HIV

2. What is HIV?
• Human: Infecting human beings
• Immunodeficiency: Decrease or weakens the body’s
ability to fight off infections and illnesses
• Virus: A pathogen having the ability to replicate only
inside a living cell
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3. What is HIV?
 Virus - identified in the 1980s
 Belongs to a group of viruses called ‘retroviruses’
 Attacks the immune system, and gradually causes damage
 Infects vital cells in the human immune system, mainly
CD4 + T cells
 Current treatment for HIV works by reducing viral load of
HIV
 India has the 3rd largest HIV epidemic in the world
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4. GLOBAL TRENDS
WORLDWIDE - 2019
 People living with HIV/AIDS: 36.9 million people
 Deaths: 6.9lakh people died of HIV-related illnesses
 New HIV infections: 1.7 million (children: 1.5lakh)
INDIA - 2019
 People living with HIV/AIDS: 2.3 million people
 Maharashtra >Andhra Pradesh> Karnataka
 Deaths due to HIV: 58,000 people died of HIV-related illnesses
 IDU > TG > MSM > FSW > OTHERS
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5. GLOBAL TRENDS
 INDIA 2017
0.2 % adult HIV prevalence (ages 15 - 49)
88,000 new HIV infections
69,000 AIDS – related deaths
56% adults on Antiretroviral treatment
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7. What is AIDS ?
Acquired Transmitted from person to
(not born with) person
Immune Affects body’s immune system,
(body’s defence system) which fight off bacteria &
viruses
Deficiency Malfunctioning of the body’s
(not working properly) immune system
Syndrome A group of signs and symptoms
(a group of signs & symptoms) that occur together and
characterize a particular
abnormality
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8. HIV vs. AIDS
 HIV is a virus and AIDS is a disease
 HIV is the virus that causes AIDS
 Not everyone who is infected with HIV has AIDS
 Everyone with AIDS is infected with HIV
 AIDS is result of the progression of HIV Infection
 Anyone infected with HIV, although healthy, can still
transmit the virus to another person
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9. Types of HIV virus
 HIV 1
 More virulent and more infective
 Initially termed lymphadenopathy associated virus (LAV)
and human T-lymphotropic virus 3 (HTLV-III)
 Most common in sub-Saharan Africa & throughout the
world
 HIV 2
 Most often found in West Central Africa, parts of Europe & India
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10. How HIV is Transmitted?
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11. How HIV is NOT Transmitted?
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12. HIV Disease Progression
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13. WHO HIV clinical stages
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14. Clinical spectrum of HIV/AIDS
 Stage I : Acute Retroviral Syndrome
(Seroconversion)
Usually asymptomatic
50% experience acute viral syndrome
Self- limiting
HIV antibodies not detectable & Tests Negative
Also known as “Window period”
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15. Window Period
 Time from initial infection with HIV until antibodies are
detected by a single test
 Usually 3-8 weeks before antibodies are detected
 May test false-negative for HIV antibodies during this time
period
 Can still pass the virus to others during this period
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16. Clinical spectrum of HIV/AIDS (Contd.)
 Stage II : Early Asymptomatic Disease
(CD4 count >500 /mm3)
HIV test becomes positive
Asymptomatic but can transmit virus
Common signs & symptoms -
Seborrheic dermatitis, Pruritis, Cellulitis,
Herpes zoster infection, Persistent generalised lymphadenopathy
Lab reports – Leucopenia & Thrombocytopenia
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17. Clinical spectrum of HIV/AIDS (Contd.)
 Stage III : Intermediate HIV Infection
(CD4 count 200 - 500 /mm3)
Early symptoms of HIV related illness
Signs & symptoms- k/a AIDS Related Complex ( ARC )
Oral thrush, diarrhoea, weight loss,
loss of energy, loss of appetite, Herpes zoster
infection, oropharyngeal or vaginal candidiasis,
Mycobacterium tuberculosis
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18. Clinical spectrum of HIV/AIDS (Contd.)
 Stage IV : Late stage HIV Disease
(CD4 count 50 - 200 /mm3)
Opportunistic infections–
Pneumocystis jiroveci pneumonia,
cerebral toxoplasmosis,
pulmonary or disseminated tuberculosis,
cryptococcal meningitis,
Kaposi sarcome,
undifferentiated B cell lymphomas, etc.
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19. Clinical spectrum of HIV/AIDS (Contd.)
 Stage V : Advanced HIV Disease
(CD4 count < 50 /mm3)
Even with therapy, mortality maybe within 2 yrs
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20. Signs & Symptoms
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Other than these are Mouth ulcers, Genital or Anal ulcers & lack of energy

21. WHO definition of AIDS
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• Adult: Atleast two major signs with atleast one minor
signs
• Children: 2 major & 2 minor signs
*confirm HIV infection in mother counts as minor criteria

