Prevention and control of sexually transmitted disease PowerPoint

1. Prevention & Control of STI
May 11, 2020 1
By: Fantahun Guteta

2. The STIs are preventable diseases and
curable (except viral STIs which includes
HIV, HPV, HBV and herpes simplex)
The Mode of transmission
• Sexual intercourse (Most common)
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• Sexual intercourse (Most common)
• Mother to child
• Blood transfusion
• Other contacts with blood or blood
products

3. Factors affecting transmission f STIS
Behavioral factors Socio-Economic factor
• Many partner. - Poverty.
• Not using condoms. -Religious restriction.
• Causal sex - Women’s positions.
Alcohol & substance use - Cultural- HTP• Alcohol & substance use - Cultural- HTP
Personal factor
• Delay on getting RX
• Noncompliance to RX

4. The Link between STIS & HIV
• STIs facilitate the transmission of HIV.
• The presence of HIV increase the Severity of
STIS & Their resistance to standard RX.
Prevention and control of STISPrevention and control of STIS
• Promotion of safer sexual behavior.
• Promotion of health care seeking behavior.
• Early DX & RX.
• Targeting valerenable groups.

5. Diagnosis & treatment of STIs
• Over 30 different organisms can cause STIs
• Many infections have similar symptoms &
signs
• Accurate treatment requires accurate• Accurate treatment requires accurate
diagnosis
• For most STIs, accurate diagnosis requires
laboratory tests
• In developing countries, laboratory tests are
often not available

6. Service provider generally use one of the
following three diagnostic approaches in
the management of STIs
• Etiologic approach:- By identifying the
causative agent using lab diagnosis.
• Clinical approach:- Using clinical
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• Clinical approach:- Using clinical
experience to identify symptoms which
are typical for specific STI.
• Syndromic approach:- identification of
clinical syndromes.

7. Etiologic approach
• Advantages:-
Avoids over treatment
Conforms to traditional clinical training
Satisfies patients who feel not properlySatisfies patients who feel not properly
attended to
Can be extended as screening for the
asymptomatics

8. Problems of etiologic approach
• Requires skilled personnel and consistent
supplies
• Treatment does not begin until results are
available
• It is time consuming and expensive• It is time consuming and expensive
• Testing facilities are not available at primary
level
• Some bacteria fastidious and difficult to culture
(H.ducrey, C.trachomatis)

9. Problems of etiologic approach…Cont’d
• Lab. results often not reliable
• Mixed infections often overlooked
• Miss-treated/untreated infections can lead• Miss-treated/untreated infections can lead
to complications and continued
transmission

10. Clinical approach
• Advantages:-
Saves time for patients
Reduces laboratory expenses
• Disadvantages:-• Disadvantages:-
Requires high clinical accuracy
Most STIs cause similar symptoms
Mixed infections are common and failure to treat
may lead to serious complications
Doesn’t identify asymtomatic STIs

11. Syndromic Approach
• Syndrome – is group of symptoms patient
complains about and clinical signs you observe
during examination
• Different organisms that cause STIs give rise to
only limited number of syndromesonly limited number of syndromes
• There are seven syndromes (aim is to identify
and manage accordingly)

12. Why Syndromic Approach?
• STI sign and symptoms are rarely specific to a
particular causative agent
• Laboratories are either non-existent or non-
functional due to lack of resourcesfunctional due to lack of resources
• Dual infections are quite common and both
clinician and laboratory may miss one of them
• Waiting time for lab. results may discourage
some patients
• Failure of cure at first contact

13. Key Features of Syndromic Management
• Problem oriented (responds to patient’s symptoms
• Highly sensitive and does not miss mixed infections
• Treats the patient at first visit
• Can be implemented at primary health care level• Can be implemented at primary health care level
• Use flow charts with logical steps
• Provides opportunity and time for education and
counseling

14. The Five Steps in Syndromic STI Case
Management
• History taking and examination
• Syndromic diagnosis and treatment, using
flow charts
• Education and counseling on HIV testing
and safer sex, including condom promotion
Education and counseling on HIV testing
and safer sex, including condom promotion
and provision
• Management of sexual partners
• Recording and reporting

15. Criteria for the selection of STI drugs
• Availability
• Low cost
• High efficacy (at least 95%)
• Acceptable toxicity and tolerance (safety)
• Organism resistance unlikely to develop or likely to be• Organism resistance unlikely to develop or likely to be
delayed
• Single dose
• Oral administration
• Not contraindicated for pregnant or lactating women.

