HIV - AIDS

HISTORY
• First recognized in USA (1981) among homosexuals & drug addicts,
suffering from Kaposi’s sarcoma & Pneumocystis carinii pneumonia

• This condition was given the name Acquired Immune Deficiency

Syndrome (AIDS)
• Luc Montagnier & colleagues (1983) isolated virus at Pasteur
Institute, Paris, France, from a west African patient with persistent
generalised lymphadenopathy & called it Lymphadenopathy
Associated Virus (LAV)

• Robert Gallo & colleagues (1984) isolated a retrovirus from AIDS

patients & called it Human T cell Lymphotropic virus-III (HTLV-III)

• International Committee on virus nomenclature (1986) named Human

Immunodeficiency Virus (HIV)

• HIV came from a similar virus found in chimpanzees - SIV

 INTRODUCTION

H human
 A acquired

I immunodeficiency
 I immune

V virus
 D deficiency
 S syndrome
 Fam : Retroviridae
 Subfam : Orthoretrovirinae
 Genus : Lentivirus

 Species : Human Immunodeficiency

Virus – 1
Human Immunodeficiency
Virus - 2
 STRUCTURE
 Spherical (90-120 nm dia)

 Enveloped :
- Lipid part: derived from host cell membrane

- Protein part:- Spikes, are virus coded

 72 knob-like glycoprotein spikes (gp120) projecting

from the anchoring trans-membrane pedicles
(gp41)
are present on surface
 STRUCTURE cntd…
 Nucleo-capsid: has an outer icosahedral shell
&
an inner cone-shaped core

 Genome: Inner core consists of 2 identical copies

of linear, +ssRNA associated with
reverse transcriptase, integrase
protease enzymes

 In infected cell viral RNA is transcribed first

into ss-DNA then to ds-DNA (Provirus) which
is integrated into host cell chromosome
HIV
 VIRAL GENES & ANTIGENS

• HIV genome contains

i) 3 Structural genes
gag
pol
env

ii) Nonstructural & regulatory genes

 Structural genes

• gag gene codes for p55, cleaved into

P24, p7/p9 - nucleocapsid protein
p18 - matrix protein

• env gene codes for gp 160, cleaved into

gp120 - surface spike glycoproteins
gp41 - transmembrane pedicle protein

• pol gene codes for

reverse transcriptase( p51) & RNAse (p66)
integrase (p31)
protease (p11/p9)

•
 Nonstructural & Regulatory genes

• tat – trans-activating gene

• rev – regulator of virus gene
• nef – negative factor gene

• vif – viral infectivity factor gene

• vpr – viral promoter region gene
enhancing maturation
• vpu gene (only in HIV-1)
and
release of progeny
• vpx gene (only in HIV-2)
virus
• LTR(long terminal repeat)
 CLASSIFICATION
• HIV undergoes frequent antigenic variation of core &
envelope antigens
• Based on molecular & antigenic differences, 2 types of HIV
HIV type-1: original isolates of HIV & related strain prevalent
all
over the world
HIV type-2: strains isolated from West Africa, react with HIV-I
antiserum either weakly or not at all

• Envelope antigens of both are different though their core

polypeptides show some cross reactivity

• HIV-2 has only 40% genetic identity with HIV-1

• HIV-2 is more closely related to Simian
immunodeficiency virus (SIV) & less virulent than HIV-1
 Major antigens of HIV-1 & HIV-2

Antigens HIV-1 HIV-2

1. Envelope antigens
-Spike antigen gp120 gp140
-Transmembrane pedicle gp41 gp36
antigen
2. Matrix protein antigen P17 P16
3. Capsid protein antigen P24 P26
 CLASSIFICATION
HIV

HIV-1 HIV-2

Group M Group O Group N 5

subtypes
(major) (outlier) (new) (A to E)

10 subtypes 9 subtypes
(A to J)
Subtype A - world wide
subtype B – America, Europe
Subtype C – India, China
Subtype E – Thailand
(in Africa - A, C, D ; in Asia – E, C, B)
 REPLICATION
 HIV infects all cells having CD4 antigens on their
surface
- TH lymphocytes (primarily infected)
- Monocytes & macrophages (10-20%)
- B lymphocytes (5-10%)
- Langerhans cells
- Follicular dendritic cells in lymph nodes
- Glial cells & Microglia in CNS

 Galactosylceramide, a CNS glycolipid, is an

alternative
receptor for gp120 & may mediate HIV entry into Glial
cells
 REPLICATION cntd….

