Basic HIV -

Basic HIV & AIDS
Education for Health Care
Patricia R Jennings DrPH, PA-C
University of Alabama at Birmingham
Learning Objectives
After completing this lecture the
participant should be able to discuss
the epidemiology and demographics of
human immunodeficiency virus (HIV)
After completing this lecture the
participant should be able to discuss
the evaluation and treatment of
patients diagnosed with HIV disease.
HIV Infection & AIDS
Essentials of Diagnosis
– Risk factors: sexual contact with an infected person,
parenteral exposure to infected blood by
transfusion or needle sharing, perinatal exposure.
– Prominent systemic complaints such as sweats,
diarrhea, weight loss, and wasting.
– Opportunistic infections due to diminished cellular
immunity – often life-threatening
– Aggressive cancers, particularly Kaposi sarcoma and
extranodal lymphoma.
– Neurologic manifestations, including dementia,
aseptic meningitis and neuropathy.
CDC Recommendations for HIV testing
Adults and Adolescents
Routine, voluntary HIV screening for all persons
13-64 in health care settings, not based on risk
Repeat HIV screening of persons with known
risk at least annually
Opt-out HIV screening with the opportunity to
ask questions and the option to decline
Include HIV consent with general consent for
care; separate signed informed consent not
Prevention counseling in conjunction with HIV
screening in health care settings is not required
Recommendations for HIV testing
Adults and Adolescents
Intended for all health care settings
Communicate test results in same
manner as other
diagnostic/screening tests
Provide clinical HIV care or establish
reliable referral to qualified
CDC AIDS case definition for
surveillance of adults and adolescents
(1) Definitive AIDS diagnosis (with or
without laboratory evidence of HIV
(2) Definitive AIDS diagnoses (with
laboratory evidence of HIV infection)
(3) Presumptive AIDS diagnoses (with
laboratory evidence of HIV infection)
Patients have AIDS when:
They are HIV+ with a CD4 cell count
that is or ever has been less than 200
They are HIV+ and have or ever have
had a CD4 percent below 14%.
They are HIV+ and have an AIDS
defining illness - regardless of CD4 cell
HIV Prevalence Estimate
At the end of 2009, an estimated
1,148,200 persons aged 13 and older
were living with HIV infection in the
United States, including 207,600
(18.1%) persons whose infections had
not been diagnosed.1
HIV Incidence Estimate
CDC estimates that approximately 50,000 people in
the United States are newly infected with HIV each
year. That number has remained stable overall in
recent years. Most (62%) were attributed to maleto-male sexual contact. Black/African American
men and women were also strongly affected and
were estimated to have an HIV incidence rate that
was almost 8 times as high as the incidence rate
among whites.
1993 definition
Prevalence (in thousands)
No. of cases and deaths (in thousands)
Estimated Number of AIDS Cases, Deaths, and
Persons Living with AIDS,1985-2004, United States
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Year of diagnosis or death
Note. Data adjusted for reporting delays.
Persons Living with AIDS
(PLWA) diagnosis
At the end of 2009, the estimated
number of persons living with an
AIDS diagnosis in the United States
and 6 U.S. dependent areas was
487,968. In the 50 states and the
District of Columbia, this included
476,186 adults and adolescents, and
546 children aged less than 13 years
at the end of the year.
The hallmark of symptomatic HIV infection is
immunodeficiency caused by continuing viral
replication. The virus can infect all cells
expressing the T4 (CD4) antigen, which HIV
uses to attach to the cell. Chemokine coreceptors (CCR5 and CXCR4) are required for
virus entry and individuals with deletions are
less likely to become infected and, once
infected, the disease is more likely to progress
HIV Lifecycle
Natural History of
Untreated HIV Infection
Untreated HIV Infection
Viral Transmission 2-3 weeks
Acute retroviral syndrome 2-3 weeks
Recovery and seroconversion 2-4 weeks
Asymptomatic, chronic HIV infection
– Average 8 – 10 years
Symptomatic, HIV infection/AIDS
– Average 1-3 years
Laboratory Tests
HIV infection is established by detecting
antibodies to the virus, viral antigens,
viral RNA/DNA or by culture.
The standard test is serology for antibody
– The time delay from infection to positive EIA
averages 10-14 days with newer test
reagents. Some do not seroconvert for 3-4
weeks, but virtually all patients seroconvert
within 6 months.
