Introduction to HIV
Etiology and Risk Factors
Diagnosis and Management
Treatment and prophylaxis
Prevention and control
Visit to PEPFAR
Beginning of HIV/AIDS
first published article related
to AIDS was in 1981. The
principal author’s name was
Michael Gottlieb and it appeared
in the Morbidity and Mortality
Weekly Report for June 5th. This
article reported that there was a
random increase in pneumocystis
carinii pneumonia (PCP), a rare
Discovery of HIV infection.
In 1982, the term Acquired Immune
Deficiency Syndrome is used for the first
time. The name was designated by the
In 1983, French scientists at the Institute
Pasteur found a new virus that they called
lymphadenopathy-associated virus or LAV.
About a year later, Dr. Robert Gallo, of the
National Cancer institute discovered HLTVIII. The first discovery was made in France
at the Institute Pasteur, but shared credit is
given to Dr. Robert Gallo, the discoverer of
AIDS and his French counterparts for
discovering HIV on April 23, 1984.
Dr. Luc Montagnier wins the
Nobel Prize in Medicine in 2008
What is Human Immune Deficiency
Subfamily-Lentivirus, which literally means slow
virus - it takes such a long time to develop
adverse effects in the body.
This virus attacks the immune system
There are two strains – HIV 1 & HIV 2
What is Human Immune
These contain RNA, the genetic
material of HIV
The outer layer of the HIV virus cell is
covered in coat proteins, which can
bind to certain WBCs. This allows the
virus to enter the cell, where it alters
The virus infects and destroys the
CD4 lymphocytes which are critical to
the body’s immune response.
History of HIV
The HIV virus first came to light during the
A number of healthy gay men in New York
began to develop rare opportunistic
infections & cancers, that were resistant to
One such viral opportunistic infection is
cytomegalovirus that causes blindness &
inflammation of the colon
Research teams in the U.S.A & France made
independent research discoveries of the virus.
French researchers discovered a virus linked to
AIDS in 1983, they called it LymphadenopathyAssociated Virus (LAV)
In 1984, American researchers isolated a virus
that caused AIDS, calling it Human T-lymph
tropic Virus type III (HTLV- III )
These two viruses were later found to be the
same virus - HIV
The emergence of HIV & AIDS has resulted
in countless debates as to where it originated
It’s suspected that it originated from S.I.V
(Simian Immunodeficiency Virus)
SIV affects Monkeys
Certain strains of SIV closely resemble the two types of
HIV 1 – was difficult to link with SIV
In 1999 SIVcpz closely related to HIV 1
Originated from chimpanzees but it has significant
differences from HIV-1
HIV 2 closely related to SIVsm
Originated from the green monkey
Family : Retroviridae
Subfamily : Lentivirus
RNA virus, 120nm in
Envelope gp160; gp120
◦ Outer matrix protein (p17)
◦ Major capsid protein (p24)
◦ Nuclear protein (p7)
Diploid RNA with several
copies of reverse
gag (group-specific antigen): makes
the cone shape viral capsid.
pol (polymerase): codes for viral
enzymes reverse transcriptase,
integrase, and viral protease.
env (envelope): makes surface protein
gp120 and trans membrane gp41,
enabling HIV to fuse to CD4 cells.
Genes Coding Structural Proteins
1 The gag gene –
core and shell
expressed as p55 – (
p18,- p17) cleaved as
p15, p18,and p24
make up as viral core
p24 seen during early
stages reappearance in
the late stages
exacerbation of disease
The env determines the
synthesizes of envelop
glycoprotein's gp160 cleaved into
two envelop components gp120
which forms the surface spike and
gp 41 which trans membrane
The gp120 antibodies are present
till the death of the patient.
Polymerase reverse transcriptase
The pol gene codes
for the polymerase
and other viral
which is cleaved into
proteins p31, p51,and
The Tran activator gene influences the function of
genes some distance away. It controls
transactivation of all HIV proteins.
The differential regulator of expression of virus
The virus infectivity factor gene is required for
infectivity as cell-free virus.
