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HIV and AIDS - Facts, Prevention and Treatment
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  2. 2. AIDS story till now India managed to reduce its HIV count by a staggering 57 % while both Bangladesh and Sri Lanka saw an increase in HIV cases by 25 %(2001-11). This has led to various international figures praising India’s HIV/AIDS prevention model PLHIV 57 Lakh(2001) 21 lakh(2011) Adult(15-49 years) Prevalence 0.41 %(2001) 0.27%(2011) Source : NACO Dec 2013 Report
  3. 3. Still a long way to go • PLHIV Estimates as of 2011 – South Africa - 5.6 million – Nigeria - 3.3 million – India - 2.1 million Source :UNAIDS Report on the Global AIDS epidemic 2013 A mere 0.1% increase in the HIV prevalence would increase the estimated number of people living with HIV by over half a million.In India 90% of the people with an unmet need for antiretroviral treatment live
  4. 4. s
  5. 5. Contents • AIDS Epidemiology • Continuum of care • HIV Testing and Counseling • Anti-Retroviral Therapy (ART) • HIV in Pregnancy • HIV-TB co-infection • HIV Vaccine • NACP- IV • References
  6. 6. AIDS- EPIDEMIOLOGY • Concentrated HIV epidemic • Generalized HIV epidemic • Mixed epidemics • Low-level epidemic
  7. 7. AIDS: Epidemiology • Concentrated HIV epidemic: HIV has spread rapidly in one or more defined subpopulation but is not well established in the general population. – Numerical proxy: HIV prevalence is consistently over 5% in at least one defined subpopulation but is less than 1% among pregnant women. • Generalized HIV epidemic: HIV is firmly established in the general population. – Numerical proxy: HIV prevalence consistently exceeding 1% among pregnant women. E.g –SubSaharan Africa
  8. 8. • Mixed epidemics: people are acquiring HIV infection in one or more subpopulations and in the general population. Mixed epidemics are therefore one or more concentrated epidemics within a generalized epidemic. e.g – Nigeria, Rwanda • Low-level epidemic: epidemics in which the prevalence of HIV infection has not consistently exceeded 1% in the general population nationally or 5% in any subpopulation. AIDS: Epidemiology
  9. 9. • ART settings acc. to uptake of ART – Low-uptake ART settings – uptake less than 50% – moderate-uptake ART settings - uptake 50-80% – high-uptake ART settings - uptake greater than 80% ( uptake of ART among those eligible for ART ) AIDS: Epidemiology
  10. 10. Epidemiology • Concentrated HIV epidemic: HIV has spread rapidly in one or more defined subpopulation but is not well established in the general population. Numerical proxy: HIV prevalence is consistently over 5% in at least one defined subpopulation but is less than 1% among pregnant women in urban areas. • Generalized HIV epidemic: HIV is firmly established in the general population. Numerical proxy: HIV prevalence consistently exceeding 1% among pregnant women. Most generalized HIV epidemics are mixed in nature, in which certain (key) subpopulations are disproportionately affected. • Mixed epidemics: people are acquiring HIV infection in one or more subpopulations and in the general population. Mixed epidemics are therefore one or more concentrated epidemics within a generalized epidemic. • Low-level epidemic: epidemics in which the prevalence of HIV infection has not consistently exceeded 1% in the general population nationally or 5% in any subpopulation. • Low-, moderate- and high-uptake ART settings refer to settings in which the uptake of ART among those eligible for ART is less than 50%, 50–80% and greater than 80%, respectively. The magnitude of the problem can be assessed from the fact that for every person who gains access to anti- retroviral drugs, two people are newly infected with HIV
  11. 11. Declining Trends of HIV Epidemic in India 22.5 21.9 21.4 21.1 20.9 0.33 0.31 0.30 0.28 0.27 0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.0 5.0 10.0 15.0 20.0 25.0 2007 2008 2009 2010 2011 AdultHIVPrevalence(%) NumberofPLHIV(Lakhs) Estimated Adult HIV Prevalence & Number of PLHIV, India, 2007-11 Number of PLHA (Lakhs) Adult HIV Prevalence (%) Female: 39% of PLHIV; Children: 7% of PLHIV Source: Technical Report India HIV Estimates 2012, NACO & NIMS
  12. 12. Key terms in HIV Epidemic HIGH RISK GROUP  Female Sex Worker(FSW)  Men who have Sex with Men(MSM)  Transgender  Injecting drug users(IDU) VULNERABLE POPULATION  Women having casual partners  Spouses of high risk groups  Youth BRIDGE POPULATION  Migrant  Truckers KEY POPULATION  HRG  Vulnerable Population  PLHA
  13. 13. Indian epidemic: Characteristics • India’s highly heterogeneous epidemic is largely concentrated in only a few states — in the south and west, and in the north‐east.(AP, Maharashtra , Karnataka, TN- >55%) • Low prevalence states of Odisha, Kerala, Jharkhand, Uttarakhand, Jammu & Kashmir, Arunachal Pradesh and Meghalaya are showing rising trends in adult HIV • Adult prevalence – 0.27% (2011) • Men- 61% Women -39% Children –7% • Urban > Rural
