Human Immunodeficiency Virus

Infection
Dr.T.V.Rao MD

Dr.T.V.Rao MD

Beginning of HIV/AIDS
The first published article related to AIDS was in 1981. The principal authors name was Michael Gottlieb and it appeared in the Morbidity and Mortality Weekly Report for June 5th. This article reported that there was a random increase in pneumocystis carinii pneumonia (PCP), a rare lung infection.
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Discovery of HIV infection.

In 1982, the term Acquired Immune Deficiency Syndrome is used for the first time. The name was designated by the CDC. In 1983, French scientists at the Institute Pasteur found a new virus that they called lymphadenopathy-associated virus or LAV. About a year later, Dr. Robert Gallo, of the National Cancer institute discovered HLTV-III. The first discovery was made in France at the Institute Pasteur, but shared credit is given to Dr. Robert Gallo, the discoverer of AIDS and his French counterparts for discovering HIV on April Dr.T.V.Rao MD 3 23, 1984.

Dr. Luc Montagnier wins the Nobel Prize in Medicine in 2008

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 Genus Retroviridae

What is Human Immune Deficiency Virus

Lentivirus, which literally means slow virus - it takes such a long time to develop adverse effects in the body. This virus attacks the immune system There are two strains HIV 1 & HIV 2
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What is Human Immune Deficiency Virus

These contain RNA, the genetic material of HIV The outer layer of the HIV virus cell is covered in coat proteins, which can bind to certain WBCs. This allows the virus to enter the cell, where it alters the DNA. The virus infects and destroys the CD4 lymphocytes which are critical to the Dr.T.V.Rao MD bodys immune response.

History of HIV
The HIV virus first came to light during the early 1980s. A number of healthy gay men in New York began to develop rare opportunistic infections & cancers, that were resistant to treatment. One such viral opportunistic infection is cytomegalovirus that causes blindness & Dr.T.V.Rao MD inflammation of the colon

HIV Origins
Research teams in the U.S.A & France made independent research discoveries of the virus. French researchers discovered a virus linked to AIDS in 1983, they called it LymphadenopathyAssociated Virus (LAV) In 1984, American researchers isolated a virus that caused AIDS, calling it Human T-lymph tropic Virus type III (HTLV- III ) These two viruses were later found to be the same virus - HIV Dr.T.V.Rao MD

HIV Origin
The emergence of HIV & AIDS has resulted in countless debates as to where it originated from

Its suspected that it originated from S.I.V (Simian Immunodeficiency Virus) SIV affects Monkeys

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HIV Origins
Certain strains of SIV closely resemble the two types of HIV HIV 1 was difficult to link with SIV In 1999 SIVcpz closely related to HIV 1 Originated from chimpanzees but it has significant differences from HIV-1 HIV 2 closely related to SIVsm Originated from the green monkey
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Family : Retroviridae Subfamily : Lentivirus

RNA virus, 120nm in diameter Envelope gp160; gp120 & gp41 Icosahedral symmetry Nucelocapsid
Outer matrix protein (p17) Major capsid protein (p24) Nuclear protein (p7)

Diploid RNA with several copies of reverse transcriptase

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Retroviral Genes
gag (group-specific antigen): makes the cone shape viral capsid. pol (polymerase): codes for viral enzymes reverse transcriptase, integrase, and viral protease. env (envelope): makes surface protein gp120 and trans membrane gp41, enabling HIV to fuse to CD4 cells.
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Genes Coding Structural Proteins gag

1 The gag gene core and shell expressed as p55 ( p18,- p17) cleaved as p15, p18,and p24 make up as viral core and shell
p24 seen during early stages reappearance in the late stages exacerbation of disease

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Envelop glycoprotein's env

The env determines the synthesizes of envelop glycoprotein's gp160 cleaved into two envelop components gp120 which forms the surface spike and gp 41 which trans membrane protein. The gp120 antibodies are present till the death of the patient.
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 The pol gene codes for the polymerase reverse transcriptase and other viral enzymes Expressed as precursor protein which is cleaved into proteins p31, p51,and p66

