MS4 level being good citizen -imperative- (1) (1).pdf
HIV (AIDS)
1. HIV/AIDS
DR MD TIPU SULTAN
Associate Professor
Department of Microbiology
Chittagong Medical College
1
2. HIV
Human Immunodeficiency Virus
H = Infects only Human beings
I = Immunodeficiency virus weakens
the immune system and increases the
risk of infection
V = Virus that attacks the body
2
3. AIDS
Acquired Immune Deficiency
Syndrome
A = Acquired, not inherited
I = Weakens the Immune system
D = Creates a Deficiency of CD4+
cells in the immune system
S = Syndrome, or a group of illnesses
taking place at the same time
3
4. HIV and AIDS
• When the immune system
becomes weakened by HIV, the
illness progresses to AIDS
• Some blood tests, symptoms or
certain infections indicate
progression of HIV to AIDS
4
5. “The greatest single public
health challenge that
humanity has ever faced.”
Dr. Robert Lue, Harvard University
5
6. HIV/AIDS Historical
Perspective
1979
CDC reported unexplained PCP in 5 previously healthy,
homosexual men
CDC reported Kaposi’s sarcoma in 26 previously healthy,
homosexual men
Initially,then the disease was named as GRID (Gay
related immune deficiency)
1981- AIDS was recognized as separate disease
1981-1982
Increased association with IV drug use, recipients of
blood transfusions, hemophiliacs
6
7. HIV/AIDS Historical
Perspective
1983
Virus isolated.Then it was 1st named as
LAV(Lymphadenopathy associated virus)
1984
Virus was named as HTLV-III (Human T-cell
Lymphotrophic Virus)
1985
Virus was named as ARV (AIDS related Virus)
1986
Virus was named as HIV by the International
committee on the taxonomy of viruses
7
8. HIV/AIDS Historical
Perspective
1985
ELISA
test developed
Today:
Broad
spectrum of disease
Asymptomatic
infection
Clinical latency
Advanced disease (AIDS)
Clearly
sexually transmitted, and
transmitted through blood products
8
9. In Bangladesh, HIV positive
cases was 1st detected in
1989 in Chittagong
9
10. Global summary of the HIV and AIDS epidemic
Number of people living
with HIV
Total
39.4 million (35.9– 44.3 million)
37.2 million (33.8–41.7 million)
Adults
Women
17.6 million (16.3– 19.5 million)
Children under 15 years 2.2 million (2.0– 2.6 million)
People newly infected
with HIV
Total
4.9 million (4.3 – 6.4 million)
Adults
4.3 million (3.7 – 5.7 million)
Children under 15 years 640 000 (570 000 – 750 000)
AIDS deaths
Total
3.1 million (2.8 – 3.5 million)
Adults
2.6 million (2.3 – 2.9 million)
Children under 15 years 510 000 (460 000 – 600 000)
The ranges around the estimates in this table define the boundar within which the actual numbers lie, based on the best avail ble information.
ies
a
00003-E-1 – December 2004
10
11. HIV/AIDS
BANGLADESH SITUATION, END 2012
Total HIV-positive people - 2384
People living with AIDS - 676
Deaths due to AIDS
- 263
Sources:DGHS, MOH&FW, December 1, 2012.
WHO: Estimated to have 13,000 to 21,000 people
are likely to be infected with HIV.
11
12. Prevalence Among High Risk
Population in Bangladesh
•The highest prevalence is among IDUs 4%.
• Street and Hotel based CSWs– 0.2% each.
•Brothel based CSWs– 0.2% to 0.7%
• MSMs – 0.2%
12
13. Important
Bangladesh was the first among the SAARC
Countries to take the threat of HIV epidemic
seriously & initiated a national response in 1985.
According to WHO, Bangladesh is one of the
fortunate 111 countries where the infection rate
has not yet reached 1 adult / 1000.
13
15. Unique Characteristics of Retroviruses
Enveloped and encloses a capsid containing two copies
of RNA genome.
RNA-dependent DNA polymerase (reverse transcriptase)
and integrase enzymes are carried in the virion.
Replication proceeds through a DNA intermediate,
termed the provirus.
The provirus integrates randomly into the host
chromosome and becomes a cellular gene.
Simple retroviruses encode gag, pol, and env genes.
Complex viruses also encode accessory genes
(e.g., tat,
rev, nef, vif, vpu for HIV).
Virus assembles and buds from the plasma membrane.
Final morphogenesis of HIV requires protease cleavage
15
of gag and gag-pol polypeptides.