22. Diagnosis of HIV/ AIDS (adults)
 Major Signs
~ Weight loss > 10% of Body weight
~ Chronic diarrhoea of > 1 month
~ Prolonged Fever of > 1 month
 Minor Signs
~ Persistent cough > 1 month duration
~ Generalised Pruritic Dermatitis
~ Oropharyngeal Candidiasis
~ Chronic progressive or disseminated herpes simplex infection
~ Generalised Lymphadenopathy
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23. Diagnosis of HIV/ AIDS (Child)
 Major : weight loss or abnormally slow growth
chronic diarrhoea for more than 1 month
prolonged fever for more than 1 month
 Minor : generalized lymph node enlargement
oropharyngeal candidiasis
recurrent common infections
persistent cough
generalized rash
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24. Investigations
 HIV Antibody Test
- HIV Rapid Test
- ELISA (Sn-99.9%), screening test
- Western Blot (Sp-99.9)%, confirmatory tests
 HIV Antigen Test
- PCR or Viral load
- P24 Antigen
 Others :
Absolute CD4 lymphocyte count
CBC- Anemia, neutropenia, thrombocytopenia
Viral load
B2 microglobulin (macrophage-monocyte stimulation,
rapid progression of disease)
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25. Treatment
HIV testing is the entry point for prevention and
treatment but about half of key populations do not
know their HIV status
“KNOW YOUR STATUS”
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26. Treatment (Contd..)
 Antiretrovirals reduces the
ability of the HIV virus as HIV replication
to replicate reduces
 In turn this increases the
body’s ability to fight immune response
the disease increases
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27. Treatment (Contd..)
 Medical Management
- Antiretroviral Therapy (Anti HIV Drugs)
- Palliative Care
- Complimentary Therapies
- Counselling
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28. Counseling
 Lifelong treatment
 Frequent monitoring
 Cost implications
 Pill burden
 Adherence and dose compliance
 Discussion regarding child bearing and treating other
affected family member
 Social implications
 PrEP in case of discordant couples/partners
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29. Current NACO Guidelines - May2017
When to initiate ART
All persons diagnosed with HIV infection
are eligible for ART initiation
regardless of CD4 count or
WHO Clinical Staging,
any age or population
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30. Principles of Therapy
 Decision regarding choice of drugs not only will affect the
immediate response to therapy but will also have effects on
the options for future therapy
 After the initiation of therapy - a rapid ↓ in plasma HIV
RNA levels within 1–2 months and then a slower decline,
to <50 copies/mL within 6 months - acceptable
 Along with this, a rise in the CD4+ T cell count of 100–
150/cells μL during the first month of therapy
 Plasma HIV RNA levels to be monitored every 3–6
months during therapy and more frequently if there is a
change in regimen (due to an increase in viral load or any
other reason)
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31. ARV Drugs
 Classes
Nucleoside Reverse Transcriptase Inhibitors
Non-Nucleoside Reverse Transcriptase Inhibitors
 Protease Inhibitors
 Entry and Fusion Inhibitors
Integrase Inhibitors
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32. ARV Drugs
1. Nucleoside Reverse
Transcriptase Inhibitors
- Zidovudine (AZT)
- Lamivudine (3TC)
- Emtricitabine (FTC)
- Stavudine (d4T)
- Abacavir (ABC)
- Tenofovir (TDF)
2. Non - Nucleoside
Reverse Transcriptase
Inhibitors
- Nevirapine (NVP)
- Efavirenz (EF)
- Rilpivirine (RPV)
- Etravirine (ETV)
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33. ARV Drugs
3. Protease Inhibitors
- Ritonavir (RTV)
- Lopinavir/Ritonavir (LPV/r)
- Atazanavir (ATV)
- Darunavir (DRV)
5. Entry Inhibitors
- Enfuvirtide (ENF)
- Maraviroc (MRV)
- Ibalizumab
4. Integrase Inhibitor
- Raltegravir (RAL)
- Elvitegravir
- Dolutegravir
- Bictegravir
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34. Initial Combination Regimens Recommended for
Most Treatment- NEW Patients Regardless of
HIV RNA Level or CD4 Count
FIRST LINE & ALTERNATE REGIMEN
 Dolutegravir + Tenofovir + Emtricitabine
 Raltegravir + Tenofovir + Emtricitabine
 Bictegravir + Tenofovir + Emtricitabine
 Elvitegravir + Cobicistat + Tenofovir + Emtricitabine
 Dolutegravir + Abacavir + Lamivudine (only for those HLA-
B*5701 negative)
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35. Indications for Changing Antiretroviral
Therapy in Patients with HIV Infection
 Less than a 1-log drop in plasma HIV RNA by 4 weeks
after the initiation of therapy
 A reproducible significant increase (defined as threefold or
greater) from the initial plasma HIV RNA level not
attributable to intercurrent infection, vaccination, or test
methodology
 Persistently declining CD4+ T cell numbers
 Clinical deterioration
 Side effects
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36. Monitoring
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37. Opportunistic Infection (OI)
 An opportunistic infection is a disease caused by a
microbial agent in the presence of a compromised host
immune system
 Tuberculosis and Candida albicans infection(CD4 200 to
500), Pneumocystis jiroveci Pneumonia (CD4 < 200),
Cytomegalovirus infection (CD4 < 100)
 ART should not be started in presence of active OI
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38. Management of OI
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39. HIV prevention programmes in India
 NACO - In 1992 India’s first National AIDS Control Program
(1992-1999) was launched, and National AIDS Control
Organization was constituted to implement the program
 NACP-IV - (2012-2017, extended to 2018), aims to reduce
annual new HIV infections by 50% through:-
1. comprehensive HIV treatment
2. education
3. care and support for the general population
4. build on targeted interventions for key affected
groups and those at high risk of HIV
transmission
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40. HIV prevention programmes in India
 Prevention of Parent to Child Transmission of HIV/AIDS
(PPTCT) program started in 2002
 23,400 sites offering PPTCT services
 Program initiates ART for all pregnant and breastfeeding
women living with HIV regardless of CD4 count or stage of
HIV infection
 During 2016/17, out of 10,715 babies exposed to HIV, 89%
were initiated on antiretroviral (ARV) prophylaxis to prevent
transmission
 In 2017, 60% of pregnant women living with HIV received
PPTCT services, a 20% increase on 2016 levels
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41.  WHO came up with Option B+ in 2013 that prioritized
pregnant women to receive ART irrespective of their CD4
counts
 In 2016, WHO guidelines recommended a 'treat all'
strategy offering ART to all found to be infected
irrespective of their CD4 counts even among resource-
limited settings as a public health tool to control HIV
epidemic
 Over 190 countries, including India, have pledged to end
AIDS by 2030 by adopting the UN Sustainable
Development Goals
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42. HIV testing and counseling (HTC) in
India
 In 1997- 67 HIV testing and counseling (HTC) sites
By 2017, around 23,400 facilities were offering HIV testing
and counseling
 Testing is offered by standalone clinics, health facilities and
through public/private partnerships
 Mobile testing units also offer community-based testing
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 After the World Health Organization (WHO) recommended
HIV self-testing, India’s Ministry of Health indicated self-testing
kits, among high-risk populations

