HIV-AIDS

Prof. OP rajoura
 HIV v/s AIDS
HIV: Human Immuno-deficiency Virus

AIDS: Acquired Immuno Deficiency Syndrome

A= not inherited
I= immune system
D= deficiency- inability to protect against illness
S= syndrome, a group of symptoms or illnesses that occur as a
result of HIV infection

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 GLOBAL HISTORY
• 1981 – beginning of the epidemic in United States
- Centers for Disease Control and Prevention (CDC) published a report about
five previously healthy homosexual men becoming infected with Pneumocystis
pneumonia
- Because the disease appeared to affect mostly homosexual men, officials
initially called it Gay-related immune deficiency, or GRID.
- CDC noted that this type of pneumonia had never affected people with
uncompromised immune systems.
• 1983 - Lymphadenopathy-Associated Virus (or LAV) retrovirus was discovered
• 1984 - National Cancer Institute found the cause of AIDS to be retrovirus
HTLV-III.

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• 1985 - Food and Drug Administration licensed the first
commercial blood test for HIV
• 1986 - the International Committee on the Taxonomy of
Viruses officially named the virus as HIV (human
immunodeficiency virus)
• 1988 - The World Health Organization declared December
1st to be World AIDS Day.
• 1991 - The red ribbon became an international symbol of
AIDS awareness.
• 2008 - Luc Antoine Montagnier was awarded Nobel Prize
in Physiology and medicine for his discovery of the human
immunodeficiency virus (HIV).

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 GLOBAL BURDEN- 2019
• People living with HIV = 38 million [31.6 million–44.5 million]
- 36.2 million  adults(>or=15 years)
- 1.8 million  children (<15 years)

• Newly infected with HIV = 1.7 million [1.2 million–2.2 million]

• 81% - knew their HIV status

• 6.9 lacs died due to AIDS related illness

• Antiretroviral therapy accessed = 25.4 million

www.unaids.org/en/resources/fact-sheet [accessed on 6/07/19] 5

 INDIA
• Suniti Solomon-first AIDS case was diagnosed in
Chennai in 1986.

• In 2009, she was awarded , “National Women

Bio-scientist Award” by Ministry of Science and
Technology, Govt. of India.

• On 25th January 2017, Govt. of India announced

“Padma shri” award for her contribution
towards Medicine

• “what has been killing people with AIDS more is

the stigma and discrimination”
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INDIA HIV/AIDS BURDEN-2017

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STATE/UTs WISE % DISTRIBUTION OF
TOTAL PLHIV IN 2017

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ADULT HIV PREVALENCE IN INDIA
1981-2017

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 STATEWISE ADULT HIV PREVALENCE -
2017

Adult HIV Prevalence

Higher than national
average
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AIDS-RELATED DEATHS OVER THE YEARS

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 KEY TERMS
• Key populations: are defined groups who, due to specific higher-risk behaviours,
are at increased risk of HIV irrespective of the epidemic type or local context.
1) men who have sex with men
2) people who inject drugs
3) people in prisons and other closed settings
4) sex workers
5) transgender people.
• Vulnerable populations are groups of people who are particularly vulnerable to
HIV infection in certain situations or contexts, such as adolescents, orphans,
street children, people with disabilities and migrant and mobile workers.
• Men who have sex with men refers to all men who engage in sexual relations
with other men.
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 • People who inject drugs: people who inject psychotropic (or
psychoactive) substances for non-medical purposes.
• Opioids, amphetamine-type stimulants, cocaine, hypno-sedatives and
hallucinogens.
• Injection may be through intravenous, intramuscular, subcutaneous or other
injectable routes.
• Transgender is an umbrella term for people whose gender identity and
expression does not conform to the norms and expectations
traditionally associated with the sex assigned to them at birth.
• Includes people who are trans-sexual, transgender or otherwise gender non-
conforming
• Sex workers include female, male and transgender adults (18 years of
age and above) who receive money or goods in exchange for sexual
services, either regularly or occasionally.
NOTE: People who self-inject medicines for medical purposes – referred to as “therapeutic injection” – are not
included in this definition. The definition also does not include individuals who self-inject non-psychotropic substances,
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such as steroids or other hormones, for body shaping or improving athletic performance.
 ETIOLOGY

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 HIV
• Enveloped ssRNA Virus,
• Genus: Lentivirus, Family Retroviridae,
• Lentiviruses (HIV 1 and 2)
• Attacks CD4+ cells
• Replicates in actively dividing T4 lymphocytes.
• The virus can remain in lymphoid tissues in latent phase until it is
activated.
• Unique ability to destroy T4 Helper cells
• Once a person gets infected, HIV remains in his body lifelong.
• The person is a symptomless carrier for years before the symptoms
actually appear.
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 HIV STRUCTURE

• HIV is composed of
three main layers:

• Envelope

• Viral Matrix

• Core

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 HIV-1 AND HIV-2
• HIV-1 and HIV-2
• Transmitted though the same routes
• Associated with similar opportunistic infections

• HIV-1 is more common worldwide

• Groups M, N, and O
• Pandemic dominated by Group M
 Group M comprised of subtypes A – J

• HIV-2 is found primarily in West Africa, Mozambique and Angola

• less easily transmitted
• is develops more slowly
• MTCT is relatively rare with HIV-2
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 ROUTE OF TRANSMISSION RISK OF TRANSMISSION
percentage
Route Efficiency
2%2% 1%
heterosexual Sexual 0.01 to 1
Transfusion of blood >90
3%
5%
PTCT products
not specified
Sharing 3-5
needles/syringes
needle and Percutaneous 0.4
syringe exposure
Mucocutaneous 0.05
homosexual
88% exposure
blood and re- Mother to child 25-30
latedproduct transmission

*Not transmitted by urine, faeces, sputum, nasal secretion, saliva, sweat, tears, or vomit that does not contain blood
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is visible to the naked eye, human bite 23
HIV in Body Fluids

Blood
Semen
18,000 Vaginal
11,000
Fluid Amniotic
7,000 Fluid
4,000 Saliva
1

Average number of HIV particles in 1 ml of these body fluids

 DISEASE PROGRESSION THROUGH DIFFERENT STAGES

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• Incubation period - Few months to 10 years or even more

• 75% of people infected with HIV develop AIDS at the end of 10 years

• Severity of illness determined by:

• amount of virus in the blood (viral load) and
• the degree of immune suppression (decreasing CD4 count)

• Higher the viral load, sooner immune suppression occurs

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• Window period:
• Time between potential exposure to HIV infection and appearance of
Antibodies in blood: 4-12 weeks

• Sero-conversion:
Development of evidence of antibody response to a disease

• Viral Load:
The amount of HIV in the blood.

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 CLINICAL FEATURES

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 RISK FACTORS FOR TRANSMISSION OF HIV
1. Unsafe sex.

2. MSM (Men having Sex with Men).

3. IDU (Injection Drug User).

4. Migration & Mobility.

5. Low status of women.

6. Widespread stigma.
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 CDC CLASSIFICATION OF HIV INFECTION

1) Acute HIV infection

2) Asymptomatic or Latent infection

3) Persistent generalized lymphadenopathy (PGL)

4) AIDS related complex ( without opprtunistic infections)

5) Full blown AIDS (Last stage)

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 WHO CLINICAL STAGING
• Primary HIV Infection:
• Asymptomatic
• Acute retroviral syndrome

• Clinical stage 1:
• Asymptomatic
• Persistent generalised lymphadenopathy

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Clinical stage 2:
• Moderate unexplained weight loss
(<10% of presumed or measured body weight)
• Recurrent respiratory tract infections
(sinusitis, bronchitis, otitis media, pharyngitis)
• Herpes zoster
• Angular cheilitis
• Recurrent oral ulcerations
• Papular pruritic eruptions
• Seborrhoeic dermatitis
• Fungal nail infections of fingers

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• Clinical stage 3:
• Severe weight loss (>10% of presumed or measured body weight)
• Unexplained chronic diarrhoea for longer than one month
• Unexplained persistent fever (intermittent or constant for longer than
one month)
• Oral candidiasis
• Oral hairy leukoplakia
• Pulmonary tuberculosis (TB) diagnosed in last two years
• Severe bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone
or joint infection, meningitis, bacteraemia)
• Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
• Unexplained Anaemia(<8gm/dL), Neutropenia (<0.5x10*9/L)
And/Or Chronic Thrombocytopenia (50x10*9/L)

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• Clinical stage 4:
• HIV wasting syndrome
• Pneumocystis carinii pneumonia (PCP)
• Recurrent severe bacterial pneumonia
• Chronic Herpes Simplex infection
( Orolabial, Genital or ano-rectal of <1 months duration or visceral at any site)
• Candidiasis (Esophageal/ Trachea/ Bronchi/Lungs)
• EPTB
• Kaposis Sarcoma
• CMV infection (Retina or other organs)
• CNS Toxoplasmosis
• HIV Encephalopathy

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• Extra-Pulmonary Cryptoccocosis
• Disseminated Mycosis
• Recurrent Septicaemia
• Lymphoma (B-cell Non Hodgkins)
• Invasive Cervical Carcinoma
• Atypical disseminated Leishmaniasis
• Symptomatic HIV-associated Nephropathy or
Cardiomyopathy.

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 OPPORTUNISTIC INFECTIONS

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 CLINICAL DIAGNOSIS
WHO case definition for AIDS surveillance-
2 major signs in combination with 1 minor sign.

