Acquired Immuno-deficiency Syndrome

(AIDS)

Dr. Assad RahhalNational AIDS Program/ MOH

Definition AIDS is a chronic, life-threatening condition caused by

the human immunodeficiency virus (HIV). By damaging immune system, HIV interferes with the body's ability to fight off viruses, bacteria and fungi that cause disease. HIV makes man more susceptible to certain types of cancers and to infections which the body would normally resist.

The virus and the infection itself are known as HIV. AIDS is the name given to the later stages of an HIV infection

Infectious agent: HIV 1, HIV 2

Scanning electron micrograph of HIV-1, colored green, budding from a cultured lymphocyte

Symptoms Early infection (window period)

Fever Headache Sore throat Swollen lymph glands Rash

Later infection (advanced HIV infection) Swollen lymph nodes — often one of the first signs of HIV

infection Diarrhea Weight loss Fever Cough and shortness of breath

Relationship between HIV copies (viral load) and CD4 counts over the average course of untreated HIV infection

CD4+ T Lymphocyte count (cells/mm³)HIV RNA copies per mL of plasma

Symptoms Latest phase of infection (AIDS)

In 1993, the Centers for Disease Control and Prevention (CDC) redefined AIDS to mean the presence of HIV infection as shown by a positive HIV-antibody test plus at least one of the following:

The development of an opportunistic infection — an infection that occurs when immune system is impaired — such as Pneumocystis carinii pneumonia (PCP)

A CD4 lymphocyte count of 200 or less — a normal count ranges from 800 to 1,200

Symptoms Latest phase of infection (AIDS)

Soaking night sweats Shaking chills or fever higher than 38 C for several

weeks Dry cough and shortness of breath Chronic diarrhea Persistent white spots or unusual lesions on the

tongue or in mouth Headaches Blurred and distorted vision Weight loss

Transmission Sexual transmission Infected blood

needle sharing accidental needle sticks tattoo, body piercing organ or tissue transplants or unsterilized dental or

surgical equipment. Mother to child

Risk factors Anyone of any age, race, sex can be infected with HIV unprotected sex with someone who is HIV-positive

(multiple partners, heterosexual, homosexual or bisexual). Unprotected sex means having sex without using a new latex or polyurethane condom every time.

Have another sexually transmitted disease, such as syphilis, genital herpes, chlamydia, gonorrhea or bacterial vaginosis.

Sharing needles during intravenous drug use. Have fewer copies of a gene called CCL3L1 that helps

fight HIV infection.

Complications Bacterial infections:

Bacterial pneumonia Mycobacterium avium complex (MAC). This infection is caused

by a group of mycobacteria, in advanced HIV infection and when CD4 lymphocyte count is less than 50, it is more likely to develop a systemic infection that can affect almost any internal organ, including bone marrow, liver or spleen

Tuberculosis (TB): the most common infection associated with HIV and a leading cause of death among people living with AIDS

Salmonellosis Bacillary angiomatosis (Bartonella henselae): purplish to bright

red patches on skin

Complications Viral infections:

Cytomegalovirus (CMV): damage to eyes, digestive tract, lungs or other organs. Most commonly, CMV causes infection and inflammation of the retina (CMV retinitis)

Viral hepatitis Herpes simplex virus (HSV) Human papillomavirus (HPV): one of the most common causes

of sexually transmitted diseases (warts on the genitals) Progressive multi-focal leuko-encephalopathy (PML): human

polyomavirus JC virus, speech problems, weakness on one side of the body, loss of vision in one eye, or numbness in one arm or leg

Complications Fungal infections:

Candidiasis Cryptococcal meningitis: caused by a fungus that is present in

soil, it may also be associated with bird or bat droppings Parasitic infections:

Pneumocystis carinii pneumonia (PCP): one of the most common opportunistic infections affecting PLWHA

Toxoplasmosis: caused by Toxoplasma gondii, a parasite spread primarily by cats. For many people with AIDS, toxoplasmosis leads to encephalitis

Cryptosporidiosis: leads to severe, chronic diarrhea in people with AIDS.

Complications Cancers:

Kaposi's sarcoma Non-Hodgkin's lymphoma

Other complications Wasting syndrome: it is defined as a loss of at least

10 percent of body weight and is often accompanied by diarrhea, chronic weakness and fever.

Neurological complications: confusion, forgetfulness, changes in behavior, depression, anxiety and trouble walking. One of the most common neurological complications is AIDS dementia complex, which leads to behavioral changes and diminished mental functioning

Kaposi sarcoma

Tests and diagnosis WHO disease staging system(1990, update in

September 2005): Stage I: HIV infection is asymptomatic and not

categorized as AIDS Stage II: includes minor mucocutaneous

manifestations and recurrent upper respiratory tract infections

Stage III: includes unexplained chronic diarrhea for longer than a month, severe bacterial infections and pulmonary tuberculosis

Stage IV: includes toxoplasmosis of the brain, candidiasis of the esophagus, trachea, bronchi or lungs and Kaposi's sarcoma; these diseases are indicators of AIDS.

