HIV/AIDS

The human immunodeficiency virus (HIV), first reported in the U.S. in 1981, is a retrovirus that causes acquired immunodeficiency syndrome (AIDS), a progressively fatal disease that destroys the immune system and the bodys ability to fight infection. It was manifested on peoples whose immunity is compromised.
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HIV/AIDS Statistics
By the end of 1998, an estimated 33.4 million people in the world were living with HIV/AIDS. In the U.S., 688,200 cases of AIDS reported by the end of 1998, with as many as 900,000 infected with HIV. In Ethiopia HIV/AIDS was diagnosed around 1984 E.C &first hospitalized AIDS in 1986 The first women who disclose her self was Belayneshe Mekuria
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AIDS-Defining Conditions
Most AIDS-defining conditions are opportunistic infections (infections in persons with a defective immune system that rarely cause harm in healthy individuals). Pneumocytis carinii pneumonia is the most frequent AIDS-defining condition in the U.S. and Europe.

 HIV belongs to a large family of ribonucleic acid (RNA) . These viruses are characterized by association with diseases of immunosuppressant. It also involve central nervous system and have long incubation periods. It is divided in to HIV 1 &HIV 2 HIV 1 is more severe &common in Africa
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Testing Options for HIV

AIDS Testing
The enzyme-linked immunosorbent assay (ELISA) is the basic screening test to detect antibodies of HIV. A confirmatory test, the Western blot, is always employed when the ELISA is positive. The two taken together have an extremely high accuracy rate. Obtaining a signed informed consent for testing is often a nursing responsibility.
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Demographics of AIDS in the United States

Age (AIDS affects mainly people during the most productive years of their life). Gender (More men from women, though womens rates are increasing). Race (The HIV/AIDS epidemic is growing most rapidly among some minority populations and is a leading cause of death of African American males).
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Modes of Transmission
The virus may be found in blood, semen, vaginal secretions, amniotic fluid and breast milk of infected individuals. No evidence that HIV is spread through sweat, tears, urine, or feces. Risk of infection from deep kissing or oral sex is unknown.

Modes of HIV/AIDS Transmission

Path physiology
HIV is the infection of immune organs Immunity may be innate or acquired Innate; it is immunity we got by nature -it Is short lived and lacks ability to recall previous infection e.g.; skin Adaptive immunity; it is type of immunity our body develops after infection. -it is slow but progressive defense against foreign bodies like infection and cancer cells e.g. Vaccination ,the body learns from vaccine to produce specific proteins called antibodies(AB).
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Continuous..
AB produced by cells called B lymphocytes and the response is known as humeral immunity. Vaccines and infections stimulate Tlymphocytes by a process called cellular immunity. Immune cells produced from thymus , bone marrow , lymph nodes ,spleen, liver and tonsil & lymphoid organs.
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How HIV Infect cells

HIV have no life alone like other viruses Mode of entry; HIV needs a receptor to attach and go inside (CD4 receptors i.e. CCR4 &CCR5) ___CD4 on T-cells will be infected and in process body will be defenseless. 1. HIV attaches , infects & destroys CD4 cells(Attachment) 2. HIV attaches to CD4 and release RNA by the enzyme transcriptase (Transcription)
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Continues.
The enzyme reverse transcriptase makes CD4 copy of viral RNA( Reverse transcription). New viral DNA is then integrates in to CD4 cell nucleolus(Integration) Then new viral component are then produced using cell machinery(Replication). Then these cells assemble together using the enzyme protease(Assemble) Then released as new viruses(Release)
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Common Diagnostic Tests for HIV and AIDS

CD4-T-cells ELISA Polymerase chain reaction (PCR) Western blot KHB, Stat pack and ELISA algorithm

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Clinical manifestation and staging of HIV

. Duration and severity of C/M of HIV/AIDS is highly depend on: 1.viral load 2. amount CD4 count 3. nutritional status of the pt

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WHO clinical staging of HIV/AIDS

WHO stages HIV in to four stages based on clinical symptoms and CD4 count pt with HIV will develop sign and symptoms after long period and pts will classify accordingly Stage I: Acute seroconverstion; it is stage where pts serum status changes from ve to +ve -in these phase pt will have flu like symptoms like fever, fatigue , pharingites, lympadenopathy and rash

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 Window period ; period from infection to sero status change -pt will have high viral load & highly infection pts will be classified in to 3 based on time of developing OI 1. Typical progressors(90%); takes 8-10 yrs .viral set point is medium to develop OI 2.Rapid progressors (5%); 3 yrs to develop OI
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- High viral set point is medium to develop OI 3. Long term non pogressors; it takes more than 8yrs & have low viral load Stage II ; pts with sign and symptoms of the following will be grouped under group II -Skin problems -wt loss(5-10%) -recurrent URTI

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 Stage III ;Wt loss >10% -> 1 month diarrhea(some times intermittent) -un explained fever - severe bacterial infection & muscle infection -TB, un explained anemia

