HIV vs AIDS HIV Human Immuno deficiency Virus AIDS Acquired Immuno Deficiency Syndrome A not inherited I immune system D deficiency inability to protect against illness S syndrome a group of symptoms or illnesses that occur as a result of HIV infection ID: 1032776
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1. HIV-AIDSProf. OP rajoura
2. HIV v/s AIDSHIV: Human Immuno-deficiency VirusAIDS: Acquired Immuno Deficiency SyndromeA= not inheritedI= immune systemD= deficiency- inability to protect against illnessS= syndrome, a group of symptoms or illnesses that occur as a result of HIV infection7/28/20202
3. GLOBAL HISTORY1981 – beginning of the epidemic in United States - Centers for Disease Control and Prevention (CDC) published a report about five previously healthy homosexual men becoming infected with Pneumocystis pneumonia - Because the disease appeared to affect mostly homosexual men, officials initially called it Gay-related immune deficiency, or GRID. - CDC noted that this type of pneumonia had never affected people with uncompromised immune systems.1983 - Lymphadenopathy-Associated Virus (or LAV) retrovirus was discovered 1984 - National Cancer Institute found the cause of AIDS to be retrovirus HTLV-III. 3
4. 1985 - Food and Drug Administration licensed the first commercial blood test for HIV 1986 - the International Committee on the Taxonomy of Viruses officially named the virus as HIV (human immunodeficiency virus)1988 - The World Health Organization declared December 1st to be World AIDS Day.1991 - The red ribbon became an international symbol of AIDS awareness.2008 - Luc Antoine Montagnier was awarded Nobel Prize in Physiology and medicine for his discovery of the human immunodeficiency virus (HIV).4
5. GLOBAL BURDEN- 2019People living with HIV = 38 million [31.6 million–44.5 million]- 36.2 million adults(>or=15 years)1.8 million children (<15 years)Newly infected with HIV = 1.7 million [1.2 million–2.2 million]81% - knew their HIV status 6.9 lacs died due to AIDS related illnessAntiretroviral therapy accessed = 25.4 million www.unaids.org/en/resources/fact-sheet [accessed on 6/07/19]5
6. INDIASuniti Solomon-first AIDS case was diagnosed in Chennai in 1986.In 2009, she was awarded , “National Women Bio-scientist Award” by Ministry of Science and Technology, Govt. of India.On 25th January 2017, Govt. of India announced “Padma shri” award for her contribution towards Medicine“what has been killing people with AIDS more is the stigma and discrimination”7/28/20206
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8. INDIA HIV/AIDS BURDEN-20178
9. STATE/UTs WISE % DISTRIBUTION OF TOTAL PLHIV IN 20179
10. ADULT HIV PREVALENCE IN INDIA 1981-201710
11. STATEWISE ADULT HIV PREVALENCE -201711Adult HIV Prevalence Higher than national average
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13. AIDS-RELATED DEATHS OVER THE YEARS 13
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17. KEY TERMSKey populations: are defined groups who, due to specific higher-risk behaviours, are at increased risk of HIV irrespective of the epidemic type or local context. men who have sex with menpeople who inject drugspeople in prisons and other closed settingssex workerstransgender people. Vulnerable populations are groups of people who are particularly vulnerable to HIV infection in certain situations or contexts, such as adolescents, orphans, street children, people with disabilities and migrant and mobile workers. Men who have sex with men refers to all men who engage in sexual relations with other men. 17
18. People who inject drugs: people who inject psychotropic (or psychoactive) substances for non-medical purposes. Opioids, amphetamine-type stimulants, cocaine, hypno-sedatives and hallucinogens.Injection may be through intravenous, intramuscular, subcutaneous or other injectable routes. Transgender is an umbrella term for people whose gender identity and expression does not conform to the norms and expectations traditionally associated with the sex assigned to them at birth.Includes people who are trans-sexual, transgender or otherwise gender non-conformingSex workers include female, male and transgender adults (18 years of age and above) who receive money or goods in exchange for sexual services, either regularly or occasionally. 18NOTE: People who self-inject medicines for medical purposes – referred to as “therapeutic injection” – are not included in this definition. The definition also does not include individuals who self-inject non-psychotropic substances, such as steroids or other hormones, for body shaping or improving athletic performance.