16. HIV Structure
HIV is composed of
three main layers:
Envelope
Viral Matrix
Core
Image from
http://www.brown.edu/Courses/Bio_160/Projects1999/hiv/images/Virion2.jpg
16
18. Types of HIV
HIV 1
Subtypes- A to I and O
Subtype A & D – found in sub Sahara
Africa
Subtype B – found in US & Canada
Subtype C – found in South Africa &
India
Subtype E – found in south east Asia
Subtype G & H - found in Russia &
Central Africa
Subtype I – found in Cyprus
HIV 2
18
19. HIV-1 and HIV-2
• HIV-1 and HIV-2 are
• Transmitted through the same routes
• Associated with similar opportunistic
infections
• HIV-1 is more common worldwide
• HIV-2 is found in West Africa, Mozambique,
and Angola
19
20. HIV-1 and HIV-2
• HIV-2 is less easily transmitted
• HIV-2 is less pathogenic
• Duration of HIV-2 infection is shorter
20
25. Transmission of
HIV
HIV is transmitted by
• Direct contact with infected blood
• Sexual contact: oral, anal, or vaginal
• Direct contact with semen or vaginal and
cervical secretions
• HIV-infected mothers to infants during
pregnancy, delivery, or breastfeeding
25
26. HIV enter the body via the bloodstream either during
sexual intercourse
needle drug abuse
transfusion with contaminated blood products
or via the placenta
During sexual intercourse, HIV 1 infects Langerhans dendritic
cells in the epithelium and these can then travel to lymph nodes.
On injection of virus into blood, the virus is likely to infect
dendritic and other monocyte-macrophage lineage cells.
26
27. Blood
Up to 10,000 infectious particles per
ml
Shared drug/drug-injecting
equipment
needles,
syringes
29. Sexual Contact
STD’s increase risk of transmission
epidemiological
exposed
trend
to one, may mean exposed to others
inflammation
make person more
vulnerable to HIV invasion
35. Transmission of HIV
HIV is not transmitted by
• Coughing, sneezing
• Insect bites
• Touching, hugging
• Water, food
• Kissing
• Public
baths
• Handshakes
• Work or school contact
• Using telephones
• Sharing cups, glasses,
plates, or other utensils
35
36. Important properties:
•HIV primarily infects CD4 T cells and cells of the
macrophage lineage
•Monocytes
•Macrophages
CD4 proteins on their surface
•Dendritic cells (skin)
•Microglial cells (CNS)
36
37. Which cells does HIV-1 infect?
Identification of molecular
targets.
Lymphocytes Receptor: CD4+,
Coreceptor: CXCR4
Macrophages: Receptor: CD4+
Coreceptor: CCR5
Dendritic cells (DC): DC recognized by gp120 on HIV
DC: primary target of mucosal infection!
DC present HIV antigen to resting lymphocytes
Microglial cells: Receptor: Galactosyl ceremide
37
44. Reduction in the numbers of CD4 T cells may result from
HIV-infected cytolysis, cytotoxic T-cell immune cytolysis.
The increased release of virus
into the blood as the numbers
of CD4 cells decrease gives
development of symptoms.
Macrophages may be spared the
cytolytic action of HIV because they
express less CD4 than T cells.
44
45. Macrophage-lineage cells express both the CCR5 & CXCR4
chemokine receptors and can be infected by M-& L-tropic HIV.
The virus reaches the lymph node
within 2 days of infection and there
the CD4 T cells are infected.
Macrophages are persistently
infected with HIV and are probably
the major reservoirs.
Continuous replication of the virus
occurs in the lymph nodes, with
subsequent release of the virus and
infected T cells into the blood
45
46. Pathogenesis(contd)
The hallmark of pathogenesis is the
profound immunodeficiency, primarily
affecting CMI
HIV infect any cells bearing CD4
receptor
-Severe depletion of CD4+ T-cell
-Impairment of function of surviving
CD4+ T-cell
46
47. Pathogenesis(contd)
Monocyte/Macrophage abnormalitiesRelatively resistant to cytolytic effect of HIV and
the consequences are
*Acts as reservoir of virus
*Transport the virus to different part of the body
B-cell abnormalitiesPolyclonal activation leads to hypergammaglobulinaemia
Unable to mount antibody response to a new antigen
due to lack of T cell help
47
48. Steps for pathogenesis of
HIV:
rapid early dissemination of virus
seeding of virus in lymphoid tissue
partial host immune responses that downregulates viral replication
sequestration of extracellular virus into
germinal center of lymph nodes
chronic activation of T lymphocytes and
secretion of immune system activating
cytokines
48
49. Steps for pathogenesis of
HIV:(cont.)
destruction of lymphoid tissue
escape of viral elements into peripheral
blood cells
direct killing of CD4 cells
49
50. Potential mechanism of CD4 T
cell depletion/dysfunction
Direct HIV mediated cytopathic effect
HIV mediated formation of syncytia
Virus specific immune response
Autoimmune mechanism
Anergy-Inappropriate cell signaling (gp120-CD4
interaction
Superantigen
Apoptosis
50
51. Three mechanisms by which
HIV evades immune system
1. Integration of viral DNA into host cell
DNA
resulting in a persistent infection.
2. A high rate of mutation of the env
gene.
3. Production of the Tat and Nef proteins that
downregulate class I MHC proteins required for
cytotoxic T cells to recognize and kill
HIV-infected cell
51
52. Progression of HIV in
the Body
Image from http://www.hivaidssearch.com/hiv-aids-links.asp?id=936
52
53. Initially, large burst of virus production &
viremia, which corresponds to the occurrence
of a mononucleosis-like syndrome.