Testing Methods
Screening test: ELISA, high sensitivity
Confirmatory test: Western Blot, high
NEVER suggest that a client/patient
donate blood to determine their HIV
CLIA Waived Rapid Tests
Rapid Tests
Persons tested must receive a “Subject
Information Notice” provided with the test
A negative test is definitive negative unless
tested in the “window period”
Positive tests are considered preliminary and
should be confirmed with a Western blot or
Indeterminate tests should be repeated in 1
Mass Screening
The recommendation is to pool
seronegative specimens for PCR
testing, with PCR testing of individual
samples from any batch that tests
In N.C., use of this method found that
acute infections accounted for 4-10%
of all newly detected HIV infections.
Primary Infection
– often asymptomatic or overlooked
– symptoms 1-6 weeks after infection
– viral like syndrome: sore throat, fever,
lymphadenopathy, rash
– differential includes EBV, CMV, hepatitis
– antibody (ELISA, Western Blot, Rapid Tests)
may not be detected
– if diagnosed during this stage it is usually by
Quantitative HIV by PCR
of the
of HIV
Clinical Latency
– usually asymptomatic
– lymph nodes site of ongoing viral
– massive viral production
– destruction of CD4 cells
Advanced Disease
Plasma viremia begins to rise
 CD4 cell count falls further
 Constitutional symptoms develop
Opportunistic infections develop:
– fever, weight loss, lymphadenopathy,
thrush, diarrhea, malignancies, wasting
syndrome, neurologic syndrome including
Modes of Transmission
Blood Exposure
Other Potentially Infectious Material (OPIM)
– semen, vaginal fluid, any bloody fluid, CSF, and pus.
Additionally, peritoneal, pleural, synovial, pericardial
and amniotic fluid
Sexual Exposure
Congenital Exposure
– antepartum, intrapartum, postpartum
Occupational Exposure
Initial Laboratory Testing
Confirm HIV antibody status
– ELISA and Western Blot
CD4 count (baseline and every 3-4 months)
viral load (baseline and every 3-4 months)
Resistance testing (the prevalence of >1
major mutation in treatment naïve patients is
genotype if newly diagnosed pt
– naïve patient with elevated viral load
Initial Laboratory Tests
renal and liver function tests, cholesterol
and triglyceride panel (fasting baseline)
RPR, STD screening (including wet mount
for trichomonas in women), hepatitis
toxoplasmosis IgG; CMV IgG; Varicella IgG
(if negative history of chickenpox)
PPD; +/- chest radiograph
Pap smear (cervical, =/- anal)
HIV Lifecycle
Therapeutic Arsenal
Fusion Inhibitors
CCR5 inhibitors
Nucleoside Reverse Transcriptase
Inhibitors (NRTIs)
Nucleotide Reverse Transcriptase
Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTIs)
Integrase Inhibitors
Protease Inhibitors (PIs)
Initiate Antiretroviral
Treat all symptomatic patients
– AIDS or severe symptoms
Treat asymptomatic patients with
CD4 < 200
Offer treatment to asymptomatic patients
CD4 200 – 500 *
Defer treatment to patients with
CD4 > 500 unless VL> 100,000 *
Goals of Therapy
Clinical Goals:
Virologic Goals:
Immunologic Goals:
Therapeutic Goals:
Epidemiologic Goals:
Health Maintenance
Memorize table 31-3
Relationship of CD4 count to
development of opportunistic
infections (Figure 31-1)
Bacterial infections, HSV, VZV, Vaginal
candidiasis, KS, M Tuberculosis (PPD > 5mm
Pneumocystis jiroveci
– CD4 < 200
Toxoplasmosis gondii, cryptococcosis
– CD4 < 100
M avium complex, CMV retinitis, CNS lymphoma
– CD4 < 50
Pneumocystis jiroveci pneumonia is the most
common opportunistic infection associated
with AIDS.
– Hypoxemia may be severe with PO2 <60
– Cornerstone of diagnosis is chest x-ray (diffuse
or perihilar infiltrates)
– Definitive diagnosis can be obtained in 50-80%
of cases by Wright-Giemsa stain or direct
fluorescence antibody test of induced sputum.