19. ETIOLOGY7/28/202019
20. HIVEnveloped ssRNA Virus, Genus: Lentivirus, Family Retroviridae, Lentiviruses (HIV 1 and 2)Attacks CD4+ cellsReplicates in actively dividing T4 lymphocytes.The virus can remain in lymphoid tissues in latent phase until it is activated.Unique ability to destroy T4 Helper cellsOnce a person gets infected, HIV remains in his body lifelong. The person is a symptomless carrier for years before the symptoms actually appear.7/28/202020
21. HIV STRUCTURE HIV is composed of three main layers: EnvelopeViral MatrixCore7/28/202021
22. HIV-1 AND HIV-2HIV-1 and HIV-2Transmitted though the same routesAssociated with similar opportunistic infectionsHIV-1 is more common worldwideGroups M, N, and OPandemic dominated by Group MGroup M comprised of subtypes A – JHIV-2 is found primarily in West Africa, Mozambique and Angolaless easily transmittedis develops more slowlyMTCT is relatively rare with HIV-27/28/202022
23. ROUTE OF TRANSMISSION *Not transmitted by urine, faeces, sputum, nasal secretion, saliva, sweat, tears, or vomit that does not contain blood that is visible to the naked eye, human bite7/28/202023RouteEfficiencySexual0.01 to 1Transfusion of blood products>90Sharing needles/syringes3-5Percutaneous exposure0.4Mucocutaneous exposure0.05Mother to child transmission25-30RISK OF TRANSMISSION
24. HIV in Body FluidsSemen11,000Vaginal Fluid7,000Blood18,000Amniotic Fluid4,000Saliva1Average number of HIV particles in 1 ml of these body fluids
25. PATHOGENESIS7/28/202025
26. DISEASE PROGRESSION THROUGH DIFFERENT STAGES7/28/202026
27. Incubation period - Few months to 10 years or even more75% of people infected with HIV develop AIDS at the end of 10 yearsSeverity of illness determined by:amount of virus in the blood (viral load) and the degree of immune suppression (decreasing CD4 count)Higher the viral load, sooner immune suppression occurs7/28/202027
28. Window period:Time between potential exposure to HIV infection and appearance of Antibodies in blood: 4-12 weeksSero-conversion: Development of evidence of antibody response to a diseaseViral Load: The amount of HIV in the blood.7/28/202028
29. CLINICAL FEATURES7/28/202029
30. RISK FACTORS FOR TRANSMISSION OF HIV1. Unsafe sex.2. MSM (Men having Sex with Men).3. IDU (Injection Drug User).4. Migration & Mobility.5. Low status of women.6. Widespread stigma.7/28/202030
31. CDC CLASSIFICATION OF HIV INFECTIONAcute HIV infectionAsymptomatic or Latent infectionPersistent generalized lymphadenopathy (PGL)AIDS related complex ( without opprtunistic infections)Full blown AIDS (Last stage)7/28/202031
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33. WHO CLINICAL STAGINGPrimary HIV Infection:Asymptomatic Acute retroviral syndromeClinical stage 1:AsymptomaticPersistent generalised lymphadenopathy7/28/202033
34. Clinical stage 2:Moderate unexplained weight loss (<10% of presumed or measured body weight)Recurrent respiratory tract infections (sinusitis, bronchitis, otitis media, pharyngitis)Herpes zosterAngular cheilitisRecurrent oral ulcerationsPapular pruritic eruptionsSeborrhoeic dermatitisFungal nail infections of fingers7/28/202034
35. Clinical stage 3:Severe weight loss (>10% of presumed or measured body weight)Unexplained chronic diarrhoea for longer than one monthUnexplained persistent fever (intermittent or constant for longer than one month)Oral candidiasisOral hairy leukoplakiaPulmonary tuberculosis (TB) diagnosed in last two yearsSevere bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone or joint infection, meningitis, bacteraemia)Acute necrotizing ulcerative stomatitis, gingivitis or periodontitisUnexplained Anaemia(<8gm/dL), Neutropenia (<0.5x10*9/L) And/Or Chronic Thrombocytopenia (50x10*9/L)7/28/202035
36. Clinical stage 4:HIV wasting syndromePneumocystis carinii pneumonia (PCP)Recurrent severe bacterial pneumoniaChronic Herpes Simplex infection ( Orolabial, Genital or ano-rectal of <1 months duration or visceral at any site)Candidiasis (Esophageal/ Trachea/ Bronchi/Lungs)EPTBKaposis SarcomaCMV infection (Retina or other organs)CNS ToxoplasmosisHIV Encephalopathy7/28/202036
37. 7/28/202037Extra-Pulmonary CryptoccocosisDisseminated MycosisRecurrent SepticaemiaLymphoma (B-cell Non Hodgkins)Invasive Cervical CarcinomaAtypical disseminated LeishmaniasisSymptomatic HIV-associated Nephropathy or Cardiomyopathy.
38. OPPORTUNISTIC INFECTIONS7/28/202038
39. MAJOR SIGNS1. Weight loss > 10% body wt.2. Chronic Diarrhoea for > 1 month. 3. Prolonged fever for > 1 monthMINOR SIGNS1. Persistent cough for > 1 month.2. Generalized pruritic dermatitis. 3. History of herpes zoster.4. Oropharyngeal candidiasis.5. Chronic herpes simplex infection.6. Generalized lymphadenopathy.7/28/202039CLINICAL DIAGNOSISWHO case definition for AIDS surveillance- 2 major signs in combination with 1 minor sign.
