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GOALS Opportunistic infections Antiretroviral treatment Mother-to-Child Transmission Psychosocial issues Ethics HIV TRANSMISSION Exchange of body fluids Exchange of infected blood transfusion or by needle piercing Mother-to-child transmission 80-90% sexual contact WHO Classification Major signs - Weight loss >10% of body weight - Fever more than one month int & cont - Chronic diarrhoea more than one month intermittent and continues WHO Classification Minor signs - Persistent cough more than one month - Gen.itchydermatitis - Recurrent, multi-dermatomal herpes zoster - oral candidiasis - Chronic progressive and disseminated herpes simplex - Generalized lymphadenopathy CDC REVISED CLASSIFICATION CD4 T-cell >500/ul 200-499/ul <200/ul A A1 A2 A3 A- Asymptomatic or PGL B- Symptomatic C – AIDS indicator B B1 B2 B3 C C1 C2 C3 CLASSIFICATION (CD4) CD4 cell count/ul disease >500 500 – 200 200 – 50 <50 Stage of HIV Early Intermediate Late or severe Far Advanced FIVE GOALS IN HIV CARE Prevention of further transmission Preservation of immune function Prophylaxis against OI Rx of OI through effective early diagnosis Counseling and other psychosocial supports COURSE OF HIV INFECTION Acute seroconversion syndrome in 1/3rd Phase of clinical latency CD4 <200/ul, OI begins to set Progress to AIDS about 8-10 yrs OPPORTUNISTIC INFECTIONS Oral candidiasis - Oral discomfort - Burning sensation when eating - Altered sense of taste - KOH Oesophageal candidiasis - Odynophagia or dysphagia - Anterior chest pain, exacerbated by swallowing OPPORTUNISTIC INFECTIONS DIARRHOEA Parasitic – Criptosporidium, Isosporabelli Microsporidia, Giardia, EH Bacteria – Solmonella, Campylobacter, C.difficile, M.tuberculosis DIARRHOEA Fungal – Candidiasis, Histoplasmosis Viral CMV, HSV, adenovirus, enterovirus, HIV M.C - Cryptosporidium, Isospora belli & Microsporidium EMPIRIC ANTIBIOTIC RX TMP/SMX Ciprofloxacin Metronidazole Paramomycin COUGH & FEVER Acute – WBC + abundant bacteria Sub acute – Few WBC – PCP Chronic – AFB+ - TB Malaria, Typhoid, Viral fever Crypto Toxo CNS MANIFESTATIONS Cryptococcal meningitis Toxoplasmosis Tuberculous meningitis Progressive multi focal leukoencephalopathy Neurosyphilis Lymphoma CT scan post contrast multiple granulomas (arrows) surrounded by minimal vasogenic edema. Presence of multiple lesions with a target sign and positive toxoplasma titre suggest toxoplasmosis PULMONARY MANIFESTATIONS Pansinusitis Pulmonary or extra pulmonary tuberculosis PCP CMV CUTANEOUS MANIFESTATIONS Infectious dermatoses Viral infections Acute HIV, HSV, VZV EBV HPV BACTERIAL INFECTIONS Staphylococcal Mycobacterial Bacillary angiomatosis T.Pallidum infection Others – Pseudo, salmo, nocardia FUNGAL INFECTIONS Superficial dermatophytosis Candidiasis Superficial mycoses Deep infections & systemic mycoses Crypto, histo, coccidio, sporotrichosis, penicilliosis, blastomycosis, aspergillous PARASITIC INFECTIONS Arthropod infestations Scabies, demodicidosis Protozoal infestations Ex-pulmonary pneumocystosis, leishmaniasis, cutaneuous toxo, acanthamoebiasis NON-INFECTIOUS DERMATOSES Seborrheic dermatitis, psoriasis, Reiter’s, ichthyosiform dermatoses Papular and follicular eruption of HIV Pigmentary idsorders Adverse cutaneous drug reactions Neoplasms: Kaposi’s, lymphoma, melanoma NAIL & HAIR CHANGES Onychomycosis Yellowish discoloration of nail Melanotic bands & black pigmentation of nail due to AZT Pre-mature graying of hair (Canities) Diffuse hair loss, male pattern alopecia, alopecia areata, hypertrichosis of the eye lashes STIs & HIV Severe/extensive Atypical/chronic No response/minimal response to standard Rx Precocious syphils TPHA & FTA – ABS – Positive STIs Syphilis, herpes, chancroid, granuloma inguinale, LGV, gonorrhea, trichomoniasis, bacterial vaginosis, vulvovaginal candidiasis, PID, anogenital warts MANAGEMENT WHO(1997) CDC (1998) Higher dose of antimicrobials Prolonged duration of therapy OCCULAR MANIFESTIATIONS IN HIV Conjunctivitis Karatitis CMV retinopathy TB retinopathy Sudden retinal detachments ENT MANIFESTATIONS IN HIV Oropharyngeal candidiasis Middle ear disorders Pan sinusitis RENAL MANIFESTATIONS IN HIV GIT MANIFESTATIONS IN HIV Acute gastric & duodenal ulcers Acute, sub acute, chronic cholecystitis Hepatitis – HBV, HCV, HIV, CMV Pancreatitis Small bowel disorders Large bowel disorders Rectum, anal canal & perianal disorders HAEMATOLOGICL DISORDERS IN HIV ANAEMIA CVS IN HIV Atherosclerosis due to CMV Cardiomyopathy due to CMV Cardiomyopathy due to anaemia CCF WOMEN & HIV OI in women as same in men Recurrent vulvovaginal candidiasis Genital herpes, HPV Bacterial vaginosis & PID Cervical dysplasia and neoplasia PAEDIATRIC HIV Diagnosis based on antibody tests >18 M Immediate diagnosis – antigen test DNA PCR, p24 antigen ANTI-RETROVIRAL THERAPY Clinical goal Virological goal Immunological goal Therapeutic goal Epidemiological goal INDICATIONS FOR ART Acute infection Symptomatic Asymptomatic - CD4 <200 to 500 - HIV RNA >20,000 copies - RT-PCR >10,000 copies bDNA ART NRTI – AZT, ddI, ddC, d4T, 3TC NNRTI – Nevi, delavir, efavir PI - Saq, ritonavir, ind, nelf, ampri Nucleotides – adefovir, dipivoxil Miscellaneous – Hydroxurea COMBINATION OF ART Mono therapy Duel therapy Highly active antiretroviral therapy Salvage therapy (rescue therapy) Recycling therapy Mega-HAART Subtraction regimen (step down therapy) ART IN TB No ART with Rifampicin Dual nucleoside therapy during rifampicin Triple therapy with Rifabutin Triple therapy with PI only with Ethambutol & INH regimen PREVENTION OF MOTHERTO-CHILD TRANSMISSION ART before, during, after delivery Infant: AZT syrup 2mg/kg/QID for first six weeks, 8 to 12 hours after birth LSCS Postpartum care Breast feeding with ART PSYCHOSOCIAL MANAGEMENT Counseling - Relationship building - Assessment - Goal setting - Intervention - Termination & follow up ETHICS Obligation of a physician to treat patients - World medical association (the professional responsibility of physicians in treating AIDS patients) should not refuse to treat a patient, a physician who is not able to provide care and service should refer to equipped hospitals. ETHICS Confidentiality - If individual feels that their status will be disclosed and in turn lead to discrimination, they may opt to get tested or treated, and that hinders offers to contain the epidemic