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2 natural history of hiv and who clinical staging naco lac m

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2 natural history of hiv and who clinical staging naco lac m

  1. 1. Natural History and Clinical Staging of HIV InfectionNatural History of HIV
  2. 2. Session ObjectivesBy the end of the session the participant will be able• To list the modes of HIV transmission• To discuss the pathogenesis and life cycle of HIV• To describe the progression of HIV• To classify an HIV-infected patient according to the WHO clinical stagingNatural History of HIV 2
  3. 3. Modes of HIV Transmission Semen and Vaginal Sharing Needles Needle Stick Fluids Injury & Syringes Through Infected During Pregnancy Breast Feeding Blood or Birth Images Courtesy HIV Basics Course for Nurses, I-TECHNatural History of HIV 3
  4. 4. HIV Transmission Risk Exposure Route HIV Transmission Blood transfusion 90-95% Perinatal 20-40% Sexual intercourse 0.1 to 1% Vaginal 0.05-0.1% Anal 0.065-0.5% Oral 0.005-0.01% Injecting drugs use 0.67% Needle stick exposure 0.3% Mucous membrane splash to eye, 0.09% oro-nasal Source: NACO PEP GuidelinesNatural History of HIV 4
  5. 5. How HIV Infects the Body HIV makes contact with cells located within the genital mucosa Virus is carried to regional lymph nodes (1-2 Days) Exponential viral replication Widespread systemic dissemination to the brain, spleen, distant lymph nodes, etc. (5-11 Days)Natural History of HIV 5
  6. 6. Path of the Virus Exposure to HIV at Day 0 mucosal surface (sex) Virus collected byDay 0-2 dendritic cells, carried to lymph nodeDay 4-11 HIV replicates in CD4 cells, released into blood Virus spreads toDay 11 on other organs Image Courtesy Kahn JO, Walker BD. NEJ Med.1998; 339: 33-39Natural History of HIV 6
  7. 7. HIV Lifecycle Image Courtesy HIV Basics Course for Nurses, I-TECH HIV Lifecycle VideoNatural History of HIV 7
  8. 8. Stages of Untreated HIV Infection Viral transmission Acute retroviral syndrome: 2-3 weeks Seroconversion: 2-4 weeks Asymptomatic chronic HIV infection: 8 yrs (Avg.) Symptomatic HIV infection/AIDS: 1.3 yrs (Avg.)Natural History of HIV 8
  9. 9. Typical Course of Untreated HIV Infection 800 Acute HIV 10^6 HIV antibodiesCD4 Asymptomaticcount HIVcells/µl RNA Minor HIV-related Copies /ml symptoms Virologic set-point 200 Varies from patient to Opportunistic patient infections 10^2 Death 1 3 about 6mths // 5yrs 10 yrs Natural History of HIV Time 9
  10. 10. Progression of HIV Disease• Acute Seroconversion (Acute HIV Syndrome)• Asymptomatic HIV (Clinical latency)• Symptomatic HIV• Acquired Immune Deficiency Syndrome (AIDS)Natural History of HIV 10
  11. 11. Acute HIV syndrome• Transient symptomatic illness• Affects 40-90% of HIV+ individuals• Ranges from mild, non- specific illness to severe illness that can result in hospitalisation HIV Web study (www.HIV webstudy.org) Supported by HRSA Natural History of HIV 11
  12. 12. Acute HIV syndrome: Clinical Manifestations Small pink macules: Trunk, limbs and face Courtesy: Kahn, NEJM, 1998 Courtesy: Walker, B. 40th IDSA, Chicago 2002.Natural History of HIV 12
  13. 13. Patterns of HIV Progression• Typical progressors• Rapid progressors• Slow progressors• Long-term non-progressorsNatural History of HIV 13
  14. 14. WHO Clinical Staging• WHO Clinical Staging 1 • Asymptomatic • Persistent generalised lymphadenopathy (PGL) • Painless enlarged lymph nodes >1 cm • In two or more non-contiguous sites (excluding inguinal), in absence of known cause and • Persisting for 3 monthsNatural History of HIV 14
  15. 15. WHO Clinical Staging 2 Unexplained moderate weight loss (<10% of presumed or measured body weight) Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis media, pharyngitis) Herpes zoster Angular cheilitis Recurrent oral ulceration Papular pruritic eruptions (PPE) Seborrhoeic dermatitis Fungal nail infectionsNatural History of HIV 15
  16. 16. WHO Clinical Staging 3 Unexplained severe weight loss (>10% of presumed or measured body weight) Unexplained chronic diarrhoea for longer than one month Unexplained persistent fever (above 37.5oC intermittent or constant for longer than one month) Persistent oral candidiasis Oral hairy leukoplakia (OHL) Pulmonary tuberculosisNatural History of HIV 16