40. LABORATORY DIAGNOSISEvidence of HIV infection Virus isolation Measurement of viral nucleic acid Detection of viral antigen Detection of viral antibodyRecognition of immunodeficiency CD4+ T cell count Recognition of AIDS related disease7/28/202040
41. LABORATORY DIAGNOSISViral infectionViral Loadp24 AntigenImmune responseAntibody (IgG, IgM)Cellular response (CD4)7/28/202041
42. TREATMENT7/28/202042
43. GOALS OF ARTClinical goals : Prolongation of life and improvement in quality of life Virological goals : Greatest possible reduction in viral load for as long as possible Immunological goals : Immune reconstitution that is both quantitative and qualitative Therapeutic goals : Rational sequencing of drugs in to achieve:clinical, virological and immunological goals while maintaining treatment options, limiting drug toxicity and facilitating adherence Reduction of HIV transmission in individuals : by suppression of viral load 7/28/2020
44. ANTI-RETROVIRAL DRUGSNRTI (Neucleoside R T Inhibitors)PI (Protease Inhibitors)NNRTI (Non-Neucleoside R T Inhibitors)Zidovudine (AZT)*Indinavir (IDV)*Nevirapine (NVP)*Lamivudine (3TC)*Nelfinavir (NFV)*Efavirenz (EFV)*Stavudine (d4T)*Saquinavir (SQV)*Delavirdine (DLV)Didanosine (ddl)*Ritonavir(RTV)*INTEGRASE INHIBITORSZalcitabine(ddC)*Amprenavir(APV)RaltegravirAbacavir (ABC)*Lopinavir (LPV)*CCR5 antagonistsTenofovir (TFV)*Atazanavir (ATV)*MaravirocEmtricitabine(FTC)Foseamprenavir 7/28/2020
45. INITIATION OF ART BASED ON CD4 COUNT AND WHO CLINICAL STAGINGWHO Clinical StageRecommendations HIV infected Adults & Adolescents (Including pregnant women) Clinical Stage I and II Start ART if CD4 < 350 cells/mm3 Clinical Stage III and IV Start ART irrespective of CD4 count For HIV and TB co-infected patients Patients with HIV and TB co-infection (Pulmonary/ Extra-Pulmonary) Start ART irrespective of CD4 count and type of tuberculosis (Start ATT first, initiate ART as early as possible between 2 weeks to 2 months when TB treatment is tolerated) For HIV and Hepatitis B and C co-infected patients HIV and HBV / HCV co-infection – without any evidence of chronic active Hepatitis Start ART if CD4 < 350 cells/mm3 HIV and HBV / HCV co-infection – With documented evidence of chronic active Hepatitis Start ART irrespective of CD4 count 7/28/202045
46. First-line ART regimens for adults (Fixed dose combinations)Principles:1. Choose 3TC (Lamivudine) in all regimens2. Choose one NRTI to combine with 3TC {AZT (Zidovudine or TDF(Tenofavir)}3. Choose one NNRTI (NVP or EFV)E.g. Tenofovir + Lamivudine + Efavirenz If TDF + 3TC or FTC(Emitricitabin) + EFV contraindicated/not availableAZT (Zidovudine) + 3TC (Lamivudine) + EFV (Efavirenz)AZT + 3TC + NVP (Nevirapine)TDF + 3TC (or FTC (Emtricitabine)) + NVPTREATMENT REGIMEN7/28/202046
47. MONITORING OF EFFICACY OF ART1. Clinical improvementWeight gain.Decrease severity of HIV related disease.2. Increase in Total Lymphocyte count.3. Improvement in biological markers of HIV.CD 4 + T – Lymphocyte count.Plasma HIV – RNA levels. 7/28/202047
48. PROPHYLAXIS OF OPPORTUNISTIC INFECTIONSHIV infected adults with CD4 <250 cells/mm3 ORWHO clinical stage 3 or 4 irrespective of CD4 countRecommendation:Commencing primary Cotrimoxazole Preventive TherapyCD4 awaitedCD4 availableWHO clinical stage 3 or 4 (includes all patients with TB)Any WHO clinical stage and CD4 <250 cells/mm3 orAny WHO clinical stage, CD4 <350 cells/mm3 and if patient is symptomaticorWHO stage 3 or 4 irrespective of CD4countDose One double-strength tablet or two single-strength tablets oncedaily– total daily dose of 960 mg (800 mg SMZ + 160 mg TMP)When to stopIf CD4 count >250 for at least 6 months and If patient is on ART for at least 6 months, is asymptomatic and well7/28/202048
49. Thank you 7/28/202049