HIV /AIDS SILENT KILLER

by : Mohamed El gamal

2011

Assistant lecture mansoura university hospitals

HIV the worst epidemic of the twentieth century

59  Infected million persons worldwide,

20 million who have already died

.33 million adults and children were living with HIV/AIDS

2million people had been newly infected with HIV in 2008

..

95%95% of all HIV-infected people in world of all HIV-infected people in world developing countriesdeveloping countries::

Developing countriesDeveloping countries

64%64% AIDS casesAIDS cases

2/3of new cases2/3of new cases

Most of these people are Most of these people are unawareunaware that they are that they are infected with HIV infected with HIV continuous spread of the continuous spread of the diseasedisease..

Subsaharan AfricaSubsaharan Africa hardest hit region then hardest hit region then Asia, India, Latin America, Eastern EuropeAsia, India, Latin America, Eastern Europe

HIV Historical Bakground

.

1982The term AIDS ("acquired immune dificiency syndrome") is used for the first time on July 27th

1983Institut Pasteur) France (finds the virus (HIV).

1985The FDA (US) approves the first HIV antibody test.

1987AZT) zidovudine, Retrovir -- -- (®becomes the first anti-HIV drug

approved by the FDA.

1996The HAART (Highly Active Antiretroviral Therapy) era begins

2008Francoise Barre-Sinoussi and Luc Montagnier share the

Nobel Medicine Prize for their discovery of the HIV virus

HIV types, groups and subtypes

HIV LIFE CYCLE

FUSION

REVERSE TRANSCRIPTION

INTEGRATION

TRANSCRIPTION

ASSEMBLY

BUDDING

STAGES OF HIV-1 INFECTION

1-Viral transmission

2-seroconversion

3-Clinical latent period with or without persistent generalized lymphadenopathy (PGL)

4-Early symptomatic HIV infection

5-AIDS CD4 below 200 /mm3

6-Advanced diseaseHIV infection characterized by a CD4 cell count below 50/mm3

Window phase!!!! SEROCONVERSION

Most people develop detectable HIV antibodies within 6 to 12 weeks of infection. In very rare cases, it can take up to 6 months

WHEN SUSPECT HIV??

Acute Retroviral Syndrome

Fever) low-grade <102 (occurs in 80-90% occult infection

Fatigue) 70-90% (Erythematous Maculopapular Rash (40-80%) Face and Trunk Extremities involving palms and soles

Headache) 32-70% (Generalized Lymphadenopathy )40-70% (

Pharyngitis) 50-70% (Myalgia or arthralgia (50-70%) Gastrointestinal symptoms (30-60%)

Nausea or Vomiting Diarrhea Hepatosplenomegaly (14%) Night Sweats (50%) Oral Aphthous Ulcers or Thrush (10-20%) Genital Ulcers (5-15%) Neurologic symptoms (12%)

Aseptic Meningitis) 25% (Peripheral Neuropathy Facial palsy Guillain-Barre Syndrome Brachial Neuritis Cognitive Impairment Psychosis Malaise Anorexia Weight loss (70%) Wasting Syndrome

Unexplained weight loss of >10% usual body weightAssociated Conditions: Other presentations in early HIV Fungal Vaginal Candidiasis Onychomycosis Thrush

Dermatologic Seborrhea Shingles

Methods of transmission:

Sexual transmission, presence of STD increases likelihood of transmission.

Exposure to infected blood or blood products.

Use of contaminated clotting factors by hemophiliacs.

Sharing contaminated needles (IV drug users).

Transplantation of infected tissues or organs.

Mother to fetus, perinatal transmission variable, dependent on viral load and mother’s CD 4 count

Blood test for HIV DiagnosisELISA

A Western blot assay

–Indirect immunofluorescence assay, .

line immunoassay

A second ELISA

PCR

Antigen test P24 test

Rapid HIV tests

.HIV DISINFECTION

Body fluids of concern include:Potentially infectious semen, vaginal secretions, other body fluids contaminated with visible blood

)undetermined risk for transmitting HIV :(cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids.

