HIV (Human Immunodeficiency Virus)&AIDS

For final year MBBS students.

2. HIV
(Human Immunodeficiency Virus)
AIDS (Aquired Immunodeficiency Syndrome)
By -
Shalini Tiwari
Shishir verma
Moderator - Dr Supriya
and

3. Overview of Presentation
•Introduction
•Problem Statement
•Pathogenesis and Mode of Transmission
•Clinical Manifestation
•Diagnosis and clinical Staging
•Management
•Post Exposure Prophylaxis
•NACP

4. DEFINITION:
AIDS:

AIDS is defined as the occurrence of life threatening
opportunistic infections (OIs) , malignancies,
neurological diseases and other specific illness in
patients with HIV infections and CD4 counts <200
cells/cubic mm.

5. Structure :

●Type of RNA virus
●Belongs to Retroviridae family and Lentivirus Genus
●Two types -
1) HIV 1 ( most common)
2) HIV 2
●Enveloped virus
●Envelope is made up of 2 components -
1. Lipid part (host cell membrane derived)
2. Protein part :
a) gp120 - main receptor of HIV that
Binds to CD4 cells of host


b) gp41 - Fusion protein
●Viral enzymes - 1) reverse transcriptase
2) Protease
3) Integrase
● Two identical copies of single stranded linear RNA

6. Disease Burden:
Global HIV Statistics :
● Estimated 39million people living with HIV (2022)
●⅔ of total are in African region alone
●1.3 million people acquired HIV
●0.63 million died from HIV related causes
●Out of all people living with HIV
A)86% knew their status
B) 76% were receiving ART
C) 71% have suppressed viral loads

7. National HIV Status
●Estimated number of people living with HIV - 2.5 million
●Estimated number of people newly infected - 0.06 million
●Estimated number of death due to HIV - 0.04 million
●Out of people living with HIV
A) 79% know their status
B) 68% receive ART
C)63% have suppressed viral load

8. Key Population Affected in India
•Intravenous Drug Users
•Transgender
•Male who have Sex with Male (MSM)
•Female Sex Worker
•Inmates
•Truck drivers
•Migrants
•ANC

9. Pathogenesis

10. Mode of Transmission

11. Clinical Manifestation
1. Initial infection with virus and development of
antibodies.

-70 % people experience mild illness
( fever , sore throat ,rash )
- No other specific symptoms for first 5 yrs
- HIV antibodies appear 2-12 weeks after

12. 2. Asymptomatic Carrier stage
•No overt sign of disease but antibodies present
•Persistent generalized lymphadenopathy

13. 3.AIDS related complex
•Unexplained diarrhea (>1month)
•Fatigue , malaise
•>10% loss of body weight
•Fever
•Night sweats
•Oral thrush
•Generalized lymphadenopathy
•Enlarged spleen
(Opportunistic infection absent)

14. 4.AIDS
•End stage of HIV infection
•Opportunistic infections occur
•Death mainly due to uncontrolled or untreatable
infection

16. Diagnosis of adults and children > 18 months of age
1. For clinically symptomatic individuals

17. 2. For clinically asymptomatic individuals

18. Diagnosis of HIV infection in infants and
Children less than 18 months of age

●NACO recommends use of TNA PCR test on dried
blood spot sample
●Detection of viral nucleic acids for diagnosis of HIV
1 infection
●Done at 6 weeks of age or at the earliest

19. Diagnosis of AIDS
1.WHO case Definition for AIDS Surveillance
Clinical
For purpose of AIDS surveillance an adult or adolescent
(>12 years of age) is considered to have AIDS if atleast 2
of the following major signs are present in combination
with atleast 1 of the minor signs listed here and if these
signs are not known to be due to a condition unrelated
to HIV infection.

21. Children
The case definition is fulfilled for AIDS is fulfilled if
atleast 2 major and 2 minor signs are present in
absence of any other known cause of
immunosuppression.

