2Some TermsVirus: Any large group of submicroscopic agents capable of infecting plants, animals and bacteria. They are characterized by a total dependence on living cells for reproduction and by a lack of independent metabolism.HIV: Human Immunodeficiency Virus.AIDS: Acquired Immune Deficiency Syndrome
3More TermsAntibody: A protein (immunoglobulin) that is secreted and produced by B lymphocytes when it finds an antigen. Antibodies can bind to and, in turn, destroy certain antigens. When you test positive for HIV, they are actually testing for antibodies.Antigen: A substance that is recognized as foreign by the immune system. Antigens are either whole microorganisms, or they can be a portion of an organism or virus.See the handout for a more complete glossary of AID related terms
4History AIDS was first recognized a new disease in 1981. First report in the medical literature was concerning 5 young, homosexual men living in the Los Angeles area that had Pneumocystis carinii pneumonia and Kaposi's sarcoma.A few weeks later there was a report from San Francisco and New York about 26 young homosexual men with the same conditions.This was followed by reports of individuals who had injected drugs with similar conditions.All of these individuals had profound immunodeficiency suggesting a depletion of CD4-positive, or T-helper, lymphocytes.
5History continuedWith the prominence of homosexual men and intravenous drug users in the early cases it was originally speculated that these individuals became immunosuppresed because of a history of drug use or because of multiple sexually transmitted diseases.HIV was 1st identified in a lab in France. Strong evidence did not show up until 1984 when 4 papers were published in one issue of Science.Several variants of the HIV were discovered during this time.
6Transmission HIV does not survive well in the environment. HIV is found in varying concentrations or amounts in blood, semen, vaginal fluid, breast milk, saliva, and tears.There have been rare occurrences of transmission between family members in households: usually resulting from contact between skin or mucous membranes and infected blood.
7Some Recommended Precautions (from the CDC) for health professionals and care givers Gloves should be worn during contact with blood or other body fluids that could possibly contain visible blood, such as urine, feces, or vomit.Cuts, sores, or breaks on both the care giver’s and patient’s exposed skin should be covered with bandages.Hands and other parts of the body should be washed immediately after contact with blood or other body fluids, and surfaces soiled with blood should be disinfected appropriately.Practices that increase the likelihood of blood contact, such as sharing of razors and toothbrushes, should be avoided.Needles and other sharp instruments should be used only when medically necessary and handled according to recommendations for health-care settings. (Do not put caps back on needles by hand or remove needles from syringes. Dispose of needles in puncture-proof containers out of the reach of children and visitors.)
8Other environmentsCDC has only found one case of HIV transmission from open mouth kissingHIV might be able to be transmitted by biting due to trauma and blood interactionContact with saliva, tears, or sweat has never been shown to result in transmission of HIV.Studies conducted by researchers at CDC and elsewhere have shown no evidence of HIV transmission through insects--even in areas where there are many cases of AIDS and large populations of insects such as mosquitoes.
9Condom useNumerous studies among sexually active people have demonstrated that a properly used latex condom provides a high degree of protection against a variety of sexually transmitted diseases, including HIV infection.
10Acute Retroviral Syndrome Not all become acutely illFlu-like illnessVery contagious
11HIV Antibodies Develop after infection (varies) Seropositive (Enzyme immunoassay followed by Western Blot or other testsClinic or home testingLymph node biopsyAntigen detection (viral load)
12Immunodeficiency Begins immediately after infection Kills CD4+ T-lymphocyte cellsCategory 1 >500 cellsCategory cellsCategory 3 <200 cellsCD8 lymphocytes attack HIVTriple drug therapy makes a difference!!!!