Polymerase reverse transcriptase pol

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Genome and Proteins of HIV

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Other genes
Tat The Tran activator gene influences the function of genes some distance away. It controls transactivation of all HIV proteins. rev The differential regulator of expression of virus protein genes. vif The virus infectivity factor gene is required for infectivity as cell-free virus. nef The negative regulator factor retards HIV replication. vpr The virus protein R gene has an undetermined function..
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Genes differ HIV I for HIV II

vpu The virus protein U gene is required for efficient viral replication and release. It is found only in HIV-1. vpx The virus protein X gene has an undetermined function. It is found only in HIV-2 and SIV.
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Types of HIV

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Subtype C is Major type in India

Subtype C is predominant in Southern and East Africa, India and Nepal. It has caused the world's worst HIV epidemics and is responsible for around half of all infections.
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Resistance
The virus are inactivated in 10 minutes at 600c and in seconds at 1000c At room temperature survive for seven days HIV are inactivated in 10 minutes by treatment with 50% ethanol 35% Isopropanol. 0.5% Lysol and paraformaldehyde 0.3% hydrogen 10% house hold bleach Hypochlorite solution at 0.5% 2% Glutaraldehyde
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HIV Replication
Attachment Penetration Uncoating Reverse Transcription Integration Replication Assembly Release
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Life Cycle of HIV

1. Attachment: Virus binds to surface molecule (CD4) of T helper cells and macrophages.
Coreceptors: Required for HIV infection. CXCR4 and CCR5 mutants are resistant to infection.

2. Fusion: Viral envelope fuses with cell membrane, releasing contents into the cell.
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HIV Life Cycle: Attachment Requires CD4 Receptor plus a Coreceptor

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 The HIV receptor

Gp160 is composed of gp41 and gp120 and forms the receptor for binding to the host cell (CD4 positive cells).

The gp41 portion is half embedded in the membrane envelope and interacts with gp120 portion on the exterior side of the membrane.
Each receptor is composed of 3 subunits of gp41 and 3 subunits of gp120.
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The HIV Receptor

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Lifecycle of HIV

HIV particles enter the body in a fluid as it can not survive without a support medium. The virus targets any cell expressing CD4, including T helper cells, macrophages, dendritic cells and Dr.T.V.Rao MD monocytes.

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Life Cycle of HIV 3. Reverse Transcription: Viral RNA is converted into DNA by unique enzyme reverse transcriptase.
Reverse transcriptase

RNA ---------------------> DNA Reverse transcriptase is the target of several HIV drugs: AZT, ddI, and ddC.
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Infection spread throughout the Body

Within the inflammatory cells of the infection (T cells) Site of replication shifts to lymphoid tissues: Lymph nodes Spleen Liver Bone marrow Macrophages and Langerhans cells become reservoirs and sites of replication but do not die themselves.
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Effects of HIV on the immune system

3 areas:

1. Destruction of CD4+ T cells population 2. Immune effects due to HIV infection

3. Progression of HIV infection to AIDS
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2.Hosts immune responses

Both humoral and cell-mediated immune responses partially control the viral production but in this process they destroy the infected CD4+T cells, leading to a gradual decline of CD4+ T cells

HIV-specific CTLs kill infected CD4+ T cells

Antibodies that recognize a variety of HIV antigens are produced - Antibody dependent cell-mediated cytotoxicity Apoptosis of infected cells
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Blood and Body fluids contain High concentration of Viral particles

Blood Semen/Vaginal fluids (as high as blood) Breast milk Pus from sores
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Low concentrations of HIV

It is highly unlikely you will be infected if you come into contact with: Sweat Tears Urine Saliva (-highly possible if blood from mouth sores is present)
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High Risk Populations:

1. Males, homosexuals & bisexuals 2. IV drug users 3. Improperly screened transfusion recipients

4. Sexual partners of persons infected with HIV 5. Infants of HIV infected mothers
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How is HIV Spread?

