Human Immune Deficiency Virus Infection

Huda Taha ST5 Oct. 2011

EpidemiologyEpidemiology VirologyVirology Natural HistoryNatural History TransmissionTransmission Seroconversion SyndromeSeroconversion Syndrome DiagnosisDiagnosis TreatmentTreatment HIV in PregnancyHIV in Pregnancy

EpidemiologyEpidemiology

The HIV pandemic continues to evolveThe HIV pandemic continues to evolve Global Prevalence of HIV stabilise at 0.8%Global Prevalence of HIV stabilise at 0.8% 25 million died of HIV25 million died of HIV 33 million living with HIV / AIDS33 million living with HIV / AIDS Every day : 4,900 die of HIV/AIDSEvery day : 4,900 die of HIV/AIDS

7,100 new HIV infection7,100 new HIV infection

3,200 on HAART3,200 on HAART 2009 : 2.6 million new infection2009 : 2.6 million new infection

2 million died of HIV/ AIDS (1.7 million <15 Year2 million died of HIV/ AIDS (1.7 million <15 Year

old)old) 4 million receive HAART in Africa( 50,000 in 2002)4 million receive HAART in Africa( 50,000 in 2002) 1 million pregnant women on HAART1 million pregnant women on HAART WHOWHO

WHOWHO

EpidemiologyEpidemiology

100,000 people were living with a whom a quarter are 100,000 people were living with a whom a quarter are unaware of their infection. unaware of their infection.

2010, there were 6,136 new diagnoses of HIV, 2010, there were 6,136 new diagnoses of HIV,

As of December 2010, there have been 6,791 diagnoses of As of December 2010, there have been 6,791 diagnoses of AIDS in the UK.AIDS in the UK.

19,912 people diagnosed with HIV have died.19,912 people diagnosed with HIV have died. 37 English PCT/ HIV prevalence >2:100037 English PCT/ HIV prevalence >2:1000 1:5 HIV+ >50 Year old1:5 HIV+ >50 Year old

DOHDOH

HIVHIV is a Lentivirus a member of the Retrovirus family that is a Lentivirus a member of the Retrovirus family that causes (AIDS). causes (AIDS).

HIV infects vital cells in the human immune system such as HIV infects vital cells in the human immune system such as helper T cells (specifically CD4helper T cells (specifically CD4++ T cells), macrophages and T cells), macrophages and dendritic cellsdendritic cells

TransmissionTransmission

SexualSexual IVDUIVDU MTCTMTCT OccupationalOccupational Blood transfusionBlood transfusion

HIV Natural HistoryHIV Natural History

Natural historyNatural history

HIV vs AIDSHIV vs AIDS Acquisition of Infection Acquisition of Infection Primary HIV infection Primary HIV infection Asymptomatic HIV infection Asymptomatic HIV infection Early symptomatic infection Early symptomatic infection Late symptomatic infection Late symptomatic infection Advance HIV disease Advance HIV disease

1200

1100

1000

900

800

700

600

500

400

300

200

100

0

1:512

1:256

1:128

1:64

1:32

1:16

1.8

1.4

1.2

0

Weeks Years0 3 6 9 1 2 3 4 5 6 7 8 9 10 1112

CD

4+T

Cel

ls/m

m3

Pla

sma

Vir

emia

Tit

re

Primaryinfection

Possible acute HIV syndrome. Wide dissemination of virusSeeding of lymphoid organs

Clinical latency

Death

Opportunisticdiseases

Constitutionalsymptoms(

)

()

Natural History of HIV Infection

Seroconversion illnessSeroconversion illness““acute retroviral syndrome”acute retroviral syndrome”

What is Seroconversion?What is Seroconversion? Why do we need to recognise it?Why do we need to recognise it? How does it present?How does it present? What to do if you suspect HIV infection?What to do if you suspect HIV infection? Appropriate testsAppropriate tests

Seroconversion syndromeSeroconversion syndrome

The period between initial exposure to and infection by The period between initial exposure to and infection by HIV and the development of an HIV-specific antibody HIV and the development of an HIV-specific antibody response.response.