16. Limitations of syndrome management
• Misses sub-clinical infection
• Needs validation study
– Require prior research to determine the common
causes of particular syndromescauses of particular syndromes
• Needs training

17. HISTORY TAKING
• Establish a good rapport with the pt.
• When the service provider makes interviews
he/she should:-
• Smile & use welcoming tone of voce.
• Introduce himself/herself.• Introduce himself/herself.
• Use the Pt’s name.

18. • Maintain confidentiality & privacy.
• Offer the pt a seat.
• Make eye contact Be respectful & understanding.
Guide for HX takingGuide for HX taking
• Pt’s General details.
• Pt’s present illness.
• His or her medical HX.
• His or her sexual HX

19. Examination of a pt with STI
– Like any other disease, the diagnosis of STIs relies on
proper history taking and physical exam.
– This entails privacy and confidentiality in order to
promote health seeking behaviour and avoid
stigmatization.
– The demographic characteristics of the pt that
include age, sex, and marital status are important
components of the history.
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components of the history.
– The occupation of the pt is also important because
long truck drivers and solders are at increased risk for
STIs.
– Multiple sexual partnership and history of STIs in the
pt or his/her partner are also important risk factors
for STIs.

20. Urethral discharge or burning on micturation in men
- Onset, unprotected casual sex, the amount of
discharge should be inquired.
* Vaginal discharge in women
- Vaginal discharge is abnormal when the women
notice change in colour, amount and odour.
- History of STI in her partner, multiple sexual partners
and change in Partner is important risk factor to
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and change in Partner is important risk factor to
consider in the history.
* Genital ulcer in men and women.
• The onset, history of recurrence, presence of pain,
location and whether the ulcer is single or multiple
should be described in the history.

21. * Lower abdominal pain in women.
• The onset, quality of pain, radiation, severity, presence
of vaginal discharge, last menstrual period, and
systemic symptoms like fever, nausea and vomiting are
essential components of the history.
* Scrotal swelling
• The health worker should ask the onset, presence of
pain, history of trauma and for concomitant urethral
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pain, history of trauma and for concomitant urethral
discharge
* Inguinal bubo.
• Presence of pain, ulceration, discharges and the
locations of the swelling are essential components of
the history.

22. Common syndromes in STIs
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23. Common STI Syndromes
SYNDROME MOST COMMON CAUSE
Genital ulcer Syphilis, chancroid, herpes
lymphgranuloma venerium(LGV)
Urethral discharge Gonorrhea, chlamydia
Vaginal discharge Vaginitis(trichomniasis, candidisisVaginal discharge Vaginitis(trichomniasis, candidisis
gonorrhea, chlamydia)
Lower abdominal pain Gonorrhea, chlamydia, mixed
anaerobes
Scrotal swelling Gonorrhea, chlamydia
Inguinal bubo Syphilis, chancroid ,chlamydia
Neonatal conjunctivitis Gonorrhea, chlamydia

24. Urethral Discharge and/or burning on urination in men
• Burning on micturation and urethral discharge are
common symptoms of urethritis
Aetiology
N. gonorrhe Commonest causes of urethral discharge & dysuria
C. Trachomatis
Urethritis caused by N. gonorrhoea has usually an acute
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Urethritis caused by N. gonorrhoea has usually an acute
onset with profuse and purulent discharge while that of
C. trachomitis will be of subacute onset with scanty
mucopurulent discharge.
• However, mixed infections by both organisms can occur
in 20% of pts

25. Examination
Look for evidence of spontaneous discharge
-Note the colour, quality, and quantity of the
discharge
-Milk the urethra to bring the discharge forward.
• Complications
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• Complications
– Disseminated gonoccocal infection
–Prostatitis (N.g)
–Urethral stricture
–Enhanced transmission of HIV

26. © Teaching-aids at low cost

27. RECOMMENDED RX
• ciprofloxacin 500mg tablet po stat OR
Spectinomycin 2gm IM stat
++
• Doxycycline 100mg POBID for 7 days OR
Erythromycin 500mg QID for 7 day if the Pt
has contraindication for TTC.

