HIV

SATURDAY 19th Feb 2011

INTRODUCTION

Retro Virus with 9 clad More than 35 million patients 25 million new cases every year 2.0 million deaths every year In UK alone incidence is > 9100 per year in UK Prevalence is ~ 73,000 Most of the cases are in Africa

25 % of the world’s disease burden 3 % of the world’s health work force 1 % of the world’s wealth share

FACT SHEET HIV / AIDS Statistics

• * 25 million children will be orphans by 2010 because of AIDS (called AIDS orphans). Africa has 12 million AIDS Orphans.

• * 2.9 million people died from AIDS last year; nearly half a million were children under the age of 15

• * 4.8 million people were newly infected with HIV last year; that’s 14,000 a day!

• * 38 million people are currently living with HIV/AIDS

• * 70 million deaths from AIDS are estimated in the next 20 years

• (Sources: UNAIDS/WHO 2006 Report on the global AIDS epidemic)

GLOBAL HIV AND AIDS ESTIMATES END OF 2009

The latest statistics of the global HIV and AIDS epidemic were published by UNAIDS in November 2010, and refer to the end of 2009.

Estimate Range

People living with HIV/AIDS in 2009 33.3 million 31.4-35.3 million

Adults living with HIV/AIDS in 2009 30.8 million 29.2-32.6 million

Women living with HIV/AIDS in 2009 15.9 million 14.8-17.2 million

Children living with HIV/AIDS in 2009 2.5 million 1.6-3.4 million

People newly infected with HIV in 2009 2.6 million 2.3-2.8 million

Adults newly infected with HIV in 2009 2.2 million 2.0-2.4 million

AIDS deaths in 2009 1.8 million 1.6-2.1 million

Orphans (0-17) due to AIDS in 2009 16.6 million 14.4-18.8 million

At the end of 2009, women accounted for just over half of all adults living with HIV worldwide.

GLOBAL TRENDS

Global trends

                                                                                                                                                                                                            

WORLD WIDE DISTRIBUTION

> 15000

HIV CASES IN THE KINGDOM• HIV cases on the rise in the Kingdom• By MD HUMAIDAN | ARAB NEWS • Published: Dec 21, 2010 22:57 Updated: Dec 21, 2010 22:57 • JEDDAH: At a symposium on Sunday at King Fahd Hospital

regarding AIDS and HIV revealed that Saudi Arabia registered 1,287 new cases of the infection in 2009, putting the total cases at 15,213, of which 4,019 are Saudis.

• The new cases included 481 Saudis and 806 foreigners who were deported after being diagnosed as HIV positive. The title of the symposium was “Towards Equal Rights With AIDS Patients.”

• According to the symposium, sexual contact was responsible for 95 % of the HIV cases among Saudi men. There were 14 cases of in utero transfer of the virus from mothers to their babies. 11 Saudis got AIDS from sharing needles with infected users.

HIV - VIRUS

TRANSMISSION

• Sexual 75 % (Incl 3-7 % Oral Sex)

• Vertical (Peri-Natal) Child Deaths 600,000/ Year

• Infected blood In UK alone 1200 New cases/ Year

• Intravenous Drug Users

IMMUNOLOGY

HIV

Envelope G

lycoprote

in

Macrophages

T Helper Cells

Monocytes

Neural cells

Lymphoid

Tissue

Billions of New

Virions

HIV

VIROLOGYHIV IS RNA VIRUS

AFTER ENTRY INTO THE BODY

DNA COPY OF RNA GENOME

INTEGRATION INTO HOST DNA

SYNTHESIS OF POLYPEPTIDES

COMPLETED VIRIONS

REVERSE TRANSCRIPTASE

VIRAL DNA INTEGRASE

VIRAL PROTEASE

STAGES

• Acute Infection Asymptomatic

• Sero-conversion 2-6 weeks

• Persistent Gen Lymphadenopathy– > 1.0 cm– > 2 Extra Inguinal Lymph Nodes– > More than three months duration