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 Stage IV ; -HIV wasting syndrome( extreme thin +chronic fever & diarrhea) -esophageal thrush - Herpes simplex ulceration(> 1 month), large & chronic painful wound on the genitalia or anus - Kaposi's sarcoma , dark purple lesions on skin mouth, eye ,lungs
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-invasive cervical Ca -EPTB -Cryptococcal meningitis ,meningitis with out neck stiffness -toxoplasma brain abscess -HIV encephalopathy; neurological impairment due to other cause

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 Advantages of staging; -uses to estimate the degree of immunity -guide to start ART -Assists to initiate OI prophylaxis when no CD4 count

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Four Stages of HIV

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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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Opportunistic infections Skin problems

seborrhea ; scaly skin eruption on boarders between face and hair -usually greasy scales and redness Prurigo; itchy skin eruption on arms & legs -may leave dark spots with light centers Herpes zoster(Hz); dark mark on chest, leg, arm or face -it never cross mid line
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 Angular cheilitis; chronic sores or cracks around lips &often corners NB; a pt with the above manifestations will be grouped under stage II

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Pneumocystis Carinii Pneumonia

The most common opportunistic infection associated with advanced HIV disease. Found primarily in the lungs, but also reported in the adrenal glands, bone marrow, skin, thyroid, kidneys, and spleen. Clinical signs include fever, shortness of breath, nonproductive cough, and crackles. Initial diagnosis made by chest x-ray. Pts with PCP grouped under stage IV
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Gastrointestinal Opportunistic Infections

Mycobacterium avium complex. Cytomegalovirus. Cryptosporidiosis. Hepatitis. HIV-wasting syndrome.

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Mycobacterium avium complex

In persons with AIDS, involvement of the bowel is usually extensive. The microorganism can fill the bone marrow and lymph nodes. Most common symptoms are chronic fever, malaise, anemia, weight loss, diarrhea, and abdominal pain.

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Cytomegalovirus (CMV)
Belongs to the herpes virus group. Causes disease by destroying the brain, lung, retina, and liver. Signs and symptoms include weight loss, fever, diarrhea, and malaise.

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Cryptosporidosis
Caused by a protozoan that usually infects the epithelial cells that line the digestive tract. Clinical signs include profuse water diarrhea, up to 20 liters a day. Abdominal pain, serious weight loss, abdominal cramping, anorexia, low-grade fever, dehydration, electrolyte imbalance and malaise may also be present.

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Hepatitis
Hepatitis B virus, C virus, and D virus are commonly seen with HIV infection. Signs and symptoms include malaise, weakness, anorexia, nausea, vomiting, and right upper quadrant pain.

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HIV-Wasting Syndrome
Defined as unexplained weight loss of more than 10% of body weight accompanied by weakness, chronic diarrhea, and fever in those affected with HIV. Signs and symptoms include anorexia, diarrhea, nausea, vomiting, changes in taste and smell, aphthous ulcers of mouth and esophagus, and abdominal pain.

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Oral Opportunistic Infections

Oral candidiasis (thrush), a fungal infection, is seen in more than 90% of AIDS clients. Symptoms include unpleasant taste, mouth dryness, and creamy, white oral plaques. Oral Hairy Leukoplakia (OHL) usually appears as a white patch on the lateral borders of the tongue. OHL is not usually bothersome to the client and may regress spontaneously.
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Esophageal Thrush
It is manifestation with difficulty of swallowing Grouped under stage II

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Gynecological Opportunistic Infections

Vaginal Candidiasis is the most common initial infection occurring in HIV-infected women. Cervical Intraepithelial Neoplasia (CIN) is of a much higher incidence in women affected with HIV.

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Central Nervous System Opportunistic Infections

AIDS dementia complex. Toxoplasmosis. Cryptococcosis.

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AIDS Dementia Complex

The most common central nervous system complication in persons with AIDS. This disorder is chronic and progressive with cognitive, motor, and behavioral dysfunction.

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Toxoplasmosis
Caused by the protozoan Toxoplasma gondii, found in cats and other animals. Clinical signs may be vague and nonspecific, ranging from mild headache, fever, and lethargy to poor coordination, seizures, and coma.

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Cryptococcosis
A fungal infection caused by Cryptococcus neoformans. The most life-threatening fungal infection associated with AIDS. Clinical symptoms include fever, headache, nausea, vomiting, dizziness, photophobia, mental status changes, seizures, and stiff neck.

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Opportunistic Malignancies:

Kaposis Sarcoma
A vascular malignancy that can occur any place in the body, including the internal organs. First lesions often appear subtly on the face or in the oral cavity.

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Opportunistic Malignancies:

Non-Hodgkins Lymphoma
Clinical manifestations include fever, night sweats, and weight loss. Treatment of NHL in clients with advanced HIV disease is often withheld, because it is not tolerated well and may even lead to earlier death.

