AIDS and HIV.pptx

Lecture notes for medical students

1. Tips on using my ppt. You can freely download, edit, modify and put your name etc. Don’t be concerned about number of slides. Half the slides are blanks except for the title. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. At the end rerun the show – show blank> ask questions > show next slide. This will be an ACTIVE LEARNING SESSION x three revisions. Good for self study also. See notes for bibliography.

2. Learning Objectives

3. Learning Objectives Introduction & History Relevant Anatomy, Physiology Aetiology Pathophysiology Pathology Classification Clinical Features Investigations Management Prevention Guidelines Take home messages

4. Introduction & History.

5. Introduction & History. Human immunodeficiency virus (HIV) is a blood-borne virus typically transmitted via sexual intercourse, shared intravenous drug paraphernalia, and mother-to-child transmission (MTCT), which can occur during the birth process or during breastfeeding.

6. Introduction & History. AIDS is a disease in which there is a severe loss of the body's cellular immunity, greatly lowering the resistance to infection and malignany . According to the  CDC definition , a patient has  AIDS  if they are infected with  HIV  and have either: a CD4+ T-cell count below 200 cells/µL. a CD4+ T-cell percentage of total lymphocytes of less than 15% or one of the  defining  illnesses . Normal 500-1500

7. AIDS-defining clinical conditions

8. AIDS-defining clinical conditions Candidiasis Coccidioidomycosis Isosporiasis Kaposi's sarcoma Lymphoma Burkitt's Toxoplasmosi – brain Tuberculosis Wasting syndrome due to HIV Cryptococcosis Cryptosporidiosis Cervical cancer invasive) Pneumonia(recurrent) Cryptosporidiosis Cytomegalovirus Encephalopathy (HIV-related) Herpes simplex

9. AIDS-defining clinical conditions Bacterial infections multiple or recurrent Lymphoid interstitial pneumonia Pneumocystis jirovecii  pneumonia Histoplasmosis Salmonella septicemia Progressive multifocal leukoencephalopathy

10. Etiology

11. Etiology Idiopathic Congenital Traumatic Infections /Infestation Autoimmune Neoplastic (Benign/Malignant) Degenerative

12. Etiology I nfection with HIV-1 or HIV-2, which are retroviruses in the Retroviridae family,  HIV-1  is the most widespread type worldwide.  HIV-2 , a less prevalent and less pathogenic (disease-causing) type, is found principally in western Africa. Large genetic  differences between HIV-1 and HIV-2 mean that tests keyed to one will not reliably detect the other.

13. Pathophysiology  

14. Pathophysiology  CD4 +  T cells express the CCR5 coreceptor , HIV seeks out and destroys CCR5 expressing CD4 +  cells during acute infection it is the host response  to viral DNA produced during abortive infection that triggers CD4 T-cell death. Reduced number of CD4 +  T cells leads to loss of cell mediated immunity.

15. Clinical Features

16. Clinical Features Demography Symptoms Signs Prognosis Complications

17. Demography

18. Demography In 2015 approximately 36.7 million people (1% of the global adult population aged 15-49 years) were infected with HIV, a decline from 2006 (39.5 million reported at that time). Approximately 2.1 million people were newly infected with HIV and that 1.1 million people died of AIDS in 2015, both statistics showing a decline over time.

19. Demography The vast majority of infections remain in sub-Saharan Africa, where 5.2% of the population is thought to be infected . Swaziland has the highest overall prevalence of HIV infection (>26% of all adults) The Ministry of Health in Zambia predicts that, without therapy and assuming current levels of prevalence, young adults have a 50% lifetime risk of dying from AIDS.

20. Demography India , has used a national prevention campaign focusing on high-risk populations that may have prevented 100,000 new HIV infections over the 5 years it has been implemented . In the developing world, HIV infection is equally common in males and females . Young adults tend to be at higher risk of acquiring HIV, typically through high-risk activities such as unprotected sexual intercourse or intravenous drug use.  The primary route of HIV transmission in the developing world is heterosexual contact.