Fluids that are not infectious unless they contain blood include: feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus.

How long a drop of blood with HIV infection?? ”...

When exposed to air The HIV/AIDS virus last about 30 seconds to 1 minute ,

in a media like blood or other liquid that is exposed to air it will live for about 2-5 minutes,

in perfect lab conditions the virus will live for about 20-40 minutes .

Standard chemical germicides AS solution of sodium hypochlorite at concentrations much lower than commonly used in practice can rapidly inactivate HIV.

In the laboratory, should be flooded with a liquid germicide before cleaning, after organic material has been removed.

. In patient-care areas, visibly soiled areas should first be cleaned and then chemically decontaminated.

Mosquito bites and HIV infection risk

HIV is not spread by mosquitoes or other biting insects. Even if the virus enters a mosquito or another sucking or biting insect, it cannot reproduce in insects. The insect cannot be infected with HIV and cannot transmit HIV to the next human it

feeds on or bites. .

HIV AND HEALTH CARE WORKERS

The risk of becoming infected with HIV after exposure to body fluids from an HIV-infected patient is low.

needlestick injuries to HCWs exposed to an HIV-infected source in the era before the introduction of highly active antiretroviral therapy (HAART) found the following

HIV transmission occurred 0.33 percentFor skin exposures, the area should be washed with soap and

water .Small wounds and punctures may be cleansed with an antiseptic such as an alcohol-based hand hygiene agent,

;antiseptics also inactivate HIV such as iodophors, chloroxylenol (PCMX) and chlorhexidine) 

The following universal infection control precautions to help protect health care workers from blood-borne infections including HIV:

Hand washing after direct contact with patients .Use of protective barriers such as gloves, gowns aprons, masks, goggles for direct contact with blood and other body

fluids .Safe collection and disposal of needles and sharps, with required puncture- and liquid- proof boxes in each patient

care area .Preventing two-handed recapping of needles .Covering all cuts and abrasions with a waterproof dressing .

Promptly and carefully cleaning up spills of blood and other body fluids.

Using a safe system for health care waste management and disposal .

HIV PULMONARY COMPLICATION

Pulmonary disease is a major source of Pulmonary disease is a major source of morbidity and mortality in HIV-infected morbidity and mortality in HIV-infected

personspersons..

Most of HIV-associated pulmonary diseases Most of HIV-associated pulmonary diseases usually present at or below a characteristic usually present at or below a characteristic CD4+ lymphocyte count and seldom occur CD4+ lymphocyte count and seldom occur above the countabove the count

Cigarette smoking is associated with Cigarette smoking is associated with incidenceincidence

CD4+ CD4+ 200 cells 200 cells::Bacterial pneumonia is often accompanied by Bacterial pneumonia is often accompanied by bacteremiabacteremia..MTB is often extrapulmonary or disseminatedMTB is often extrapulmonary or disseminated..

Pneumocystis & Cryptococcus neoformans Pneumocystis & Cryptococcus neoformans become a considerationbecome a consideration

CD4+ count CD4+ count 50 – 100 cells / 50 – 100 cells / L L::

Endemic fungiEndemic fungiViruses (CMV)Viruses (CMV)Non-tuberculous mycobacteria (MAC)Non-tuberculous mycobacteria (MAC)Kaposi’s sarcomaKaposi’s sarcomaExtrapulmonary & disseminated manifestations Extrapulmonary & disseminated manifestations dominate the clinical presentationdominate the clinical presentation..

) ) AA ( (BacteriaBacteria

S.pneumoniae, Hemophilus, influenzaeS.pneumoniae, Hemophilus, influenzae

P.Aeruginoso (CD4 lymphocyte count < 50 cell / P.Aeruginoso (CD4 lymphocyte count < 50 cell / L)L)..

legionella pneumophila Rhodococcus equi and Nocardia legionella pneumophila Rhodococcus equi and Nocardia

speciesspecies

. .

