5. 5
Epidemiology
Since the first cases of AIDS were identified
in 1981, close to 30 million people have died
as a result of HIV infection. This makes AIDS
one of the most destructive epidemics in
recorded history. The epidemic remains
extremely dynamic, and no country in the
world is unaffected.
In 2009, HIV infected approximately 33
million people worldwide. Approximately
68% of these cases are in sub-Saharan
6. 6
Epidemiology
In 2009 alone, approximately 1.8 million
people died from AIDS and 2.6 million
people were newly infected with HIV.
Most of these infections were acquired
through heterosexual transmission.
As of December 2009, women accounted for
52% of all people living with HIV worldwide.
Persons aged 15 to 24 years accounted for
approximately 40% of new HIV infections
worldwide.
7. 7
HIV
Human Immunodeficiency Virus
H = Infects only Human beings
I = Immunodeficiency virus
weakens the immune system and
increases the risk of infection
V = Virus that attacks the body
8. 8
HIV virus infection
The HIV Virus:
Invades the helper T cells (CD4
cells) in the body of the host
(defense mechanism of a person).
Is threatening a global epidemic.
Is preventable & manageable but is
NOT curable.
9. 9
AIDS
Acquired Immune Deficiency
Syndrome
A = Acquired, not inherited
I = Weakens the Immune system
D = Creates a Deficiency of CD4+
cells in the immune system
S = Syndrome, or a group of
illnesses taking place at the same
time
10. 10
HIV and AIDS
When the immune system becomes
weakened by HIV, the illness
progresses to AIDS
Some blood tests, symptoms or
certain infections indicate
progression of HIV to AIDS
11. 11
HIV and AIDS
AIDS Predisposes our body to other
opportunistic infections.
Opportunistic infections and malignancies that
rarely occur in the absence of severe
immunodeficiency (e.g. Pneumocystis
pneumonia, central nervous system lymphoma).
Persons with positive HIV serology who have
ever had a CD4 lymphocyte count below 200
cells/mcL or a CD4 lymphocyte percentage
below 14% are considered to have AIDS.
12. 12
Viral Genome
enveloped virus of the
lentivirus subfamily of
retroviruses.
Retroviruses transcribe
RNA to DNA.
13. 13
Viral Genome
Two viral strands of RNA found in core
surrounded by protein outer coat.
Outer envelope contains a lipid matrix within
which specific viral glycoproteins are
imbedded.
These knob-like structures responsible for
binding to target cell.
15. 15
Types
HIV –1
Group M- 10 subtypes, 90% of all cases
world wide
Group O (Now able to be detected with most
routine HIV antibody tests)
HIV – 2
1% of cases world wide
Slower progression
West Africa
79 cases in US, but most were African born
16. 16
HIV-1 and HIV-2
Transmitted through the same routes
Associated with similar opportunistic
infections
HIV-1 is more common worldwide
HIV-2 is found in West Africa,
Mozambique, and Angola
HIV-2 is less easily transmitted
HIV-2 is less pathogenic
Duration of HIV-2 infection is shorter
17. 17
Overview of Pathophysiology
HIV destroys body’s immune system by
selectively attacking T-4 Lymphocytes,
also macrophages & B cells
HIV indirectly affects CNS by neurotoxins
produced by the infected macrophages
As CD4+ count declines, body becomes
more susceptible to opportunistic infections
19. 19
Risk Factors
I. Sexual Practices that promote
Disease Transmission
Under the influence of drugs
Multiple partners
Sores in genital area
20. 20
Risk Factors
II. Exposure to blood/body fluids
Administration of blood or blood products
Transplantation of tissue or organs
Implantation of infected semen
III. Use of injected drugs(drug abuse)
IV. Occupational exposure
o Accidental needle stick
V. HIV-infected mothers to infants during
pregnancy, delivery, or breastfeeding
21. 21
Other Risk Factors
Ulcerative STD’s
o Syphilis
o Herpes simplex
o Chancroid
Non-ulcerative STD’s
o Gonorrhea
o Chlamydia
o Trichomoniasis
24. 24
Primary infection
(Acute HIV)
Most develop a flu-like illness within a month
or two after the virus enters the body.
may last for a few weeks.
Fever , Headache ,Muscle aches and joint pain
Rash
Sore throat and painful mouth sores
Swollen lymph glands, mainly on the neck
These symptoms can be so mild that you might
not even notice them.
26. 26
Clinical latent infection
(Chronic HIV)
Person is HIV+ but asymptomatic
lasts for several years (subclinical)
o viral replication occurring up to 10 billion
virons per day
Chronic lymphadenopathy
27. 27
Early Symptomatic
Disease
CD4 counts drop to 500-600 cells/ml
Symptoms:
o recurrent fever, night sweats,
malaise, headache
Physical findings:
o lymphadenopathy, spleen enlarged,
rash, weight loss
28. 28
Symptomatic HIV infection
Fever
Fatigue
Swollen lymph nodes — often one of the
first signs of HIV infection
Diarrhea
Weight loss
Oral yeast infection (thrush)
Shingles (herpes zoster)
29. 29
Progression to AIDS
Average time between infection and AIDS
was 10 years
time has increased with new protease
inhibitors
CD4 count <200/mm
majority of manifestations due to
opportunistic infections due to
immunosuppression rather than direct
injury by virus
30. 30
Some symptoms of AIDS
Soaking night sweats
Recurring fever
Chronic diarrhea
Persistent white spots or unusual lesions
on your tongue or in your mouth
Persistent, unexplained fatigue
Weight loss
Skin rashes or bumps
34. 34
Other Complications
Wasting syndrome.
