Pulmonary complications                      www.aidsknowledgehub.org  Regional Knowledge Hub for the Care and Treatment o...
Цель занятия • Цель занятия: рассмотреть вопросы   касающиеся заболеваний органов дыхания у   пациентов с ВИЧ инфекцией. •...
Respiratory illnesses in persons     with HIV infection & AID Bacterial infections:                               Viral in...
CAUSE of PULMONARY DISODERS              WITH HIV • The single major prospective study of pulmonary   complications of HIV...
Pneumonia etiology correlated            with CD4 countCD4 count                          S. pneumoniae, M. tuberculosis, ...
Uncommon association of chest X-ray  changes and etiology of pneumoniaConsolidation                  Nocardia, M. tubercul...
Correlation of Chest X-ray Changes   and Etiology of Pneumonia Consolidation                  Pyogenic bacteria, Kaposi’s ...
Bacterial infection: Gram-negative bacilli • Course: Acute, purulent sputum • Frequency: uncommon (except with nosocomial ...
Bacterial infection: Haemophilus influenzae • Course: Acute, purulent sputum • Frequency: 100-fold higher then healthy   c...
Bacterial infection: Legionella • Course: Acute mucopurulent sputum • Frequency: uncommon. • Setting: HIV-associated is de...
Bacterial infection: Nocardia • Course: Chronic or asymptomatic;   sputum production • Frequency: Uncommon • Setting: Freq...
Bacterial infection: Staph. aureus • Course: Acute, subacute, or chronic purulent   sputum • Frequency: Uncommon, except w...
Bacterial infection: Strept. pneumoniae • Course: Acute, purulent sputum ±pleurisy • Frequency: common, all stages; 100-fo...
Fungal infection: Aspergillus • Course: Acute or subacute • Frequency: Up to 4% of AIDS patients • Setting: usually advanc...
Fungal infection: Candida • Course: Chronic or subacute • Frequency: Common isolate, rare cause of   pulmonary disease (me...
Fungal infection: Coccidioides immitis • Course: Chronic or subacute • Frequency: Up to 10% of AIDS patients in   endemic ...
Fungal infection: Cryptococcus • Course: Chronic, subacute, or symptomatic • Frequency: Up to 8% to 10% in AIDS patients •...
Fungal infection: Histoplasma                             capsulatum • Course: Chronic or subacute • Frequency: Up to 15% ...
Fungal infection: Pneumocystis jiroveci     (previously known as Pneumocystis carinii)   • Course: Acute or subacute   • P...
PCP                                                                    severe PCPRegional Knowledge Hub for the Care and T...
PCPRegional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia   www.aidsknowledgehub.org
Fungal infection: Pneumocystis jiroveci    (previously known as Pneumocystis carinii)• X-ray findings:      - Interstitial...
Viruses infection: CMV • Course: Subacute or chronic • Frequency: Common isolate, rare cause of   pulmonary disease • Sett...
Viruses infection: HCV, VZV, RSV,                       parainfluenza • Course: Acute • Frequency: Rare causes of pneumoni...
Viruses infection: influenza • Course: Acute, purulent sputum • Frequency: Frequency and course minimally   different from...
Mycobacterium avium complex (MAC) • Course: Chronic or asymptomatic • Frequency: Moderate for disseminated disease   but u...
Mycobacterium kansasii • Course: Chronic or asymptomatic • Frequency: Uncommon • Setting: Late-stage HIV (median CD4 50   ...
Kaposi’s sarcoma (KS)• Course: Asymptomatic or chronic progressive  cough and dyspnea• Frequency: Moderately common in pat...
Lymphocytic interstitial pneumonia (LIP)• Course: Chronic or subacute• Frequency: Uncommon in adults• Setting: median CD4 ...
Lymphoma • Course: Chronic or asymptomatic • Frequency: Uncommon, but may be   presenting site • Typical findings: Interst...
Treatment (except pneumocystis)Gram-negative Need in vitro susceptibility tests. Long-term ciprofloxacinbacilli       usua...
Treatment (except pneumocystis)CMV                         Ganciclovir, foscarnet or cidofovirHSV, VZV, RSV,              ...