The negative regulator factor retards HIV
The virus protein R gene has an undetermined
Genes differ HIV I for HIV II
The virus protein U gene is required
for efficient viral replication and
release. It is found only in HIV-1.
The virus protein X gene has an
undetermined function. It is found
only in HIV-2 and SIV.
Ejezie Tobenna K.
Epidemiology of HIV
HIV is a global pandemic, as of 2011
approximately 34million people had HIV
worldwide. Of these approximately 17.2million are
men, 16.8million are women and 3.4million are
less than 15 years of age. Sub-saharan Africa is
the region most affected with HIV. South Africa
has the highest population of people living with
HIV of any country in the world with about
In Nigeria, about 3.1million people are living with
HIV and about 300,000 new infections occur
annually with people between the ages of 15-24
contributing to 60% of the infection. Prevalence
between women of 15-24 years of age is estimated
to be three times higher than that of men of the
same age, females constitute about 58% of
persons living with HIV in Nigeria. Research shows
that Benue state has the largest number of people
living with HIV in Nigeria. In Enugu state, a greater
percentage of people living with HIV are said to be
found in Nsukka area of the state for reasons not
Aetiology and Risk factors of
The causative agents of the disease are strains of
two structurally and geographically relatively
distinct retroviruses; HIV-1 and HIV-2 of which man
is the only known reservoir. Amongst the various
aetiological factors of HIV/AIDS, the following are
the most important predisposing factors to HIV
1.Unprotected sexual intercourse (including anal
and oral sex); rape, sexual assault, multiple sexual
partners, homosexual practise.
2. Transfusion of unscreened and contaminated
3. Use of unsterilized needles like syringes in
clinical practise and blades of clippers as used in
barbing saloons. Note that intravenous drug
abusers are at high risk of infection cause of
continuous puncturing of veins with same needles
used by different individuals who also engage in
the same practise.
Sexually transmitted disease which produce open
sores on the genitals which act as door ways to
entry of the virus.
Another very important risk factor is that of
mother to child transmission which has caused an
increase in HIV infected newborns.
Ekpemiro, C. C. U
Four fluids are essentially involved in the
transmission of HIV.
◦ Blood , Breast milk, Semen, Vaginal fluid
( have a potential for high HIV load-exchange ≈
[Tears, saliva, sweat, and urine have a low
concentration of the virus( natural cpds that
decrease the conc. & infectiousness of HIV)].
Heterosexual intercourse with infected
Injections with infected needles
Through blood or blood products
Transplacental transfer from mother to
(all involve tranmission of body fluids which
contain lymphocytes to which HIV
attaches and more or less becomes a
vehicle for transmission)
HIV is not transmitted by
◦ Handshakes, hugging, use of the same
feeding utensils, sharing of conveniences
HIV virus contains numerous external spikes
formed by two major envelope proteins;
the external gp120 and
the transmembrane gp41
[ both responsible for cell attachment and entry].
Has genes that encode
the structural proteins of the virus: structural gene
the enzymes responsible for reverse transcription
and integration -Polymorphic gene [pol]
the envelope glycoprotein- envelope gene [env]
[gp 120 to
membrane to host cell
membrane[ virus binds to
ccr5 orcxcr4 coreceptors]
[viral in host
[integration into host
Budding off host membrane
Protease- viral peices
Each point in the life cycle of HIV is a real or
potential target for therapeutic intervention.
Hallmark of HIV infection is
Antibodies to HIV are produced
invariably within 8 weeks of onset of
primary infection. Detection of these
antibodies forms the basis of most
diagnostic screening test.
Phases in HIV infection
Acute Clinical syndrome : initial infection
◦ Non specific symptoms lasting ≈ 1-3 wks.
Phase of asymptomatic infection
◦ Period btw infections and onset of clinical
symptoms( clinical latency) ≈ 2-15yrs not
◦ Persistent replication of virus, gradual decline in
function and number of CD4+ T-cells. This
stage marks the establishment of chronic and
persistent infection which is the hallmark of HIV
Early Symptomatic disease phase:
◦ onset of minor opportunistic infections.
