Sindh AIDS Control Program• Objectives• To create awareness of the seriousness of the disease Ensure that people of Sindh are equipped with knowledge and tools to protect themselves Reduce transmission of HIV and other STI infections through blood and blood products In case of infection, the patient should be encouraged to seek treatment 5
Infra Structure and Services on Ground• Provincial Implementation UNIT (PIU) At I. I Depot, Rafique Shaheed Road near JPMC.• Referral Lab Established for laboratory diagnosis and confirmation of HIV/AIDS Cases & Sexually Transmitted Infections.• Voluntary Counseling & Testing centers 21 VCT Centers have been Established for screening of HIV/AIDS cases• STIs clinics 46 STIs Clinics have been Established at teaching and DHQ hospitals for management of STI,s• Establishment of Resource Center With Facilities of Digital Library. For trainees and projects staff• PPTCT Centers 03 (Prevention of Parents to Chid Transmission) 6
History of HIV/AIDSHIV came from a similar virus found in chimpanzees - SIV.HIV probably entered the United States around 1970CDC in 1981 noticed unusual clusters of Kaposi’s sarcoma ingay men in NY and San Francisco, which led to the disease tobe called GRID (Gay Related Immune Deficiency).By 1982 the disease was apparent in heterosexuals and wasrenamed AIDS (Acquired Immune Deficiency). 10
1981 History 8 cases of KS among young gay men June 5, 1981: 5 cases of PCP(Pneumocystis Pneumonia ) in gay men Los Angeles, San Francisco and New York, who had developed PCP ... from UCLA (MMWR) 11 collected by Dr MZ
Morbidity and Mortality Weekly Report (MMWR) MMWR SEARCHIn the period October 1980-May 1981, 5 young men, allactive homosexuals, were treated for biopsy-confirmedPneumocystis carinii pneumonia at 3 different hospitals inLos Angeles, California. Two of the patients died. All 5 patients had laboratory-confirmed previous or current cytomegalovirus (CMV)infection and candidal mucosal infection. 12
2006 HistoryUS National Institutes of Health revealedthe results of two African trials of malecircumcision as an HIV preventionmethod with clear evidence that theintervention reduced HIVtransmission by around 50%.+ The WHO and other organizationssuggested they would soon beginpromoting male circumcision in areaswith severe HIV epidemics. 13 collected by Dr MZ
Global summary of the AIDS epidemic 2009Number of people Total 33.3 million Adults 30.8 millionliving with HIV Women 15.9 million Children (<15 years) 2.5 million Total 2.6 millionPeople newly infected Adults 2.2 millionwith HIV in 2009 Children (<15 years) 370 000AIDS deaths in 2009 Total 1.8 million Adults 1.6 million Children (<15 years) 260 000
Over 7000 new HIV infections a day in 2009 About 97% are in low and middle income countries About 1000 are in children under 15 years of age About 6000 are in adults aged 15 years and older, of whom: ─ almost 51% are among women ─ about 41% are among young people (15-24)
HIV/AIDS in Pakistan•Pakistan is going through a transition of the HIVepidemic; from a low Prevalence state to aconcentrated epidemic.•Although the estimated prevalence among thegeneral population is less than 0.1% in the country,• Recent surveillance results clearly indicate thatthe epidemic is becoming established amongcertain high risk groups (HRGs). 17
Pakistan’s HIV epidemic•At present the most prominent face ofPakistan’s HIV epidemic are the IDUs.•In this regards, Pakistan is following the Asian Epidemic Model,•where the HIV epidemic first establishes amongIDUs and then spreads to the rest of the population via sexworkers who have sexual contact with IDUs. 18
SUGGESTIVE HISTORY & RISK FACTORS RISK FACTORS/RISK BEHAVIOURS• People with multiple sexual partners• People with recent or prior STDs• Commercial sex workers & their partners• Homosexuals• Travelers to high prevalence areas• Sexually active injection drug users• Sexual partners of at risk persons• Recipients of blood products prior to HIV screening• Children born to HIV positive mothers
But HIV/AIDS does not discriminate Everybody is vulnerable. The virus is not restricted to any age group, race, social class, gender, or religion. In many countries of Asia and the Pacific HIV/AIDS has spread to the general population. 20
Pakistan’s HIV epidemicA combination of risk factors is currentlyputting Pakistan at serious risk of furthertransmission from high to low risk groupsthrough bridging populations. 21
Example of high risk sexual networks in a populationFSW Male Clients IDU General Population MSW Women
