Hiv 201111111

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  • 1. HIV /AIDS SILENT KILLER
    • by : Mohamed El gamal
    • 2011
    • Assistant lecture mansoura university hospitals
  • 2.
    • HIV the worst epidemic of the twentieth century
    • 59  Infected million persons worldwide,
    • 20 million who have already died
    • . 33 million adults and children were living with HIV/AIDS
    • 2million people had been newly infected with HIV in 2008
  • 3.
    • .
    • 95% of all HIV-infected people in world  developing countries:
      • Developing countries
      • 64% AIDS cases
      • 2/3of new cases
    • Most of these people are unaware that they are infected with HIV  continuous spread of the disease.
    • Subsaharan Africa  hardest hit region then Asia, India, Latin America, Eastern Europe
  • 4. HIV Historical Bakground
    • .
  • 5.
    • 1982
    • The term AIDS (" acquired immune dificiency syndrome ") is used for the first time on July 27 th
    • 1983
    • Institut Pasteur (France) finds the virus (HIV).
    • 1985
    • The FDA (US) approves the first HIV antibody test.
    • 1987
    • AZT (zidovudine, Retrovir®) -- -- becomes the first anti-HIV drug approved by the FDA .
    • 1996
    • The HAART (Highly Active Antiretroviral Therapy) era begins
    • 2008
    • Francoise Barre - Sinoussi and Luc Montagnier share the Nobel Medicine Prize for their discovery of the HIV virus
  • 6. HIV types, groups and subtypes
  • 7. HIV LIFE CYCLE
  • 8.
    • FUSION
    • REVERSE TRANSCRIPTION
    • INTEGRATION
    • TRANSCRIPTION
    • ASSEMBLY
    • BUDDING
  • 9.  
  • 10.
    • STAGES OF HIV-1 INFECTION
    • 1-Viral transmission
    • 2-seroconversion
    • 3-Clinical latent period with or without persistent generalized lymphadenopathy (PGL)
    • 4-Early symptomatic HIV infection
    • 5-AIDS CD4 below 200 /mm3
    • 6-Advanced diseaseHIV infection characterized by a CD4 cell count below 50/mm3
  • 11. Window phase!!!! SEROCONVERSION
    • Most people develop detectable HIV antibodies within 6 to 12 weeks of infection . In very rare cases, it can take up to 6 months
  • 12.
    • WHEN SUSPECT HIV ??
  • 13.
    • Acute Retroviral Syndrome
    • Fever (low-grade <102) occurs in 80-90% occult infection
    • Fatigue (70-90%) Erythematous Maculopapular Rash (40-80%) Face and Trunk Extremities involving palms and soles
    • Headache (32-70%) Generalized Lymphadenopathy (40-70%)
    • Pharyngitis (50-70%) Myalgia or arthralgia (50-70%)
    • Gastrointestinal symptoms (30-60%)
      • Nausea or Vomiting Diarrhea
    • Hepatosplenomegaly (14%) Night Sweats (50%)
    • Oral Aphthous Ulcer s or Thrush (10-20%)
    • Genital Ulcer s (5-15%) Neurologic symptoms (12%)
  • 14.
      • Aseptic Meningitis (25%) Peripheral Neuropathy
      • Facial palsy Guillain-Barre Syndrome Brachial Neuritis Cognitive Impairment Psychosis Malaise
    • Anorexia Weight loss (70%) Wasting Syndrome
      • Unexplained weight loss of >10% usual body weight
    • Associated Conditions: Other presentations in early HIV
    • Fungal
      • Vaginal Candidiasis Onychomycosis Thrush
    • Dermatologic
      • Seborrhea Shingles
  • 15. Methods of transmission:
      • Sexual transmission, presence of STD increases likelihood of transmission.
      • Exposure to infected blood or blood products.
      • Use of contaminated clotting factors by hemophiliacs.
      • Sharing contaminated needles (IV drug users).
      • Transplantation of infected tissues or organs.
      • Mother to fetus, perinatal transmission variable, dependent on viral load and mother’s CD 4 count
  • 16.
    • Blood test for HIV Diagnosis
    • ELISA
    • A Western blot assay
    • – Indirect immunofluorescence assay, .
    • line immunoassay
    • A second ELISA
    • PCR
    • Antigen test P24 test
    • Rapid HIV tests
  • 17.
    • . HIV DISINFECTION
  • 18.
    • Body fluids of concern include:
    • Potentially infectious semen, vaginal secretions, other body fluids contaminated with visible blood
    • (undetermined risk for transmitting HIV ): cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids.
    • Fluids that are not infectious unless they contain blood include: feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus.
  • 19. How long a drop of blood with HIV infection ?? ...”
