H.I.V.
WHAT IS HIV??
 “Human Immunodeficiency Virus”
 A unique type of virus (a retrovirus)
 Invades the helper T cells (CD4 cells) in the body of
the host (defense mechanism of a person)
 Threatening a global epidemic.
 Preventable, managable but not curable.
HIV/AIDS Info & History
 In 1981,1 the first cases of AIDS were identified among gay men
in the US. However, scientists later found evidence that the
disease existed in the world as early as 1959.
 The first documented case of HIV was traced back to 1959 using
preserved blood samples, which were analyzed in 1998.
 In first-world countries, AIDS is now a chronic disease, but this
was not the case in the past.
 AIDS is 100% preventable, and yet there were 56,300 new
infections in 2006 in the US alone.2
1.
1. Advert.org
2.
2. Centers for Disease Control and Prevention
AIDS is a Global Problem
 33 million people worldwide have HIV/AIDS.
 571,378 people in the United States are
HIV-positive.
 New HIV infections occur every 6 seconds.1
1. UNAIDS
From Terminal to Chronic
1980s
3 Months
Today
27 Years…and counting!
Infection
Statistics
 Worldwide: Over 33 million people are
living with HIV.1
• 50 percent are women.1
• 2 million are children under age 15 years.1
 United States: Over 570,000 people are living
with HIV.2
1. UNAIDS
2. Centers for Disease Control and Prevention
An individual is at risk if she or he…
 Has had unprotected sex—ever.
 Has had multiple partners within one year.
 Has shared needles, or if the partner has shared needles.
 Has had a sexually transmitted disease, or sexually transmitted
infection—ever.
 Uses alcohol or drugs.
• This is an indirect risk factor as it causes impaired judgment, which can
lead to high-risk behaviors.
Definitions
 H - Human
 I-
Immunodeficiency
 V-
Virus
OTHER NAMES FOR HIV
 Former names of the virus include:

Human T cell lymphotrophic virus (HTLV-III)

Lymphadenopathy associated virus (LAV)

AIDS associated retrovirus (ARV)
Definitions
 A - Acquired
 I - Immune
 D - Deficiency
 S - Syndrome
WHAT IS AIDS ???
 “Acquired Immunodeficiency Syndrome”
 HIV is the virus that causes AIDS
 Disease limits the body’s ability to fight infection
due to markedly reduced helper T cells.
 Patients have a very weak immune system (defense
mechanism)
 Patients predisposed to multiple opportunistic
infections leading to death.
Normal Immune Response
Virus binds to T-cells
Virus
Tcells
Normal response: Virus invades
blood stream and binds to
lymphocytes. Lymphocytes make
antibodies to the virus. Antibodies
bind to the virus and destroy
the virus.
Vir
us
Antibodi
es bind
to virus
Antibodies
kill virus
Immune Response to HIV
HIV HIV destroys
T-cells (CD4
cells)
T-cells cannot
produce antibodies
Cannot destroy virus
What’s the difference between HIV and
AIDS?
 HIV, a virus, eventually causes AIDS,
a syndrome.
Spectrum of HIV
Infection
Possible Minor Symptoms
Blood tests
positive
Healthy, HIV+
can last for years
Symptomatic
HIV/AIDS
T-Cell Count
 If 1,200 or higher, the individual has a normal
immune system.
 If 800 or less, the immune system is weakened
and individual is susceptible to infection.
 If 200 or less, AIDS is diagnosed.
 Once a person is diagnosed with AIDS, she or he
is always categorized as having AIDS, even if
her or his T-cell count increases.
Criteria for Diagnosing AIDS
 A CD4 cell (type of T-cell) count of 200
or less,
or
 One opportunistic infection.
• An opportunistic infection is an infection
that typically does not affect individuals with
normal immune systems.
AIDS (definition)
 Opportunistic infections and malignancies that
rarely occur in the absence of severe
immunodeficiency (eg, Pneumocystis pneumonia,
central nervous system lymphoma).
 Persons with positive HIV serology who have ever
had a CD4 lymphocyte count below 200 cells/mcL or
a CD4 lymphocyte percentage below 14% are
considered to have AIDS.
Opportunistic Infections
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Mycobacterium Avium Complex
Salmonellosis
Syphilis and Neurosyphilis
Tuberculosis
Bacillary angiomatosis
Aspergillosis
Candidiasis
Coccidioidomycosis
Cryptococcal Meningitis
Histoplasmosis
Kaposi’s Sarcoma
Systemic Non-Hodgkin’s Lymphoma
Primary CNS Lymphoma
Cryptosporidiosis
Isosporiasis
Microsporidiosis
Pneumocystis Carinii Pneumonia
Toxoplasmosis
Cytomegalovirus
Hepatitis
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Herpes Simplex
Herpes Zoster
Human Papillomavirus
Molluscum Contagiosum
Oral Hairy Leukoplakia
Progressive Multifocal Leukoencephalopathy
AIDS Dementia Complex
Peripheral Neuropathy
Apthous Ulcers
Malabsorption
Depression
Diarrhea
Thrombocytopenia
Wasting Syndrome
Idiopathic Thrombocytopenic Purpura
Listeriosis
Pelvic Inflammatory Disease
Burkitt’s Lymphoma
Immunoblastic Lymphoma
Valley Fever
MRSA
Source: AIDS Education Global Information System
“THE VIRAL GENOME”
 Icosahedral (20 sided), enveloped virus of the
lentivirus subfamily of retroviruses.
 Retroviruses transcribe RNA to DNA.
Two viral strands of RNA
found in core surrounded by
protein outer coat.
Outer envelope contains a lipid
matrix within which specific
viral glycoproteins are
imbedded.
These knob-like structures
responsible for binding to
target cell.
Modes of HIV/AIDS
Transmission
Through Bodily Fluids
 Blood products
 Semen
 Vaginal fluids
Fluids that can transmit HIV
Fluids that DO
transmit HIV:
Fluids that DO NOT
transmit HIV:
 Blood
 Saliva
 Semen
 Tears
 Vaginal Fluid
 Mucus
 Breast Milk
(in order of the highest
concentration of HIV)
 Urine
 Sweat
 Feces
IntraVenous Drug Abuse
 Sharing Needles
 Without sterilization Increases the chances of
contracting HIV
 Unsterilized blades
Relative Risk
High risk:
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Sharing needles
Unprotected sex
Breast feeding
Lower risk:

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Protected sex
Any opportunity for exchange of body fluids
No risk:

Casual contact
Through Sex
 Unprotected Intercourse
Oral
 Anal

Mother-to-Baby
 Before Birth
 During Birth
Myths about transmission
Universal Precautions
 Wash your hands!
 Disinfect utensils and living space.
 Use barriers—preferably latex.
HIV cannot be spread through casual contact,
but these are good practices for preventing
opportunistic infections.
Barriers include:
 Latex Gloves
 Latex Condoms
 Sheepskin condoms do NOT protect!
 Latex Dental Dams
 Anything that protects your skin from a fluid
Prevention
 What is the only 100% effective way to prevent
HIV infection?
ABSTINENCE!
 What does abstinence include?
 Do not have sex with infected, possibly infected, or
multiple partners.
 Do not share needles.
Other Prevention Options
 If not abstinence, barriers can greatly reduce
the risk of HIV transmission.
 Use latex condoms and water-based lubricants
or dental dams.
NATURAL COURSE OF HIV/AIDS
Stage 1 - Primary
 Short, flu-like illness
- occurs one to six
weeks after infection
 Mild symptoms
 Infected person can
infect other people
Stage 2 - Asymptomatic
 Lasts for an average of ten years
 This stage is free from symptoms
 There may be swollen glands
 The level of HIV in the blood drops to low
levels
 HIV antibodies are detectable in the blood
Stage 3 - Symptomatic
 The immune system deteriorates
 Opportunistic infections and cancers start to
appear.
Stage 4 - HIV  AIDS
 The immune system
weakens too much as
CD4 cells decrease in
number.
Opportunistic Infections associated with AIDS
CD4<500
 Bacterial infections
 Tuberculosis (TB)
 Herpes Simplex
 Herpes Zoster
 Vaginal candidiasis
 Hairy leukoplakia
 Kaposi’s sarcoma
Opportunistic Infections associated with AIDS
CD4<200
 Pneumocystic carinii
 Toxoplasmosis
 Cryptococcosis
 Coccidiodomycosis
 Cryptosporiosis
 Non hodgkin’s
lymphoma
CD4 <50
 Disseminated mycobacterium avium complex (MAC)
infection
 Histoplasmosis
 CMV retinitis
 CNS lymphoma
 Progressive multifocal leukoencephalopathy
 HIV dementia
TB & HIV CO-INFECTION
 TB is the most common opportunistic infection in HIV and
the first cause of mortality in HIV infected patients (1030%)
 10 million patients co-infected in the world.
 Immunosuppression induced by HIV modifies the
clinical presentation of TB :
1.
2.
3.
Subnormal clinical and roentgen presentation
High rate of MDR/XDR
High rate of treatment failure and relapse (5% vs < 1% in HIV)
Testing Options for HIV
Anonymous Testing
 No name is used
 Unique identifying number
 Results issued only to test recipient
23659874515
Anonymous
Testing
 The test is for antibodies against HIV, not for the
virus itself.
 It can take up to three months for the body to
produce antibodies against HIV.
 A negative test result may mean recent infection.
It is possible to infect others during this stage.
 An individual should be tested three months after
possible exposure to guarantee an accurate result.
Timeline
Test
Date
New Test
Date
Three-month
window from
first exposure
First
exposure
Second Three-month
exposure window from
second
exposure
Blood Detection Tests
HIV enzyme-linked
immunosorbent assay (ELISA)
Screening test for HIV
Sensitivity > 99.9%
Western blot
Confirmatory test