PreventionPrevention

Polysaccharide pneumococcal vaccinePolysaccharide pneumococcal vaccine

use of G.CSF when neutrophil count < 500 cells use of G.CSF when neutrophil count < 500 cells ll

) ) BB ( (MycobacteriaMycobacteria11 . .Mycobacterium tuberculosisMycobacterium tuberculosis::

Major opportunistic infection complicating HIV Major opportunistic infection complicating HIV epidemic worldwideepidemic worldwide..

Cause of death in 11% of all adult AIDS deathsCause of death in 11% of all adult AIDS deaths

HIV infection significantly increases the risk of HIV infection significantly increases the risk of developing primary TB as well as progressing developing primary TB as well as progressing from latent TB infection (LTBI) to active from latent TB infection (LTBI) to active tuberculous diseasetuberculous disease..

Risk of drug resistant TB is greater among HIV-Risk of drug resistant TB is greater among HIV-infected persons than among othersinfected persons than among others..

PreventionPrevention::11 . .Repeat tuberculin test every year for Repeat tuberculin test every year for

persons with negative tuberculin skin test & persons with negative tuberculin skin test & risk for exposure to MTBrisk for exposure to MTB..

55 mm induration is recommended cut off mm induration is recommended cut off point for LTBI in HIV-infected personspoint for LTBI in HIV-infected persons..

High incidence of false negative test with High incidence of false negative test with CD4 CD4 < 400 cells / < 400 cells / LL..

ChemoprophylaxisChemoprophylaxis???? ????

BCGBCG???? :???? :

22 . .Mycobacterium avium complex (MAC)Mycobacterium avium complex (MAC)::

Isolated pulmonary disease is rareIsolated pulmonary disease is rareAbd pain, diarrhea (chronic), HSM, Abd pain, diarrhea (chronic), HSM,

lymphadenopathy progressive anemialymphadenopathy progressive anemia.(.(

CD4 CD4 50 cells / 50 cells / LL

Diagnosis :Culture from blood, bone marrow, Diagnosis :Culture from blood, bone marrow, liver lymph nodes or respiratory liver lymph nodes or respiratory specimensspecimens..

TTT : Macrolide with ethambutol and TTT : Macrolide with ethambutol and rifaputinrifaputin

33 . .Mycobacterium kansasiiMycobacterium kansasii?? :?? :

))CC ( (FungiFungi

11 . .Pneumocystis jiroveciiPneumocystis jiroveciiMost common AIDS-defining opportunistic Most common AIDS-defining opportunistic infection in USAinfection in USA..

Use of HAART & pneumocystis prophylaxis have Use of HAART & pneumocystis prophylaxis have combined & dramatically combined & dramatically overall number of overall number of casescases..

..Studies suggest – mode of infection eitherStudies suggest – mode of infection either::

Reactivation of latent infectionReactivation of latent infection.. Possible person to person transmissionPossible person to person transmission..

C/PC/P::

Long prodrome 28 daysLong prodrome 28 days..

Fever, nonproductive cough, dyspnea with Fever, nonproductive cough, dyspnea with excertionexcertion..

Physical examinationPhysical examination::May be normalMay be normal..

Presence of crackles Presence of crackles severity of disease & severity of disease & mortalitymortality..

CXRCXR::Classically Classically

bilateral symmetrical reticular or granular bilateral symmetrical reticular or granular opacities, perihilar.May be unilateral or opacities, perihilar.May be unilateral or asymmetricalasymmetrical..

PneumatocelePneumatocele pneumothoraxpneumothorax..

Coexistent pathology: TB, kaposi’s sarcoma, Coexistent pathology: TB, kaposi’s sarcoma, fungus, fungal pneumoniafungus, fungal pneumonia..

