1.HUMAN IMMUNODEFICIENCY VIRUS SUBMITTED BY- GROUP D1 MEDICAL WARD25.4.2006

2.

First described in 1981

Reported as lymphadenopathy associated virus (LAV) in paris 1983 at Pasteur Institute by Lue Montagrier and associates

In U.S. , called human T lymphotropic virus type III (HTLV III) by Robert Gallo and colleagues at National Institute of Health

Assigned a uniform name, the Human Immunodeficiency virus (HIV) by the International Committee on the Taxonomy of virus in 1986

3.

Family retrovirus

RNA virus

HIV 1 has widest distribution , world wide

HIV 2 found mostly in western Africa

HIV 2 less aggressive than HIV 1

Second leading cause of disease burden world-wide

Leading cause of death in Africa( >20% of deaths

4.

In 2000, WHO estimated that over 36 million people living with HIV/AIDS, 5.3 million new infection and 3 million deaths

Rising alarmingly in heavily populated parts of the world including some Eastern European countries ( Ukraine , Russia) and South East Asian countries (Thailand , Myanmar)

5. Mode of transmission 6. Major mode of spreads

Sexual (vaginal , anal ,oral)

parenteral (blood and blood product recipients, injection drugs users and those experiencing occupational injury)

Vertical transmission

Major route of transmission (>70%) world-wide is hetrosexual

7. Transmission risk after exposure

>90 % for blood and blood products

15-40 % for vertical transmission

0.5-1 % for injection drug users

0.2-0.5 % for genital mucous membrane

half of patient )

(1) Pneumocystic carinii pneumonia most common AIDS defining illness , rarely occur when CD4 counts more than 200cells/ mm3

(2)Mycobacterium tuberculosis reactivating latent infection or acquired from open contact develop progressive primary disease , disseminated , miliary or extra pulmonary tuberculosis

23. Cardiac

(3)Bacterial infection -S pneumoniae , H influenzae ,Staph aureus , pseudomonas and norcardia infection

Myocarditis , cardiomyopathy (25 40 % of the patients ), pericardial effusion , congestive cardiac failure

24. Renal Endocrine

HIV associated nephropathy is the most important renal condition usually present with nephrotic syndrome, chronic renal disease or combination of both.

Reduced level of testosterone , abnormal adrenal function (hypoadrenalism in 25% of patients )

25. Mucocutaneous

Seborrhoeic dermatitis (80%)

Herpes infection (20%)

Molluscum contagiosum ( 10%)

Fungal infection ( candidiasis )

Drug allergy Stephen Johnsons syndrome

Recurrent apthous ulceration

26. Haematology

Disorders of all 3 major cell lines may occur in HIV

Most frequent in late-stage disease

Anaemia 70 %

Leucopenia 50 %

Thrombocytopenia 40 %

27. Neoplasms

Kaposi sarcoma and Non-Hodgkins lymphoma are most common opportunistic malignancies associated with HIV and are considered AIDS defining diagnosis

Primary CNS lymphoma-usually complicate late stage HIV

Genital cancer-anogenital (vulval, vaginal, anal, penile) and cervical cancer closely associated with HPV is more frequently observed in HIV

28.

HIV associated lymphoma (non-Hodgkins lymphoma it is late manifestation of HIV )

29. Opportunistic infection

Protozoa toxoplasmosis , cryptosporidiosis , microsporidiosis,

Virus CMV , Herpes , EBV , HPV , Papova virus ,

Fungus PCP , Cryptococcus , Candida , Dermatophytes , Aspergillus , Histoplasma

Bacteria Mycobacteria ,Staphylococci , Non-typhoidal salmonellosis ,

Others Disseminated strongyloidiasis , Giadiasis, Crustes ( Norwegian )scabes

30. Common AIDS defining condition

Oesophageal candidiasis

Cryptococcal meningitis

Chronic cryptosporidial diarrhoea

CMV retinitis

Chronic mucocutaneous herpes simplex

Disseminated Mycobacterium avium intracellulare

Miliary or extrapulmonary tuberculosis

PCP

Progressive multifocal leuco-encephalopathy

31.

