HIV:AIDS.PSM, COMMUNITY MEDINE,MBBBS,BPH,MD,MPH,DR NARENDRA KUMAR YADAV

HIV:AIDS.PSM, COMMUNITY MEDINE,DR NARENDRA KUMAR YADAV

1. HIV/AIDS DR NARENDRA KUMAR YADAV MD Community Medicine & Tropical Diseases, BPKIHS AIDS (Acquired Immunodeficiency Syndrome)

2. HIV/AIDS: Outline of the Chapter: History Burden of Disease Mode of transmission Clinical manifestations: Diagnosis of HIV/AIDS: Clinical Laboratory Diagnosis WHO Clinical Staging for HIV Infection New post exposure guideline for HIV Prevention and control of disease in the community

3. AIDS Patients: AIDS (Acquired Immunodeficiency Syndrome)

4. Case-Scenario: Q. Ms. Sabita, 28 years old who is intravenous drug user had presented in community hospital with significant weight loss and chronic diarrhoea for more than 2 months. On physical examination, multiple lymph nodes were palpable and tongue was coated with white plaques. On further inquiry she revealed she lost her husband 2 years back because of similar condition. What is your diagnosis? Justify your diagnosis. Describe the epidemiology of given disease. b. Discuss the various ways Sabita can transmit her disease to others. c. Explain the clinical stages of the disease. d. Discuss on prevention and control of disease in the community.

5. Case-Scenario: Q. A patient came to PHC with the complains of fever, diarrhoea, sore throat and rash. About 4 months before he had visited a brothel (Prostitute). Which screening test you will use for the provisional diagnosis and how will you conform the diagnosis? Write the various modes of transmission. Which are the major and minor criteria for the diagnosis? Discuss on prevention and control of disease in the community.

6. HIV/AIDS A/K/A: SLIMS DISEASE Causative Agent: HIV (HTLV-3, LAP). HIV (Human immunodeficiency virus): Lentivirus (Retrovirus) AIDS(Acquired immunodeficiency syndrome): Most advanced stage of the disease. AIDS: CD4 count is < 200 cells/mm 3 of blood ( WHO ) HIV to AIDS: 7-10 years ( Chronic Phase ) Incubation Period : Few months to 10 years NORMAL CD4 count: ( 800-1200 cells/ mm 3 ) HTLV-3: Human T-lymphotropic virus 3 LAP: Lymph adenopathy associated virus

7. History of HIV/ AIDS: First case of HIV in the WORLD was reported in: 1981 (USA) First case of HIV in INDIA was reported in : 1986 (Chennai) First case of HIV in NEPAL was reported in: 1988 HIV Virus Discovery: HIV-1: 1983 HIV-2: 1986 HIV 1 ( M/C ) > HIV 2

8. Epidemiology of HIV/AIDS : Burden of disease: WORLD: People Living with HIV/AIDS (PLHA) = 0.7% ( 37 Million) INDIA: People Living with HIV /AIDS (PLHA) = 0.22% ( 2.4 Million) NEPAL: People Living with HIV /AIDS (PLHA) = 0.13% ( 19,118) M/C Age group of having HIV Nepal / India: 30-44 years HIV afflicted age group in Nepal and India: (30-44 years) > (15-29 years) > (45 + years) > under 15

9. Epidemiological determinants of HIV/AIDS: Epidemiological triad of HIV/AIDS: 1. Agent factors: a. AGENT: HIV (HIV 1 > HIV 2) b. RESERVOIR OF INFECTION: Cases and Carriers. c. SOURCE OF INFECTION: The virus has been found in greatest concentration in blood, semen and CSF. 2. Host factors: a. AGE: (30-44 years) > (15-29 years) > (45 + years) > under 15 b. HIGH-RISK GROUPS: Bisexual men, multiple sexual partners, anal intercourse, prostitutes, intravenous drug abusers, transfusion recipients of blood and blood products .

10. High risk group of HIV infection: Sex workers iv drug users Transfusion recipients of blood and blood products. Transport workers Migrant Workers Health care workers Military and police

11. Mode of transmission: 1. Sexual transmission: M/C (90% Cases) (Male to Female) > (Female to Male) Anal intercourse > vaginal intercourse Heterosexual > Homosexual 2. Mother to child transmission (MTCT): A/K/A Vertical transmission ( 5% ) 3. Needle/ Syringe ( 2% ) 4.Blood contact: L/C Route of Transmission ( 0.5%-1% ) Pediatrics: Vertical transmission is M/C route of transmission.

12. Mode of transmission: Cont.… Efficiency wise: Most Efficient (most dangerous) route of HIV Transmission: Blood (90 % Chances) Least Efficient (least dangerous) route of HIV Transmission: Sexual (0.01 -1% Chances)

13. Mode of transmission: Cont.…

14. . Mother to foetus/infant transmission: through Placenta OR during delivery OR by breast-feeding . Transmission of HIV from mother to child can be prevented by: 1. Anti-retroviral drug prophylaxis to the mother and newborn after delivery. 2. Caesarian section before onset of labour & rupture of membrane 3. Refraining (avoiding) from breast feeding. Mother to child transmission (MTCT): A/K/A Vertical Zidovudine to mother antenatal and newborn after delivery.

