4. People living with HIV(2016)
• About 64% are in sub-Saharan Africa
• New HIV infections in 2016 -1.8
million [1.6 million–2.1 million]
• About 5000 new HIV infections (adults
and children) a day
• 17.8 million [15.4 million–20.3 million]
women
• 2.1 million [1.7 million–2.6 million]
children (<15 years)
Source: UNAIDS factsheet 2016
4
6. AIDS related deaths
Total estimated deaths since
1981 – 36 million
Deaths in 2016 – 1 million [830
000–1.2 million]
Source: UNAIDS factsheet 2016
6
7. INDIA
National adult (15–49 years) HIV
prevalence estimated at 0.26%
(0.22%–0.32%)
0.30% among males
0.22% among females
Manipur (1.15%) > Mizoram
(0.80%) >Nagaland (0.78%)>
Andhra Pradesh & Telangana
(0.66%),
Prevalence of HIV in India (1990-2015)
SOURCE : NACO ANNUAL REPORT 2016-177
8. People living with
HIV in India
• Estimated at 21.17 lakhs
(17.11 lakhs–26.49 lakhs)
compared with 22.26 lakhs
(18.00 lakhs-27.85 lakhs) in
2007.
• New infections in 2015
estimated to be around 86
(56–129) thousand
• Selected state distribution of
people living wit HIV AIDS.
Source : NACO ANNUAL REPORT 2016-17
8
12. • High risk groups :
• Intravenous drug users (9.9%)
• Trans genders (8.82%)
• MSM (men having sex with
men)(4.3%)
• Truckers (2.59%)
• Female sex workers (2.2%)
• Migrants (0.99%)
• ANC (0.29%)
0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00%
ANC
Migrants
FSW
Truckers
MSM
Transgenders
IDUs
Prevalence of HIV in high risk groups in India
SOURCE : NACO ANNUAL REPORT 2016-17
12
13. AIDS Related Deaths
An estimated 67.6 [46.4–106.0]
thousand people died of AIDS-
related causes nationally
Since 2007 the annual number
of AIDS- related deaths has
declined by 54%
Decline consistent with the
rapid expansion of access to
ART.
Source : NACO ANNUAL REPORT 2016-17
13
14. New Delhi (2015)
• Estimated Prevalence – 0.23% (
0.10-0.50)
• People living with HIV (adults and
children – 30,216 (11,874 – 67,917)
• Annual new infections – 1,591(641-
3365)
• AIDS related deaths – 331(182-744)
Source : NACO state fact sheet 2014
14
15. AGENT : HUMAN IMMUNO DEFICIENCY VIRUS
• Icosahedral (20 sided), enveloped
virus of the lentivirus subfamily of
retroviruses.
• 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. 15
16. HIV I : More virulent and widespread (M
subtype)
HIV 2 : Less virulent and mostly concentrated in
west African region
16
17. HISTORY :
• 1981 – beginning of the epidemic in united states
• 1983 - Discovery of a new retrovirus called Lymphadenopathy-
Associated Virus (or LAV)
• 1984- National Cancer Institute found the cause of AIDS, the
retrovirus HTLV-III.
• I1986 - the International Committee on the Taxonomy of Viruses
officially named HIV (human immunodeficiency virus)
• 2008- Luc Antoine Montagnier received Nobel Prize in
Physiology and medicine for his discovery of the human
immunodeficiency virus (HIV).
17
19. • First step, HIV attaches to
susceptible host cell.
• Site of attachment is the CD4
antigen found on a variety of
cells:
• macrophages
• monocytes
• B cells
• microglial brain cells
• intestinal cells
• T cells (infected later on)
Viral Replication
19
20. 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
20
21. • 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.