13Asymptomatic HIV Infection Herpes zoster (“shingles”)Goal of antiretrovial therapy is to reduce viral load to undetectable
14Early HIV Category A: lymph node swelling, acute infection Category B: Candidiasis (oral or vaginal), peripheral neuropathy, herpes zoster, fatigue, low energyCatergory C: 23 qualifying infections e.g. pneumocystis carinni (pneumonia) or kaposi’s sarcomaAny system might be affected:General—fever, weight loss, fatigue, painDermatologic—rash, dry skin, papules (raised bumps), macules (non-raised spots), vesicles (blisters), exfoliationLymphatic—swelling of lymph nodesOcular—peripheral field defects, spots, retinitisOral—White plaques, ulceration, purple lesions, periodontitisCardiac—abnormal heart sounds, cardiomegalyPulmonary—cough, rales, rhonchi (abnormal breath sounds), hypoxiaGastrointestinal—hepatomegaly, splenomegaly, diarrheaGenitourinary and rerineal—ulcerations, chancres, discharge, warts, fissuresNeurological—motor or sensory deficits, spasticity, abnormal cognition, loss of memory or concentration, decreased alertness, ataxia (incoordination)
15Conditions Associated with AIDS 27 clinical conditions can be used in diagnosing AIDS along with HIV + statusInclude the presence of “opportunistic infections” that take advantage of weakened immune systemAlso include cancer, clinical conditions, and other infections3
16Conditions Associated with AIDS Opportunistic infections:Often caused by common bacteria present in healthy people; immune suppression makes people with AIDS vulnerablePneumocystis carinii pneumonia (PCP)Common organism multiplies in lungsFluid accumulates (pneumonia)Mycobacterium avium intracellulareMost common tuberculosis in people with AIDS, may affect many organsResistant to most antibiotics
17Conditions Associated with AIDS Mycobacterium tuberculosisOccurs in lungsInfectious, but treatable with antibioticsBacterial pneumoniaCaused by several common bacteriaPatient may have many episodesToxoplasmosisDisease of brain and central nervous system (spinal cord)Caused by parasite found in cat feces3
18Conditions Associated with AIDS Cancers:Kaposi’s sarcomaCancer of the blood vesselsRed/purple splotches under skinLymphomasCancer of the lymphatic system/brainInvasive cervical cancerCan lead to uterine cancer if untreated4
19Clinical Conditions Associated with AIDS Wasting syndromesevere weight loss, with weakness and diarrheaHIV encephalopathy/ AIDS dementiaDirect infection of the brainImpairment of mental functioning, changes in moodOther infectionsCandidiasis or “Thrush”: yeast infection of mouthHerpes simplex: persistent lesions of mouth, lungs, esophagusCytomegalovirus: infects brain, retina, lungs5
20Symptoms of HIV Infection and AIDS Unexplained persistent fatigueFever, chills, night sweatsUnexplained weight lossSwollen lymph nodesPink, red, purple, or brown blotchesPersistent dry coughPersistent, fuzzy, white spots in mouth, tongue, or throatMemory loss or depressionAbnormal pap smearsPersistent vaginal candidiasisAbdominal cramping (due to Pelvic inflammatory Disease)Persistent Diarrhea6
21The Immune System and HIV Leukocytes – white blood cellsMacrophagesEngulf foreign particlesAntigensStimulate immune system, react with antibodiesAntibodiesInactivate antigens, mark them for destructionB cells and T cells7
22Treatment AZT (zidovudine) Protease inhibitors HAART (highly active anti-retroviral therapy)Fatality rate dropped from 90% to 5% in USSecondary treatment of infections & tumorsAntiretroviral—zidovudine, didanosine, zalcitabine—side effects include anemia, neutropenia (reduced white blood cells), myopathy, anorexia, nausea, fatigue, headache, malaise, myalgia, insomnia, pancreatitis, peripheral neuropathy, vomiting, rash, stomatitis (inflamation of the mouth)Protease inhibitors—saquinavir, ritonavir, indinavir, nelfinavir—side effects include nausea, diarrhea, abdominal discomfort, rash, vomiting, anorexia, headaches, asthenia (weakness), fatigue, taste disturbances, paresthesia (abnormal sensations like burning, prickling, tingling
24Phases of Infection Time from HIV infection to AIDS variable Ranges from few months to 17 yearsEarly phaseflu-like symptomsIntermediate phaseT cells decrease to /milliliter of bloodAdvanced phaseT cells drop to under 200, virus is detectable in bloodPerson with AIDS dies from opportunistic disease8
26Epidemiology of HIVEpidemic: rapid and wide spreading of a contagious diseaseWorldwide, over 36 million people have been infected with HIV29 million people in sub-Saharan AfricaFive million people newly HIV infected each yearIn the U.S., 816,000 people are infectedAbout 40,000 people a year are infected with HIV in the U.S.9