ANY type of sexual activity (highest risk) Sharing used drug needles Pregnancy-from mother to child Sharing razors- if blood is present Kissing- if even the smallest amount of blood is present. (-membranes of mouth are thin enough for HIV to enter straight into the body.) Tattoos/body piercing if equipment is not clean. Dr.T.V.Rao MD 38

HIV in Body Fluids

Blood 18,000

Semen 11,000

Vaginal Fluid 7,000

Amniotic Fluid 4,000

Saliva 1
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Dr.T.V.Rao Average number of HIV particles MD 1 ml of these body fluids in

Transmission
Vaginal Intercourse Anal Intercourse (10x higher infection rate than vaginal intercourse because of tissue tear is higher Oral Intercourse Blood Transfusion (risk greater than 90% if sample is already infected) Needles (tattoos, injections) Infected mother to the infant through: Pregnancy (placenta), Birth, and breastfeeding
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Window Period
This is the period of time after becoming infected when an HIV test is negative 90 percent of cases test positive within three months of exposure 10 percent of cases test positive within three to six months of exposure
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Pathogenesis of HIV / AIDS Infected T-Cell

HIV Virus

T-Cell

HIV Infected T-Cell

New HIV Virus

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 Immune responses fail to eradicate all viruses. Viral load is maintained at low level Continuous decline of CD4+ T cells

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Immune defects due to HIV infection

B cells impaired humoral response B-cell hyper reactivity Polyclonal hypergammaglobulinemia due to enhanced nonspecific IgG and IgA production. Impaired Ab-isotype switching and inability to respond to specific antigen. High incidence of B-cell lymphomas Lymph nodes HIV kills cells in the lymph nodes Early HIV infection: destruction of dendritic cells Late stage: extensive damage, tissue necrosis, a loss of follicular dendritic cells and germinal centres. Dr.T.V.Rao MD An inability to trap Ag or support activation of T+B cells

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CDC Classification of HIV

Category 1: > 500 cells/mm3 (or CD4% > 28%) Category 2: 200-499 cells/mm3 (or CD4% 14% 28%) Category 3: < 200 cells/mm3 (or CD4% < 14%)(CD4+ T-lymphocyte counts per microliter of blood)
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Progression of HIV infection

After initial infection with HIV, there is usually an acute flu-like illness.
Progression of HIV infection
Exposure to HIV normal Acute HIV disease

But after this most individuals are clinically asymptomatic for years. This is called the clinical latency period.

Immune competence

This illness may include Fever Headache Tiredness Enlarged lymph nodes

Slightly reduced

Clinical latency period -declining CD4+ T cell amount

Abnormal

AIDS

Severely impaired

Opportunistic infections

Time

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WHO clinical case definition for AIDS in South-East Asia

WHO clinical case definition for AIDS in South-East Asia Clinical AIDS in an adult is defined as an individual who has been identified as meeting the two criteria A and B below:

A. Positive test for HIV infection by two tests based on preferably two different antigens.
B. Any one of the following criteria: - Weight loss of 10% body weight or cachexia, not known to be due to a condition unrelated to HIV infection - Chronic diarrhoea of one month's duration, intermittent or constant
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WHO clinical case definition for AIDS in South-East Asia

Disseminated, miliary or extra pulmonary tuberculosis Candidiasis of the oesophagus; diagnosable as dysphasia, odynophagia and oral Candidiasis Neurological impairment restricting daily activities, not known to be due to a condition unrelated to HIV (e.g. trauma) Kaposi's sarcoma.
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Stage 1 - Primary
Short, flu-like illness - occurs one to six weeks after infection no symptoms at all

Infected person can infect other people

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Stage 2 - Asymptomatic
Lasts for an average of ten years
This stage is free from symptoms There may be swollen glands The level of HIV in the blood drops to very low levels

HIV antibodies are detectable in the blood

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Stage 3 - Symptomatic
The symptoms are mild

The immune system deteriorates

Emergence of opportunistic infections and cancers

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Stage 4 - HIV AIDS

The immune system weakens The illnesses become more severe leading to an AIDS diagnosis
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Progression to AIDS
During the latency period, lymph nodes and the spleen are sites of continuous HIV replication and cell destruction.