Enormous viremia.Enormous viremia. Vigorous immune response.Vigorous immune response. Rapid decline in CD4 cell count Rapid decline in CD4 cell count

Why do we need to recognise Seroconversion illnessWhy do we need to recognise Seroconversion illness??

1 in 3 HIV + people in the UK remain undiagnosed.1 in 3 HIV + people in the UK remain undiagnosed.

80% will have symptoms of Seroconversion80% will have symptoms of Seroconversion

60-70% will seek help60-70% will seek help

Only 5% are diagnosedOnly 5% are diagnosed

Why do we need to recognise Seroconversion illness?Why do we need to recognise Seroconversion illness?

To protect others:To protect others: Higher risk of transmission in primary HIV infectionHigher risk of transmission in primary HIV infection Easier to contact trace earlyEasier to contact trace early

How Does Seroconversion Illness How Does Seroconversion Illness Present?Present?

Seroconversion syndromeSeroconversion syndrome

Spectrum of PresentationSpectrum of Presentation completely asymptomatic infection to severe illness completely asymptomatic infection to severe illness

requiring admission to the hospitalrequiring admission to the hospital Typically, within 5 to 30 days after exposure; Typically, within 5 to 30 days after exposure; median duration of symptoms is 14 days.median duration of symptoms is 14 days.

How Does Seroconversion Illness Present?How Does Seroconversion Illness Present?

Non-specific, self-limiting symptoms:Non-specific, self-limiting symptoms:

Fever (80-97%)Fever (80-97%) Lymphadenopathy (40-77%)Lymphadenopathy (40-77%) Rash (51-70%)Rash (51-70%) Pharyngitis (44-73%)Pharyngitis (44-73%) Myalgia/ arthralgia (49-70%)Myalgia/ arthralgia (49-70%) Headache/aseptic meningitis (30-70%)Headache/aseptic meningitis (30-70%) Also – mucosal ulcers, peripheral neuropathy, Bell’s Also – mucosal ulcers, peripheral neuropathy, Bell’s

Palsy, diarrhoea, nausea/vomitingPalsy, diarrhoea, nausea/vomiting

BloodsBloods

ThrombocytopeniaThrombocytopenia NeutropeniaNeutropenia Deranged LFTsDeranged LFTs

So, fever, lymphadenopathy, rash, So, fever, lymphadenopathy, rash, pharyngitispharyngitis – – THINK HIV!THINK HIV!

What would you do if you suspected What would you do if you suspected HIV?HIV?

Sexual history including IVDU/ travel history Sexual history including IVDU/ travel history Get consent for an HIV testGet consent for an HIV testFull sexual health screen (refer to GUM)Full sexual health screen (refer to GUM)

CONFIDENTIALITYCONFIDENTIALITY

HIV TestingHIV Testing

Antibody/antigen testingAntibody/antigen testing– EIA antibody test + p24 antigen testEIA antibody test + p24 antigen test– Antibody test may still be negative up to 3/12 post-Antibody test may still be negative up to 3/12 post-

exposure.exposure.– P24 antigen likely to be positive at 6 weeksP24 antigen likely to be positive at 6 weeks– If test positive or strong suspicion – refer to GUM for If test positive or strong suspicion – refer to GUM for

viral load testing.viral load testing.

What if the Test is Positive?What if the Test is Positive?

Refer to GUMRefer to GUM Patient will need to be seen by Health Advisors for support Patient will need to be seen by Health Advisors for support

and adviceand advice Follow up by the HIV team for CD4 count and viral load Follow up by the HIV team for CD4 count and viral load

monitoringmonitoring..

To conclude:To conclude:

Seroconversion illness is a non-specific multisystem Seroconversion illness is a non-specific multisystem disease.disease.

Suspect in patients with fever, rash, lymphadenopathy and Suspect in patients with fever, rash, lymphadenopathy and pharyngitis or other unusual symptoms.pharyngitis or other unusual symptoms.

Early diagnosis will benefit the patient and their contactsEarly diagnosis will benefit the patient and their contacts Always refer +ve/likely +ve patients to GUM.Always refer +ve/likely +ve patients to GUM.

