The human immunodeficiency virus (HIV) is a lentivirus (a subgroup of retrovirus) that causes HIV infection and over time acquired immunodeficiency syndrome (AIDS).
At the end of the session, the students shall be able to
Describe the HIV AIDS introduction, epidemiology of HIV AIDS, diagnosis of HIV AIDS, treatment of HIV AIDS and prevention control of HIV AIDS.
Polio: flaccid paralysis, major and minor
disease, fecal-oral
Coxsackievirus A: vesicular diseases,
meningitis; coxsackievirus B (body):
pleurodynia, myocarditis
Other echovirus and enteroviruses: like
coxsackievirus
Rhinoviruses: common cold, acid labile, does
not replicate above 33° C
Biology, Virulence, and Disease
• Small size, icosahedral capsid, positive RNA
genome with terminal protein
• Genome is sufficient for infection
• Encodes RNA-dependent RNA polymerase,
replicates in cytoplasm
Enteroviruses
• Capsid virus resistant to inactivation
• Disease due to lytic infection of important
target tissue
• Polio: cytolytic infection of motor neurons of
anterior horn and brainstem, paralysis
• Coxsackievirus A: herpangina, hand-foot-
and-mouth disease, common cold,
meningitis
• Coxsackievirus B: pleurodynia, neonatal
myocarditis, type 1 diabetes
Rhinoviruses
• Acid labile and cannot replicate at body
temperature
• Restricted to upper respiratory tract
• Common cold
Epidemiology
• Enteroviruses transmitted by fecal-oral route
and aerosols
• Rhinoviruses transmitted by aerosols and
contact
Diagnosis
• Immune assays (ELISA) or RT-PCR genome
analysis of blood, CSF, or other relevant
sample
Treatment, Prevention, and Control
• OPV and IPV polio vaccines
P
icornaviridae is one of the largest families of viruses and
includes some of the most important human and animal
viruses (Box 46-1). As the name indicates, these viruses are
small (pico) ribonucleic acid (RNA) viruses that have a
naked capsid structure. The family has more than 230
members divided into nine genera, including Enterovirus,
Rhinovirus, Hepatovirus (hepatitis A virus; discussed in
Chapter 55), Cardiovirus, and Aphthovirus. The enterovi-
ruses are distinguished from the rhinoviruses by the stabil-
ity of the capsid at pH 3, the optimum temperature
for growth, the mode of transmission, and their diseases
HIV AIDS Lecture Presented by me in my Community Dentistry Class, BIBI ASIFA DENTAL COLLEGE, SHAHEED MOHTARMA BENAZIR BHUTTO MEDICAL UNIVERSITY LARKANA, SINDH, PAKISTAN.
A detailed description of HIV covering virology, morphology, pathogenesis, clinical stages and manifestations, laboratory diagnosis, and diagnostic strategy, and therapeutic options and prevention.
The human immunodeficiency virus (HIV) is a lentivirus (a subgroup of retrovirus) that causes HIV infection and over time acquired immunodeficiency syndrome (AIDS).
At the end of the session, the students shall be able to
Describe the HIV AIDS introduction, epidemiology of HIV AIDS, diagnosis of HIV AIDS, treatment of HIV AIDS and prevention control of HIV AIDS.