Tests and diagnosis HIV is diagnosed by testing your blood or oral mucus for

the presence of antibodies to the virus Enzyme-linked immunosorbent assay (ELISA) and

Western blot tests (checks for the presence of HIV proteins)

Rapid tests Home tests Viral load: used to decide when to start and when to

change treatment

WHEN TO START ARV THERAPY ?

Clinically advanced HIV disease: WHO Stage IV HIV disease, irrespective of

the CD4 cell count; WHO Stage III disease with consideration of

using CD4 cell counts <350/mm3 to assist decision-making

WHO Stage I or II HIV disease with CD4 cell counts <200/mm3

Factors considered in the selection of ART regimens potency; side-effect profile; laboratory monitoring requirements; potential for maintenance of future

treatment options; anticipated patient adherence; coexistent conditions (e.g. coinfections,

metabolic abnormalities);

Factors considered in the selection of ART regimens

pregnancy or the risk thereof; use of concomitant medications (i.e. potential drug

interactions); potential for infection with a virus strain with diminished

susceptibility to one or more ARVs, including that resulting from prior exposure to ARVs given for prophylaxis or treatment;

very importantly, availability and cost. The use of quality-assured a antiretroviral in fixed-dose

combinations

Treatments and drugs Improve quality of life, none of drugs can cure HIV/AIDS Treatment should focus on achieving the maximum suppression of

symptoms for as long as possible (highly active anti-retroviral therapy HAART)

Anti-retroviral drugs: Nucleoside analogue reverse transcriptase inhibitors

(NRTIs): • inhibit the replication of an HIV enzyme called reverse transcriptase

(zidovudine, lamivudine, didanosine, stavudine, abacavir, emtricitabine

• Protease inhibitors (PIs): interrupt HIV replication at a later stage in its life cycle by interfering with an enzyme known as HIV protease (saquinavir ritonavir, indinavir, nelfinavir, amprenavir, lopinavir/ritonavir (Kaletra), atazanavir and tipranavir. PIs are usually prescribed with other medications, to help avoid drug resistance.

Treatments and drugs Anti-retroviral drugs:

• Non-nucleoside reverse transcriptase inhibitors (NNRTIs): bind directly to the enzyme reverse transcriptase (nevirapine, delavirdine, efavirenz and etravirine)

• Nucleotide reverse transcriptase inhibitors (NtRTIs): interfere with the replication of reverse transcriptase and prevent the virus from inserting its genetic material into cells (tenofovir)

FIRST-LINE ARV REGIMENS IN ADULTS AND ADOLESCENTS

Usage in women (of childbearing age or pregnant

Major potential toxicities *ARV regimen

Yes d4T-related neuropathy, pancreatitis and lipoatrophy;NVP-related hepatotoxicity and severe rash

Stavudine (d4T)/Lamivudine (3TC)/Nevirapine (NVP)

Yes ZDV-related GI intolerance, anemia, and neutropenia;NVP-related hepatotoxicity and severe rash

Zidovudine (ZDV)/3TC/NVP

No d4T-related neuropathy, pancreatitis and lipoatrophy;EFV-related CNS toxicity and potential for teratogenicity

d4T/3TC/Efavirenz (EFV)

No ZDV-related GI intolerance, anemia and neutropenia;EFV-related CNS toxicity and potential for teratogenicity

ZDV/3TC/EFV

*2 NRTIs + 1 NNRTIs

Stages of the epidemic

Low Grade Prevalence of HIV is consistently below 5% in any “high

risk groups” and below 1% in the “general population” Concentrated

Prevalence of HIV has surpassed 5% on a consistent basis in one or more “high risk groups” but remains below 1% in the “general population”

Generalized Prevalence of HIV has surpassed 1% in the “general

population”

Estimated per act risk for acquisitionof HIV by exposure route

Estimated infectionsper 10,000 exposuresto an infected source

Exposure Route Estimated infectionsper 10,000 exposuresto an infected source

Exposure Route

6.5 Insertive anal intercourse

9000 Blood Transfusion

10 Receptive penile-vaginal intercourse

2,500 Childbirth

5 Insertive penile-vaginal intercourse

67 Needle-sharing injection drug use

1 Receptive oral intercourse

30 Percutaneous needle stick

.5 Insertive oral intercourse

50 Receptive anal intercourse

Life expectancy in some Southern African countries/ 1958 - 2003

Prevention and control Prevention programs:

Health education: public, schools Abstain, Be faith, and Condom use (ABC) Treatment and rehabilitation of IDUs, harm reduction

and needle exchange programs VCT services, BCC, MARPs programs

Blood safety and universal precautions PMTCT Male circumcision Immunization of infected children (no BCG for

symptomatic)

Prevention and control Comprehensive STIs treatment and care Care and support for PLWHA Reporting of cases Notification of contacts and source of

infection (confidentiality) Provision of treatment, tuberculin test Viral load and CD+4 T cell count