HIV /AIDS UPDATE
Marguerite E. Ball-Thomas, O.D., F.A.A.O.
Eye Associates of Winter Park
1928 Howell Branch Road
Winter Park, FL 32792
407-671-5445 / fax 407-671-2899
mballwsurf@aol.com
I.
Introduction:
A. Global Pandemic
B. World Cumulative Total (living with HIV/AIDS-Dec. 2003): 40 million (37 million
adults / 2.5 million children (< 15 yrs. of age)
C. AIDS Deaths in 2003: 3 million
II.
History:
A. 1981: 1st Recognized in U.S.
B. 1984: HIV Discovered
C. 1985: Reliable HIV Tests
III.
Etiology:
A. Human Immunodeficiency Virus (HIV)
B. Retrovirus
C. Attacks cells with CD4+ protein (T-Helper lymphocytes, glial cells, etc.)
D. HIV-1 vs. HIV-2
IV.
Human Acquired Immunity:
A. Humoral Immunity
B. Cellular Immunity
V.
Immunopathogenesis:
A. Viral RNA converted to viral DNA
B. HIV takes over CD4+ cells
VI.
Definitions/Natural History:
A. HIV Infection Progression: Inoculation to AIDS (transmission, infection,
seroconversion, asymptomatic chronic infection, symptomatic infection)
B. AIDS Changing Definition: AIDS Indicator Conditions, CD4+ count < 200/mm3
VII. HIV Testing:
A. Enzyme immunoabsorbant assay (EIA)
B. Western Blot (WB)
C. Immunofluorescent assay (IFA)
D. Home Testing
E. “Window Period”
F. Viral Load Testing
Positive vs. Negative Results
VllI. Epidemiology: United States (December 2002)
A. Total AIDS Cases: 886,575 (living & dead)
1. Adult/Adolescent: 877,275
Children (<13 yrs.): 9,300
a) Men: 718,002
b) Women: 159,271
2. By Race/Ethnicity:
a) Whites: 364,458
f) Race/ethnicity unknown: 887
b) Blacks: 347,491
c) Hispanics: 163,940
d) Asians & Pacific Islanders: 6,924
e) American Indians & Alaskan Natives: 2,875
3. By Exposure Category (adults & adolescent)
a) Male to Male Sexual Contact (MSM): 420,790
b) Injection Drug Use (IDU): 240,268 (172,351 M; 67,917 F)
c) Heterosexual Contact: 135,628 (50,793 M; 84,835 F)
d) Blood or Blood Products: 14,263 (10,057 M; 4206 F)
e) MSM & IDU: 59,719
f) Other: 20,869 (14,350 M; 6,519 F)
4. By Exposure Category (children < 13 yrs.)
a) Hemophilia/Coagulation Disorder: 236
b) Mother with or at risk for HIV infection: 8,629
c) Receipt of blood transfusion, blood components, or tissue: 390
5. Other/risk not reported or identified: 45
6. By Age:
a) Under 13: 9,300
e) Ages 35 to 44: 347,860
b) Ages 13 to 14: 839
f) Ages 45 to 54: 138,386
c) Ages 15 to 24: 35,460
g) Ages 55 to 64: 40,584
d) Ages 25 to 34: 301,278
h) Ages 65 or older: 12,868
B. Reported to CDC as living with HIV infection or AIDS through 12/02: 517,414
C. Estimated living with HIV in 1999: 800,000 to 900,000
D. Reported to CDC as living with AIDS through 12/02: 384,906
E. New HIV (not AIDS) cases in 2002: 35,147 (only 39 areas reporting)
E. Total AIDS Deaths (through 12/02): 501,669 (496,354 adults/adolescents; 5,315
children < 15)
F. Trends
1. Increased AIDS cases in Blacks & Hispanics
2. Increased AIDS cases in women (increased proportion infected heterosexually)
3. Decreased AIDS cased in MSM (however, still the largest single exposure group)
4. Increased incidence in South
5. With new tx: decreased AIDS incidence; decreased AIDS deaths; increased AIDS
prevalence
G. Health Care Workers Exposure Rates: 56 confirmed as of June 2000 (25 with AIDS)
IX. HIV Transmission:
A. Fluids with highest HIV Concentration: infected blood, semen, vaginal secretions
1. Possible source of infection: breast milk
2. Minute quantities of virus: tears, saliva, perspiration
B. Routes of Transmission of HIV: sexual, blood exposure, perinatal
C. HIV Transmission Criteria
D. High Risk vs. Less Risky Behavior: sexual, blood product contact, drug use
E. Universal Precautions
F. Blood Supply Safety in U.S.: risk is extremely low
X. HIV Infection Prevention:
A. Behavior for Risk Elimination: abstinence & no drug paraphernalia sharing
B. Next Best Option: Long term mutually monogamous relationship w/ HIV(-) person
C. “Safer Sex”: condoms, foams, jellies, mouth dams
D. Universal Precautions: hand washing, protective barriers, needle handling
E. Office Infection Control/Precautions: hand washing, barriers, instrument disinfection
F. Injection Drug Users: no needle sharing, needle exchange programs, needle
disinfection
XI. Antiretroviral Treatment of AIDS:
A. Mean survival rate is directly related to viral load (viral load of < 500 = survival rate
of > 10 yrs.; > 30,000 = 4.4 yrs.) Ann Intern Med 1997, 112:946)
B. Indications for Initiation for Antiretroviral Therapy:
1. Symptomatic (AIDS, thrush, explained fever): treat w/ any value of CD4+ or
viral load count
2. Asymptomatic: Offer treatment if CD4+ < 500 or viral load > 10,000
3. Asymptomatic: May or may not treat is CD4+ > 500 or viral load < 10,000
C. Nucleoside Reverse Transcriptase Inhibitors (NRTI)
1. Zidovudine (AZT, ZDU): Retrovir 3/87
2. Didanosine (ddI): Videx 10/91
3. Zalcitabine (ddC): Hivid 6/92
4. Stavudine (d4T): Zerit 6/94
5. Lamivudine (3TC): Epivir 11/95
6. Zidovudine & Lamivudine: Combivir 11/97
7. Abacavir (ABC): Ziagen 2/99
D. Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI)
1. Nevirapine (NFV): Viramune 6/96
2. Delavirdine (DLV): Rescriptor 4/97
3. Efavirenz (EFV): Sustiva 9/98
E. Protease Inhibitors (PI):
1. Saquinavir (SQV, hgc): Invirase 12/95
2. Rinovavir (RTV): Norvir 3/96
3. Indinavir (IDV): Crixivan 3/96
4. Nelfinavir (NFV): Viracept 3/97
5. Saquinavir (SQV): Fortovase 11/97
6. Amprenavir (APV): Agenerase 4/99
F. Initial Regimen (JAMA 2000, 283:381): HAART (highly active antiretroviral
treatment)
1. Preferred
a. 2 nucleosides and a PI
b. 2 nucleosides and a NNRTI
2. Under evaluation:
a. 3 nucleosides
b. Consider in pts. W/CD4+ count < 50 or viral load >100,000:
1) NRTIs +2 PIs or
2) 2 NRTIs + PI + NNRTI
G. HIV Post-Exposure Prophylaxis (PEP): MMWR, 47:RR-7
1. Four weeks of AZT + 3TC + Indinavir or AZT + 3TC + nelfinavir
2. 1996 CDC retrospective case control study (updated 1997): HIV infected needle
stick injuries (33 seroconverted, 739 controls)
a. Seroconversion risk
b. AZT prophylaxis: 79% reduction in transmission rate
c. Must administer within 24-48 hours
H. Perinatal Transmission/Prevention:
1. “Pregnant women should be treated according to standard guidelines for
antiretroviral therapy in adults, with the objective of reducing viral load to as low as
possible for as long as possible.”
2. Reducing viral load helps to prevent HIV progression & to reduce perinatal
transmission.
3. Initial Studies (ACTG 076): AZT reduced perinatal transmission rate from 22.6
% to 7.6 %; AZT given prenatally, during labor, to infant x 6 wks.
