HIV 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.

1. Acquired Immunodeficiency
Syndrome
Dr. Jayaramachandran S
Associate Professor
Department of Community Medicine
MGMCRI

2. Introduction
•AIDS–Acquired Immuno-Deficiency Syndrome ("slim disease")
•Retrovirus –Human Immune-deficiency Virus (HIV)
•Breaks down the body's immune system
•Victim vulnerable to a host of life-threatening opportunistic
infections, neurological disorders. or unusual malignancies
•Modern pandemic -affect both industrialized & developing countries

3. Historical aspect of HIV Epidemic
•1981 -In USA, sudden outbreak of opportunistic infections & cancers
in homosexual men
•1982 -Disease was named as AIDS
•1984 -HIV isolated -Luc Montanier(Pasteur Institute, Paris) & Robert
Gallo (NIH, Bethesda, USA)
•1985 -HIV diagnostic tests developed.
•1986 -First antiretroviral drug, zidovudine, developed.
•Since 1988 -1st December -World AIDS day.
NFHS-3, India, 2005-06

4. Problem statement

6. WHO and UNAIDS define the different types
of HIV epidemics as follows:
1.Low-level HIV epidemics: HIV prevalence has not consistently
exceeded 5% in any defined subpopulation.
2.Concentrated HIV epidemics: HIV prevalence is consistently over
5% in at least one defined sub-population but is below 1% in
pregnant women in urban areas.
3.Generalized HIV epidemics: HIV prevalence consistently over 1% in
pregnant women.

7. New Infections
•Most new infections are transmitted heterosexually
•New infections globally (2017) –40% in key populations and their
sexual partners.
GroupRisk of HIV acquisition
Gay men and MSM 28 times higher
IVD abusers22 times higher
Female sex workers 13 times higher
Transgenders13 times higher

8. HIV Incidence
•HIV incidence –Key parameter that prevention efforts aim to reduce
the total number of persons living with HIV –Potential source of
further transmission
•Annual new infections peaked to 3.2 million cases globally in 1997
which has fallen to 2.1 million in 2015.
•This reduction in the result of prevention programmes resulting in
behavioural changes in different contexts

9. HIV in women
•Women –Worldwide 50% of all people living with HIV
•More than half (60%) in sub-Saharan Africa.
•HIV is the leading cause of death among women in reproductive age.
•Why?
•Gender inequalities, differential access to services and sexual violence
increase women's vulnerability to HIV, and women, especially
younger women, are biologically more susceptible to HIV

10. Treatment Revision
•In 2013 –WHO issued revised treatment guidelines
•Earlier initiation of ART -CD4count of ≤ 500 cells/mm3.
•Increased the total number of people medically eligible for therapy
from 16.7 million to 25.9 million

11. UNAIDS 2016-2021 strategy
•"Fast-Track Fast Track : Ending the AIDS Epidemic by 2030"
•Close the testing gap
•90-90-90 treatment targets –90% of the people with HIV being
aware of their infection –90% of people aware that they have HIV
initiating ART and 90 % of those receiving ART having undetectable
levels of HIV in their blood by 2020.
•Target: 75% ↓ in new infection between 2010 & 2020 –annual HIV-
related deaths to less than 5,00,000 by 2020 globally.

12. The Sustainable Development Goal
•Target : End the AIDS epidemic by 2030
•How?
1.A focus on population left behind by the HIV response, such as
adolescent girls, key population (sex workers, men who have sex
with men, people who inject drugs and transgender people),
migrants and children;
2.A focus on locations where the greatest HIV transmission is
occurring and with the greatest HIV burden

13. The Sustainable Development Goal (Contd…)
3.An integrated HIV response that expands the contribution towards
universal health care, including health workforce, procurement
systems. injection and blood safety, and treatment of coinfections
4.Sustainable programmes with transitioning to domestic funding of
essential HIV services.