Upcoming SlideShare
Loading in...5
×

Pulmonary complications eng_d4-5

258

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
258
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
9
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Pulmonary complications eng_d4-5

  1. 1. Pulmonary complications www.aidsknowledgehub.org Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia Advanced ART Training for Adults and Adolescents – Ukraine, 2004
  2. 2. Цель занятия • Цель занятия: рассмотреть вопросы касающиеся заболеваний органов дыхания у пациентов с ВИЧ инфекцией. • Задачи: усвоив материал занятия, Вы будете: – Знать причины инфекционного и неинфекционного поражения лёгких – Уметь предполагать этиологию поражения лёгких в зависимости от количества CD4 – Знать особенности рентгенологических изменений в зависимости от этиологии поражения лёгких – Уметь проводить лечение и профилактику поражений лёгкихRegional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  3. 3. Respiratory illnesses in persons with HIV infection & AID Bacterial infections: Viral infections: Pneumococcal pneumonia Cytomegalovirus H. influenzae pneumoniae Herpes simplex virus Klebsiella pneumonia Staphylococcal pneumonia Possible complications: M. tuberculosis pneumoniae Lymphocytic interstitial pneumonitis MAC pneumonia Fungal infections: Possible complications: Pneumocystis pneumonia ·Lung abscess Cryptococcosis ·Empyema Histoplasmosis ·Pleural effusion Aspergillosis ·Pericardial effusion ·Pneumothorax Other conditions: Kaposis sarcoma LymphomaWHO HIV/AIDS Treatment and Care Protocols of HIV/AIDS in EurasiaCommonwealth of Independent States.March.2004Regional Knowledge Hub for the Care and Treatment for countries of the www.aidsknowledgehub.org
  4. 4. CAUSE of PULMONARY DISODERS WITH HIV • The single major prospective study of pulmonary complications of HIV was discontinued in the pre-HAART era – 1995. Data from 3 years (1992-1995) showed 521 infections: - PCP – 232 (45%), - Pyogenic bacteria – 220 (42%), - Tuberculosis – 25 (5%), - CMV – 19 (4%), - Aspergillus – 12 (2%), and - Tryptococcosis – 7 (1%) John G. Bartlett. Medical management of HIV infection, 2003Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  5. 5. Pneumonia etiology correlated with CD4 countCD4 count S. pneumoniae, M. tuberculosis, S.>200 aureus (IDU), Influenzacells/mm3CD4 count Above + P. carinii, cryptococcosis,50-200 cells/ histoplasmosis, coccidioidomycosis,mm3 Nocardia, M. kansasii, Kaposi’s sarcomaCD4 count Above + P. aeruginosa, Aspergillus,<50 MAC, CMVcells/mm3 John G. Bartlett. Medical management of HIV infection, 2003Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  6. 6. Uncommon association of chest X-ray changes and etiology of pneumoniaConsolidation Nocardia, M. tuberculosis, M. kansasii, Legionella, B. BronchisepticaReticulonodular Kaposi’s sarcoma, toxoplasmosis, CMV, leishmania,infiltrates lymphoid interstital pneumonitisNodules Kaposi’s sarcoma, NocardiaCavity M. kansasii, MAC, Legionella, P. carinii, lymphoma, Klebsiella, Rhodococcus equiHilar nodes M. kansasii, MACPleural effusion Cryptococcosis, MAC, histoplasmosis, coccidioidomycosis, aspergillosis, anaerobes, Nocardia, lymphoma, toxoplasmosis, primary effusion lymphoma John G. Bartlett. Medical management of HIV infection, 2003Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  7. 7. Correlation of Chest X-ray Changes and Etiology of Pneumonia Consolidation Pyogenic bacteria, Kaposi’s sarcoma, cryptococcosis Reticulonodular P. carinii, M. tuberculosis, histoplasmosis, infiltrates coccidioidomycosis Nodules M. tuberculosis, cryptococcosis Cavity M. tuberculosis, S. Aureus (IDU), Nocardia, P. aeruginosa, cryptococcosis, coccidioidomycosis, histoplasmosis, aspergillosis, anaerobes Hilar nodes M. tuberculosis, histoplasmosis, coccidioidomycosis, lymphoma, Kaposi’s sarcoma Pleural effusion Pyogenic bacteria, Kaposi’s sarcoma, M. tuberculosis (congestive heart failure, hypoalbuminemia) John G. Bartlett. Medical management of HIV infection, 2003Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  8. 8. Bacterial infection: Gram-negative bacilli • Course: Acute, purulent sputum • Frequency: uncommon (except with nosocomial infection or neutropenia) • Setting: P. auruginosa is relatively common in late-stage disease, cavitary disease, or chronic antibiotic exposure (median CD4 50 cells/mm3) • Typical findings: Lobar or bronchopneumonia • Diagnosis: Sputum GS and culture (sensitivity is >80%, but specificity is poor) John G. Bartlett. Medical management of HIV infection, 2003Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  9. 