HIV-infection, AIDS.

1. HІV-infection
HIV-associated infections
and invasions
“To know AIDS, its necessary to know all medicine”
ASSOC. PROF., DR. ANIUTA SYDORCHUK MD, PHD
DEPARTMENT OF INTERNAL MEDICINE & INFECTIOUS DISEASES
HIGHER STATE EDUCATIONAL ESTABLISHMENT OF UKRAINE
BUKOVINIAN STATE MEDICAL UNIVERSITY
CHERNIVTSI
BSMU

2. HIV-Infection
HIV infection is a pandemic infectious disease whose
impact on societies is without precedent.
It is caused by a retroviruses – HIV-1 and HIV-2 that infects and
replicates in human lymphocytes and macrophages, eroding the
integrity of the human immune system over a number of years,
culminating in immune deficiency and a susceptibility to a series of
opportunistic and other infections as well as the development of
certain malignancies.
AIDS (a syndrome of a constellation of infections, conditions,
or malignancies) occurs as a result of HIV infection, and
usually develops over 10-15 years (median 11 years).

3. Epidemiology
Globally, there were 37.9 million people living with HIV
worldwide at the end of 2018, with approximately 1.7
million becoming newly infected in 2018. Approximately
70% of people living with HIV are in sub Saharan Africa.
Transmission among heterosexuals was the largest
single route of infection, accounting for 49.4% of newly
diagnosed cases. A total of 21.2% of new infections
were attributed to men who have sex with men (MSM),
and 13% to injecting drug use.

4. L. Montonae R. Gallo

5. Epidemic
process
1. Source – infected human
2. Ways – blood transfusion,
sharing syringes, sexual,
vertical, through direct
contact with blood drops
and mucosa membranes,
wounds, etc. All body
fluids contain virus but in
different concentrations.
Even sweat and tears.
But the highest
concentration is in blood
and genital fluids
3. Susceptibility – general
https://www.pbs.org/wgbh/pages/frontline/aids/virus/virus.html
Structure of virus

6. Electronogram of HIV

7. Types of Agent:
Human immunodeficiency virus -1 (HIV -
1), widespread in the entire countries of
world;
Human immunodeficiency virus -2 (HIV
-2), widespread mainly in Western Africa,
but already turns out in different countries
of Europe and America.

8. African Green Monkey

9. HIV Risk Factors Groups :
Homo- and multiple partnership
individuals;
drug users (intravenously).
Recipients of blood, its preparations and
organs.
Sex workers (males, females).
Sick on STDs plus viral hepatitis B, C, D.
Intrauterine transmission within delivery
and vertical during pregnancy.

10. Life cycle and interaction with host
After HIV enters the body, it hunts down and penetrates the CD4 cell, which functions as
the immune system's quarterback: It tells the other cells what they need to do to rid the
body of an invader. HIV hijacks the CD4 cell and uses the cell's machinery to make new
virions, or virus particles. Here's how:
After penetrating a CD4 cell, the virus goes to work turning it into an HIV factory.
HIV disguises itself behind a layer of sugars, which makes it appear harmless (although some cells do recognize and
destroy HIV particles). Because immune system cells are constantly circulating in and out of the lymph organs, the HIV-
infected cell will soon carry the virus straight to the stronghold of the lymphatic system, where CD4 cells are most
abundant. Once there, HIV begins replicating and infecting CD4 cells very quickly. It replicates itself billions of times each
day.
Imagine HIV as a sphere with spiky proteins all over its surface. In order to infect a CD4 cell, one of those proteins,
known as gp120, fits together with a receptor protein, CCR4, on the CD4 cell's surface, like a key fits into a lock. A
second protein, called gp41, then locks onto a second receptor protein, CCR5. Once both connections are made, the
virus can penetrate the outer wall of the cell and insert its viral proteins and RNA.
After penetrating a CD4 cell, the virus goes to work turning it into an HIV factory. An
enzyme called reverse transcriptase transcribes the viral RNA into DNA. Then another
enzyme, known as integrase, cuts apart the cell's own DNA, and inserts the viral DNA.
The virus has become a provirus -- a viral cell that can lie dormant for years until it's
activated. Once the cell is activated, its DNA tells the cell to produce more copies of the
RNA and other proteins needed to make new HIV virions. After the copies are made, they
gather at the cell's surface and form buds before finally disconnecting from the host cell.
Once they're free, an enzyme called protease cuts the new proteins and RNA into small,
usable pieces. The new virions are now mature, and ready to do battle with the body.

