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Epidemiology of AIDS

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Epidemiology of AIDS

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Epidemiology of AIDS

  1. 1. EPIDEMIOLOGY OF AIDS Acquired Immune DeficiencyAcquired Immune Deficiency SyndromeSyndrome By Dr. Anusha Divvi Post graduate student Department of Public Health Dentistry
  2. 2. CONTENTS • History • Problem statement • AIDS in world • AIDS in India • Epidemiological features • Clinical manifestations
  3. 3. • Diagnosis of AIDS • Control of AIDS • Summary • Conclusion • References
  4. 4. What is HIV? • H  Human • I  Immunodeficiency • V  Virus • It affects only humans and lives only in humans • Immunodeficiency refers to lack(deficiency) or breakdown of immune system
  5. 5. What is AIDS? • AIDS Acquired Immunodeficiency Syndrome • To acquire -- to develop over a period of time • Immune system gets deficient • Syndrome - group of signs and symptoms that collectively indicate a disease
  6. 6. Where it came from?? • In 1999 - SIV (Simian Immunodeficiency virus) - chimpanzee - almost identical to HIV • Chimpanzees were the source of HIV-1 - virus - from chimps to humans • More research - how SIV could have developed in the chimps
  7. 7. • Chimps had hunted and eaten 2 smaller species of monkeys and became infected with 2 different strains of SIV. Greater spot- nosed monkey Red-capped mangabeys Chimp hunting
  8. 8. HOW DID VIRUS CROSS FROM CHIMPS TO HUMANS? • Simple and plausible theory - “Hunter Theory” or “Bush Meat Theory” • Blood of chimps getting into cuts or wounds on the human hunter
  9. 9. DID HIV START IN AFRICA? • Researchers concluded that the first transmission of SIV to HIV in humans took place around 1920 in Kinshasa in the Democratic Republic of Congo, Central Africa.
  10. 10. How the virus came out of Kinshasa??? SEX TRADE MIGRANTS
  11. 11. TIME - TRAVEL • First reported case (1981) • 1982 CDC coined “acquired immunodeficiency syndrome” (AIDS) • First isolation of LAV (1983) – Luc Montagnier and colleagues - African patient – lymphadenopathy – LAV
  12. 12. • First isolation of HTLV (1984) – Robert Gallo and colleagues • First cases of HIV - India - 1986 - sex workers - Chennai • May 1986 - HIV • National AIDS committee - 1986 • First AIDS case - 1987 in Mumbai. • March 19, 1987 - Zidovudine - Food and Drug Administration (FDA)
  13. 13. • 1st December - World AIDS Day - 1988 • Red ribbon - International symbol of AIDS awareness – 1991 • NACO and NACP - 1992 • Triple-drug therapy - 1996 - world AIDS conference in Vancouver • David Ho - 1997 - a new treatment strategy “Hit early, hit hard”
  14. 14. PROBLEM STATEMENT • Global statistics (2015) – 36.7 million [34.0 million–39.8 million] people globally were living with HIV – 2.1 million [1.8 million–2.4 million] people became newly infected with HIV – 1.1 million people died from AIDS-related illnesses – (http://www.unaids.org)
  15. 15. • 17 million people were accessing antiretroviral therapy • 78 million people have become infected with HIV since the start of the epidemic • 35 million people have died from AIDS- related illnesses since the start of the epidemic
  16. 16. Indian statistics 2015 Estimated No. of people with HIV 21,16,581 Adults 19,78,125 Children (<15) 1,38,456 Male 12,60,094 Female 8,56,487 Estimated AIDS prevalence Total 0.26 Male 0.30 Female 0.22
  17. 17. Estimated No. of annual new HIV infections Total 86,309 Adults 75,948 Children (<15) 10,361 Estimated No. of AIDS related deaths Total 67,612 Adults 60,086 Children (<15) 7,526
  18. 18. Estimated ART need Adults 12,70,678 Children (<15) 74,220 Estimated No. of mothers needing PPTCT Mothers needing PPTCT 35,255
  19. 19. OVERVIEW OF HIV IN INDIA Prevalence of HIV in different states • Manipur – 1.15% • Mizoram – 0.80% • Nagaland – 0.78% • Andhra Pradesh – 0.66% • Karnataka – 0.53% • Tamilnadu – 0.28%
  20. 20. HIV EPIDEMICS Who and UNAIDS defined 3 types of HIV epidemics • Low level HIV epidemics • Concentrated HIV epidemics • Generalized HIV epidemics
  21. 21. • Low level – prevalence has not consistently exceeded 5% in any defined sub-population • Concentrated – prevalence is consistently over 5% in at least one defined sub-population but is below 1% in pregnant women • Generalized – prevalence consistently over 1% in pregnant women
  22. 22. EPIDEMIOLOGICAL FEATURES 1. AGENT • Group: Lentivirus • Subgroup: Retrovirus • CD4+ T lymphocytes • Macrophages and monocytes • Slow infection with prolonged incubation period.