 Binding to CD4 molecules by gp120

Infection can be blocked by monoclonal-Abs to CD4 & recombinant

soluble CD4
 Entry into cell by fusion requires gp41 & co-receptors
CXCR4 (alpha chemokine receptor) for T cell-tropic strains
CCR5 (beta chemokine receptor) for macrophage-tropic strains

These chemokine receptors provide new targets for

antiviral
 Infectedtherapy
cells express gp120 on their surface, which
binds to uninfected neighboring CD4 cells, causing
fusion to form multinucleated giant cells (syncytium)
 Mutation in CCR 5 (Delta 32 Mutation)
• This mutation results in blockade of HIV entry into the cells

• It is observed principally in some lucky people of Europe and

Western Asia who are either:
‰. Completely resistant to HIV infection: If they are
homozygous for delta 32 mutation genes (seen in 1% of
Northern Europeans, particularly in Sweden) or

‰. Susceptible, but progression to AIDS is delayed: If

they
are heterozygous for the same gene ( seen in 10–15% of
Europeans)
 REPLICATION cntd….

 After entering host cell, envelope lost & RNA

uncoated

 DNA made from RNA using reverse transcriptase

(RNA-directed DNA polymerase) in cytoplasm

 DNA & integrase migrate to nucleus to form a

provirus by integrating viral DNA to host DNA

 Rate of viral replication regulated by the

activity of regulatory proteins (tat/rev, nef etc., )
 Coinfections (e.g., Mycobacterial) stimulate HIV-
infected cells to produce more virus

 Virion proteins & genomes are synthesized in the

nucleus by cellular RNA Polymerase –II using the
integrated provirus as a template

 Transported into cytoplasm through golgi for

viral assembly

 Naked virions bud out through host cell membrane

& acquires lipoprotein envelope
HIV
HIV Lifecycle
Lifecycle

©I-TECH, 2005
 RESISTANCE
 Heat labile; inactivated in 10 min at 60ºC & in
seconds at 100ºC

 Can survive up to 7 days at room temp in dried

blood

 At autopsy, can be isolated up to 16 days from

various tissues

 Inactivated in 10 min by 35% isopropyl alcohol,

70% ethanol, 0.5% lysol, 2% glutaraldehyde,
0.5% sodium hypochlorite, 3% H2O2
 RESISTANCE cntd….
 Bleaching powder is effective for surface
decontamination
 For contaminated medical instruments
- 2% Glutaraldehyde is useful
 Because of the presence of lipid envelope, it
is susceptible to detergents & organic
solvents

 To decontaminate clothes & household

utensils, washing with detergents is useful

 Withstands lyophilisation
 TRANSMISSION

1. Sexual contact
Male homosexuals & heterosexuals
with multiple partners
(Risk is higher in persons having genital ulcers -
chancre or chancroid)

- Risk of transmission :0.1-1% (worldwide)

- Total % of transmission: 75% ( worldwide)

2.Transfusion of
infected blood & blood
products,
hemophiliacs
-Risk of transmission; 90-95%
Worldwide

-Total % of transmissin : 5%
3. Sharing of contaminate
needles and syringes,
particularly in intravenous
drug addicts, needle stick inju
- 10% of total transmission
- risk of transmission is 0.5-1%
4. Organ & Tissue transplants
5. HIV-infected mother to child
by vertical transmission
in utero (transplacental) or
during birth (perinatal) or
through breast feeding
 HIV infection is NOT acquired
by
1. Casual contact
2. Shaking hands
3. Hugging
4. Putting cheeks together
5. Sharing bed sheets
6. Sharing utensils
7. Blood sucking insects
8. Air, food, water
9. Kissing (no transmission through saliva,
though virus is present in saliva)
 PATHOGENICITY

