HIV-AIDS

MBBS, 3rd year

Kishor Adhikari, Asst. Prof., Com. Med

National Medical College , Birgunj 1
 Introduction

HIV wasfirst Identified in 1981 in USA among

homosexuals

In1983, French investigator named

Lymphadenopathy associated virus (LAV).

 In 1984 virus was isolated by Gallo and co-

workers from national institute of health in United
States.
They named Human T-cell Lymphotropic virus III
(HTLV-III).

2
 Contd.
Thailand was the first country in the SEAR to
report a case of AIDS, in 1984.
In 1986, a new strain of HIV was isolated in West
African patient with AIDS which is called HIV-2.

In May 1986, international committee on

taxonomy gave a new name called Human
immune deficiency virus.

Since its identification, HIV/AIDS is devastating

disease of mankind
3
 Etiology

Human Immuno Deficiency Virus

Size: 1/10,000th of a millimeter in diameter.
It is a protein capsule containing two short
strands of genetic material (RNA) and enzymes.
Two types: HIV-1 and HIV-2

4
 Reservoir of infection

Cases and carriers.

Once a person is infected, virus remains life-long
It can be transmitted even if the person is
symptoms less.

5
 Source of infection
Virus has been found in greatest
concentration in blood, semen and CSF.
Lower concentration have been detected in
tears, saliva, breast milk, urine, and
cervical and vaginal secretion.
To date, only blood and semen have been
conclusively shown to transmit the virus.

6
Pathogenesis of HIV infection
HIV Virus

CD4 cells

Uncoating and
reverse transcription

Proviral DNA

Budding of virus particles

and cytopathic phase

7
 Host factors:
1. Age: Most cases have occurred among
sexually active persons aged 20-49
2. Sex: In Africa: More female are affected
In North America, Europe and
Australia, about 51 per cent of cases are
homosexual or bisexual men.
In Nepal: 2:1

8
Risk Groups for HIV infection
Sex workers
IDUs
Clients of sex workers
Labor migrant / Transport workers
MSM
Partners of migrants / house wives
Street children
Military, police
Health care workers 9
PHASES OF HIV INFECTION

1. Phase 1 (3-12 weeks)

 Acute HIV syndrome
 Sore throat
 Fever
 Skin rash
 Meningitis
 High viremia

10
 Contd.
2. Middle chronic Phase(10-12 years)
 Competition between HIV and host
immune system
 Patient asymptomatic or has mild
symptoms
 Moderate viremia

11
3. Phase 3
Fullblown AIDS
Severe immuno- suppression
Drop in CD4 count below 200/µl
(normal count: > 950 CD4 cells/µl }
High viremia

12
AIDS-signs
1. Major
Weight loss >10% body weight
 Chronic diarrhea >1 months duration
 Prolonged fever >1 month
2. Minor
Recurrent oral-pharyngeal candidiasis
 Persistent generalized lymphadenopathy
 Persistent cough>1 month
 Recurrent herpes zoster

Diagnosis is made on the basis of presence of at

least two major and one minor sign

13
Mode of Transmission:

14
 HIV is transmitted:
During sexual contact
• Unprotected sex
Anal (10 times higher risk)
Vaginal
Oral
• transmission from male to female is more
(twice) as compared to female to male.
• STDs facilitate for transmission of HIV.

15
 HIV is transmitted:
Through infected blood

• Sharing
needles

• Use of
contaminated needles
and syringes
16
 HIV is transmitted:

Though infected blood / blood

products

• Transfusion of
HIV infected blood
or
blood products

17
 HIV is transmitted:
From mother to child

• During pregnancy
• During child birth
• Through breast
feeding

18
Lab diagnosis
Direct tests
ELISA (enzyme-linked-immunosorbent
serologic assay)
Recombinant DNA techniques
Viral isolation in culture
PCR
Indirect Tests
CD4 counts
Lymphopenia
Lymphnode biopsy

19
 Incubation period:
Current data suggest that the incubation
periods is uncertain, (from a few months to
10 years or even more)

20
Severity of the epidemics determined by:

1. % of adult men visiting sex workers

(5% in Hong Kong, 9% in China, 20% in
Thailand and Cambodia)

2. Number of sex workers’ clients per night

3. % of sex workers using condoms consistently

4. % of injecting drug users who are clients of sex

workers

21
 prevention
Raising awareness
- To be faithful to partner
- Use of Condom
- IDUs should be informed not to share
needle and syringes.
- Distribution of IEC materials.
- Advertisement from different media
or channels.

22
 Contd.
Prevention of blood borne HIV Transmission
People in high-risk groups should be urged to
refrain from donation of blood, body organs,
sperm or other tissues.
The donors blood should be screened for HIV 1
and HIV 2 before transfusion.
Strict sterilization techniques should be applied to
the hospitals and clinics.
Avoid injections unless they are absolutely
necessary.
Rehabilitation of HIV/AIDS cases,
23
HIV/AIDS – Global
and Regional scenario

24
34 million people living with HIV.
26 million are eligible for antiretroviral
therapy, under WHO 2013 consolidated
ARV guidelines.
At the end of 2012, about 10 million
people had access to ARV therapy.
HIV claimed more than 25 million lives over
the past three decades.
Sub-Saharan Africa is the most affected
region, with nearly 1 in every 20 adults
living with HIV.
69% per cent of all people living with HIV
are living in this region.
WHO
 HIV situation in Nepal
In Nepal, first case of HIV/AIDS was diagnosed
in 1988.