14. India –4thDecade
•India's epidemic is marked by heterogeneity –not a single epidemic
but made up of a number of distinct epidemics, in some places within
the same state.
•Third largest HIV epidemic in the world.
•In 2017, HIV prevalence among adults {aged 15-49 years) –0.2%
•This figure is small as compared to most other middle-income
countries, but because of India's huge population (1.3 billion people)
this equates to 2.1 million people living with HIV.

15. India –4thDecade (Contd…)
•Overall, India's HIV epidemic is slowing down.
•Between 2010 and 2017 new infections declined by 27 %
•AIDS-related deaths falling by 56%
•88,000 new HIV infections & 69,000 AIDS-related deaths in 2017
•In 2017, 79% of the people living with HIV were aware of their status,
of whom 56% were on antiretroviral treatment

16. Key population affected in India
•The HIV epidemic in India is driven by sexual transmission
•Accounts for 86% of new infections in 2017
•Followed by parent-to-child, injecting drug users, homosexuals and
blood and blood products use etc.

18. Epidemiological Features

19. India's epidemic
General population
Bridge population (clients of sex workers, STD patients, Migrant
population, population in conflict areas and partners of drug users)
The epidemic shifts from the High risk group (commercial sex
workers, homosexual men, drug users)

20. Based on sentinel surveillance

21. Agent
•Retrovirus: have two RNA
strands.
•Replicate in actively dividing T4lymphocytes.
•Remain latent stage in lymphoid
cells.
•Cross blood-brain barrier.

22. Agent
•HIV type (distinguished genetically):
•HIV1: > worldwide pandemic (current ~ 40 M people).
•HIV2 : > isolated in West Africa; causes AIDS much more slowly than HIV-1
but otherwise clinically similar.
•Rapidly killed by heat, Readily inactivated by Ether, Acitone, 20%
ethanol & 1:400 dilution of beta-propiolactone. Relatively resistant to
ionizing radiation & ultraviolet.
•Reservoir of infection: Case & carriers.

23. Agent
•Source of infection
•Body fluids:
•High concentration: Blood, Semen, CSF
•Lower concentration: Tear, Saliva, Breast milk, Urine, Cervical &
vaginal secretion.
•Tissue: Brain tissue, Lymph nodes, Bone-marrow cells & skin.

24. Host factors
•AGE: 20 –49 years
•Sex: In North America, Europe and Australia –51% of cases are
homosexual or bisexual men.
•Certain sexual practices increase the risk of infection more than
others, e.g., multiple sexual partners, anal intercourse, and male
homosexuality. Higher rate of HIV infection is found in prostitutes.

25. Host factors
•High risk groups : Male homosexuals and bisexuals, heterosexual
partners (including prostitutes), intravenous drug abusers, transfusion
recipients of blood and blood products, haemophiliacs and clients of
STD.

26. Modes of HIV/AIDS Transmission

27. Modes of HIV/AIDS Transmission
•Sexual transmission
•Unprotected Sexual Intercourse
•Oral
•Anal

28. Modes of HIV/AIDS Transmission
•Blood Contact
•Blood products
•Semen
•Vaginal fluids

29. Modes of HIV/AIDS Transmission
•Intravenous Drug Abuse
•Sharing Needles
•Without sterilization
•Increases the chances of
contracting HIV
•Unsterilized blades
•Any skin piercing (including
injections. ear-piercing,
tattooing, accupunctureor
scarification) can transmit the
virus, if the instruments used
have not been sterilized and
have previously been used on an
infected person

30. Modes of HIV/AIDS Transmission
•Maternal-to-fetous
•Before Birth
•During Birth

31. Incubation period
•Uncertain, as natural history of HIV infection is not yet known.
•Range from a few months to 10 years or more
•The percentage of people infected with HIV, who will develop clinical
disease remains uncertain : 10-30 % will develop AIDS & 25-30 % will
develop AIDS-related complex.
•Estimated : 75 % of those infected with HIV will develop AIDS by the
end of ten years

32. Clinical manifestations

33. Clinical manifestations
•The clinical features of HIV infection have been classified into four
broad categories:
1.Initial infection with the virus and development of antibodies
2.Asymptomatic carrier state
3.AIDS-related complex (ARC)
4.AIDS