HIV treatmentHIV treatment

CART/ ARV/ ART/ HAARTCART/ ARV/ ART/ HAART

NRTINRTI NNRTINNRTI PIPI CCR5 InhibitorCCR5 Inhibitor Integrase InhibitorsIntegrase Inhibitors Fusion InhibitorsFusion Inhibitors

When to initiate therapyWhen to initiate therapy

Primary HIV infectionPrimary HIV infection: clinical trial/ neurological involvement/ or CD4 <200 : clinical trial/ neurological involvement/ or CD4 <200 cells/mL / AIDS-defining illness.cells/mL / AIDS-defining illness.

Established HIV infection:Established HIV infection: CD4 <200 cells/mL TreatCD4 <200 cells/mL Treat CD4 201–350 cells/mL Treat as soon as possible when patient readyCD4 201–350 cells/mL Treat as soon as possible when patient ready CD4 351–500 cells/mL Treat in specific situations with higher risk of CD4 351–500 cells/mL Treat in specific situations with higher risk of

clinical events clinical events CD4 4500 cells/mL Consider enrolment into ‘when to start’ trialCD4 4500 cells/mL Consider enrolment into ‘when to start’ trial AIDS diagnosis Treat (except for tuberculosis)AIDS diagnosis Treat (except for tuberculosis)

Preferred regimens:Preferred regimens:

2NRTI2NRTI(Tenofovir + Emtricitabine (Tenofovir + Emtricitabine OROR Abacavir +Lamivudine) Abacavir +Lamivudine) PLUSPLUS

NNRTNNRTI ( Efavirenz)I ( Efavirenz)

Alternative: Alternative: 2 NRTI2 NRTI PLUSPLUS Protease InhibitorsProtease Inhibitors:: Lopinavir/Ritonavir Lopinavir/Ritonavir

HIV In PregnancyHIV In Pregnancy

The prevalence of HIV infection in women giving birth The prevalence of HIV infection in women giving birth reached 1 in 238 (0.42%) in London, 1 in 705 (0.14%) in reached 1 in 238 (0.42%) in London, 1 in 705 (0.14%) in the rest of England.the rest of England.

Surveillance of ( MTCT) HIV relies on confidential Surveillance of ( MTCT) HIV relies on confidential voluntary reports from paediatricians and obstetricsvoluntary reports from paediatricians and obstetrics

Surveillance of ( MTCT) HIV relies on confidential voluntary reports Surveillance of ( MTCT) HIV relies on confidential voluntary reports from paediatricians and obstetricians.from paediatricians and obstetricians.

By the end of December 2010, 1,943 children in the UK had been By the end of December 2010, 1,943 children in the UK had been diagnosed with HIV ( MTCT).diagnosed with HIV ( MTCT).

Of these, 994 were diagnosed after having being infected abroad. Of these, 994 were diagnosed after having being infected abroad.

The number of mother-to-child HIV infections almost doubled from The number of mother-to-child HIV infections almost doubled from 56 in 1995 to 107 in 2006.56 in 1995 to 107 in 2006.

However, due to the widespread use of ARV to prevent MTCT However, due to the widespread use of ARV to prevent MTCT these rates are still far lower than many other countries.these rates are still far lower than many other countries.

HIV in PregnancyHIV in Pregnancy

ANC Testing ANC Testing (100%) BHIVA guidelines(100%) BHIVA guidelines

Sexual Health of HIV + women.Sexual Health of HIV + women. Preconception and fertility managementPreconception and fertility management MDT & documentationMDT & documentation Psychosocial issuesPsychosocial issues AZT monotherapy AZT monotherapy vsvs CART CART Avoid Stavudine plus Didanosine as the NRTI backboneAvoid Stavudine plus Didanosine as the NRTI backbone

whenever possible (and monitor lactate if unavoidable).whenever possible (and monitor lactate if unavoidable). HIV testing in childrenHIV testing in children Breast feedingBreast feeding

SummerySummery HIV RNA virusHIV RNA virus Transmission/ Transmission/ risk factorsrisk factors Seroconversion illness/ could be asymptomaticSeroconversion illness/ could be asymptomatic HIV testing. SUPPORTHIV testing. SUPPORT CARTCART Pregnant women/ babyPregnant women/ baby

Thanks

Suggested site:

http://www.bhiva.org