HIV:AIDS.PSM, COMMUNITY MEDINE,DR NARENDRA KUMAR YADAV

1. HIV/AIDS
DR NARENDRA KUMAR YADAV
MD Community Medicine & Tropical Diseases, BPKIHS
AIDS (Acquired Immunodeficiency Syndrome)

2. HIV/AIDS:
Outline of the Chapter:
History
Burden of Disease
Mode of transmission
Clinical manifestations:
Diagnosis of HIV/AIDS: Clinical
Laboratory Diagnosis
WHO Clinical Staging for HIV Infection
New post exposure guideline for HIV
Prevention and control of disease in the community

3. AIDS Patients: AIDS (Acquired Immunodeficiency Syndrome)

4. Case-Scenario:
Q. Ms. Sabita, 28 years old who is intravenous drug user had presented in community
hospital with significant weight loss and chronic diarrhoea for more than 2 months. On
physical examination, multiple lymph nodes were palpable and tongue was coated with
white plaques. On further inquiry she revealed she lost her husband 2 years back because
of similar condition.
a. What is your diagnosis? Justify your diagnosis.
b. Describe the epidemiology of given disease.
b. Discuss the various ways Sabita can transmit her disease to others.
c. Explain the clinical stages of the disease.
d. Discuss on prevention and control of disease in the community.

5. Case-Scenario:
Q. A patient came to PHC with the complains of fever, diarrhoea, sore throat
and rash. About 4 months before he had visited a brothel (Prostitute).
1. Which screening test you will use for the provisional diagnosis and how
will you conform the diagnosis?
2. Write the various modes of transmission.
3. Which are the major and minor criteria for the diagnosis?
4. Discuss on prevention and control of disease in the community.

6. HIV/AIDS
 A/K/A: SLIMS DISEASE
Causative Agent: HIV (HTLV-3, LAP).
HIV (Human immunodeficiency virus): Lentivirus (Retrovirus)
 AIDS(Acquired immunodeficiency syndrome): Most advanced stage of the disease.
 AIDS: CD4 count is < 200 cells/mm3 of blood (WHO)
 HIV to AIDS: 7-10 years (Chronic Phase)
 Incubation Period: Few months to 10 years
 NORMAL CD4 count: (800-1200 cells/ mm3 )
HTLV-3: Human T-lymphotropic virus 3
LAP: Lymph adenopathy associated virus

7. History of HIV/ AIDS:
First case of HIV in the WORLD was reported in: 1981 (USA)
First case of HIV in INDIA was reported in : 1986 (Chennai)
First case of HIV in NEPAL was reported in: 1988
 HIV Virus Discovery:
 HIV-1: 1983
 HIV-2: 1986
 HIV 1 (M/C) > HIV 2

8. Epidemiology of HIV/AIDS:
Burden of disease:
WORLD: People Living with HIV/AIDS (PLHA) = 0.7% (37 Million)
INDIA: People Living with HIV /AIDS (PLHA) = 0.22% (2.4 Million)
NEPAL: People Living with HIV /AIDS (PLHA) = 0.13% (19,118)
 M/C Age group of having HIV Nepal / India: 30-44 years
 HIV afflicted age group in Nepal and India: (30-44 years) > (15-29
years) > (45+ years) > under 15

9. Epidemiological determinants of HIV/AIDS:
Epidemiological triad of HIV/AIDS:
1. Agent factors:
a. AGENT: HIV (HIV 1 > HIV 2)
b. RESERVOIR OF INFECTION: Cases and Carriers.
c. SOURCE OF INFECTION: The virus has been found in greatest concentration in
blood, semen and CSF.
2. Host factors:
a. AGE: (30-44 years) > (15-29 years) > (45+ years) > under 15
b. HIGH-RISK GROUPS: Bisexual men, multiple sexual partners, anal intercourse,
prostitutes, intravenous drug abusers, transfusion recipients of blood and blood products.

