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Human Immunodeficiency Virus (HIV)
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HIV HIV-a retrovirus Etiology Epidemiology Clinical Presentation
Modes of Transmission Clinical Presentation HIV infection / Diagnosis Aids Infection / Diagnosis Treatment Preventive Measures
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EO HIV The Human Immunodeficiency Virus (HIV) causes Acquired Immunodeficiency Syndrome (AIDS) HIV attacks the immune system, resulting in a chronic, progressive illness and leaving infected people vulnerable to opportunistic infections and cancers The median time from infection to AIDS diagnosis now exceeds 10 years AIDS can be fatal
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HIV HIV searches for immune system cells that have CD4 surface receptors, because this particular receptor enables the virus to bind to the cell. Although HIV infects a variety of immune system cells, its key target is the T-lymphocyte, a white blood cell that has numerous CD4 receptors Once HIV binds to a CD4+ cell, it transfers its genetic material and vital enzymes into the cell where it integrates with the genetic material of the host cell, => new “batch” of HIV is produced.
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HIV Although CD4+ T cells appear to be HIV's main target, other immune system cells with CD4 molecules on their surfaces are infected as well: Monocytes Macrophages CD4+ T cells also serve as important reservoirs of HIV: a small proportion of these cells harbor HIV in a stable, inactive form. Normal immune processes may activate these cells, resulting in the production of new HIV virions. which apparently can harbor large quantities of the virus without being killed, thus acting as reservoirs of HIV.
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Don’t memorize, and no test questions on this slide!
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**AIDS defining illness: -CD4<200 (15%)
-Resp or esophageal Candidiasis -Cervical Ca -Coccidioides -Cryptococcus -Cryptosporidium -Cytomegalovirus -Encephalopathy (HIV) -HSV (ulcer >1mo or esophagus or resp) -Histoplasma (dissem or extrapulm) -Isospora -Kaposi sarcoma -Lymphoma (Burkitt’s) -Mycobacterium avium complex -Mycobacterium, other sp, (dissem or extrapulm) -PCP -Pneumonia (recurrent) -Progressive multifocal leukoencephalopathy -Salmonella -Toxoplasma -TB (disseminated) -Wasting syndrome due to HIV. Lots of infections that can signal immune system insufficiency.
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HIV Retrovirus -depends on reverse transcriptase to replicate within host cells. HIV genome has 3 basic structural proteins and 5 other regulatory proteins: Gag codes = group antigen proteins Pol codes = polymerase Env codes = external envelope protein ( greatest variability) Since neutralizing activity is found in antibodies directed against this envelope …this variability causes problems in vaccine development.
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HIV Epidemiology-Modes of transmission
Risky behaviors, such as: - sharing needles and syringes, - buying sex male-to-male sex without the use of condoms anal, oral. CMDT 2005 Number of cofactors are increase the risk of HIV Transmission during a given encounter: Ulcerative or inflammatory STDs Trauma Menses Lack of male circumcision
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Epidemiology
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Epidemiology Reliable data on HIV prevalence in Afghanistan is sparse.
About 650 HIV cases registered by the MoPH number of people living with HIV/AIDS estimated at 3,000, Afghanistan is as yet relatively unscathed, but remains vulnerable. HIV epidemic is at an early stage and concentrated among high-risk groups, mainly injecting drug users and their partners.
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Modes of transmission
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HIV Epidemiology-Modes of transmission
Needle stick injury risk is 1: 300 Factors increasing risk: Depth of penetration Hollow bore needles Visible blood on the needle Advanced stage of disease in the source Mucosal splash risk unknown but assumed to be lower. Think of ways to handle needles safely
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HIV Epidemiology-Modes of transmission
HIV not been shown to be spread by: Respiratory droplet spread Vectors such as mosquitos Casual non-sexual contact Shaking hands
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Clinical Presentation - HIV
Acute HIV Infection Primary or acute HIV infection may be associated with symptoms resembling mononucleosis or the flu within 2 to 4 weeks of exposure HIV seroconversion (converting from HIV negative to HIV positive) occurs within 3 months of exposure
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Clinical Presentation - HIV
Symptoms: Many individuals can be asymptomatic for years Sx’s can be very non-specific Combination of complaints is more suggestive of HIV infection than any one symptom. Physical exam: Non-specific to very specific: Hairy leukoplakia of the tongue Disseminated Kaposi’s sarcoma Cutaneous bacillary angiomatosis Pictures of Kaposi’s later
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Pg CMDT 2005
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HIV Signs & Symptoms sore throat muscular stiffness or aching headache
EO HIV Signs & Symptoms sore throat muscular stiffness or aching headache diarrhea lymphadenopathy fever fatigue
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HIV Signs & Symptoms rash of various types joint pain elbow pain
EO HIV Signs & Symptoms rash of various types joint pain elbow pain hip pain knee pain ankle pain
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Lymphadenopathy Cervical lymphadenopathy
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Rash and Sore Throat Acute HIV Rash Palatal Ulcerations
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HIV Constitutional Sxs:
Fever night sweats and weight loss common and can occur without opportunistic infections. Weight loss Loss of muscle mass being the most distressing. Anorexia, nausea, vomiting Varying degrees of malabsorption Increased metabolic rate Decreased protein synthesis
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AIDS AIDS Patient Note the severe weight loss
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HIV Oral lesions: Oral candidiasis
Hairy leukoplakia (Epstein-Barr virus) White lesion on lateral aspect of the tongue Parallel lines that have a raised or “hairy apperance”. These patients have a high rate of progression to AIDS despite CD4 counts Angular chelitis, gingival infections, and aphthous ulcers are also common.