Polio: flaccid paralysis, major and minor
disease, fecal-oral
Coxsackievirus A: vesicular diseases,
meningitis; coxsackievirus B (body):
pleurodynia, myocarditis
Other echovirus and enteroviruses: like
coxsackievirus
Rhinoviruses: common cold, acid labile, does
not replicate above 33° C
Biology, Virulence, and Disease
• Small size, icosahedral capsid, positive RNA
genome with terminal protein
• Genome is sufficient for infection
• Encodes RNA-dependent RNA polymerase,
replicates in cytoplasm
Enteroviruses
• Capsid virus resistant to inactivation
• Disease due to lytic infection of important
target tissue
• Polio: cytolytic infection of motor neurons of
anterior horn and brainstem, paralysis
• Coxsackievirus A: herpangina, hand-foot-
and-mouth disease, common cold,
meningitis
• Coxsackievirus B: pleurodynia, neonatal
myocarditis, type 1 diabetes
Rhinoviruses
• Acid labile and cannot replicate at body
temperature
• Restricted to upper respiratory tract
• Common cold
Epidemiology
• Enteroviruses transmitted by fecal-oral route
and aerosols
• Rhinoviruses transmitted by aerosols and
contact
Diagnosis
• Immune assays (ELISA) or RT-PCR genome
analysis of blood, CSF, or other relevant
sample
Treatment, Prevention, and Control
• OPV and IPV polio vaccines
P
icornaviridae is one of the largest families of viruses and
includes some of the most important human and animal
viruses (Box 46-1). As the name indicates, these viruses are
small (pico) ribonucleic acid (RNA) viruses that have a
naked capsid structure. The family has more than 230
members divided into nine genera, including Enterovirus,
Rhinovirus, Hepatovirus (hepatitis A virus; discussed in
Chapter 55), Cardiovirus, and Aphthovirus. The enterovi-
ruses are distinguished from the rhinoviruses by the stabil-
ity of the capsid at pH 3, the optimum temperature
for growth, the mode of transmission, and their diseases
HIV AIDS Lecture Presented by me in my Community Dentistry Class, BIBI ASIFA DENTAL COLLEGE, SHAHEED MOHTARMA BENAZIR BHUTTO MEDICAL UNIVERSITY LARKANA, SINDH, PAKISTAN.
A detailed description of HIV covering virology, morphology, pathogenesis, clinical stages and manifestations, laboratory diagnosis, and diagnostic strategy, and therapeutic options and prevention.
1
Final Course Project Outline
Final Course Project Outline: The Role of Pharmaceutical Industry in
the Era of Climate Change
Ruinan Yang
King Graduate School, Monroe College
MG630: Organizational Behavior and Leadership in the 21st Century
Dr. Judith Riggs
November 20, 2021
2
Final Course Project Outline
I. Introduction
a. Environmental, Social and Governance (ESG)
b. Climate change and sustainable development
II. Case Study on Pharmaceutical Companies with Notable ESG
Scores
a. What is ESG score?
b. Case study: Boehringer Ingelheim, a German pharmaceutical company
III. Critical Analysis of The Role of Pharmaceutical Industry on Climate Change
IV. Conclusion: My Role as a Leader
V. Reference
HIV AND AIDS
TITLE
Prepared by:
Teacher :
OUTLINE:
Introduction
Pathogenesis
Risk factors
Clinical Manifestation
Diagnosis
History taking
Physical examination
Laboratory studies
VI. Infection control Policies
VII. Nursing Diagnosis And Intervention
VIII. Summary
OBJECTIVES:
At the end of this lecture, students will be able to:
1. Know and understand what is HIV AND AIDS.
2. Understand the process how disease develop.
3. Practice how to deal and take care a patient according to infection control sets of guidelines.
4. Identify Nursing diagnosis and make interventions that help promote patient care and comfort.
INTRODUCTION
The human immunodeficiency virus (HIV) targets the immune system and weakens people's defense against many infections and some types of cancer that people with healthy immune systems can fight off. As the virus destroys and impairs the function of immune cells, infected individuals gradually become immunodeficient. Immune function is typically measured by CD4 cell count.
The most advanced stage of HIV infection is acquired immunodeficiency syndrome (AIDS), which can take many years to develop if not treated, depending on the individual. AIDS is defined by the development of certain cancers, infections or other severe long-term clinical manifestations.
Since HIV was first identified almost 30 years ago, remarkable progress has been made in improving the quality and duration of life for people living with HIV disease.
HIV or human immunodeficiency virus and acquired immunodeficiency syndrome is a chronic condition that requires daily medication.
HIV- 1 is a retrovirus isolated and recognized as the etiologic agent of AIDS.
HIV-2 is a retrovirus identified in 1986 in AIDS patients in West
HIV
AIDS
is defined by the Centers for Disease Control and Prevention (CDC) as any person with HIV infection and a CD4 lymphocyte count below 200 cells/mcL (or a CD4 count below 14%) or having an AIDS-indicator condition
The primary route of transmission of the HIV virus is by entering the mucosal surface (predominantly sexual contact).