◦ Mild bacterial, fungal, & viral infections but with
longer duration than in healthy people.
◦ ARC or Pre-AIDS
Onset of definite AIDS;
◦ Onset of AIDS opportunistic infections which
are life threatening. They include disease of
body organs, secondary neoplasm, infectious
disease, constitutional neurologic disease.
Progression ( depends on response
◦ Median time from HIV to AIDS approx 10yrs.
Some before 5yrs.
◦ Currently considered long term survivors 1015yrs initial infections at this time most have
immunodeficiency & opportunistic infections.
Some have CD4+ T-cell count below 200/ul
Non progressors ( 5%):
◦ infected for a long time(10yrs), normal
CD4+ counts, stable, never received antiretroviral therapy = long term nonprogressors.
There are four clinical stages which
encapsulates some of the clinical features in
Clinical stage 1
Acute (primary) HIV infection
Performance scale 1: asymptomatic, normal
Clinical stage 2
- Weight loss < 10% of body weight
- Minor mucocutaneous manifestation
(seborrheic dermatitis, prurigo, finger nail
infections, recurrent oral ulcerations,
Herpes zoster within the last five
- Recurrent upper respiratory tract
Performance scale 2: symptomatic, normal
DIAGNOSIS OF HIV
HIV can be diagnosed in the laboratory by
- Antibody tests
- Antigen detection methods.
It is most commonly diagnosed by testing body
fluids(usually blood) for the presence of antibodies to
the virus. However, these tests are not accurate
immediately after infection because it takes about
3week to 6months for these antibodies to be
A newer type of test which checks for the HIV
antigen, a protein produced by the virus immediately
Clinical diagnosis may not be feasible
except in advanced disease where
HIV symptoms and associated
complications are present. These may
be a good pointer to the existence of
DIAGNOSIS OF HIV
HIV Enzyme linked Immunosorbent Assay (EIA)
Gives false positives
Simple/Rapid HIV Test
Western blot(immunoblot) test:
Sensitive and specific
ANTIGEN DETECTION TESTS- detects virus in
Viral culture- time consuming and expensive
DNA Polymerase Chain Reaction(PCR)
RNA PCR(viral load)- most sensitive
test of choice in children less than 18 months
because maternal antibodies persists for 1518months of age. The test is best done within 23months of life in non-breastfeeding infants, and
3months after cessation of breastfeeding.
Also recommended for patients in the window
HIV COUNSELLING AND TESTING
-discuss purpose of test
-explore knowledge of the disease and risk assessment,
transmission and reduction
-explain test procedure and obtain informed consent from
Screening test : if negative, repeat test 3months afterwards
if positive, confirm using two different immunoassays
or western blot.
- if negative, discuss transmission and behavioural
modification, advice to repeat test 3months afterwards.
-if positive, explain significance and implication, organize
urgent medical follow up, discuss confidentiality issues, provide
MANAGEMENT OF HIV
This involves the treatment of the virus
and prevention of opportunistic
The aim is to prevent the immune
system from deteriorating to the point
that opportunistic infection s becomes
Treatment does not eradicate the
MANAGEMENT OF HIV
Assess time of HIV acquisition: previous negative
test, previous antenatal screening, history
consistent with seroconversion, known HIVinfected sexual partner, presence of HIV indicator
Recreational drug use
Occupation, residence, birthplace, travel history
Partners and children
Past History of TB or any HIV indicator disease
Immunization History BCG, Hep B and C
Review of systems
General: fever, generalised rashes, skin lesions, dry
cough/tachypnoea, weight loss, generalized
lymphadenopathy, jaundice, dermatitis.
Eye: uveitis , retinitis
Mouth and Oropharynx:
White patches( oropharyngeal candidiasis, hairy
leukoplakia), aphthous ulcers, herpes simplex infections.
Gingivitis or periodontitis may be seen on the teeth.
Chest : dull percussion, crepitations
Anorectal region: rashes, ulcer, anal cancer, herpes
CNS: Meningeal symptoms, dementia, Primary
lymphoma, peripheral neuropathy.