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Review OI and CD4

Cd4 no 300-400 200-300 Possible OIS HZ, TB Oral candidacies

100-200
50-100

pcp , esophageal candidacies

<50

Toxoplasmosis ,Cryptococcus Pgl(multiple)

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OI prophylaxis
It is the prophylaxis of opportunistic infections Criteria to start OI prophylaxis ; -WHO stage 2,3or 4 with out CD4 count -CD4 <350 - Pt with TB &HIV co-infection -pt with history of PCP

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Common drugs of OI prophylaxis

Cotrimoxazole 960mg PO per day for 1 month Fluconazole prophylaxis with cryptococal meningitis INH prophylaxis for pts with out PTB

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Post exposure prophylaxis(PEP)

PEP a short term ARV treatment to reduce infection of HIV/AIDS after potential exposure It may be occupational or sexual exposure algorithm -first test the exposed person, if +ve no need of PEP -If the exposed is ve; test the source ,if the source is ve no need of PEP -if the source is +ve and exposed is ve ;PEP will be given for 1 month
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 Drugs used for PEP are different according to type of exposure e.g.. Needle injury with sexual assault ZDV-3TC D4T-3TC Tenoravir-3TC NB; the above drugs commonly prescribed for PEPS
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ART
ART(antiretroviral therapy) is the treatment of HIV which is taken for life long after starts ART doesnt cure but elongate life of the pt by decreasing viral load and increase CD4 It is better not to start than default We have to advice for adherence before we start ART

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Criteria to start ART

1. Clinical stage 2.TLC(total lymphocyte count) 3. CD4 count Stage I; only if CD4 count is<200 Stage II; only if CD4 <200 & TLC <1200/mm3 Stage III; if no CD4 for all , if CD4 <350 & evaluate for adherence Stage IV ;All

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ARV Drugs
We have 3 main groups of ARV drugs We give In regime or group in order to improve efficiency of drugs by acting on d/t stages of HIV 1. NRTI (nucleoside and nucleotide reverse transcriptase inhibiter , NsRTI & NtRTI) 2. NNRTI( non nucleoside reverse transcriptase inhibiter)
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3. Protein inhibiter (IP) NRTI &NNRTI prevents HIV from entering to infected cell nucleus. So HIV cant copy it self. PI prevents cutting & make putting together so HIV cant leave the infected cell

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Drugs under NsRTI -Stavudine(d4t) -lamuvidine(3tc) -zidovudine(AZT or ZDV) -Didanosine(ddi) -abacavir(ABc)

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NtRTI
-Fumarate(TDF) -Tenofovir -disoproxil

NNRTI
-Neverapin(NVP) -Efaviranze(EFV)
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PI -Saqunavir(sqvvir) -Retnonavir(RTV) -Indinavir(IDVIR) Advantage of compination -minimum of 3 drugs will be companied in order to decrease viral load(daily a billion copies)
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 So a combination of form a treatment called HAART(highly active ART) There are two regimes in the treatment of HIV/AIDS ; these are 1. First regime ; these are combination of two NRTIs and one NNRTI -this regime is given for a person who has no ART experience before
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D4t-3TC-NVP D4t-3TC-EFV AZT-3TC-EFV AZT-3TC-NVP In Ethiopia the common first regime is -D4T or ZDV-3TC-NVP or EVP -Second regime ; ddv-TDF-ABC-NVP or SQVIR -These regime is given who takes ART before but default due to different reasons

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prevention of HIV AIDS

Abstinence Be faithful Condom PMTCT( prevention of mother to child transmission)
PMTCT ;have four strategies

1. Primary prevention of HIV infection ; keeping parents to be HIV-ve

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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 use

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Protected Sex

Use condoms (female or male) every time you have sex (vaginal or anal) Always use latex or polyurethane condom (not a natural skin condom) Always use a latex barrier during oral sex
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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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When Using A Condom Remember To:

Make sure the package is not expired Make sure to check the package for damages Do not open the package with your teeth for risk of tearing Never use the condom more than once Use water-based rather than oil-based condoms

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Sterile Needles
If a needle/syringe or cooker is shared, it must be disinfected:
Fill the syringe with undiluted bleach and wait at least 30 seconds. thoroughly rinse with water Do this between each persons use

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Needle Exchange Program

Non-profit Organization, which provides sterile needles in exchange for contaminated ones
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PMTCT
PMTCT ;have four strategies

1. Primary prevention of HIV infection ; keeping parents to be HIV-ve

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2. Prevention of un intended Px on HIV +ve women 3.pvt transmission from +ve mother to child 4. Provision of treatment, care ,support for women with HIV, their infants & family

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 Clinical staging of px mother is similar with others except wt loss . Un able to gain wt is considered as wt loss In ART ; if no CD4 give ART for stage 3&4 In stage two if TLC is <1200/mm3 In the presence of CD4 count -stage 4(no mater to CD4 count) -stage 3 (CD4 <350) -stage 1 or 2(CD4 <200)
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 ART for mother & ARV prophylaxis is given to child is give immediately after birth Child AZT is given for 7 days Mother; AZT-3TC-NVP If the mother is on ART before continue it but avoid evaviranz during first trimester( to avoid birth defect, so substitute by NVP) Dont give ddi-d4t combination through px period(toxic)
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Counseling

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Pre-test Counseling
Transmission Prevention Risk Factors Voluntary & Confidential Reportability of Positive Test Results

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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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Thank You!

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