28. Genital Ulcer
–Primary syphilis, genital herpes, chancroid, LGV, and
granuloma inguinale are common ulcerative lesions
of the genitalia in men and women.
Aetiology
Common causes of genital ulcer are
• Treponema palidum – syphilis
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• Treponema palidum – syphilis
• Herpes simplex virus – herpes genitalia
(genital herpes)
• Haemophilus ducreyi-chancroid
• Chylamidia trachomatis ----LGV

29. Clinical Features
Syphilis (Hard chancre)
– A disease characterized by a primary lesion, a later
secondary eruption on the skin and mucus
membranes, then a long period of latency, and finally
late lesion, of skin, bones, viscera, CNS and CVS
Etioiopy – Treponema pallidum, a spirochete
Three stages are described in the clinical
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Three stages are described in the clinical
presentation of syphilis.
• Genital ulcer occurs in the primary stage of the
disease.
• It starts as a small papular lesion that rapidly
ulcerates to produce a non –tender, indurated
lesion with a clean base and a raised edge known
as hard chancre.

30. Clinical manifestations
The clinical presentation is divided in to three
stages
Primary syphilis
• Consists of hard chancre, the primary lesion of
syphilis, together with regional lymphadenitis.
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• The hard chancre is a single, painless ulcer on the
genitalia or elsewhere (lips, tongue, breasts) and
heals spontaneously in a few weeks with out Rx.
• The lymph glands are bilaterally enlarged and
not painful. There will not be suppuration.

31. Primary Syphilis Chancre
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35. Secondary syphilis
• After 4-6 weeks of the primary infection, a
generalized secondary eruption appears,
often accompanied by mild constitutional
symptoms.
• These early rashes tend to be symmetrical,
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• These early rashes tend to be symmetrical,
quickly passing and don’t itch.
• These early skin lesions are highly infective
and many spirochetes are demonstrated in
them.
• Condylomata Lata

36. Secondary Syphilis Rash
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37. Secondary Syphilis: Generalized Body
Rash
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38. Secondary Syphilis Rash
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39. Secondary Syphilis Rash
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40. Secondary Syphilis –Condylomata Lata
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41. Tertiary syphilis
• This stage is characterized by destructive, non-
infectious lesions of the skin, bones, viscera,
and mucosal surfaces.
• Other disabling manifestations occur in the CVS
(aortic incompetence, aneurysms) or CNS
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(aortic incompetence, aneurysms) or CNS
(dementia, paralytica, tabes dorsalis)

42. Herpes genitalia (Genital herpes)
• Latency and frequent recurrence characterise herpes genitalias
producing a life long infection after the primary infection.
• The lesions are painful initially presenting erythematous
macules, which then progress to vesicles, pustules, ulcers and
finally crusts.
• Prolonged and severe disease with extensive tissue
involvement and higher rate of dissemination occur in patients
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involvement and higher rate of dissemination occur in patients
with HIV infection.
• First episode primary genital herpes is x-zed by fever, head
ache, malaise and myalgias.
• Pain, itching, dysuria, vaginal and urethral discharge, and
tender inguinal lymph adenopathy are the predominant local
symptoms.