I. Prophylactic Treatment Initiation for Possible Opportunistic Infections (MMWR
1999:48 (RR-10)
1. Strongly Recommended as Standard of Care:
a. Pneumoncystic carinii risk: CD4+ < 200, prior PCP, thrush
i. TMP-SMX 1 DS/day or 1 SS/day
ii. Pts. w/increased CD4+ >200 x 3-6 mos: d/c PCP prophylaxis
b. M.Tuberculosis risk (MMWR 1998): (+) PPD, recent TB contact,
inadequately treated TB
i. INH 300 mg/d + pyridoxine 50 mg/d>270 doses, 9-12 mos.
ii. alternatives
c. Toxoplasma gondii risk: CD4+ <100 + (+) IgG serology x T. gondii
i. TMP-SMX 1DS/d
ii. Pts. w/ CD4+ count > 100 x 3-6 mos can discontinue prophylaxis
unless prior toxoplasmosis (need lifelong prophylaxis)
d. M. avium: CD4+ <50
i. Clarithromycin 500 mg or BID or azithromycin 1200 mg po weekly
ii.. Discontinue prophylaxis when CD4+ >100 x 3-6 mos (cont. if prior
h/o MAC)
e. Varicella: significant exposure to chickenpox or shingles
i. VZIG 5 vials (6.25 mL) IM wi/96 hrs.
ii. Prophylactic acyclovir (? Clinical efficacy)
2. Generally Recommended:
a. S. pneumonia: all pts. CD4+ >200
b. Hepatitis B: Recombinvax HB 10 ug IM x 3 or Energix –B 20 ug IM x 3
c. Influenza: all pts. annually (preferably Oct.-Nov.)
d. Hepatitis A: pts. w/ chronic Hepatitis C infection
3. Not recommended x most pts (consider only x select pts.)
a. Cryptococcosis: CD4 <50
b. Histoplasmosis: CD4<100 + endemic area
c. CMV: CD4 <50 + positive CMV serology
i. oral ganciclovir 1 gm po tid
ii. D/C if CD4 >100-150 x 3-6 mos, non-sight-threatening lesion, adequate
VA in contralateral eye, regular ophthalmic exams (Ophthal. 1998, 105:1259)
d. Bacterial Infection: Neutropenia
XII. Professional, Ethical, and Legal Standards:
A. Consent to Test (Florida Statute 381.6091 (3): Informed consent
B. Confidentiality: “Superconfidential”
C. Reporting Requirements: HIV vs. AIDS
D. March 2000: 35 states conduct confidential name-based HIV case surveillance (FL
1997)
E. All states are required to report full-blown AIDS cases (adult & peds)
F. American Disabilities Act: cannot discriminate against an HIV (+) individual for
either hiring, firing, insurance qualification, etc.
G. Appropriate Attitudes & Behaviors of Caregivers
H. Cultural sensitivity
I. Caregiver’s prejudices toward certain behavioral practices
J. Source of infection: not the concern of caregiver
K. Offer hope, compassion, & respect (not condemnation or censure)
L. Use Golden Rule approach
M. Comprehensive human services available to those w/HIV infection:
N. CDC National AIDS Hotline: 800-342-AIDS
Florida AIDS Hotline: 800-352-AIDS
Center x Substance Abuse Prevention (CSAP) National Clearinghouse x Alcohol
& Drug Info: 800-729-6686
XIII. Ocular Manifestations: 90 % OF AIDS pts. in the absence of HAART
A. Orbital Neoplasms
1. Kaposi’s Sarcoma
2. Orbital Lymphoma
B. Anterior Segment
1. Dry Eyes
2. Conjunctivitis
3. Corneal Ulcers
4. Herpes Zoster Ophthalmicus
5. Herpes Simplex Keratitis
6. Microsporidia Keratitis
C. Non-infectious Retinal Microangiopathy
D. Venous Occlusive Disease
E. Posterior Pole Opportunistic Infections
1. Cytomegalovirus (CMV) Retinitis:
a. Presentation
b. Disease Course
c. Latest Treatment Modalities
2. Acute Retinal Necrosis (ARN)
3. Toxoplasmosis
4. Candida
5. Syphilitic Retinitis
6. Pneumocystis Choroiditis
7. Cryptococcus
8. Other
F. Neuro-ophthalmic Complications
XIV. Future:
A. Increased Longevity: chronic illness
B. Present Studies
C. Future Medications