    • When exposed to air The HIV / AIDS virus last about 30 seconds to 1 minute ,
    • in a media like blood or other liquid that is exposed to air it will live for about 2-5 minutes,
    • in perfect lab conditions the virus will live for about 20-40 minutes .
  • 20.
    • Standard chemical germicides AS solution of sodium hypochlorite at concentrations much lower than commonly used in practice can rapidly inactivate HIV.
    • In the laboratory, should be flooded with a liquid germicide before cleaning, after organic material has been removed.
    • . In patient-care areas, visibly soiled areas should first be cleaned and then chemically decontaminated.
  • 21. Mosquito bites and HIV infection risk
    • HIV is not spread by mosquitoes or other biting insects. Even if the virus enters a mosquito or another sucking or biting insect, it cannot reproduce in insects. The insect cannot be infected with HIV and cannot transmit HIV to the next human it feeds on or bites . .
  • 22. HIV AND HEALTH CARE WORKERS
  • 23.
    • The risk of becoming infected with HIV after exposure to body fluids from an HIV-infected patient is low.
    • needlestick injuries to HCWs exposed to an HIV-infected source in the era before the introduction of highly active antiretroviral therapy (HAART) found the following
    • HIV transmission occurred 0.33 percent
    • For skin exposures , the area should be washed with soap and water.
    • Small wounds and punctures may be cleansed with an antiseptic such as an alcohol-based hand hygiene agent,
    • ; antiseptics also inactivate HIV such as iodophors, chloroxylenol (PCMX) and chlorhexidine (
  • 24.
    • The following universal infection control precautions to help protect health care workers from blood-borne infections including HIV:
    • Hand washing after direct contact with patients.
    • Use of protective barriers such as gloves, gowns aprons, masks, goggles for direct contact with blood and other body fluids.
    • Safe collection and disposal of needles and sharps, with required puncture- and liquid- proof boxes in each patient care area.
    • Preventing two-handed recapping of needles .
    • Covering all cuts and abrasions with a waterproof dressing.
    • Promptly and carefully cleaning up spills of blood and other body fluids.
    • Using a safe system for health care waste management and disposal.
  • 25. HIV PULMONARY COMPLICATION
  • 26.
    • Pulmonary disease is a major source of morbidity and mortality in HIV-infected persons.
    • Most of HIV-associated pulmonary diseases usually present at or below a characteristic CD4+ lymphocyte count and seldom occur above the count
    • Cigarette smoking is associated with  incidence
  • 27.  
  • 28.
      • CD4+  200 cells:
        • Bacterial pneumonia is often accompanied by bacteremia.
        • MTB is often extrapulmonary or disseminated.
        • Pneumocystis & Cryptococcus neoformans become a consideration
    • CD4+ count  50 – 100 cells /  L:
        • Endemic fungi
        • Viruses (CMV)
        • Non-tuberculous mycobacteria (MAC)
        • Kaposi’s sarcoma
      • Extrapulmonary & disseminated manifestations dominate the clinical presentation.
  • 29. (A) Bacteria
    • S.pneumoniae, Hemophilus, influenzae
    • P.Aeruginoso (CD4 lymphocyte count < 50 cell /  L).
      • legionella pneumophila Rhodococcus equi and Nocardia species
      • .
      • Prevention
      • Polysaccharide pneumococcal vaccine
      • use of G.CSF when neutrophil count < 500 cells  l
  • 30.
    • (B) Mycobacteria
    • 1 . Mycobacterium tuberculosis:
      • Major opportunistic infection complicating HIV epidemic worldwide.
      • Cause of death in 11% of all adult AIDS deaths
      • HIV infection significantly increases the risk of developing primary TB as well as progressing from latent TB infection (LTBI) to active tuberculous disease.
      • Risk of drug resistant TB is greater among HIV-infected persons than among others.
  • 31.
    • Prevention:
      • 1. Repeat tuberculin test every year for persons with negative tuberculin skin test & risk for exposure to MTB.
        • 5 mm induration is recommended cut off point for LTBI in HIV-infected persons.
        • High incidence of false negative test with CD4  < 400 cells /  L.
        • Chemoprophylaxis ????
        • BCG : ????
  • 32.
    • 2. Mycobacterium avium complex (MAC):
    • Isolated pulmonary disease is rare
      • Abd pain, diarrhea (chronic), HSM, lymphadenopathy progressive anemia).
      • CD4  50 cells /  L
      • Diagnosis :Culture from blood, bone marrow, liver lymph nodes or respiratory specimens.
      • TTT : Macrolide with ethambutol and rifaputin
      • 3. Mycobacterium kansasii: ??
  • 33.
    • (C) Fungi
    • 1 . Pneumocystis jirovecii
      • Most common AIDS-defining opportunistic infection in USA.
      • Use of HAART & pneumocystis prophylaxis have combined & dramatically  overall number of cases.