9. Bacterial infection: Haemophilus influenzae • Course: Acute, purulent sputum • Frequency: 100-fold higher then healthy controls • Setting: most infections are caused by unencapsulated strains • Typical findings: bronchopneumonia • Diagnosis: Sputum GS and culture (sensitivity of culture is 50%; prior antibiotics usually preclude growth) John G. Bartlett. Medical management of HIV infection, 2003Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  10. 10. Bacterial infection: Legionella • Course: Acute mucopurulent sputum • Frequency: uncommon. • Setting: HIV-associated is debated • Typical findings: bronchopneumonia; sometimes multiple infiltrates in noncontiguous segments • Diagnosis: Sputum culture; urinary antigen John G. Bartlett. Medical management of HIV infection, 2003Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  11. 11. Bacterial infection: Nocardia • Course: Chronic or asymptomatic; sputum production • Frequency: Uncommon • Setting: Frequency higher with chronic corticosteroid use (median CD4 50 cells/mm3) • Typical findings: Nodule or cavity • Diagnosis: Sputum or fiberoptic bronchoscopy; GS John G. Bartlett. Medical management of HIV infection, 2003Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  12. 12. Bacterial infection: Staph. aureus • Course: Acute, subacute, or chronic purulent sputum • Frequency: Uncommon, except with injected drug use and tricuspid valve endocarditis with septic emboli • Typical findings: Bronchopneumonia, cavitary disease, septic emboli with cavities ± effusion • Diagnosis: Blood, sputum GS and culture(sputum culture is sensitive, but specificity is poor). Blood cultures are nearly always positive with endocarditis (John G. Bartlett. Medical management of HIV infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  13. 13. Bacterial infection: Strept. pneumoniae • Course: Acute, purulent sputum ±pleurisy • Frequency: common, all stages; 100-fold higher then healthy controls • Setting: higher with low CD4 and with smoking • Typical findings: Lobar or bronchopneumonia ±pleural effusion • Diagnosis: Blood cultures often positive, sputum GS, Quellung, culture (sensitivity of culture is 50%; prior antibiotics usually preclude growth) (John G. Bartlett. Medical management of HIV infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  14. 14. Fungal infection: Aspergillus • Course: Acute or subacute • Frequency: Up to 4% of AIDS patients • Setting: usually advanced HIV infection (median CD4 count 30 cells/mm3); about 50% have severe neutropenia (ANC <500/mm3) ± chronic steroids; disseminated disease is uncommon • Typical findings: Focal infiltrate; cavity - often pleural-based, diffuse infiltrates or reticulonodular infiltrates • Diagnosis: Sputum stain and culture; falsepositive and false-negativecultures common. Best tests:Tissue pathology or sputum smear and typical CT and clinical features (John G. Bartlett. Medical management of HIV infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  15. 15. Fungal infection: Candida • Course: Chronic or subacute • Frequency: Common isolate, rare cause of pulmonary disease (median CD4 count 50 cells/ mm3) • Typical findings: Bronchitis; rare cause of pneumonia (some say it does not exist) • Diagnosis: Recovery in sputum or FOB specimen is meaningless (up to 30% of all expectorated sputumand FOB cultures in unselected patients yield Candida sp.); must have histologic evidence of invasion on biopsyWHO HIV/AIDS Treatment and Care Protocols for countries of the Commonwealth of Independent States.March.2004 John G. Bartlett. Medical management of HIV infection, 2003Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  16. 16. Fungal infection: Coccidioides immitis • Course: Chronic or subacute • Frequency: Up to 10% of AIDS patients in endemic area • Setting: usually advanced HIV infection (median CD4 count 50 cells/mm3); disseminated disease in 20% to 40% • Typical findings: Diffuse nodular infiltrates, focal infiltrate, cavity; hilar adenopathy • Diagnosis: Sputum, induced sputum, or FOB stain and culture; KOH of expectorated sputum is rarely positive; serology positive in 70%; blood cultures positive in 10% (John G. Bartlett. Medical management of HIV infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  17. 