10. High risk group of HIV infection:
 Sex workers
 iv drug users
Transfusion recipients of blood and blood products.
Transport workers
 Migrant Workers
 Health care workers
 Military and police

11. Mode of transmission:
1. Sexual transmission: M/C (90% Cases)
 (Male to Female) > (Female to Male)
 Anal intercourse > vaginal intercourse
 Heterosexual > Homosexual
2. Mother to child transmission (MTCT): A/K/A Vertical transmission (5%)
3. Needle/ Syringe (2%)
4.Blood contact: L/C Route of Transmission (0.5%-1%)
Pediatrics: Vertical transmission
is M/C route of transmission.

12. Mode of transmission: Cont.…
Efficiency wise:
Most Efficient (most dangerous) route of HIV Transmission: Blood
(90 % Chances)
Least Efficient (least dangerous) route of HIV Transmission: Sexual
(0.01 -1% Chances)

13. Mode of transmission: Cont.…

14. .
Mother to foetus/infant transmission: through Placenta OR during delivery
OR by breast-feeding.
Transmission of HIV from mother to child can be prevented by:
1. Anti-retroviral drug prophylaxis to the mother and newborn after delivery.
2. Caesarian section before onset of labour & rupture of membrane
3. Refraining (avoiding) from breast feeding.
Mother to child transmission (MTCT): A/K/A Vertical
Zidovudine to mother antenatal
and newborn after delivery.

15. Blood contact:
By Contaminated Blood transfusion
Blood contact: L/C Route of Transmission (0.5%)
M/C Efficient Route of Transmission: Blood (90 % Chances)
Needle/ Syringe:
By Contaminated needle, syringe or any other skin-piercing
instrument
 Needle-sharing by drug users

16. Clinical manifestations:
The clinical features of HIV infection have been classified into 4
categories:
1. Initial infection with the virus and development of antibodies
2. Asymptomatic carrier state (ACS)
3. AIDS-related complex (ARC)
4. AIDS.
AIDS (Acquired Immunodeficiency Syndrome)

17. Clinical manifestations: Cont.…
1. Initial infection with the virus and development of antibodies:
 Generally asymptomatic for the first 5 years.
Except, mild illness (fever, sore throat and rash): 70%
HIV antibodies appear in the blood-stream between 2 to 12 weeks.
The period before antibodies are produced is the "window period”: Highly
infectious period.

18. Clinical manifestations: Cont.…
2. Asymptomatic carrier state (ACS):
But no overt signs of disease, except persistent generalized
lymphadenopathy.
 Infected people have antibodies.

19. Clinical manifestations: Cont.…
3.AIDS-related complex (ARC)
ARC is caused by damage to the immune system, but without the
opportunistic infections and cancer associated with AIDS.
BUT, one or more of the following sign is present:
a. Weight loss ≥ 10% of body weight
b. Fever, night sweat, fatigue, malaise etc.
c. Oral thrush, Generalized lymphadenopathy Oral thrush

20. Clinical manifestations: Cont.…
4. AIDS:
AIDS is the end-stage of HIV infection.
AIDS: CD4 count is < 200cells/mm3 (WHO)
 AIDS opportunist infections with or without Cancer associated with AIDS are
commonly occur at this stage.
M/C Opportunistic infection:
 World: P. Jiroveci Pneumonia(PCP)
 Nepal/India: Tuberculosis (>Candida > PCP)
M/C/C of death in AIDS : Uncontrolled or untreatable infection.
AIDS associated Malignancy
(cancer):
1. NHL
2. Kaposi sarcoma
3. Cervix cancer

21. Q. M/C Opportunistic infection in AIDS:
World: P. Jiroveci Pneumonia(PCP)
Nepal/ India: Tuberculosis (>Candida > PCP)
Q. AIDS defining Malignancy (cancer):
1. NHL
2. Kaposi sarcoma
3. Cervix cancer

23. Opportunistic infection:
CD4 < 200: Pneumocystis carinni and NHL
CD4 < 100: Cryptococcus infection
CD4 < 50: CMV

24. .
DIAGNOSIS OF AIDS:
Diagnosis Criteria
1. for adult >12 years
2. for Children

25. DIAGNOSIS OF AIDS: for adult >12 years
.
WHO case definition for AIDS surveillance : 2 major signs + 1 minor sign
Major signs: Minor Signs:
Weight loss ≥ 10% of body weight
Chronic diarrhoea > 1 month
Prolonged fever > 1 month (Intermittent
OR Constant)
Persistent cough > 1 month
Oropharyngeal candidiasis
Generalized pruritic dermatitis
H/O Herpes zoster infection
Herpes simplex infection
Generalized lymphadenopathy
 The presence of either generalized Kaposi sarcoma OR cryptococcal meningitis is
sufficient for the diagnosis of AIDS for surveillance purposes.