      • .
      • Studies suggest – mode of infection either:
        • Reactivation of latent infection.
        • Possible person to person transmission.
  • 34.
      • C/P:
      • Long prodrome 28 days.
      • Fever, nonproductive cough, dyspnea with excertion.
      • Physical examination:
        • May be normal.
        • Presence of crackles   severity of disease &  mortality.
  • 35.
      • CXR:
        • Classically 
        • bilateral symmetrical reticular or granular opacities, perihilar.May be unilateral or asymmetrical.
        • Pneumatocele
        • pneumothorax.
        • Coexistent pathology: TB, kaposi’s sarcoma, fungus, fungal pneumonia.
        • Normal.
  • 36.
    • Diagnosis:
      • Sputum induction
      • Bronchoscopy & BAL upper lobe and middle lobe (-ve BAL  rules out PCP)
      • TBBX
      • PFT:
        • Restrictive ventilatory pattern
        •  lung volume
        •  expiratory flow.
        • DLCo: Sensitive indicator < 75% of predicted – 90% of PCP with normal CXR.
    • N.B: Combination of normal CXR, DLCo < 75% exclude PCP.
        • HRCT  alternate to DLCo.
  • 37.
    • Diagnosis rests on microscope visualization of charactersitic P. jirovecii cysts or trophic forms or both on stained specimen.
    • Stain:
      • silver.
      • Toulidine blue-O
      • Giemsa & Diff Quick .
    • Monoclonal antibodies.
    • PCR based techniques.
  • 38.
    • Prevention:
      • Avoid close contact ??
      • CD4  200 TMP-SMX (DS/d)
      • Atovaquon (1500 mg/d)
      • Pentamidine (300 mg/m)
      • TERTMENT
    • TMP-SMX 15-20 mg/kg
    • Trimethoprim + dapsone
    • Clindamycin + primaquine
    • Atovaquoune
  • 39. PCP
  • 40.
    • 2. Cryptococcus neoformans:
    • Only encapsulated fungus infects human
    • Meningitis, cutaneous lesions (kaposi’s sarcoma, molluscum contagiosum).
    • Cxry
        • Diffuse bilat infiltrates
        • Consolidation
        • Nodular infiltration
        • Cavitation
        • Pleural effusion
        • Normal CXR
        • TTT : Treatment:
        • Amphotricin B
        • Fluconazole
  • 41.
    • 3. Histoplasma capsulatum
    • C/P:
      • Febrile wasting illness in HIV-infected patients.
      • CD4  50 – 100 cells /  L
    • CXR:
      • Normal.
      • Reticular or reticulonodular.
      • Focal opacities.
      • Hilar & mediastinal opacities
      • Prevention:
        • Avoid activities that  exposure.
        • Intraconazole (CD4  100 cells /  L or endemic area).
      • Treatment
        • Amphotricin
        • Intraconazole
  • 42.
    • 5. Aspergillus species:
    • fimigatus most common
    • Risk factors:
      • Corticosteroids
      • Broad spectrum antimicrobial drugs
    • CXR
      • Unilateral or bilateral infiltrate.
      • Cavity lesions.
      • Nodular.
      • Pl. effusion.
      • Diagnosis culture
      • Treatment:
      • Amphotricin B
  • 43.
    • D ) Viruses
    • Members of herpes virus family.
      • - CMV - VZV - HSV - EBV
    • Influenza virus.
    • Parainfluenza visu.
    • Respiratory syncytial virus.
    • Measles.
    • Adenovirus.
    • Rhinovirus.
    • Metapneumovirus.
      • Only CMV is regarded an important pathogenic pulmonary agent.
  • 44. CMV
    • 100% of MSM are infected with viruses
    • CXR:
      • Reticular or ground glass.Alveolar infiltrate.
      • Nodular opacities Pl. effusion
      • Increased CMV IgG & IgM + C/P  Aids in diagnosis.
    • Treatment Ganciclovir Prevention:
      • CMV IgG –.
      • Oral ganciclovir
  • 45. E) Parasites
    • : . Toxoplasma gondii
      • Cryptosporidiosis
      • Microsporidiosis
      • Strongyloides stercoralis
  • 46.
    • Non-infectious Pulmonary Disorders
    • I. Malignancies:
    • 1 . Kaposi’s sarcoma:
      • Most common HIV-associated malignancy.
      •  with MSM 20.000 – 73.000 fold 
      • Relation to (HHV8)
      •  CD4  50 cells /  L.
      • Associated mucocutaneous disease.
      • Concurrent pulmonary opportunistic infection most frequently PCP.
      • Opportunistic infection  Rapid progression of kaposi’s sarcoma mimics infectious process.
  • 47.
    • C/P:
      • Non productive cough, dyspnea, fever. Chest pain, hemoptysis.
