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Human Immune Deficiency Virus Infection
Huda Taha
ST5
Oct. 2011
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Epidemiology
Virology
Natural History
Transmission
Seroconversion Syndrome
Diagnosis
Treatment
HIV in Pregnancy
Epidemiology
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The HIV pandemic continues to evolve
Global Prevalence of HIV stabilise at 0.8%
25 million died of HIV
33 million living with HIV / AIDS
Every day : 4,900 die of HIV/AIDS
7,100 new HIV infection
3,200 on HAART
 2009 : 2.6 million new infection
2 million died of HIV/ AIDS (1.7 million <15 Year
old)
 4 million receive HAART in Africa( 50,000 in 2002)
 1 million pregnant women on HAART
WHO
Epidemiology
 100,000 people were living with a whom a quarter are
unaware of their infection.
 2010, there were 6,136 new diagnoses of HIV,
 As of December 2010, there have been 6,791 diagnoses of
AIDS in the UK.
 19,912 people diagnosed with HIV have died.
 37 English PCT/ HIV prevalence >2:1000
 1:5 HIV+ >50 Year old
DOH
 HIV is a Lentivirus a member of the Retrovirus family that
causes (AIDS).
 HIV infects vital cells in the human immune system such as
helper T cells (specifically CD4+ T cells), macrophages and
dendritic cells
Transmission
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Sexual
IVDU
MTCT
Occupational
Blood transfusion
HIV Natural History
Natural history
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HIV vs AIDS
Acquisition of Infection
Primary HIV infection
Asymptomatic HIV infection
Early symptomatic infection
Late symptomatic infection
Advance HIV disease
Natural History of HIV Infection
Possible acute HIV syndrome.
Wide dissemination of virus
Seeding of lymphoid organs
Death
Opportunistic
diseases
900
1:512
Clinical latency
700
1:128
Constitutional
symptoms
600
1:64
500
1:32
400
1:16
300
1.8
200
1.4
100
1.2
0
0
0
3
6
9
Weeks
12
1
2
3
4
5
6
7
Years
8
9
10
11
)
1:256
)
800
(
CD4+ T Cells/mm3
1000
(
1100
Plasma Viremia Titre
Primary
infection
1200
Seroconversion illness
“acute retroviral syndrome”
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What is Seroconversion?
Why do we need to recognise it?
How does it present?
What to do if you suspect HIV infection?
Appropriate tests
Seroconversion syndrome
 The period between initial exposure to and infection by
HIV and the development of an HIV-specific antibody
response.
 Enormous viremia.
 Vigorous immune response.
 Rapid decline in CD4 cell count
Why do we need to recognise Seroconversion illness?
 1 in 3 HIV + people in the UK remain undiagnosed.
 80% will have symptoms of Seroconversion
 60-70% will seek help
 Only 5% are diagnosed
Why do we need to recognise Seroconversion illness?
 To protect others:
 Higher risk of transmission in primary HIV infection
 Easier to contact trace early
How Does Seroconversion Illness Present?
Seroconversion syndrome
 Spectrum of Presentation
 completely asymptomatic infection to severe illness
requiring admission to the hospital
 Typically, within 5 to 30 days after exposure;
 median duration of symptoms is 14 days.
How Does Seroconversion Illness Present?
 Non-specific, self-limiting symptoms:
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Fever (80-97%)
Lymphadenopathy (40-77%)
Rash (51-70%)
Pharyngitis (44-73%)
Myalgia/ arthralgia (49-70%)
Headache/aseptic meningitis (30-70%)
Also – mucosal ulcers, peripheral neuropathy, Bell’s
Palsy, diarrhoea, nausea/vomiting
Bloods
 Thrombocytopenia
 Neutropenia
 Deranged LFTs
So, fever, lymphadenopathy, rash,
pharyngitis – THINK HIV!
What would you do if you suspected
HIV?
Sexual history including IVDU/ travel history
Get consent for an HIV test
Full sexual health screen (refer to GUM)
CONFIDENTIALITY
HIV Testing
 Antibody/antigen testing
– EIA antibody test + p24 antigen test
– Antibody test may still be negative up to 3/12 postexposure.
– P24 antigen likely to be positive at 6 weeks
– If test positive or strong suspicion – refer to GUM for
viral load testing.
What if the Test is Positive?
 Refer to GUM
 Patient will need to be seen by Health Advisors for support
and advice
 Follow up by the HIV team for CD4 count and viral load
monitoring.
To conclude:
 Seroconversion illness is a non-specific multisystem
disease.
 Suspect in patients with fever, rash, lymphadenopathy and
pharyngitis or other unusual symptoms.
 Early diagnosis will benefit the patient and their contacts
 Always refer +ve/likely +ve patients to GUM.
HIV treatment
CART/ ARV/ ART/ HAART
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NRTI
NNRTI
PI
CCR5 Inhibitor
Integrase Inhibitors
Fusion Inhibitors
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When to initiate therapy
Primary HIV infection: clinical trial/ neurological involvement/ or CD4 <200
cells/mL / AIDS-defining illness.
Established HIV infection:
CD4 <200 cells/mL Treat
CD4 201–350 cells/mL Treat as soon as possible when patient ready
CD4 351–500 cells/mL Treat in specific situations with higher risk of
clinical events
 CD4 4500 cells/mL Consider enrolment into ‘when to start’ trial
 AIDS diagnosis Treat (except for tuberculosis)
 Preferred regimens:
 2NRTI(Tenofovir + Emtricitabine OR Abacavir +Lamivudine) PLUS
NNRTI ( Efavirenz)
 Alternative:
 2 NRTI PLUS Protease Inhibitors: Lopinavir/Ritonavir
HIV In Pregnancy
 The prevalence of HIV infection in women giving birth
reached 1 in 238 (0.42%) in London, 1 in 705 (0.14%) in
the rest of England.
 Surveillance of ( MTCT) HIV relies on confidential
voluntary reports from paediatricians and obstetrics
 Surveillance of ( MTCT) HIV relies on confidential voluntary reports
from paediatricians and obstetricians.
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By the end of December 2010, 1,943 children in the UK had been
diagnosed with HIV ( MTCT).
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Of these, 994 were diagnosed after having being infected abroad.
 The number of mother-to-child HIV infections almost doubled from
56 in 1995 to 107 in 2006.
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However, due to the widespread use of ARV to prevent MTCT these
rates are still far lower than many other countries.
HIV in Pregnancy
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ANC Testing (100%) BHIVA guidelines
Sexual Health of HIV + women.
Preconception and fertility management
MDT & documentation
Psychosocial issues
AZT monotherapy vs CART
Avoid Stavudine plus Didanosine as the NRTI backbone
whenever possible (and monitor lactate if unavoidable).
 HIV testing in children
 Breast feeding
Summery
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HIV RNA virus
Transmission/ risk factors
Seroconversion illness/ could be asymptomatic
HIV testing. SUPPORT
CART
Pregnant women/ baby
Thanks
Suggested site:
http://www.bhiva.org