21
22. Reservoir
• All cases and carriers are
reservoir for the infection
• Once a person is infected
the virus remains in the
body life long
• The risk of developing AIDS
increases with lifetime
• Symptomless carriers can
infect other people for
years
22
23. Source of infection
Virus can be isolated from :
Brain tissue Lymph nodes
Bone marrow cells Skin
high low none
Blood Cervical and vaginal
secretions
Tears
Semen Breast milk Saliva
CSF Urine Feaces
23
24. Modes Of Transmission
• Transmission through
sexual route
Homosexual
Heterosexual
• Transmission through
infected blood and
blood products
• Intravenous drug
injection
• Vertical transmission –
mother to child
Transmission percentage in India
Heterosexual
blood and blood products
intavenous drug injection
Mother to child
Homosexual
24
25. Sexual Transmission
• Unprotected Vaginal Anal or oral sex with an infected person exposes the
uninfected partner to the risk of infection
• A European study suggests that transmission of HIV infection from male to female
is twice as likely from female to male
• Anal intercourse carries higher risk of transmission than vaginal
• Exposed adolescent girls and women aged above 45 years more prone to get
infected
• Associated STD in either partner facilitates risk of transmission 8 to 10 times
• HIV positive partners more infectious during “window period” and when infection
is well advanced
25
26. Blood contact
• Contaminated blood cells, platelets and factor VIII and IX derived from human plasma
• Risk of contracting HIV infection from transfusion of a unit of infected blood is over 95%
• Significant route of transmission in intravenous drug users because of repeated exposure
• Any skin piercing
• Injection
• Ear piercing
• Tattooing
• Accupuncture
• scarification
26
28. Host Factors
High risk groups :
Intravenous drug users
(9.9%)
Trans Genders(8.82%)
MSM(men having sex with
men)(4.3%)
Truckers(2.59%)
Female sex workers(2.2%)
ANC (0.29%)
Bridge population :
Migrants
Long Distance Truckers
Source : NACO Annual Report 2016- 2017
28
29. Some Definitions
• ARV (antiretroviral) drugs refer to the medicines used to treat HIV.
• ART (antiretroviral therapy) refers to the use of a combination of
three or more ARV drugs for treating HIV infection. ART involves
lifelong treatment.
• Viral suppression refers to a viral load below the detection threshold
using viral assays.
• Viral failure is defined by a persistently detectable viral load
exceeding 1000 copies/mL (two consecutive viral load
measurements within a 3-month interval) after at least 6 months of
using ART.
29
30. • Universal access to ART is defined broadly as a high level of
treatment coverage (80% or more of the eligible population)
that is accessible and affordable. It does not necessarily
mean 100% coverage
• Substantial risk of HIV infection: is provisionally defined as
HIV incidence around 3 per 100 person-years or higher in
the absence of PrEP.
• HIV incidence higher than 2 per 100 person-years is
considered sufficient to warrant offering oral PrEP in the
recommendations issued by the International Antiviral
Society
30
31. Continuum of linkage to care and prevention
Create
demand
for HIV
testing and
treatment
Link to
HIV testing
Deliver
pre-test
information
HIV
diagnosis
Post test
counselling
Refer and
link to
other
health
services
31
32. Contents of Pre test Counselling
• Information on HIV and AIDS
• Benefits of HIV testing
• “Opt out” testing
• Risk assessment of the individual
• Information on genital, menstrual and sexual hygiene
• Information on spouse/sexual partner testing
• Conduct symptomatic screening for STI/RTI
• Conduct verbal screening (4 Symptom Screening) for tuberculosis
32
33. Diagnosis of HIV Infection
• Laboratory diagnosis by HIV testing is the only method of
determining the HIV status
• HIV diagnosis is made by either demonstrating the presence
of virus or viral products in the host
• Serological assays to detect HIV specific antibodies or by
• Nucleic Acid Amplification Test (NAAT) to detect HIV
nucleic acids
33
34. Serological Diagnosis of HIV Infection
• These tests are used as screening tests and/or confirmatory
tests.
• Commonly used screening tests are:
1. Enzyme Linked Immunosorbent Assay (ELISA)
2. Rapid tests
• Immunoconcentration /Dot Blot assay (vertical flow)
• Agglutination assay
• Immunochromatographic assay (lateral flow)
• Dipstick and comb assay based on Enzyme Immune Assay
(EIA)
34
35. • Rapid Anti-HIV Tests
• Visual point of care tests, do not require any special equipment.
Available in smaller test packs.
• Suitable for a laboratory that tests small number of specimens.
• Technically simple to perform. Most of them have sensitivity and
specificity comparable to an ELISA.
• Western Blot Test
• WB tests detect the presence of antibodies against specific HIV
proteins, similar to ELISA test, except that the product is insoluble
• WB tests are a highly specific conformational test. NACO is presently
providing it at the National Reference Laboratory level
35
36. Limitations of Antibody Assays
• Window period
• Children below 18 months of age.
