Human Immunodeficiency Virus

1. Saddam Ansari
Tbilisi State Medical University
Human Immunodeficiency Virus (HIV)

2. Introduction
Etiologic agent of Acquired Immunodeficiency
Syndrome (AIDS).
Discovered independently by Luc Montagnier of France
and Robert Gallo of the US in 1983-84.
Former names of the virus include:
Human T cell lymphotrophic virus (HTLV-III)
Lymphadenopathy associated virus (LAV)
AIDS associated retrovirus (ARV)

3. Introduction
HIV-2 discovered in 1986, antigenically distinct virus
endemic in West Africa.
One million people infected in US, 30 million
worldwide are infected.
Leading cause of death of men aged 25-44 and 4th
leading cause of death of women in this age group in the
US.

4. Characteristics of the virus
Icosahedral (20 sided), enveloped virus of the lentivirus
subfamily of retroviruses.
Retroviruses transcribe RNA to DNA.
Two viral strands of RNA found in core surrounded by
protein outer coat.
Outer envelope contains a lipid matrix within which specific
viral glycoproteins are imbedded.
These knob-like structures responsible for binding to target
cell.

5. Characteristics of the virus

6. Structural Genes
Three main structural genes:
Group Specific Antigen (Gag)
Envelope (Env)
Polymerase (Pol)

7. Group Specific Antigen (Gag)
Located in nucelocapsid of virus.
Icosahedryl capsid surrounds the internal nucleic
acids made up of p24 andp15.
p17 lies between protein core and envelope and
is embedded in the internal portion of the
envelope.
Two additional p55 products, p7 and p9, are
nucleic acid binding proteins closely associated
with the RNA.

8. Envelope (Env)
Envelope (Env) gene codes for envelope proteins gp160,
gp120 and gp41.
These polyproteins will eventually be cleaved by proteases to
become HIV envelope glycoproteins gp120 and gp41.
gp160 cleaved to form gp120 and gp41.
gp120 forms the 72 knobs which protrude from outer
envelope.
gp41 is a transmembrane glycoprotein antigen that spans the
inner and outer membranes and attaches to gp120.
gp120 and gp41 both involved with fusion and attachment of
HIV to CD4 antigen on host cells.

9. Polymerase (Pol)
Polymerase (Pol) codes for p66 and p51 subunits of
reverse transcriptase and p31 an endonuclease.
Located in the core, close to nucleic acids.
Responsible for conversion of viral RNA into DNA,
integration of DNA into host cell DNA and cleavage of
protein precursors.

11. Viral Replication
First step, HIV attaches to susceptible host cell.
Site of attachment is the CD4 antigen found on a
variety of cells
helper T cells
macrophages
monocytes
B cells
microglial brain cells
intestinal cells
T cells infected later on.

12. Early Phase HIV Infection
In early phase HIV
infection, initial viruses are
M-tropic. Their envelope
glycoprotein gp120 is able
to bind to CD4 molecules
and chemokine receptors
called CCR5 found on
macrophages

13. In late phase HIV infection,
most of the viruses are T-
tropic, having gp120
capable of binding to CD4
and CXCR4 found on T4-
lymphocytes.

14. Viral Replication
The gp120 protein on virus binds specifically to CD4
receptor on host cell with high affinity.
Gp41 causes fusion of the virus to the cell membrane.
After fusion virus particle enters cell.
Viral genome exposed by uncoating particle.

15. Viral Replication
Reverse transcriptase produces viral DNA from RNA.
Becomes a provirus which integrates into host DNA.
Period of latency occurs.

16. Viral Replication
After a period of latency lasting up to 10 years viral
replication is triggered and occurs at high rate.
CD4 cell may be destroyed in the process, body
attempts to replace lost CD4 cells, but over the course
of many years body is unable to keep the count at a safe
level.
Destruction of large numbers of CD4 cause symptoms
of HIV to appear with increased susceptibility to
opportunistic infections, disease and malignancy.