Neurological complications. such as
confusion, forgetfulness, depression,
anxiety and difficulty walking and
dementia complex.
Kidney disease.
37. 37
Laboratory diagnosis
Evidence of HIV infection
Virus isolation
Measurement of viral nucleic acid
Detection of viral antigen
Detection of viral antibody
Recognition of immunodeficiency
CD4+ T cell count
Recognition of AIDS related disease
38. 38
Laboratory diagnosis
A. Virus isolation:
HIV can be cultured from lymphocytes in
peripheral blood.
B. Detection of viral Nucleic Acid :
By RT-PCR
Branched-chain DNA
39. 39
Laboratory diagnosis
C. Detection of HIV Antigen
Detect the presence of HIV in blood
P24 antigen tests measure one of the
proteins found in HIV
D. Detection of antibody
measuring antibodies by ELISA.
Western Blot assay
40. 40
Laboratory diagnosis
Window period:
Early in infection when the blood of an
infected person can contain HIV but antibodies
are not detectable.
Seroconversion:
Development of evidence of antibody
response to a disease.
Viral Load:
The amount of HIV in the blood.
41. 41
Window Period
A period of 4-6 weeks after HIV
exposure when antibodies to HIV are
not detectable in the blood
A person at high risk who initially
tests negative should be retested at 3
months to confirm diagnosis
46. 46
Maintain Health
Baseline & q 6-12 mos.
CBC
Chemistries
Annual Screening
TB Skin tests/Chest x-ray
Pregnancy
Hep A & B to determine need for
immunization; Hep B and/or C co-infection
Testing for pathogens known to cause
opportunistic infections
CD4 & Viral load testing (every 3-6 months)
47. 47
Antiretroviral therapy
There's no cure for HIV/AIDS, but many
different drugs are available to control the
virus called Antiretroviral therapy, or ART.
Each class of drug blocks the virus in
different ways.
ART is now recommended for everyone,
regardless of CD4 T cell counts.
It's recommended to combine three drugs
from two classes to avoid creating drug-
resistant strains of HIV.
48. 48
Initiate & maintain ART
Viral load is 5000- 10,000
Evidence of clinical or immunologic
deterioration
(CD4 counts <500 mm3)
Viral load > 20,000 even without
evidence of clinical deterioration
49. 49
When to start treatment
Everyone with HIV infection, regardless of
CD4 T cell count, should be offered antiviral
medication.
HIV therapy is particularly important for the
following situations:
severe symptoms.
Presence of an opportunistic infection.
CD4 T cell count is under 350.
Pregnant.
HIV-related kidney disease.
Presence of hepatitis B or C.
53. 53
Antiretroviral Agents
Reverse Transcriptase Inhibitors
i. Nucleoside reverse transcriptase inhibitors
(NsRTIs)Incorporate into viral DNA
terminating its construction
E.g. Lamivudine - Abacavir
ii. Non-Nucleoside Reverse Transcriptase
Inhibitors (NNRTI’s)
Action is similar to NRTI’s; bind directly to
reverse transcriptase
E.g. Nevirapine
54. 54
Antiretroviral Agents
Reverse Transcriptase Inhibitors
iii. Nucleotide Reverse Transctriptase
Inhibitors (NtRTI’s)
E.g. Tenofovir
56. 56
Antiretroviral Agents
Integrase inhibitors
work by disabling a protein called
integrase, which HIV uses to insert
its genetic material into CD4 T
cells.
E.g raltegravir
57. 57
Antiretroviral Agents
Regimen
All recommended regimens for initial treatment
contain an NNRTI, a ritonavir-boosted PI, or an
INSTI in combination with tenofovir (NtRTI) and
emtricitabine (NRTI).
The preferred agents are as follows:
1. NRTI/NtRTI combination: Tenofovir and
emtricitabine
2. PIs: Atazanavir/ritonavir
3. NNRTI: Efavirenz
4. INSTI: Raltegravir
58. 58
Evaluation of treatment
Criteria
o HIV RNA (viral load) in blood
o Count of T cells
o Appropriate clinical response
Treatment Failure
o viral load with low T-cell count
o Clinical deterioration
o New opportunistic infections
59. 59
Strategies to maximize
benefits/minimize toxicities
1) Alternating therapies
2) Combination therapy:
Demonstrated more beneficial than
monotherapy
i. Decreased emergence of resistance
ii. Decreased risk of toxicity
60. 60
Adherence
Major cause of resistance is sub-therapeutic
dosing :
failure to take prescribed dose
failure to take prescribed dose at prescribed
intervals
interactions with other drugs that decrease
blood levels of ART
62. 62
HIV infected Pregnant
Female
Standard antiretroviral therapy should
be used in the HIV infected pregnant
female
Possible risk of premature delivery
(highest in non-treated individuals)
64. 64
Prevention of HIV
Infections
I. Vaccines
Pre-clinical work in animals is promising
II. Education, Counseling & Behavior mod.
III. Free needles for IV drug users
IV. Improved blood supply
Greatly decreased risk for hemophiliacs
V. Screening and treating pregnant women
65. 65
Prevent Opportunistic
Infection
Pneumocystosis jirovecii Pneumonia (80%) at least
once
Prophylaxis when CD4+ count < 200mm³
o Dapsone
o TMP-SMX
Mycobacterium avium complex (60%) found to
have active infection at death
Prophylaxis when CD4+ count < 50 mm³
+PPD with ø CM’s of active Tb
o Prophylaxis with INH-9 mos
o Pyridoxine to prevent peripheral neuropathy