ACQUIRED IMMUNE DEFICIENCY SYNDROME V V L N

ACQUIRED IMMUNE DEFICIENCY SYNDROME V. V. L. N. S. N. Gupta 1

ACQUIRED IMMUNE DEFICIENCY SYNDROME Agent : RETROVIRUS Initially called Lymphadenopathy Associated Virus (LAV) Then Human T – cell lymphotrophic virus III Then Human Immuno Deficiency Virus (HIV) in 1986 2

Fatal Illness Caused by retrovirus (Human Immuno Deficiency Virus) Virus breaks down body’s immune system: Victim vulnerable to 1. a) Many infections life-threatening opportunistic 2. b) Neurological disorders 3. c) Unusual malignancies Once infected, person is infected for life. 3

Recognized only in 1980 s AIDS has rapidly established itself throughout the world In 2001 No. of adults/children living with AIDS worldwide – 40 million Dying with AIDS worldwide – 3 million Male – 52% Female – 48% (including 7. 6 million Females 15 – 49 yrs of age) living with HIV/AIDS 4

>95% Cases in developing countries In developed nations, nos are decreasing due to combined Antiretroviral therapy In India --- 2 nd decade Increasing no. of Males Increasing infection in children 5

Setbacks: · Increased Mortality · Increased cost of treatment/containment · Decreased productivity due to morbidity AIDS continues to roll back hard-won development gains in many regions of the world In South East Asian Region (SEAR), Thailand first to report a case of AIDS Pandemic (Global epidemic) 6

RESERVOIRS OF INFECTION: Cases and carriers Once a person is infected, virus remains in body lifelong Risk of developing AIDS increases with time HIV infection takes years to manifest & so symptomless carrier can infect other people for years. 7

SOURCE OF INFECTION: Virus (Large concentration) + in blood, semen, CSF Virus (lower concentration) + in tears, saliva, breast milk, Urine, Vaginal secretions Virus is also isolated from Brain tissue Lymph nodes Bone-marrow cells Skin Till now only Blood & Semen have been conclusively shown to transit the virus. 8

HOST FACTORS: Age: Sexually active persons 20 – 49 years - most productive members of society - those responsible for O Child bearing Child rearing 9

Sex: Some sexual practices Increase risk of infection more than others Eg. , Multiple sex partners, Anal intercourse, Male homosexuality Higher rate of HIV infection found in prostitutes 10

HIGH RISK GROUPS: Male homosexual & Bisexuals Heterosexual partners (including prostitutes) IV drug abusers Transfusion recipients of blood & blood products Haemophiliacs Clients of STD 11

IMMUNOLOGY: Immune system disorders of HIV are due to gradual decrease in specialized type of WBC (Lymphocytes) called T-helper or T 4 cells (CD 4 + T Lymphocytes) HIV Specially infects CD 4 + T Cells along with other cells e. g. , B-cells, , Microphages, Nerve cells. When virus reproduces, infected T-helper cells are destroyed decreases WBCs (<500. cmm) 12

IMMUNOLOGY: Alteration in T-cell function due to infection causes • • • Development of neoplasms Development of opportunistic infections Inability to mount a delayed hypersensitivity response 13

MODE OF TRANSMISSION: Sexual transmission Blood contact Maternal-foetal transmission (Mother child) 14

Sexual transmission: AIDS is first and foremost a sexually transmitted disease Any vaginal, oral or anal sex can spread AIDS Every single act of unprotected intercourse with an HIV infected person exposes the uninfected partner to risk of infection 15

Size of risk is affected by : Presence of STD Sex and age of uninfected partner Type of sexual act Stage of illness of infected partner Virulence of HIV Strain involved Causes of transmission from Male to Female twice as much As Female to Male because a) Larger surface exposed in Females b) Semen contains higher concentration of HIV than vagina or 16

Anal intercourse has higher risk of transmission than Vaginal intercourse due to increased tissue injury involved For all forms of sex, risk increases where there is abrasion of skin or mucus membrane 17