Other Infectious
Pulmonary Diseases
Community-acquired pneumonia is the
most common cause of pulmonary disease
in HIV-infected persons.
The incidence of Mycobacterium
tuberculosis (TB) has markedly increased
in metropolitan areas (TB occurs in an
estimated 4% of persons in the US who
have AIDS.)
Noninfectious Pulmonary
Kaposi sarcoma
Non-Hodgkin’s lymphoma
Interstitial pneumonitis
 Sinusitis
Chronic sinusitis can be frustrating
– Non-smoking patients: amoxicillin
– Patients who smoke: amoxicillin-potassium
with clavulanate
– DURATION: most require 3 – 6 weeks
CNS disease
Toxoplasmosis is the most common spaceoccupying lesion in HIV-infected patients.
– Headaches, focal neurologic deficits, seizures or
altered mental status may be presenting
– Diagnosis is made presumptively based on the
characteristic appearance of cerebral imaging
studies in patients with + toxo IgG serology
– “Multiple contrast-enhancing lesions” on CT scan
Other CNS infections
Primary non-Hodgkin’s lymphoma is the
second most common space-occupying lesion
in HIV-infected persons (lymphoma tends to
be more solitary)
AIDS dementia complex: neuropsych testing
Cryptococcal meningitis: + “CRAG” (1273)
HIV myelopathy: leg weakness, incontinence
Progressive Multifocal Leukoencephalopathy
(PML): non-enhancing white matter lesions
Peripheral Neuropathy
Peripheral neuropathy is common
among HIV-infected persons.
Patients complain of numbness, tingling,
and pain in the lower extremities.
Treatment is aimed at symptomatic
relief. Patients are initially treated with
CMV retinitis, characterized by
perivascular hemorrhages and white
fluffy exudates, is the most common
retinal infection in AIDS patients.
Oral Lesions
The presence of oral candidiasis or hairy
leukoplakia is suggestive of HIV infection in
patients who do not know their HIV status.
Hairy leukoplakia is caused by the EpsteinBarr virus.
Angular cheilitis (fissures at the sides of the
mouth), Aphthous ulcers, herpes
stomatitis, gingivitis, Kaposi sarcoma, and
warts (HPV)
Candidal esophagitis, Hepatic Disease,
Billary Disease
Malabsorption syndrome : (do not produce
enough acid) can lead to inability to absorb
drugs that require an acid medium.
Endocrinologic manifestations:
hypogonadism is probably the most
common endocrinologic abnormality in
HIV-infected men
AIDS patients appear to have
abnormalities of thyroid function tests
different from those of patients with other
chronic diseases.
Skin manifestations
Herpes simplex infections: occur more
frequently, tend to be more severe and are
more likely to disseminate in AIDS
Herpes zoster: common manifestation in
HIV infection.
Staphylococcus is the most common
bacterial cause of skin disease in HIVinfected persons.
Immune reconstitution
syndromes or “IRIS”
With initiation of HAART, some patients
experience inflammatory reactions that
appear to be associated with immune
reconstitution as indicated by a rapid
increase in CD4 count. These inflammatory
reactions may present with generalized signs
of fevers, sweats, and malaise with or
without more localized manifestations that
usually represent unusual presentation of
opportunistic infections.
Until vaccination is a reality, prevention of
HIV infection will depend on effective
precautions regarding sexual practices and
injection drug use, use of perinatal HIV
prophylaxis, screening of blood products and
infection control practices in the health care
Primary care clinicians should routinely obtain
a sexual history and provide risk factor
assessment of their patients.
Secondary Prevention
S pneumoniae
Hepatitis B
Hepatitis A (some authorities recommend
HAV for all susceptible patients as defined by
negative HAV serology)
Inactivated Influenza
Daily multi-vitamin
Do not consume raw eggs/meat
Counseling for support of chronic illness
With improvements in therapy, patients
are living longer after the diagnosis of
Sustaining lower mortality will require
developing new treatments for patients
in whom resistance to existing agents
Unfortunately, not all individuals have
access to care.
Contact Information
Patricia R Jennings DrPH, PA_C
Professor and Program Director
Physician Assistant Program
University of Alabama at Birmingham
1720 2nd Ave S., SHPB 482
Birmingham, AL 35294-1212

similar documents