NormalNormal..

DiagnosisDiagnosis::Sputum inductionSputum induction

Bronchoscopy & BAL upper lobe and middle lobe (-Bronchoscopy & BAL upper lobe and middle lobe (-ve BAL ve BAL rules out PCP) rules out PCP)

TBBXTBBX

PFTPFT::Restrictive ventilatory patternRestrictive ventilatory pattern

lung volumelung volume

expiratory flowexpiratory flow . .

DLCo: Sensitive indicator < 75% of predicted – 90% of PCP DLCo: Sensitive indicator < 75% of predicted – 90% of PCP with normal CXRwith normal CXR..

N.B: Combination of normal CXR, DLCo < 75% N.B: Combination of normal CXR, DLCo < 75% exclude PCPexclude PCP..HRCT HRCT alternate to DLCo alternate to DLCo..

Diagnosis rests on microscope visualization Diagnosis rests on microscope visualization of charactersitic P. jirovecii cysts or trophic of charactersitic P. jirovecii cysts or trophic forms or both on stained specimenforms or both on stained specimen..

StainStain::silversilver..

Toulidine blue-OToulidine blue-O

Giemsa & Diff QuickGiemsa & Diff Quick..

Monoclonal antibodiesMonoclonal antibodies..

PCR based techniquesPCR based techniques..

PreventionPrevention::Avoid close contactAvoid close contact?? ??

CD4 CD4 200 TMP-SMX (DS/d) 200 TMP-SMX (DS/d)

Atovaquon (1500 mg/d)Atovaquon (1500 mg/d)

Pentamidine (300 mg/m)Pentamidine (300 mg/m)

TERTMENTTERTMENTTMP-SMX 15-20 mg/kgTMP-SMX 15-20 mg/kg

Trimethoprim + dapsoneTrimethoprim + dapsone

Clindamycin + primaquineClindamycin + primaquine

AtovaquouneAtovaquoune

PCP

22 . .Cryptococcus neoformansCryptococcus neoformans::Only encapsulated fungus infects humanOnly encapsulated fungus infects humanMeningitis, cutaneous lesions (kaposi’s sarcoma, Meningitis, cutaneous lesions (kaposi’s sarcoma, molluscum contagiosum)molluscum contagiosum)..

CxryCxry Diffuse bilat infiltratesDiffuse bilat infiltratesConsolidationConsolidationNodular infiltrationNodular infiltrationCavitationCavitationPleural effusionPleural effusionNormal CXRNormal CXR

TTT : TreatmentTTT : Treatment:: Amphotricin BAmphotricin B

FluconazoleFluconazole

33 . .Histoplasma capsulatumHistoplasma capsulatumC/PC/P::Febrile wasting illness in HIV-infected patientsFebrile wasting illness in HIV-infected patients..CD4 CD4 50 – 100 cells / 50 – 100 cells / LL

CXRCXR::NormalNormal..Reticular or reticulonodularReticular or reticulonodular..Focal opacitiesFocal opacities..

Hilar & mediastinal opacitiesHilar & mediastinal opacities

PreventionPrevention::Avoid activities that Avoid activities that exposure exposure..Intraconazole (CD4 Intraconazole (CD4 100 cells / 100 cells / L or endemic area)L or endemic area)..

TreatmentTreatment AmphotricinAmphotricin

IntraconazoleIntraconazole

5. Aspergillus species:5. Aspergillus species:

fimigatus most commonfimigatus most commonRisk factorsRisk factors::

CorticosteroidsCorticosteroidsBroad spectrum antimicrobial drugsBroad spectrum antimicrobial drugs

CXRCXRUnilateral or bilateral infiltrateUnilateral or bilateral infiltrate..Cavity lesionsCavity lesions..NodularNodular..Pl. effusionPl. effusion..