53
54. Virus levels in the blood decrease during a
clinically latent period, but viral replication
continues in the lymph nodes.
54
55. Late in the disease, virus levels in the blood
increase, CD4 levels are significantly decreased.
the structure of the lymph nodes is destroyed,
and the patient becomes immunosuppressed
55
58. Prolonged Asymptomatic
Infection
person is HIV+ but asymptomatic
lasts
for several years (subclinical)
viral
replication occurring
up to 10 billion virons per day
chronic
lymphadenopathy
58
59. Early Symptomatic
Disease
CD4 counts drop to 500-600 cells/ml
symptoms: recurrent fever, night
sweats, malaise, headache
physical findings: lymphadenopathy,
spleen enlarged, rash, weight loss
59
60. Opportunistic Infection
infection by a pathogenic organism
that
is normally present but not harmful
becomes infectious in
immunocompromised person
60
62. Average time between infection and
AIDS was 10 years
time
has increased with new protease
inhibitors
63. Symptoms of HIV - “classic 6”
−
−
−
−
−
−
fatigue/malaise
lymphadenopathy
weight loss
fever
night sweats
diarrhea
63
64. AIDS
CD4 count less than 200/mm
majority of manifestations due to opportunistic
infections due to immunosuppression
rather than direct injury by virus
It is a condition in which common curable
infectious disease turned into incurable form
due to immunodeficiency, caused by HIV
infection
64
65. Clinical Course of
HIV/AIDS
HIV Infection
Virus deposited on mucosal surface
Acute infection (mono-like symptoms)
Viral dissemination
HIV-specific immune response
Replication of virus
Destruction of CD4+ lymphocytes
Rate of progression is correlated with viral load
Latent Period
65
66. Clinical Course of
HIV/AIDS
AIDS
Immunologic
dysregulation
Opportunistic infections and cancers
Risk of infections is correlated with number
of CD4+ lymphocytes
Average patient with AIDS dies in 1-3
years
66
67. WHO classification of clinical
stages of infection
Children – Three stages
Adults & Adolescents – Four stages
67
68. WHO Clinical stage I
in Children
Asymptomatic
Generalized lymphadenopathy
68
69. WHO Clinical stage II
in Children
Unexplained chronic diarrhoea
Severe persistent or recurrent
candidiasis outside the neonatal
period
Weight loss or failure to thrive
Persistent fever
Recurrent severe bacterial infection
69
70. WHO Clinical stage III
in Children
AIDS – defining opportunistic
infections
Severe failure to thrive
Progressive encephalopathy
Malignancy
Recurrent septicaemia or meningitis
70
71. WHO Clinical stage I
in Adults & Adolescents
Asymptomatic
Persistent generalized
lymphadenopathy
Performance scale 1:
asymptomatic, normal activity
71
72. WHO Clinical stage II
in Adults & Adolescents
Weight loss, <10% of the body weight
Minor mucocutaneous manifestations
Herpes Zoster within the last 5 years
Recurrent upper respiratory tract
infections
Performance scale 2: symtomatic,
normal activity
72
73. WHO Clinical stage III
in Adults & Adolescents
Weight loss, >10% of the body weight
Unexplained chronic diarrhoea >1 month
Unexplained prolonged fever (interminant
or constant) >1 month
Oral candidiasis (thrush)
Pulmunary tuberculosis
Severe bacterial infection
Performance scale 3: bed-ridden, >50% of
the day during the last month
73
74. WHO Clinical stage IV
in Adults & Adolescents
HIV wasting syndrome
Pneumocystis carinii pneumonia
Toxoplasmosis of the brain
Cryptosporidiosis with diarrhoea
Cryptococcosis, extra pulmonary
Atypical mycobacteriosis
Salmonella septicaemia
Progressive multifocal leukoencephalopathy
Performance scale 4: bed-ridden, >50% of the
day during the last month
74
75. WHO Clinical stage IV
in Adults & Adolescents
(Cond.)
Cytomegalovirus disease of an organ other
than liver, spleen or lymph nodes.
Hepes simplex virus infection, mucateneous
>1 month, or visceral any duration
Progressive multifocal leukoencephalopathy
Any disseminated endemic mycosis
(I.e. histoplasmosis,
coccidiodomycosis)
Candidiasis of the oesophagus, trachea,
bronchi or lungs
Lymphoma
75
77. AIDS in Children
Infants who are seropositive at 18
months are infected
Infants progress to AIDS more rapidly,
usually in 3 years
HIV testing during pregnancy
77
78. AIDS in Children
Transmission is usually perinatal
100% are HIV+ at birth
25% are actually infected
1
in 4 chance of passing on virus
less if mother is treated
78
82. Laboratory diagnosis
Evidence of HIV infection
Virus isolation
Measurement of viral nucleic acid
Detection of viral antigen
Detection of viral antibody
Recognition of immunodeficiency
CD4+ T cell count
Recognition of AIDS related disease
82
83. 1.Virus isolation :
HIV can be cultured from lymphocytes
in peripheral blood.
