1 natural course of hiv infection haivn harvard medical school aids initiative in vietnam
TRANSCRIPT
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By the end of this session, participants will be able to:
Explain the process that HIV infect the human cell
Describe the natural progression of HIV infection
Explain the factors that influence the progression of HIV infection
Identify the clinical stage according to the World Health Organization (WHO)
Learning Objectives
HIV Life Cycle & Mechanism of ARV
ReverseTranscriptaseInhibitors(14)
ProteaseInhibitors(10)
Fusion/Entry
Inhibitors (2)
IntegrationInhibitors(1)
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HIV test identifies antibodies to the HIV virus in the blood
HIV test become positive after HIV infection 1-3 months
Results of two additional HIV tests should be confirmed positive before diagnosis of HIV infection
Xét nghiệm HIV
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Antibody testsRapid ELISA / Rapid EIA (“Rapid test”): • Results in 10 minutes to 2 hours • Positive results must be confirmed with
additional testingWestern Blot (WB)• Used as a confirmatory test
Dry Blood Spot(DBS):• Used for early HIV diagnosis for infants by
PCR at 4-6 weeks of age
Các phương pháp xét nghiệm HIV
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Two common tests used to assess and monitor HIV patients are:
CD4 count
Total lymphocyte count (TLC)
Testing in HIV patient
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Plasma HIV RNA levels indicate:• the magnitude of HIV replication and • the rate of destruction of CD4+ cells
CD4 and T cell counts indicate the extent of HIV-induced immune damage already suffered
CD4 Count and Viral Load Testing
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Natural Progression of HIV Disease
0
100
200
300
400
500
600
700
800
900
1000
0 1 2 3 4 5 1 2 3 4 5 6 7 8 9 10 11
CD
4+
ce
ll C
ou
nt
AsymptomaticAsymptomatic
HZVHZV
OHLOHL
OCOCPPEPPE
PCPPCP
CMV, MACCMV, MACTBTB
TBTB
Months Years After HIV Infection
Acute HIVAcute HIVinfectioninfectionsyndromesyndrome
Relative level of Plasma HIV-RNA
CD4+ T cells
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CD4
5yrs 10yrs 15yrs
500
200
Long term non-progression
Rapid progressionDeath
Death
OI OI
Typical Progression
Variable Progression of HIV infection
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HIV progresses through various stages which include:
1. Primary HIV Infection
2. Latent Period
3. AIDS (advanced HIV Infection)
Diễn biến tự nhiên của nhiễm HIV
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Occurs 2-4 weeks after acquiring HIV infection
Symptoms last 1-2 weeks In the US and Europe, 53-93% of
patients have symptoms In Vietnam and development
country, there’s no data about incidence
Primary HIV Infection (1)Incidence
Symptoms Rate
Fever 95%
Muscle/ joint pain 80%
Lymphadenopathy 75%
Pharyngitis 75%
Rash 70%
Nausea/vomiting/diarrhea 30-60%
Headache 33%
Primary HIV Infection:Clinical Manifestations
The Sanford Guide to HIV/AIDS Therapy 2005
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A generalized rash is a common finding:• 5-10 mm macular or papular
erythematous lesions • appears 48-72 hours after fever starts• lasts for 5 – 8 days• most often involves the face and trunk• typically not pruritic• can be accompanied by oral, esophagus,
anus and genital ulcerations
Primary HIV InfectionRash(1)
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Characterized by gradual decline in CD4 count
Patients may be healthy for 5-10 years before symptoms develop
Symptoms can develop when CD4 < 500 cells/mm3
OIs develop when CD4 < 200 cells/mm3
Latent Period: Asymptomatic HIV Disease
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Generally occurs when CD4 < 500 Conditions that may be seen when
CD4 count is 200 – 500 include:• Generalized lymphadenopathy• Prolonged fevers or diarrhea for > 1
month• Oral candidiasis• Pulmonary tuberculosis• Herpes zoster (Zona)• Vaginal candidiasis
Latent Period: Symptomatic HIV Infection
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AIDS (Advanced HIV Infection)
Criteria for DiagnosisAdvanced HIV Infection
Any condition under clinical stage 3 or 4 (presumptive or definitive diagnosis)
and/or
CD4 cell count < 350 cells/mm3
AIDS Any condition under clinical stage 4 (presumptive or definitive diagnosis)
orCD4 cell count < 200 cells/mm3
Final stage in the natural progression of HIV Infection
Guidelines for the Diagnosis and Treatment of HIV/AIDS. Ministry of Health, 2009.
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Manifestations of HIV Infection Vary Greatly
Some patients with CD4 > 200 can be ill with many symptoms
Some patients with low CD4 < 100 can feel healthy with no symptoms at all
All patients have decreased immune function and are at risk for OIs when:• WHO Clinical Stage
3 or 4, • CD4 < 200 • TLC < 1200
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What Factors Affect the Rate of Disease Progression?
Speeds disease progression:• Age• Symptoms during
primary HIV• Nutritional status• Opportunistic
infections (eg: TB)• High viral load• Intravenous drug
use?
Slows disease progression: • OI Prophylaxis with
cotrimoxazole• Antiretroviral
Therapy
Antiviral Therapy (ART) and HIV Progression
No ARV1 ARV
2 ARV
3 ARV
% O
f p
atie
nts
did
no
t sh
ow
AID
S
or
dea
th
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WHO Clinical Stage can be used to: Estimate degree of damage done to
a patient’s immune system Follow progression of HIV disease Determine when to start:• prophylactic treatment with cotrimoxazole
• antiretroviral therapy (ART)(with or without CD4 count)
Giai đoạn lâm sàng theo TCTYTG
WHO Clinical Stage should be evaluated at every clinic visit
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Most typical/common syndromes:• Asymptomatic• Persistent generalized
lymphadenophathy
Performance Scale 1: No symtom, Normal activity
Stage 1: Asymptomatic
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Most typical/common syndromes:• Moderate unexplained weight loss (<
10% of body weight)• Recurrent respiratory infections• Zona (Herpes zoster)• Papular pruritic eruption (PPE)
Performance Scale 2: symptomatic but normal activity
Stage 2: Mildly Symptomatic
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Most typical/common syndromes:• severe weight loss (> 10% of body
weight)• chronic diarrhea for > 1 month• Recurrent oral candidiasis• Pulmonary tuberculosis
Performance Scale 3: symptomatic, in bed < 50% of the time
Stage 3: Progressively Symptomatic
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Most typical/common syndromes:• Wasting syndrome due to HIV
weight loss> 10% chronic diarrhea unexplained> 1 month prolonged fever unexplained > 1 month
• OIs Performance Scale 4 : bedridden>
50% of the time
Stage 4: Severely Symptomatic
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Primary HIV Infection phase have very high risk of infection although the test result is usually negative
On average, it takes 5-10 years from time of initial HIV infection to become ill or have symptoms
AIDS is defined as CD4 <200 or stage 4 according to WHO Clinical Stages
CD4 is the best tests to evaluate immune system status
Key Points