Hep B and C status
HIV resistance test
Toxoplasma and CMV IgG antibody(annually if negative initially)
Liver function test
Full blood count.
Serum electrolyte, Urea, creatinine
Cervical smear for women(yearly is normal at previous test)
TB In Immunocompetent patients.
In UNTH, the tests routinely done are: viral load,
CD4 count, SEUCr, FBC Liver function tests, hep B
and C, Chest X-ray.
These tests are repeated 6monthly.
Patient is seen 1month after samples are taken for
the test on the 1st visit for possible commencement of
Abnormal test results may contraindicate the
administration of certain drugs
A chest x-ray suggestive of TB co-infection may
require patient to be seen by the Chest Unit where
the DOTs therapy is administered for at least 2wks
before commencement antiretroviral therapy.
The cornerstone In the management and
treatment of HIV is the Highly Active Antiretroviral
It involves multiple drug therapy. The principle of
combining drugs serves to provide additive
antiviral activity and reduction in emergence of
The decision to start therapy is dependent on
several factors of which the CD4 count is the
Research data led the US guideline in 2011 to
recommend the initiation of ART in patients with
CD4 count threshold of 350cells/microL or in
patients with a history of AIDS defining illness.
2013 guidelines from WHO now however
recommends that a threshold of
500cells/microL. It also states that ART
should begin immediately regardless of CD4
count, in HIV positive serodiscordant couples,
patients with Hep B co-infection, HIVAssociated nephropathy, pregnant and
breastfeeding women and children under
Choice of drugs made based on
-virologic efficacy, toxicity, pill burden,
dosing frequency, drug-drug reaction potential,
co-morbid conditions, drug resistance test
CONTROL OF HIV
Egwuatu, Emmanuel C.
The standard for treatment of HIV infection & PMTCT is the Combination
HAART (Highly Active Antiretroviral Therapy)-is a combination of about 3diff.
drugs from diff. classes of ARV drugs(atleast 2 diff grps eg 2 NRTIs + 1
CLASSES OF ARV DRUGS:
1.Reverse Transcriptase Inhibitors:
-NRTIs –Zidovudine,stavudine,lamivudine, didanosine, abacavir, zalcitabine
NNRTIs- Nevirapine, Efavirenz
2. Protease Inhibitors:
Saquinavir, retronavir, indinavir, nelfanavir.
3. Entry inhibitors –enfuvirtide,maraviroc.
4. integrase inhibitors –raltegravir
N/B : The most widely used ARV drugs in Nigeria, which are approved by
NAFDAC are those in the class of reverse transcriptase inhibitors &
protease inhibitors. WE HAVE NO CURE FOR HIV/AIDS presently!!!!.
Adult Regime & Dosages :
1st line drugs used in Nigeria viz:
Zidovudine, stavudine,lamivudine, nevirapine, efavirenz.
These are used under the ff fixed combination :
stavudine (dt4)+ lamivudine(3TC) + nevirapine(NVP)
zidovudine(AZT)+ lamivudine (3TC) +
Doses of these 1st line drugs given:
Stav(dt4) --40mg 2x daily (30mg if < 60kg)
Zido(AZT) --250-300mg 2x daily
Lami(3TC) --150mg 2x daily
Efavirenz(EFV) --600mg x1 daily
Nevirapine(NVP) : 1st 2wks -200mg x1 daily
if no rxn – 200mg x2 daily
Choice and onset of ART depends on :
Clinical condition of the patient(+ knowledge of side effect of the ARV drugs)
CD 4+ cell count(</>350 cells/mm)
Clinical staging (esp stages 3 & 4)
Childrens regime & dosages:
Both children and adolescents are best managed by a specialist in paed. HIV
infection & a multidisciplinary approach shld be employed due to the peculiarites
of HIV /AIDS mgt in children.