23. 2.Explained WHO case Definition for AIDS Surveillance
For the purpose of AIDS surveillance an adult or
adolescent (>12 years of age) is considered to have AIDS
if a test for HIV antibody gives a postive result and one
or more than one of the following conditions are
present.

26. Treatment

●All HIV positive patients should be treated irrespective of
CD4 cell count .

●Classification of Anti Retroviral drugs:

●Goals of ART

●Rapid ART initiation algorithm

●Drug Regimen:

28. Goals of ART

30. Drug Regimen
3 Drug combination
Nucleotide Reverse Transcriptase inhibitors + NRTI +
Integrase Inhibitor (Preferred combination)

TED regimen
Tenofovir disoproxil (300mg OD)+ Emtricitabine (200 mg
OD ) + Dolutegravir (50mg OD)

•NACO regimen/ TLD regimen:
Tenofovir disoproxil (300 mg OD) + Lamivudine (300mg) +
Dolutegravir (50mg OD)

31. According to age, regimens are:

1) > 10 yrs/> 30 kg

TLD regimen:

Tenofovir disoproxil fumarate (300 mg) + Lamivudine (3TC) 300 mg +
Dolutegravir (DTG) 50 mg

* Fixed dose combination at same time everyday.

C/I of TLD:
•< 10 yrs of age.
•Low weight.
•Renal & hepatic dysfunction.

32. 2) 6-10 yrs/20-30 kg

ALD regimen
Abacavir + Lamivudine + Dolutegravir.

3) <6 yrs/< 20 kg

AL+ LPV/r
Abacavir + Lamivudine + lopinavir/ritonavir

33. Clinical failure in adults and adolescents:

Development of a new or recurrent WHO stage 3 or 4 conditions,
while on treatment (after the first 6 months), is considered functional
evidence of the progression of HIV disease.

Clinical failure in CLHIV:

•New/recurrent WHO stage 4 condition (after 6 months of ART)
•Growth failure
•Progressive neurologic developmental deterioration
* Different condition than IRIS

34. Monitoring of patients on ART

35. Few side effects of ARV drugs:


●Tenofovir- Renal toxicity,bone demineralisation
●Zidovudine - Anemia, neutropenia, headache, insomnia
●Abacavir- Hypersensitivity reaction (3-5% people), respiratory
symptoms
●Efavirenz- Dizziness, hallucinations
●Nevirapine - Hepatitis, severe skin rashes
●Dolutegravir- Insomnia, weight gain, tiredness
●Ritonavir- GI symptoms

37. Case (1)
A known HIV + patient conceives and is already
on ART

Here, we will continue same regimen throughout
pregnancy,labour, breastfeeding and lifelong if responding to it
adequately.

38. Case( 2)
Newly diagnosed case of HIV in a pregnant female

Here, we will start ART immediately without any delay
irrespective of
●gestational age
●CD4 count
●WHO clinical staging and continue it lifelong

First line regime for HIV infected pregnant woman:
•Tenofovir (TDF) 300mg + Lamivudine (3TC) 300mg + Efavirenz
(EFV) 600mg (If no prior exposure to NNRTIs NVP/EFZ at any
gestational age).

39. Case (3)
HIV positive Pregnant female with previous
exposure to Nevirapine (NVP) /Efavirenz in
previous pregnancy.


Here , Efavirenz is ineffective; start on

Tenofovir 300 mg (1tab/day) + Lamivudine 300 mg (1 tab/ day)
+ Loponavir 200mg / Ritonavir 50mg (2 tabs BD daily)

40. Case (4)
Pregnant female in labour with unknown HIV status
(unbooked case) .

•Routine screening test ( whole blood finger prick ) with opt out option.
If patient refuses test ; follow universal precautions during delivery and
continue.
Step (1) If screening is positive,initiate 3 drug regimen [Tenofovir (TDF)
300mg + Lamivudine (3TC) 300mg + Efavirenz (EFV) 600mg]
immediately.
Step (2) Next day send 3 rapid antibody tests for confirmation and send
CD4 counts (ICTC center).