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Aphthous Ulcer Tongue Throat Candidiasis
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Hairy Leukoplakia
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HIV ENT: Chronic Sinusitis Candidiasis: oropharygeal and esophageal
GI: Hepatic disease Biliary Disease
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HIV GI cont’d: Enterocolitis:
Bacteria (campylobacter, salmonella, shigella) Viruses (Cytomegalovirus, adenovirus) Protozoans (Cryptosporidium, giardia, entamoeba hystolytica) Gastropathy – decreased stomach acid Malabsorption syndromes
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HIV Respiratory: Pneumocystis carinii pneumonia
Most common opportunistic infection associated with AIDS is difficult to diagnosis Fever, cough, SOB – all non-specific Symptoms can be mild to full blown respiratory distress. CXR: Diffuse or perihilar infiltrates in 2/3 of pts Definite diagnosis.: Induced sputum collection 50-80% of cases Bronchiolar lavage – 95% of cases Normal cxr in 5-10% while the rest have atypical infiltrates.
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Pneumocystis jiroveci (formerly carinii) pneumonia
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HIV Other Infectious Pulmonary disease: Community acquired pneumonia
Mycobacterium Tuberculosis Viral pneumonias Non-infectious pulmonary disease: Kaposi’s sarcoma Non-Hodgkins lymphoma Interstitial pneumonitis
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EO HIV Diagnosis An HIV ELISA/Western blot may show positive HIV antibody; if negative, the test should be repeated in 3 months. CD4 count may show suppression of the immune system A blood differential may show abnormalities. Tests will depend greatly upon local resources. Consult the plan established by your command for instance MoD, MoPH, MoI. A normal person has a CD4 T-cell count of 450 to 1,200 cells per microliter. When people with HIV have their T-cell counts drop to 200 or lower, they have reached the stage of AIDS. The ELISA is used as a screening test. A positive result does not necessarily mean that the subject has exposure to the HIV virus or HIV disease. The western-blot is used as a confirmatory test, and may be negative, positive, or indeterminate. A positive western blot is generally regarded as conclusive for an HIV infection. Negative tests do not necessarily rule out HIV infection, because there is a time interval between HIV infection and the appearance of measurable anti-HIV antibodies (the so-called "window period"). An infected individual may transmit HIV during the window period (even with a negative anti-HIV ELISA or western-blot test). Note: Studies have shown that a recent flu shot can result in a false positive HIV ELISA. However, if this is the reason you tested positive the western-blot test will confirm that you are HIV negative. After about 3 months the HIV ELISA will convert back to a negative result. Inform your health care provider if you are considering having this test performed and have had a flu shot within the past 3 months.
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EO AIDS Diagnosis HIV antibody test ELISA (Enzyme Linked Immunoabsorbent Assay) and Western Blot are positive absolute CD4 lymphocyte count is less than 200 p24 antigen is abnormal T (thymus derived) lymphocyte count is abnormal Immunodeficiency is the defining characteristic of AIDS The ELISA is used as a screening test. A positive result does not necessarily mean that the subject has exposure to the HIV virus or HIV disease. The western-blot is used as a confirmatory test, and may be negative, positive, or indeterminate. A positive western blot is generally regarded as conclusive for an HIV infection. Negative tests do not necessarily rule out HIV infection, because there is a time interval between HIV infection and the appearance of measurable anti-HIV antibodies (the so-called "window period"). An infected individual may transmit HIV during the window period (even with a negative anti-HIV ELISA or western-blot test). Note: Studies have shown that a recent flu shot can result in a false positive HIV ELISA. However, if this is the reason you tested positive the western-blot test will confirm that you are HIV negative. After about 3 months the HIV ELISA will convert back to a negative result. Inform your health care provider if you are considering having this test performed and have had a flu shot within the past 3 months.
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prolonged, unexplained fatigue swollen glands (lymph nodes)
EO AIDS Signs & Symptoms prolonged, unexplained fatigue swollen glands (lymph nodes) fever lasting more than 10 days chills excessive sweating especially night sweats mouth lesions including yeast lesions and painful, swollen gums sore throat cough ( sounds like malaria!!!)