• NACO is now promoting the use of the DBS technique for
early infant diagnosis, based on the detection of HIV-1 DNA
viral nucleic acid
36
37. EID
• Maternal HIV antibody can persist for as long as 18 months
in children born to HIV-infected mothers.
• Breastfed children have ongoing risk for HIV transmission,
HIV infection can only be excluded after 6 weeks of complete
cessation of breast-feeding.
• In the current Early Infant Diagnosis (EID) program,
virological tests i.e. HIV-1 DNA PCR by Dried Blood Spot
(DBS) and on Whole Blood Sample (WBS) are being done for
infants and children below 18 months of age.
37
39. Detection of Acute HIV Infection
• NAT
• NATs include tests for the qualitative detection of HIV-1 DNA or RNA,
as well as the quantitative detection of HIV-1 RNA (viral load
determination) through various assays
39
qualitative quantitative
• Qualitative Polymerase Chain
Reaction for HIV DNA
• Qualitative Polymerase Chain
Reaction for HIV RNA
1) Quantitative HIV-1 RNA assays
detect plasma (cell-free) viral RNA by
using various techniques
2) Signal amplification by branched-
chain DNA technique (Bdna)
43. NACO HIV Testing Strategies
• Strategy 1 : Blood
transfusion/transplant safety
• Strategy 2 A: used in sentinel
surveillance
43
44. • Strategy 2 B: used for diagnosis in
symptomatic patients
• Strategy 3 (used for diagnosis in
asymptomatic patients)
44
45. • Assays A1, A2, A3 represent 3 different assays based on different
principles or different antigenic compositions. Assay A1 should be of
high sensitivity and A2 and A3 should be of high specificity.
45
46. HIV testing for Adults and Children (above the age of 18 months)
• In view of the low prevalence of HIV in India, it is recommended to
use three different principles or antigen-based rapid tests to confirm
the diagnosis.
• Screening: At an F-ICTC, PPP–ICTC, mobile F-ICTC, community-based
screening etc. - using a single rapid test kit.
• Confirmation: Confirmation is done at an SA-ICTC using three rapid
tests of three different antigens or principles.
• Individual is considered HIV-negative if the first test is nonreactive
And
• HIV-positive when all two/ three tests show reactive results.
46
47. Linkage
• HIV Testing is the entry point for those at risk and PLHIV, so it must be
linked to various other service providers to meet the need of better
preventive services and a quality life to PLHIV.
47
48. UNAIDS: 90-90-90 Targets
• Reach the following goals by
2020.
o90% of PLHIV should know
HIV status
o90% of diagnosed to receive
ART
o90% of those on ART to have
suppressed viral load.
48
49. Goals of ARV therapy
• Clinical goal : Prolongation of life and improvement in quality
of life
• Virological goal : Greatest possible reduction in viral load.
• Immunological goal : Immune reconstitution.
• Therapeutic goal : Rational sequencing of drugs to achieves
clinical, virological and immunological goals, limiting drug
toxicity and facilitating adherence
• Reduction of HIV transmission in individuals : by suppression
of viral load
49
51. 2016 WHO GUIDELINES ON WHEN TO START ART
Target
population
Specific recommendation
Adults ART to be initiated in all adults living with HIV at any CD4 cell count
As a priority, initiation in WHO clinical stage 3 or 4 and individuals with CD4 count less
than equal to 350 cells/mm3
Adolescent ART to be initiated in all adolescents living with HIV at any CD4 cell count
As a priority, initiation in WHO clinical stage 3 or 4 and individuals with CD4 count less
than equal to 350 cells/mm3
Pregnant &
BFW
ART should be initiated in all pregnant and BFW living with HIV at any CD4 cell count
and continued lifelong
51
52. Children (1-
10 yrs)
ART to be initiated in all mentioned group living with HIV at any CD4
cell count
As a priority, ART should be initiated among all children <2 yrs old and in WHO
clinical stage 3 or 4 and individuals with CD4% <25% ( if < 5 yrs old )or CD4 count
less than equal to 350 cells/mm3 ( if greater than equal to 5 yrs old)
Children (<1 yr) ART to be initiated in all mentioned group living with HIV at any CD4
cell count
Recommendation: Oral pre-exposure prophylaxis to prevent HIV infection
HIV negative
individuals at
substantial risk
of HIV infection
Oral PrEP ( containing TDF) should be offered as an additional
prevention choice as part of combination prevention approaches
52
57. HIV & TB Co- infection
• CBNAAT for rapid diagnosis of TB among PLHIV.