For vaginal sex, risk is increased during menses. • Exposed adolescent girls (Cervix being less efficient barrier to HIV and less production of mucus in genital tract of adolescent and menopausal Females ) and Females over 45 are more prone to get HIV due to thinning mucosa at menopause • Presence of STD in HIV negative or HIV partner facilitates transmission of HIV • If an STD e. g. . , Herpes, Syphilis, Chancoid cause ulceration in genital or perineal area of uninfected partner, HIV easily passes into his/her tissue. 18

STD inflammation T-cells Monocytes Macrophages Get concentrated in genital area – easily catch HIV from infected partner 19

HIV infected persons – more infectious in early stages (before antibody production) or window period and when infection is well advanced due to levels of virus in blood. 20

BLOOD CONTACT: Contaminated Blood transfusion of whole blood cells, platelets, factors VIII & IX (derived from plasma) NOT TRANSMITTED via Albumin Igs Hepatitis Vaccines that are as per WHO norms 21

Risk of HIV from contaminated blood transfusion – 95% Needle prick – Low risk of infection Regular needle uses by drug addicts – High risk due to repeated use (cocaine, heroin) Skin piercing (including injections, ear piercing, tattooing, Acupuncture) – High risk 22

Maternal-foetal transmission: Through placenta During delivery Breast-feeding 1/3 rd children of HIV +ve mothers get infected by this route. Risk is high if mother newly infected or has AIDS Infants & children progress rapidly to AIDS 23

NOT TRANSMITTED BY: a) Mosquitoes/insects b) Casual social contact with infected persons including within households or c) By food or water or d) To health workers in their professional contact with AIDS patients 24

INCUBATION PERIOD: Few months to 6 years CLINICAL FEATURES: Four categories I) Initial infection with virus & development of antibodies II) Asymptomatic carrier state III) AIDS related complex IV) AIDS 25

INITIAL INFECTION: Mild – fever, sore throat, rash, few weeks after initial contact Increased risk of transmission HIV antibodies take 2 -12 weeks to appear in blood stream (Window period) 26

ASYMPTOMATIC CARRIER STATE: Antibodies positive, but no sign of disease except Persistent generalized lymphadenopathy. 27

AIDS RELATED COMPLEX: Illnesses caused by damage to immune system but without opportunistic infection & cancers associated with AIDS but have one or more of the following: • Unexplained diarrhoea more than 1 month • Fatigue, malaise • Fever • Night sweats • Oral thrush • General lymphadenopathy 28

AIDS End stage of HIV infection • Opportunistic infections and/or cancer occur • Death is due to uncontrolled/untreatable infection • TB/Kaposi’s Sarcoma/Candida oesophaitis • Cryptococcus meningitis/ pencillosis • Pnemocystitis carinii pneumonia/ Toxoplasma encephalitis • Wasting syndrome in some • AIDS encephalopathy or dementia • Persistent generalized lymphadenopathy 29

WHO case of definition for AIDS surveillance Adult or adolescent (>12 yrs) is considered to have AIDS if a test for HIV antibody is positive and one or more of the following are positive. A) >10% body weight loss/cachexia with diarrhoea or fever or both, intermittent or constant, for at least one month, not known to be due to condition unrelated to AIDS B) Cryptococcal meningitis C) Kaposi’s sarcoma 30

D. Pulmonary/Extra Pulmonary TB E. Neurological impairment sufficient to prevent independent daily activities not known to be due to condition unrelated to HIV F. Candidiasis of esophagus G. Clinically diagnosed life threatening or recurrent episodes of pneumonia H. Invasive cervical CA 31

LAB. DIAGNOSIS: a. A) Detection of antibody to HIV Elisa (to detect antibody) sensitive test Western Blot (to confirm HIV) – Confirmation test B) Virus isolation from cultured lymphocytes 32

Non-specific findings: Anemia Leukopenia (especially lymphocytopenia) Thrombocytopenia Polyclonal Hypergammaglobulinemia Most widely used marker -- Absolute CD 4 Lymphocyte count as it decreases, opportunistic infection risk increases People with healthy immune system have >950 People with AIDS >200 (Prognostic) 33

CONTROL OF AIDS: Prevention a) Education: Enabling people to make life-saving choices I. Avoiding indiscriminate sex II. Using condoms III. Avoid use shared razors & toothbrushes IV. Avoid sharing needles & syringes in IV drug users V. Females suffering from AIDS or at high risk of infection are asked to avoid getting pregnant, but decision is patient’s 34

