HUMAN IMMUNODEFFICIENCY

SYNDROME
NKELIA JONES, NIKITA JACOBS
Definition

HIV is a retrovirus that causes progressive

immune system dysfunction which predisposes
patients to various opportunistic infections and
malignancies.

AIDS (Acquired Immune Deficiency Syndrome)

is related to HIV. A person has AIDS only in the
final stages of HIV, after the immune system
becomes unable to defend itself against foreign
invaders like bacteria, other viruses, and allows
the development of certain cancers.
Types

HIV-1 and HIV-2

Both are transmitted via the same routes and

lead to AIDS but HIV-2 is generally less virulent
HIV-1 is the predominant type in North America
and most of the world.
HIV-2 is found mainly in West Africa. It is less
easily transmitted and develops more slowly
Incidence

Since 1981 1.7 million people in the United States alone

are estimated to have been infected with HIV.
The Caribbean is the second-most affected region in the
world in terms of HIV prevalence rates. Based on 2009
data, about 1.0 percent of the adult population (240,000
people) is living with the disease, which is higher than
any other region except Sub-Saharan Africa.
1 in 5 of those infected are unaware.
MSM (Men who have sex with men ) accounted for 61%
of all new HIV infections in the U.S. in 2009.
Over 619,000 with HIV have already died since the
epidemic began.
Aetiology

The early 1980s introduced us to HIV/AIDS.

The most likely theories assume that HIV-1 was

transmitted to humans from chimpanzees
sometime in the early 20th century.
Natural History

Acute (Infection) Retroviral Syndrome

2-6 weeks post exposure:
40-90% experience an acute "flu-like" illness
lasting 10-15 days; may include fever,
pharyngitis, lymphadenopathy, rash, arthralgias,
myalgias, GI symptoms, oral ulcers, weight loss.
Heamatologic disturbances; lymphopenia,
thrombocytopenia.
10-20% present with aseptic meningitis; HIV RNA
and/or p24 may be detected in CSF associated
with a high level of plasma viremia and therefore
high risk of transmission
Stage II

Asymptomatic (Latent) Stage

HIV active and reproducing at low levels in
CD4+ T lymphocytes.
CD4 count drops 60-100 cells/mm3 per year (N:
500-1,100)
10 years post-infection:
50% have AIDS,
30% demonstrate milder symptoms,
<20% are asymptomatic if left untreated
Stage III

AIDS Definition in United States

CD4+ T-lymphocyte count of <200 cells/L OR
CD4+ T-lymphocyte percentage of total
lymphocytes of <14% OR documentation of an
AIDS-defining condition
Most severe stage of infection
Increased number of opportunistic infections.
If no treatment average survival is 3 yrs
Natural History

Severity of disease is determined by:

Amount of virus in the body (virus load)
Degree of immune suppression (CD4 count)

The higher the viral the load the sooner the

immune suppression.
Virus attacks CD4 white blood cells
Ability to fight infections lost
Opportunistic diseases occur
CD4 count Clinical Features/Symptoms
CD4 count tresholds
<500cells/mm3 for classic clinical
Often asymptomatic
presentations. Constitutional
weight loss
symptoms: fever, night sweats, fatigue,

Mucocutaneous lesions: seborrheic dermatitis, HSV, VZV

(shingles), oral hairy leukoplakia (EBV),
candidiasis (oral, esophageal, vaginal), Kaposis sarcoma
(KS)
Recurrent bacterial infections, especially pneumonia
Pulmonary and extrapulmonary tuberculosis
Lymphoma

<200cells/mm3 Pneumocystis jiroveci pneumonia (formerly PCP)

KS
Oral thrush
Local and/or disseminated fungal infections: Cryptococcus
neoformans, Coccidioides immitis,
Histoplasma capsulatum

<100 cells/mm3 Progressive multifocal leukoencephalopathy (PML) JC virus

CNS toxoplasmosis

<50 cells/mm3 CMV infection: retinitis, colitis, cholangiopathy, CNS disease

Mycobacterium avium complex (MAC)
Bacillary angiomatosis (disseminated Bartonella)
Primary central nervous system lymphoma (PCNSL)
Laboratory
HIV-Related Opportunistic
Disease
Mode of Transmission
HIV Invasion Site Sub-Location Transmission
Medium
Female genital tract Vagina, ectocervix, semen
endocervix
Male genital tract Inner foreskin, penile Cervicovaginal and
urethra rectal secretions
and desquamations

Intestinal tract Rectum Semen

Upper GI tract Semen
Maternal
blood/genital
secretions
Breast milk
Placenta Chorionic villi Maternal blood
Blood stream Contaminated blood
products
Sharp/needlestick
injuries
Mode of Transmission