• ART should be started in all TB patients living with HIV,
regardless of CD4 cell count.
• TB treatment should be initiated first, followed by ART,
possibly within the first 8 weeks of treatment.
• HIV-positive TB patients with profound immunosuppression
(e.g. CD4 counts less than 50 cells/mm3) should receive ART
within the first two weeks of initiating TB treatment.
57
58. Patient flow for initial TB screening and for IPT at ART Centre
58
59. Opportunistic Infections
Clinical Picture Actions
Any undiagnosed active
infection with fever
Diagnose and treat first; start ART when stable
TB Treat TB first; start ART as recommended
PCP Treat PCP first; start ART when PCP treatment is completed
Invasive fungal diseases:
oesophageal
candidiasis, cryptococcal
meningitis, penicilliosis,
histoplasmosis
Treat esophageal candidiasis first; start ART as soon as the patient can swallow
comfortably
Treat cryptococcal meningitis, penicilliosis, histoplasmosis first; start ART
when patient is stabilized or OI treatment is completed
Bacterial pneumonia Treat pneumonia first; start ART when treatment is
completed
Malaria Treat malaria first; start ART when treatment is completed
59
60. Opportunistic Infections
Drug reaction Do not start ART during an acute reaction
Acute diarrhoea which may
reduce absorption of ART
Diagnose and treat first; start ART when diarrhoea is stabilized or
controlled
Non-severe anaemia (Hb <
8 g/litre)
Start ART if no other causes for anaemia are found (HIV is often the cause
of anaemia); avoid AZT
Skin conditions such as
dermatitis, psoriasis, HIV-
related exfoliative
dermatitis
Start ART (ART may resolve these problems)
Suspected MAC,
cryptosporidiosis and
microsporidiosis
Start ART (ART may resolve these problems)
Cytomegalovirus infection Treat if drugs available; if not, start ART
Toxoplasmosis Treat; start ART after 6 weeks of treatment and when patient is stabilized
60
61. Opioid Substitution Therapy
• Drugs recommended
• Methadone and buprenorphine
• OST programmes in India use buprenorphine sublingual tablets
• Methadone based OST launched recently at RIMS, Imphal.
61
62. Post Exposure Prophylaxis for HIV
Eligibility of post-exposure prophylaxis
• Commencement within 72 hrs of possible
infection
• Based on HIV status of the source whenever
possible
• Parenteral or mucus membrane exposure and
certain body fluids like blood, breast milk, genital
secretions etc. can pose risk
• PEP not required when the exposed individual is
already HIV positive and source is established to
be HIV negative and exposure to bodily fluids that
does not pose a risk like tears, non blood stained
saliva, urine, sweat.
Preferred
regimen
Preferred third
drug or
alternative
regimen
For adults and
Adolescents
TDF +3TC ( or
FTC)
LPV/r or ATV/r
is the
preferred third
drug
EFV in India
For Children ≤
10 yrs
old
AZT+3TC ABC+3TC or
TDF
+3TC(or FTC) as
alternative.
LPV/r recom.
as third drug
A 28 day prescription of AR drugs should be
provided for HIV post exposure prophylaxis
following initial risk assessment 62
63. USE OF CO-TRIMOXAZOLE FOR HIV RELATED INFECTIONS
For adults (Including
PW)
Any WHO clinical stage and CD4 <250 cells/mm3 or
Any WHO clinical stage, CD4 <350 cells/mm3 and if patient is
symptomatic or
WHO stage 3 or 4 irrespective of CD4 countDosage: 960 (800+160)
mg OD
Infants, children and
adolescents
Recommended to all
but priority to children <5 yrs regardless of CD4 count or clinical
stage and to children with WHO clinical stage 3 or 4 and for CD4
count ≤350 cells/mm3
When to stop: If CD4 count >250 for at least 6 months ,
AND If patient is on ART for at least 6 months and is asymptomatic
It should be administered to all HIV-infected people with active TB disease
regardless of CD4 cell.