43. © Teaching-aids at low cost

44. Chancroid /soft chancre/
• It is a bacterial infection characterized by single
or multiple painful necrotizing ulcers at the site
of infection.
• The lesions are painful progressing from a small
papule to pustule and then ulcer with soft
margins described as soft chancre.
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margins described as soft chancre.
• Inguinal adenopathy that becomes necrotic and
fluctuant (buboes) follow the ulcer.
• Most frequently diagnosed in men, especially
those who frequently prostitutes.
Complication
Penile auto amputation

45. LGV (lymphgranuloma venerium)
• The diseaese starts as a small painless papule that
develops to an ulcer.
• After a week or so painful regional lymphadenopathy
develops with symptoms of fever, chills, head ache,
malaise, anorexia and wt loss.
• Elephantiasis of genitalia, scrotum and vulva occur in
either sex.
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either sex.
Complication
• Genital edema
• Salphingitis
• Infertility
• PID

46. Granuloma Inguinale
• It is a chronically progressive ulcerative disease
with out systemic symptoms.
• The pt usually presents with a non-suppurative
genital lesion, which develop from a small firm
papule to a painless ulcer with a beefy red
appearance and non – purulent base.
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appearance and non – purulent base.
Complication
• Genital pseudo elephantiasis ?
• Adhesion
• Urethral, vaginal or rectal stenosis.

47. Recommended RX for genital ulcer.
• Benzathin penicillin 2.4 millon untis IM stat
OR
• (in penicillin allergy) Doxycycline 100mg BID for
14 days.
++
• Ciprofloxacin 500mg BID orally for 3 days. OR
Erythromycin tab 500mg QID for 7 days.
+
• Acyclovir 400mg TID orally for 10 days.

48. Vaginal Discharge
Causes of vaginal discharge
• Neisseria gonorrhoea
• Chylamydia trachomatis
• Trichomonas vaginalis
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• Trichomonas vaginalis
• Gardnerella vaginalis
• Candida albicans

49. Vaginitis
• Bacterial vaginosis, vaginal thrush and
trichomoniasis are the usual causes of vaginitis.
• Bacterial vaginosis and trichomoniasis are
more frequent among sexually active women
while vaginal thrush occurs when there is
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while vaginal thrush occurs when there is
impairment of local or systemic defence
mechanisms.
• Risk assessment is usually negative and cervix
looks healthy and discharge is not coming from
the cervical opening in isolated vaginitis

50. Cervicitis
• The presence of purulent or mucopurulent
exudation from the cervical os frequently
indicates gonococcal or chlamydial infection.
• The risk factors include age less than 25 yrs,
single status, multiple sexual partners, a change
of sexual partner recently and history of STI
previously either in the pt or in the partner.
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previously either in the pt or in the partner.
• On speculum examination the presence of
redness, contact bleeding, spotting and
endocervical discharge suggests the diagnosis of
cervicitis

51. 51
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52. Complications
• PID
• PROM(pregnancy)
• PTL (preterm labour)
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• PTL (preterm labour)

53. Recommended treatment for V. discharge
• Ciprofloxacin 500 mg PO stat
Or
• Spectinomycin 2g IM stat
Plus
• Doxycycline 100mg PO BID for 7 days
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• Doxycycline 100mg PO BID for 7 days
Plus
• Metronidazole 500 mg PO BID for 10 days
Plus
• Clotrimazole vaginal tab 200mg at bed time for 3
days

54. Lower abdominal pain due to PID
• PID refers to an acute clinical syndrome that results
from ascending infection from the cervix and/or
vagina.
• The upper structures of the female genital organs are
affected.
• The term PID includes
 Endometritis,
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 Endometritis,
 Salphingitis,
 Oophoritis,
 Pelvic peritonitis,
 Tuboovarian abscess and
 Inflammation around the liver, spleen, or appendix.

55. • The common pathogens associated with PID,
which are transmitted through sexual route,
include N. gonorrhoea, C. trachomatis, M.
Homonis and bacteroides.
• Other organism like streptococcus species
E.coli and H. influenza may some times cause
May 11, 2020 55
E.coli and H. influenza may some times cause
PID but their transmission is not via the sexual
route.
• PID and STI share many of the same risk
factors and in most instances PID is caused by
STIs.

56. Clinical Features
• The occurrence of vaginal discharge may be an
antecedent event and supports the diagnosis
of PID.
• Bilateral lower abdominal pain or pelvic pain is
the most common clinical complaints but
ranges from abrupt and fulminant presentation
May 11, 2020 56
ranges from abrupt and fulminant presentation
to a subacute form with mild symptoms often
described as dull pain.
• Lower abdominal tenderness together with
cervical excitation tenderness are indicative of
PID.

