11 Demographic Trends 1. HIV+ tests (all ages) highest in 1995 at 2,990 lowest in 2000 at 2,106increased in 2001 and 2002 and then plateaued at 2,5002. Increasing among older adults (age >40 yrs)3. HIV+ tests among MSM: increasing since 20014. Steady decline among injection drug users5. Steady increase among Heterosexuals68% increase in Ontario over the past 5 years (11%/yr)
17 Sexual contact with exchange of bodily fluids TransmissionSexual contact with exchange of bodily fluidsExposure of mucous membranesSharing injection drug paraphernaliaNeedles, snorting strawsTransfusion of infected blood or blood productsCurrently 1 in 500,000Mother to child (vertical)Perinatal and breast feeding
18 Sexual Transmission of HIV: HIV is contained in:SemenVaginal secretionsRectal secretions(Saliva at very low levels)
19 Exposure to HIVIn these fluids:HIV is present as free virusHIV is contained in infected CD4 cells
20 Mucous Membranes: the target Mucous membranes are the moist epithelial linings of body cavities including the:oral cavityrectumvagina and cervixinner foreskinLive cells line the surface.
21 Mucous Membrane: the target Only 2% of the body’s immune cells circulate in the blood98% of the body’s immune cells are located in the lymph nodes and the mucous membranesMucous membranes are rich in T-cells and macrophages to provide defenceThe majority of these cells are organized into “lymphoid follicles” just under the surface of the mucosal membrane
22 Mucous Membrane: rectum Lymphoid follicles: 15/cm2 in the colon and increase to 25/cm2 in the rectum.
23 Mucous Membrane: the target M-cells transport HIV directlyinto the lymphoid follicleOwen, RL. Pathobiology, 1998.
24 Mucous Membrane: cervix Lymphoid follicle in the cervix. CD4 cells are stained brown Kobayashi, Am J Pathology, 2002
25 Mucous Membrane: the target Hladik F. Immunity, 2007.McCoombe. AIDS, 2006.
26 Transmission: Injection drug paraphernalia Sharing injection drug paraphernaliaAccess to clean needlesDrug rehabilitation programs
27 Transmission: Blood transfusion Transfusion of infected blood or blood productsScreening donated bloodELISA: 2-3 month window periodPCR: essentially no window period
28 Transmission: Mother to child Mother to child (vertical)In utero (trans-placental)Peri-natal accounts for majority of casesBy blood-blood mixingBreast feeding.
36 HIV Disease HIV enters the body and slowly destroys the immune system without treatment, HIV is continuously activewithout treatment, the average length of time between infection and the onset of symptomatic disease is yearsthe competency of the immune system is reflected by the CD4 count
37 Viral Load What is the viral load? How much virus per ml of blood Range 100’s to >500,000Viral load and progression are roughly correlatedEach patient has their own “set-point”
38 CD4 Count What is the CD4 count? 800-1000 is normal >500 no worry a bit of a gray zone.<200 at risk<50 at significant risk
39 Risk of Illness based on CD4 Count >500: usually no symptoms. May have fever, nightsweats, lymphadenopathy, weight loss: recurrent HSV, zoster, sinusitis, pneumonia candidiasis (oral, vaginal), lymphoma<200: PCP, Toxo, KS, Cryptococcus<50: MAC, CMV, PML, dementia, wasting
63 Treatment Goals Maximal viral suppression (VL<50) Undetectable does not mean absentDurable suppressionRestoration and preservation of immune functionImproved quality of lifeReduction in morbidity and mortalityCurrent projected life-expectancy from time of diagnosis: 43 years!
68 Adverse Effects: Drug Specific AZT: marrow suppression, nausead4T: neuropathy, lactic acidosis and lipodystrophyAbacavir: hypersensitivity reactionTenofovir: renal failureDidanosine: peripheral neuropathy, pancreatitisEfavirenz: CNS symptoms, sleep disturbanceNevirapine: rash, hepatotoxicityAtazanavir: hyperbilirubinemiaLopinavir: diarrheaSaquinavir: GI intoleranceIndinavir: nephrolithiasis
69 Adverse Effects: Lipodystrophy Syndrome Hyperlipidemia:Total cholesterol, LDL and triglyceridesRisk of atherosclerosisPravastatin, Crestor and Fibrates are drugs of choiceLipodysmorphic FeaturesFat atrophy of face and limbsFat accumulation dorsocervical pad, stomach, breastsInsulin ResistanceMay consider metformin
72 Transmission of HIV from mother to infant occurs predominantly at the time of delivery.
73 Women and Infant Transmission Study, 1999 Viral Load Transmission< %1000 – 10, %10,000 – 50, %50,000 – 100, %> 100, %Average risk of transmission to the infant: 30%
74 ACTG 076 Study (1994) Protocol: AZT given IV during labour AZT to the infant for 6 weeksSuccess:67.5% reduction in transmissionFrom 30% to 8.3%
75 Reducing Mother to Child Transmission: If mother not diagnosed previously: perinatal AZT and C-section (risk < 5%)If mother known HIV+: antiretroviral therapy beginning week 28If mother known HIV+ and on antiretroviral therapy: continue therapy (change if on EFV)If maternal VL < 50, then risk of perinatal transmission < 1%Breast feeding only if no access to formula
79 Indications for Surgery: not on therapy Intracranial lesionPrimary CNS lymphomaToxoplasmaTBGummaPMLBacterial abscessStereotactic needle biopsy
80 Indications for Surgery: not on therapy Lymph node biopsylymphoma, TB, MACCholecystitisCholelithiasisCrytosporidium, CMV, MAC
81 Indications for Surgery: on therapy Coronary by-passAntiretrovirals associated with increased lipids50% of HIV+ individuals smoke cigarettesIncreased rates of CVDResection of malignanciesCervical cancer (HPV)Anal cancer (HPV)LymphomaHepatoma(No increase in breast or lung cancer)
86 ARV and SurgeryImpact of highly active antiretroviral therapy on outcome of cholecystectomy in patients with human immunodeficiency virus infection.Department of S. Siro Clinical Institute, University of Milan, Milan, Italy.Br J Surg Nov; 93(11):HAART was shown to be protective. A low HIV RNA load and a high CD4(+) cell count were significant predictors of uncomplicated surgical outcomes. CONCLUSION: HAART significantly reduces the risk of complications after cholecystectomy in patients with HIV infection.
