Prevalance of hiv and AIDS, Laboratory Diagnosis, Treatment of hiv and aids, Health of HIV infected person, life of hiv and aids infected person

1. Basics of HIV/AIDS
Management
Dr Ketan Ranpariya
(MBBS, PGDHM)
HIV / AIDS CONSULTANAT
Helpline Number +91-7575887070

2. Highest burden of HIV:
Top 3 Country of world

3. Highest burden of HIV:
Top 3 Country of world
1. South Africa
2. Nigeria
3. India

4. HIV Transmission Risk
Exposure Route HIV Transmission
Blood transfusion
Perinatal
Sexual intercourse
Vaginal
Anal
Oral
Injecting drugs use
Needle stick exposure
Mucous membrane splash to eye,
oro-nasal

5. HIV Transmission Risk
Exposure Route HIV Transmission
Blood transfusion >98%
Perinatal Discuss Later
Sexual intercourse 0.1 to 1%
Vaginal 0.05-0.1%
Anal 0.065-0.5%
Oral 0.005-0.01%
Injecting drugs use 0.67%
Needle stick exposure 0.3%
Mucous membrane splash to eye,
oro-nasal
0.09%

6. Who is more vulnerable ?
MALE or FEMALE to acquired HIV infection ? And
Why ???
• HIV POSITIVE MALE to hiv negative female
• HIV POSITIVE FEMAL to Hiv negative male

7. What is the role of Sexually
Transmitted Infection in HIV
transmission?
• Is it decreased or increased transmission
of HIV ??? And WHY ???

8. What role does circumcision play in
HIV transmission?
• Is it decreased or increased the risk of
transmission of HIV ??? And WHY ???

9. When to Suspect HIV ?
• What is WHO Clinical Stages of HIV Infection ?

10. WHO Clinical Staging Adults
Clinical Staging 1
Asymptomatic
Persistent generalized lymphadenopathy (PGL)
1. Painless enlarged lymph nodes >1 cm
2. In two or more non-contiguous sites (excluding
inguinal), in the absence of known cause
3. Persisting for 3 months

11. WHO Clinical Staging Adults
Clinical Staging 2
Adults
Moderate unexplained weight loss (<10% of presumed or
measured body weight)
Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis
media, pharyngitis)
Herpes zoster
Angular cheilitis
Recurrent oral ulceration
Papular pruritic eruption (PPE)
Fungal nail infections
Seborrhoeic dermatitis

12. WHO Clinical Staging Adults
Clinical Staging 3
Adults
Unexplained severe weight loss (>10% of presumed or measured
body weight)
Unexplained chronic diarrhoea for longer than 1 month
Unexplained persistent fever (intermittent or constant for longer
than 1 month)
Persistent oral candidiasis
Oral hairy leukoplakia (OHL)
Pulmonary tuberculosis (PT)
Severe bacterial infections (such as pneumonia, empyema,
pyomyositis, bone or joint infection, meningitis, bacteraemia)
Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
Unexplained anaemia (<8 g/dl), neutropaenia (<0.5 x 109/l) and/or
chronic thrombocytopaenia (<50 x 109/l)

13. Adults
HIV wasting syndrome
Pneumocystis (jirovecii ) pneumonia (PCP)
Recurrent severe bacterial pneumonia
Chronic herpes simplex infection (orolabial, genital or
anorectal of more than 1 month’s duration or visceral at any
site)
Oesophageal candidiasis (or candidiasis of trachea, bronchi
or lungs)
Extrapulmonary tuberculosis (EPTB)
WHO Clinical Staging Adult
Clinical Staging 4

14. WHO Clinical Staging Adults
Clinical Staging 4
Adults
Kaposi sarcoma (KS)
Cytomegalovirus infection CMV (retinitis or infection of other
organs)
Central nervous system toxoplasmosis
HIV encephalopathy
Extrapulmonary cryptococcosis, including meningitis
Disseminated nontuberculous mycobacterial infection
Progressive multifocal leukoencephalopathy (PML)
Chronic cryptosporidiosis
Chronic isosporiasis