57. Recommended Rx for PID
Outpatient
• Ciprofloxacin 500 mg PO stat
Or
• Spectinomicin 2g IM stat
Plus
• Doxycycline 100mg PO BID for 14 days
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• Doxycycline 100mg PO BID for 14 days
Plus
• Metronidazole 500mg PO BID for 14 days
• Remove IUD and do counselling for
contraception
• Admit if there is no improvement with in 72 hrs

58. Inpatient
• Ceftriaxone 250mg IV/IM daily
Or
• Spectinomicin 2g IM BID
Plus
• Doxycycline 100mg PO BID for 14 days
Plus
May 11, 2020 58
Plus
• Metronidazole 500mg PO BID for 14 days
or
• CAF 500mg IV QID
– Inpatient regimen is given for at least 48 hrs and the pt
clinically improves
– After discharge from hospital the pt has to continue with
the oral Rx.

59. May 11, 2020 59

60. Scrotal swelling
• The cause of scrotal swelling can vary
depending on the age of the pt.
• Among pts who are younger than 35
years, the swelling is likely to be caused
May 11, 2020 60
years, the swelling is likely to be caused
by N. gonorrhoea and c. trachomatis.
• However scrotal swelling among patients
older than 35 yrs is commonly caused by
gram-negative organisms.

61. Scrotal swelling….
Complications
• Epididymitis
• Infertility
• Impotence
• Prostatitis
May 11, 2020 61

62. Recommended Rx of scrotal swelling
The Rx of scrotal swelling suspected to be of STI
origin is similar to that of a urethral discharge.
• Ciprofloxacin 500mg PO stat
Or
• Spectinomycin 2gm IM stat
May 11, 2020 62
• Spectinomycin 2gm IM stat
Plus
• Doxycycline 100mg PO BID for 7days
Or
• TTC 500mg PO BID for 7 days

63. Inguinal bubo
• It is swelling of inguinal lymph nodes as a result of STI,
• The common sexually transmitted pathogens that cause inguinal
swelling include T. pallidum, C. trachomatis, H. ducreyi and
C. granulomatis.
• However, unlike other causes of inguinal bubo, syphilis doesn’t
cause necrosis and abscess collection in the lymph nodes.
In conditions where the clinical examination doesn’t reveal
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• In conditions where the clinical examination doesn’t reveal
fluctuant bubo, syphilis should be considered and be treated
accordingly.
• Surgical incisions are contraindicated and the pus should only be
aspirated using a hypodermic needle.

64. Inguinal Bubo
64 Courtesy of CDC/ Susan Lindsley

65. Recommended Treatment
• B. Penicillin 2.4 MIU IM stat
Plus
• Erythromycin 500mg PO QID for 15 days
Or
Co-trimoxazole double strength tablet PO BID
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• Co-trimoxazole double strength tablet PO BID
for 15 days.

66. Neonatal conjunctivitis
• It is purulent conjunctivitis occurring in a baby
<1month of age.
• It is acquired during birth as a result of genital
infection of the mother by N. gonorrhoea and
C. trachomitis.
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C. trachomitis.

67. © Teaching-aids at low cost

68. C/M—redness, swelling, of the eye lid
_discharge from the eye
Cause__ N.Gomorrhea
__Chlamydia
Prevention__ As soon as the baby is born carefully
Wipe both eyes with dry, clean cotton ThenWipe both eyes with dry, clean cotton Then
apply
-1%Silver nitrate solution
-0.5% Erythromycin ointment
-1%TTC eye ointment
May 11, 2020 68

69. May 11, 2020 69
Treatment
Spectinomycin 50 mg /kg IM stat
Plus
Erythromycin 50 mg/kg PO in 4 divided doses
for 10 days.

