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HIV & AIDS

HIV & AIDS. YP Beh ST6 GUM Coventry & Warwickshire PT 19.6.12. Objectives. Biology of HIV Virus Epidemiology Clinical Presentations HIV Testing HIV and Antiretroviral Treatment Chronic HIV associated conditions HIV and Pregnancy Post exposure prophylaxis for HIV. Biology of HIV 1.

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HIV & AIDS

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  1. HIV & AIDS YP Beh ST6 GUM Coventry & Warwickshire PT 19.6.12

  2. Objectives • Biology of HIV Virus • Epidemiology • Clinical Presentations • HIV Testing • HIV and Antiretroviral Treatment • Chronic HIV associated conditions • HIV and Pregnancy • Post exposure prophylaxis for HIV

  3. Biology of HIV 1 • HIV is a retrovirus • It cannot replicate by itself and must utilise host cell machinery in order to produce new virus particles • It can convert its RNA genome into DNA • HIV DNA integration into the host cell genome allows it to access host biochemical pathways to reproduce • The RNA – DNA reaction is catalysed by reverse transcriptase • HIV DNA is subsequently integrated into the host cell’s genome

  4. HIV life cycle • http://highered.mcgraw-hill.com/sites/0072495855/student_view0/chapter24/animation__how_the_hiv_infection_cycle_works.html

  5. CD4 & Viral Load CD4 Lymphocyte count Normal Value 500 -1200 cells Indication ‘strength’ of the immune system AIDS if CD4 less than 200 cells Viral Load The amount of HIV Virus in the blood Measurement of viral copies/ml

  6. Estimated number of people living with HIV infection: United Kingdom, 2010 Total with HIV = 91,500 (85,400 − 99,000)Total diagnosed = 69,250 (67,800 − 70,800)Total undiagnosed = 22,200 (16,350 − 29,650)

  7. New HIV diagnoses by exposure group: United Kingdom, 2001 – 2010

  8. Probable recent infection among people newly diagnosed with HIV by exposure group: England and Northern Ireland, 2010

  9. New HIV diagnoses by probable country of infection : 2001-2010

  10. Late diagnoses of HIV by exposure group: UK, 2010

  11. Presentations of HIV • Asymptomatic • Seroconversion period • AIDS-related conditions • Chronic HIV-associated conditions

  12. HIV Seroconversion

  13. Primary HIV Infection • Two – four weeks post-infection • Symptoms • Fever, maculopapular rash, myalgia, pharyngitis, headache, lymphadenopathy • Varies from very mild to severe enough to require hospital admission • Be aware in high-risk groups! • Highly infectious time because of high viral load • Transient fall in CD4 count can lead to OI

  14. HIV and the Lung • Infections • Tuberculosis • Pneumocystis jiroveci pneumonia • Fungal pneumonia • Bacterial pneumonia • Malignancy • Kaposi’s sarcoma • Lymphoma • Non-malignant conditions • Lymphoid interstitial pneumonitis

  15. Pulmonary Infections - PCP

  16. Pulmonary Infections - TB

  17. Lymph nodes TB Lymphoma HIV

  18. HIV and the Brain • Opportunistic infections • Toxoplasma gondii - abscesses and encephalitis (<200) • Cryptococcus neoformans - meningitis (<200) • JC virus – Progressive Multifocal Leucoencephalopathy (<100) • CMV - retinitis, encephalitis, mononeuritis multiplex, cauda equina syndrome • Tumours • Primary CNS lymphoma • HIV-related disorders • HIV-associated dementia complex • Peripheral neuropathy (distal sensory polyneuropathy)

  19. Progressive multi-focal leuco- encephalopathy (PML)

  20. Cryptococcoma

  21. HIV & Eye infection Retinitis

  22. HIV and the Gut • Oesophageal candidiasis • Infective Diarrhoea • Bacteria e.g. campylobacter, shigella, MAI • Protozoa e.g. cryptosporidium, isospora belli, microsporidium • Viruses e.g. CMV, adenovirus • Malignancy • Kaposis sarcoma • Drug Side-Effects • HIV Wasting Syndrome

  23. Oesophageal candidiasis

  24. HIV and the Skin • Seborrhoeic dermatitis • Aphthous ulceration • Oral candida (<300) • Kaposi’s Sarcoma (<200) • Bacteria: • Impetigo, folliculitis • Fungi • Tinea pedis, cruris; pityriasis versicolor • Candida - genital, perianal, other • Viruses • HSV 1 and 2 • Varicella zoster • EBV (<300) • HPV • Molluscum contagiosum • Neoplasia • Cervical dysplasia

  25. Kaposi’s sarcoma

  26. Who should be tested? Opt Out’ for: All patients attending GUM or sexual health clinics. All women attending antenatal services. All women attending termination of pregnancy services. All patients registering with drug dependency programmes reporting a history of injecting drug use. All patients diagnosed with Tuberculosis, Hepatitis B, Hepatitis C and Lymphoma.