The immune system remains competent at handling most infections with opportunistic microbes but the number of CD4+ T cells steadily declines.
Symptoms often experienced months to years before the onset of AIDS. Lack of energy Weight loss Frequent fevers and sweats Persistent or frequent yeast infections Persistent skin rashes Dysfunction of CNS
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Progression to AIDS
Final stage of HIV infection - AIDS

Occurs when the destruction of peripheral lymphoid tissue is complete and the blood CD4+ T cell count drops below 200 cells/mm3. (Healthy adults usually have CD4+ T-cell counts of 1,000 or more). AIDS acquired immunodeficiency syndrome is marked by development of various opportunistic infections and malignancies.
The level of virus in the blood and CD4+ T cell count can predict the risk of developing AIDS. Voral titers often accelerate as the patient progresses towards AIDS. Without treatment, at least 50% of people infected with HIV will develop AIDS within ten years. Dr.T.V.Rao MD 54

Mother-to-Baby
Before Birth During Birth Postpartum
After the birth

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How is HIV not spread?

Shaking hands Hugging Swimming pools Toilet seats Insect bites Donating blood
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THE NATIONAL HIV TESTING POLICY

No individual should be made to undergo a mandatory testing for HIV No mandatory HIV testing should be imposed as a precondition for - Employment - Providing health care services and facilities Any HIV testing must be accompanied by a pretest and posttest counseling services (through VCTC) Testing without consent hindrance to the control of the epidemic
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Counseling

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Pre-test Counseling explain to individuals

Transmission Prevention Risk Factors Voluntary & Confidential Report ability of Positive Test

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Post-test Counseling
Clarifies test results Need for additional testing Promotion of safe behavior Release of results

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Three types of tests

(i) Screening tests - ELISA and

simple/rapid tests.
(ii) Confirmatory or supplemental testsWestern Blot assay. (iii) Nucleic acid and antigen screening tests. Polymerase chain reaction (PCR), Ligase chain reaction (LCR), Nucleic acid based Sequence assays (NASBA) and some ELISA tests.
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Diagnosis of HIV
Initial test for HIV is an indirect ELISA test Economic, rapid, performed easily, high sensitivity and specificity Detects anti-HIV antibodies in patient serum Antibodies are generally detectable within 3 months of infection Antibodies are typically directed at the envelope glycoproteins (gp120 and gp41)
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Absence of Antibodies to do not confirm absence of HIV infection

Absence of antibody, as in window period does not exclude the presence of the virus which can be detected by PCR amplification approx. ten days after infection Window period time between infection and detection of serological viral marker Direct ELISA for p24 antigen can also be used although the false negative rate is higher

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HIV Testing
EIA/ELISA Test
Negative No HIV Exposure Low Risk Negative HIV Exposure High Risk Repeat ELISA Every 3 months for 1 year Repeat every 6 months for continued High risk behavior End Testing Negative
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Positive

Repeat Positive Run IFA Confirmation

Positive

Indeterminate Repeat at 3 weeks

Negative Repeat at 2-4 months

Positive

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Diagnosis of HIV
Positive or indeterminate ELISA tests for anti-HIV antibodies are confirmed by immunoblotting (Western Blotting) which identifies specific HIV virus proteins PCR can also be used Detects pro-viral DNA or viral RNA It is highly sensitive and specific but is more costly than ELISA
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Can be used to test infants born to HIV-infected mothers

Indirect ELISA test

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Western blot Test

Confirms HIV infection Proteins are separated by electrophoresis and transferred to a nitrocellulose membrane by the passage of an electric current The proteins are treated with antibodies Similar to ELISA technique, addition of secondary antibodies with an enzyme attached allows the use of colour to detect a particular protein
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Western Blotting
A discrete protein band represents the specific antigen that the antibody recognizes The bands from a positive Western blot are from antibodies binding to specific proteins and glycoprotein's from the HIV virus The CDC recommends that the blot should be positive for two of the p24, gp41 and gp120/160 markers (gp160 is the precursor form of gp41 and gp120, the envelope protein)
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HIV Western blot

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Rapid Tests
ADVANTAGES:
quicker to perform
do not require batching do not require specialised equipment or trained personnel results delivered on the same day
Only WHO recommended Rapid HIV antibody tests should be used to ensure quality.
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The Window period Aware of it

Follows acute infection with HIV, before HIV antibodies can be detected in the patients blood stream. Patient is highly infectious, despite testing HIV antibody negative, HIV is replicating rapidly in all body compartments. Typically up to 12 weeks duration but may be shorter in more sensitive HIV antibody assays.
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Paediatric HIV Testing

Infants born to HIV infected mothers will have antibodies to HIV in their serum as a result of:
maternal-fetal transfer during pregnancy delivery breast-feeding

they may not necessarily be infected !