17. Fungal infection: Cryptococcus • Course: Chronic, subacute, or symptomatic • Frequency: Up to 8% to 10% in AIDS patients • Setting: late-stage HIV infection (median CD4 count 50 cells/mm3); 80% have cryptococcal meningitis • Typical findings: Nodule, cavity, diffuse or nodular infiltrates • Diagnosis: Sputum, induced sputum, or FOB stain and culture; serum cryptococcal antigen usually positive; CSF analysis indicated if antigen or organism found at any site (John G. Bartlett. Medical management of HIV infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  18. 18. Fungal infection: Histoplasma capsulatum • Course: Chronic or subacute • Frequency: Up to 15% of AIDS patients in endemic area • Setting: usually advanced HIV infection with disseminated histoplasmosis (median CD4 count 50 cells/mm3) • Common features: Fever, weight loss, hepatosplenomegaly, lymphadenopathy • Typical findings: Diffuse nodular infiltrates, nodule, focal infiltrate, cavity, hilar adenopathy • Diagnosis: Best test for diagnosis and followup of treatment is serum and urine polysaccharide antigen assay, with yield of 85% (blood) and 97% (urine). Serology positive in 50% to 70%; yield with culture of sputum – 80%, marrow – 80%; blood cultures positive in 60% to 85% (John G. Bartlett. Medical management of HIV infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  19. 19. Fungal infection: Pneumocystis jiroveci (previously known as Pneumocystis carinii) • Course: Acute or subacute • Presentation: - Usually present with cough, shortness of breath and fever - Often patients have features of respiratory failure (shortness of breath and cyanosis) - Occasionally patients have no chest signs • Frequency: Very common in late stages of HIV infection (>95% have CD4 <200 cell/mm3) • Setting: infrequent in patients compliant with TMP-SMX prophylaxisWHO HIV/AIDS Treatment and Care Protocols for countries of the Commonwealth of IndependentStates.March.2004 John G. Bartlett. Medical management of HIV infection, 2003 Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  20. 20. PCP severe PCPRegional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  21. 21. PCPRegional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  22. 22. Fungal infection: Pneumocystis jiroveci (previously known as Pneumocystis carinii)• X-ray findings: - Interstitial infiltrates with characteristic ground glass appearance; - Negative X-ray in early stages, about 15% to 20%; - Atypical findings in 20% (upper lobe infiltrates, focal infiltrates, nodules, cavitary disease, or mediastinal lymphadenopathy)• Diagnosis: Cytology of induced sputum (mean yield of 60% in proven cases) and bronchoalveolar lavage (mean yield of 95%)• Treatment and prophylaxis: see D3-3John G. Bartlett. Medical management of HIV infection, 2003WHO HIV/AIDS Treatment and Care Protocols for countries of the Commonwealth of Independent States.March.2004 Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  23. 23. Viruses infection: CMV • Course: Subacute or chronic • Frequency: Common isolate, rare cause of pulmonary disease • Setting: Advanced HIV infection (median CD4 count 20 cells/mm3) • Typical findings: Interstitial infiltrates • Diagnosis: Yield with FOB is 20% to 50%, culture requires more than 1 week; shell culture 1 to 2 days; diagnosis of CMV pneumonitis (disease) requires CMV seen on cytopath or biopsy, progressive disease, and no alternative pathogen (John G. Bartlett. Medical management of HIV infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  24. 24. Viruses infection: HCV, VZV, RSV, parainfluenza • Course: Acute • Frequency: Rare causes of pneumonia • Typical findings: Diffuse or nodular pneumonia, bronchopneumonia • Diagnosis: – Culture of sputum or FOB commonly yields HSV as a contaminant from upper airways – RSV is rare in adults but has increased frequency in immunosuppressed host, is easily detected with DFA stain of respiratory secretions (John G. Bartlett. Medical management of HIV infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  25. 