15. Blood contact: By Contaminated Blood transfusion Blood contact: L/C Route of Transmission (0.5%) M/C Efficient Route of Transmission: Blood (90 % Chances) Needle/ Syringe: By Contaminated needle, syringe or any other skin-piercing instrument Needle-sharing by drug users

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

17. Clinical manifestations: Cont.… Initial infection with the virus and development of antibodies: Generally asymptomatic for the first 5 years. Except, mild illness ( fever, sore throat and rash ): 70% HIV antibodies appear in the blood-stream between 2 to 12 weeks. The period before antibodies are produced is the " window period ”: Highly infectious period.

18. Clinical manifestations: Cont.… 2. Asymptomatic carrier state (ACS): But no overt signs of disease, except persistent generalized lymphadenopathy. Infected people have antibodies.

19. Clinical manifestations : Cont.… 3.AIDS-related complex (ARC) ARC is caused by damage to the immune system , but without the opportunistic infections and cancer associated with AIDS. BUT, one or more of the following sign is present: a. Weight loss ≥   10% of body weight b. Fever, night sweat, fatigue, malaise etc. c. Oral thrush, Generalized lymphadenopathy Oral thrush

20. Clinical manifestations: Cont.… 4. AIDS: AIDS is the end-stage of HIV infection. AIDS: CD 4 count is < 200cells/mm 3 ( WHO ) AIDS opportunist infections with or without Cancer associated with AIDS are commonly occur at this stage. M/C Opportunistic infection: World: P. Jiroveci Pneumonia(PCP) Nepal/India: Tuberculosis (>Candida > PCP) M/C/C of death in AIDS : Uncontrolled or untreatable infection . AIDS associated Malignancy (cancer): NHL Kaposi sarcoma Cervix cancer

21. Q. M/C Opportunistic infection in AIDS: World: P. Jiroveci Pneumonia(PCP) Nepal/ India: Tuberculosis (>Candida > PCP) Q. AIDS defining Malignancy (cancer): NHL Kaposi sarcoma Cervix cancer

22. Opportunistic infection: CD4 < 200: Pneumocystis carinni and NHL CD4 < 100: Cryptococcus infection CD4 < 50: CMV

23. . DIAGNOSIS OF AIDS: Diagnosis Criteria for adult >12 years for Children

24. DIAGNOSIS OF AIDS: for adult >12 years . WHO case definition for AIDS surveillance : 2 major signs + 1 minor sign Major signs: Minor Signs: Weight loss ≥   10% of body weight Chronic diarrhoea > 1 month Prolonged fever > 1 month (Intermittent OR Constant) Persistent cough > 1 month Oropharyngeal candidiasis Generalized pruritic dermatitis H/O Herpes zoster infection 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.

25. DIAGNOSIS OF AIDS: for Children . WHO case definition for AIDS surveillance : 2 major signs + 2 minor signs Major signs: Minor Signs: Weight loss OR abnormally slow growth Chronic diarrhoea > 1 month Prolonged fever > 1 month (Intermittent OR Constant) Persistent cough Recurrent infection: Pharyngitis, Ear inf Oropharyngeal candidiasis Generalized rash Generalized lymphadenopathy

26. Laboratory Diagnosis: Screening Tests: ELISA (HIV Enzyme-Linked Immunosorbent Assay)   Western Blot: Previously Confirmatory Test was Western Blot. IOC: RT-PCR (Now, Confirmatory Test is RT-PCR). Absolute CD4 lymphocyte count CD4 lymphocyte % HIV viral load tests B2 - Microglobulin p24antigen CBC ELISA stands for Enzyme-Linked Immunosorbent Assay. RT-PCR stands for Reverse Transcription Polymerase Chain Reaction.

27. Herpes zoster infection Herpes simplex infection

28. Kaposi sarcoma:

29. WHO Clinical Staging for HIV Infection:

30. Prevention and control of HIV/AIDS in the community: Health education: Avoid unsafe sex (Use Condom) Avoid the sharing of needle and syringes Women suffering from AIDS should avoid becoming pregnant. 2. Prevention of Blood-Borne HIV transmission Screening of blood for HIV Pre-sterilized disposable syringe and needle 3. HAART (Highly active antiretroviral therapy):

31. New post exposure guideline for HIV

32. TB HIV Co infection: HIV is the most potent risk factor for TB. HIV-infection increases the risk of TB 20-fold compared with person without HIV. World: 10-15% of PLHIV are infected with TB. World: More than 1 million people have HIV/ TB co-infection . Early detection and effective treatment (DOTS): Reduce mortality

33. QQQQQ UNAIDS 90-90-90 Target UNAIDS 95-95-95 Target

34. Who and UNAIDS has define different types of hiv epidemics. Explain

35. HIV can be treated and prevented with antiretroviral therapy (ART). Untreated HIV can progress to AIDS, often after many years. There is no cure for HIV infection. It is treated with antiretroviral drugs, which stop the virus from replicating in the body.