Following mucosal entry, the virus binds to peripheral circulating T cells and macrophages (e.g., dendritic cells) that express the CD4 and CCR5 receptors.
As the dis ...
What is HIV? How an HIV infections advances to AIDS? What is AIDS? What are the medicine to stop HIV replication? What are the diagnostic tests? What are the medical managements for AIDS? What are the categories of HIV infection? Symptoms of HIV infection? What should be the nurse care plan for an AIDS patient? How can people prevent HIV infection? All these questions are answered in this presentation.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
1. HIV INFECTION AND AIDS
Dr. Navin Adhikari
IM Second Year Resident
NAMS
2. EPIDEMOLOGY
• AIDS was first recognized in the United States in 1981.
• Globally, 38.0 million people were living with HIV in 2019,
with 1.7 million newly infected in same year. 690000 people
died from AIDS-related illnesses in 2019. 26 million people
were accessing antiretroviral therapy as of the end of June
2020.
• In Nepal 28,500 people were living with HIV in 2019 with
790 new infection. 19410 were under ART as of July, 2020.
3. ETIOLOGIC AGENT
• HIV is the etiologic agent of AIDS, belongs to human
retroviruses (Retroviridae) and the subfamily of lentiviruses.
• HIV-1 and HIV-2 are strains. HIV-1 is the cause of the global
HIV pandemic, while HIV-2, which causes a similar illness to
HIV-1 but progresses more slowly and is less transmissible, is
restricted mainly to western Africa.
• HIV-2 has only 40% structural homology with HIV-1.
• On the basis of DNA sequencing, HIV-1 is divided into three
groups, which probably represent three zoonotic transfer
from the chimpanzee: M (‘major’, worldwide distribution), O
(‘outlier’) and N (‘non-major and non-outlier’).
4. MORPHOLOGY OF HIV
• HIV virion is an icosahedral structure
containing numerous external spikes
formed by the two major envelope
proteins, the external gp120 and the
transmembrane gp41.
• Two molecules of single stranded RNA
within the nucleus.
• The reverse transcriptase polymerase
converts viral RNA into DNA (a
characteristic of retroviruses).
• The protease includes integrase (p32
and p10).
• The p24 is core protein, its levels can
be used to monitor HIV disease.
• P17 is the matrix protein.
5. HIV GENOME
• Genes that encode the structural proteins of the virus:
Gag encodes the proteins that form the core of the virion
(including p24 antigen)
Pol encodes the enzymes responsible for protease processing
of viral proteins, reverse transcription, and integration.
Env encodes the envelope glycoproteins.
• It also contains at least six other regulatory genes (tat, rev,
nef, vif, vpr, and vpu) which code for proteins involved in the
modification of the host cell to enhance virus growth and the
regulation of viral gene expression.
6. HIV ENTRY AND REPLICATION
• The HIV binds to host CD4 molecules via the envelope
glycoprotein gp120.
• Gp120 binding to secondary receptors (chemokine receptors,
CXCR4, CCR5) and subsequent conformational change results
infusion between gp41 and the cell membrane.
• Entry of the viral capsid is followed by uncoating of RNA.
• DNA copies are made from both RNA templates (reverse
transcriptase).
• In the nucleus the virally encoded DNA is inserted into the
host genome (integration).
• Regulatory proteins control transcription (a process in which
an RNA molecule is synthesized from a DNA template).
• The virus is reassembled in the cytoplasm and budded out
from the host cell.
7.
8. HIV INFECTION
HIV infection can be divided into the following stages:
1. Viral transmission
2. Acute HIV infection (also called primary HIV infection or
acute seroconversion syndrome)
3.Chronic HIV infection, is subdivided into :
•Chronic infection, without AIDS
•AIDS, characterized by a CD4 cell count <200 cells/microL
•Advanced HIV infection, characterized by a CD4 cell count
<50 cells/microL
9. VIRAL TRANSMISSION
• HIV is transmitted by sexual
contact, by exposure to
blood and blood products.
• Vertical transmission to
infants of HIV-infected
mothers (who may be
infected in utero, perinatally
or via breastfeeding).
• The risk of contracting HIV
after exposure to infected
body fluid is dependent on
the integrity of the exposed
site, the type and volume of
fluid, and the level of
viraemia in the source
person.