87 ARV and SurgeryOutcomes of hysterectomy in HIV-seropositive women compared to seronegative women.Department of Gynecology and Obstetrics, Emory University, Atlanta, USA.Infect Dis Obstet Gynecol Sep;13(3):167-9.No significant differences in complication rates were found among HIV-infected women compared with uninfected women.
88 ARV and SurgeryHIV-positive renal recipients can achieve survival rates similar to those of HIV-negative patients.Terasaki Foundation Laboratory, Los Angeles, CA, USA.Transplantation Jun 27;81(12):Although not statistically significant, graft survival was higher among HIV-positive patients compared with their negative controls, as was patient survival.Graft survival: 76.1% vs. 65.1% at 5 years (p=0.21)Patient survival: 91.3% vs. 87.3% at 5 years (p=0.72)
89 ARV and SurgeryExcellent outcomes of cardiac surgery in patients infected with HIV in the current era.Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New YorkClin Infect Dis Aug 15;43(4):532-6.The surgeon and AIDS: twenty years later.Department of Surgery, Medical Center, University of California-Irvine, CAArch Surg Oct;140(10):961-7.Since the first reports on indications and outcome for abdominal procedures in the HIV/AIDS patient were published 20 years ago, the epidemiology and presentation of surgical illness have changed remarkably with the advent of new antiviral regimens.
91 Occupational Exposures Pietrabissa et al (1997)- surveyed 15,375 procedures in 39 hospitals by 122 surgeons over 6 months:a) 3.9% of procedures had percutaneous or eye exposuresb) needle sticks accounted for 84% of injuriesc) 58% occurred at wound closured) direct correlation between length of procedure and number of injuries
92 Occupational Exposures Prospective surveillance of HCW exposed to HIV conducted by CDC from 1983 to 1992:89% percutaneous5% mucous membraneOf Percutaneous: 34% by syringe needles40% by suture needles4% by scaples2% by lancets4% other
94 What do we worry about? 1) Hepatitis B: 30% risk - chronic hepatitis, cirrhosis, carcinoma2) Hepatitis C: 3% risk3) HIV: 0.3% risk
95 What do I do? 1) Don’t panic! 2) Dispose of the needle in a sharps container3) Express blood from the wound4) Clean thoroughly with Providone iodine, or chlohexidine, or soap and water5) If eyes or mucous membranes: lots of water6) Go to the Emergency Dept.
96 Risk Assessment:1) You2) The patient3) The Injury
97 You: 1) Are you vaccinated against HepB? 2) Are you immune to HepB? Get your titers measured!3) General health4) Blood work: CBC, lytes, liver function
98 The Patient: 1) HIV status 2) HepB status 3) HepC status Don’t Know? Then request:1) HIV test STAT, with consent from patient2) HBsAg, HBsAb3) HCV-Ab and PCR
99 The Patient: Do know: 1) HIV: what is the viral load? how sick is the patient?2) HepB: is he/she sAg+
100 The Injury: Risk Factors: depth of skin invasion? Exposure to broken skin?hollow bore or suture needle?did the needle enter a blood vessel of the pt?visible blood on the needle?were you wearing gloves?
102 HIV Post Exposure Prophylaxis There is minimal evidence for PEP:1) case controlled study of HCW2) ACTG 076, perinatal HIV transmission3) Animal models
103 HIV Post Exposure Prophylaxis AZT 300 mg BID3TC 150 mg BIDKaletra II tabs BIDshould begin ASAP, within 48 hours of injurytotal course = 28 daysside effects: nausea, vomiting, diarrhea, headache, fatigue, anemia, drug interactions
104 HIV Post Exposure Prophylaxis Seen in clinic within 2 daysRepeat HIV tests at 1, 3 and 6 monthsuse condoms with all sex partnersdo not donate bloodcost: $1200 for one month supply
105 Hepatitis B You should be vaccinated! If not vaccinated and not immune,liver function testsHBIG and HepB vaccinationHBsAg and HBsAb at 1, 3 and 6 months
106 Hepatitis C Takes up to three months to develop antibodies HCV RNA detectable in blood withindays
107 Hepatitis CRecent trial of 44 health care workers exposed to HCV via needle sticksreceived IFN daily for 1 month followed by IFN 3x per week for 5 months95% response rate
110 Protecting Yourself and Others What body fluids contain HIV?
111 Protecting Yourself and Others What body fluids contain HIV?Bloodsemenvaginal fluids
112 Protecting Yourself and Others What body fluids do not contain HIV?Saliva TearsSweat UrineStool/diarrhea Vomit*unless contaminated with blood
113 Protecting Yourself and Others Wear gloves for venipunctureWear gloves for cleaning up any body fluidsCarefully dispose of sharps!!Bedding, towels, etc stained with blood or vaginal fluids are laundered normallyNo gowns! No masks! (except for bloody procedures)
114 Protecting the Patient Do Not isolate because of HIV!!!HIV+ individuals deserve your respectIf you don’t know about HIV, learn somethingMaintain confidentiality!!