• MAJOR SIGNS • MINOR SIGNS

1. Weight loss > 10% body 1. Persistent cough for > 1 month.
wt. 2. Generalized pruritic dermatitis.
2. Chronic Diarrhoea for > 1 3. History of herpes zoster.
month. 4. Oropharyngeal candidiasis.
3. Prolonged fever for > 1 5. Chronic herpes simplex
month infection.
6. Generalized lymphadenopathy.

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LABORATORY DIAGNOSIS
• Viral infection
• Viral Load
• p24 Antigen
• Immune response
• Antibody (IgG, IgM)
• Cellular response (CD4)

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 TREATMENT

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 GOALS OF ART
• Clinical goals : Prolongation of life and improvement in quality of life
• Virological goals : Greatest possible reduction in viral load for as long
as possible
• Immunological goals : Immune reconstitution that is both
quantitative and qualitative
• Therapeutic goals : Rational sequencing of drugs in to achieve:
• clinical, virological and immunological goals while maintaining
treatment options, limiting drug toxicity and facilitating
adherence
• Reduction of HIV transmission in individuals : by suppression of viral
load

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 ANTI-RETROVIRAL DRUGS
NRTI PI (Protease Inhibitors) NNRTI
(Neucleoside R T Inhibitors) (Non-Neucleoside R T Inhibitors)

Zidovudine (AZT)* Indinavir (IDV)* Nevirapine (NVP)*

Lamivudine (3TC)* Nelfinavir (NFV)* Efavirenz (EFV)*

Stavudine (d4T)* Saquinavir (SQV)* Delavirdine (DLV)

INTEGRASE INHIBITORS
Didanosine (ddl)* Ritonavir(RTV)*

Zalcitabine(ddC)* Amprenavir(APV) Raltegravir

Abacavir (ABC)* Lopinavir (LPV)* CCR5 antagonists

Tenofovir (TFV)* Atazanavir (ATV)* Maraviroc

Emtricitabine(FTC) Foseamprenavir  
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INITIATION OF ART BASED ON CD4 COUNT AND WHO CLINICAL STAGING
WHO Clinical Stage Recommendations
HIV infected Adults & Adolescents (Including pregnant women)
Clinical Stage I and II Start ART if CD4 < 350 cells/mm3
Clinical Stage III and IV Start ART irrespective of CD4 count
For HIV and TB co-infected patients
Patients with HIV and TB co-infection Start ART irrespective of CD4 count and type of
(Pulmonary/ Extra-Pulmonary) tuberculosis
(Start ATT first, initiate ART as early as possible between 2
weeks to 2 months when TB treatment is tolerated)

For HIV and Hepatitis B and C co-infected patients

HIV and HBV / HCV co-infection – without any evidence Start ART if CD4 < 350 cells/mm3
of chronic active Hepatitis

HIV and HBV / HCV co-infection – With documented Start ART irrespective of CD4 count
evidence of chronic active Hepatitis

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 TREATMENT REGIMEN
First-line ART regimens for adults (Fixed dose combinations)
• Principles:
1. Choose 3TC (Lamivudine) in all regimens
2. Choose one NRTI to combine with 3TC {AZT (Zidovudine or
TDF(Tenofavir)}
3. Choose one NNRTI (NVP or EFV)
• E.g. Tenofovir + Lamivudine + Efavirenz

• If TDF + 3TC or FTC(Emitricitabin) + EFV contraindicated/not available

• AZT (Zidovudine) + 3TC (Lamivudine) + EFV (Efavirenz)
• AZT + 3TC + NVP (Nevirapine)
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TDF + 3TC (or FTC (Emtricitabine)) + NVP 46
 MONITORING OF EFFICACY OF ART

1. Clinical improvement
- Weight gain.
- Decrease severity of HIV related disease.

2. Increase in Total Lymphocyte count.

3. Improvement in biological markers of HIV.

- CD 4 + T – Lymphocyte count.
- Plasma HIV – RNA levels.

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 PROPHYLAXIS OF OPPORTUNISTIC INFECTIONS
• HIV infected adults with CD4 <250 cells/mm3 OR
• WHO clinical stage 3 or 4 irrespective of CD4 count
• Recommendation:
Commencing CD4 awaited CD4 available
primary WHO clinical stage 3 or 4 Any WHO clinical stage and CD4
Cotrimoxazole (includes all patients with TB) <250 cells/mm3 or
Preventive Any WHO clinical stage,
Therapy CD4 <350 cells/mm3 and if patient is
symptomatic
or
WHO stage 3 or 4 irrespective of CD4
count
Dose One double-strength tablet or two single-strength tablets once
daily– total daily dose of 960 mg (800 mg SMZ + 160 mg TMP)
When to stop If CD4 count >250 for at least 6 months and If patient is on ART for at
least 6 months, is asymptomatic and well

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 Thank you

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