The prevalence of HIV/AIDS is 0.3/1000 among

general population NCASC 2012).
Nepal succeed in decreasing new HIV infections
by more than 25% in last one decade: UNAIDS
report on the global AIDS epidemic.

27
HIV cases in Nepal
 Nepal 2011 HIV Infections Estimates
Estimated HIV
Proportion
Population Groups Infections (15-49
(%)
years)
People who Inject Drugs (PWIDs) 939 2.2
MSW, TG and Clients 3,099 7.2
Other MSM who do not sell and/or
6,245 14.4
buy sex
Female Sex Workers (FSWs) 647 1.5
Clients of FSWs 1,915 4.4
Male Labour Migrants 11,672 27.0
Remaining Male Population 6,914 16.0
Remaining Female Population 11,808 27.3
Total 43,239 100.0
Estimated Number of HIV Infections and HIV
Prevalence among Adults : 1985-2015
70,000 1
Estimated HIV Infections
0.9
60,000 Estimated HIV prevalence
50288
0.8
50,000 0.7
0.6
40,000
0.5 %
30,000
0.4

20,000 0.3
0.2
10,000
0.1
0 0
 Routes of Transmission among
Reported
HIV cases, 2011
N = 2,060
7.7%

87.9% Mother to child

100% 0.2%
80%
4.2% Blood and blood products
60%
40%
Sharing unsafe needles
20%
0%
Sexual transmision
Why is Nepal vulnerable?
(Determinants of HIV/AIDS in Nepal)
Poverty
Low education
Gender inequalities
Stigma and Discrimination
Lack of adequate health care delivery
Insurgency and insecurity
Migration ( Push and Pull factors)
Alcoholism and drug abuse
Women trafficking/child abuse
Social traditions
35
Plan and policy implementation
1988 Launched the first National AIDS
Prevention and Control Program
(short term)
1990-1992 First Medium Term Plan
1993-1997 Second Medium Term Plan
1993 National Policy on Blood safety
1995 Adopted National Policy on HIV/AIDS
1997–2001 Strategic Plan for HIV/AIDS Prevention
2002–2006 National HIV/AIDS Strategic Plan
2003-2007 National HIV/AIDS Operational Plan
2006 National HIV/AIDS Strategic Plan (2006-
11) 36
 Vision and Goal of National policy on
HIV and STI 2010
Vision: To establish Nepal free of HIV, AIDS and
STIs society

Goal: To ensure the people’s rights to health by

reducing impact of HIV among people by reducing
HIV incidence
 Key Policy Points
 Policy making and • Bi- and multi-lateral

planning approach

 Prevention, treatment, care • Structural arrangement

and support • Research

 Harm reduction • Community based

 Rights and confidentiality programme

 Rehabilitation • Financial management

and social
integration • Monitoring and
evaluation
 Key Challenges

◦ HIV and AIDS " is still seen as 'health' issue not a

social issue.
◦ Multi-sectoral partnership needs to be further
strengthened
◦ Prevailing Stigma and Discrimination (SWs, MSM,
IDUs)
◦ 'Not my problem!' Attitude among high level
decision makers or programmers.

39
Contd.
◦ Gap in knowledge and behaviour change.
◦ Legal implications on IDUs.
◦ Access to STI, HIV and AIDS and OIs-sevices.
◦ Scaling up of program including ART, PMTCT.
◦ Community and home based care and support for
infected and affected needs to be addressed.

40
 Antiretroviral Treatment
1.Nucleoside analogue
 Introduced in 1987
Zidovudine (AZT), didanosine ‘ddl’(Videx),
zalcitabine ‘ddc’(Hivid), stavudine etc.
These are not effective if used alone.
These drugs slow HIV growth.
Also prevents transmission of HIV from an infected
mother to her newborn.
2. protease inhibitors

More powerful than previous, producing

dramatic decreases in HIV levels in the
blood.
This reduced viral load, in turn, enables
CD4 cell levels to skyrocket.
Ritonavir (Norvir), indinavir (Crixivan),
nelfinavir (Viracept), amprenavir
(Agenerase), etc.
 Contd.
3. Non-nucleoside reverse transcriptase
inhibitors (NNRTIs):
Introduced in 1996
Three NNRTIs are available: nevirapine
(Viramune), delavirdine (Rescriptor), and
efavirenz (Sustiva).
These drugs bind directly to reverse
transcriptase, preventing the enzyme from
converting RNA to DNA.
NNRTIs work best when used in combination
with nucleoside analogues.
Atripla
A new combined drug, introduced in July
2006.
Combination of Sustiva (the NNRTI
efavirenz) and Truvada (the NRTIs
emtricitabine and tenofovir) in a special
formulation.
Post exposure prophylactics treatment

PEP should be started within hours.

Its for accidental niddle exposure to HIV
among health care workers.
It decrease the chances of being infected
by nearly 80%.
47