Transcript Acquired Immuno-deficiency Syndrome (AIDS) Prepared by: Dr

Acquired Immunodeficiency Syndrome
(AIDS)
Dr. Assad Rahhal
National AIDS Program/ MOH
Definition
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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
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Early infection (window period)
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Fever
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Headache
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Sore throat
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Swollen lymph glands
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Rash
Later infection (advanced HIV infection)
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Swollen lymph nodes — often one of the first signs of HIV
infection
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Diarrhea
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Weight loss
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Fever
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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
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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 HIVantibody 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
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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
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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
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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
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Bacterial infections:
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Bacterial pneumonia
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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
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Bacillary angiomatosis (Bartonella henselae): purplish to bright
red patches on skin
Complications
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Viral infections:
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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
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Fungal infections:
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Candidiasis
Cryptococcal meningitis: caused by a fungus that is present in
soil, it may also be associated with bird or bat droppings
Parasitic infections:
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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
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Cancers:
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Kaposi's sarcoma
Non-Hodgkin's lymphoma
Other complications
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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
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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
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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
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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
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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
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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:
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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
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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
*ARV regimen
Major potential toxicities
Stavudine (d4T)/
Lamivudine (3TC)/
Nevirapine (NVP)
d4T-related neuropathy, pancreatitis and
lipoatrophy;
NVP-related hepatotoxicity and severe rash
Yes
Zidovudine (ZDV)/
3TC/NVP
ZDV-related GI intolerance, anemia, and
neutropenia;
NVP-related hepatotoxicity and severe rash
Yes
d4T/3TC/
Efavirenz (EFV)
d4T-related neuropathy, pancreatitis and
lipoatrophy;
EFV-related CNS toxicity and potential for
teratogenicity
No
ZDV/3TC/EFV
ZDV-related GI intolerance, anemia and
neutropenia;
EFV-related CNS toxicity and potential for
teratogenicity
No
*2 NRTIs + 1 NNRTIs
Usage in women (of
childbearing age or
pregnant
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
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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
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Prevalence of HIV has surpassed 1% in the “general
population”
Estimated per act risk for acquisition
of HIV by exposure route
Exposure Route
Estimated infections
Exposure Route
per 10,000 exposures
to an infected source
Estimated infections
per 10,000 exposures
to an infected source
Blood Transfusion
9000
Insertive anal
intercourse
6.5
Childbirth
2,500
Receptive penilevaginal
intercourse
10
Needle-sharing
injection drug use
67
Insertive penilevaginal
intercourse
5
Percutaneous
needle stick
30
Receptive oral
intercourse
1
Receptive anal
intercourse
50
Insertive oral
intercourse
.5
Life expectancy in some Southern African
countries/ 1958 - 2003
Prevention and control
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Prevention programs:
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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