(Co-culture of patients T-cell with Leukaemic
or mitogen stimulated CD4+ Tcell line).
83
84. 2. Detection of viral Nucleic Acid :
By RT-PCR
Branched-chain DNA
To detect viral RNA in clinical specimens.
84
85. Viral RNA Assay Dynamics of HIVbillions of viruses produced and
destroyed daily
Rate
of viral replication stabilizes after
primary infection at a “set point: in each
individual. (102-106 HIV RNA copies/ml) of
plasma
Remains stable over months and possibly
years
85
86. Viral RNA Assay (cont.)
Viral RNA - indirect reflection of the number
productively infected cells in the body as a
whole
Appears to be a proportion between plasma viral
RNA and the amount of viruses in the fixed
lymphoid tissues
Set point associated with the rate of disease
progression and time of death
HIV RNA levels appear more predictive of
progression than CD counts
4
86
88. Therefore utility of HIV RNA
assays include:
Assessing
baseline status in newly diagonal
HIV patient
Assessing response to therapy
Assessing development of resistance to current
therapy
Typically 109-1010 virions are produced daily
Reductions in plasma viremia correlates with
increased CD4 cells and AIDS-free survival
88
89. 3. Detection of HIV
Antigen
HIV antigen tests detect the presence
of HIV in blood
P24 antigen tests measure one of the
proteins found in HIV
The antigen often becomes undetectable after antibodies develop
and may reappear at low levels intermittently during the period
of clinical latency and in some people as infection progresses
89
90. 3. Detection of viral p24 Antigens:
Low levels of circulating HIV p24 antigen can be
detected in the plasma by ELISA soon after infection.
usually disappeared by 8-10 weeks after exposure.
It can be a useful marker in individuals who have been
infected recently
but have not had time to
mount an antibody response
90
91. 4. Detection of antibody
measuring antibodies by ELISA.
HIV antibody may develop slowly,
4-8 wks in most patients.
A positive test in a serum sample must be confirmed by a repeat test
If the repeat ELISA test is reactive, a confirmation test is performed.
By immunofluorescence, Western blot technique or
Line immunoblot assay
91
92. Detection of IgG antibody to envelope components(gp120
and its subunits)
This is the most commonly used marker of infection
The routine tests used for screening are based on ELISA techniques,
which may be confirmed with Western blot assays.
Up to 3 months may elapse from initial infection to
antibody detection (serological latency, or window period).
IgG antibody to p24 (anti-p24)
This can be detected from the earliest weeks of infection and
through the asymptomatic phase. It is frequently lost as disease
progresses.
92
93. Window period:
Early in infection when the blood of an infected
person can contain HIV but antibodies are not
detectable.
Seroconversion:
Development of evidence of
antibody response to a disease.
Viral Load:
The amount of HIV in the blood.
93
94. “Window Period”
A period of 4-6 weeks after HIV exposure
when antibodies to HIV are not detectable
in the blood
A person at high risk who initially tests
negative should be retested at 3 months to
confirm diagnosis
94
95. “Window Period”
Time between infection with HIV and
detection of HIV antibodies in the serum
(time to seroconvert)
“Seropositive”: detectable antibodies to
HIV in the serum
person
becomes infectious within 2 weeks
of exposure
97. Tests which detect
antibodies
Enzyme linked immunosorbent assay (ELISA)
Particle agglutination test (PAT)
Screening tests
Latex agglutination test
Indirect fluorescence antibody test (IFAT)
Radio immunoprecipitation assay (RIA)
Immunochromatographic test (ICT)
Line immunoblot assay (LIA)
Western Blot assay (WB)
Confirmatory tests
97
98. ELISA for HIV antibody
ELISA false-positive:
immunologic abnormalities
neoplasms
multiple transfused
pregnancy
Microplate ELISA for HIV antibody: colored wells indicate
reactivity
98
99. Western Blot
HIV-1 Western Blot
Lane1 : Positive Control
Lane 2 : Negative
Control
Sample A: Negative
Sample B: Indeterminate
Sample C: Positive
99
100. Western blot to be considered positive
At least two bands including
p24, gp41, or gp120/gp160 should be present.
(antibodies to HIV proteins of specific molecular weight
can be detected)
Western blot is confirmatory test for HIV antibody
detection, because the test can detect all the HIV-specific
antibodies according to their molecular weight
100
102. 5. CD4:CD8 cell count:
Absolute number of CD4+ cell and
ratio of helper cell to inducer cell are
abnormally low.
102
103. Selection of the HIV
Test
Is site-specific based on:
National/local
policies
Availability of supplies and laboratory
support
Availability of trained personnel
Evaluation of specific tests in the country
Costs
103
104. The Testing Process
• Test sample
• Blood, saliva, urine
• Process the sample, on-site or in lab
• Obtain results
• Keep confidential
• Method determined by clinic protocols and
client
• Provide results to client
• Provide post-test counselling, support and
104
105. Guiding Principles for
Counselling and Testing
Information on HIV status kept private
Information shared only with providers
directly involved in care—and only on a
“need to know” basis
Medical records kept in safe place
105
106. Guiding principles
(contd.)