63
64. Infant Prophylaxis
Infants Recommendation
Infants of mothers, who started ART
during intrapartum period
AZT (twice daily) plus NVP (once daily) for
first 6 weeks
AZT (twice daily) plus NVP (once daily) or
NVP (once daily) ALONE for next 6 weeks
Infants of mothers, who are on ART since AP
period
daily NVP for 6 weeks
Daily dose of NVP: <2000g- 2 mg/kg, 2000-2500g – 10 mg, >2500g – 15 mg
Live vaccines should be avoided in all severely immune compromised infants (CD4
%< 25% or WHO stage 3 and 4).
64
65. Monitoring Progression of HIV Infection and the response
to Antiretroviral Therapy
• The laboratory tests currently available for monitoring the stage and
progression of HIV infection can be classified into:
• Immunologic tests
• CD4 T cell enumeration
• Virological assays
• HIV RNA load assays
• Other Assays - Measurement of HIV p24, Reverse Transcriptase
(RT) activity assay
65
66. Recommended tests for HIV screening and monitoring
Phase of HIV management Recommended Desirable
HIV diagnosis Serology
EID for <18 months children
CD4 count
TB symptom screening
HBV, HCV, STIs
Cryptococcal screening (if count
<100)
Pregnancy test, NCD screening
Follow up before ART CD4 count
Initiation of ART CBC, LFT, RFT, Pregnancy test
Receiving ART HIV viral load q 12 months
CD4 count q 6 months
S. Cr, pregnancy test
Suspected treatment failure S. Cr, pregnancy test HBV
For HIV/HBV coinfected individuals who are already using TDF-containing regimens and develop ART
failure, this NRTI should be maintained regardless of the selected second-line regimen.
66
69. New initiatives under NACO CST
• Viral load testing scale up: Monitoring with VL instead of CD4 count provides an
early and more accurate indication of treatment failure and switching to second
line ART.
10 VL testing facility across the country.
• Launch of third line ART: Darunavir 300mg/ Ritonovir 100mg BD and Raltegravir
400 mg BD.
Presently 109 patients are on 3rd line ART.
• Linking PLHIV data to ADHAAR
• National programe on EID for children upto18 months: current test of choice is
HIV-1 PCR
69
71. ART Failure
• Clinical failure: New or recurrent WHO stage 4 condition, after at
least 6 months of ART
• Immunological failure: • Fall of CD4 count to pre-therapy
• 50% fall from the on-treatment peak value
• Persistent CD4 levels below 100 cells/mm
• Virological Failure: Plasma viral load >5,000 copies/ml after at least 6
months of ART
71
72. WHO CLINICAL STAGING OF HIV DISEASE IN ADULTS, ADOLESCENTS AND
CHILDREN
• Clinical stage 1
• Adults
• Asymptomatic
• PGL
• For children
• Asymptomatic
• PGL
• Clinical stage 2 (Adults)
• Moderate unexplained weight loss ( under
10% of BW)
• Recurrent RTI
• Herpes zoster/Angular cheilitis
• Recurrent oral infections
• Papular pruritic eruptions
• Seborrhoeic dermatitis
• Fungal nail infections
• For children
• Unexplained chronic diarrhoea
• Severe persistent candidiasis outside the
neonatal period
• Weight loss or FTT
• Persistent fever
• Recurrent Severe bacterial infections
72
73. • Clinical stage 3 (Adults)
Moderate unexplained weight loss
(over 10% of BW)
Unexplained chronic diarrhoea for
more than 1 month
Unexplained persistent fever for
more than 1 month
Oral candidiasis/oral hairy
leukoplakia/PTB
Bacterial infections
Stomatitis, gingivitis or periodontitis
Unexplained anaemia (< 8g/dl),
neutropenia, thrombocytopenia
• For children
AIDS-defining opportunistic
infections
Severe failure to thrive
Progressive encephalopathy
Malignancy
Recurrent Septicaemia or meningitis
• Clinical stage 4 (Adults)
HIV wasting syndrome
Pneumocystis jiroveci pneumonia
Several bacterial pneumonia
Chronic herpes simplex infections
Oesophageal candidiasis
EPTB/ Kapsoi Sarcoma
CMV disease, CNS toxoplasmosis
HIV encephalopathy
Extra pulmonary cyptococcosis including
meningitis
Disseminated nontuberculous mycobacteria
infection
Progressive multifocal leukoencephalopathy
Chronic cryptosporidiosis, Chronic isosporiasis
Disseminated mycosis
Septicemia/lymphoma
Invasive cervical carcinoma
Atypical disseminated Leishmaniasis
73
74. Nutritional Aspects of HIV
Food items to avoid: Special effects
• Raw eggs
• Food that has not been thoroughly
cooked,
• Unboiled water or juices made with
unboiled water
• Alcohol and coffee
• Stale food
• Nuts and oil seed: Protein, energy,
vitamin B
• Fiber
• Garlic : contains Allicin,
antibacterial, antiviral and
antioxidant properties.