HISTORY OF HIV IN PAKISTAN• 1986 – An African Sailor Died in Karachi• 1987 – First Pakistani Citizen Diagnosed with AIDS in Lahore• 1987 – First Husband-Wife-Child transmission of HIV occurred in Rawalpindi• 1993 – First Breastfed Baby gets AIDS in Karachi• 2003 First outbreak among Injecting Drug Users was identified in Larkana 24
HIV & AIDS in Pakistan (2nd Quarter 2010)• Total Estimated Cases = 106000• Total reported HIV & AIDS cases in the country are = 7574• HIV Positive – 7049• AIDS Cases – 525
• Sindh is in the concentrated phase of epidemic among :• IDU’s = 27%• Hijra Sex workers =15.45% 29
• HIV epidemic is still considered ‘low’ or ‘concentrated,’ confined mainly to individuals who engage in high risk behaviors,• An epidemic is considered ‘concentrated’ when less than one per cent of the general population but more than five per cent of any ‘high risk’ group are HIV- positive• An epidemic is considered ‘generalized’ when more than one per cent of the population is HIV-positive. 30
HIV ?• HIV is different from most other viruses because it attacks the immune system• The immune system gives our bodies the ability to fight infections.• HIV finds and destroys a type of white blood cell WBC (T cells or CD4 cells) that the immune system must have to fight disease.• People can live a long healthy life with HIV without symptoms, even without medications.• Once the immune system begins to break down over time, and the person develops more symptoms,• This often means they have progressed to AIDS. 33
Caused by immune deficiency virus• HIV-1• HIV-2
Genetic Subtypes of HIV• Groups : HIV 1 , HIV 2• Genetic subtypes : Groups : HIV 1- M(main),O(outlier),N (new) Subtypes(clades) M(11 subtypes A-I,CRF) HIV 2—Six subtypes A-F
DIFFERENCE B/W HIV-1 & HIV-2• HIV-1 and HIV-2 are closely related, they are thought to have jumped from primates to humans at different times (and from different species).• HIV-1 is more easily transmitted, it also spreads more readily and therefore accounts for the vast majority of global HIV infections.• HIV-2, is much less transmittable, is largely confined to West Africa (where it is thought to have originated) and to West African migrant communities in Europe. 39
DIFFERENCE B/W HIV-1 & HIV-2• HIV-1 also mutates more efficiently that HIV-2 and generally progresses to AIDS at a significantly faster rate than HIV-2 does.• Also, HIV-2 has Vpr and Vpx proteins. HIV-1 has only Vpr.• Differences between these proteins are actually on research. 40
HIV-1 and HIV-2 Infections• HIV-2 has the same genetic organization as HIV-1 but there are significant differences in the envelope glycoprotein• Similar diseases associated with both HIV-1 and HIV-2 but most west Africans remain asymptomatic• Progression from HIV to AIDS is faster in HIV-1 as compared to HIV-2, either it is less pathogenic or it has a long period of latency• HIV-2 infected children have far better survival rates
VIROLOGY / LIFE CYCLE• HIV is a retrovirus belonging to the family of Lentivirus• Able to use the RNA and the host DNA to make viral DNA• Long incubation period/Clinical latency
THE HIV LIFE CYCLECONTINUOUS VIRAL REPLICATION LEADING TO IMMUNODEFICIENCY IS THE HALLMARK OF THE DISEASE!!
! The Immune System T Cells (CD4 Cells) = Part of body’s immune system CD4 The average person has between 800 & 1500 CD4 cells per cubic millimetre of blood The immune system helps fight diseases CD4 Disease Disease IMMUNE ATTACKS DISEASE KILLS DISEASE SYSTEM
HIV and the Immune SystemWhen HIV enters the body it must enter a cell to live and reproduce. The HIVvirus attacks CD4 cells, eventually killing them CD4 HI HIV V HIV HI CD4 V HI V HIV Enters CD4 Cells HIV Replicates Kills CD4 CellsThe newly produced HIV then moves into new CD4 cells and infects them.The body’s immune system tries to replace the lost CD4 cells, but overtime it is unable to keep these levels up.
HIV-Infected T-CellHIV HIV Infected New HIV T-Cell T-Cell VirusVirus
VIROLOGYgp 120 & gp 41 have the major role to recognize CD 4 cells thus promoting attachment
HIV Replication• HIV is a retrovirus.• Viral envelope protein gp120 and gp41 attach to the CD4 antigen complex on host cells• CD4 found on T helper lymphocyte,B lymphocytes, monocytes and tissue macrophages.• HIV uses RT to convert RNA to DNA• HIV DNA enters nucleus of CD4 cell and integrates into host DNA.• HIV DNA instructs cell to make copies of original virus.• New virus particles are assembled and leave cell, ready to infect other CD4 cells.
