1. Natural History and Clinical Staging of HIV Training for Medical Officers Day 2 Session 7

2. Natural History of HIV and Staging of HIV 2 Session Objectives List the modes of HIV transmission Discuss the pathogenesis and life cycle of HIV Describe the progression of HIV Classify an HIV-infected patient according to the WHO clinical stages

3. Natural History of HIV and Staging of HIV 3 Modes of HIV Transmission Sharing Semen and Vaginal Fluids Sharing Needles & Syringes Through Infected Blood During Pregnancy or Birth Breast Feeding © I-TECH, 2005 Needle Stick Injury

4. Natural History of HIV and Staging of HIV 4 Risk of HIV Transmission with Single Unprotected Exposure ( Risk per 10,000 exposures) Source: HIV Web Study, 2006

5. Natural History of HIV and Staging of HIV 5 How HIV Infects the Body HIV makes contact with cells located within the genital mucosa Virus is carried to regional lymph nodes (1-2 Days) Exponential viral replication Widespread systemic dissemination to the brain, spleen, distant lymph nodes, etc. (5-11 Days) Source: GHTM Fellowship Programme, 2006

6. Natural History of HIV and Staging of HIV 6 © 1998 Massachusetts Medical Society. All Rights Reserved HIV exposure at mucosal surface (sex) Virus collected by dendritic cells, carried to lymph node HIV replicates in CD4 cells, released into blood Virus spreads to other organs Day 0 Day 0-2 Day 4-11 Day 11+ Path of the Virus

7. Natural History of HIV and Staging of HIV 7 HIV Lifecycle ©I-TECH, 2005

8. Natural History of HIV and Staging of HIV 8 Life Cycle of HIV

9. Natural History of HIV and Staging of HIV 9 Stages of HIV Infection Viral transmission (2-3 wks) Acute retroviral syndrome (2-3 wks) Seroconversion (2-4 wks) Asymptomatic chronic HIV infection (Avg. 8yrs) Symptomatic HIV infection/AIDS (Avg. 1.3 yrs)

10. Natural History of HIV and Staging of HIV 10 CD4 Count & Viral Load Over Time Source: Fauci, et al, Immu. Mech HIV Inf, 1996

11. Natural History of HIV and Staging of HIV 11 Progression of HIV Acute Seroconversion Asymptomatic HIV (Clinical latency) Symptomatic HIV Acquired Immune Deficiency Syndrome (AIDS)

12. Natural History of HIV and Staging of HIV 12 Patterns of HIV Progression Typical progressors Rapid progressors Slow progressors Long-term non-progressors

13. Natural History of HIV and Staging of HIV 13 WHO Clinical Staging 11 Case Studies

14. Natural History of HIV and Staging of HIV 14 © I-TECH, 2005 Case Study 1

15. Natural History of HIV and Staging of HIV 15 Case Study 2 © I-TECH, 2005

16. Natural History of HIV and Staging of HIV 16 Case Study 3 © I-TECH, 2005

17. Natural History of HIV and Staging of HIV 17 Case Study 4 © I-TECH, 2005

18. Natural History of HIV and Staging of HIV 18 Case Study 5 © I-TECH, 2005

19. Natural History of HIV and Staging of HIV 19 Case Study 6 © I-TECH, 2005

20. Natural History of HIV and Staging of HIV 20 Indian Ink Staining of Cryptococcus in CSF Case Study 7 © I-TECH, 2005

21. Natural History of HIV and Staging of HIV 21 Case Study 8 © I-TECH, 2005

22. Natural History of HIV and Staging of HIV 22 Case Study 9 Courtesy of : GHTM, Chennai, 2006

23. Natural History of HIV and Staging of HIV 23 Case Study 10 37 year-old HIV-positive male Lost 9 kg in last 3 months (previously 75 kg) Reports having a fever for the past month Goes to bed by late afternoon Treated for pulmonary TB 5 months ago What is his WHO clinical stage?

24. Natural History of HIV and Staging of HIV 24 Case 11 34 year-old HIV positive male Suffers from bacterial sinusitis and a fungal infection on his toes Has no problem keeping up with his usual activities and weight is stable Treated for herpes zoster 4 years ago What is his WHO Clinical Stage?

25. Natural History of HIV and Staging of HIV 25 Key Points The most common mode of HIV transmission in India is sexual Understanding the natural history of HIV is important in predicting progress of the disease and determining when to begin ART Clinical staging allows clinicians to reliably predict in patients: – The risk for death and opportunistic infections – The need for disease prevention and ART