• Turmeric : contains polyphenol;
antioxidant properties- ability to
fight inflammation.
74
75. Palliative care
• Pain Management: Analgesics
• Symptom Management: Pharmacological and non- pharmacological.
• End of life care: Comfort measures near the end of life
• Moisten lips, mouth, eyes
• Keep the patient clean and dry and prepare for incontinence of bowel
and bladder
• Only give essential medications—pain relief, antidiarrheal, treat fever
and pain
• Eating less is OK. Ensure hydration
• Skin care/turning every 2 hours or more frequently to prevent bed
sores
• Bereavement counselling
75
77. UNIVERSAL PRECAUTIONS
• Universal Precautions are control guidelines designed to protect
workers from exposure to diseases spread by blood and other body
fluids.
• Now, Standard precautions to reduce the risk of transmission of
blood borne and other pathogens from both recognized and
unrecognized sources to a susceptible host.
Hand washing.
Safe collection and disposal of needles.
Wearing gloves.
Wearing a mask and a gown.
Covering all cuts and abrasions.
Using safe system for health care waste management and
disposals
77
78. AIDS VACCINE
• Major Challenges towards the
development of an effective HIV/AIDS
vaccine
• Genetic diversity: HIV multiplies at very
rapid pace and is different from the parent
virus.
• Failure in formation of virus neutralizing
antibodies
• Lack of proper animal model since
infection can occur with SIV
78
80. SUMMARY
HIV continue to be major public health
issue globally claiming more than 36
million lives so far.
• Can be transmitted via exchange of
variety of body fluids from infected
individuals
• Risk Factors
Unprotected vaginal or anal sex
and having STI
Sharing contaminated needles,
syringe, receiving unsafe
injections and Needle stick
injury
• All HIV testing services must include 5
C's recommended by WHO; consent,
confidentiality, Counselling, Correct
test result and connection
• Prevention
Male and female condom use
Testing and counselling for HIV
and STI
ART for prevention
80
Editor's Notes
It is estimated that the scale-up of free ART since 2004 has saved cumulatively around 4.5 lakhs lives in India until 2014.
The first verified case of HIV is from a blood sample taken in 1959 from a man living in Kinshasa in the Democratic Republic of Congo. The sample was retrospectively analyzed and HIV detected.
Using the earliest known sample of HIV, scientists have been able to create a 'family-tree' ancestry of HIV transmission, allowing them to discover where HIV started.
Their studies concluded that the first transmission of SIV to HIV in humans took place around 1920 in Kinshasa in the Democratic Republic of Congo (DR Congo).
The same area is known for having the most genetic diversity in HIV strains in the world, reflecting the number of different times SIV was passed to humans. Many of the first cases of AIDS were recorded there too.
Continuum of HIV care refers to a comprehensive package of HIV testing, prevention, treatment and care services provided for people at risk of acquiring HIV and people living with HIV and their families
Information on HIV and AIDS: about disease, route of transmission, prevention, care, support and treatment services
Benefits of HIV testing and assurance of confidentiality
Their right to opt out of HIV testing and this won’t affect their access to any other health-related services
Obtain informed consent.
Carry out a risk assessment of the individual
Provide information on genital, menstrual and sexual hygiene
Demonstrate the use of a condom using a model
Provide information on spouse/sexual partner testing
Conduct symptomatic screening for STI/RTI
Conduct verbal screening (4 Symptom Screening) for tuberculosis
Extend the opportunity to the individual to ask and clarify doubts
The information may be delivered in a local language and tailored to the specific audience.
Serological Diagnosis of HIV Infection
HIV diagnosis at ICTCs and other laboratories is based on the demonstration of antibodies.
Antibody detection can be done using an ELISA test, rapid test, and western blot test.
