HIV & AIDS

Clinical features, principles of management

HIV is very closely related to SIV, earliest transmission occurred from monkeys to human Cameroon or Congo is believed to be the place where this event took place A Canadian airline steward named Gaetan Dugas was referred to as "Patient 0" in an early AIDS study by Dr. William Darrow of the Centers for Disease Control. Because of this, many people had considered Dugas to be responsible for bringing HIV to North America

History

Widespread awareness of HIV disease began with a brief report in 1981, published in the Morbidity and Mortality Weekly Report, of a rare pneumonia caused by Pneumocystis carinii (now known as P jiroveci) as well as other unusual infections in 5 young homosexual men in Los Angeles

History

similar immune deficiency syndromes were described in New York, California and elsewhere among homosexual men, intravenous drug users, hemophiliacs, recipients of blood transfusions, infants, female sexual partners of infected men, prisoners, and Africans

In 1983, human retrovirus was isolated as the putative etiologic agent. That virus was eventually named human immunodeficiency virus, or HIV

By 1985, serologic assays had been developed to test for HIV infection in asymptomatic persons, to identify new infections by seroconversion, and to screen blood donations.

In 1987, zidovudine (AZT, or azidothymidine) became the first drug approved by the U.S. Food and Drug Administration (FDA) for the treatment of AIDS

The introduction of protease inhibitors (PIs) in the mid-1990s revolutionized the treatment of HIV. Very soon thereafter, countries in which effective ART was available began to note sharply declining morbidity and mortality associated with HIV infection

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, manageable but not curable.

Human immunodeficiency virus

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

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.

AIDS Definition

Sexual contact vertical transmission( from mother to child)

Though placenta Perinatal Through breast feed

Blood and blood products Organ donations Needle-sharing/ needle-stick injuries

Modes of transmission

Eating together Working together Shaking hand Sharing washroom etc

AIDS doesn't transmit through:

Natural course of HIV infection

Short, flu-like illness - occurs one to six weeks after infection

Mild symptoms

Infected person can infect other people

Stage 1. Primary infection

Lasts for an average of ten years

This stage is free from symptoms There may be swollen lymph nodes The level of HIV in the blood drops to low levels HIV antibodies are detectable in the blood

Stage 2. Asymptomatic

The immune system deteriorates

Opportunistic infections and cancers start to appear.

Stage 3. Symptomatic

The immune system weakens too much as CD4 cells decrease in number.

Stage 4. AIDS

Opportunistic infections associated with AIDS

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

CD4<500

Pneumocystic carinii Toxoplasmosis Cryptococcosis Coccidiodomycosis Cryptosporiosis Non hodgkins lymphoma

CD4<200

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

CD4 <50

TB is the most common opportunistic infection in HIV and the first cause of mortality in HIV infected patients (10-30%) 10 million patients co-infected in the world. Immunosuppression induced by HIV modifies the clinical presentation of TB :

1. Subnormal clinical and X-ray presentation 2. High rate of MDR/XDR 3. High rate of treatment failure and relapse (5% vs < 1% in HIV)

HIV and TB

HIV and TB

HIV enzyme-linked immunosorbent assay (ELISA) Western blot HIV rapid antibody test Absolute CD4 lymphocyte count HIV viral load tests

Investigations

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

Orasure

Treatment Options

Nucleoside Reverse Transcriptase inhibitors

AZT (Zidovudine)

Non-Nucleoside Transcriptase inhibitors

Viramune (Nevirapine)

Protease inhibitors
Norvir (Ritonavir)

Antiretroviral dugs - HAART

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

For all HIV-infected individuals:

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

For all HIV-infected individuals:

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

PRIMARY PREVENTION: Five ways to protect

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

Pakistan-Estimated HIV situation