• AIDS is the last stage in the wide spectrum

of clinical features of HIV infection

• CDC (USA) classified the clinical course of

HIV infection under various groups
Group Acute HIV syndrome
I
Group Asymptomatic infection
II
Group Persistent generalised lymphadenopathy
III (PGL)
Group Other diseases
IV
Subgroup Constitutional disease-ARC
A
Subgroup Neurologic diseases
B
Subgroup Secondary opportunistic infectious
C diseases
Subgroup Secondary infectious diseases-P.carinii
C1 pneumonia, cryptosporidiosis,
toxoplasmosis, generalised
strongyloidiasis, cryptococcosis, CMV or
herpes diseases
 1. Acute HIV infection
 2 - 8 weeks after initial infection 50 % of persons
experience
Acute phase viremia or primary infection with :
low grade fever, malaise, headache, sore throat,
lymphadenopathy, sometimes rash and rarely acute
encephalopathy
- HIV destroys infected T cells
 Large amounts of virus & capsid protein (p24) antigens are
present in blood

 Antibodies appear in 2 to 10 weeks after initial infection

(Seroconversion illness)

 Spontaneous recovery occurs within weeks

 2. Aymptomatic or Latent infection-
 Acute phase viremia will be reduced with the
appearance of CMI & AMI
 CD4 T-cell count become normal

 Immune response can not clear HIV completely

 HIV infected cell are present in Lymph nodes with
continuous replication in lymphatic cells.

 May remain asymptomatic for 8 to 10 years or more

( period of clinical Latency)
 Positive for HIV antibodies

 Infectious stage
 3. Persistent Generalised
Lymphadenopathy
 Presence of enlarged lymph nodes ( 1 cm in dia,at
2 or more sites ,other than inguinal) as a result of
viral replication

 Persist for at least 3 months, in absence of any

illness or medication that may cause
lymphadenopathy

 Benign, but may progress to ARC or AIDS

 4. AIDS related complex (ARC)
 Patients will develop immunodeficiency & suffer
from various integral symptoms or minor
opportunistic infections

 Typical symptoms are :

Persistent diarrhea
Chronic fevers
Soaking night sweats
Persistent white spots or unusual lesions on
tongue
Dry cough & shortness of breath
Weight loss (more than 10% of body weight)
Persistent unexplained fatigue
 Common opportunistic infections are
Oral candidiasis
Herpes zoster
Hairy cell leukoplakia
Salmonellosis
Tuberculosis
 Generalised lymphadenopathy & splenomegaly are
usually present

 Patients: severly ill, Many of them progress to AIDS in

few
months

 CD4+(T4) decreased & T4:T8 (helper : suppressor) cell

ratio is reversed, leading to immunodeficiency
 Opportunistic microoganisms in AIDS-

1. Bacteria
M. tuberculosis
M. avium-intracellulare
Salmonella
Listeria monocytogenes
Campylobacter
Nocardia asteroides
Actinomyces
Legionella pneumophila
Streptococcus
2. Viruses
CMV, HSV, VZV, EBV
HBV
Adenoviruses
JC virus (papovavirus)
3. Protozoa
Toxoplasma gondii
Cryptosporidium parvum
Isospora belli

4. Helminthes
Strongyloides stercoralis
5. Fungi
Pneumocystis jirovecii (carinii)

Candida albicans
Cryptococcus neoformans
Aspergillus
Histoplasma capsulatum
Coccidiodes immitis
• Malignancies associated with AIDS-

 Kaposi sarcoma:
a vascular tumor of endothelial origin
that appears in skin, mucus membranes, lymph
nodes & visceral organs, and may be
associated with Kaposi sarcoma-associated
herpes virus or HHV-8

 Lymphomas caused by EB virus

 Anogenital cancers may arise as a result of

coinfection with HPV
Kaposi’s sarcoma
CD4+
CD4+ count
count less
less than
than 200
200 per
per
microliter
microliter &&
appearance
appearance of of increasingly
increasingly frequent
frequent &
&
serious
serious diseases
diseases & & opportunistic
opportunistic
infections
infections
(AIDS-defining
(AIDS-defining illness),
illness),
the
the patient
patient is
is said
said toto have
have AIDS
AIDS
 5. AIDS
 End stage disease