ELISA and Rapid tests are highly sensitive tests, sensitivity (>99.9%)
Point-of-care testing is conducted at or near the site at which care is being provided. The test results are usually returned rapidly so that clinical decisions can be made in a timely and cost-effective manner.
13 NRL, In Delhi- AIIMS, DELHI and NCDC, Delhi.
UCMS has a SRL and it comes under NCDC, delhi
Antibodies are not detectable in the window period. Therefore, antibody detection tests are of no use during this period.
Diagnostic tests based on antibody detection are also not useful in the diagnosis of infection in children below 18 months of age. Babies born to HIV positive mothers may have passively acquired maternal antibodies.
Antibody tests, using rapid test method can be used for children > 18 months of age for diagnosis of HIV infection as in adults.
The sensitivity of a traditional PCR test – for the diagnosis of HIV infection and the qualitative detection of HIV DNA – is as high as 90 to 100 percent by the age of 4- 6 weeks.
NACO’s first choice for the diagnosis of HIV-1 infection in infants and children less than 18 months of age (starting at 6 weeks of age or at the earliestopportunity thereafter) is the HIV-1 DNA PCR test.
For DNA- AMPLICOR HIV-1 DNA PCR Test,
For RNA- APTIMA HIV-1 qualitative RNA assay
Quantitative HIV-1 RNA assays detect plasma (cell-free) viral RNA by using various techniques
a. Reverse transcriptase PCR (RT-PCR)
b. Real time PCR (qPCR)
c. Nucleic acid sequence-based amplification (NASBA)
Quantitative NAT are mainly used to determine viral load.
Virus isolation- culture with peripheral mononuclear cells in a media containing IL-2, for 28 days
P24 antigen= free or bound, ELISA based test, its less sensitive, highly specific so not preferred over viral load
In settings with less than 5% HIV prevalence in the population tested, a diagnosis of HIV positive should be provided to people with three sequential reactive tests.
In settings with greater than 5% HIV prevalence in the population tested, a diagnosis of HIV positive should be provided to people with two sequential reactive tests.
ELISA/ Rapid tests (E/R) used in strategy I, II, & Ill
Confirmatory tests with high specificity, like WBs and line immunoassays, are used in problem cases, e.g., in cases of indeterminate/discordant result of E/R.
NACO recommends the use of ELISARapid kits with a sensitivity of ≥99.5 percent and the specificity of ≥98 percent
2B: two sequential reactive test (WHO’s high prevalence strategy)
3: three sequential reactive results (WHO’s low prevalence strategy)
Testing Approaches
Unlinked Anonymous Testing: This testing approach is used for HIV surveillance purposes.
Voluntary Confidential Counselling and Testing; This approach is followed for the diagnosis of HIV infection in an individual.
Mandatory Testing: Mandatory testing is recommended in India, only for the screening of donated blood and tissues.
No mandatory HIV testing should be imposed as a precondition for employment or for providing healthcare services and facilities
PLHIV- 36.7 MILLION
60% know their HIV status
<50% are on ART
38% have achieved suppressed viral level.
Clinical goal : Prolongation of life and improvement in quality of life
Virological goal : Greatest possible reduction in viral load for as long as possible
Immunological goal : Immune reconstitution that is both quantitative and qualitative
Therapeutic goal : Rational sequencing of drugs to achieves clinical, virological and immunological goals while maintaining treatment options, limiting drug toxicity and facilitating adherence
Reduction of HIV transmission in individuals : Reduction of HIV transmission by suppression of viral load
Drugs shown in red are not available in India.
HIV-2 is intrinsically resistant to NNRTI.
Block binding of HIV to target cell (fusion inhibitors)
(ii) Block viral RNA cleavage and one that inhibits reverse transcriptase (reverse transcriptase inhibitors)
(iii) Block the enzyme, integrase, which helps in the incorporation of the proviral DNA into the host cell chromosome (integrase inhibitors)
(iv) Block the RNA to prevent viral protein production
(v) Block the enzyme protease (protease inhibitors)
(vi) Inhibit the budding of virus from host cells
(PrEP): Oral PrEP of HIV is the use of ARV drugs by people who are not infected with HIV to block the acquisition of HIV.
Combination prevention refers to a combination of behavioural, biomedical and structural approaches to HIV prevention to achieve maximum impact on reducing HIV transmission and acquisition.