11. Natural course
1. Initial phase – transmitted by semen, blood,
cervicovaginal secretions and maternal milk. After
infection, about half of adults will have a recognizable
acute retroviral syndrome within days to a few weeks.
May present a mono-like syndrome within or without
acute encephalitis, psychiatric symptoms, acute
myelitis, lymphocytic meningitis, or polyradiculoneuritis.
All symptoms disappear spontaneously. Serology
becomes positive 3-6 weeks postinfection and very
rarely later (Western blot, ELISA).
2. Latency phase – patients can remain without
symptoms or have only chronic lymphadenopathy for
years. The latter does not portend a systematically bad
prognosis.

12. Clinical stages
1. One
- Asymptomatic
- Persistent generalized lymphadenopathy
2. Two
- Moderate unexplained weight loss
- Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis media, or pharyngitis)
- Herpes zoster
- Angular chelitis
- Recurrent oral ulceration
- Papular pruritic eruptions
- Seborrheic dermatitis
- Fungal nail infections
3. Three
- Unexplained severe weight loss (over 10%)
- Unexplained chronic diarrhea for more 1 month
- Unexplained persistent fever
- Persistent oral candidiasis
- Oral hairy leukoplakia
- Pulmonary tuberculosis
- Severe bacterial infections
- Acute necrotizing ulcerative stomatitis
- Unexplained anemia, neutropenia, chronic thrombocytopenia

13. Clinical stages
4. Four
- HIV wasting syndrome
- Pneumocystic pneumonia
- Recurrent severe bacterial pneumonia
- Chronic herpes simplex infection
- Esophageal candidiasis
- Extrapulmonary tuberculosis
- Kaposi sarcoma
- CMV infection
- CNS toxoplasmosis
- HIV encephalopathy
- Recurrent septicemia
- Lymphoma
- Invasive cervical carcinoma
- Disseminated mycosis
- Progressive multifocal leucoencephalopathy

14. AIDS
The CDC and WHO have different classifications to determine the
disease. According to the latter, AIDS defining clinical conditions,
with a positive HIV serology, are as follows:
• Bacterial infections (multiple or recurrent)
• Candidiasis of bronchi, trachea or lungs;
• Candidiasis of esophagus;
• Cervical cancer;
• Invasive coccidioidomycosis; disseminated or extrapulmonary
cryptococcosis;
• Extrapulmonary cryptosporidiosis (chronic, duration more 1
month, intestinal);
• CMV retinitis;
• Encephalopathy;
• Herpes simplex chronic;

15. • Histoplasmosis;
• Isosporiasis;
• Kaposi sarcoma;
• Burkitt lymphoma;
• Brain primary lymphoma;
• Brain toxoplasmosis;
• Pneumocystic pneumonia;
• Mycobacterium tuberculosis;
• Wasting syndrome attributed to HIV;
CONTINUED AIDS

16. Lymphadenopathy in HIV-infection

17. Progressive weight loss in
patient with AIDS

18. Kaposhi sarcoma in patients with AIDS

19. Kaposi sarcoma in patients
with AIDS

20. Kaposi sarcoma in patients with AIDS

21. Kaposi sarcoma in patients
with AIDS

22. Level CD4
T-cells in
1 mcl
Clinical categories
A. Asymptomatic,
acute HIV-infection
or peripheral
generalized
lymphoadenopathy
B. Manifesting,
but not A also not
C
С. AIDS-indicator
state
>500
200 - 499
<200
А1
А2
А3
В1
В2
В3
С1
С2
С3

23. GENERAL CRITERIA :
 Epidemiologic positive data;
 Clinical data;
 Suspect if patient has long lasted fever;
 Unexplained diarrhea;
 Generalized lymphadenopathy;
 Loss of weight ( 10 % and more);
 Opportunistic-related infections;
 Positive p24 antigen findings;
 Positive antibodies to p24 antigen;
 Anti-HIV in ELISA or in Western blotting method

24. Diagnostic
Epidemic anamnesis (risk group)
Main clinical criteria of AIDS ( loss of weight, long hypertermia,
diarrhea, lymphadenopathy, dementia)
Laboratory dates – leukopenia, lymphopenia, decreasing of T-
helpers, decreasing of correlation Th/Ts, insensibility of lymphocytes to
mitogens, increasing of IgA, IgG, IgE, CircIC, decreasing of interferon's
production
Determination of specific HIV markers (p24, gp41, gp120,
gp160) in IFA, immune bloating, RNA (load with virus) in PLR
Laboratory investigation after the patients agreement only