21. Demography Co-infection with HIV and tuberculosis is very common. The immunosuppressed state induced by HIV infection contributes not only to a higher rate of tuberculosis reactivation but also to an increased disease severity, as with many other opportunistic infections. .

22. History

23. History The history should address risk factors for possible exposure to HIV, including the following: Unprotected sexual intercourse, especially receptive anal intercourse A large number of sexual partners Previous or current sexually transmitted diseases (STDs) Sharing of intravenous (IV) drug paraphernalia

24. History Receipt of blood products (before 1985 in the United States) Mucosal contact with infected blood or needle-stick injuries Maternal HIV infection (for newborns, infants, and children)

25. Clinical features

26. Clinical features Acute seroconversion manifests as a flulike illness, consisting of fever, malaise, and a generalized rash The asymptomatic phase is generally benign Generalized lymphadenopathy is common and may be a presenting symptom AIDS manifests as recurrent, severe, and occasionally life-threatening infections or opportunistic malignancies

27. Clinical features HIV infection can cause some sequelae , including AIDS-associated dementia/encephalopathy and HIV wasting syndrome (chronic diarrhea and weight loss with no identifiable cause).

28. Prognosis

29. Prognosis The prognosis in patients with untreated HIV infection is poor, with an overall mortality rate of more than 90%. The average time from infection to death is 8-10 years Once infection has progressed to AIDS, the survival period is usually less than 2 years in untreated patients

30. Investigations

31. Investigations Laboratory Studies Routine Special Imaging Studies Tissue diagnosis Cytology FNAC Histlogy

32. Laboratory Studies

33. Laboratory Studies enzyme-linked immunoabsorbent assay (ELISA) should be used for screening Western blot assays 

34. Laboratory Studies The CD4 T-cell count reliably reflects the current risk of acquiring opportunistic infections, as follows: Reference range, 500-2000 cells/ μL Because CD4 counts vary, serial counts are generally a better measure of significant changes After seroconversion , CD4 counts tend to decrease (~700/ μL ) and continue to decline over time

35. Laboratory Studies For surveillance, a CD4 count below 200/ μL is considered AIDS-defining in the United States In children younger than 5 years, the CD4 T-cell percentage is considered more important than the absolute count (< 25% is considered to warrant therapy) In adults with chronic hepatitis C and low absolute CD4 T-cells, the CD4 percentage may also be more useful

36. Laboratory Studies Viral load in peripheral blood is used as a surrogate marker of viral replication rate; however, quantitative viral-load assays should not be used as a diagnostic tool. Clinical relevance is as follows: Rate of progression to AIDS and death is related to the viral load; patients with viral loads greater than 30,000/ μL are 18.5 times more likely to die of AIDS than those with undetectable viral loads .

37. Laboratory Studies With therapy, viral loads can often be suppressed to an undetectable level (< 20-75 copies/mL; optimal viral suppression); complete inhibition of viral replication appears impossible and may be unnecessary Successfully treated patients may demonstrate intermittent low-level viremia ( eg , < 400 copies/mL), but this is not thought to represent viral replication or to predict virologic failure (defined as a confirmed viral load of > 200 copies/mL

38. Laboratory Studies Alere Determine HIV-1/2 Ag/ Ab Combo test ( Orgenics , Ltd) as the first rapid HIV test for the simultaneous detection of HIV-1 p24 antigen as well as antibodies to both HIV-1 and HIV-2 in human serum, plasma, and venous or fingerstick whole blood specimens.

39. Laboratory Studies urified protein derivative (PPD) skin testing for tuberculosis Cytomegalovirus (CMV) testing Syphilis testing Rapid amplification testing for gonococcal and chlamydial infection Hepatitis A, B, and C serology Anti-  Toxoplasma  antibody Ophthalmologic examination

40. Differential Diagnosis

41. Differential Diagnosis  (HIV) infection should be considered in any patient with unusual or recurrent serious infections without another cause, especially in those with risk factors for HIV infection. Any of the opportunistic infections or cancers associated with acquired immune deficiency syndrome (AIDS) can also occur in the absence of HIV infection,

42. Differential Diagnosis  Other causes of immune suppression ( eg , chemotherapy, immune disorders, severe combined immune deficiency [SCID], severe malnutrition)

43. Management

44. Management The CDC classifies HIV infection into 3 categories, as follows  [8]  : Category A: Asymptomatic HIV infection without a history of symptoms or AIDS-defining conditions Category B: HIV infection with symptoms that are directly attributable to HIV infection (or a defect in T-cell–mediated immunity) or that are complicated by HIV infection.