  14. 14. District-wise Scenario of AIDS Category NACP-III Definition A > 1% ANC prevalence in any of the sites in the last 3 years B < 1% ANC prevalence in all the sites during last 3 years with > 5% prevalence in any HRG site (STD/FSW/MSM/IDU) C < 1% ANC prevalence in all sites during last 3 years with < 5% in all STD clinic attendees or any HRG, with known hot spots D < 1% ANC prevalence in all sites during last 3 years with < 5% in all STD clinic attendees or any HRG OR no or poor HIV data with no known hot spots Category NACP-III A 156 B 39 C 296 D 118 New Districts 30 Total 609
  15. 15. Haryana : AIDS Scenario • Total Estimated HIV Positive cases – 42000 • No. of AIDS cases (2012) - 2585 • Maximum no. of cases (Rohtak) - 590 • ART Centre - 1 • No. of persons registered(upto Feb’13) -11606 • Community care centre(CCC) - 1 • Drop in Centres - 2
  16. 16. Kuala Lumpur, Malaysia , 30 June - 3 July 2013 HIV Concentrated in HRG & Bridge Pop. Source: HIV Sentinel Surveillance 2010-11 – A Technical Brief, NACO
  18. 18. WHO HIV clinical stages Short, flu-like illness occurs 1-6 weeks after infection Infected person can infect other people Average- 10 years Mild symptoms HIV in blood drops to very low levels Antibodies are detectable in the blood The immune system deteriorates Opportunistic infections (OI)start to appear Rapid decline in the number of CD4+ T cells Opportunistic infections become severe and cancer may develop
  19. 19. HIV Infection and Antibody Response 6 month ~ Years ~ Years ~ Years ~ Years Virus Antibody Infection Occurs AIDS Symptoms ---Initial Stage---- ---------------Intermediate or Latent Stage-------------- ---Illness Stage--- Flu-like Symptoms Or No Symptoms Symptom-free < ---- ----
  20. 20. HIV Testing and Counselling VCTC • Voluntary Counseling and Testing Centres • People motivated were referred to these centres VCCTC • Voluntary Confidential Counseling and Testing Centres • Emphasis on maintaining confidentiality ICTC • Integrated Counseling and Testing Centres • Integration of VCCTC + PPTCT PITC • Provider Initiated Counseling and Testing Centres
  21. 21. ICTC ICTC Stand- Alone ICTC Supported financially and logistically by NACP Facility ICTC(F-ICTC) Staff from existing facilities trained in counseling and testing PPP-ICTC Established in private facilities based on F-ICTC model Mobile ICTC Takes the package of services to community 12897 4508 8389
  22. 22. Topic Old Guidelines New Guidelines HIV Testing Initiating testing and counseling based on referrals in hospital set up Community-based HIV testing and counseling with linkage to prevention, care and treatment services is recommended, in addition to old guidelines. Couples Voluntary HIV testing and counseling HIV Testing & counselling
  23. 23. Working pattern of ICTC HIV Suspect ICTC Counselor Reason for testing Risk Assessment Pre-test COUNSELING consent BLOOD TEST HIV -ve Post test COUNSELING •Change risky life pattern •Preventive measures HIV +ve confirmed Post test COUNSELING ART PPTCT Drop-in Centres
  24. 24. Delivery of HIV treatment and care THREE TIER STRUCTURE
  25. 25. COE CENTRES OF EXCELLENCE  Provision of second line and alternative first line ART  Training, research and mentoring of ART centers linked to them ART CENTRES  CD4 Testing  Pre ART care and counseling  ART provision  Treatment of OI LINK ART CENTRES  Accessible and facilitate delivery of ART  Monitoring patients on ART COMMUNITY CARE CENTRES  Counseling for ARV treatment preparedness and drug adherence, nutrition and prevention  treatment of OI  referral and outreach services for follow-up  Social support services DROP IN CENTRES  Psychosocial support  Counseling  Sharing and caring  Referrals to ICTC, DOTS  Needle and syringe exchange 10 380 840
  26. 26. ART PLUS CENTRES • Assessment and initiate treatment for alternate first line and second line • Accessible and facilitate delivery of second line ART • Viral load testing • Number-21 LINK ART PLUS CENTRES(LAC PLUS) • ARV drug dispensing • Enrolment of PLHIV in HIV care and treatment (Pre-ART Care) • Monitoring of PLHIV on ART • Baseline lab tests • Counseling on adherence, nutrition & prevention Delivery of HIV treatment and care
  27. 27. Highly Active Anti Retroviral Therapy(HAART)
  29. 29. Goals of ARV Therapy • Reduce HIV-associated morbidity and prolong the duration and quality of survival, • Restore and preserve immunologic function • Maximally suppress plasma HIV viral load • Prevent HIV transmission
  30. 30. Overview of WHO 2013 guidelines • The 2013 consolidated guidelines compile new , existing recommendations and other guidance across the continuum of HIV care. • Includes guidance on HIV diagnosis, general HIV care and the strategic use of ARV drugs. • Developed in accordance with procedures outlined by the WHO Guidelines Review Committee and are based on the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system.