25. DIFFERENTIAL DIAGNOSIS
Congenital immunodeficiency
Secondary immune insufficiency after serious
inflammatory and oncohematologic diseases, bleeding,
radiation, poisoning by chemical substances,
medicaments
Infectious mononucleosis
ARVI
Diphtheria
Lymphadenitis
Idiopathic form of sarcoma Kaposi

26. TREATMENT (HААRТ)
Treatment is for life
Monitor allergies and viral resistance
Standard antiretroviral therapy consists of a combination of at least
three antiretroviral drugs
When CD4 cell count is not available, start treatment at clinical stage 3
or 4.
For adults and adolescents, first-line combinations include
zidovudine/lamivudine, tenofovir/emtricitabine, stavudine/lamivudine.
All + niverapine, or efavirenz.
1-st group - nucleoside inhibitors of reverse transcriptase azidotimidin
(AZT, zinovudin) , didanozin, stavudin
2-nd group – non nucleoside inhibitors of reverse transcriptase
nevirapin (viramun), efavirenz
3-d group – inhibitors of proteases (IP)
indiravir (cricsivan), sacvinavir (fortovase), lopinavir/ritonavir (kaletra)
For pregnant women, WHO guidelines recommend an initial regimen of
zidovudine+lamivudine+nevirapine.

27. TREATMENT
Immune correction – interleukin-2 (roncoleukin), tactivin,
timalin, inerferones, immunofan, splenin, specific (monoclonal)
antibodies, transplantation of thymus gland аnd osteal brain
Treatment of opportunistic infections (protozoa– bactrim,
pirimethamin-sulfamеtоxаzоl, metronidazol, pentamedin;
mycosis – amphotericin В, kеtоkоnаzоl, flukonazol;
herpetic infection –acylovir;
CMV-infection – gancyklovir, foskarnet;
bacterial – antibiotics –macrolids, fluorohinolons, karbopemens,
cephalosporins)
Pathogenetic and symptomatic

28. Prophylaxis
HIV/AIDS in blood transfusions
Selection and investigation of donors
(obligatory 6-months quarantine of all donors plasma)
Blood transfusions based upon vital disorders
only
Patients agreement (or relatives)
Obligatory investigation of recipient 3 months
after transfusion

29. Medical personal prophylaxis
In case of medical accident –
Pre-treatment of dirty skin with 70 % ethyl alkohol,
washing by water with soap, mucous membranes –
with clean water
To register of case in special journal
Investigation of suffer person concerning of HIV
antibodies presence (in first 5 days, then – after 1, 3
and 6 months)
Performing of post contact prophylaxis
(scheme № 2) during 72 hours (better 24-36) after
accident
In case of positive reaction – conclusion of special
commission about the professional contamination

30. Prophylaxis of perinatal
contamination
Treatment of HIV from 28 weeks of
pregnancy
Cesarean section in 38 weeks term
Treatment of mother and newborn
Prohibition of breast feeding

31. Groups for HIV investigation
All donors – blood, plasma, others biological tissues and fluids
Recipients (during 3 months after transfusions and
transplantation)
Pregnant
Professional contamination in case of medical
accident
According clinical features – infectious mononucleosis,
hepatitis В, С, D, recidives of herpes zoster and pneumonia,
tuberculosis, candidoses, CMV-infection etc.
Foreign citizens
Risk groups

32. HIV- infected child's
Childs of HIV-infected mothers observed 1,5 years
They may stay in organized collectives (kitchen
gardens, school)
Provisional isolation till the recovering (in case of
moist ulcers of skin)
Plan inoculations according to Calendar – except
alive vaccines (change to artificial polyvalent
vaccines)
Vaccination don’t perform for child's with AIDS,
passive immune prophylaxis with immune
globulins only

33. Prophylaxis
Educational work– propaganda of safety sex
Observance of hygiene and moral norms
Anonymous testing for antibodies to HIV
Utilization of one using instruments (syringes, needles,
systems)
Processing (desinfection, sterilization) of repeated using
instruments
Individual defense of medical personal (gloves, masks,
special dress)
Observe ant epidemic regimen of laboratory and specialized
clinical department
NO VACCINE IS AVAILABLE

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sidorchuk@bsmu.edu.ua