36. MCQ Q . The first country in the world to report AIDS was: USA India Thailand Nepal

37. Ans: a (USA): 1981

38. MCQ Q. The first country in the South East Asian Region (SEAR) to report AIDS was: Sri Lanka India Thailand Nepal

39. Ans: C (Thailand): 1984

40. MCQ Q. HIV virus was discovered in the year: 1981 1983 1986 1996

41. Ans: b (1983) HIV-1 discovered in 1983 HIV-2 discovered in 1986 HIV discovered by: Robert Gallo(USA) Luc Montagnier, Barre Sinnousi (France): Awarded Nobel Prize

42. MCQ Q. The highest number of AIDS case in Nepal and India have occurred in age of: 0-14 years 15-29 years 30-44 years Above 45 years

43. Ans: C (30-44 years) HIV afflicted age group in Nepal and India: (30-44 years) > (15-29 years) > (45 + years) > under 15

44. MCQ Q. In a HIV infected child which vaccine should not be given: DPT OPV Hepatitis B Typhoid vaccine

45. Ans: b (OPV)

46. MCQ Q. M/C subtype of HIV in Nepal and India is: HIV-A HIV-B HIV-C Non of the above

47. Ans: C (HIV-C)

48. MCQ Q. The most common mode of HIV transmission in Nepal and India is: Blood transfusion Mother to child transmission Sexual transmission Use of unsterile syringes and needle

49. Ans: C (Sexual transmission) Route of transmission Percentage of total case Efficiency of route Sexual transmission 90% 0.01- 1% Mother to child transmission 05% 30% Sharing needles/ Syringes 02% 0.3% Blood and blood product 01% > 90%

50. MCQ Q. The commonest mode of transmission of AIDS in Nepal and India ( in Descending order) is: Transplacental, Homosexual, Heterosexual Homosexual, Heterosexual, Transplacental Heterosexual, Transplacental, Homosexual Heterosexual, Homosexual, Transplacental

51. Ans: C (Heterosexual, Transplacental, Homosexual) Route of transmission Percentage of total case Efficiency of route Sexual 87% 0.01- 1% Mother to child transmission 05% 30% Sharing needles/ Syringes 02% 0.3% Blood and blood product 01% > 90%

52. MCQ Q. Major signs for AIDS case definition according to WHO are all except: Prolong fever for >1 month Prolong cough for >1 month Chronic diarrhoea >1 month Weight loss >10%

53. Ans: b (Prolong cough for >1 month)

54. MCQ Q. HIV transmission Mother to Child can be stopped by all except: Caesarean Section Vitamin A Supplementation Stopping Breast feeding Zidovudine to mother antenatal and newborn after delivery

55. Ans: b (Vitamin A Supplementation) Vitamin A Supplementation neither increase nor decrease the risk of HIV

56. MCQ Q. HIV post exposure prophylaxis should be started with in: 24 hours 48 hours 72 hours 6 hours

57. Ans: c (72 hours)

58. . Bisexual men: Bisexual men are individuals who are attracted to both men and women. Homosexual: Homosexuality is a natural variation in human sexuality where individuals are emotionally and/or sexually attracted to people of the same gender. Heterosexual: Heterosexuality refers to a sexual orientation in which an individual is primarily or exclusively attracted to people of a different gender.

59. . Q why prevalence of HIV/ AIDS is high in Heterosexual than Homosexual??? Vaginal intercourse, which is common in heterosexual relationships, carries a higher risk of HIV transmission compared to some sexual activities among homosexual individuals.

60. . Q. Why aids prevalence is high in Military and police? High-Risk Behaviors : Some military and police environments may have factors that increase the risk of HIV transmission, such as multiple sexual partners, unprotected sex, drug use, and exposure to infected blood through injuries or medical procedures. Mandatory Testing : Some military forces may implement mandatory HIV testing as part of routine health screenings, which can lead to the identification of more cases compared to civilian populations where testing is voluntary.

61. . Non-Hodgkin lymphoma (NHL): Non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL) are two types of cancers that affect the lymphatic system, CD4: are A/K/A T cells/T helper cells of immune system. CD4 cells fight off infections and keep you from getting sick. Kaposi sarcoma: Cancer of skin or mucous membrane.

62. . Herpes zoster infection: A/K/A shingles, is caused by reactivation of Varicella zoster virus(VZV), the same virus that causes varicella (chickenpox) Herpes simplex infection: A/K/A herpes, is caused by herpes simplex virus. Two types: HSV1 and HSV2 Cryptococcal meningitis: an infection caused by the fungus Cryptococcus after it spreads from the lungs to the brain.

63. . During the window period of HIV infection, which is the time between initial infection and the development of detectable antibodies, standard antibody tests may not be able to detect the virus. However, during this window period, it is possible to detect the virus itself using nucleic acid tests (NATs) such as polymerase chain reaction (PCR) tests. These tests directly detect the genetic material of the virus (RNA) rather than relying on the presence of antibodies. NATs are highly sensitive and can detect HIV infection within days to weeks after exposure, much earlier than antibody tests.

64. The End