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Hiv

HIV was first recognized in the USA in 1981 and is caused by the virus that leads to AIDS, with two main types: HIV-1 and HIV-2. The virus primarily infects CD4 cells, leading to immune system destruction and opportunistic infections. Diagnosis involves antibody detection and PCR, while antiretroviral therapy (ART) aims to suppress viral replication and improve patient outcomes.

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12 views27 pages

Hiv

HIV was first recognized in the USA in 1981 and is caused by the virus that leads to AIDS, with two main types: HIV-1 and HIV-2. The virus primarily infects CD4 cells, leading to immune system destruction and opportunistic infections. Diagnosis involves antibody detection and PCR, while antiretroviral therapy (ART) aims to suppress viral replication and improve patient outcomes.

Uploaded by

Fufa Yaddessa
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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HUMAN IMMUNO DEFICIENCY VIRUS ( HIV)

It is first recognized in USA 1981 when PCP,


Kaposis sarcoma appear in Homosexuals ,IV
drug abusers and after blood transmission in
heamophiliacs who were relatively healthy
before. It raised the suspicion to some thing
unknown is going on.
• In 1983 HIV is isolated from patient with lymphadenopathy.
• In 1984 it was demonstrated that HIV causes AIDS.
• HIV belong to large family called Retroviridae which mainly infect
vertebrates.
• It is RNA virus.
• It has two forms HIV-1 which has A-J sub types and which the
predominating and most sever pattern of disease causing.The other
form is HIV-2 which is common in west Africa has slow
progression of the disease. Both types differ in their envelop
glycoprotein.
Mechanism of disease

1.Tissue destruction by the virus.


2.Host’s response to the virus.
3.Malignant transformation of an infected
cell and induction of immunodeficiency
state leads to opportunistic diseases.
Pathogenesis
HIV infect all cells expressing CD4 antigen which is located on
lymphocytes and macrophagesand serve as the receptor for HIV. The
virus then fuse with host cell membrane,Uncoate its envelope and enters
the cell. By the help of the enzyme called Reverse transcriptase the RNA
of the virus is transformed to DNA again with help of Integrase enzyme
the virus is integrated to host DNA after this the virus controls the DNA
machinery of the cell and produces only the HIV viral DNA and use it
for its replication finally form bud from the main cell by the help of
protease enzyme and rupture out to infect other cells.
Transmission
1. Sexual-HIV is one of STDs. Transmission of
HIV with the presence of other STDs is very
high because most of them cause ulcerative
lesions and discharges.
2. By blood and blood products i.e. by contact to
exposed surface or with transfusion of
infected blood and it one the major
occupational hazard to health workers.
Transmission … CONT.

3.Maternal –Fetal.
•During pregnancy.
•During delivery.
•Breast feeding.
4.By other body fluids i.e. semen, Cervical
secretions, Breast milk, tears ,saliva, Cell free
plasma,CSF,but Blood and the above 2 secretions are
the most important for transmission.
Clinical spectrum of HIV disease
• The median time from infection to development of AIDS is above
10 years unlike children which usually happen in their first year of
life in fast progressors.
• Acute retroviral syndrome appear as flu like symptom.
• The first 3-6 months of infection before antibody is produced is
called WINDOW period.
 It is the time of Highest viral load.
 Highest risk of transmission.
 Time of ELISA negative test and asymptomatic period.
Early symptomatic HIV disease

• Fever, night sweat, chronic diarrhea, Fatigue.

Late symptomatic or Advanced HIV disease


• Major opportunistic infections and secondary
cancers.
Infections commonly associated with HIV

1.Protozoal
• Pneumocystitis jiroveci pneumonia( PCP).
• CNS toxoplasmosis.
• Cryptosporidiosis.
2.Fungal
• Candidiasis-oral ,esophageal…
• Cryptococcal meningitis.
3.Bacterial
•Common bacteria-salmonella,st.pneumonea…
•M.Tuberculosis.
•Atypical Mycobacterial infections (MAC).
4.Viral
•Herpes Simplex (Type 1 and 2).
•Herpes Zoster.
•Cytomegalovirus (CMV).
•Epstein-Barr virus (EBV).
WHO classification of HIV infection