25. Viruses infection: influenza • Course: Acute, purulent sputum • Frequency: Frequency and course minimally different from patients without HIV infection • Setting: Bacterial super-infection is common with S. pneumoniae, S. aureus and H. influenza • Typical findings: Bronchopneumonia, interstitial infiltrates • Diagnosis: Culture of throat, nasopharyngeal aspirates, washing, and serology; John G. Bartlett. Medical management of HIV infection, 2003Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  26. 26. Mycobacterium avium complex (MAC) • Course: Chronic or asymptomatic • Frequency: Moderate for disseminated disease but uncommon for pulmonary disease • Setting: late stage HIV (median CD4 20 cells/mm3) • Typical findings: Variable • Diagnosis: Sputum, FOB, or induced sputum AFB stain and culture; must distinguish from MTB (DNA probe or radiometric culture technique); MAC may colonize airways without causing pulmonary disease; requires 1 to 2 weeks for growth in Bactec system John G. Bartlett. Medical management of HIV infection, 2003Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  27. 27. Mycobacterium kansasii • Course: Chronic or asymptomatic • Frequency: Uncommon • Setting: Late-stage HIV (median CD4 50 cells/mm3) • Typical findings: Cavitary disease, nodule, cyst, infiltrate, or normal chest Х- ray • Diagnosis: Sputum, induced sputum, or FOB, AFB stain and culture John G. Bartlett. Medical management of HIV infection, 2003Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  28. 28. Kaposi’s sarcoma (KS)• Course: Asymptomatic or chronic progressive cough and dyspnea• Frequency: Moderately common in patients with cutaneous KS and advanced HIV disease• Typical findings: Interstitial, alveolar, or nodular infiltrates, hilar adenopathy (25%), scan usually negative, pleural effusions (40%); gallium• Diagnosis: FOB often shows discolored endobronchial nodule(s); yield of histopathology from transbronchial or transthoracic biopsy is only 20% to 30%. Pulmonary infiltrate on x-ray with negative gallium scan is highly suggestive John G. Bartlett. Medical management of HIV infection, 2003Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  29. 29. Lymphocytic interstitial pneumonia (LIP)• Course: Chronic or subacute• Frequency: Uncommon in adults• Setting: median CD4 - 200-400 cells/mm3• Typical findings: Diffuse reticulonodular infiltrates, resembles PCP on chest x-ray• Diagnosis: Requires tissue for histopathology; yield with FOB biopsy is 30% to 50%; open lung biopsy often required John G. Bartlett. Medical management of HIV infection, 2003Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  30. 30. Lymphoma • Course: Chronic or asymptomatic • Frequency: Uncommon, but may be presenting site • Typical findings: Interstitial, alveolar, or nodular infiltrates; cavity, hilar adenopathy, pleural effusions • Diagnosis: Requires tissue for histopathology; yield with FOB biopsy is poor; open lung biopsy often required John G. Bartlett. Medical management of HIV infection, 2003Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  31. 31. Treatment (except pneumocystis)Gram-negative Need in vitro susceptibility tests. Long-term ciprofloxacinbacilli usually results in relapse and resistance to P. aeruginosa.Staph.aureus -MSSA: Nafcillin/oxacillin, cefuroxime, TMP-SMX, clindamycin -MRSA: VancomycinHaemophilus Oral: Amox-CA, azithromycin, TMP-SMX,influenzae fluoroquinolone, cephalosporin; Intravenous: Cefotaxime, ceftriaxoneAspergillus Amphotericin B or itraconazole or caspofunginCandida Fluconazole or amphotericin BC.immitis Fluconazole, itraconazole, or amphotericin BCryptococcus Fluconazole without CNS involvement amphotericin BH.capsulatum Itraconazole or amphotericin BLegionella Fluoroquinolone, macrolide, doxycycline John G. Bartlett. Medical management of HIV infection, 2003 Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  32. 32. Treatment (except pneumocystis)CMV Ganciclovir, foscarnet or cidofovirHSV, VZV, RSV, HSV, VZV: Acyclovirparainfluenza RSV: Ribavirin (?)Influenza Amantadine/ramantadine neuramidase inhibitors: Oseltamivir or zanamivirAsp.pneumonia 1)Clindamycin 2)Beta-lactam + Betalactamase inhibitorKS -Liposomal daunorubicin or doxorubicin -Taxol -Adriamycin, bleomycin/vincristin, or vinblastinLIP Prednisone (?)Lymphoma 1)CHOP 2)BACOD + G-CSFStr.pneumoniae PO: Amoxicillin, macrolide, cefpodoxime, fluoroquinolone IV: Cefotaxime, ceftriaxone, fluoroquinolone John G. Bartlett. Medical management of HIV infection, 2003 Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×