70. HIV and AIDS
What is HIV?
• Human Immunodeficiency Virus
• A retrovirus virus that can escape –
and infect – the immune system and
various organs
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and infect – the immune system and
various organs
• Particularly “likes” to infect CD4 cells
• Leads to “immunodeficiency” by
depleting CD4 cells

71. The HIV virus
 This cutaway
diagram of HIV
May 11, 2020 71
diagram of HIV
shows its outer
shell and most
of its internal
parts

72. HIV and AIDS
What is AIDS?
• Acquired Immune Deficiency
Syndrome
• “Immune deficiency” or
“immunodeficiency” = weak
May 11, 2020 72
“immunodeficiency” = weak
immune system
• When immune system is too weak,
the body is left open to diseases;
infections & cancers

73. Transmission of HIV
• Blood
• Seminal fluids
• Pre-ejaculatory fluids
• Breast milk
• Vaginal secretions
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• Vaginal secretions
• Sexual- oral, vaginal & anal
• Mother to child- delivery, breast milk
• IDU (unclean needles) + Hep. C co-infection
• Needle stick injury or non-occupational exposure = PEP
• Blood transfusion prior to 1985

74. Risk factors of transmission
• Oral sex- low risk
unless cuts, tears,
in mucosa of
mouth
• Use of dirty or
contaminated
syringes & needles
• IDU –materials used
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mouth • IDU –materials used
for injections :

75. Risk factors of transmission: Mother to child
• Mother to child during pregnancy,
labor, delivery, breastfeeding
• 25% of transmission during birth
without treatment
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without treatment
• With treatment and Caesarean,
transmission can be reduced to 2%

76. Symptoms of HIV infection
General symptoms
 Flu like symptoms such as
fatigue, fever, sore throat,
swollen lymph nodes, headache,
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swollen lymph nodes, headache,
loss of appetite or rash.
 Symptoms may last as long as a
few weeks.

77. 4 Stages of HIV infection
1.Primary infection - general symptoms or
sero-conversion - making antibodies to
HIV (1 to 3 months)
2.Asymptomatic- feeling well, maybe
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2.Asymptomatic- feeling well, maybe
swollen lymph glands (SLG)
3.Symptomatic- SLG, night sweats, fever,
diarrhea, weight loss, tiredness, thrush
4. AIDS – Ols, cancers

78. Primary HIV Infection
 Asymptomatic
 Acute retroviral syndrome
May 11, 2020 78
Clinical Stage 1
 Asymptomatic
 Persistent generalized lymphadenopathy

79. Clinical Stage 2
 Moderate unexplained weight loss (<10% of
presumed or measured body weight)
 Recurrent respiratory infections (sinusitis,
tonsillitis, otitis media, and pharyngitis)
May 11, 2020 79
tonsillitis, otitis media, and pharyngitis)
 Herpes zoster
 Angular cheilitis
 Recurrent oral ulceration
 Papular pruritic eruptions
 Seborrheic dermatitis
 Fungal nail infections

80. Clinical Stage 3
 Unexplained severe weight loss (>10% of presumed or measured
body weight)
 Unexplained chronic diarrhea for >1 month
 Unexplained persistent fever for >1 month (>37.6ºC, intermittent or
constant)
 Persistent oral candidiasis (thrush)
 Oral hairy leukoplakia
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 Oral hairy leukoplakia
 Pulmonary tuberculosis (current)
 Severe presumed bacterial infections (e.g., pneumonia, empyema,
pyomyositis, bone or joint infection, meningitis, bacteremia)
 Acute necrotizing ulcerative stomatitis, gingivitis, or periodontitis
 Unexplained anemia (hemoglobin <8 g/dL)
 Neutropenia (neutrophils <500 cells/µL)
 Chronic thrombocytopenia (platelets <50,000 cells/µL)