10.
11. ACUTE HIV INFECTION
• 50–70% of individuals with HIV infection experience an acute
clinical syndrome within 3–6 weeks after primary infection.
• Symptomatic acute HIV infection is characterized by fever,
lymphadenopathy, sore throat, rash, myalgia/arthralgia,
diarrhea, and headache (often described as a mononucleosis-
like illness).
• Symptoms usually persist for one to several weeks and
gradually subside as an immune response to HIV develops
and the levels of plasma viremia decrease
• The differential diagnosis of primary HIV includes acute EBV,
primary CMV infection, rubella, primary toxoplasmosis and
secondary syphilis.
12.
13. CHRONIC HIV INFECTION, WITHOUT AIDS
• Chronic HIV infection is characterized by relative stability of
the viral level and a progressive decline in the CD4 cell count.
• In the absence of antiretroviral therapy (ART), the average
time from HIV acquisition to a CD4 cell count <200
cells/microL is approximately 8 to 10 years.
• Persons with HIV at this stage of disease can have generalized
lymphadenopathy on physical examination. This is referred to
as "persistent generalized lymphadenopathy" when the
enlarged lymph nodes involve at least two noncontiguous
sites other than inguinal nodes for more than three to six
months without an alternative explanation.
• Some patients experience generalized/nonspecific symptoms
and signs such as fatigue, sweats, or weight loss.
15. AIDS AND ADVANCED HIV INFECTION
• AIDS is chronic HIV infection with CD4 cell count <200
cells/microL or the presence of any AIDS-defining condition
regardless of the CD4 cell count.
• The term advanced HIV infection is often used to refer to
infection when the CD4 cell count is <50 cells/microL.
• When patients achieve immune reconstitution (eg, increase in
the CD4 cell count to >200 cells/microL) with antiretroviral
therapy (ART) and have no AIDS-defining conditions, they are
no longer considered to have AIDS.
16. AIDS-DEFINING CONDITIONS
• AIDS-defining conditions are illnesses that occur more
frequently or more severely because of immunosuppression.
• These include mainly opportunistic infections but also
certain malignancies as well as conditions without clear
alternative etiology thought to be related to uncontrolled HIV
infection itself.
• The AIDS-defining conditions listed by the United States
Centers for Disease Control and Prevention (used in high-
income countries) and the World Health Organization criteria (
used in low- and middle-income countries) vary slightly.
19. Clinical Features
Direct consequence of HIV infection
1. AIDS dementia complex (ADC), sensory polyneuropathy and
aseptic meningitis.
2. Anaemia of chronic HIV infection is usually mild,
normochromic and normocytic
3. HIV-associated nephropathy
4. Symptomatic HIV-associated cardiomyopathy
5. HIV wasting syndrome
6. HIV cholangiopathy
21. DIAGNOSIS
• The detection of HIV infection depends on the presence of
antibodies and virus component, which depends on the days
since initial infection.
• Eclipse period- This period refers to the period of about 7–10
days following HIV infection, during which currently available
assays cannot detect any marker of HIV infection.
• Window period. The period between HIV infection and the
detection of HIV1/2 antibodies using immunological assays is
the window period.
• Recent infection. Any infection detected within six months of
infection is considered recent infection.
22. Diagnostic tests
1. Detection of IgG antibody to envelope components - based
on ELISA techniques, which may be confirmed with Western
blot assays.
2. IgG antibody to p24 (anti-p24)
3. Genome detection assays- Nucleic acid-based assays that
amplify and test for components of the HIV genome, aid
diagnosis of HIV in the babies of HIV-infected mothers or in
situations where serological tests may be inadequate, such
as in early infection.
4. Viral p24 antigen (p24ag)
5. Fourth generation HIV test- detect both HIV antibody and
HIV p24 antigen.
23.
24. National HIV testing algorithm
• A three-test HIV testing algorithm is adopted.
• The first assay (A1) should be the most sensitive, and the
second and third tests should have higher specificity.
27. ART INITIATION
• National Centre for AIDS and STI Control (NCASC) has adopted
the WHO “TREAT ALL” policy since the revision of the national
HIV testing and treatment guidelines in 2017.