  17. 17. WHO Clinical Staging 3 Severe bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone or joint infection, meningitis, bacteraemia) Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis Unexplained  Anaemia (<8 g/dl)  Neutropenia (<0.5 x 109 /L) and or  Chronic thrombocytopenia (<50 X 109 /L)Natural History of HIV 17
  18. 18. WHO Clinical Staging 4 HIV wasting syndrome Pneumocystis pneumonia (PCP) Recurrent severe bacterial pneumonia Chronic herpes simplex infection (orolabial, genital or anorectal of more than one month’s duration or visceral at any site) Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs) Extra pulmonary tuberculosis Kaposi’s sarcomaNatural History of HIV 18
  19. 19. WHO Clinical Staging 4 Cytomegalovirus infection (retinitis or infection of other organs) Central nervous system toxoplasmosis HIV encephalopathy Extra pulmonary cryptococcosis including meningitis Disseminated non-tuberculous mycobacteria infection Progressive multifocal leukoencephalopathy Chronic cryptosporidiosis Chronic isosporiasisNatural History of HIV 19
  20. 20. WHO Clinical Staging 4 Disseminated mycosis (extra pulmonary histoplasmosis, coccidiomycosis) Recurrent septicaemia (including non-typhoidal salmonella) Lymphoma (cerebral or B cell non-Hodgkin) Invasive cervical carcinoma Atypical disseminated leishmaniasis Symptomatic HIV associated nephropathy or Symptomatic HIV associated cardiomyopathyNatural History of HIV 20
  21. 21. WHO Clinical Staging Case Studies (17) • Each trainee has to discuss one case study • Look into the clinical photograph / X-ray • Describe the lesion, as you observe • Discuss Differential Diagnosis • Identify Clinical staging of HIV infectionNatural History of HIV 21
  22. 22. Case Study 1 and 2 Source: GHTM, Tambaram, Chennai• Describe the lesion• Identify Clinical staging of HIV infectionNatural History of HIV 22
  23. 23. Case Study 3 Source: GHTM, Tambaram, ChennaiNatural History of HIV 23
  24. 24. Case Study 4 Image Courtesy: GHTM/ITECH Fellowship Programme, Tambaram, ChennaiWHO Clinical Staging in CLHIV 24
  25. 25. Case Study 5 & 6Image Courtesy :GHTM, Tambaram, Chennai OI Curriculum, GHTM-I-TECH, 2004 Natural History of HIV 25
  26. 26. Case Study 7 Images Courtesy: I-TECH-GHTM Fellowship Programme, Tambaram, ChennaiNatural History of HIV 26
  27. 27. Case Study 8 • Describe the lesion • What are the differential diagnosis? • Clinical staging? Image Courtesy: Bowring Hospital, BangaloreNatural History of HIV 27
  28. 28. Case Study 9 Image Courtesy GHTM , Tambaram HIV Fellowship ProgrammeNatural History of HIV 28
  29. 29. Case Study 10 Images Courtesy: GHTM/ITECH Fellowship Programme, Tambaram, ChennaiWHO Clinical Staging in CLHIV 29
  30. 30. Case Study 11 Case Study 12 Images Courtesy: Indian Academy of PediatricsWHO Clinical Staging in CLHIV 30
  31. 31. Case Study 13 Image Courtesy: Indian Academy of PediatricsWHO Clinical Staging in CLHIV 31
  32. 32. Case Study 14 Image Courtesy: GHTM/ITECH Fellowship Programme, Tambaram, ChennaiWHO Clinical Staging in CLHIV 32
  33. 33. Case Study 15• 5 year old child• Respiratory distress• Cough+• No sputum• Respiratory Rate: 45/mt• Lung signs: Bilateral basal inspiratory crackles Image courtesy: TRC, Chennai 33
  34. 34. Case Study 16• 37 year-old HIV positive male• Lost 9 kg in last 3 months (Previously his body weight was 75 kg)• Reports having a fever for the past month• Treated for pulmonary TB 5 months ago What is his WHO clinical staging?Natural History of HIV 34
  35. 35. Case Study 17• 34 year-old HIV positive male• Suffers from bacterial sinusitis and a fungal infection on his toes• Has no problem keeping up with his usual activities and weight is stable• Treated for herpes zoster 4 years ago What is his WHO clinical staging?Natural History of HIV 35
  36. 36. Key Points• The most common mode of HIV transmission in India is sexual• Understanding the natural history of HIV is important in predicting progress of the disease• Clinical staging allows clinicians to reliably predict in patients: – The risk of opportunistic infections and death – The need for disease prevention & pre ART Care – ART InitiationNatural History of HIV 36

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