  27. 4th generation tests eg Determine test Antigen & Antibody detection Previous 3rd gen tests Antibody only (INSTI) All must be confirmed by formal venepuncture HIV Testing

  28. BASHH Statement on HIV window period • 4th generation tests are recommended which test for HIV antibodies and p24 antigen simultaneously • They will detect the great majority of individuals who have been infected with HIV 4 weeks after exposure • A negative result at 4 weeks post exposure is very reassuring • An additional HIV test should be offered to all persons at 3 months to definitively exclude HIV infection

  29. Highly Active Anti-Retroviral Therapy (HAART) • Suppress Viral Load & Increases CD4 • Combination therapy • HAART Initiation when CD4 <350cells/mm3 • Reduced risk of disease progression • Life expectancy

  30. Late 90s Now

  31. HAART & the HIV Life Cycle

  32. When to start? BHIVA guideline 2008

  33. Chronic HIV-Associated Conditions

  34. Rate of Heart Attacks in HIV Positive and HIV Negative Patients 100 HIV+ 80 HIV– 60 Events per 1000 Person-Years 40 20 0 45-54 18-34 35-44 55-64 65-74 Age Group (Years) Age Triant VA,et al. J Clin Endocrinol Metab. 2007;92:2506-2512.

  35. HIV and Hepatitis B • 100 times more infectious than HIV • 10 times more infectious than HCV • Lives outside the body for up to 7 days

  36. Progression of Chronic Hepatitis Liver Cancer (HCC) 5%–10% 10%–15% in 5 yr Liver Transplantation Cirrhosis Death Chronic Infection 30% 23% in 5 yr Liver Failure Adapted from: Fattovich, et al. Gastroenterology. 2004;127:S35-S50. Torresi, et al. Gastroenterology. 2000;118:S83-S103. Fattovich, et al. Hepatology. 1995;21:77-82. Perrillo, et al. Hepatology. 2001;33:424-432.

  37. HIV & Bone Disease: Greater risk of fractures in HIV-Infected individuals Fracture prevalence/100 persons p<0.001 Triant VA, Brown TT, Lee H, Grinspoon SK. Fracture prevalence among human immunodeficiency virus (HIV)-infected versus non-HIV-infected patients in a large U.S. healthcare system. J Clin Endocrinol Metab 2008; 93:3499–3504

  38. Other chronic co-morbidities with HIV • Cancer • Kidney Disease • Renal function slowly declines with age • Diabetes • Neurocognitive decline

  39. HIV and Pregnancy – Reducing VL • When to treat • Continue treatment if conception occurs on HAART • Between 20/40 and 28/40 • Aim for undetectable VL by 36/40 • What to treat with • At least 3 drugs – usually combivir + PIs • ZDV monotherapy

  40. HIV and Pregnancy – Post-Delivery • Therapy for baby • 4/52 triple therapy for babies born to mothers with detectable VL • 4/52 ZDV for babies born to mothers with undetectable VL • Recommend EXCLUSIVE formula feeding • Testing baby • Loss of maternal antibody at 18/12 • PCR testing; primers to amplify maternal virus

  41. Post-Exposure Prophylaxis PEP consists of 28 days of triple therapy Not licensed Offered only where the risk is high Should be offered within 72 hours Best result within 1 hour of the contact Reduces the risk of transmission by 80% Common side effects are nausea, diarrhoea and fatigue Less common side effects are renal dysfunction, insulin resistance, lipid disorders

  42. HIV Transmission

  43. Recommended information sources • ABC of AIDS, BMJ Books • www.BHIVA.com • www.aidsmap.com • http://www.hiv-druginteractions.org/ • www.medscape.com

  44. Summary • HIV is a treatable condition • Can present with any symptom, or none • People living with HIV in the UK can expect a near-normal life expectancy • Importance of diagnosing early infection

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