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Treatment of HIV
Eradication of HIV infection not possible with currently available drugs Viral replication can not be completely suppressed Latently infected CD4+ T cells established at early stage Goals of antiretroviral therapy are to: - Suppress viral replication - Restore and/or preserve immune function - Improve quality of life - Reduce HIV-associated morbidity and mortality Combinations of antiretroviral drugs are used Referred to as HAART (highly active antiretroviral therapy) Suppress levels of plasma viraemia for long periods Plasma viraemia is a strong prognostic factor in HIV Dr.T.V.Rao MD 73 infection

Antiretroviral Drugs
Significant declines in AIDS related morbidity and mortality are seen as a result of HAART Several strategies for development of effective antiviral drugs Potential therapies based on knowledge of the way in which HIV gains access into the cells and its method of replication Targets for therapeutic anti-retroviral drugs: - Inhibiting reverse transcription - Inhibiting proteases - Inhibiting integrate interferes with integration of viral DNA into host genome - Inhibiting fusion prevents virus from fusing with host cell
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Therapeutic Options
Combination of RT inhibitors protease inhibitors results in potent anti-viral activity
In most cases, two nucleoside analogues and one protease inhibitor are taken together HAART lowers plasma viral loads in many cases to levels not detectable by current methods Has improved the health of AIDS patients to the point that they can function at a normal level
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AIDS (Pregnancy & AIDS)

Zidovudine(AZT) recommended for px of maternal fetal HIV transmission & adm after 14mg AOG (PO meds); IVIT during labor; w/ neonate post birth for 6 wks. Postpartum monitor for s/of infxn place mother in isolation if mother is immune suppressed. -restrict breastfeeding infant/neonate is seen by physician at birth, 1 wk. or 2 wks., a mos., 2 mos., & 4 mos. of life * Neonate- asymptomatic for 1st several yrs. Of life & monitored for early signMD immunodeficiency 76 of Dr.T.V.Rao

Antiretroviral Drugs
Nucleoside Reverse Transcriptase inhibitors
AZT (Zidovudine)

Non-Nucleoside Transcriptase inhibitors

Viramune (Nevirapine)

Protease inhibitors
Norvir (Ritonavir)

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Prevention and control of HIV

Education Prevention of blood born HIV transmission Anti Retro Viral treatment Combination therapy Post exposure prophylaxis Specific prophylaxis Primary health care
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HIV Occupational Exposure

Review facility policy and report the incident Medical follow-up is necessary to determine the exposure risk and course of treatment Baseline and follow-up HIV testing Four week course of medication initiated one to two hours after exposure AZT (200mg)-TID +lamivudine(3TC)(150mg)BID x 4days Nelfinavir (750 mg) TID ,AZT/3TC Exposure precautions practiced Dr.T.V.Rao MD 79

HIV Non-Occupational Exposure

PREVENTION --- FIRST
No data exists on the efficacy of antiretroviral medication after non-occupational exposures The health care provider and patient may decide to use antiretroviral therapy after weighing the risks and benefits Antiretroviral should not be used for those with low-risk transmissions or exposures occurring more than 72 hours after exposure
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Play safe
Use the common sense Be faithful to one partner, Use Condom. Antiretroviral drugs Caesarean delivery

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Abstinence
It is the only 100 % effective method of not acquiring HIV/AIDS. Refraining from sexual contact: oral, anal, or vaginal. Refraining from intravenous drug Dr.T.V.Rao MD

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Monogamous relationship
A mutually monogamous (only one sex partner) relationship with a person who is not infected with HIV HIV testing before intercourse is necessary to prove your partner is not infected

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Sex Education Best option to Prevent

AIDS
Move from Past to Future

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World AIDS Day,

World AIDS Day, observed December 1 each year, is dedicated to raising awareness of the AIDS pandemic caused by the spread of HIV infection. It is common to hold memorials to honour persons who have died from HIV/AIDS on this day. Government and health officials also observe the event, often with speeches or forums on the AIDS topics.
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Do not Discriminate AIDS Patients

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 Created by Dr.T.V.Rao MD for Medical and Paramedical Students in the Developing World
Email
doctortvrao@gmail.com

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