45. Management Category C: HIV infection with AIDS-defining opportunistic infections

46. Management These 3 categories are further subdivided on the basis of the CD4 +  T-cell count, as follows: > 500/µL: Categories A1, B1, C1 200-400/µL: Categories A2, B2, C2 < 200/µL: Categories A3, B3, C3

47. Therapy

48. Therapy Antiretroviral therapy should be initiated in all patients with a history of an AIDS-defining illness or with a CD4 count below 350/µL Antiretroviral therapy should be initiated regardless of CD4 count in pregnant patients, patients with HIV-associated nephropathy, and those with hepatitis B virus (HBV) coinfection when treatment of HBV infection is indicated

49. Therapy Highly active antiretroviral therapy (HAART) Nucleoside reverse transcriptase inhibitors (NRTIs) Protease inhibitors (PIs) Nonnucleoside reverse transcriptase inhibitors (NNRTIs) Fusion inhibitors CCR5 co-receptor antagonists (entry inhibitors) HIV integrase strand transfer inhibitors

50. Therapy INSTI-based regimens are as follows:Dolutegravir / abacavir /lamivudine (DTG/ABC/3TC) - only for patients who are HLA-B*5701–negative DTG plus tenofovir disoproxil fumarate / emtricitabine (TDF/FTC) Elvitegravir / cobicistat /TDF/FTC (EVG/c/TDF/FTC) - only for patients with pre-ART creatinine clearance ( CrCl ) of >70 mL/min

51. Therapy Raltegravir (RAL) plus TDF/FTC The PI/r-based regimen is darunavir /ritonavir (DRV/r) plus TDF/FTC HIV-2 is intrinsically resistant to NNRTIs and enfuvirtide .

52. Therapy Prophylaxis Pneumocystis jiroveci Toxoplasma Mycobacterium avium  complex Fungal and viral infections: with CD4  +  T-cell counts under 50/µL oral ganciclovir is indicated for CMV prophylaxis in patients with advanced AIDS

53. Therapy Treatment of opportunistic infections (directed at the specific pathogen) Treatment of HIV lipodystrophy ( tesamorelin ) Suppressive therapy for herpes simplex virus 2 (HSV-2) infection (acyclovir) Treatment of HIV-associated diarrhea ( crofelemer

54. Postexposure prophylaxis (PEP) regimens

55. Postexposure prophylaxis (PEP) regimens Basic PEP 2-drug regimen : Tenofovir plus emtricitabine (preferred); alternatives include zidovudine plus lamivudine, zidovudine plus emtricitabine , or tenofovir plus lamivudine Alternative basic PEP regimen : Lamivudine plus stavudine , lamivudine plus didanosine , emtricitabine plus stavudine , or emtricitabine plus didanosine Expanded PEP regimen: Basic PEP regimen plus raltegravir (preferred) or lopinavir -ritonavir

56. Prevent HIV IN OT

57. Prevent HIV IN OT Handle sharps with instruments. -Pass sharps to each other via kidney tray.  -Pass needle to and fro between needle holder & thumb forceps without catching needle in hand.  -Use thumb forceps in left hand during suturing  -Use instrument for retraction. -Wear goggles during surgery.  -Throw sharps into sharp collector.  -Use skin stapler.  -Wear gumboots in O.T.  -Report needle pricks to ART center.  -Soak used instruments in bleach before washing.

58. Prevent HIV IN OT -Do not Catch needle with hands.  -Do not Pass sharps hand to hand.  -Do not Recap used needles.  -Do not Use straight needle for suturing.  -Do not Use hands for retraction. Watch “How to suture” on You tube channel of Dr. Pradeep Pande

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