43. HIV testing and counseling (Contd..)
VCTC
• Voluntary Counseling and Testing Centers
• People motivated were referred to these centers
VCCTC
• Voluntary Confidential Counseling and Testing Centers
• Emphasis on maintaining confidentiality
ICTC
• Integrated Counseling and Testing Centers
• Integration of VCCTC + PPTCT
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PITC
• Provider Initiated Counseling and Testing Centers

44. Integrated Counseling and Testing
Center (ICTC) in India
 As on 31st August 2016, there are 20,756 Integrated Counseling
and Testing Centers (ICTC), mainly in govt. hospitals
 Main functions of an ICTC are:
~ Conducting HIV diagnostic tests
~ Providing basic information on the modes of HIV transmission
~ Promoting behavioral change to reduce vulnerability
~ Link people with other HIV prevention, care & treatment services
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45. Working pattern of ICTC
HIV Suspect ICTC Counselor Reason for testing
Risk Assessment
consent Pre-test COUNSELING
BLOOD TEST
HIV –ve HIV +ve
Post test counseling Confirmed
 Change risky life pattern
 Preventive measures Post test counseling
ART PPTCT Drop in centres
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46. Pre-exposure prophylaxis (PrEP)
 A daily course of ARVs taken by HIV-negative people to
protect themselves from infection
 The combination of Tenofovir and Emtricitabine - indicated
in individuals at high risk of HIV
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 As of 2018, a demonstration project and feasibility study
was being conducted with female and transgender sex workers

47. Post Exposure Prophylaxis
 Taking Antiretroviral medicines after being potentially exposed to
HIV can prevent becoming infected
 Must be started within 72 hours after a possible exposure to HIV
and continued for 28 days
 PEP is highly effective in preventing HIV transmission
(Seroconversion rate reduces by 83%)
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 For consultation of occupational exposures to HIV, the
clinician can call the National Clinicians’ Post-Exposure
Prophylaxis Hotline (PEPline) at 888-448-4911. This service
is available 24 hours
1097- GENERAL PUBLIC

48. Recent updates in treatment guidelines
 Joint United Nations Programme on HIV and AIDS
(UNAIDS) has set a goal to end acquired immune
deficiency syndrome (AIDS) by 2030 using 90–90–90
strategy that aims at:
1. detecting 90% of all HIV-infected individuals
2. linking 90% of these people to ART services
3. Ensuring that 90% of these linked patients have
suppressed plasma viral loads.
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49. 90-90-90
An ambitious treatment target to help end AIDS epidemic
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51. Treatment
 Antiviral agents : nucleoside and
nucleotide analogues,
non-nucleoside analogues
protease inhibitors,
fusion inhibitors and
integrase inhibitors
 New antiviral strategies : antisense nucleic acids and
maturation inhibitors
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53. Conclusion
 ART is the present mainstay of management against HIV
virus
 Counseling prior to initiation of ART and regular follow up
with periodic evaluation of CD4 counts is essential
 ART when effectively delivered can increase the life
expectancy and help to combat comorbid infections leading
to early mortality
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