  23. 23. Structure of the virus • 120nm in diameter • Envelope gp160; gp120 & gp41 • Icosahedral symmetry • Nucelocapsid • Outer matrix protein (p17) • Major capsid protein (p24) • Nuclear protein (p7) • RNA with reverse transcriptase
  24. 24. RETRO VIRAL GENES • 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.
  25. 25. RETRO VIRAL GENES • Tat The Trans activator gene influences the function of genes some distance away. • Rav The differential regulator of expression of
  26. 26. RETRO VIRAL GENES • vif • The virus infectivity factor gene required for infectivity • nef • The negative regulator factor retards HIV replication • vpr virus protein R - undetermined function
  27. 27. GENES IN HIV 1 AND HIV 2 • vpu • Virus protein U gene is required for efficient viral replication • Found only in HIV-1 • vpx • The virus protein X gene has an undetermined function. • It is found only in HIV-2
  28. 28. HIV REPLICATION – Attachment – Penetration – Uncoating – Reverse Transcription – Integration – Replication – Assembly – Release
  29. 29. Reservoir of infection • Cases and carriers. • Once infected, the virus remains in life-long • Risk of developing AIDS increases with time • Symptomless carrier can infect other people for years
  30. 30. SOURCE OF INFECTION High concentration • Blood • Semen/Vaginal fluids (as high as blood) • Pus from sores • CSF Low concentration • Sweat • Tears • Urine • Saliva • Breast milk
  31. 31. 2. HOST FACTORS • Age: 20-49 years • High risk groups: Male homosexuals, bisexuals, intravenous drug abusers, transfusion recipients of blood and blood products, hemophiliacs
  32. 32. IMMUNOLOGY • HIV selectively infects T-helper cells • Healthy individual - twice as many helper cells as suppressor cells • It is reversed in AIDS • striking feature - total lymphocyte count - below 500 cu.mm. • More prone for opportunistic infection, neoplasm
  33. 33. MODE OF TRANSMISSION • Sexual transmission • Blood contact • Maternal – foetal transmission
  34. 34. • Unprotected sex with multiple partners • Sharing needles • Pregnancy • Breast feeding • Blood transfusion • Wound contacts • Occupational exposure
  35. 35. INCUBATION PERIOD • Current data suggest that the incubation period is uncertain • From a few months to 10 years or more • Virus can lie silent in the body for many years • Among the people infected with HIV- possibly 10-30 % - develop AIDS
  36. 36. • Another 25-30 % - AIDS-related complex. • 75 per cent of those infected with HIV will develop AIDS by the end of ten years
  37. 37. CLINICAL MANIFESTATIONS 1. Initial infection with the virus and development of antibodies 2. Asymptomatic carrier state 3. AIDS – related complex 4. AIDS
  38. 38. INITIAL INFECTION • Most HIV - infected people have no symptoms for the first five years • Look healthy and feel well • Can transmit the virus to others. • Once infected, people are infected for life • HIV antibodies – 2 to 12 weeks – blood stream
  39. 39. • Window period • Period before the antibodies are produced • Although the person is infectious he will test negative on standard antibody blood test
  40. 40. ASYMPTOMATIC CARRIER STATE • Infected people have antibodies • No overt signs of disease • Persistent generalized lymphadenopathy
  41. 41. AIDS RELATED COMPLEX • Unexplained diarrhoea • Fatigue • Malaise • Loss of more than 10% body weight • Fever • Night sweats and generalized lymphadenopathy • No opportunistic infections or cancers
  42. 42. AIDS • End stage of HIV infection • Tuberculosis and Kaposi sarcoma – seen early • When T helper cells dropped to 100: – Candida oesophagitis, Cryptococcus meningitis and penicillosis – Parasitic infections such as Pneumocystis carini pneumonia or Toxoplasma gondii encephalitis • AIDS encephalopathy dementia