• The goals of ART are to reduce the viral load to an
undetectable level for as long as possible , improve the CD4
count to over 200 cells/mm3 so that severe HIV-related
disease is unlikely, improve the quantity and quality of life
without unacceptable drug toxicity and reduce HIV
transmission.
• ART should be initiated in all adults living with HIV, regardless
of WHO clinical stage and at any CD4 cell count.
• A comprehensive clinical assessment should be done as
baseline status and to rule out OIs.
28. • In patients with major opportunistic infections, ART should
generally be started within 2 weeks, with two important
exceptions: in cryptococcal meningitis, ART should be
deferred for 5 weeks, as earlier initiation increases the risk of
death; and in tuberculosis, ART should be deferred until 8
weeks (except if the CD4 count is < 50 cells/mm3 ), as earlier
initiation increases the risk of the immune reconstitution
inflammatory syndrome.
31. ANTIRETROVIRAL REGIMEN
• In 2018, WHO published interim guidelines recommending
dolutegravir (DTG)- containing regimens as the preferred first-
and second-line ART regimens for PLHIV.
• In 2019 updated systematic review showed first-line regimen
of DTG combined with two nucleoside reverse transcriptase
inhibitors (NRTIs) leads to higher viral suppression and lower
risk of discontinuing treatment and developing HIV drug
resistance compared with efavirenz (EFV)-based regimens
among treatment-naive adults.
• DTG has other advantages over EFV, including lower potential
for drug–drug interactions, more rapid viral suppression and a
higher genetic barrier to developing HIV drug resistance
(HIVDR). DTG is also active against HIV-2 infection, which is
naturally resistant to EFV.
32.
33. MONITORING
• Follow up is required for opportunistic infections and/or
immune reconstitution inflammatory syndrome (IRIS), as well
as early adverse drug reactions (ADR), such as drug
hypersensitivity and treatment treatment failure.
• Treatment failure is defined as persistently detectable Viral
Load (VL) exceeding 1000 copies/mL in two consecutive VL
measurements within a 3-month interval with adherence
support between measurements after 6 months of starting a
new ART regimen.
• The national programme recommends VL testing and CD4
count at 6 months and 12 months and only VL for stable
patients every 12 months. CD4 testing is stopped in virally
supressed patients
34. CD4 COUNT MONITORING
• Long-term CD4 cell count monitoring adds little value in
people who are stable on ART.
• However, CD4 count is important for assessing the baseline
risk of disease progression, particularly for individuals
presenting with advanced disease, and decisions regarding
starting and stopping prophylaxis for OIs.
• CD4 cell count measurement may also be important for
people who are failing ART and for unstable patients.
35.
36.
37. CLINICAL, IMMUNOLOGICAL AND
VIROLOGICAL FAILURE
• Clinical failure - New or recurrent clinical event indicating
severe immunodeficiency (WHO clinical stage 4 condition)
after 6 months of effective treatment.
• Immunological failure - CD4 count at or below 250 cells/ mm³
following clinical failure b or Persistent CD4 levels below 100
cells/mm³.
• Virological failure - Viral load above 1000 copies/mL based on
two consecutive viral load measurements in 3 months, with
adherence support following the first viral load test.
38. ARV TOXICITY
• Lamivudine- Flare of hepatitis in HBVco-infected patients
• Zidovudine- Anemia, granulocytopenia, myopathy, lactic
acidosis,
• Abacavir- Hypersensitivity reaction In HLA-B5701, ever, rash,
nausea, vomiting, malaise or fatigue, and loss of appetite
• Tenofovir- Renal toxicity, osteomalacia, flare of hepatitis in
HBVco-infected patients
• Nevirapine- Skin rash, hepatotoxicity
• Etravirine- Rash, nausea, hypersensitivity reactions
• Dolutegravir- Insomnia, headache, hypersensitivity reactions,
hepatotoxicity
• Efavirenz- Rash, dysphoria, elevated liver function tests,
drowsiness
39.
40.
