HIV presentation and discussion

1. HIV/AIDS

2. Introduction
Dr. Asif Nawas
TMC 5th
BD

3. 5 cases of Pneumocystis carinii5 cases of Pneumocystis carinii
pneumonia in 8 months inpneumonia in 8 months in
young homosexuals whoseyoung homosexuals whose
immune system had no apparentimmune system had no apparent
reason for mal functionreason for mal function
(Gottlieb et.al, 1981)(Gottlieb et.al, 1981)

4. December 1967 to NovemberDecember 1967 to November
1979 treatment (Pentamidine1979 treatment (Pentamidine
isothionate) was sought for twoisothionate) was sought for two
cases of pneumocystis cariniicases of pneumocystis carinii
pneumonia. These opportunisticpneumonia. These opportunistic
infection occurred due toinfection occurred due to
immunodeficiency caused byimmunodeficiency caused by
immunosuppressive drug orimmunosuppressive drug or
cancer.cancer.

5. In 30 months time 26 cases ofIn 30 months time 26 cases of
Kaposi’s sarcoma in youngKaposi’s sarcoma in young
homosexual men in New Yorkhomosexual men in New York
and California, many with P.and California, many with P.
Carinii + immunodeficiencyCarinii + immunodeficiency
(Hymes. K.B., et al 1981)(Hymes. K.B., et al 1981)

6. •Fever> 2 Months
•Diarrhoea > 2 Months
•Loss of Weight > 10% of body
weight within short period of time.
•Night sweat
• Lymphadenopathy
All were associated with acquired immune
deficiency
Acquired immune deficiency
syndrome or AIDS

7. New retrovirus from
Lymphadenopathy in a
homosexual in 1983-Prof Luc
Montagnier Pasteur institute,
Paris named Lymphadenopathy
Associated Virus (LAV) (Barre-
Sinoussi, F, et al, 1983)

8. Dr. Robert Gallo, National
Cancer Institute confirmed that
a retrovirus was the causative
agent of AIDS in 1984, named
HTLV-III (Gallo, R. et al.,
1984)
HTLV-I –1978
HTLV-II- 1981

9. Human Retroviurs subcommittee
of the international committee on
taxonomy of viruses (ICTV).
Recommended in 1986 the name
Human Immunodeficiency virus
(HIV) (Coffin, et al, 1986).

10. One HIV was isolated in Pasteur
Institute, Paris from a west African
patient (Calvel, et al,. 1986).

11. Virologist at Harvard School of
Public Health isolated one HIV
from a patient from Senegal
(Kanki, et al., 1986)

12. There were some difference in
antigenicity between these two
isolates and differences were
also noticed in clinical
manifestations produced in the
infected persons.

13. Human retrovirus sub
committee on taxonomy of
viruses (ICTV) subsequently
recommended that HIV-isolated
from western patient to be
named-HIV-1.
HIV isolated from African
patient was named HIV-2.

14. Transmission

15. •Sexual
•Parenteral
•Perinatal

16. Male Female
• Large surface area
• Higher concentration of HIV in semen
• Recipient of infectious material
• Menstruation
• Trauma is more frequent
• Dendritic cell
• Social cause
Sexual Transmission : (01 % to 1%)

17. Female MaleFemale Male
Male/FemaleMale/Female Male/FemaleMale/Female STD and TrumaSTD and Truma

18. Parenteral transmission
 Blood (100%) and blood product
 Syringe, needle (o.37%), surgery, dentistry,
tattooing ear-nose piercing, acupuncture, razor.

19. Perinatal (ET- 20% to 45%)
• Intrauterine
• During delivery
• Breast feeding 5% to 20%
15% to 30 %
* De Cock KM et al. JAMA, 2000, 283 (9):1175-1182
Risk of MTCT can be reduced below 2%
by intervention ( ARV, elective Caesar and
by completely avoiding breast feeding)
•Dorenbaum A et al. JAMA, 2002, 288 (2): 189-198.
•Thorne C, Newell ML. AIDS, 2004, 18 (2) 344-347.