It is formulated based on research for


management of patients with HIV/AIDS in poor
resource setting where CD4 level determination is
difficult.
Clinical stage 1
• Asymptomatic infection.
• Persistent generalized lymphadenopathy.
• Acute retroviral infection.
*performance stage 1-asymptomatic, normal activity.
Clinical stage 2
•Unintentional weight loss <10% body weight.
•Minor Mucocutaneous manifestations e.g. Dermatitis, fungal
nail infections, angular cheilitis.
•Hepes Zoster with in previous 5 years.
•Recurrent Upper respiratory tract infection.
Clinical stage 3
•Unintentional weight loss >10% body weight.
•Chronic diarrhea >1 month.
•Prolonged fever >1 month.
•Oral candidiasis.
•Oral hairy leukoplakia.
•Pulmonary TB.
•Sever bacterial infection (Pneumonia…).
•Vulvovaginal candidiasis.
*Performance < 50% of normal day time.
Clinical stage 4
• HIV wasting syndrome.
• PCP.
• Toxoplasmosis of the brain.
• AIDS dementia complex.
• Primary CNS lymphoma.
• Cryptosporidiosis with diarrhea >1 month.
• Isosporiosis with diarrhea> 1 month.
• Progressive multi focal leukoencephalopathy.
• Candidiasis of Esophagus,trachea,bronchi or lung.
• Disseminated TB.
• Kaposis sarcoma…
Correlation of CD4 count with respiratory disease

URTI,Bacterial
Any CD4 count pneumonia,TB,Lymphoma

PCP,Disseminated TB,Cryptococcus
CD4 count <200 pneumonia,Sepsis.

Bacterial pneumonia due to


pseudomonas
CD4 count < 100 aeruginosa,Toxoplasmosis,kaposis.
MAC, CMV, Disseminated fungal
CD4 < 50 infections.
Diagnosis of HIV infection
1.Detection of anti-HIV antibody-ELISA, Western blot.

2.Polymerase chain reaction (PCR).


First Assay

Positive Negative

Second assay Report negative

positive Negative

Report positive western blot or third assay

Positive Negative

Report positive Report Negative


Principles of ART

Primary goal
• Maximum and durable suppression of viral
replication.
• Restoration of immunologic function which help to
decrease HIV related morbidity and mortality and
also improve quality of life and survival of PLWHA.
Secondary goal
•Increase testing for HIV for prevention and HIV
care.
•Change perception of HIV so people regard AIDS
as treatable chronic disease.
•Raise Hope of individuals ,families, community …
•Increase PMTCT.
•Decrease HIV transmission in the population.
•Decrease incidence of TB.
Criteria for initiation of ART

1. CD4 ≤ 350.

2. WHO stage 3 and 4.

3. WHO stage 2 +Total lymphocyte count

<1200/mm3( if CD4 count not available).


NB-In 2007 AIDS in Ethiopia report there are > 1 million
PLWHIV and 258,264 require ART and it is only 24% of them
started with ART.
Nucloside reverse
transcriptase Dose
inhibitors(NRTI)
Lamivudine (3TC) 150 mg po bid or 300mg daily.
Stavudine (d4T) 30 mg bid.
Zidovudine (ZDV) or (AZT) 300mg bid.
Abacavir ( ABC) 300mg bid.
Didanosine (ddi) 400 mg/d if with TDF 250mg/d.

Non nucleoside RTI(NNRTI)


Efavirenz (EFV) 600mg daily.
200mg/d first 2 weeks then
Nevirapine (NVP) bid.

Pritease inhibitors (PI)


Nelfinavir (NFV) 1250mg bid
*2 NRTI + 1 NNRTI or 1 PI.

*ART is triple medication which help to avoid viral

mutation and drug resistance.

e.g. ZDV/3TC/NVP or EFV.

D4T/3TC/NVP or EFV.
Drug interaction

• If the patient is also case TB and taking Rifampicine use

Efaverenze instead of Neverapine because rifampicine induce

Cytochrome- 480 enzyme in the liver and increase Neverapine

destruction.

• If the patient is pregnant avoid EFV because it is teratogenic.


Adherence and virologic response to ART

Adherence to ART (in %) Viral load < 400copies/ml ( in%)

>95 78

90-95 45

80-90 33

70-80 29

<70 18
*Always treat Opportunistic infections first.

*ART is life long.

*No down grading i.e. once stage 4 always is i.e. if the

CD4 count elevated after treatment we don’t change the

stage.
Factors of poor adherence.

•Treatment fatigue.
•Transport cost.
•Lack of support.
•Undiagnosed depression.
•Poor quality service delivery.
•Non-disclosure.
•Drug side effect.
• Pill burden.
•Stigma and substance use like cigarette,
chat, alcohol…
Consider major side Effect and change of drug when

1. Develop jaundice.

2. Hgb< 6.5 gm/dl.

3. Sever skin rash with mucosal involvement.

4. ALT > 5x.

Fatigue, nausea, vomiting, Hepatomegally.

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