HIV / AIDS

Dr Jaya ChakravartyAssistant Professor

Department of MedicineIMS, BHU

Introduction• In 1981- CDC reported PCP pneumonia & kaposi’s

sarcoma in homosexual males.

• In 1983- Human immunodeficiency virus was isolated.

• In 1984- HIV virus was shown to be the causative agent.

• In 1985- ELISA was developed to diagnose HIV infection.

• In 1987- First drug Zidovudine produced

HIV/ AIDS – Indian scenario

• The first AIDS case in India was detected in 1986

• Till 2005 around 5.2 million people were estimated to be living with HIV in India.

• In 2007-People living with HIV/AIDS- 2.31million

• Third highest burden in the world• Adult (15 years or above) HIV prevalence 0.34%

District-wise Scenario of HIV/AIDSCategory / Districts NACP-III Definition

A 156 >1% ANC prevalence in any of the sites in the last 3 years

B 39<1% ANC prevalence in all the sites during last 3 years with >5% prevalence in any HRG site (STD/FSW/MSM/IDU)

C 296

<1% ANC prevalence in all sites during last 3 years with <5% in all STD clinic attendees or any HRG, with known hot spots

D 118

<1% ANC prevalence in all sites during last 3 years with <5% in all STD clinic attendees or any HRG OR no or poor HIV data with no known hot spots

New Districts: 30

Total Districts: 609

National AIDS Control Programme 13

Natural Staging and Clinical History of HIV

6

Modes of HIV Transmission

Sharing Semen and Vaginal Fluids

Sharing Needles & Syringes

Through Infected Blood

During Pregnancyor Birth

Breast Feeding

Images Courtesy HIV Basics Course for Nurses, I-TECH

Needle StickInjury

Natural Staging and Clinical History of HIV 7

HIV Transmission RiskExposure Route HIV Transmission

Blood transfusion 90-95%

Perinatal 20-40%

Sexual intercourse 0.1 to 10%

Vaginal 0.05-0.1%

Anal 0.065-0.5%

Oral 0.005-0.01%

Injecting drugs use 0.67%

Needle stick exposure 0.3%

Mucous membrane splash to eye, oro-nasal

0.09%

Source: NACO PEP Guidelines

Human Immunodeficiency virus• HIV is a RNA virus.

• HIV-1 is more common worldwide

• HIV-2 is restricted to West Africa.

• The virus has an enzyme reverse transcriptase which transcribes the RNA genome to double stranded DNA and is incorporated into host cell.

• The target for HIV is the CD-4+ Helper T-Cells, which are the backbone of the immune system.

Structure of HIV

HIV Lifecycle

Virus enters the immune cells (CD4 cells)↓

Gets integrated to the cells nucleus↓

Replicates inside the cells↓

Ultimately destroys the immune cells↓

Immunodeficiency↓

Multiple infections

How HIV affects our body

Acute seroconversion (2-3 wks)↓

Asymptomatic HIV (8-10 yrs)↓

Symptomatic HIV↓

Acquired immuno deficiency syndrome (AIDS) – Severe immunosuppression associated with

opportunistic infection.

Is HIV & AIDS the same thing?

HIV RNA Copies/ml

†

Typical Course of Untreated HIV Infection

1 3 about 6mths // 5yrs 10 yrs

Acute HIV

Opportunisticinfections

Asymptomatic

Minor HIV-relatedsymptoms

800

200

10^6

10^2

Virologic set-point Varies from patient

to patient

HIV antibodiesAcute HIV

Asymptomatic

800

200

HIV antibodies

CD4 countcells/µl

Time Source: NACO

Approach to OIs: Fever andRespiratory Infections 16

Source: NACO

Opportunistic Infections Among Reported AIDS Cases in India

• Persistent fever• Persistent loose stool• Weight loss

• High Risk - Female sex workers MSM(men having sex with

men) Intravenous drug abuse Sexually transmitted disease Migrant population H/o blood transfusion

When should you suspect HIV?

in a high risk population

Diagnosis of HIV

• HIV antibody test – using different antigen &/ or with different principle of the test

• Viral antigen test - used for screening blood donors in USA

• Detection of viral nucleic acid in blood.

• Determining the CD4 counts to assess the disease progression.

• ICTC centre (Integrated Counseling & Testing Centre)

– District Hospitals

– Medical colleges

• Free HIV testing

• Confidential counseling

• Referral to nearest ART (Anti Retroviral Therapy) centre ,DOTS,PPTCT, STD.

Where should you get yourself tested?

• NO, HIV is treatable but not curable.

• Anti retroviral (ARV) drugs suppress the virus and improve immune status.

However, the patient remains HIV positive for life and can transmit the disease to others.

Is HIV curable?

What is ART ?

• Anti-retroviral therapy (ART) is a combination of at least three drugs from different groups.