15. WHO Clinical Staging Adults & Children
Clinical Staging 4
Adults
Disseminated mycosis (extrapulmonary histoplasmosis,
coccidioidomycosis)
Lymphoma (cerebral or B-cell non-Hodgkin)
Symptomatic HIV-associated nephropathy or
cardiomyopathy
Recurrent septicaemia (including nontyphoidal Salmonella)
Invasive cervical carcinoma
Atypical disseminated leishmaniasis

16. Testing Related to HIV

17. Tests for Diagnosing HIV
• Screening Tests: Antibody Tests
– Rapid tests
– 3rd Generation Enzyme linked immunosorbent
assays (ELISA)
• Confirmatory/Supplemental Tests
– 2nd & 3 rd Rapid/ELISA tests to confirm 1st HIV test
– 4th Generation ELISA (HIV DUO Antigen plus
Antibodody)
– Western blot assay

18. What is CD4 test ?
• What is it mean ?
• What’s its indicate and usefullness ?

19. • CD4 indicates immunity level
• Usefulness
1. Current Status of Immunity
2. Prognosis
3. To monitor effect of Therapy
4. Identify Treatment Faillure

20. What s the difference between HIV
and AIDS ???

21. HIV
• Human: seen in Mankind
• Immunodeficiency: Decrease
Immunity of Body
• Virus: Type of Infective Agent

22. AIDS
• Acquired Immuno Deficiency Syndrome
(AIDS) is defined as
• the occurrence of life threatening Opportunistic
infections
• Malignancies
• Neurological diseases and other specific illnesses
in patients with HIV infection and CD4 counts
<200 cells/mm3 or < 14 % CD4

23. Natural History
and
Clinical Staging of
HIV Infection

24. Viral transmission
Acute retroviral syndrome: 2-3 weeks
Seroconversion: 2-20 weeks
Asymptomatic chronic HIV infection: 8 yrs. (Avg.)
Symptomatic HIV infection/AIDS 1.3 yr (Avg)
Stages of Untreated HIV Infection

25. Patterns of HIV Progression
Type of HIV
Progression
Proportion
among
PLHIV
CD4 cells
drop
Characteristic
features
Typical
progression
50-70%
35-50 CD4
cells/year
Develop end-stage disease within
8-10 years after seroconversion
Rapid
progression
10%
50 CD4
cells/month
Develop symptoms of AIDS or
end-stage HIV disease
within 2-3 years after infection &
also in children
Slow
progression
5-15% Very slow
Remain free of symptoms of AIDS
for more than 10-15 years
Long term
Non-progression
5-10%
Stable CD4
count
Living with HIV for >15 years
and have stable CD4+ counts of
≥ 500 cells/mm³ blood.
No HIV related diseases and
no previous ART

26. Initiation of
Anti Retroviral Therapy

27. Antiretroviral Therapy (ART)
• ART is the combination of
different classes of ARV drugs
– To achieve maximal and
most durable suppression
of viral replication
– To prevent emergence of
drug resistant mutants
– To improve survival and
quality of life
Before ART
One year after ART
Images Courtesy GHTM Tambaram /I-TECH

28. Goals of ART
Goals Principle
Clinical To prolong life & improve quality of life
Virological
Greatest possible reduction in viral load
as long as possible to halt disease progression and
to prevent or delay resistance
Immunological
Immune reconstitution is both:
1.Quantitative (CD4 within normal range)
2.Qualitative (pathogen specific immune response)
Therapeutic
Rational sequencing of drugs to achieve
previous 3 goals while:
1.Maintaining future therapeutic options
2.Minimising drug toxicities & side effects
3.Maximising treatment adherence
Epidemiological Reduce HIV transmission

29. When to Initiate ART
in Adults and Adolescents

30. Initiate ART
• If CD4 cell count < 500 Cells/mm3
• If WHO Clinical Stage 3 or 4
Initiate ART Regardless of WHO clinical stage and CD4
cell count
• Active TB Disease or Past History of TB in life time
• HBV or HCV Co-infection with sever chronic liver disease
• Pregnant and lactating woman with HIV
• HIV positive individual in a serodiscordant partnship (to reduce
HIV tranmission risk)