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AIDS Signs & Symptoms shortness of breath
EO AIDS Signs & Symptoms shortness of breath changes in bowel habits including constipation frequent diarrhea symptoms of a specific opportunistic infection (such as candida, pneumocystis, and so on) tumor (Kaposi sarcoma) skin rashes or lesions of various types unintentional weight loss general discomfort or uneasiness (malaise) headache
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Additional symptoms that may be associated with this disease:
EO AIDS Signs & Symptoms Additional symptoms that may be associated with this disease: speech impairment muscle atrophy memory loss decreasing intellectual function joint swelling joint stiffness joint pain
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AIDS Signs & Symptoms cold intolerance bone pain or tenderness
EO AIDS Signs & Symptoms cold intolerance bone pain or tenderness unusual or strange behaviour slow, sluggish, lethargic movement anxiety, stress, and tension groin lump generalized itching (pruritus) genital sores (female)
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AIDS Signs & Symptoms genital sores (male) blurred vision
EO AIDS Signs & Symptoms genital sores (male) blurred vision double vision (diplopia) light sensitivity blind spots in the vision decreased vision or blindness chest pain flank pain or pain in the sides
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AIDS Signs & Symptoms back pain abdominal pain
EO AIDS Signs & Symptoms back pain abdominal pain loss of appetite, indigestion, or other gastrointestinal upset muscle pain bone pain or tenderness numbness and tingling seizures
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AIDS Complications Protozoal infections pneumocystis carinii pneumonia
EO AIDS Complications Protozoal infections pneumocystis carinii pneumonia toxoplasmosis cryptosporidium enterocolitis giardiasis
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AIDS Complications Fungal infections esophagitis candida
EO AIDS Complications Fungal infections esophagitis candida cryptococcal meningitis coccidioidomycosis histoplasmosis aspergillosis
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AIDS Complications Oral candidiasis Fungal infections
esophagitis candida cryptococcal meningitis coccidioidomycosis histoplasmosis aspergillosis
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AIDS Complications Bacterial infections Viral infections
EO AIDS Complications Bacterial infections pulmonary tuberculosis atypical mycobacterial infection disseminated tuberculosis recurrent bacterial pneumonias Viral infections herpes simplex virus cytomegalovirus Epstein-Barr varicella - herpes zoster
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AIDS Complications Malignancies Kaposi's sarcoma Lymphoma
EO AIDS Complications Malignancies Kaposi's sarcoma Lymphoma Non-hodgkins and Hodgkins Anal dysplasia and Squamous cell cancer (cervical)
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Kaposi’s Sarcoma Lesions may appear anywhere. Remember: eyelids, conjunctiva, pinnae, palate, and web spaces. 40% of pts with skin lesions also have visceral disease (Gastrointestinal, Respiratory)
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Kaposi’s Sarcoma can range from disfiguring to …..
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organ and limb threatening …
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Treatment of HIV/AIDS
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Treatment of HIV/AIDS So many Drugs!!!!
Do not worry about memorizing these drugs, the treatment of HIV/AIDS will be decided by experts in the disease.
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EO Standard Precautions Refers to a method of infection control in which all human blood and other potentially infectious materials are treated as if known to be infectious for HIV and HBV and HCV Do not apply to faeces, nasal secretions, sputum, sweat, tears, urine or vomitus unless they contain visible blood
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EO Standard Precautions Using protective equipment when applicable to protect the skin and mucous membranes The mandatory use of gloves, gowns, masks and eye protection if handling bio-hazardous waste The washing of hands after handling bio-hazardous waste
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Standard Precautions Proper use of Personal Protective Equipment (PPE)
Effectively cleaning blood spills Proper disposal of bio-hazardous waste Proper handling of sharps Appropriate response to occupational exposures
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Gloves Gloves should be worn when …
EO Gloves Gloves should be worn when … there is contact or potential for contact with blood and/or body fluids there is contact or potential for contact with mucous membranes, non-intact skin there is contact or potential for contact with items/surfaces soiled with blood and/or body fluids performing venipuncture starting IV’s any invasive procedures change gloves after contact with each patient wash hands after gloves are removed
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EO Gowns Impervious gowns should be worn during procedures that are likely to generate splashes of blood and/or body fluids onto your clothing or exposed skin Masks and protective eyewear (or masks with attached face shield or full face shield) should be worn during procedures that are likely to generate splashing of blood and/or body fluids into the mucous membranes of the mouth, nose, or eyes
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Precautions Avoid unsafe sexual practices
EO Precautions Avoid unsafe sexual practices number and frequency of sexual contacts Avoid high risk practices, e.g., anal intercourse Use barrier protection Avoid use of shared needles Seek help if addicted to IV opium
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