And continue ART post partum if antibody tests positive.

41. HIV 2 in Pregnancy
It is rare and slower progression to AIDS than HIV 1.
Less transmissible from mother to child.
NNRTI drugs like NVP,EFZ aren't effective against HIV 2.

Treatment regimen:
•Tenofovir (TDF) 300mg + Lamivudine (3TC) 300mg + Lopinavir
800mg /Ritonavir 200 mg
* Zidovudine (AZT) to be given to the infant for 6 weeks.

Note: Preferred mode of delivery is Vaginal Delivery (unless
there is any obstetric indication for LSCS)

42. Cotrimoxazole (CPT) prophylaxis

Role:
Helps reducing morbidity and mortality by preventing opportunistic
infections.

Criteria for CPT prophylaxis:
* CD 4 counts < 350cells/cubic mm
•WHO clinical stage 3 & 4

Regimen: 1 double strength tablet Cotrimoxazole
(Sulfamethoxazole/ Trimethoprim) (800mg /160mg) OD

Alternate regimen: Dapsone (100 mg) OD daily

43. POST EXPOSURE PROPHYLAXIS (8)
Comprehensive management instituted to
minimize the risk of infection following potential
exposure to blood borne pathogens (HIV, HCV,
HBV)

44. Who is at risk?

•emergency care providers
•Nursing staff &Labour room personnel
•Surgeons and OT staff
•Laboratory technicians, mortuary staff , waste handlers
* Physicians and Interns

Management of the exposed person:

* Standard workplace precautions by the care giver
* First aid to the exposure site
•Etablishment of eligibility of PEP
•Counselling for PEP
•Assessing need for PEP and prescribing PEP

46. Category of exposure:
1) Mild
Mucous membrane/non intact skin with small volume

2) Moderate
Like superficial cut or needle stick injury penetrating glove

3) Severe
Percutaneous exposure with large volume
•accident with high calibre needle (>18G)
•deep wound
•accident with material used earlier IV or intra-arterially.

47. Category of situations

49. NACO recommendation for PEP for health care personnel
based on exposure and HIV source code

50. PEP regimen

51. NATIONAL AIDS CONTROL PROGRAM ( NACP )
●Started by NACO
●Started in 1992 (Phase 1) , currently Phase 5
●It comes under Ministry of Health and Family Welfare
●World AIDS Day -1 December
Targets:
●Reduce new HIV by 80%
●Reduce HIV deaths by 80%
●Elimination of vertical transmission of HIV & Syphilis
●Achieve zero discrimination and social stigma

52. NACP
●>80% reduction in HIV incidence by 2024 compared to
2010

●95 - 95 - 95 Strategy
95 % patients should be diagnosed
95 % of PLHIV should be on treatment
95 % should have decreased viral load
Sustainable Development Goals (3)
●End HIV / AIDS epidemic by year 2030

53. Targeted interventions

Specific interventions packages in highly vulnerable
populations ,i.e,

●Commercial sex workers, Transgenders
●Men having sex with men
●Migrant labourers, street children, Adolescents
●Long distance truck drivers
●Injecting drug users(Highest P)

54. ICTC
(Integrated Counseling & Testing Centre)

For HIV screening and counselling.
Levels
●Standalone ICTC
●Facility Integrated ICTC centres(m/c)
●Mobile ICTC

55. PPTCT
(Prevention of Parent to child transmission)

Vision:
Women and children alive and free from HIV

Goal:
●To eliminate Paediatric HIV
●To improve Maternal life(Living with HIV)

57. References:

•https://www.who.int/news-room/fact-sheets/detail/hiv-aids
•Park's textbook of Preventive & Social Medicine(27th edition)
•NACO 2021 guidelines
•https://www.hiv.gov/hiv-basics/overview/about-hiv-and-aids/what-
are-hiv-and-aids
•https://hivinfo.nih.gov/understanding-hiv/fact-sheets/hiv-treatment-
basics