• Pre-test Group education
• Informed Consent
• Identifies:
• Purpose of testing and processes involved
• Benefits and risks of testing
• Available treatment and support
• Respects
• Individual’s autonomy and right to confidentiality
106
107. Counseling and Testing as an
Entry Point to MCH/HIV
Prevention
Community action
to reduce Stigma
& discrimination
Post - delivery
care and support
Safer infant
feeding
Primary
prevention of new
HIV infection
VCT
and its links
with other
services
Prevention of
unintended
pregnancy
Safer obstetric
practices
Antiretroviral
prophylaxis
107
108. Pre-test Information
Group education in
Relevant HIV and AIDS information
Transmission and prevention
STIs and HIV
HIV testing and test result interpretation
Implications of both positive and negative results
Benefits and risks of HIV testing
Individual counselling and risk assessment
Identification of supportive services
Privacy and Confidentiality
108
109. Post-Test
Counselling
Provide the woman with her HIV test result
Help her understand what the result means
Provide support, information, and referral when
indicated
Encourage risk- reducing behavior
Encourage disclosure and partner testing
109
110. Post-Test
Counselling
HIV-negative
Review window period if indicated
• Prevent future infection
• Review risk with new infection
• Educate partner and encourage partner testing
110
111. Post-Test
Counselling
HIV-positive result
• Clarify understanding
• Acknowledge feelings
• Review benefits of knowing HIV status
• Address immediate concerns
• Schedule follow-up visit
• Provide support ,name and telephone
number of contact person
111
112. Diagnosing HIV in HIVExposed Infant
ARV prophylaxis reduces but does not eliminate
Mother to child transmission of HIV infection
Since maternal antibodies cross the placenta,
antibody testing is not recommended prior to 18
months of age
Infants who are breastfeeding require additional
testing 6 weeks after complete cessation of
breastfeeding
HIV viral assays are not used for diagnosis of HIV
infection in the infant
112
113. Summary
• Pre-test information, HIV testing, and post-test
counselling should be available to all pregnant
women
• The need for pre-test counselling should be
determined on an individual basis
• The healthcare provider and the facility must
maintain confidentiality of HIV status.
• Partner testing and couples counselling should be
encouraged
113
114. Summary (contd.)
Rapid tests with same day results are the
recommended procedure for most settings.
Infant diagnosis is complex but important for
clinical management
•
Standard diagnosis is done by antibody test at 18 months
•
Earlier diagnosis is possible with PCR testing
Post-test counseling is important for all women,
including HIV-negative women
114
116. CURRENT TESTING FACILITIES
IN BANGLADESH
Screening Purposes :
Latex agglutination
Immunochromatography
Particle agglutination
ELISA
For Confirmation :
BSMMU, Dhaka-Western blot
Dhaka-Western blot
ICDDR,B-Dhaka-Western blot
Dhaka-Western blot
Medical College-Line immunoassy, ELISA
Chittagong Medical College-Line immunoassy, ELISA
Sylhet Medical College-Line immunoassy, ELISA
AFIP,
IEDCR,
Dhaka
116
117. EXISTING DIAGNOSTIC FACILITIES ( CONTD)
Screening tests for HIV [ PAT and ELISA ] are also carried
out in blood transfusion centres to ensure safe blood
transfusion
Currently, 98 safe blood transfusion centres are present
in our country [ Medical Colleges- 13, Specialized hospitals
- 6, District hospitals- 53, CMH- 13, Other big hospital- 10,
Red crescent- 3 ]
117
125. Therapy might be started when PVL is
over 10,000. If therapy is in progress,
several PVL tests a year monitor the
status. If PVL goes up, medication
needs to be changed, quite obviously.
The goal is to clear detectable virus
from the blood in 16-24 weeks.
126
127. Why is HIV so hard to
treat?
1.
HIV-1 and other lentiviruses have the unique
property among retroviruses to replicate in
nondividing cells.
2.
Mutation rate is maximum permissible
3.
Latent period of incubation
4.
Integration into host genome unpredictable
128
128. 4 Questions that Need Answers
for HIV Therapy
When to initiate therapy?
Which types of drugs to use?
When to change therapy?
Which drugs to use when changing
therapy?
129
129. When to Initiate Therapy?
2001
Recommended for patients with RNA > 30,000
copies/ml
CD4 cell counts < 350/µl irrespective of RNA level.
RNA levels 5000-30,000 and CD4 between 350500/µl
130
130. What Drugs should be
Initiated in Newly Diagnosed
HIV + Patient?