81. Clinical Stage 4
 HIV wasting syndrome
 Pneumocystis pneumonia
 Recurrent severe bacterial pneumonia
 Chronic herpes simplex infection (orolabial, genital, or anorectal site for >1 month or visceral herpes at any site)
 Esophageal candidiasis (or candidiasis of trachea, bronchi, or lungs)
 Extrapulmonary tuberculosis
 Kaposi sarcoma
 Cytomegalovirus infection (retinitis or infection of other organs)
 Central nervous system toxoplasmosis
 HIV encephalopathy
 Cryptococcosis, extrapulmonary (including meningitis)
 Disseminated nontuberculosis mycobacteria infection
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 Progressive multifocal leukoencephalopathy
 Candida of the trachea, bronchi, or lungs
 Chronic cryptosporidiosis (with diarrhea)
 Chronic isosporiasis
 Disseminated mycosis (e.g., histoplasmosis, coccidioidomycosis, penicilliosis)
 Recurrent nontyphoidal Salmonella bacteremia
 Lymphoma (cerebral or B-cell non-Hodgkin)
 Invasive cervical carcinoma
 Atypical disseminated leishmaniasis
 Symptomatic HIV-associated nephropathy
 Symptomatic HIV-associated cardiomyopathy
 Reactivation of American trypanosomiasis (meningoencephalitis or myocarditis)

82. The Immune System
• CD4 and other immune
cells are mostly found in
the “lymphatic system”
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the “lymphatic system”
and the bloodstream

83. HIV test
 Window period of 3 months following exposure.
 The test detects antibodies to the virus NOT the virus
itself.
 Test can be done named, unnamed or anonymous test
Includes 2 test .
• Standard ELSIA followed by Western Blot.
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• Standard ELSIA followed by Western Blot.
• ELISA done 2x (repeatedly reactive)
•Western Blot , confirmatory test

84. Immune markers: CD4 and Viral load
CD4 ( T4) are white blood cells that control
infections; decrease with HIV replication
Normal range is 500-1400 cells/mm3 [slightly
higher in women]
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higher in women]
Higher CD4s = stronger immune system
Percentage of CD4s are 30-50% of lymphocytes

85. CD4
• Generally gets lower, the longer
one has been HIV+
• CD4 counts can vary from lab test
to test, and may be temporarily
May 11, 2020 85
to test, and may be temporarily
lowered by common infections
such as flu.

86. Viral load
A measurement of amount of HIV
virus in blood
• This is only about 2% of the total
HIV - rest is in lymph nodes, gut,
sexual fluids, CNS and elsewhere
May 11, 2020 86
sexual fluids, CNS and elsewhere
• Can be anywhere from hundreds
(100s) to millions (1,000,000s)
per millilitres

87. HIV progression: Viral load
• Generally, the higher the viral load, the faster
CD4 counts will drop.
• Higher viral load = more stress on immune
system & higher risk of disease progression
May 11, 2020 87
• HIV treatment recommendations also depend
on viral load as well as CD4s
• Two people with same CD4 count will have
different risks if their viral loads are different

88. CD4 cells
“Primary infection”
Antibodies form
Typical untreated HIV disease
Viral load
…Symptom-free period…
TIME
Risk of illness
(weeks) (years)
May 11, 2020 88

89. Opportunistic Infections (OIs)
• Infections that take “opportunity” of
a weakened immune system
• Include malignancies (cancers) such
as Kaposi’s Sarcoma
May 11, 2020 89
as Kaposi’s Sarcoma
• Some less serious (e.g. oral thrush),
some life-threatening (e.g. PCP,
toxoplasmosis)

90. Opportunistic Infections (OIs)
• Risk of OIs as CD4
• Some, are “AIDS-defining illnesses” and
some are not.
Most are quite treatable if detected
May 11, 2020 90
• Most are quite treatable if detected
early on or prevented through anti-HIV
drug therapy.
• Once OIs occur, more likely to recur.

91. Ols and CD4 counts
• Most OIs can be prevented (“prophylaxis”) or
treated (eg, Septra for PCP pneumonia)
• OIs are much less common in the era of
highly active antiretroviral therapy
(HAART)
May 11, 2020 91
(HAART)
• Overall trend is more important than any
single count

92. Opportunistic Infections
• If the CD4 is at 200 or below, more
susceptible to PCP, CMV,
Toxoplasmosis, lymphoma, etc.
May 11, 2020 92
• The current guidelines for treating
People with HIV/AIDs with
prophylaxis are; if the CD4+ count is
below 200cells/mm3