Speicificity > 99.9% (when combined with
ELIZA)
HIV rapid antibody test
Screening test for HIV
Simple to perform
Absolute CD4 lymphocyte count
Predictor of HIV progression
Risk of opportunistic infections and AIDS when
<200
HIV viral load tests
Best test for diagnosis of acute HIV infection
Correlates with disease progression and
response to HAART
Urine Testing
 Urine Western Blot
 As sensitive as testing blood
 Safe way to screen for HIV
 Can cause false positives in certain
people at high risk for HIV
Oral Testing
 Orasure
 The only FDA approved HIV
antibody.
 As accurate as blood testing
 Draws blood-derived fluids
from the gum tissue.
 NOT A SALIVA TEST!
Real Life Application
 At a party three months ago, I engaged in some
high-risk behaviors….When should I get tested?
 Before I came here today, I got high with a used
needle…now what do I need to do?
Avoid the possibility of infecting others!
The ONLY way to know
is to get TESTED!
Find a Testing Site Near You!
 Go to
www.hivtest.org
 Enter your zip code.
 Instantly receive list of all HIV-testing sites
in your area.
Treatment Options
Treatment
 Today, in the US, HIV/AIDS is a chronic disease.
 Anti-retroviral drugs are used in combination, known
as Highly Active Anti-Retroviral Therapy (HAART).
 Side effects can be severe, but the risks of not being
treated are more severe.
 Cornell University estimates the monthly cost of
treatment as $2,100, with a lifetime cost of treatment
of $618,900.
HAART = highly active anti-retroviral treatment
Antiretroviral Drugs (HAART)
 Nucleoside Reverse Transcriptase inhibitors
 AZT (Zidovudine)
 Non-Nucleoside Transcriptase inhibitors
 Viramune (Nevirapine)
 Protease inhibitors
 Norvir (Ritonavir)
EFFECTIVENESS OF HAART IN REDUCING
MORTALITY
HEALTH CARE FOLLOW UP OF HIV
INFECTED PATIENTS
For all HIV-infected individuals:
 CD4 counts every 3–6 months
 Viral load tests every 3–6 months and 1 month following a change in therapy
 PPD
 INH for those with positive PPD and normal chest radiograph
 RPR or VDRL for syphilis
 Toxoplasma IgG serology
 CMV IgG serology
 Pneumococcal vaccine
 Influenza vaccine in season
 Hepatitis B vaccine for those who are HBsAb-negative
 Haemophilus influenzae type b vaccination
 Papanicolaou smears every 6 months for women
 For HIV-infected individuals with CD4 < 200
cells/mcL:

Pneumocystis jiroveci1 prophylaxis
 For HIV-infected individuals with CD4 < 75
cells/mcL:

Mycobacterium avium complex prophylaxis
 For HIV-infected individuals with CD4 < 50
cells/mcL:

Consider CMV prophylaxis
PRIMARY PREVENTION:
Five ways to protect yourself?
 Abstinence
 Monogamous Relationship
 Protected Sex
 Sterile needles
 New shaving/cutting blades
Abstinence
 It is the most effective method of not acquiring
HIV/AIDS.
 Refraining from unprotected sex: oral, anal, or
vaginal.
 Refraining from intravenous drug use
Monogamous relationship
 A mutually monogamous (only one sex
partner) relationship with a person who is not
infected with HIV
 HIV testing before intercourse is necessary to
prove your partner is not infected
Protected Sex
 Use condoms every time you have
sex
 Always use latex or polyurethane
condom (not a natural skin
condom)
 Always use a latex barrier during
oral sex
When Using A Condom Remember To:
 Make sure the package is