The onset of ART depends on the stage & age of the child;this can be started in
All HIV+ve children(<24 mths)
All HIV+ve children >24mths with WHO stages 3&4(regardless of CD 4 count)
All HIV+ve children aged 24-59 mths with CD4 count <25%(<750cells/mm3)
All HIV+ve children >5yrs with CD 4 count <350 cells/mm3
The 1st line ARV combination therapy for children viz:
AZT + 3TC + ABC ---For HIV+TB cotreatment
AZT + 3TC + NVP --- child < 3yrs (<10kg)
AZT + 3TC + NVP/EFV ---child > 3yrs(>10kg)
Common side effects of ART:
Zidovudine : anaemia(c/I if Hb <8g/dl),
leucopenia, thrombocytopenia, GI
Nevirapine : lethal hepatotoxicity, stevenjohnson syndrome,lactic acidosis (if CD 4
count >350 cells/mm3).
Efavirenz :embryopathy(esp neural tube
defects-thus avoided in 1st trimester),CNS
effects (hallucinations, insomnia-C/I in px with
Stavudine : severe lactic acidosis.
Protease inhibitors : muscular dystrophy (with
These may refer to inadequate responses to treatment
when given a combination of ARV drugs.There are diff.
Chemical or virologic failure: where viral load remain
high/is increasing despite treatment.
Clinical failure : more AIDS related symptoms arising
Immunological failure : CD 4 count not increasing
2 strong indicators for measuring response to treatment
remain – CD 4 count & viral load. Thus with failure, the
combination can be changed & with exhaustion of 1st
line drugs, 2nd line drugs can be used.
There are various measures designed to prevent and control HIV infections,
and these span the diff. stages of prevention:
1. GENERAL HEALTH PROMOTION : -
Universal and Health sector precautions. The prevention & control of HIV
transmission will be achieved via continuous health education on AIDS
control, aimed at modifying the behaviour of the target population.
Universal precaution :
- Create awareness of the presence & danger of HIV/AIDS(introduction of world
AIDS day -1st Dec)
-Avoidance of promiscuity(hetero-/homosexual esp among young adults-1449yrs).
-Avoidance of IV drug use.
-Practice of safe sex (espcially with those of high risk behaviour).
-Avoidance of use of unsterilised needles/sharp objects for surgical
procedures/cultural rituals/social practices(mani-, pedicure,barbing).
-Male circumcision should be encouraged (known to decrease transmission
-Sero +ve women should avoid unplanned pregnancy by utilizing family
Health sector precautions:
Thorough handwashing (soap+H2O)& drying the arm with
single use towel after contact with any patient.
Use of protective barriers(eg disposable gloves) for any
invasive procedure/handling of body fluids to avoid direct
Surgeon should ensure they double glove during all surgical
Cuts, bruises by health workers should be covered with
Sharp instruments should be handled safely &disposed
properly after use .
Containers for disposing sharps should be puncture resistant.
Proper decontamination/sterilisation should be done for
reusable sharp/invasive instruments.
Adeq. screening of blood & blood products, organs for
transplantation, semen for artificial insemination.
2. SPECIFIC PROTECTION AGAINST HIV
A) PREVENTION OF MOTHER TO CHILD TRANSMISSION
MTCT is the primary route of infection in children <15yrs
(especially during labour, in-utero via placenta,& postpartum via
• N/B: Nigeria has the highest burden of MTCT of HIV
Thus mothers should be educated on HIV prevention at ANC.
HIV positive mothers should be advised on family planning
measures to prevent unwanted pregnancy.
• In cases of pregnancy: Prophylactic ART shld be instituted
to prevent MTCT.
Proper ANC should be & safe delivery practices employed.
Proper infant feeding practice shld be
For prophylactic ART: Every HIV+ve preg. woman should
be started on prophylactic ART irrespective of CD 4 count,
viral load or clinical staging of the disease.
• Time of commencement &choice of drug depends on the ff
Woman already on ART:
• Continue ART(but in 1st trimester,replace efavirenz with NVPto prevent neural tube defect)
• Infant receives NVP till 6 wks only.
Women not on ART:
If she meets the adult criteria for ART- start ART (ZDV+ 3TC+
NVP/EFV);If px also has TB,replace NVP with EFV (rifampicin
dec bioavailability of NVP).
Then infant shld receive NVP for 6 wks.