93. The immune status Vs the CD4 counts the lymphocyte
counts & the presence of symptomatic disease.
Clinical Condition CD4 cell count Lymphocyte count
Well with no symptoms >500cells/mm3 >2500cells/mm3
Minor symptoms 350-500cells/mm3 1000-2500cells/mm3
May 11, 2020 93
Minor symptoms 350-500cells/mm3 1000-2500cells/mm3
Major symptoms and
opportunistic diseases
200-350 cells/mm3 500-1000cells/mm3
AIDS <200 cells/mm3 <500cells/mm3

94. Women and OIs
• Cervical dysplasia
• Cervical cancer
• Menstrual problems
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• Menstrual problems
• PID (Pelvic Inflammatory Disease)
• Thrush (oral)
• Yeast infections (vaginal)

95. HIV and TB Co-infection
• Can become infected with TB at any
CD4+ count
• One can develop active TB easily if
one has advanced HIV disease + TB
May 11, 2020 95
one has advanced HIV disease + TB
infection
• TB can make the HIV virus multiply
faster and can increase progression
of HIV disease much worse

96. Antiretroviral drugs for HIV
Antiretroviral drugs:
• What we use to treat HIV
The viral life cycle and the
May 11, 2020 96
• The viral life cycle and the
different classes of drugs

97. Goals of anti HIV therapy
 HIV can infect cells and remain there
 Drugs cannot completely eliminate
the virus
 By stopping/slowing the virus By stopping/slowing the virus
multiplication, viral load is reduced
 Lowered stress on immune system
allows it to recover.
May 11, 2020 97

98. Antiretroviral drugs
• HIV can’t reproduce on its own
• Needs to infect and “hijack” human
cells (like CD4 cells) to “replicate”
• Infected cells are like little “assembly
lines” producing new viruses
May 11, 2020 98
lines” producing new viruses
• Antiretroviral drugs are designed to
stop the assembly lines from
forming and/or replicating the HIV
virus.

99. The HIV “life cycle” and the classes of drugs
Fusion
(T-20)
Reverse
Transcription
(AZT, 3tc, d4T)
Assembly (Protease)
(Indinavir,
ritonavir,etc)
HIV
(AZT, 3tc, d4T)
Integration
Infected cell
May 11, 2020 99

100. Antiretroviral drug classes
On market:
 Reverse transcriptase inhibitors:
 “Nucleoside analogues” and
 “Non-nucleoside analogues” “Non-nucleoside analogues”
 Protease inhibitors
In market or in development:
 Fusion/entry inhibitors
 Integrase inhibitors
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101. Side effects of HIV medication
Short term:4-9 wks
• Nausea, diarrhea,
fever, chills,
peripheral
Long term
• Coronary disease-lipids,
cholesterol
• Diabetes 2-insulin
May 11, 2020 101
peripheral
neuropathy, anemia,
neutropenia,
gastrointestinal, etc.
• Diabetes 2-insulin
resistance
• Lipodystrophy or
lipoatrophy
• Bone loss

102. Pregnancy and HIV
• Consider treatment if VL >1,000 copies/mL
• Factors; HIV-positive women are at increased risk
for premature birth
May 11, 2020 102
• Premature birth increases the risk of HIV
transmission .
• Even if the viral load is low (< 1,000 copies) it is
always a good idea for the mother to be on HAART
just incase the membranes rupture prematurely
increasing the fetus' risk of acquiring HIV.

103. When to Start Medications
from Medical Point of View
• Still a subject of debate; no consensus
• Anyone asymptomatic with viral loads
of > 100,000 copies/mL and/or CD4
counts of < less than 350 cells/mm3
May 11, 2020 103
counts of < less than 350 cells/mm3
• All pregnant women with VL greater
than 1,000 copies/mL
• Anyone who has symptomatic HIV
disease

104. Risk and benefit of delaying antiHIV
therapy
Risks:
• Possibility of irreversible
immune system damage
that may have been
reversible with early
therapy.
Benefits:
• Minimizing treatment-related
negative effects on quality of
life and drug toxicities.
May 11, 2020 104
therapy.
• Possibility that
suppression of viral
replication may be more
difficult at later stage
• Increased risk of
transmitting virus to
others
• Preserving future treatment
options.
• Delaying development of
drug resistance.

105. Thank you !
May 11, 2020 105

106. 106