Human Immune Deficiency Virus Infection Dr Huda Taha Sep 2015.
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Human Immune Deficiency Virus Infection
Dr Huda Taha Sep 2015
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EpidemiologyVirologyNatural HistoryDiagnosisTransmissionHIV pregnancy
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• HIV pandemic continues to evolve• Global Prevalence of HIV stabilise at 0.8%• 25 million died of HIV• 33 million living with HIV/ AIDS
• Every day: 4,900 die of HIV/AIDS 7,100 new HIV infection 3,200 on HAART
• 2009-2010: 2.6 million new infection 2 million died of HIV/ AIDS (1.7 million<15 Year old)
• 4 million receive HAART in Africa (50,000 in 2002)• 1 million pregnant women on HAART
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100,000 people are living with HIV, quarter are unaware of their infection (16,000 in 1990)
2010-2011; 6660 new diagnoses of HIV
37 English PCT/ HIV prevalence >2:1000
1:5 HIV+ >50 Year old
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“HIV in the UK” report
• Infection acquired within the UK almost doubled/ exceed those acquired abroad
• In the last 10 years, the biggest increases in people living with diagnosed HIV, East of England, the West Midlands and the North East.
• 2010 over 3000 gay men were diagnosed with HIV: 1 in 20 gay men are now infected with HIV nationally 1 in 10 in London
• Universal testing
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HIV is a Lentivirus a member of the Retrovirus family
HIV infects vital cells in the human immune system such as helper T cells (specifically CD4+ T cells), macrophages and dendritic cells
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Natural history
HIV vs AIDSAcquisition of Infection Primary HIV infection Asymptomatic HIV infection Early symptomatic infection Late symptomatic infection Advance HIV disease
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1200
1100
1000
900
800
700
600
500
400
300
200
100
0
1:512
1:256
1:128
1:64
1:32
1:16
1.8
1.4
1.2
0
Weeks Years0 3 6 9 1 2 3 4 5 6 7 8 9 10 1112
CD
4+T
Cel
ls/m
m3
Plas
ma
Vir
emia
Titr
e
Primaryinfection
Possible acute HIV syndrome. Wide dissemination of virusSeeding of lymphoid organs
Clinical latency
Death
Opportunisticdiseases
Constitutionalsymptoms(
)
()
Natural History of HIV Infection
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HIV infectionin pregnant women
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Case 1
Conceiving on HAART;;
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Use of antiretroviral therapy in pregnancy
Should continue HAART
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Case 2Case 2
Naïve to HAART: mother needs ART for herself
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Use of antiretroviral therapy in pregnancy
Commence treatment as soon as possible
NRTIs plus third agent ( NNRTI or PI)
Consider third trimester TDM
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Case 3Case 3
Naïve to HAART: mother does not need HAART for herself
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Use of antiretroviral therapy in pregnancy
All women should have commenced ART by week 24 preg.
NRTIs plus PI
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Case 4
Late-presenting woman not on treatment
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Use of antiretroviral therapy in pregnancy
After 28 weeks should commence HAART without delay
Unknown VL or >100 000 HAART plus Raltegravir
Untreated woman presenting in labour ; HAART plus Raltegravir
IV zidovudine for the duration of labour and delivery.
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Women presenting ROM without a documented HIV result must be recommended to have an urgent HIV test
A reactive/positive test must be acted upon immediately with initiation of the interventions for prevention of PMTCT without waiting for further/ formal serological confirmation.
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Case 5
Untreated women; CD-4 count ≥ 350 cells/ml and VL <50 copies/mL (confirmed on a separate assay)
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Elite controllers
Can be treated with zidovudine monotherapy or with HAART
Can aim for a vaginal delivery
Should exclusively formula feed their infant
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HIV in Pregnancy
ANC Testing ANC Testing Sexual Health Sexual Health Preconception and fertility managementPreconception and fertility managementMDT & documentationMDT & documentationPsychosocial issuesPsychosocial issuesAZT monotherapy AZT monotherapy vsvs CART CARTHIV testing in childrenHIV testing in childrenBreast feedingBreast feeding
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STI screening
Recommended for pregnant women newly diagnosed with HIV.
Suggested for HIV-positive women already engaged in care
Genital tract infections should be treated according to BASHH guidelines.
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Laboratory monitoring
Routine Antenatal investigationsHIV resistance testing Post short course treatment a further resistance test recommendedCD-4 count Viral load 2–4 weeks after commencing HAART
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LFT at initiation of HAART and then at each antenatal visit.
If not achieved VL <50 copies/mL at 36 weeks the following interventions are recommended:
- Review adherence and concomitant medication - Perform resistance test if appropriate - Consider therapeutic drug monitoring - Optimise to best regimen - Consider intensification
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ART postpartum
Continue HAART if CD4 count < 350 cells/ml 350-500 co- infection with Hep C or Hep B > 500 if sero-discordant or co morbidity
Can consider continuing between 350-350 even if no co morbidities
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Infant testing
HIV DNA PCR (or HIV RNA testing) During the first 48 hours and prior to hospital discharge 6 weeks of age 12 weeks of age On other occasions if additional risk (breast-feeding)
HIV antibody testing for seroreversion should be done at age 18 months
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Psychosocial issues
Antenatal HIV care should be delivered by a multidisciplinary team (MDT)
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