  31. 31. Recommendations: When to Start TARGET POPULATION (ARV-NAIVE) 2010 ART GUIDELINES 2013 ART GUIDELINES STRENGTH OF RECOMMENDATION & QUALITY OF EVIDENCE HIV+ ASYMPTOMATIC CD4 ≤350 cells/mm3 CD4 ≤500 cells/mm3 (CD4 ≤ 350 cells/mm3 as a priority) Strong, moderate- quality evidence HIV+ SYMPTOMATIC WHO clinical stage 3 or 4 regardless of CD4 cell count No change Strong, moderate- quality evidence PREGNANT AND BREASTFEEDING WOMEN WITH HIV CD4 ≤350 cells/mm3 or WHO clinical stage 3 or 4 Regardless of CD4 cell count or WHO clinical stage Strong, moderate- quality evidence HIV/TB CO- INFECTION Presence of active TB disease, regardless of CD4 cell count No change Strong, low-quality evidence HIV/HBV CO- INFECTION Evidence of chronic active HBV disease, regardless of CD4 cell count Evidence of severe chronic HBV liver disease, regardless of CD4 cell count Strong, low-quality evidence HIV+ PARTNERS IN SD COUPLE No recommendation established Regardless of CD4 cell count or WHO clinical stage Strong, high-quality evidence
  32. 32. Populations With No Specific Recommendations Insufficient evidence and/or favorable risk-benefit profile for ART initiation at CD4 > 500 cells/mm3 (or regardless of CD4 count) in the following situations:  Individuals with HIV who are 50 years of age and older  Individuals co-infected with HIV and HCV  Individuals with HIV-2  Key populations with a high risk of HIV transmission (e.g.: MSM, sex workers, IDU) These populations should follow the same principles and recommendations as for other adults with HIV
  33. 33. Lab monitoring before starting ART Phase of HIV management Recommended Desirable (if feasible) HIV diagnosis HIV serology, CD4 TB screening HBV (HBsAg) serology Cryptococcus antigen if CD4 ≤100 Screening for STIs Assessment for major NCD’s and comorbidities F/U before ART CD4 cell count (every 6–12 mths) ART initiation CD4 cell count Hemoglobin for AZT Pregnancy test Blood pressure Urine dipsticks for glycosuria and serum creatinine for TDF LFT for NVP
  34. 34. Receiving ART CD4 (every 6 months) HIV viral load (at 6months after initiating ART and every 12 months ) Serum creatinine for TDF Treatment failure CD4 (Persistent CD4<100) HIV viral load (>1000) Lab monitoring during ART Phase of HIV management Recommended Desirable (if feasible)
  35. 35. ART Regimens :NACO
  36. 36. ART Scale up for PLHIV in India, 2005 - 2012
  37. 37. HIV-TB Co-infection • A setting with a high burden of TB and HIV refers to settings with adult HIV prevalence ≥1% or HIV prevalence among people with TB ≥5% • Among PLHA, TB is the most frequent life-threatening opportunistic infection and a leading cause of death(25%). • HIV care settings should implement the WHO Three I’s strategy: – Intensified TB case-finding, – Isoniazid preventive therapy (IPT) – Infection control at all clinical encounters
  38. 38. DIAGNOSIS OF TB IN HIV • Frequently negative sputum smears • Atypical radiographic findings • Resemblance to other opportunistic pulmonary infections like pneumonia WHY is it difficult to diagnose TB in HIV infected patient Arrow points to cavity in patient's right upper lobe --typical finding in patient with TB
  39. 39.  HIV infection increases the likelihood that new infection with M. tuberculosis (due to immune suppression) will progress rapidly to TB disease.  Among HIV-infected individuals, lifetime risk of developing active TB is 50%, compared to 5-10% in persons who are not HIV-infected.  In a person infected with HIV, the presence of other infections, including TB, allows HIV to multiply more quickly. This may result in more rapid progression of HIV infection  HIV infected persons have approximately an 8‐times greater risk of TB than persons without HIV infection HIV-TB Co-infection
  40. 40. CD4 Cell count ART Regimen ATT Regimen CD4 < 50/ mm3 Start immediately Start immediately CD4 < 250/ mm3 Start as soon as ATT tolerated (2-4 wks) Start immediately CD4 250 -350/ mm3 Start after the initial phase(8 wks) of TB treatment completed Start immediately CD4 >350/ mm3 Re-evaluate with repeat CD4 count after TB treatment Start immediately
  41. 41. PPTCT :4 Pronged approach Prevention of HIV in women Prevention of unintended pregnancies in HIV+ women Prevention of HIV transmission from HIV+ women to infants Provision of care, treatment and support to mothers living with HIV and their families
