Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest...

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Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor of Medicine,Division of Infectious Diseases University of Washington, Seattle

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Transcript of Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest...

Page 1: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

Spach/HIV/Acute HIV/PP

HIV: Acute (Primary) Infection

David H. Spach, MD

Medical Director, Northwest AIDS Education and Training CenterAssociate Professor of Medicine,Division of Infectious Diseases

University of Washington, Seattle

Page 2: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

Acute (Primary) HIV

Spach/HIV/Acute HIV/PP

Page 3: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

Spach/HIV/Acute HIV/PP

Page 4: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

Case History

A 27-year-old man presents with a 48 hour history of fever, lymphadenopathy, severe fatigue, and rash. He had high risk sexual activity with 2 other men 7 days ago. He has no known prior medical problems.

Spach/HIV/Acute HIV/PP

Page 5: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

Acute (Primary) HIV

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8Time

HIV RNA

“Set Point”

6 months3 months

HIV Antibodies

Acute HIV

Spach/HIV/Acute HIV/PP

Page 6: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

Acute HIVEarly Events in

Transmucosal Infection

From: Kahn J, Walker BD.N Engl J Med 1998;339:33-9.

Spach/HIV/Acute HIV/PP

Page 7: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

Case History: Question

A diagnosis of acute (primary) HIV is suspected. Which of the following best supports this diagnosis?

1) A negative HIV antibody test and HIV RNA 1,0002) A negative HIV antibody test and HIV RNA 200,000 3) A positive HIV antibody test and HIV RNA of 2,0004) A positive HIV antibody test and HIV RNA of 50,000

Spach/HIV/Acute HIV/PP

Page 8: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

HIV: Manifestations of Primary Infection

44%

52%

55%

57%

59%

74%

86%

0 20 40 60 80 100Patients %

Adenopathy

Pharyngitis

Headache

Rash

Myalgias

Lethargy

Fever

Most Common Symptoms: N = 160

ii

From: Vanhems P. AIDS 2000;14:375.Spach/HIV/Acute HIV/PP

Page 9: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

Acute (Primary) HIV

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8Time

HIV RNA

“Set Point”

6 months3 months

HIV Antibodies

Spach/HIV/Acute HIV/PP

Page 10: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

Plasma HIV RNA Levels

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8Time

HIV RNA

Acute HIV

“Set Point”

6 months

Spach/HIV/Acute HIV/PP

Page 11: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

HIV Infection: Natural History

0

200

400

600

800

1000

0 2 4 6 8 10 12 14

Years

CD4 Cell Count

Acute HIV Infection

Year 1

Spach/HIV/Acute HIV/PP

Page 12: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

Risk of Progression to AIDS: HIV RNA & CD4

19

42

73

93

22

40

57

78

5 15

26

48

67

0

20

40

60

80

100

Percentage with AIDS

CD4 <350 CD4 351-500 CD4 > 500

Progression to AIDS at 6 Years < 500

501 - 3,000 3,001 - 10,000

10,001 - 30,000 > 30,000

From: Mellors J et al. Science 1996;272:1167-70.

HIV RNA Level (bDNA)

Spach/HIV/Acute HIV/PP

Page 13: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

Immune Response to Acute HIV Infection

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8Time

HIV RNA

Acute HIV

Weak CTL

Moderate CTL

Strong CTL

Rapid Progression

Moderate Progression

Slow Progression

From: Walker BD. Nature 2000;407:313-4.

6 months

Spach/HIV/Acute HIV/PP

Page 14: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

HIV Primary Infection Isolates

2

1

7

2

6

0

2

4

6

8

10

Resistant Isolates %

NRTI NNRTI PI

1996-1998

1999-2000

3

From: Little SJ. JAMA 1999;282:1142-9. Little SJ. 8th Conf Retrovirus. Abstract 756

N = 108 PatientsNewly HIV-Infected Phenotypic Data: 10-fold Resistance

Spach/HIV/Acute HIV/PP

Page 15: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

HIV Primary Infection Isolates

NRTI NNRTI PI

2 1 1

10

16

1

0

5

10

15

20

Resistant Isolates %

> 2.5-10 Fold Resistance

> 10 Fold Resistance

From: Little SJ. JAMA 1999;282:1142-9.

N = 141 Patients Phenotypic Data

Spach/HIV/Acute HIV/PP

Page 16: Spach/HIV/Acute HIV/PP HIV: Acute (Primary) Infection David H. Spach, MD Medical Director, Northwest AIDS Education and Training Center Associate Professor.

HIV Primary Infection Isolates

16.3%

12.5%

7.5%

2.5%3.8%

0

5

10

15

20

25

30

Resistant Isolates %

Any Antiretroviral Drug

Any Nucleoside Analog

Any Non-nucleoside Analog

Any Protease Inhibitor

Multi-Drug Resistant

From: Boden D. JAMA 1999;282:1135-1141.

N = 80 Patients Genotypic Data

Spach/HIV/Acute HIV/PP


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