Download HIV/AIDS – CLINICAL MANAGEMENT

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