  42. 42. PPTCT (Cont.) • Without any intervention risk of transmission of HIV from infected mother to her child is between 20-45%. • SD-NVP is highly effective in reducing risk of transmission from about 45% to less than 10% • Multiple drugs for PPTCT can reduce transmission to less than 5% if started early in pregnancy and continued throughout period of delivery and breast feeding. Adults 57 % Children 35%
  43. 43. PMTCT program option Pregnant and breastfeeding women with HIV HIV-exposed infant Use lifelong ART for all pregnant and breastfeeding women (“Option B+”) Regardless of WHO clinical stage or CD4 Breastfeeding Replacement feeding Initiate ART and maintain after delivery & cessation of breastfeeding 6 weeks of infant prophylaxis with once-daily NVP 6 weeks of infant prophylaxis with once-daily NVP Use lifelong ART only for pregnant and breastfeeding women eligible for treatment (“Option B”) Eligible for Treatment (CD4 Count) Not eligible for treatment Initiate ART and maintain after delivery and cessation of breastfeeding Initiate ART and stop after delivery and cessation of Breastfeeding
  44. 44. Establish HIV Status of Pregnant Women HIV -venewly detected HIV infection Continue ART From ICTC collect the blood Sample for CD4 and sent it to ART center and refer women to there ART Center: Initiate ART to HIV +ve pregnant mother regardless of WHO Clinical Stage and CD4counts Preferred Regimen : TDF+3TC+EFV ART center will collect sample for baseline and other investigations Repeat HIV as per guidelines for window period &h/o risk factor Known HIV infected case and already receiving ART
  45. 45. Mother :Continue ART during labour and delivery(intrapartum) Mother: Continue ART(Postpartum) Infant: Daily NVP from birth until 6 weeks of age then stop (Irrespective of choice of infant feeding) Exclusive BF/RF Continue ART Continued
  46. 46. Duration of BF in HIV • Breastfeeding should only stop once a nutritionally adequate and safe diet without breast-milk can be provided.(AFASS Criteria) – Acceptable – Feasible – Affordable – Sustainable – Safe
  47. 47. HIV in Body Fluids Semen 11,000 Vaginal Fluid 7,000 Blood 18,000 Amniotic Fluid 4,000 Saliva 1 50 Semen 11,000 Vaginal Fluid 7,000 Amniotic Fluid 4,000 Saliva 1 Average number of HIV particles in 1 ml of these body fluids
  48. 48. AIDS: modes of spread 1.7 5
  49. 49. Kuala Lumpur, Malaysia , 30 June - 3 July 2013 Routes of HIV Transmission
  50. 50. HIV: Prophylaxis • Standard Precautions:  Hand washing  Use of protective barriers e.g- gloves,masks,goggles,gowns  Safe handling and safe disposal of sharps  Respiratory hygiene and cough etiquettes  Safe decontamination and disposal of contaminated waste
  51. 51. Post-exposure Prophylaxis Comprehensive management given to minimize the risk of infection following potential exposure to blood-borne pathogens e.g. HIV. This includes: 1. First aid 2. Counseling 3. Risk assessment 4. Relevant laboratory investigations based on informed consent of the exposed person. 5. Depending on the risk assessment, the provision of short term (4 weeks) of ART. 6. Follow up and support
  52. 52. • Post-exposure prophylaxis (PEP) has its greatest effect if begun within 2 hours of exposure. There is little benefit if started >72 hours. • The prophylaxis needs to be continued for 4 weeks (28 days). Preferred PEP regimen : • Initially: – 2 drug regimen (Zidovudine + Lamivudine) – then 3 drug regimen : after expert opinion ( AZT + 3TC + NVP) • Clinical follow-up: the exposed person must be monitored for the eventual appearance of signs indicating an HIV. These symptoms almost always appears within 3 to 6 weeks after exposure. • Laboratory follow-up : after exposure testing at 3 months and 6 months is recommended. Post-exposure Prophylaxis
  53. 53. Oral pre-exposure prophylaxis Serodiscordant couples daily oral PrEP ( TDF or TDF + FTC) Men and transgender women daily oral PrEP (Specifically TDF + Emtricitabine) ART for prevention among serodiscordant couples PLHIV in serodiscordant couples who start ART for their own health, ART is also recommended to reduce HIV transmission to the uninfected partner. HIV-positive partners with a CD4 count ≥350 cells/mm3. HIV prevention based on ARV drugs
  54. 54. Post-exposure prophylaxis for occupational and non-occupational exposure to HIV Post-exposure prophylaxis for women within 72 hours of a sexual assault • Recommended duration of PoEP is 28 days, • First dose as soon as possible within 72 hours • The choice based on first-line ART regimen.