• It works to control HIV replication in the body and prevent the destruction of CD4 Cells. Hence it delays disease progression, prevents OIs, reduces hospitalization, reduces transmission of HIV.

• ART increases survival & quality of life.

• It is a life long therapy, requires high adherence, similar to treatment taken for high BP and diabetes.

• They have certain side-effects should be prescribed by specialized physicians .

Early diagnosis

• Early treatment of opportunistic infection

• Improved survival

• Better quality of life

• Start of ARV at the appropriate time

• Decreased chance of transmission of HIV to others.

Why should I get tested/treated if there is no cure?

TREATMENT

• All HIV +ve patients do not require T/t immediately.

• T/t is started depending on the patients level of immunosuppression.

• Degree of immunosuppression depends on patients CD4 count.

• Even if they do not require T/t they need to be followed up regularly.

Where are ARV drugs available ?

• ART programme started on 1st April 2004 at 8 institutions

• Target under NACP-III: 300 Centres functioning

• Currently, 4.07 lakh PLHIV including 22,000 children alive and on treatment

• ART centers– Provides free ARV drugs – Free drugs for OI– Counseling

As on March 2011

National AIDS Control Programme 36

MAMC- Feb 2009

ANTIRETROVIRAL DRUGS

Fu

sio

n I

nh

ibit

or:

En

fuvi

rtid

e (T

-20)

NRTI NNRTI PI

Zidovudine (AZT)* Nevirapine(NVP)* Indinavir(IDV)*

Lamivudine (3TC)* Efavirenz(EFV)* Nelfinavir(NFV)*

Stavudine (d4T)* Delavirdine(DLV) Saquinavir(SQV)*

Didanosine (ddl)*INTEGRASE INHIBITORS Ritonavir(RTV)*

Zalcitabine(ddC)* Raltegravir Amprenavir(APV)

Abacavir(ABC)* CCR5 antagonists Lopinavir(LPV)*

Tenofovir(TFV)* Maraviroc Atazanavir(ATV)*

Emtricitabine(FTC)   Foseamprenavir

* Available in India , available under national programme

Cost of Therapy reduced from Rs.30,000 in 1998 to Rs1000 per month in 2006, no. of pills from 32 to 1 or 2 per day,

• Avoid multiple partners – use CONDOMS • Use sterile needles each time for injection• Never share needles• Avoid unnecessary blood transfusions• Never buy blood from professional donors. • Donate blood• All pregnant women should be tested for HIV

PREVENTION

Prevention

• Use standard work precautions – hand hygiene, personal protective gear.

• Proper disposal of biomedical waste.• Immunization against HBV• Education

Potentially Infectious Body FluidExposure to body fluid

considered “at risk”Exposure to body fluid

considered “not at risk”

Blood Tear

Semen Sweat

Vaginal Secretion Urine / Faeces

CSF Saliva

Synovial, Pleural, Pericardial, Peritoneal fluid Sputum

Amniotic fluid Vomitus

Any body fluid contaminated with “visible blood” shall be considered “at risk”

PEP

Occupational Exposure

HCW comes in contact with potentially infectious body fluids due to –

• A percutaneous injury ( needle stick, cut with sharp object)

• Contact with mucous membrane• Contact with non intact skin (abraded,

chapped, dermatitis )

PEP

Relative Risk of Seroconversion with Percutaneous Injury

HIV HCV HBsAg+ HBeAg- HBsAg+ HBeAg+0

10

20

30

40

50

0.3% 2%

30%

50%

Sero

conv

ersi

on %

AZT + 3TC

Source: CDC. MMWR 2001; 50 (RR11): 1-42

PEP

Management of Exposure site

• Do not panic

• Skin

– Wash wound & surrounding with soap/water

– Rinse well

– Do not scrub

– Do not use Antiseptic or Skin washes

PEP

Management of Exposure site

• Splash of Blood/OPIM

– Eye• Eye irrigation with water or Saline• If using contact lens leave them in place while

irrigating .Remove once eye is cleaned remove them & clean

– Mouth• Spit fluid immediately• Rinse mouth thoroughly with water / saline

repeatedly• Do not use soap or disinfectant

PEP

PEP Prescription

• Contact ART specialist

• Decision of starting PEP based on Exposure type & HIV status of source

• Decide PEP regimens

– Basic regimen 2 drug combination

– Expanded regimen 3 drug combination

• If source person is on ART drugs expert should be consulted after starting 2 drugs

PEP

• In India recommended for occupational exposure

• It should be started as early as possible (within 72 hours)

• ARV is given for 4 weeks

• HIV testing should be done at baseline, 6wks, 3mths & 6mths

Post Exposure Prophylaxis

What is the risk for environmental transmission of HIV?

– No environmental transmission reported

– HIV inactivated quickly outside the body

– HIV does not multiply outside the body

– Infectivity is lost quickly after fluid dries

PEP

• HIV is not transmitted by mosquito bites or bites of other insects.

• Not transmitted through casual every day contact.