AZT
+ 3TC + either PI or NNRTI
131
131. Two strategies to maximize
benefits/minimize toxicities:
Alternating therapies
Combination therapy-demonstrated
more beneficial than monotherapy
Decreased
emergence of resistance
Decreased risk of toxicity
132
132. HIV infected Pregnant Female
Standard antiretroviral therapy should be used in the
HIV infected pregnant female
Possible risk of premature delivery (highest in non-treated
individuals)
133
133. Reduced transmission of
HIV from mother to infant
Proportion of infants of HIV (+) mothers
who acquired HIV
40
30
33
% 20
10
0
8
No ARV
With ARV
134
134. Pediatric Patients with HIV
Therapy:
AZT + 3TC + either PI (nelfinavir) or NNRTI (efavirenz)
Expanded access of liquid formulations
ddC zalcitabine (from Roche), efavirenz (from Dupont), Kaletra
(from Abbott)
Not recommended: overlapping toxicities or undesirable
effects
Monotherpay
d4T and AZT
ddC and ddI
ddC and d4T
ddC and 3TC
135
135. Reasons to Change Regimen?
Plasma HIV RNA levels measured on 2
separate occasions
CD4 count (changes in these counts)
Remaining treatment options for potency
Potential resistance patterns from prior
antiretroviral therapies
Potential for adherence/tolerance
Potential for side effects, drug interactions,
possible need to alter concomitant
medications
136
136. 3 Patient Populations
Identified as Needing
Therapeutic Changing
Patients receiving incompletely suppressive
therapy (single or double NRTI) with
detectable or undetectable plasma viral load
Patients who have been on potent
combination therapy and whose viremia was
initially suppressed to undetectable levels but
has again become detectable
Patients receiving potent combination therapy
and whose viremia was never suppressed to
below detectable limits
137
137. Goal of Therapy
Suppressing viremia to below
detectable levels as consistently as
possible.
Requires
a level of commitment to be
adherent
even a low level of non-adherence will
result in the development of resistance
which could render the therapy useless.
138
140. Prevention of HIV
Infections
Vaccines
Pre-clinical work in animals is promising
Education, Counseling & Behavior mod.
Worked in the US for homosexual men
Free needles for IV drug users
Societal debate
Improved blood supply
Greatly decreased risk for hemophiliacs
Screening and treating pregnant women
Area where interventions are well accepted
141
141. Why is HIV so hard to
fight?
Some antibodies that the body produces actually
work to enhance HIV replication.
Some antibodies that work to neutralize HIV
replication can become enhancing antibodies when
the virus mutates.
Cells other than helper T-cells can be infected,
therefore the virus can colonize many tissues of the
body.
HIV can kill cells that it doesn’t even infect.
142
142. Vaccine development is difficult
1. HIV mutates rapidly
2. Not expressed in all cells that are infected
& is not completely cleared by the host
immune response after primary infection.
3. Protective immunity are not known
4. Vaccine based on attenuated or inactivated
HIV or in simian isolates don’t ensure safety
against possible vector-induced disease
5. Lack of appropriate animal modal for HIV.
143
143. AIDS Vaccine
Two vaccines on trial
AIDSVAX B/B – tested in North
America & Amsterdam
AIDSVAX B/E – tested in Thailand
Each mixed the surface proteins
(gp120) from two strains of HIV
144
144. New vaccines on human trial
tgAAC09 – begun in Belgium
Single shot vaccine
Uses Targeted Genetics ‘ rAAV
(recombinant adeno associated viral
vector) Technology
145
145. New DNA vaccines on human trial
Vaccine - ADVAX
Vaccine is tailored for C strain of HIV
Worked by The Aron Diamond AIDS
ResearchCenter & International AIDS
Vaccine initiative
Trail in New York & Rochester
Developed on synthetic DNA based on
the genetic material available
Safe to use
146
146. SURVEILLANCE
SYSTEM
IN BANGLADESH
Surveillance is carried out in phases.
Currently 4th round of HIV surveillance has been
done :
-Surveillance on high risk population
-Surveillance on mass population
No case has been detected on mass population
So emphasis should be given on high risk
population.
147
147. MOST PRESSING ISSUES
IN HIV/AIDS CONTROL
MEASURE IN
BANGLADESH
High numbers of migrant workers
Low socio-economic condition & illiteracy
High prevalence rate of STI among sex workers
Unsafe sex practice by sex workers
Sharing of needles by the IDUs
148
148. A Short Preview Of The Existing Guideline On
HIV/AIDS And STD Related Issues :
The government of Bangladesh has Formulated
Guidelines On The Following Specific Areas Related
To HIV/AIDS :
Epidemiological surveillance, Testing policy,
Infection management, Counseling , Safe blood
transfusion , Education , Information , Awareness
development , Promotion of preventive measures ,
Social science and behavioral research , Clinical
vaccine trial , Ethical and legal aspects
149
The establishment that the disease is caused by a virus and therefore the ability to produce antibodies against viral antigens led to the first tests for HIV, the ELIZA and Western blot tests. However, there is a 1 to 2 month time lag before antibodies are produced. This can be overcome by using a test that identifies viral RNA rather than antibodies produced against viral protein e.g PCR.