20. Increased risk of HIV infection associated with common
STDs and their curability
STD Increased risk of
HIV infection
Curability
Gonorrhoeae + + Over 95%
Chlamydia + + Over 95%
Syphilis + + + Over 95%
Chancroid + + + + Over 95%
Trichomoniasis + Over 95%

21. Efficiency of HIV transmission by different routes
Efficiency
%
Global
infection%
Sexual
transmission
0.1 -1 75-85
Blood and Blood
project
> 90 5-10
Parenteral
(Needle) 0.37 Rare
Mother to child
25-35 (33) 5-10

22. Following are the materials, which areFollowing are the materials, which are
capable of transmitting HIV from infectedcapable of transmitting HIV from infected
person:person:
Blood
Semen
Vaginal fluid
Breast milk
Saliva
Sweat
Stool
Urine
Tear

23. HIV can be inactivated by
- Boiling-water in seconds (<Minute)
- 70% Ethanol
- 2% Gluteraldehyde
- 1% House hold bleach (available in the market as 3.5%)
- Soap and Water
- 5% Formaldehyde
- 10% Sodium hypochlorite
- 3% Hydrogen peroxide
- - 35% Isopropyl alcohol,
- 0.5% Lysol
2 - 5% Tween-20
30 minutes

24. Pathogenesis

25.  Incubation period
 Window period
 Acute infection
 Carrier state
 Constitutional symptoms (ARC)
 Carrier state
 Opportunistic infections
 Malignancy

27. Incubation periodIncubation period
2-12 weeks

28. Window periodWindow period
HIV in blood
No HIV antibody

29. Acute infection: (65%)
•Self limited Flue like syndrome
•Infectious mononeuclosis like syndrome with
lyaphadenopathy

30. Carrier state
Variable, HIV and HIV antibody both
present, CD4 cell count < normal but not
very low.

31. Constitutional symptoms (ARC)
• Fever for >2 months
• Diarrhoea for > 2 months
• Loss of weight > 10% of body wait within short
period.
• Night sweat
• Loss of appetite
• CD4 cell count low
• p24 positive

32. Opportunistic infections of AIDSOpportunistic infections of AIDS
1. Protozoal infections:
a) Pneumocystis carinii
b) Toxoplasma gondii
c) Cryptosporidium
d) Isospora belli

33. Opportunistic infections of AIDSOpportunistic infections of AIDS
2. Fungal infections:
a) Candida
b) Cryptococcus
c) Aspergillus

34. 3. Bacterial infections:
Opportunistic infections of AIDSOpportunistic infections of AIDS
a) Mycobacterium
b) Salmonella
c) Pyogenic bacteria

35. Opportunistic infections of AIDSOpportunistic infections of AIDS
4. Viral infections:
a) Herpes simplex virus (HSV)
b) Herpes zoster virus
c) Cytomegalovirus (CMV)

36. MalignancyMalignancy
1. Kaposi’s sacoma
2. Non-hodgkin’s lymphoma

37. HIV structureThe Human Immunodefeciency virus (HIV)

39. HIV Antibody Tests

40. HIV antibody test by ELISAHIV antibody test by ELISA
detects antibody to gp41detects antibody to gp41

41. Western BlotWestern Blot
INNO-LIATM
HIV
Confirmation

44. Reverse transcriptase inhibitor (RTI)Reverse transcriptase inhibitor (RTI)
Nucleoside RTI
Non Nucleoside RTI
Nucleotide analogs

45. –Engage reverse transcriptase
–Compete with normal nucleotide
(Produce defective DNA)
Nucleoside RTI

46. Non Nucleoside RTI
Engage reverse transcriptase and
blocks its activation site.

47. Nucleotide analogsNucleotide analogs
Tenofovi (TDF)

48. Some nucleoside analog
- Azido thymidine (AZT, Zidovudine)
- Dideoxythiocytidine (Lamivudine, 3 TC)
-Dideoxycytidine (Zalcitadine, DDC)
-Didanosine (ddI)
-Slavudine (d4T)

49. Non Nucleoside analog
Nevirapine
Efavirenz (EFV)

50. Protease inhibitors:
1. Indinavir
2. Ritonavir
3. Saquinavir
4. Nelfinavir (NFV)
Prevents cleavage of HIV gag-pol precursor
molecules by inhibiting protease enzyme by
binding to its active sites resulting into non
infectious HIV

51. Fusion inhibitorFusion inhibitor
Trial is going on
The fusion inhibitors T20 and T1249 are
synthetic peptides that bind to gp41 at
different regions and prevent the
conformational change in gp41 necessary to
facilitate fusion prior to virus entry.