31. Latest Recommendation

32. HIV and Tuberculosis

33. HIV-TB synergy
1. Out of total TB patients 5 % suffered from HIV
infection
2. In Life time, Developing TB in healthy individual is
10 percent while developing TB in HIV infected
individual is 10 percent per annum
3. Drug Resistant TB are more prevalent in HIV
infected People
Conclusion Suspect TB in every HIV patients and
Suspect HIV in every TB patients

34. HIV Medicine are extremely costly ?
• True or False ???
• Middle and even Upper Social Economical Class can
not afford HIV treatment ???? !!!!!

35. Some facts about ART
• 1996 Highly Active Anti-Retroviral Therapy (HAART)
• The problems were high costs, large number of pills
and side effects of these drugs
• Cost of Therapy came down from Rs.30,000 in 1998 to
Rs 2000 per month in 2006; the number of pills reduced
from 32 to 1 or 2 per day; regimens were simplified with,
the newer drugs; reduced drug side effects
• ART has changed the outlook of HIV/AIDS from a ‘virtual
death sentence’ to a ‘chronic manageable disease’

36. • ~80% adherence may be sufficient to achieve
therapeutic goals in other chronic disease states
(e.g. Hypertension)
• If HIV is a chronic, manageable disease like
Hypertension, is this level of adherence (80%)
adequate for effectively managing it?
• >95% adherence is necessary to achieve an
undetectable viral load in 81% of patients
• 10% reduction in adherence is associated with a
doubling of HIV RNA level
Adherence

37. Issues related to ARV treatment
• Treatment is life long
• Complete adherence is essential
• Lack of adherence
– Drug resistance / treatment failure
– Client may have many difficulties
– Client based strategies are important

38. A General Approach to
Opportunistic Infections
in PLHIV

39. Definition of an Opportunistic
Infection
• An opportunistic infection (OI) is a disease
caused by a microbial agent in the presence
of a compromised host immune system
• Appearance of OI is needed for the diagnosis
of AIDS

40. When does it occur?
• It occurs when the CD4 declines
• Depending on the CD4 Count, Opportunistic
infection can be predicted

41. Association between OIs & CD4 CountCD4cellcount
Toxoplasmosis; Cryptococcosis;
Cryptosporidiosis;
PML; CMV; MAC
Herpes Zoster
Tuberculosis
PCP; Oesophageal Candidiasis;
Mucocutaneous Herpes
Oral Candidiasis
Time

42. Bacterial Viral Fungal Parasites
Tuberculosis Varicella Zoster Candida Toxoplasma
Respiratory
Pathogens:
Streptococcus
H. influenza
Herpes simplex
Pneumocystis
jiroveci (PCP)
Intestinal:
Cryptosporidium
Isospora
Microspora
Intestinal:
Salmonella,
Shigella
Cytomegalo virus Cryptococcus
Giardia
Entamoeba H
Human papiloma Penicillium M. Leishmania
Ebstein Barr Virus
(Oral Hairy Leukoplakia;
Lymphoma)
Histoplasma
capsulatum
JC Virus (PML)
Common OIs seen in India

43. Husband and Wife Both are HIV
infected, will you advice to use
condom Consistently ???
• If YES, why ?
• If NO, why ?

44. Case
• HIV Positive Husband and HIV Positive Wife want to
conceive means want a baby…!!!!
What you advice to couple ??

45. Estimated Risk of Mother to Child transmission
in absence of any intervention
Risk of HIV Transmission
Transmission
Rate
During pregnancy 5-10%
During labour and delivery 10-15%
During breastfeeding 5-20%
Overall without breastfeeding 15-25%
Overall with breastfeeding up-to six months 20-35%
Overall with breastfeeding for 18-24 months 30-45%
Source: WHO

46. Case
• HIV positive Mother asked you “should I give breast
feeding to my baby ?”
• What will you advice ???

47. Case
• HIV Negative Wife and HIV Positive Husband comes
to you for advice regarding family planning because
they want child ???
• What will you advice ???

48. Any Questions...???

49. Thanks...!!!