The very fact that we can use an antibody test shows us that there is a good immune response and it is neutralizing antibody which gives hope for a vaccine. But the virus is not completely neutralized which argues that a vaccine may be difficult to develop. The virus goes underground within the cells and because it is a retrovirus, is prone to genetic drift. As it changes it overcomes the immune system.
As we shall see retroviral vaccines pose special problems and HIV is more complicated than other retroviruses
Bacterial Infection Increases HIV Infection Through Upregulation of Viral Co-Receptors
WESTPORT, CT (Reuters Health) Oct 18 - Concurrent bacterial infection can stimulate HIV replication through upregulation of the chemokine receptors CXCR4 and CCR5 on CD4+ T cells, researchers from the Netherlands report.
"Intercurrent febrile diseases are associated with a transient rise in HIV replication," Dr. Tom van der Poll explained in an interview with Reuters Health. To see if this could be explained by upregulation of CXCR4 and CCR5, he and colleagues from the University of Amsterdam injected eight HIV-negative volunteers with the bacterial cell wall component lipopolysaccharide.
As the researchers report in the October 15th issue of Blood, the injection increased the surface levels of CXCR4 and CCR5 per CD4+ T cell, in addition to increasing the fraction of CD4+ T cells expressing CXCR4. The increase in CXCR4 levels correlated with an increase in infectability with a T-tropic HIV-1 strain, but the increase in CCR5 did not correlate with increased infectability with an M-tropic HIV-1 strain.
"We were surprised," Dr. van der Poll said. He suggested that bacterial infection could stimulate the release of CCR5 ligands such as RANTES and MIP-1-beta, which were indeed elevated, and could counteract the enhancing effect of increased CCR5 levels on HIV replication.
Similar in vitro experiments, where the researchers stimulated blood cells with antigens from Mycobacterium tuberculosis and Staphylococcus aureus, produced similar increases in the levels of CXCR4 and CCR5 on CD4+ T cells. The upregulation appeared to be due in part to tumor necrosis factor and interferon-gamma. In addition, interleukin-10 specifically upregulated CCR5 but not CXCR4.
"Pathogens commonly found in HIV-infected patients may increase viral burden in blood by upregulation of CXCR4," Dr. van der Poll and colleagues write. "Moreover, intercurrent infections may contribute to the selection of CXCR4-using viruses during the course of disease progression."
"This is more a mechanistic study that needs confirmation in patient populations," Dr. van der Poll noted in the interview. "Possibly, blocking of CXCR4 may reduce the transient upregulation of HIV replication during intercurrent febrile illnesses."
In the journal, he and colleagues suggest that intercurrent disease should be closely monitored and aggressively treated in HIV-infected patients. "For some pathogens, adequate antibiotic prophylaxis may reduce the HIV load."
Blood 2000;96:2649-2654.
92% of children reported to be infected with HIV in 1996 were infected through vertical transmission- transmission from infected mother to baby. Vertical transmission can take place in several ways: (1) the virus can be transmitted to the fetus while it is still in the uterus; (2) the infection can take place in the birth process during which the baby comes in direct contact with large quantities of the infected blood of the mother; or (3) the virus can be passed on through breast milk.The chance of infection through breastfeeding, however, is small
Because HIV is transmitted by sex or contaminant blood, the groups that are at increased risk of contracting the disease are listed in this slide. Men, practicing unsafe sex are at high risk if they are homosexual or bisexual. If a patient uses IV drugs and shares needles with another that is HIV positive, this is another means of contracting the disease. The other groups are self-evident. Certain patient may have had a blood transfusion between 1987 and 1992 and became infected by that route also.
This slide details some of the steps that are necessary for HIV pathogenesisity. After HIV entry into the body by the different routes, within 2-4 weeks, the patient will have the peak viremia. However, the patient will be negative by HIV serology. This means that a patient can be infected with HIV and if tested too soon, the patient will have a negative HIV test however, the patient may still be HIV-positive. HIV will enter lymph tissue after infecting CD4 cells as early as 5 days after acute infection.
After the initial peak plasma viremia, virus-specific immune responses can be detected and may contribute to both the control of the initial peak of virus replication and the reduction in plasma viremia. The immune response lack the ability to control HIV and block progression of the disease. This is different than other viruses such as Epstein-Barr virus where the immune response will stop progression of the disease.
Soon after the acute infection, a pool of latently infected CD4 cell contain the virus and is capable of replicating. This is the key to the immunopathogenesis of HIV. This stable reservoir remains sheltered from the effects of host response and drug therapy.
Certainly with these mechanisms in place, HIV can then destroy lymph tissue and directly kill CD4 cells leading to immune suppression and opportunistic infections and neoplastic diseases.
time has increased with new protease inhibitors
must be used in combination with other drugs
This slide details the classic 6 symptoms of patients in the primary HIV infection period. These symptoms can continue and may be the reason why patients seek medical attention. Therefore, physicians and other health care practitioners must be aware of these symptoms for adequate identification of the high risk patient. Certain questions should be asked of all patients between 17 and 30 regarding sexual preferences and activity when patients present to outpatient clinics with these symptoms.