26. DIAGNOSIS OF AIDS: for Children
.
WHO case definition for AIDS surveillance: 2 major signs + 2 minor signs
Major signs: Minor Signs:
Weight loss OR abnormally slow growth
Chronic diarrhoea > 1 month
Prolonged fever > 1 month (Intermittent
OR Constant)
Persistent cough
Recurrent infection: Pharyngitis, Ear inf
Oropharyngeal candidiasis
Generalized rash
Generalized lymphadenopathy

27. Laboratory Diagnosis:
Screening Tests: ELISA (HIV Enzyme-Linked Immunosorbent Assay)
 Western Blot: Previously Confirmatory Test was Western Blot.
 IOC: RT-PCR (Now, Confirmatory Test is RT-PCR).
Absolute CD4 lymphocyte count
CD4 lymphocyte%
HIV viral load tests
B2 - Microglobulin
p24antigen
CBC
 ELISA stands for Enzyme-Linked Immunosorbent As
 RT-PCR stands for Reverse Transcription
Polymerase Chain Reaction.

28. Herpes zoster infection
Herpes simplex
infection

29. Kaposi sarcoma:

30. WHO Clinical Staging for HIV Infection:

31. Prevention and control of HIV/AIDS in the community:
1. Health education:
 Avoid unsafe sex (Use Condom)
 Avoid the sharing of needle and syringes
 Women suffering from AIDS should avoid becoming pregnant.
2. Prevention of Blood-Borne HIV transmission
Screening of blood for HIV
Pre-sterilized disposable syringe and needle
3. HAART (Highly active antiretroviral therapy):

32. New post exposure guideline for HIV

33. TB HIV Co infection:
HIV is the most potent risk factor for TB.
HIV-infection increases the risk of TB 20-fold compared with person
without HIV.
World: 10-15% of PLHIV are infected with TB.
World: More than 1 million people have HIV/ TB co-infection.
Early detection and effective treatment (DOTS): Reduce mortality

34. QQQQQ
•UNAIDS 90-90-90 Target
•UNAIDS 95-95-95 Target

36. • Who and UNAIDS has define different types of hiv epidemics. Explain

37. • HIV can be treated and prevented with antiretroviral therapy (ART).
• Untreated HIV can progress to AIDS, often after many years.
• There is no cure for HIV infection. It is treated with antiretroviral
drugs, which stop the virus from replicating in the body.

38. MCQ
Q. The first country in the world to report AIDS was:
a. USA
b. India
c. Thailand
d. Nepal

39. Ans: a (USA): 1981

40. MCQ
Q. The first country in the South East Asian Region (SEAR) to
report AIDS was:
a. Sri Lanka
b. India
c. Thailand
d. Nepal

41. Ans: C (Thailand): 1984

42. MCQ
Q. HIV virus was discovered in the year:
a. 1981
b. 1983
c. 1986
d. 1996

43. Ans: b (1983)
HIV-1 discovered in 1983
HIV-2 discovered in 1986
HIV discovered by:
oRobert Gallo(USA)
oLuc Montagnier, Barre Sinnousi (France): Awarded Nobel Prize

44. MCQ
Q. The highest number of AIDS case in Nepal and India have
occurred in age of:
a. 0-14 years
b. 15-29 years
c. 30-44 years
d. Above 45 years

45. Ans: C (30-44 years)
HIV afflicted age group in Nepal and India: (30-44 years) > (15-29
years) > (45+ years) > under 15

46. MCQ
Q. In a HIV infected child which vaccine should not be given:
a. DPT
b. OPV
c. Hepatitis B
d. Typhoid vaccine

47. Ans: b (OPV)

48. MCQ
Q. M/C subtype of HIV in Nepal and India is:
a. HIV-A
b. HIV-B
c. HIV-C
d. Non of the above

49. Ans: C (HIV-C)

50. MCQ
Q. The most common mode of HIV transmission in Nepal and
India is:
a. Blood transfusion
b. Mother to child transmission
c. Sexual transmission
d. Use of unsterile syringes and needle