Behavioural- promotion of HIV risk reducing and protective behaviour, by promoting the use of products (condoms), services (HCTC)
Biomedical- intervention used to limit the transmission and infectiousness, ART
Structural- programs addressing stigma and discrimination, gender inequality and gender based violence, income generating activities, integration of health services,
Principles for selecting the first-line regimen
1. Choose 3TC (Lamivudine) in all regimens
2. Choose one NRTI to combine with 3TC (AZT or TDF)
3. Choose one NNRTI (NVP or EFV)
Fixed-dose combinations (FDCs) are preferred because they are easy to use, have distribution advantages (procurement and stock management), improve adherence to treatment and thus reduce the chances of development of drug resistance. The current national experience shows that bid (twice a day) regimens of FDCs are well tolerated and complied with.
EFV is contraindicated in pregnant HIV-infected women during the first trimester of pregnancy because of concerns of teratogenicity
Ideally, second-line regimens should include at least three active drugs; one of them from a new class, in order to increase the likelihood of the success of the treatment and to minimize the risk of cross-resistance. The PI class should be reserved for second-line treatments.
ART should be started in any child with active TB disease as soon as possible and within 8 weeks following the initiation of anti tuberculosis treatment, regardless of the CD4 cell count and clinical stage.
Cartridge based Nucleic Acid Amplification Test (CBNAAT) for rapid diagnosis of TB among PLHIV.
All ARTs except 39 are linked with CBNAAT facility.
Isoniazid- its most effective bactericidal drug, it protects both against activation of latent TB infection as well as from reinfection when exposed to active TB cases.
Dosage- Isoniazid 300 + Pyridoxine 50 OD for 6 months
Children >12 months- 10 mg/kg plus pyridoxine 25 OD for 6 months.
Do not start ART in the presence of an active OI. In general, OIs should be treated or stabilized before commencing ART. Mycobacterium Avium Complex (MAC) and progressive multifocal leukoencephalopathy (PML) are exceptions, in which commencing ART may be the preferred treatment,
It’s a important principal of comprehensive care of HIV/AIDS among IDUs.
OST is the most effective treatment for opioid dependence
Cd4 T cell enumeration and HIV RNA load tests are well-established assays, with many techniques having gained FDA approval. Assays, based on quantitating p24 or viral reverse transcriptase, are newer techniques that are under development.
viral RNA load, is presently considered one of the primary tests for monitoring the progression of HIV infection, But due to relative use of performance and lower cost CD count is still preferred. However, NACO has introduced Viral load monitoring at selected testing facilities and planning to scale u[ across the country.
In India, the HIV/AIDS epidemic is occurring in populations in which malnutrition is already endemic.
Moreover, Increased Resting Energy Expenditure (REE) is observed in HIV-infected Adults.
Nutritional counselling is necessary every time the PLHA visits the clinic.
Stale food is no longer fresh or good to eat
Palliative care, is the active total care of patients whose disease is not responsive to curative treatment.
It should be family and patient-centred and should address physical, intellectual, emotional, social and spiritual needs.
Pain Management: Analgesics
Emotional support.
Physical methods: Touch (stroking, massage, rocking, vibration). Ice or heat. Deep breathing
Cognitive methods: distraction such as radio, music, imagining a pleasant scene.
Prayer (with respect to patient’s practice).
End of life care- its for terminal phase and The terminal phase is defined as the period when day-to-day deterioration, particularly of strength, appetite and awareness. The aim of care at this stage should be to ensure the patient’s comfort holistically, and a peaceful and dignified death
Hand washing after any direct contacts with patients. Prevent recapping of needles
Safe collection and disposal of needles.
Wearing gloves for contact with body fluids, non- intact skin and mucus membrane.
Wearing a mask for eye protection, and a gown if blood or other body fluids might splash.
Covering all cuts and abrasions. Carefully cleaning up spills of blood and other body fluids
Using safe system for health care waste management and disposals
More than 40 different African primate species are endemically infected with their own unique strain of SIV. Owing to thousands of years of virus-host co-evolution, these natural SIV hosts typically do not develop disease as a result of their infections and are thus not useful as pathogenic models.
World largest trail phase III was done in Thailand from 2003-2009. Trial is known as RV 144 "prime (ALVACHIV)—boost (AIDS VAX B/E)" combination