS Prevention and Control Program (NACP) in 1987

In its early stages, the program was focused on diagnosis of cases that came to hospitals, but progressively began to shift toward a community focus

The government has indicated in the recent

scaling up of its response to HIV/AIDS, more needs to be done.

NON GOVERNMENTAL ORGANIZATIONS

54 NGOs are involved in HIV/AIDS public

awareness and in the care and support of persons living with HIV/AIDS. Also working on education and prevention interventions targeting sex workers, truck drivers, and other high-risk groups. But reaching less than 5 percent of the vulnerable population.

WORLD BANK RESPONSE

Largest financer of HIV/AIDS program in Pakistan Providing 37.1 million US dollars Enhanced program is making encouraging progress

with expansion of coverage.

WHAT WE CAN DO??

UNAIDS Outcome Framework 20092011: nine priority areas We can reduce sexual transmission of HIV. We can prevent mothers from dying and babies from becoming infected with HIV. We can ensure that people living with HIV receive treatment. We can prevent people living with HIV from dying of tuberculosis. We can protect drug users from becoming infected with HIV. We can remove punitive laws, policies, practices, stigma and discrimination that block effective responses to AIDS. We can stop violence against women and girls. We can empower young people to protect themselves from HIV. We can enhance social protection for people affected by HIV.

LIVING WITH HIV/AIDS