34. Stage 1 : Initial infection
•Fever, sore throat and rash -70%
of people experience a few
weeks after initial infection
•HIV antibodies usually take
between 2 to 12 weeks to
appear in the blood-stream
•The period before antibodies are
produced is the "window
period"

35. Stage 2 : Asymptomatic carrier state
•Infected people have antibodies,
•No overt signs of disease, except persistent generalized
lymphadenopathy.
•It is not clear how long the asymptomatic carrier state lasts

36. Stage 3 : AIDS-related complex (ARC)
•A person with ARC has illnesses caused by damage to the immune
system, but without the opportunistic infections and cancers
associated with AIDS
•Clinical signs : unexplained diarrhoea lasting longer than a month ,
fatigue, malaise, loss of more than 10% body weight, fever, night
sweats, or other milder opportunistic infections such as oral thrush,
generalized lymphadenopathy or enlarged spleen

37. Stage 3 : AIDS-related complex (ARC)
•Patients from high-risk groups who have two or more of these
manifestations (typically including generalised lymphadenopathy),
and who have a decreased number of T-helper lymphocytes are
considered to have AIDS-related complex.

38. Stage 4 : AIDS
•AIDS is the end-stage of HIV infection.
•A number of opportunist infections commonly occur at this stage
•Tuberculosis and Kaposi sarcoma are usually seen relatively early.
•Serious fungal infections such as tend to occur, when T-helper cell
count has dropped to around 100.
•People whose counts are below 50 have the late opportunistic
infections such as cytomegalouiralretinitis.

39. TB & HIV co-infection
•TB is the most common opportunistic infection in HIV
•HIV-positive individuals were 30-50 times more likely to develop
active tuberculosis than HIV-negative people.
•Immunosuppression induced by HIV modifies the clinical presentation
of TB :
•Subnormal clinical and roentgen presentation
•High rate of MDR/XDR
•High rate of treatment failure and relapse (5% vs < 1% in HIV)

41. Diagnosis of AIDS

42. Diagnosis of AIDS
•WHO case definition for AIDS surveillance
•For the purposes of AIDS surveillance an adult or adolescent (> 12
years of age) is considered to have AIDS if at least 2 of the following
major signs are present in combination with at least 1 of the minor
signs listed below, and if these signs are not known to be due to a
condition unrelated to HIV infection

43. Diagnosis of AIDS –Major signs
•Weight loss ≥ 10% of body weight
•Chronic diarrhoea for more than 1 month
•Prolonged fever for more than 1 month (intermittent or constant).

44. Diagnosis of AIDS -Minor signs
•Persistent cough for more than 1 month
•Generalized pruritic dermatitis
•History of Herpes Zoster B
•Oropharyngeal candidiasis
•Chronic progressive or disseminated herpes simplex infection
•Generalized lymphadenopathy
The presence of either
generalized Kaposi
sarcoma or cryptococcal
meningitis is sufficient for
the diagnosis of AIDS for
surveillance purposes

45. Diagnosis of AIDS
•The clinical case definition was developed to enable reporting of the
number of people with AIDS for the purposes of public health
surveillance, rather than for patient care.

46. Diagnosis of AIDS –Children
•The case definition for AIDS is fulfilled if at least 2 major signs and 2
minor signs are present (if there is no other known cause of
immunosuppression).

47. Diagnosis of AIDS –Children –Major signs
•Weight loss or abnormally slow growth
•Chronic diarrhoea for more than 1 month
•Prolonged fever for more than 1 month.