• Not transmitted from contact with non-bloody sweat, tears or urine.

• HIV can affect people around you e.g. children, housewives etc.

MYTHS

• HIV epidemic is spreading from high risk to low risk population.

• Most important factor for spread is LACK OF KNOWLEDGE.

• It is associated with social stigma and misconceptions.

• HIV is no longer synonymous with death.

• HIV is a preventable disease, so TAKE PRECAUTIONS.

Take home message

Universal Precautions Prevention is the key step!

Always use protective gear Consider all blood samples infectious

Follow universal precaution Safe Handling of Sharps Use needle destroyer

PEP

Where are ARV drugs available?

• At ART centers established by NACO.• 300 ART centers all over India, in U.P.• ART center, IMS, BHU – established in 2005.• 11000 registered HIV +ve patients.• ART centers

– Provides free ARV drugs – Free drugs for OI– Counseling

ART Scale up in India

Apr-0

4

Oct-04

Mar-0

5

Aug-0

5

Sep-0

5

Oct-05

Nov-0

5

Mar-0

6

Aug-0

6

Sep-0

6

Mar-0

7

Aug-0

7

Sep-0

7

Mar-0

8

Apr-0

8

May-0

8

Jun-

08

Jul-0

8

Aug-0

8

Sep-0

8

Oct-08

Nov-0

8

Dec-0

80

50

100

150

200

250

0

50000

100000

150000

200000

250000

ART Scale up 2004- 2009

ART Centres

No of Patients on ART

Months

No

of

AR

T C

entr

es

Pat

ien

ts o

n A

RT

THE NATIONAL HIV TESTING POLICY

• No mandatory HIV testing should be imposed as a precondition for– Employment – Providing health care services and facilities.

• Any HIV testing must be accompanied by a pretest and post test counseling services (through ICTC)

• Testing without consent – hindrance to the control of the epidemic

Clinical Pharmacology of ARV Drugs 42

Classes of ARV DrugsNRTI NNRTI PI Fusion

Inhibitor

Azidothymidine (AZT), Zidovudine

Nevirapine (NVP)

Indinavir (IDV) Enfuviritide (T-20)

Lamivudine (3TC)

Efavirenz (EFV)

Nelfinavir (NFV)

Stavudine (d4T) Delavirdine (DLV)

Saquinavir (SQV) Integrase Inhibitors

Didanosine (ddI) Ritonavir (RTV) Raltegravir

Zalcitabine (ddC) Amprenavir (APV)

Abacavir (ABC) Fosamprenavir CCR5 antagonists

Emtricitabine (FTC)

Lopinavir (LPV) Maraviroc

NtRTI:Tenofovir (TFV)

Atazanavir (ATZ) * The highlighted drugs are NOW available in the NACO ART program: AZT, 3TC, d4T, NVP and EFV

MAMC- Feb 2009

Some facts about ART

ART has changed the outlook of HIV/AIDS from a ‘virtual death sentence’ to a ‘chronic manageable disease’.

1996 was watershed year for ART when PIs were introduced and the era of HAART came in.

The problems were high costs, large number of pills and side effects of these drugs.

Cost of Therapy reduced from Rs.30,000 in 1998 to Rs1200 per month in 2004 and Rs.550/- per month in 2005..

Over 20 drugs available world wide, 14 in India. When ‘3 by 5’ initiative was launched, over 6 million people in developing

countries were in need of ART, only 2,70,000 were getting it, and half of these were in one country (Brazil).

Testing strategies• Surveillance – ELISA by two different antigen preparations

• Transfusion safety – Single ELISA.

• Voluntary – 3 different ELISA/Rapid/Simple (E/R/S) by three different antigens.

• Research – According to the specific objectives and decided by the researcher

Testing strategies

• Unlinked and anonymous – Surveillance• Voluntary and confidential Asymptomatic

AIDS cases Research• Mandatory – Transfusion safety

Regimen under National Programme-2006

Zidovudine / Lamivudine / NevirapineOr

Stavudine / Lamivudine / Nevirapine

* Efavirenz in place of Nevarapine if coinfected with TB or side effects with NVP, Tenofovir under consideration for special situations only* The Zidovudine & Stavudine based combinations are procured in 50:50 proportion.* NVP & Efv are procured in 80:20

Global summary of the AIDS epidemic

Number of people living with HIV in 2007• Total 33.2 million [30.6–36.1 million]• Adults 30.8 million [28.2–33.6 million]• Children under 15 years 2.5 million [2.2–2.6 million]People newly infected with HIV in 2007• Total 2.5 million [1.8–4.1 million]• Adults 2.1 million [1.4–3.6 million]• Children under 15 years 420 000 [350 000–540 000]AIDS deaths in 2007 Total 2.1 million [1.9–2.4 million]• Adults 1.7 million [1.6–2.1 million]• Children under 15 years 330 000 [310 000–380 000]