HIV cannot be transmitted by:

Saliva (coughing, sneezing) and tears not mixed
with blood,
Insect bites (mosquitoes),
Skin contact without broken skin (touching,
hugging),
Sharing dishes, water, food.
Sharing toilets, telephones.
Prevention of
Transmission
Public Health Strategies
Screen all blood and blood products
Educate the public on safer sex practices
Identify and treat STIs
Provide referral for treatment of drug dependence
or resistance
Apply PMTCT approach to prevent perinatal
Transmission
Awareness of spread via used needles and
syringes
Diagnosis

HIV TESTING AND COUNSELLING

RECOMMENDATION

WHO GUIDELINES
Diagnosis

To be tested for HIV you usually give a sample

of blood, urine or a swab of fluids from your
mouth
WHO GUIDELINES FOR
HIV TESTING
WHO 5 Cs of HTC:
Consent
Confidentiality
Counselling
Correct results
Linkage to Care
Key Populations at Risk

Men who have sex with men

People in prisons and other closed settings
People who inject drugs
Sex workers
Transgender people
 Unaware of HIV status. It is estimated that, globally, about half of
the people currently living with HIV do not know their HIV status .
For people from key populations, access to HTC and, thus,
knowledge of HIV status tend to be much less. People from key
populations often test late and often fail to link from HTC to care
and assessment for ART . Thus, many start treatment when
already significantly immunocompromised, when poor health
outcomes and, for pregnant women presenting late in antenatal
care or at delivery, vertical HIV transmission are more likely.

Counselling is an essential component of testing. Pre-test

counselling must provide
accurate information about the test and the implications of a positive
or negative result in order to enable the person seeking testing to
make an informed choice. Post-test counselling must offer, among
much else, support concerning disclosure of HIV status. Also, HTC
offers a valuable opportunity to provide accurate information about
safer sex and harm reduction that is relevant to the person being
tested, reflecting the test result. Behavioural change and risk
reduction counselling may also have value.
Multiple settings. Rapid HIV testing enables health workers to
provide clients with same-day results. Thus, HTC can be
offered in a variety of settings, including primary care clinics
(e.g. maternal, neonatal and child health clinics), and by a
variety of providers, including outreach workers.

Community-based testing, linked to prevention, care and

treatment, has the potential to reach greater numbers of
people than clinic-based HTC particularly those unlikely to go
to a facility for testing and those who are asymptomatic. It is
important to have clear procedures in place, following national
HIV testing strategies and algorithms, to confirm positive HIV
test results and to link clients to treatment and care.
Recommendations and
Guidelines
ALL KEY POPULATION GROUPS
Voluntary HTC should be routinely offered to all key
populations in both the community and clinical
settings.
Community-based HIV testing and counselling for
key populations, with linkage to prevention, care and
treatment services, is recommended, in addition to
provider-initiated testing and counselling .
Additional remark
Couples and partners should be offered voluntary
HTC with support for mutual disclosure .
Related recommendations and
contextual issues for specific key
population groups
PEOPLE IN PRISONS AND OTHER CLOSED SETTINGS
It is important to guard against negative consequences
of testing in prisons for example, segregation of
prisoners and to respect confidentiality. It is also
important that people who test positive have access
and are linked to HIV care and treatment services
HIV testing and counselling should be voluntary.
The use of HIV rapid testing can increase the likelihood
of prisoners receiving their results.
Testing in conjunction with other risk-reduction services
such as the provision of condoms with lubricants and STI
screening can increase the benefits of testing and
counselling.
ADOLESCENTS FROM KEY
POPULATIONS
In all epidemic settings accessible and acceptable HTC services must
be available to adolescents and provided in ways that do not put them
at risk. Countries are encouraged to examine their current consent
policies and consider revising them to reduce age-related barriers to
access and uptake of HTC and to linkages to prevention, treatment and
care following testing. Young people should be able to obtain HTC
without required parental or guardian consent or presence.
HIV testing and counselling, with linkages to prevention, treatment
and care, is recommended for adolescents from key populations in all
settings (generalized, low and concentrated epidemics) (strong
recommendation, very low quality of evidence).
Adolescents should be counselled about the potential benefits and
risks of disclosure of their HIV status and empowered and supported to
determine when, how and to whom to disclose (conditional
recommendation, very low quality of evidence).
Children of school age should be told their HIV-positive status
(strong recommendation, low quality of evidence)
References

Centers for Disease Control and Prevention,

http://www.cdc.gov/hiv/ August 1st 2016.

World Health Organisation,

http://www.who.int/hiv/en/ 2016

http://aids.about.com , 2016

PMTCT generic Training Module, World Health

Organisation, http://www.who.int/, 2016
 Thank You