  43. 43. ORAL MANIFESTATIONS OF AIDS Hairy leukoplakia Kaposi sarcoma Herpes simplex
  44. 44. QUESTIONS • Target cells of HIV _________ • World’s AIDS day __________ • 3rd clinical stage of HIV infection ______ • The genetic material of HIV _________ • GP 41 is ___________
  45. 45. THANKYOU
  46. 46. EPIDEMIOLOGY OF AIDS Acquired Immune DeficiencyAcquired Immune Deficiency SyndromeSyndrome By Dr. Anusha Divvi Post graduate student Department of Public Health Dentistry
  47. 47. • Diagnosis of AIDS • Control of AIDS • Summary • Conclusion • References
  48. 48. DIAGNOSIS A. Clinical diagnosis B. Laboratory diagnosis
  49. 49. CLINICAL 1. WHO case definition for AIDS surveillance • At least 2 major signs in combination with at least 1 of the minor signs • Not due to a condition unrelated to HIV infection
  50. 50. • Major signs – Weight loss > 10% of body weight – Chronic diarrhoea – Prolonged fever • Minor signs • Persistent cough • Oropharyngeal candidiasis • Generalized lymphadenopathy
  51. 51. • History of herpes zoster • Generalized pruritic dermatitis • Chronic progressive herpes simplex infection HSV 1
  52. 52. CHILDREN • At least 2 major signs and 2 minor signs are present
  53. 53. Expanded WHO case definition for AIDS surveillance • For the purposes of AIDS surveillance • If a test for HIV antibody gives a positive result, and one or more of the following conditions are present :
  54. 54. • > 10% body weight loss with diarrhoea or fever or both • Cryptococcal meningitis • Pulmonary or extra-pulmonary tuberculosis • Kaposi sarcoma • Neurological impairment • Candidiasis of oesphagus • Invasive cervical cancer
  55. 55. CLINICAL STAGING • WHO has developed a clinical staging system, based on clinical criteria • Clinical stage is important as a criterion for starting antiretroviral therapy
  56. 56. • Clinical stage 1 – Asymptomatic – Persistent generalized lymphadenopathy
  57. 57. • CLINICAL STAGE 2 • Moderate unexplained weight loss • Recurrent respiratory tract infections • Herpes zoster • Angular cheilitis • Recurrent oral ulcerations • Papular pruritic eruptions • Seborrhoeic dermatitis • Fungal nail infections
  58. 58. • Clinical stage 3 • Unexplained severe weight loss • Unexplained chronic diarrhoea for longer than one month • Unexplained persistent fever • Persistent oral candidiasis • Oral hairy leukoplakia • Pulmonary tuberculosis • Severe bacterial infections
  59. 59. Clinical stage 4 • HIV wasting syndrome • Severe bacterial pneumonia • Chronic herpes simplex infection • Extra pulmonary tuberculosis • Kaposi sarcoma • HIV encephalopathy • Invasive cervical carcinoma
  60. 60. Laboratory diagnosis of AIDS • Immunological tests • Specific tests – Antigen detection – Virus isolation – Polymerase chain reaction – Antibody detection
  61. 61. Immunological tests • Lymphocyte count falls below 2000/cu mm • T helper cell count will be less than 200/cu mm • T4 : T8 cell ratio is reversed • Thrombocytopenia • Raised IgG levels
  62. 62. SPECIFIC TESTS • Antigen detection • Antibody detection • Virus isolation
  63. 63. • P24 detection – ELISA • Virus isolation – cultivation of patients lymphocytes on uninfected lymphocytes • Polymerase chain reaction: – Gold standard for diagnosis – Amplification of DNA segments for the detection of pathogenic virus • Antibody detection – ELISA – screening – Western blot - confirmatory
  64. 64. • To ensure accuracy two different tests • First a sensitive test is used to detect the HIV- antibodies • second confirmatory test - any false positive results.