28Populations most affected by HIV/AIDS HIV/AIDS occurs in all population groupsFour populations most affected by HIV /AIDSMen who have sex with menInjection drug usersHeterosexual personsHigher rates for people who use drugs, exchange sex for drugs, have other STIsInfants whose mothers have untreated HIV infectionsAfrican Americans are disproportionately affectedSince the mid 1990s: more African-Americans with AIDS than white Americans in US
30Modes of TransmissionVaginal or anal intercourse, oral sex without a latex or polyurethane condom or barrierSharing needles - drug use, tattooing/piercingPassing virus from mother to fetus10
31Modes of Transmission Breastfeeding from HIV-positive mother Sharing sex toysAccidental contamination with infected bloodContaminated blood transfusions or organ transplants performed before April 1, 1985
32Sexual Transmission Anal intercourse Vaginal intercourse Oral sex Sex toys11
33STIs and HIV transmission STIs increase likelihood of HIV infection two to five timesAn HIV-infected person also infected with STI is three to five times more likely to transmit HIV through sexual contact
34Uncommon Transmission Modes Nonsexual contactHealth care worker risk low with standard infection control precautionsAccidentsBlood transfusions and organ donationsBlood has been screened for HIV since 1985Organs, semen donations screened for HIV12
35U.S. AIDS Demographics People of Color Gay community Women and HIV Increasing infection among African AmericansGay communityMen who have sex with men 55% of 2001 AIDS casesWomen and HIVRisk from drug use, at-risk sex partners: 26% of casesChildren and HIVMost due to exposure at birth, HIV positive motherTeens and college studentsHalf of new infections among young people 13-24Older adults13
38Poverty, Ethnicity and HIV In 2001, minorities were 68% of diagnosed AIDS casesRace and ethnicity are not risk factors: they correlate with homelessness, access to health care
39Poverty, Ethnicity and HIV AIDS leading cause of death in African-American women 25-34, African-American men 35-44African-American HIV infection rate 16 times that of Non-Hispanic WhitesHispanic AIDS incidence four times that of non-Hispanic WhitesSouthern U.S. has disproportionate share of cases
40PreventionBe aware that alcohol and drug use increases risky behaviorsDevelop communication skills to be able to discuss risks and prevention with partnersBe aware of information on HIV testingBecome familiar with condoms14
41Education about HIV/AIDS Prevention has reduced new infections from 150,000/year to 40,000/yearObstacles to education: blame and denialAIDS seen as disease of marginalized group, not “us”HIV/AIDS education in schoolsOutreach programsHeterosexual adultsMen who have sex with menYouthsDrug users
42HIV TestingTests should be taken 12 weeks after high-risk behavior, repeated 6 months after an uncertain resultTypes of testsOraQuick Rapid HIV-1 Antibody testTakes 20 minutes, 99.6% accurateELISA - enzyme-linked immunosorbent assayWestern blot –rechecks ELISA resultsViral load tests measure HIV in bloodstreamNotifying current and past partners15
43HIV Drugs Nucleoside reverse transcriptase inhibitors (RT inhibitors) Interrupt virus making copies at early stageProtease inhibitorsInterrupt virus reproduction at later stageFusion InhibitorBlock HIV before it enters the cellHAART – Highly Active Antiretroviral TherapyRT inhibitors and protease inhibitors combinedReduces HIV in blood to undetectable levels
44The case of FritzFritz is a 43-year-old single white man that has been HIV positive for the past six years. He has been getting medical treatment at a county public health AIDS clinic and has been taking AZT for the past 5 years.Fritz has been employed full-time as a hairdresser at the same medium-sized salon for over 12 years. Lately he has been having problems with fatigue and has complained of loss of concentration and becoming forgetful. He has been occasionally forgetting what his customers tell him and has been making some mistakes while cutting and setting hair. Likewise, he has become rather tired standing all day. A friend who received vocational rehabilitation services years ago for a different condition referred Fritz to VR services. Fritz indicated that he has not told him employer that he is HIV positive, but has a good working relationship with the owner of the salon. Fritz’s physician does not think that he has the symptoms of AIDS as of yet.
45Discussion on the case of Fritz What are the possible functional limitations associated with Fritz’s medical condition that would influence his rehabilitation potential?How would you explain Fritz’s disability to his employer?What vocational changes (if any) would you suggest?