48. Diagnosis of AIDS –Children –Minor signs
•Generalized lymph node enlargement
•Oropharyngeal candidiasis
•Recurrent common infections, e.g. ear infection, pharyngitis
•Persistent cough
•Generalized rash

49. Diagnosis of AIDS –Expanded WHO case
definition for AIDS surveillance
•For the purposes of AIDS surveillance an adult or adolescent (> 12
years of age) is considered to have AIDS if a test for HIV antibody
gives a positive result, and one or more of the following conditions
are present
•≥ 10% body weight loss or cachexia, with diarrhoea or fever, or both,
intermittent or constant, for at least 1 month, not known to be due to
a condition unrelated to HIV infection
•Cryptococcal meningitis

50. Diagnosis of AIDS
•Pulmonary or extra-pulmonary tuberculosis
•Kaposi sarcoma
•Neurological impairment that is sufficient to prevent independent
daily activities, not known to be due to a condition unrelated to HIV
infection (for example, trauma or cerebrovascular accident)
•Candidiasis of the oesophagus (which may be presumptively
diagnosed based on the presence of oral candidiasis accompanied by
dysphagia)

51. Diagnosis of AIDS
•Clinically diagnosed life-threatening or recurrent episodes of
pneumonia, with or without aetiological confirmation ·
•Invasive cervical cancer.
•Major features of this expanded surveillance case definition are that
it requires an HIV serological test, and includes a broader spectrum of
clinical manifestations of HIV such as tuberculosis, neurological
impairment, pneumonia, and invasive cervical cancer.
•The expanded definition is simple to use and has a higher specificity

52. Laboratory testing

53. Anonymous Testing –ICTC / VCTC
•No name is used
•Unique identifying number
•Results issued only to test recipient
23659874515
Anonymous

54. Blood Detection Tests
HIV enzyme-linked
immunosorbent assay (ELISA)
Screening test for HIV
Sensitivity > 99.9%
Western blotConfirmatory test : Specificity > 99.9% (when
combined with ELIZA
HIV rapid antibody testScreening test for HIV, Simpleto perform
Absolute CD4lymphocyte countPredictor of HIV progression, Riskof
opportunistic infections and AIDS when <200
HIV viral load tests
Best test for diagnosisof acute HIV infection
Correlates with diseaseprogression and response
to HAART

58. Treatment Options

59. HAART = Highly Active Anti-Retroviral
Treatment

60. Antiretroviral Drugs (HAART)
•Nucleoside Reverse Transcriptase inhibitors
•AZT (Zidovudine)
•Non-Nucleoside Transcriptase inhibitors
•Viramune(Nevirapine)
•Protease inhibitors
•Norvir(Ritonavir)

63. Health care follow up of HIV infected patients
•CD4 counts every 3–6 months
•Viral load tests every 3–6 months & 1 month following a change in therapy
•PPD
•INH for those with positive PPD and normal chest radiograph
•RPR or VDRL for syphilis
•Toxoplasma IgG serology

64. Health care follow up of HIV infected patients
•CMV IgG serology
•Pneumococcal vaccine
•Influenza vaccine in season
•Hepatitis B vaccine for those who are HBsAg -Negative
•Haemophilusinfluenzae type Bvaccination
•Papanicolaou smears every 6 months for women

65. Prevention & control
•Health education
•Abstinence
•Monogamous Relationship
•Protected Sex
•Sterile needles
•New shaving/cutting blades
•Blood safety
•Anti retroviral treatment

66. Post exposure prophylaxis
•First aid care;
•counseling and risk assessment;
•HIV testing and counseling; and,
•depending on the risk assessment, the short term (28-day) provision
of antiretroviral drugs,
•support and follow up.

67. Post exposure prophylaxis
•TDF + 3TC (or FTC) is recommended as the preferred backbone
regimen for HIV post-exposure prophylaxis among adults and
adolescents.
•AZT -r-3TC is recommended as the preferred backbone regimen for
HIV post-exposure prophylaxis among children 10 years and younger.
•A 28-days prescription
•Enhanced adherence counselling

68. Specific prophylaxis
•Primary prophylaxis against P. carinei pneumonia should be offered to
patients with CD4 count below 200 cells/pl.
•The regimens available are trimethoprine -sulfamethoxazole,
aerosolized pentamidine and dapsone.

69. Ending the HIV epidemic

71. Undetectable viral load