51. Ans: C (Sexual transmission)
Route of transmission Percentage of total
case
Efficiency of route
Sexual transmission 90% 0.01- 1%
Mother to child transmission 05% 30%
Sharing needles/ Syringes 02% 0.3%
Blood and blood product 01% > 90%

52. MCQ
Q. The commonest mode of transmission of AIDS in Nepal
and India ( in Descending order) is:
a. Transplacental, Homosexual, Heterosexual
b. Homosexual, Heterosexual, Transplacental
c. Heterosexual, Transplacental, Homosexual
d. Heterosexual, Homosexual, Transplacental

53. Ans: C (Heterosexual, Transplacental, Homosexual)
Route of transmission Percentage of total
case
Efficiency of route
Sexual 87% 0.01- 1%
Mother to child transmission 05% 30%
Sharing needles/ Syringes 02% 0.3%
Blood and blood product 01% > 90%

54. MCQ
Q. Major signs for AIDS case definition according to WHO are
all except:
a. Prolong fever for >1 month
b. Prolong cough for >1 month
c. Chronic diarrhoea >1 month
d. Weight loss >10%

55. Ans: b (Prolong cough for >1 month)

56. MCQ
Q. HIV transmission Mother to Child can be stopped by all
except:
a. Caesarean Section
b. Vitamin A Supplementation
c. Stopping Breast feeding
d. Zidovudine to mother antenatal and newborn after delivery

57. Ans: b (Vitamin A Supplementation)
Vitamin A Supplementation neither increase nor decrease the risk of
HIV

58. MCQ
Q. HIV post exposure prophylaxis should be started with
in:
a. 24 hours
b. 48 hours
c. 72 hours
d. 6 hours

59. Ans: c (72 hours)

60. .
Bisexual men: Bisexual men are individuals who are attracted to both
men and women.
Homosexual: Homosexuality is a natural variation in human sexuality
where individuals are emotionally and/or sexually attracted to people
of the same gender.
Heterosexual: Heterosexuality refers to a sexual orientation in which
an individual is primarily or exclusively attracted to people of a
different gender.

61. .
Q why prevalence of HIV/ AIDS is high in Heterosexual than
Homosexual???
Vaginal intercourse, which is common in heterosexual
relationships, carries a higher risk of HIV transmission
compared to some sexual activities among homosexual
individuals.

62. .
Q. Why aids prevalence is high in Military and police?
High-Risk Behaviors: Some military and police environments may
have factors that increase the risk of HIV transmission, such as
multiple sexual partners, unprotected sex, drug use, and exposure to
infected blood through injuries or medical procedures.
Mandatory Testing: Some military forces may implement mandatory
HIV testing as part of routine health screenings, which can lead to the
identification of more cases compared to civilian populations where
testing is voluntary.

63. .
Non-Hodgkin lymphoma (NHL): Non-Hodgkin lymphoma
(NHL) and Hodgkin lymphoma (HL) are two types of cancers
that affect the lymphatic system,
CD4: are A/K/A T cells/T helper cells of immune system. CD4
cells fight off infections and keep you from getting sick.
Kaposi sarcoma: Cancer of skin or mucous membrane.

64. .
Herpes zoster infection: A/K/A shingles, is caused by reactivation of
Varicella zoster virus(VZV), the same virus that causes varicella
(chickenpox)
Herpes simplex infection: A/K/A herpes, is caused by herpes simplex
virus. Two types: HSV1 and HSV2
Cryptococcal meningitis: an infection caused by the fungus
Cryptococcus after it spreads from the lungs to the brain.

65. .
• During the window period of HIV infection, which is the time between
initial infection and the development of detectable antibodies,
standard antibody tests may not be able to detect the virus.
• However, during this window period, it is possible to detect the virus
itself using nucleic acid tests (NATs) such as polymerase chain reaction
(PCR) tests. These tests directly detect the genetic material of the
virus (RNA) rather than relying on the presence of antibodies. NATs
are highly sensitive and can detect HIV infection within days to weeks
after exposure, much earlier than antibody tests.

66. The End