Viral RNA yellow,DNA blue Reverse Transcription Attachment Entry of the Viral RNAReverse TranscriptaseInhibitor (red) Integration of Viral DNA Transcription: Back to RNA Translation: RNA -> Proteins Protease Inhibitors Viral Protease Assembly and Budding
HIV Transmission• HIV enters the bloodstream through: – Open Cuts – Breaks in the skin – Mucous membranes – Direct injection
MODES OF TRANSMISSION• Blood/Blood products, tissues, organs- More than 90%• Sexual Intercourse - 0.1 to 1% (however frequency is high causing high rate of infection)• IDU – 0.5 to 1 %• Parent to child – 30% 53
HIV Modes of Transmission1. Sexual2. Infected blood and blood products3. Mother to Child
HIV Modes of Transmission Cont’d…1. Sexual: • Through sex with infected man or woman. • Transmit by Hetrosexual & Homosexual and Bisexual Practice • Ulcerative STIs increases the risk of infection several folds
HIV Modes of Transmission Cont’d…2. Infected blood and blood products • Contaminated Blood/Blood Products transfer • Organ/Tissue Transplants • Use of Contaminated Syringes and Needles • Tattooing • Ear piercing etc.
HIV Modes of Transmission Cont’d…3. From mother to child (Vertical) • Pregnancy • Delivery • Lactation
How you catch up HIV?• The virus spread from human to human by body fluids : Blood, Semen, female vagina fluids and mother milk.• HIV do spread in full sexual Intercourse that include penetration to female vagina or the rectum without the use of Condom, and that’s because its lives within the human fluids, as mention above.• HIV also do spread by using common needle, because AIDS lives in the blood, due to that fact, drugs addict are extremely vulnerable for HIV infection.• HIV is spreading by a breast feeding, because it can live within mother milks.
HIV Transmission cont’d…• Common fluids that are a means of transmission: – Blood – Semen – Vaginal Secretions – Breast Milk – Saliva
? How can you get HIV?1. Through these bodily fluids VAGINAL BREAST SECRETIONS MILK BLOOD CERVICAL SECRETIONS SEMEN2. Through these acts: H INFECTED MOTHER: UNPROTECTED PENETRATIVE 1. INJECTION OR TRANSFUSION OF INFECTED DURING INTERCOURSE (HOMOSEXUAL OR BLOOD / BLOOD PRODUCTS 1. PREGNANCY HETEROSEXUAL) WITH SOMEONE 2. SHARING UNSTERILISED NEEDLES WITH 2. BIRTH WHO IS INFECTED SOMEONE WHO IS INFECTED 3. BREAST FEEDING 62
HIV in Body FluidsBlood Semen18,000 Vaginal 11,000 Fluid Amniotic 7,000 Fluid 4,000 Saliva 1Average number of HIV particles in 1 ml of these body fluids
TRANSMISSION RISK AFTER EXPOSURE• 95% for blood and blood products•15-40% for vertical transmission• 0.5% -1.0% for injection drug use• 0.2-0.5% for for genital mucous membranes•< 0.1% for non genital mucous membranes• Needle stick injury : 1 in 300 World wide major route of transmission Heterosexual(70%) Transmission
Estimated PPTCT RatesWithout interventionDuring pregnancy 5–10%During labour and delivery About 15%During breastfeeding 5-20%MTCT infection rates = up to 40%
HIV Routes of TransmissionSexual Contact: Male-to-male Male-to-female or vice versa Female-to-femaleBlood Exposure: Injecting drug use/needle sharing Occupational exposure Transfusion of blood productsPerinatal: Transmission from mother to baby Pregnancy, delivery and breastfeeding
HIV Infection and Antibody Response ---Initial Stage---- ---------------Intermediate or Latent Stage-------------- ---Illness Stage--- Flu-like Symptoms Or Symptom-free AIDS Symptoms No Symptoms ----Infection Virus Occurs Antibody ---- < 6 month ~ Years ~ Years ~ Years ~ Years
Window Period• This is the period of time after becoming infected when an HIV test is negative• 90 percent of cases test positive within three months of exposure• 10 percent of cases test positive within three to six months of exposure
Infections in relation to CD4+ cell count400 Herpes Zoster Tuberculosis300 Oral Candidiasis200 PCP Esophageal Candidiasis A Mucocutaneous herpes100 I Toxoplasmosis Cryptococcosis D (Mycobacterium avium complex ) MAC (Cytomegalovirus) CMV50 S (Progressive Multifocal Leuko encephalopathy) PML Cryptosporiodiosis Time
AIDS • A Acquired • I Immunity • D Deficiency • S SyndromeIt destroys the immune system of infected person.