41. CHEMOPROPHYLAXIS
Co-trimoxazole primary prophylaxis is started in
1. HIV-infected persons with a CD4 count < 350/mm3
2. all adults with severe and advanced HIV disease (WHO
stage 3 or 4)
3. In settings where malaria and/or severe bacterial infections
are highly prevalent regardless of CD4 cell count or WHO
stage.
4. all HIV-infected patients with active TB disease regardless of
CD4 cell count.
• Co-trimoxazole prophylaxis may be discontinued in adults
with HIV who are clinically stable on ART with evidence of
immune recovery and viral suppression.
42. • A macrolide (azithromycin or clarithromycin) is recommended
to prevent Mycobacterium avium complex ( MAC )in patients
with a CD4 count below 50 cells/mm3 , which can be
discontinued once the CD4 count has risen to over 100
cells/mm3 on ART.
• Serum cryptococcal antigen test should be done in patients
with a CD4 count below 100 cells/mm3 . If this is positive,
pre-emptive therapy with fluconazole should be commenced.
43. HIV-TB COINFECTION
• Tuberculosis is the most frequent life-threatening OI
• PLHIV are around 20 times more likely to develop TB disease
than those without HIV infection
• TB preventive treatment (TPT) is an important intervention
for preventing and reducing active TB among PLHIV.
• Active TB must be excluded before beginning TB preventive
treatment.
• The 2020 update of WHO guidelines on TPT makes 9H, 6H, 4R,
3HP, 3HR, 1HP as options for use across all disease burden
settings.
• The national HIV programme currently recommends the 6-
month isoniazid (6H) regimen for TPT.
45. TB management in PLHIV
• All HIV-infected people with diagnosed active TB should be
put on TB treatment immediately.
• Antituberculosis treatment (ATT) should be initiated first,
followed by ART as soon as possible within the first 8 weeks
of treatment (2 weeks, if CD4 count < 50 cells/mm3).
• IRIS may occur after initiation of ART. Both ART and TB
treatment should be continued while managing IRIS.
• DTG 50 mg BID (instead of 50 mg once daily) should be used
for patients using rifampicin-based TB drugs.
• In case a patient on a PI-based regimen needs to start ATT, the
dose of PI should be doubled.
46. Immune reconstitution inflammatory
syndrome (IRIS)
• The term "immune reconstitution inflammatory syndrome"
(IRIS) describes a collection of inflammatory disorders
associated with paradoxical worsening of preexisting
infectious processes following the initiation of antiretroviral
therapy (ART) in HIV-infected individuals.
• It occurs in 10–30% of patients initiating ART, usually within
the first 4–8 weeks but can occur up to six months.
• After a patient starts ART, IRIS may manifest as a worsening of
previously diagnosed disease, termed paradoxical IRIS, or as
the appearance of a previously undiagnosed disease, termed
unmasking IRIS.
47. • IRIS should be considered only when the presentation
cannot be explained by a new infection, expected
course of a known infection or drug toxicity.
• IRIS should be diagnosed by excluding: active OIs,
treatment failure, side-effects of ARVs, ARV resistance
• The most serious and life-threatening forms of
paradoxical IRIS are for TB, cryptococcosis, Kaposi
sarcoma and herpes zoster.
• IRIS is generally self-limiting, and interruption of ART is
rarely indicated. Glucocorticoids are often used for
more severe IRIS manifestations.
48. Prevention of HIV
• Pre-exposure prophylaxis- daily tenofovir plus emtricitabine
has been shown to reduce the risk of HIV acquisition in
people at ongoing high risk and is well tolerated.
• Post-exposure prophylaxis- Start as soon as possible,
preferably within 2 hours and maximum within 72 hours of
exposure. The duration of treatment is 28 days. The choice of
PEP drugs should be based on the country’s first-line ART
regimen to treat HIV infection. Get a baseline HIV antibody
test and monitor for seroconversion at 6 weeks, 3 months and
6 months after exposure.
49.
50. References
• Harrison's Principles of Internal Medicine, 20th
Edition.
• Davidson Principles and Practice of medicine
23rd Edition.
• Kumar & Clark's Clinical Medicine, 7th Edition
• Manson’s Tropical Disease, 23ed
• National-HIV-Testing-Guidelines-May-10-2020,
Nepal
• Uptodate
• https://www.unaids.org/en