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not expired
Make sure to check the
package for damages
Do not open the package
with your teeth for risk of
tearing
Never use the condom
more than once
Use water-based rather
than oil-based condoms
GLOBAL ESTIMATES 2008
ESCALATING EPIDEMIC !!!
Source: WHO/UNAIDS/UN The Millennium Development Goals Report, 2009, p.32 and WHO.
HIV PREVALENCE IN VARIOUS REGIONS
Sub-Saharan Africa
South/South-East Asia
18%
Latin America
4%
Eurasia
4%
North America
3%
East Asia
3%
Western Europe
North Africa/Middle East
2%
1%
Caribbean
1%
Oceania
< 1%
Total = 39.4 million
Source: UNAIDS, AIDS Epidemic Update, December 2004.
42%
NEWLY INFECTED CASES OF HIV IN VARIOUS REGIONS
63%
Sub-Saharan Africa
18%
South/South-East Asia
6%
East Asia
5%
Latin America
Eurasia
North Africa/Middle East
4%
2%
Caribbean
1%
North America
1%
Western Europe <1%
Oceania
<1%
Source: UNAIDS, AIDS Epidemic Update, December 2004
Total = 4.9 million
ESTIMATED HIV BURDEN IN PAKISTAN
 0.1% of the adult population in Pakistan
 Total Population (2008) = 180,800,000
 People living with HIV/AIDS (2008) = 96,000
 Women (aged 15+) with HIV/AIDS (2008) = 27,000
 Children with HIV/AIDS (2008) = nd
 Adult HIV prevalence(%) (2008) = 0.1%
 AIDS deaths (2008) = 5,100
ESCALATING EPIDEMIC OF HIV IN HIGH RISK
GROUPS IN PAKISTAN
20%
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
4%
2%
1%
POTENTIAL THREATS IN PAKISTAN
 100,000 commercial sex workers with poor safe sex
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awareness in three major cities
Estimated 60,000 iv drug users in pakistan (1 in 5 infected
with HIV)
38,000 homosexuals reported in lahore in 2002
40% of 1.5 million annual blood donors not screened for
HIV
20% of blood transfusions come from professional donors
with high prevalence of infectious diseases
Significantly large number of migrants and refugees.
UNDER-REPORTING
Until September 2004, only 300 cases of full-blown
AIDS and another 2300 cases of HIV infection
were reported to the National AIDS Control
Program.
The reasons for under reporting are:
 Social stigma attached to the infection,
 Limited surveillance
 Voluntary counseling and testing systems
 Lack of knowledge among the general population
and health practitioners.
NATIONAL RESPONSE TO HIV/AIDS
 Pakistan’s Federal Ministry of Health initiated
a National AIDS Prevention and Control
Program (NACP) in 1987

In its early stages, the program was focused on
diagnosis of cases that came to hospitals, but
progressively began to shift toward a community
focus
 The government has indicated in the recent
scaling up of its response to HIV/AIDS, more
needs to be done.
NON GOVERNMENTAL ORGANIZATIONS
 54 NGOs are involved in HIV/AIDS public
awareness and in the care and support of persons
living with HIV/AIDS.
 Also working on education and prevention
interventions targeting sex workers, truck drivers,
and other high-risk groups.
 But reaching less than 5 percent of the vulnerable
population.
WORLD BANK RESPONSE
 Largest financer of HIV/AIDS program in Pakistan
 Providing 37.1 million US dollars
 Enhanced program is making encouraging progress
with expansion of coverage.
WHAT WE CAN DO??
UNAIDS Outcome Framework 2009–2011: nine priority areas
 We can reduce sexual transmission of HIV.
 We can prevent mothers from dying and babies from becoming infected with
HIV.
 We can ensure that people living with HIV receive treatment.
 We can prevent people living with HIV from dying of tuberculosis.
 We can protect drug users from becoming infected with HIV.
 We can remove punitive laws, policies, practices, stigma and discrimination
that
 block effective responses to AIDS.
 We can stop violence against women and girls.
 We can empower young people to protect themselves from HIV.
 We can enhance social protection for people affected by HIV.
LIVING WITH HIV/AIDS