  55. 55. HIV Vaccine Need Despite the remarkable achievements in development of anti-retroviral therapies and recent advances in new prevention technologies, the rate of new HIV infections continues to outpace efforts on prevention and control. Challenges • H.I.V. mutates rapidly; H.I.V. mutates in one day as much as influenza viruses do in a year. • The virus has developed multiple mechanisms to evade the body’s defenses • Targets the very cells (CD4) that coordinate the immune response to viral infections. • Broadly neutralising antibodies usually appear between 2-- 4 years but by that time the antibodies cannot save them because they are overwhelmed by the mutating virus.
  56. 56. HIV Vaccine:the new hope • AIDSVax Recombinant protein (HIV gp120) adjuvant with alum Recombinant adeno associated virus vaccine(rAAV) Recombinant adenovirus type-5 vaccine containing HIV gag, pol and nef genes RV144 Canarypox vector prime + monomeric gp120 boost Failed in Phase II trials  Failed in MSM  Paradoxically increased the risk of infection among uncircumcised men with exposure to the virus used in the vaccine.  vaccine with the greatest promise till date.  31% efficacy in Phase III trials
  57. 57. NACP – IV: Priorities  Preventing new infections  Preventing of Parent to child transmission  Focusing on IEC strategies for behaviour change in HRG, awareness among general population and demand generation for HIV services  Providing comprehensive care, support and treatment to eligible PLHIV  Integrating HIV services with health systems in a phased manner  Reducing stigma and discrimination through greater involvement of people living with HIV(GIPA)
  58. 58. •Needle-Syringe Exchange Programme and Opioid Substitution Therapy for IDUs •Targeted Interventions for High Risk Groups (FSW, MSM, IDU, Truckers & Migrants) • Link Worker Scheme for rural population •Prevention & Control of Sexually Transmitted Infections •IEC, Social Mobilization & Mainstreaming •Condom promotion •Blood safety •Counselling & Testing Services (ICTC, PPTCT, HIV/TB) •First line & second line ART • Care &Support Centres •HIV-TB Coordination •Focus on PPTCT •Treatment of Opportunistic Infections Prevention is the main stay High risk populations Low risk populations People living with HIV/AIDS Care, Support and Treatment NACP IV Strategies Capacity BuildingStrategic Information Management
  59. 59. References • Joint United Nations Programme on HIV/AIDS (UNAIDS). Report on the global AIDS epidemic .UNAIDS 2013 • National AIDS Control Organisation. About NACO;NACO 2013. Available from: . • Chawla S, Sahoo SS, Jain RB, Khanna P, Mehta B, Singh I.HIV-Is a vaccine the answer? Hum Vaccin Immunother 2013;10(1). • • • World Health Organization. Global HIV/AIDS Response– Epidemic update and health sector progress towards Universal Access – Progress Report 2013.
  60. 60. References • WHO. Antiretroviral Therapy for HIV infection in Adults and Adolescents in Resource-limited settings: Towards Universal Access. Recommendations for a public health approach. 2006 revision. • • Guidelines for the Use of Antiretroviral Agents in HIV Infected Adults and Adolescents,2013.Available from: ( • International AIDS committee(IAS);Kualalumpur,Malaysia,30 June – 3July 2013
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