18. HIV (arrows) Infecting a T-lymphocyte

19. Viral Replication
Methods of transmission:
Sexual transmission, presence of STD increases
likelihood of transmission.
Exposure to infected blood or blood products.
Use of contaminated clotting factors by hemophiliacs.
Sharing contaminated needles (IV drug users).
Transplantation of infected tissues or organs.
Mother to fetus, perinatal transmission variable,
dependent on viral load and mother’s CD 4 count.

20. Transmission

21. Primary HIV Syndrome
Mononucleosis-like, cold or flu-like symptoms may
occur 6 to 12 weeks after infection.
lymphadenopathy
fever
rash
headache
Fatigue
diarrhea
sore throat
neurologic manifestations.
no symptoms (sometimes)

22. Primary HIV Syndrome
Symptoms are relatively nonspecific.
HIV antibody test often negative but becomes positive
within 3 to 6 months, this process is known as
seroconversion.
Large amount of HIV in the peripheral blood.
Primary HIV can be diagnosed using viral load titer assay
or other tests.
Primary HIV syndrome resolves itself and HIV infected
person remains asymptomatic for a prolonged period of
time, often years.

23. Clinical Latency Period
HIV continues to reproduce, CD4 count gradually
declines from its normal value of 500-1200.
Once CD4 count drops below 500, HIV infected person
at risk for opportunistic infections.
The following diseases are predictive of the
progression to AIDS:
persistent herpes-zoster infection (shingles)
oral candidiasis (thrush)
oral hairy leukoplakia
Kaposi’s sarcoma (KS)

24. Oral Candidiasis (thrush)

25. Oral Hairy Leukoplakia
Being that HIV reduces immunologic activity, the intraoral
environment is a prime target for chronic secondary infections and
inflammatory processes, including OHL, which is due to the Epstein-
Barr virus under immunosuppressed conditions

26. Kaposi’s sarcoma (KS)
Kaposi’s sarcoma (shown) is a
rare cancer of the blood vessels
that is associated with HIV. It
manifests as bluish-red oval-
shaped patches that may
eventually become thickened.
Lesions may appear singly or in
clusters.

27. AIDS
CD4 count drops below 200 person is
considered to have advanced HIV disease
If preventative medications not started the HIV
infected person is now at risk for:
Pneumocystis carinii pneumonia (PCP)
cryptococcal meningitis
toxoplasmosis

28. Contined…
If CD4 count drops below 50:
Mycobacterium avium
Cytomegalovirus infections
lymphoma
dementia
Most deaths occur with CD4 counts below 50.

29. Other Opportunistic Infections
Respiratory system
Pneumocystis Carinii Pneumonia (PCP)
Tuberculosis (TB)
Kaposi's Sarcoma (KS)
Gastro-intestinal system
Cryptosporidiosis
Candida
Cytomegolavirus (CMV)
Isosporiasis
Kaposi's Sarcoma

30. Continued…
Central/peripheral Nervous system
Cytomegolavirus
Toxoplasmosis
Cryptococcosis
Non Hodgkin's lymphoma
Varicella Zoster
Herpes simplex
Skin
Herpes simple
Kaposi's sarcoma
Varicella Zoster

31. Infants with HIV
Failure to thrive
Persistent oral candidiasis
Hepatosplenomegaly
Lymphadenopathy
Recurrent diarrhea
Recurrent bacterial infections
Abnormal neurologic findings.

32. Immunologic Manifestations
Early stage slight depression of CD4 count, few symptoms,
temporary.
Window of up to 6 weeks before antibody is detected, by 6
months 95% positive.
During window p24 antigen present, acute viremia and
antigenemia.

33. Immunologic Manifestations
Antibodies produced to all major antigens.
First antibodies detected produced against gag
proteins p24 and p55.
Followed by antibody to p51, p120 and gp41
As disease progresses antibody levels decrease.