After HIV infection (without ARV) • Most will develop AIDS 8-10 years later • 5-10% will develop AIDS first few years • 5-10% will not progress to AIDS for 15 or more years Evaluation
HIV Risk Reduction• Avoid unprotected sexual contact• Use barriers such as condoms• Limit multiple partners by maintaining a long- term relationship with one person
Infectious• Aids can’t be spread in a full sexual intercourse with condom because the condom prevents infected body fluids.
How you watch out? Using condom every time you are making an intercourse. Aids have not yet come with vaccine or remedies that bring for a recovery. Condom is the only tool for preventing infection with AIDS during an intercourse. Those are the facts, this is your life, think good and decide how you want to behave.
HIV Risk Reduction Cont’d…Condoms Using condoms is not 100 percent effective in preventing transmission of sexually transmitted infections including HIV Condoms = Safer sex Condoms ≠ Safe sex
HIV Risk Reduction Cont’d…Condom Use• Should be used consistently and correctly• Should be the responsibility of both partners for the protection of both partners• Male and female condoms are available
Female initiated methods of prevention• Female condoms: 97% effective yet currently only manufactured by one company and too expensive• Microbicides: gel, film, sponge, lubricant or suppository. Still in development User controlled, protection against HIV/STIs, could be available in contraceptive and non-contraceptive forms. Researchers predict a microbicide that is only 60% effective could prevent more than 2.5 million infections within three years of its introduction. Currently in clinical trials and may be available over the counter within 5-7 years
HIV Risk Reduction Cont’d…• Avoid drug and alcohol use to maintain good judgment• Don’t share needles used by others for: Drugs Tattoos Body piercing• Make sure GP is using a new syringe• Avoid exposure to blood products
Drugs Alcohol and• Aids Drugs and What the connection between Alcohol?• Alcohol and drugs causing you for misjudgment, so if you drunk you can,t better follow the rules of safe sex, and for drugs injections, can transpose the virus.
People Infected with HIV• Can look healthy• Can be unaware of their infection• Can live long productive lives when their HIV infection is managed• Can infect people when they engage in high-risk behavior
How you know?• You can’t identify a person who carry HIV and in most cases, he/she himself doesn’t know about it. You can found out the virus only in HIV tests. A person can carry the virus for many years, he can be seen, feel and function as usual,.• Don’t hope from your partner to tell you, that he/she carry the HIV virus. Because most people living with the virus are feared from rejection and anger, even though you love each other.• The responsibility defending your health is only in your hands!
HIV Exposure and Infection• Some people have had multiple exposures without becoming infected• Some people have been exposed one time and become infected
HIV AIDS• Once a person is infected s/he is always infected• Medications are available to prolong life but they do not cure the disease• Those who are infected are capable of infecting others without having symptoms or knowing of the infection
Suggested tips• To reduce the risk you have to…• Avoiding from ejaculation in your mouth• Avoiding sucking woman sexual organ during period.• Avoiding from swallowing female secreting• Make sure no active herpes wounds or others wounds Suggested not to brush your teeth two hours, because of gums sensitivity
Not Transmitted By Shaking Hands• HIV/AIDS doesn’t Spread in a hand shaking, because the virus doesn’t live in air or on skin.
Not Transmitted By Hugging• HIV/AIDS doesn’t Spread in a Hugging, because the virus doesn’t live in air or on skin. 88
Not Transmitted By KISS• Because in the spittle they are enzymes that neutralized the virus. but…..? 89
infectious• HIV/AIDS doesn’t spread by drinking from the same cup, glass, using, plate, spoons etc. because it can’t live in air or spittle.
So we can live together and don’tDiscriminate or Stigmatize the peoplesleaving with HIV/AIDS. 91
HIV is NOT Transmitted via Casual contactTears, sweat and salivaCoughing and sneezingNot transmitted via Mosquitoes, Fly, Bee, Buds etc.
Infectious• Aids doesn’t spread by a mosquito bite because mosquito can’t carry the human virus of HIV