If she does not meet the criteria – wait and start treatment any
time after 14wk(1st trimester) using ZDV +3TC +NVP.
Woman presents 1st time in labour:
Single dose NVP 200mg stat (+ ZDV 300mg + 3TC 150mg
- 12hrly till delivery)
Woman presents 1st after delivery :
mother – determine if she needs ART & follow appropriate
Child – breastfed + mother not on ART=Give NVP till 1wk
after cessation of breastfeeding.
- breastfed + mother on ART =Give NVP till 6wkafter
mother starts ART.
-If not breastfed =Give NVP till 6wk
N/B: child shld follow the standard immunization schedule
; if symptomatic , live vaccine(BCG ,OPV,YF) shld be
B)POST EXPOSURE PROPHYLAXIS(PEP)
Indications: Needle stick injury/injury with sharp objects
used on HIV+ve
- Mucus memb./broken skin exposed to potentially
For effectiveness, PEP should commence: within 1-6hrs of
exposure (not be
>72hrs) & last for 28days . Follow up
HIV testings should be done (at
baseline, 4wk, 12wk,
PEP Dosages :
Low risk exposures: ZDV (250-300mg bd) + 3TC (150mg
High risk exposure : ZDV + 3TC + Indinavir/Efavirenz
3. EARLY DIAGNOSIS & TREATMENT :
Early diagnosis & treatment is best achieved via Voluntary Counselling &
testing – a process whereby an individual undergo counselling to enable
him/her make an informed choice about being tested for HIV, and to be
informed on the healthy sexual behaviour & +ve way of living with HIV, if
he/she tests +ve.
This process should be voluntary, confidential and focused on dealing with
the fears, guilts, stigma and other issues related to HIV/AIDS.
HIV tests done may include: Rapid or ELISA test – for screening ,while the
Western blot – for confirmation.
Thus many elements are required viz:
-Materials for testing, prophylaxis and treatment.
-Motivated staff with atleast training in minimum standard of counselling
-Campaigns which should be done to create awareness on the importance
Fortunately PEPFAR & other agencies has been instrumental in Nigeria, in
providing fund & materials needed. Likewise Govt. & other private agencies can
4. LIMITING FURTHER
PERSONS LIVING WITH HIV/AIDS:
The following measures can be employed to this end :
•Isoniazid preventive therapy (IPT)– to prevent co infection with
•Cotrimoxazole preventive therapy(CPT)-to prevent
•Adequate compliance to medication once started.
•Timely consultation of a competent clinician in cases of
5. REHABILITATION :
This will be achieved via efforts to –
Provide psychosocial support to
people living with HIV/AIDS.
Develop social groups- to enhance the
sharing of experiences & ideas , and
promote the possibilites of pairing up
Lets hope for a cure, although
presently we have NO CURE for
PREVENTION is the BEST option –
chastity, abstinence, faithfulness
remain the best advice.
`He who is
The visit to the PEPFAR Clinic UNTH took
place on the 5th of November 2013 .
There, we were attended to by Dr
Onyebueke, a resident in the Unit.
What we learnt
PEPFAR- means US Presidential Emergency
Plan For AIDS Relieve. It is sponsored by
United States (Harvard).
APIN- AIDS Prevention in Nigeria plus
We were taught what happens on the various
days of Visit
Day 1-counselling, consent to treat the
patient, history, clinical examination, send
patient for investigations.
In UNTH 7 investigations are carried
Consultation and other services are free.
Patient is seen 1month afterwards when
the results are available.
On the day 2 of visit, a pre-assessment
form is filled.
If patient qualifies for ART, an Entry form
is filled. If not the patient is advised on
If qualified for ART, he/she is started on
Once ART is started, it is not stopped
despite improvement in patient’s health
status, except in specific cases.
Other form of support
counselling, PEP, abstinence, Fidelity
Human Immunodeficiency virus
Infection by Dr T.V. Rao MD,
Kumar V.,Abbas A.K.,Aster J.C.,9th
Kumar P.,Clark M.,8th
“E NO DEY SHOW FOR
THE BEST POLICY FOR US