Presentation on theme: "Seafarers and HIV infection"— Presentation transcript:
1Seafarers and HIV infection Dr. Michaela SchuhwerkGUM PhysicianMRCP, DTMH, DipGUM, DFFP, MSc, CCST in GUM Medicine
2Overview Objectives: I. History of epidemic To provide an overview over the following topicsI. History of epidemicEpidemiology (worldwide and UK)Clinical features of HIVIV. DiagnosisV. TreatmentVI. Relevance for occupational health physicians
3I. History of the epidemic -1 1981 First cases of PCP pneumonia and Kaposi’s sarcoma described in USA1983 Discovery of the virus. First cases of AIDS in the UK1984 Development of first antibody test1987 AZT becomes available to treat HIV1996: Protease inhibitors available, change dramatically treatment of HIV1998 routine antenatal HIV testing with opt out policy2009: 33 Mio worldwide HIV infected individuals
4I. History of the epidemic -2 2009:HIV is now a chronic treatable conditions with a near normal life expectancyThis depends on timely diagnosis and access to antiretroviral therapy
6Source: UNAIDS/WHO AIDS Epidemic Update: December 2007 Number of people living with HIV worldwide in 2007Adults31.0 millionWomen15.5 millionChildren under 15 years2.0 millionTotal33 millionPeople newly infected with HIV worldwide in 20072.7 million370,0003.07 millionAIDS deaths worldwide in 20072 million270,000
8UK epidemiology 2007individuals HIV positivePrevalence UK: 0.12 %Proportion of risk groups infected43% MSM31% Heterosexual women21% Heterosexual men4% IVDU61% of all cases in African born individuals unaware of diagnosis29% of HIV cases undiagnosed (21600)
9Estimated late diagnosis1 of HIV infection and AIDS at HIV diagnosis by prevention group, UK: 2006 1CD4 cell count less than 200 cells/mm3 within 30 days of diagnosis among adults (aged >14 years)HIV/AIDS diagnoses and death reports, and surveillance of CD4 cell counts inHIV-infected persons
11III. Clinical Features1. Seroconversion illness - seen in 10% of individuals a few weeks after exposure and coincides with seroconversion. Presents with an infectious mononucleosis like illness.2. Incubation period - this is the period when the patient is completely asymptomatic and may vary from a few months to a more than 10 years. The median incubation period is 8-10 years.3. AIDS-related complex or persistent generalized lymphadenopathy.4. Full-blown AIDS.
12IV. Opportunistic Infections Protozoal pneumocystis carinii (now thought to be a fungi),toxoplasmosis, crytosporidosisFungal candidiasis, crytococcosishistoplasmosis, coccidiodomycosisBacterial Mycobacterium avium complex, MTBatypical mycobacterial diseasesalmonella septicaemiamultiple or recurrent pyogenic bacterial infectionViral CMV, HSV, VZV, JCV
13Opportunistic Tumours The most frequent opportunistic tumour, Kaposi's sarcoma, is observed in 20% of patients with AIDS.KS is observed mostly in homosexuals and its relative incidence is declining. It is now associated with a human herpes virus 8 (HHV-8).Malignant lymphomas are also frequently seen in AIDS patients.
17Other ManifestationsIt is now recognised that HIV-infected patients may develop a number of manifestations that are not explained by opportunistic infections or tumours.The most frequent neurological disorder is AIDS encephalopathy which is seen in two thirds of cases.Other manifestations include characteristic skin eruptions and persistent diarrhoea.
18IV. Diagnosis1. Clinical diagnosis because of suspicious features, high risk group or reported symptoms2. Laboratory diagnosis
19Laboratory Diagnosis Antibody tests only: window period up to 3 months Combination ag/ab tests: p24/antibody tests positive after 4 weeksIn special circumstances pro viral DNA
29HIV positive seafarerIn all cases of confirmed HIV positive status the assessment and decision taking process should be informed by advice from the clinician responsible for the care of the individual. It is the clinician and not the Approved Doctor who is responsible for the determining the frequency of surveillance needed to guide clinical care, where it needs to take place and for treatment while the seafarer is at sea. However it is for the Approved Doctor to take the final decision and issue a fitness certificate in line with the guidance below.
30The HIV positive seafarer Routine pre employment HIV testing is not recommended.Yet: HIV testing is recommended and should strongly be suggested, if an individual, unknown to be HIV positive, exhibits physical signs during the medical examination, that rise suspicion of advanced HIV disease (and as such would be at greater risk to his/her health if undiagnosed than the implications of a positive HIV diagnosis to his/her employment otherwise.
31Criteria for fitness decision CD4 count > 350 ?Clinically well/ asymptomatic?Any AIDS defining illnesses? If yes, which?On HAART?If yes, since when?Any side effectsComplianceresistance
33Clinical stage 2 Clinical Stage 2 Weight loss, < 10% of body mass Minor mucocutaneous manifestationsHerpes Zoster in the last 5 yearsRecurrent upper respiratory tract infectionPerformance scale 2: Symptomatic, normal activity
34Clinical Stage 3 Weight loss, >10% of body mass Unexplained chronic diarrhoea>1 monthUnexplained prolonged fever> 1 monthOral candidiasis, Oral hairy leukoplakiaPulmonary tuberculosis, Severe Bacterial infectionsPerformance scale 3: bed ridden < 50% of the day during the last month.
35Clinical stage 4 AIDS complex HIV wasting syndrome: weight loss >10% body mass, plus unexplained chronic diarrhoea (>1 month) or chronic weakness and unexplained fever(>1 month)Performance Scale 4: bedridden for>50% day during the last month.
36HIV seafarer and fitness categories Category 1 Fitness:(no restrictions)Stage 1No complicationsCD4 count above 350 and never been on treatmentLimit duration to time of next specialist appointment if start of HAART is anticipated.
37HIV seafarer and fitness categories Category 2 Fitness:(fit with restrictions)Stage 2CD4 count above 350 and seafarer on antiretroviral medication that needs regular monitoring;Restriction s apply toproof of regular treatment monitoring by specialist andlocality: near coastal: until well established on antiretroviral regimen when specialist screening interval is only every 3-6 months
38HIV seafarer and fitness categories Category 3 Fitness (temporarily unfit)Stage 3 (if symptoms impact significantly on performance status; e.g. oral candidiasis should not lead to being temporarily unfit)Initiation and change of antiretroviral therapyAIDS diagnosis:Most AIDS defining conditions that can be treated and in conjunction with antiretroviral therapy will significantly reduce the chance of relapse or further AIDS defining illnesses. The CD4 count should be as a minimum above 200 and the seafarer on antiretroviral medication.
39HIV seafarer and fitness categories Category 4: (permanently unfit):No scope for improvement in condition (mainly limited to late diagnosis of HIV disease with CD4 counts often <=100, Lymphomas, Dementia, loss of vision with CMV retinitis etc).Resistant to all antiretroviral regimens with likelihood of CD4 count falling
40Finally HIV very different disease in 2009 from 1983! Chronic treatable conditionSurvival very different only if HIV status known!Early diagnosis very importantHigh level of suspicion in certain groups and with certain clinical signsDiagnosis prolongs life!!!
41Thank you! Important Websites: www.bhiva.org.uk www.medfash.org.uk