34. Immunologic Manifestations
Immune abnormalities associated with increased viral
replication.
Decrease in CD4 cells due to virus budding from cells, fusion
of uninfected cells with virally infected cells and apoptosis.
B cells have decreased response to antigens possibly due to
blockage of T cell/B cell interaction by binding of viral proteins
to CD4 site.
CD8 cells initially increase and may remain elevated.
As HIV infection progresses, CD4 T cells drop resulting in
immunosuppression and susceptibility of patient to
opportunistic infections.
Death comes due to immuno-incompetence.

35. Immunologic Manifestations
Immune abnormalities associated with increased viral
replication.
Decrease in CD4 cells due to virus budding from cells, fusion
of uninfected cells with virally infected cells and apoptosis.
B cells have decreased response to antigens possibly due to
blockage of T cell/B cell interaction by binding of viral proteins
to CD4 site.
CD8 cells initially increase and may remain elevated.
As HIV infection progresses, CD4 T cells drop resulting in
immunosuppression and susceptibility of patient to
opportunistic infections.
Death comes due to immuno-incompetence.

36. Laboratory Diagnosis of HIV Infection
Methods utilized to detect:
Antibody
Antigen
Viral nucleic acid
Virus in culture

37. Western Blot
Most popular confirmatory test.
Utilizes a lysate prepared from HIV virus.
The lysate is electrophoresed to separate out the HIV proteins
(antigens).
The paper is cut into strips and reacted with test sera.
After incubation and washing anti-antibody tagged with
radioisotope or enzyme is added.
Specific bands form where antibody has reacted with different
antigens.
Most critical reagent of test is purest quality HIV antigen.
The following antigens must be present: p17, p24, p31, gp41,
p51, p55, p66, gp120 and gp160.

38. Western Blot
Antibodies to p24 and p55 appear earliest but decrease or
become undetectable.
Antibodies to gp31, gp41, gp 120, and gp160 appear later
but are present throughout all stages of the disease.

39. Western Blot
Interpretation of results.
No bands, negative.
In order to be interpreted as positive a minimum of 3 bands
directed against the following antigens must be present: p24,
p31, gp41 or gp120/160.
CDC criteria require 2 bands of the following: p24, gp41 or
gp120/160.

40. DNA PCRDNA PCR
RNA PCRRNA PCR
p24 Agp24 Ag
3rd gen ELISA
1st gen ELISA
Detuned ELISA
1wk 2wk 3wk 2mo 6mo 1yr 2yr 3yr +8yr
gp160
gp120
p68
p55
p53
gp41-45
p40
p34
p24
p18
p12
gp160
gp120
p68
p55
p53
gp41-45
p40
p34
p24
p18
p12
gp160
gp120
p68
p55
p53
gp41-45
p40
p34
p24
p18
p12
earlyrecent / establishedadvanced
Spectrum Spectrum
of anti-HIV of anti-HIV
testing testing

41. Western Blot
Indeterminate results are those samples that produce bands but
not enough to be positive, may be due to the following:
prior blood transfusions, even with non-HIV-1 infected blood
prior or current infection with syphilis
prior or current infection with malaria
autoimmune diseases (e.g., diabetes, Grave’s disease, etc)
infection with other human retroviruses
second or subsequent pregnancies in women.
run an alternate HIV confirmatory assay.
Quality control of Western Blot is critical and requires testing
with strongly positive, weakly positive and negative controls.

42. Testing of Neonates
Difficult due to presence of maternal IgG antibodies.
Use tests to detect IgM or IgA antibodies, IgM lacks
sensitivity, IgA more promising.
Measurement of p24 antigen.
PCR testing may be helpful but still not detecting antigen
soon enough: 38 days to 6 months to be positive.

43. The Move Toward Lower Pill Burdens
Dosing Daily pill burdenRegimen
1996
Zerit/Epivir/Crixivan10 pills, Q8H
2002
3 pills, BIDCombivir (AZT/3TC)/EFV
1998
Retrovir/Epivir/Sustiva5 pills, BID
2003
3 pills, QDViread/ Emtriva/Sustiva
2004
2 pills, QDTruvada/Sustiva