  65. 65. • The screening test is normally the ELISA •
  66. 66. • The confirmatory test is Western Blot - detecting specific antibody to viral core protein (p24) and envelop glycoprotein (gp41)
  67. 67. CONTROL OF HIV/AIDS • There are four basic approaches to the control of AIDS : 1. Prevention 2. Antiretroviral treatment 3. Specific prophylaxis 4. Primary health care
  68. 68. PREVENTION : a)Education b) Prevention of blood-borne HIV transmission
  69. 69. II. ANTIRETROVIRAL TREATMENT:  Advent of potent antiretroviral therapy - 1996 - revolution in the care of patients.  Treatments are not for cure  Meant for reduction of morbidity and mortality
  70. 70. DRUGS USED FOR ART • Nucleoside reverse transcriptase inhibitors –Lamivudine –Stavudine –Zidovudine • Fusion inhibitors –Enfuvirtide
  71. 71. • Nucleotide reverse transcriptase inhibitors • Tenofovir • Non nucleoside reverse transcriptase inhibitors • Efavirenz • Etravirine • Nevirapine
  72. 72. • Protease inhibitors • Saquinavir • Ritonavir • Indinavir • Integrase strand transfer inhibitors • Raltegravir
  73. 73. HAART(Highly active antiretroviral therapy) • Synergistic combinations of NRTIs and Protease inhibitors • Popular HAART combinations • NRTIs(2)+PI(1) • NRTI(1)+NNRTI(1)+PI(1) • NRTI(1)+NNRTI(1)+PI(2)
  74. 74. III. SPECIFIC PROPHYLAXIS: • Prophylaxis against M. tuberculosis is 300 mg Isoniazid daily for 9 months to 1 year • Kaposi's sarcoma might be treated with interferon or chemotherapy •Antifungal drugs for candidiasis
  75. 75. IV. PRIMARY HEALTH CARE Focus on five strategic directions: 1. Increasing knowledge of HIV serostatus 2. Accelerating HIV prevention 3. Accelerating the scale-up of HIV treatment and care 4. Health systems strengthening
  76. 76. National AIDS control program • It was launched in India in the year 1987. • To implement and closely monitor the various components of the programme • Aim - to prevent further transmission of HIV to decrease morbidity and mortality
  77. 77. • The Govt. of India initiated programmes of prevention and raising awareness under: »NACP-I (1992-99) »NACP-II (1999-2006) »NACP- III( 2006-2011)
  78. 78. • India has now developed the fourth National Programme Implementation Plan (NACP-IV, 2012-2017). • To halt and reverse - over the next 5 years by integrating programmes for prevention, care, support and treatment.
