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 (CD 4 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 body’s 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 CD 4 lymphocyte count below 200 cells/mc. L or a CD 4 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
Intra. Venous 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 CD 4 cells decrease in number.
Opportunistic Infections associated with AIDS CD 4<500 Bacterial infections Tuberculosis (TB) Herpes Simplex Herpes Zoster Vaginal candidiasis Hairy leukoplakia Kaposi’s sarcoma
Opportunistic Infections associated with AIDS CD 4<200 Pneumocystic carinii Toxoplasmosis Cryptococcosis Coccidiodomycosis Cryptosporiosis Non hodgkin’s lymphoma
CD 4 <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) Screening test for HIV Sensitivity > 99. 9% Western blot Confirmatory test Speicificity > 99. 9% (when combined with ELIZA) HIV rapid antibody test Screening test for HIV Simple to perform Absolute CD 4 lymphocyte count Predictor of HIV progression Risk of opportunistic infections and AIDS when <200 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: CD 4 counts every 3– 6 months Viral load tests every 3– 6 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 Ig. G serology CMV Ig. G serology Pneumococcal vaccine Influenza vaccine in season Hepatitis B vaccine for those who are HBs. Ab-negative Haemophilus influenzae type b vaccination Papanicolaou smears every 6 months for women
For HIV-infected individuals with CD 4 < 200 cells/mc. L: Pneumocystis jiroveci 1 prophylaxis For HIV-infected individuals with CD 4 < 75 cells/mc. L: Mycobacterium avium complex prophylaxis For HIV-infected individuals with CD 4 < 50 cells/mc. L: 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 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% Latin America Eurasia North America East Asia Western Europe Total = 39. 4 million North Africa/Middle East Caribbean Oceania < Source: UNAIDS, AIDS Epidemic Update, December 2004.
NEWLY INFECTED CASES OF HIV IN VARIOUS REGIONS 63% Total = 4. 9 million Source: UNAIDS, AIDS Epidemic Update, December 2004
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% 15% 10% 4% 5% 2% 1% IV S O TH ER ER D EN G D IR TH M O H D RU G A O SE BU X U SE AL RS S 0%
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 Pakistan’s 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 2009– 2011: 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