• AIDs Complex (Indicator Disease) Cd4 <200

DIAGNOSIS

Serum or Saliva HIV Antibodies by ELISA

Confirmed by Western Blot

Window Period HIV RNA (PCR)/ Core P24 Ag

OR

Repeat after 6 weeks & 12 weeks

4th Generation Kits Over The Counter

HIV-A & B ( UK ) HIV-D (Africa) Hybrid form is more fatal

SERO-CONVERSION

Early Identification Matters Signs are like “Glandular Fever” **

Flue like Symptoms Fever Malaise Myalgia Pharyngitis Maculo-papular Skin Lesions ** Meningoencephalitis (Rare) Generalized Lymphadenopathy

History Taking is Extremely Important Other Direct Effects

Osteoporosis Dementia

COMPLICATIONS

• All Newly Diagnosed must under go – Tuberculin test To identify past

– Toxoplasmosis Serology or current infections

– CMV that may progress with

– Hepatitis B & C immunosuppression

– Syphilis– Chest infections Incl Various

Pneumonias

PRVENTION

PREVENTION

• Blood Screening

• Disposable Surgical Equipment

• Perinatal anti retro-viral agents for HIV +ve mothers

• Caesarian Section Births

• Encourage Bottle feeding

STOP HIV MANIFESTO

• Good Information• HIV tests• Use of Condoms• Redefining Sexual Skills• Abstinence• Fewer Sexual Partners• Discourage Use of Alcohol• Circumcision

WHAT A DOCTOR MUST KNOW

• Good Communication Skills• Be Comfortable to talk about sex and sexuality and requesting

HIV test or STD serology at early stage if suspected• Warn about ‘sexual tourism” dangers• Negative role of Alcohol use• Human Rights• Guide drug users about dangers of needle sharing• Relationship of HIV & STD• Encourage HIV testing in pregnancy• Early Diagnosis of HIV

HIGH INDEX OF SUSPISCION

• Patients with – Tuberculosis– Pneumonia– Prolonged Diarrhea– Meningitis– Lympadenopathies/ Lymphoma– Weight Loss– Repeated Fungal Infection e.g Candidiasis

POST EXPOSURE PROPHYLAXIS

• Sero-conversion rate of needle stick injury– HIV 0.4 %– HBV 30 %

• Wash well• Note down complete profile of donor• Store blood from both parties• Immunization both active and passive.• Council test recipient 3 months and 6 months• Follow up testing at 12 weeks and 24 weeks• Before Prophylaxis do “Pregnancy Test”

WHOM TO TREAT

• History of AIDS defining illness or Cd4 count ≤ 350 cells /µL

• In following groups regardless of cd4 counts – Pregnant– HIV associated nephropathy– Pts co-infected with HBV, when treatment is indicated for

HBV

• Retroviral therapy can be considered even if Cd4 count is ≥ 350 cells /µL if Cd4 count is falling very rapidly

ANTI RETREOVIRAL AGENTS• NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

– Zidovudine (AZT) 250 – 300 mg/ 12hr – Didonosine 250 mg / 24 hr– Lamivudine 150 mg /12 hr– Emtricitabine – Stavudine 30 – 40 mg /12 hr– Tenofovir 245 mg / 24 hr– Abacovir 300 mg/ 12 hr

• PROTEASE INHIBITORS– Indinavir 800 mg 8 hr– Ritonavir 300 – 600 mg /12 hr– Soquinovir 1 G 12 hr

• NON NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)– Nevirapine 200 mg / 24 hr - 200 mg /12 hr– Efavirenz 600 mg / 24 hr

• INTEGRASE INHIBITORS Reltegravir 245 mg /24hr• CCR5 ANTAGONISTS Maraviroc 300 mg /12 hr

• BEYOND PHARMACOLOGY

MONITORING

• Routine tests– Cd4 T cell count (every 3 – 6 months)– Cd4 T cell counts are expensive hence an alternative is

TLC ( TLC of 1400 ≈ Cd4 count of 200 cells /micro liter)

• Other Tests– Pregnancy test– Drug resistance tests

QUESTIONS

THAN - Q