Diagnosis Diagnosis cultureculture

TreatmentTreatment::Amphotricin BAmphotricin B

DD) Viruses) VirusesMembers of herpes virus familyMembers of herpes virus family..

- -CMVCMV- VZV- VZV- HSV- HSV- EBV- EBVInfluenza virusInfluenza virus..Parainfluenza visuParainfluenza visu..Respiratory syncytial virusRespiratory syncytial virus..MeaslesMeasles..AdenovirusAdenovirus..RhinovirusRhinovirus..MetapneumovirusMetapneumovirus..

Only CMV is regarded an important Only CMV is regarded an important pathogenic pulmonary agentpathogenic pulmonary agent..

CMVCMV

100% of MSM are infected with viruses100% of MSM are infected with viruses

CXRCXR::Reticular or ground glass.Alveolar infiltrateReticular or ground glass.Alveolar infiltrate..

Nodular opacities Pl. effusionNodular opacities Pl. effusion• Increased CMV IgG & IgM + C/P Increased CMV IgG & IgM + C/P Aids in Aids in

diagnosis.diagnosis.

Treatment Ganciclovir PreventionTreatment Ganciclovir Prevention::CMV IgGCMV IgG.– .–

Oral ganciclovirOral ganciclovir

E) ParasitesE) Parasites

. : . :Toxoplasma gondiiToxoplasma gondiiCryptosporidiosisCryptosporidiosis

MicrosporidiosisMicrosporidiosis

Strongyloides stercoralisStrongyloides stercoralis

Non-infectious Pulmonary DisordersNon-infectious Pulmonary Disorders

I. MalignanciesI. Malignancies::

11 . .Kaposi’s sarcomaKaposi’s sarcoma::Most common HIV-associated malignancyMost common HIV-associated malignancy..

with MSM 20.000 – 73.000 fold with MSM 20.000 – 73.000 fold Relation to (HHV8)Relation to (HHV8)

CD4 CD4 50 cells / 50 cells / LL..

Associated mucocutaneous diseaseAssociated mucocutaneous disease..

Concurrent pulmonary opportunistic infection most Concurrent pulmonary opportunistic infection most frequently PCPfrequently PCP..

Opportunistic infection Opportunistic infection Rapid progression of kaposi’s Rapid progression of kaposi’s sarcoma mimics infectious processsarcoma mimics infectious process..

C/PC/P::Non productive cough, dyspnea, fever. Chest Non productive cough, dyspnea, fever. Chest pain, hemoptysispain, hemoptysis..

ExaminationExamination::Normal (usually). Crackles, wheezes. EffusionNormal (usually). Crackles, wheezes. Effusion..

CXRCXR::Bilat opacities in a central or perihilar Bilat opacities in a central or perihilar distributiondistribution..Linear densities, nodules, pl. effusionLinear densities, nodules, pl. effusion..AdenopathyAdenopathy..

No RADIOGRAPH is diagnostic for Kaposi’s No RADIOGRAPH is diagnostic for Kaposi’s sarcomasarcoma

DiagnosisDiagnosis::Bronchoscopy. :Endobronchial, red, violaceous flat or Bronchoscopy. :Endobronchial, red, violaceous flat or slightly raised lesionsslightly raised lesions..

EffusionEffusion : :Exudate or transudateExudate or transudate..

Serous, serosanginous or frank bloodSerous, serosanginous or frank blood..

Chylous (obstructive)Chylous (obstructive)..

--ve Gallium scanve Gallium scan..

Chemotherapy:TTTChemotherapy:TTTLiposomal anthracycline (doxorubocin)Liposomal anthracycline (doxorubocin)..

Paclitaxel Paclitaxel resistant resistant..