 Represents irreversible breakdown of immune defense

mechanisms

 Highly susceptible to secondary opportunistic

infections & malignancies

 Increases the opportunity for generation of virus

mutants;
- highly cytocidal & rapidly multiplying
- more virulent & induce syncytium promoting fusion
between infected & uninfected cells
 AIDS
cntd…
T-cell precursors are also infected so that the capacity to
generate new CD4+ cells is gradually lost

 Infection of blood cell progenitors in bone marrow leads to

anemia

 Eye may be affected, where focal areas of ischemia are

produced in retina

 wasting syndrome seen in last stages of AIDS is related to

infected macrophages induced to produce cytokines,
especially TNF

 Illness progresses & death occurs in a few months or years

 LAB DIAGNOSIS
• 1. Isolation of virus

• 2. Detection of viral antigens

• 3. Detection of viral nucleic acids

• 4. Demonstration of antibodies
- Screening Tests
- Confirmatory tests
• 1. Isolation of virus-
 Cocultivation of patient’s CD4 lymphocytes with
uninfected lymphocytes in presence of IL-2

 Viral growth is detected by testing culture fluids for

reverse transcriptase activity or virus-specific
antigens (P24)

 Not suitable as a routine diagnostic test

2. Detection of viral antigens
 p24 antigen (earliest marker) capture assay
(ELISA)
 Uses anti - p24 Ab
 Useful for diagnosis of window period

3. Detection of viral nucleic acids

 Amplification of viral RNA or DNA proviruses
by PCR
 Useful for diagnosis of window period
4. Demonstration of antibodies-
• Detectable antibodies may appear 2 – 8 weeks
after infection & during this period, person may
be highly infectious
• This seronegative infective stage is known as
window period

• Antibodies to p24, gp41, gp120 or gp160 are

most commonly detected

• Serological tests for anti-HIV are of 2 types:

1. Screening tests
2. Confirmatory tests
1.Screening Tests
ELISA
Rapid tests
- Dot blot assay
- Latex agglutination test
. HIV spot test
. HIV comb test
2. Confirmatory tests
Westen blot test
IFA
Radioimmunoprecipitation
Enzyme ImmunoAssays (EIAs)
 Western
blot
 HIV proteins separated according to their
electrophoretic mobility by PAGE, blotted on to
nitrocellulose paper strips
 These strips are reacted with patient sera & then
with enzyme conjugated antihuman globulin
 A suitable substrate is then added, which
produces a prominent color band where the
specific antibody has reacted with viral protein
antigen
 In a positive serum bands are seen with multiple
proteins typically with p24, p31, gp41, gp120 or
gp160
 For a western blot to be considered positive,
atleast 2 bands including P24, gp41 or
gp120/gp160 should be present
5. Other parameters to establish
immunodeficiency
 decreased T cell count
 T4: T8 ratio reversed
 Leucopenia
 Thrombocytopenia
 Diminished CMI
 PROPHYLAXIS
 No specific vaccine is available
 Health education
 Identification of sources
 Elimination of high risk activities

 Use of physical barriers (condoms)

 Use of disposable sterile syringes & needles

 Screening blood for HIV before blood transfusion

 Screening donors organs, tissues for HIV before
transplantation
 HIV-infected mothers may be advised against pregnancy
 Don’t share needles, razor blades & tooth brushes
•
 Prevention by commonsense

ABC rule
 Abstinence
 Be Faithful (one partner)
 Condom
 TREATMENT
• Specific treatment with antiretroviral
drugs
• HAART (Highly
Nucleoside RT Non-
ActiveNucleotide
Anti Retrovial
Protease Fusion
Therapy) Nucleoside RT inhibitors inhibitors inhibitors
inhibitors
inhibitors

Azidothymidine Nevirapine Tenofovir Saquinavir Enfuvirtide

(AZT), (Zidovudine)

Didanosine Delaviridine Retonovir

Zalcitabine Loviride Nelfinavir

Stavudine Amprenavir

Lamivudine Tipranavir

Abacavir Indinavir
Thank
you !