CONTROL OF AIDS: VI. Educational material & guidelines for prevention should be made widely available VII. All mass media channels should be involved in educating people including international travelers 35

CONTROL OF AIDS: PREVENTION OF BLOOD TRANSMISSION BORNE HIV • Advise people in high risk groups to avoid donating Blood, Body organs, sperm or other tissues • All blood should be screened for HIV 1 & 2 before Blood Transfusion • Transmission to hemophiliacs can be decreased by introducing heat treatment of factors VIII & IX • Strict sterilization practices ensured in hospitals & clinics • Pre- sterilized disposable syringes & needles 36

CONTROL OF AIDS: ANTIRETROVIRAL TREATMENT: • No vaccine or cure for HIV infection/ AIDS • Drugs available suppress the HIV infection rather than its complication • Therapy is useful in prolonging the life of severely ill patients but not a cure • These drugs suppress viral replication • These drugs given as combination therapy 37

CONTROL OF AIDS: ANTIRETROVIRAL TREATMENT: • Post exposure prophylactic treatment started with in hours of accidental exposure to virus • 4 weeks of treatment with Azathioprine decreases risk exposure by 79% • Combination therapy also useful (AZT + LAMIVUDINE) • Advanced AIDS in source individual (AZT + Nelfinavir) • With failure to resond – Stavudine + Didanosine 38

CONTROL OF AIDS: ANTIRETROVIRAL TREATMENT: • Specific Prophylaxis P. Carinii pneumonia – CD 4 >200 – Cotrimoxazole Pentamidine Dapsone M. avium complex – Rifabutin 39

NATIONAL AIDS PREVENTION & CONTROL POLICY Objective: To bring about zero transmission of AIDS by 2007 Blood Safety programme • Only licensed blood banks allowed to operate in India • Voluntary Blood donation encouraged • Zonal blood testing centers – Test samples of blood for blood banks & report HIV results the same day 40

NATIONAL AIDS PREVENTION & CONTROL POLICY • Testing of every unit of blood mandatory • HIV • HCV • Hepatitis – B • Malaria • Syphilis 41

Policy on HIV testing: Voluntary basis with appropriate pre-test & post-test counseling STD Control program • Condom promotion: social marketing of condom as a priced item but at subsidized rate • Vending machine near brothels 42

HIV Surveillance: • Information, Education, communication & Social Mobilization • Family Health awareness campaign • Prevention of HIV transmission from mother to child • Post exposure prophylaxis for health care workers • National AIDS Telephone help line -- 1097 43

What should one do if found HIV positive? • Consult a clinician experienced in treating HIV/AIDS. • Protect your sex partner(s) from HIV by following safe-sex guidelines. • Inform sex partner(s) who may also be infected. • Do not share needles. • Get psychological support from a counsellor and/or join a support group for people with HIV. • . 44

What should one do if found HIV positive? • Get information and social and legal support from AIDS service organisations. • Don't share your HIV status with people who do not need to know. Only tell people you can count on for support. Think about whom do you want to share your HIV status with. • Maintain a strong immune system with a healthy lifestyle and regular medical examinations. • Consider using antiretroviral therapies that may slow the progress of the infection in consultation with a qualified physician 45

The Risk Chart - Practice Safe Sex No risk or very low risk - No reported cases due to these behaviors • Masturbation - mutual masturbation • Touching - massage • Erotic massage - body rubbing • Kissing • Oral sex on a man with a condom • Oral sex on a woman with a dental dam, glyde dam, plastic wrap, or cut-open condom • Not sharing drug injecting, body piercing instruments, needles, syringes • Using properly sterilised hospital tools 46

The Risk Chart - Practice Safe Sex Low risk - Rare reported cases due to these behaviors • Deep kissing • Oral sex • Vaginal intercourse with a condom or female condom • Anal intercourse with a condom (Try not to get semen or blood into the mouth or on broken skin. ) 47

The Risk Chart - Practice Safe Sex High risk - Hundreds of thousands of reported cases are associated with the following. • Vaginal intercourse without a condom • Anal intercourse without a condom • Sharing needles, syringes and other body piercing instruments 48

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The Red ribbon is a symbol for solidarity with HIVpositive people and those living with AIDS. 50