This slide indicates the laundry list of opportunistic infections that patients can experience with a reduction in the numbers of CD4 cells. Most occur with CD4 cells < 200/mm3.
Additionally, patients can develop HIV associated cancers as this slide indicates.
The key element in HIV pathogenesis is the high rate of viral replication and infected CD4 cell. The rate of viral replication stabilizes after primary infection and remains stable over months or years.
At steady-state in the untreated state, the amount of virus produced and cleared each day are roughly equal. The quantity of virus in the blood of an infected patient is a function of the rate of virus production in that patient. The rate of CD4 destruction is also proportional to the rate of virus production. Measurements of plasma HIV RNA levels provide an estimate of the rate at which the immune system is being depleted. Studies have shown that the quantitative measurement of plasma HIV RNA is correlated to disease state.
During therapy, the decline in plasma RNA levels is strongly associated with a decreased risk of disease progression. Therefore, monitoring plasma HIV RNA levels provides a direct correlation to risk of disease progression and ultimately mortality.
Plasma HIV RNA levels should be determined in all patients who have HIV infection as part of their initial evaluation. Results can be used to assess the patient’s risk of disease progression and help make decisions regarding therapy. If viral RNA levels are > 30,000 copies/ml, treatment should be highly recommended. Patients who have titers < 10,000 copies/ml and CD4 counts > 500/l are at very low risk of progression. Treatment in this case may be deferred and virus load monitored every 3-6 months. Plasma RNA assay should be repeated within 4-6 weeks of either initiating therapy or changing therapy. A minimum of a 1-log decrease in plasma RNA should be observed within this time frame. If not, presence of drug resistance, poor treatment adherence or an insufficiently potent regimen should be considered.
This slide helps to determine the questions that need to be answered when faced with a patient that requires therapy. Let’s review the discussion points associated with these questions.
This slide indicates the patients that therapy is recommended. Therapy should be highly recommended to patients with RNA levels > 30,000 copies/ml regardless of their CD4 cell counts. Additionally, therapy should be highly recommended for patients with CD4 cell counts < 350/l irrespective of viral RNA level. Therapy should be encouraged in patients with viral RNA levels between 5,000-30,000 copies/ml or with CD4 cell counts between 350 and 500/l.
Dual NRTIs are used in most 3 to 4-drug regimens. There are no current data regarding preferred sequencing of NRTI however, AZT and D4T should not be used together because of drug-drug antagonism. ddC plus ddI or D4T is not recommended due to overlapping toxicities. Lamivudine should be reserved for regimens that maximally suppress replication as M184V mutation results in loss of lamivudine activity.
AZT + 3TC use results in loss of abacavir effectiveness. Abacavir is useful in initial regiments but its effectiveness with NRTI combinations other than AZT + 3TC is not well characterized.
Efavirenz+3TC+AZT produced HIV suppression and CD4 cell count elevation is at least comparable to that with indinavir+3TC+AZT. Remember it is contraindicated in the 1st trimester of pregnancy. Potential for high-level resistance as a result of a single reverse transcriptase mutation suggests that NNRTI should be used only in regimens designed to maximally suppress HIV.
Dual protease inhibitors (PI) are increasingly being used because of pharmacokinetic advantages of low-dose ritonavir inhibiting P4503A metabolism of the other PI improving the plasma concentrations of these drugs. May offer increased potency and reduced pill counts.
The present objective of antiretroviral therapy is to prevent disease progression and prolong survival while maintaining quality of life. The use of combinations of antiretrovirals with no overlapping toxicity and demonstrated antiviral synergy is recommended.
Currently, pediatric patients represent a minority of patients but are more difficult due to both toxicities and formulation problems. This slide shows recommended and non-recommended therapies for pediatric patients.
If a patient received chemoprophylaxis with AZT, and now is determine to be HIV +, then immediate starting of therapy would be recommended. Risk of mortality is primarily viral loads > 100,000 copies/uL.
This slide details reasons to change therapy in a patient that has not met the goal of therapy. A patient that has detectable levels of viral RNA and/or their CD4 cell counts are not increasing, may need a change in therapy. The goal would be a target level of < 50 copies/ml by 16-24 weeks should raise concern in either poor adherence, inadequate drug absorption, or drug resistance.
This slide details the patient populations that require a therapeutic change.
This slide details the goal of therapy. If for whatever reason, this goal can not be reached, some investigators admit that withholding therapy until the patient can meet these expectations may be necessary for some patients.
This slide details the changes that have been made to ascertain how therapy has impacted the virus and patient’s well-being. During the early part of this disease in the late 1980s, when monotherapy was all we had to offer patient, the viral load would go down over time and then return to pre-treatment levels after the virus developed resistance to AZT. In the early 1990s, when patients received dual NRTIs the viral load would go down and then stay down longer than monotherapy. However, eventually, the viral load would come back up and CD4 cells would be killed. Since 1998, we now have HAART and this includes triple drug combinations and now we can see that viral load go down and remain at non-detectable levels unless patient are nonadherent to their therapy regimen.