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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 body’s 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.

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• 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

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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 women’s 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.

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Modes of HIV/AIDS Transmission

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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.; skinAdaptive 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 T-lymphocytes 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 pt’s 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 OI3. Long term non pogressors; it takes more than 8yrs

& have low viral loadStage II ; pt’s 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 infectionsSkin 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.• Pt’s 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:Kaposi’s 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-Hodgkin’s 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 CD4Cd4 no Possible OIS

300-400 HZ, TB

200-300 Oral candidacies

100-200 pcp , esophageal candidacies

50-100 Toxoplasmosis ,Cryptococcus

<50 Pgl(multiple)

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OI prophylaxis

• It is the prophylaxis of opportunistic infectionsCriteria 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 pt’s 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 exposurealgorithm -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 doesn’t 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 can’t copy it self.

• PI prevents cutting & make putting together so HIV can’t 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 ofHIV/AIDS ; these are

1. First regime ; these are combination of two NRTI’s 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

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 CondomRemember 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

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 person’s 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.pv’t transmission from +ve mother to child4. 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)

• Don’t 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!