  79. 79. The services are : 1. Prevention services 2. Care support and treatment services
  80. 80. Preventive services • Needle syringe exchange program • Prevention and control of sexually transmitted diseases • Blood safety • HIV counselling and testing services • Prevention of parent to child transmission • Condom promotion
  81. 81. Care support and treatment services • Laboratory services for CD4 testing and other investigations • Free antiretroviral therapy • Early infant diagnosis for HIV exposed infants and children below 18 months • HIV- TB coordination • Treatment of opportunistic infections
  82. 82. Guidelines on HIV and infant feeding • Till 2009, WHO advised HIV – positive mothers to avoid breast feeding if they were able to afford and store formula milk safely • On 30th November 2009, WHO released new recommendations on infant feeding by HIV positive mothers
  83. 83. • HIV positive mothers or their infants take antiretroviral drugs throughout the period of breast feeding and until the infant is 12 months old • Child can benefit from breast feeding with very little risk of becoming infected with HIV
  84. 84. Nutrition requirements for people living with HIV/AIDS • Energy requirements – increase by 10% - asymptomatic HIV infected adults and children • 20 -30 % - symptomatic HIV and AIDS • HIV infected 6-59 month old children – Vitamin A supplements – 1 lakh IU – every 4-6 months
  85. 85. HIV SURVEILLANCE : • To detect the spread of the disease • To make appropriate strategy for prevention and control • Types of surveillance : • HIV sero surveillance • HIV sentinel surveillance • AIDS case surveillance • STD surveillance
  86. 86. Counselling and HIV testing services 1. Integrated counselling and testing centres(ICTC) 2.Prevention of parents to child transmission of HIV ( PPTCT) 3. HIV/ tuberculosis collaborative activities.
  87. 87. I. Integrated counselling and testing centres(ICTC): A) Fixed facility ICTCs: i.Standalone ICTC( SA-ICTC) ii.Facility integrated counselling and testing centres( F-ICTC) B) Mobile ICTC:
  88. 88. 2. Prevention of parents to child transmission of HIV ( PPTCT)  Started in 2002 Now 15000 ICTCs offer PPTCT services to pregnant women Single dose of Nevirapine to multi-drug ARV prophylaxis from 2012
  89. 89. • Andhra Pradesh, Karnataka and Tamil Nadu. • From May 2013 national wide implementation has done
  90. 90. 3. HIV/ tuberculosis collaborative activities The risk of TB infection in HIV positive persons increases manifolds. NACO - with RNTCP - promoting cross referrals for early diagnosis and treatment of tuberculosis
  91. 91. NATIONAL AIDS TELEPHONE HELPLINE : • A toll free national AIDS telephone helpline has been set up to provide access to information and counselling, on HIV/AIDS related issues. • This is a computerized 4 digit number 1097, with a voice response system linked with a telephone helpline
  92. 92. HIV VACCINE • Developing a safe, effective and affordable vaccine to prevent HIV infection is the best hope for controlling HIV epidemic • In 2015 NIAID and collaborators launched HVTN 100, an early stage clinical trial in South Africa • Designed to determine whether the regimen is safe, tolerable and effective
  93. 93. • Further information about HIV vaccine will be announced in November 2016
  94. 94. CONCLUSION • AIDS has rapidly established itself throughout the world. • Still a major health problem and lot needs to be done to ensure the sustainability of these programs • Evolve mechanisms to ensure that HIV care is provided along with general health care.
  95. 95. REFERENCES 1. Park.K. A textbook of Preventive and Social Medicine.23rd edition. Jabalpur. M/s Banarsidas Bhanot Publishers:2014 2. Current Medical Diagnosis and Treatment edited by Lawrence M. Tierncy, Jr Siephen J. McPhee and Maxine A. Papadakis, 43rdEd.2004
  96. 96. 3. WHO 2004: Scaling up antiretroviral therapy in resource-limited settings: treatment guidelines for a public health approach; 27-47 4. WHO. 2008. Operations Manual for Delivery of HIV Prevention, Care and Treatment at Primary Health Centres in High-Prevalence 5. WHO Technical Consultation on Nutrient Requirements for People Living with HIV/AIDS (2003 : Geneva, Switzerland)
  97. 97. 6. Nutrient requirements for people living with HIV/AIDS: report of a technical consultation, World Health Organization, Geneva, 13-15 May 2003. 7. Coors M et al. Acute phase response and energy balance in stable human immunodeficiency virus- infected patients: a doubly labelled water study. Journal of Laboratory and Clinical Medicine, 2001, 138:94-100.
  98. 98. 8.Govt. of India (2011), Strategy and Implementation Plan. National AIDS Control Programme Phase IV (2012-2017), NACO. Ministry of Health and Family Welfare, New Delhi. 9. http://www.unaids.org 10. http://www.naco.gov.in 11. http://www.who.int

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