Recurrent non-typhi salmonella septicaemia

Cerebral toxoplasmosis

Karposis sarcoma

Non-Hodgkins lymphoma

Primary cerebral lymphoma

HIV associated wasting

HIV associated dementia

32. CLINICAL COURSE 33. Primary infection

Mild in most patients and only identify by retrospective enquiry

Symptoms appear 2 to 4 wks after exposure ( seroconversion illness)

Manifest as fever , erythematous or maculopapular rash over the body , fatigue , pharyngitis , cervical lymphadenopathy , myalgia , arthralgia , retro-orbital headache, mucosal ulceration

34.

Rarely present with aseptic meningitis, encephalitis, myelitis , polyneuritis

Coincides with surge in plasma HIV RNA level and fall in CED4 count .

Recover after 1- 2 wks associated with fall in viral load and rise in CD4 count but not to its previous value .

HIV antibody appear at 3 12 wks

35. Asymptomatic infection (CD4> 500/cumm)

Variable period in which infected individual remains well with no evidence of disease

May present with persistent generalized lymphadenopathy ( PGL)( enlarged lymph nodes at two or more extra inguinal sites persists for 3 months without any other causes of generalized lymphadenopathy )

Sustained viraemia with decline in CD 4 counts

36. Mildly symptomatic disease ( ARC)( CD4 200-500/cumm)

Impaired cellular immunity median interval from infection is 7-10 yrs

Chronic weight loss, fever , diarrhoea , oral or vaginal candidiasis , oral hairy leucoplakia, recurrent herpes zoster infection , severe pelvic inflammatory disease , bacillary angiomatosis , ITP and cervical dysplasia

37. Acquired immune deficiency syndrome

Development of

- 1) specified opportunistic infection ,

- 2) tumors ,

- 3) wasting and

- 4) dementia

Disease correlate with level of CD 4 count

38.

CD 4 < 200 PCP pneumonia , mucocutaneous herpes simplex , cryptosporidiosis , microsporidiasis, oesophageal candidiasis, miliary or extra pulmonary TB , wasting and peripheral neuropathy

CD 4 < 100 Cerebral toxoplasmosis , cryptococcal meningitis , primary CNS lymphoma , non Hodgkins lymphoma , dementia and progressive multifocal leucoencephalopathy

CD 4 < 50 Cytomegalovirus retinitis , gastrointestinal disease , disseminated mycobacterium avian intracellulare

39. Major signs

weight loss >10 %

Diarrhoea > 1 month

Fever > 1 month

CRITERIA USED IN MYANMAR 40. Minor signs

Persistent cough > 1 month ( not due to tuberculosis )

Candidiasis ( oropharyngeal )

Herpes zoster ( recurrent )

Herpes simplex ( chronic progressive and disseminated)

Generalized pruritic dermatitis

Generalized lymphadenopathy

41. INVESTIGATION 42. laboratory confirmation

Serology test using ELISA antibody testing { false positive are rare but it is important that any (+)ve results are confirmed by using other immunoassays ,e.g. immunoblot }

Seroconversion ( HIV antibody negative ) and vertical transmission ( HIV antibody positive ) , ELISA test is unhelpful and HIV RNA must be measured by using PCR ( reverse transcriptase ) , b DNA , NASBA technique

Ag detection for P24 Ag

43. Pre and post test counselling

Prior to HIV antibody testing , the patient must see a counsellor

Pretest counselling involve assessment of the risk of exposure and explore a persons knowledge about HIV infection

Post-test counselling ( return +ve)- to provide emotional support , organised continuous contact and medical follow up , safer sex and needle exchange

44. Baseline investigations

all patients

-CD4 count-viral load

-HBV surface antigen-HCV antibody

-HBV core antibody-HAV IgG antibody

-Toxoplasma antibody

-CMV IgG antibody

-Treponema serology

-Chest radiograph

45.

CD 4350 200-350