Combination HAARTCombination HAART

2. Non-Hodgkin’s lymphoma:2. Non-Hodgkin’s lymphoma:

Primary pleural effusion lymphoma:Primary pleural effusion lymphoma:

33 . .Bronchogenic carcinomaBronchogenic carcinoma::

frequency, at younger age, aggressive frequency, at younger age, aggressive coursecourse

6.56.5 fold as Non HIVfold as Non HIV

Adenocarcinoma (most frequent)Adenocarcinoma (most frequent)

Lymphocytic interstitial pneumonitisLymphocytic interstitial pneumonitis

Non specific interstitial pneumonitisNon specific interstitial pneumonitis

. .Obstructive lung diseaseObstructive lung disease

. .Pulmonary hypertensionPulmonary hypertension..

33 . .Pulmonary alveolar hemorrhagePulmonary alveolar hemorrhage..

44 . .Pulmonary alveolar proteinosis Pulmonary alveolar proteinosis secondary to opportunistic infectionsecondary to opportunistic infection..

55 . .DAD & interstiail fibrosisDAD & interstiail fibrosis..

66 . .BOOPBOOP..

77 . .SarcoidosisSarcoidosis

HIV TREATMENT

There is no cure for HIV, but treatment can keep virus levels low and

.Some drugs interfere with proteins HIV needs to copy itself

;others block the virus from entering or inserting its genetic material into your

immune cells .

PREVENTION IS NOT BETTER THAN CURE. IT IS THE ONLY CURE“

Today, there are 31 antiretroviral drugs (ARVs) approved by the Food and Drug Administration to treat HIV infection

Reverse Transcriptase (RT) Inhibitors

Protease Inhibitors

Fusion/Entry Inhibitors

Integrase Inhibitors

Multidrug Combination Products (HAART).

Why is a vaccine for HIV difficult to develop?

First HIV is highly mutable it can evade the two major arms of the adaptive immune system; humoral (antibody-mediated) and cellular (mediated by T

cells) immunity .

Second, HIV isolates are themselves highly variable. HIV can be categorized into multiple subtypes with

a high degree of genetic divergence ..

SO Any vaccine that lacks this breadth is unlikely to be effective.

HIV IN EGYPT

مصر فى ايدز حالة 1986اول مص فى االيدز لمكافحة الوطنى البرنامج انشاء 1986تم من اقل النسبة ولذا مليون كل خمسة االصابة %2نسبة حتى والمسجلين المصابين منهم HIV 4000حوالى 2008عد

AIDS 1000 اى النسة تلك اصعاف خمسة تتقع لصحة منظمة 12000ولكن

حالة المصاب االناث عدد من مصر فى تقترب الرجال نسبة االصابة بنسبة نسبة الجنسي االتصال عبر الفيروس انتقال

بنسبة% 49.5 المثلي الجنسي االتصال يليه ويمثل% 22.9، ،نسبة بالحقن المخدرات انتقال% 4.6تعاطي نسبة تبلغ كما ،

بنسبة الطفل إلي األم من الدم% 1.8المرض ونقل ،5 %الكلوي إصابة% 8.9والغسيل وترجع إلي% 8.7، الحاالت من

معروفة " غير أسباب

” … ، نساعدك نقدر االيدز لمرض الساخن الخط الوالتالية األرقام يطلب من كل يسمعها جملة

0223152801_ 0223152802_ 0227947839 _الصحة 08007008000 وزارة خصصتها والتي ،

واالستفسار للتوعية جديدة كوسيلة عنها وأعلنتجدا ضعيف عليها اإلقبال لكن الفيروس، عن المباشر

على 3بالمادة 7 الفقرة تنص حيث العمل، بقانوننقص“ مرض من األجنبى خلو تفيد شهادة مطلوب

( فى ( التجديد وعند مرة، ألول اإليدز البشرى المناعةالشهادة تلك من يعفى للبالد، األجنبى مغادرة حالة

وأبناؤهم،( مصريين من المتزوجون األجانبلهم يسبق لم والذين بالبالد، المقيمون واألجانب

.( األخيرة سنوات العشر خالل منها الخروج

Thank Thank youyou