      • Examination:
        • Normal (usually). Crackles, wheezes. Effusion
        • .
    • CXR:
      • Bilat opacities in a central or perihilar distribution.
      • Linear densities, nodules, pl. effusion.
      • Adenopathy.
      • No RADIOGRAPH is diagnostic for Kaposi’s sarcoma
  • 48.
    • Diagnosis:
      • Bronchoscopy. :Endobronchial, red, violaceous flat or slightly raised lesions.
      • Effusion:
        • Exudate or transudate.
        • Serous, serosanginous or frank blood.
        • Chylous (obstructive).
      • -ve Gallium scan.
      • Chemotherapy:TTT
        • Liposomal anthracycline (doxorubocin).
        • Paclitaxel  resistant.
        • Combination HAART
  • 49.  
  • 50.
    • 2. Non-Hodgkin’s lymphoma:
    • Primary pleural effusion lymphoma:
    • 3. Bronchogenic carcinoma:
      • frequency, at younger age, aggressive course
      • 6.5 fold as Non HIV
      • Adenocarcinoma (most frequent)
  • 51.
    • Lymphocytic interstitial pneumonitis
    • Non specific interstitial pneumonitis
    • . Obstructive lung disease
    • . Pulmonary hypertension.
    • 3. Pulmonary alveolar hemorrhage.
    • 4. Pulmonary alveolar proteinosis  secondary to opportunistic infection.
    • 5. DAD & interstiail fibrosis.
    • 6. BOOP.
    • 7. Sarcoidosis
  • 52. HIV TREATMENT
  • 53.
    • There is no cure for HIV, but treatment can keep virus levels low and
    • . Some drugs interfere with proteins HIV needs to copy itself
    • ; others block the virus from entering or inserting its genetic material into your immune cells .
    • PREVENTION IS NOT BETTER THAN CURE. IT IS THE ONLY CURE“
  • 54.
    • Today, there are 31 antiretroviral drugs (ARVs) approved by the Food and Drug Administration to treat HIV infection
    • Reverse Transcriptase ( RT ) Inhibitors
    • Protease Inhibitors
    • Fusion / Entry Inhibitors
    • Integrase Inhibitors
    • Multidrug Combination Products ( HAART ).
  • 55. Why is a vaccine for HIV difficult to develop ?
    • First HIV is highly mutable it can evade the two major arms of the adaptive immune system; humoral ( antibody - mediated ) and cellular ( mediated by T cells ) immunity .
    • Second, HIV isolates are themselves highly variable . HIV can be categorized into multiple subtypes with a high degree of genetic divergence ..
    • SO Any vaccine that lacks this breadth is unlikely to be effective .
  • 56. HIV IN EGYPT
  • 57.
    • اول حالة ايدز فى مصر 1986
    • تم انشاء البرنامج الوطنى لمكافحة الايدز فى مص 1986
    • نسبة الاصابة خمسة كل مليون ولذا النسبة اقل من 2%
    • عد المصابين والمسجلين حتى 2008 حوالى HIV 4000 منهم AIDS 1000
    • ولكن منظمة لصحة تتقع خمسة اصعاف تلك النسة اى 12000 حالة
    • نسبة الرجال تقترب فى مصر من عدد الاناث المصاب
    • نسبة الاصابة انتقال الفيروس عبر الاتصال الجنسي بنسبة 49.5% ، يليه الاتصال الجنسي المثلي بنسبة 22.9% ، ويمثل تعاطي المخدرات بالحقن نسبة 4.6% ، كما تبلغ نسبة انتقال المرض من الأم إلي الطفل بنسبة 1.8% ، ونقل الدم 5% والغسيل الكلوي 8.9% ، وترجع إصابة 8.7% من الحالات إلي أسباب &quot; غير معروفة
  • 58.
    • الو الخط الساخن لمرض الايدز …نقدر نساعدك”، جملة يسمعها كل من يطلب الأرقام التالية 0223152801 _0223152802 _0227947839_ 08007008000 ، والتي خصصتها وزارة الصحة وأعلنت عنها كوسيلة جديدة للتوعية والاستفسار المباشر عن الفيروس، لكن الإقبال عليها ضعيف جدا
    • الفقرة 7 بالمادة 3 بقانون العمل، حيث تنص على “مطلوب شهادة تفيد خلو الأجنبى من مرض نقص المناعة البشرى ( الإيدز ) لأول مرة، وعند التجديد فى حالة مغادرة الأجنبى للبلاد، يعفى من تلك الشهادة ( الأجانب المتزوجون من مصريين وأبناؤهم، والأجانب المقيمون بالبلاد، والذين لم يسبق لهم الخروج منها خلال العشر سنوات الأخيرة ).
  • 59. Thank you