52. Yearly cases detection (BSMMU)
Year Male (240) Female (62) Total (306)
1989 1 0 1
1990 2 0 2
1991 4 2 6
1992 2 0 2
1993 10 2 12
1994 9 4 13
1995 9 1 10
1996 23 6 29
1997 17 2 19
1998 11 1 12
1999 16 4 20
2000 23 8 31
2001 20 5 25
2002 31 7 40 (2 unknown)
2003 21 3 24
2004 18 4 23 (1 unknown)
2005 (Till Agust-22) 23 13 37 (1 unknown)

53. Total number cases detected by year in the Department
of Virology, BSMMU
0
5
10
15
20
25
30
35
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005(TillAgust-22)
Male (240)
Female (62)

54. Total number cases detected by year in the Department
of Virology, BSMMU
0
5
10
15
20
25
30
35
1989
1991
1993
1995
1997
1999
2001
2003
2005(TillAgust-22)
Male (240)
Female (62

55. Detected HIV case in Bangladesh
Year Male (380) Female (77) Total (465)
1989 1 0 1
1990 2 0 2
1991 4 2 6
1992 2 0 2
1993 10 2 12
1994 9 4 13
1995 9 1 10
1996 23 6 29
1997 17 2 19
1998 11 1 12
1999 16 4 20
2000 23 8 31
2001 22 5 31 (4 unknown)
2002 47 13 60
2003 112 3 115
2004 72 26 102 (4 unknown)

56. Detected HIV case in Bangladesh
0
20
40
60
80
100
120
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004(Till1stDecember)
Male (380)
Female (77)

57. Age Male (201) Female (45)
0-4 1 2
5-9 2 1
10-14 1 1
15-19 2 8
20-24 8 11
25-29 49 9
30-34 49 4
35-39 27 2
40-44 19 2
45-49 10 0
50-54 2 0
55-59 0 0
60-64 0 1
Not available 31 4
Age Distribution of HIV/AIDS patients detectedAge Distribution of HIV/AIDS patients detected
till 1till 1stst
December, 2003 (BSMMU)December, 2003 (BSMMU)

58. Age distribution of HIV/AIDS cases detected till 1st
december, 2003 (BSMMU)
0
10
20
30
40
50
60
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
Not
Male (201)
Female (45)

59. Risk factors in BangladeshRisk factors in Bangladesh
Low awareness
High STD prevalence
Large number of CSWs
– High client output
– Low condom use 20 %
MSM
STD patients

60. Risk factors in BangladeshRisk factors in Bangladesh
• IVDU
• Emigrant workers
• Trafficked women
• Surrounded by high prevalent countries
• Porous border
•Electronic media.
• Religion (Complacency)
•Poverty

61. • Internal movement of population
• Rural:
syphilis women 1%
• Urban slum:
Syphilis women 5.2 %
Syphilis men 11.8 %
Risk factors in BangladeshRisk factors in Bangladesh

62. Immunity of BangladeshImmunity of Bangladesh
Religion
Social norm
Familial bondage
Safe blood transfusion
Improvement in syringe and needle

63. Country 1988 1989 1991 1995 2001 2002
Thailand 1% 39% - - - -
Myanmar 0% - 71% - - -
Monipur
(India)
1% - - 56% - -
Bangladesh - - - - 1.7% 4%
IVDU

64. StigmaStigma
Sexual Transmission
Mortality rate 100%
Misconception (Transmission)

65.  Loss of job
 Children out of school
 Isolated from society
 Left out by the family
 Become friend less
 Deprived of health care
 Loss of hope
 Measurable life
DiscriminationDiscrimination

66. Indicators of vulnerabilityIndicators of vulnerability
20052005
IVDU CSW MSM STI Anti-Natal
Patients
HIV 4.9% <1% <1% <1% <1%
Syphilis 9.4 - 19% 13.6 - 32.6% 6.2 - 11.8% 3.8% 1% - 5.2%

67. StudentsStudents
50% of male STD patients are students
 80% of the students acquired STD from CSWs

68. From 2007 to 2013From 2007 to 2013
Years HIV
Positive
Increases AIDS Increases Death
2007 1207 - 365 - 123
2008 1495 288 476 111 165
2009 1745 250 619 143 204
2010 2088 343 850 231 241
2011 2533 445 1101 251 325
2012 2916 383 1204 103 65
2013 3286 370 1303 099 82
2014 - - - - -

69. Thank youThank you