Approach to HIV

Dr. Tejaswee Banavathu

Topics to be discussed:
• Introduction
• Epidemiology
• Virus Characteristics
• Pathogenesis and Life cycle of HIV
• Transmission
• Staging and Clinical features
• Diagnosis
• Brief on Opportunistic infections
Introduction:
• HIV is a single stranded human retrovirus which has RNA dependant
DNA polymerase
• Causes infection and CD4 cell depletion
• Severe immunosuppression Opportunistic infections, secondary
malignancies and systemic manifestations

• AIDS: Advanced stage of HIV infection

Clinical diagnosis of any Stage IV condition or CD4 cell count <
200 cells/cumm or < 15 % with confirmed HIV infection
Global Epidemiology:
Indian Epidemiology:
• Adult (15–49 years) HIV prevalence was estimated at 0.22% (0.17%–0.29%) i.e
23.19 lakh (18.33 lakh– 29.78 lakh) in 2020

• HIV incidence was estimated at 0.04 (0.02–0.09) per 1,000 uninfected population in the calendar
year 2020

• 51,000 (34,800–77,200) deaths among PLHIV in 2020, with almost 63% deaths being AIDS-related

• Nationally, there were an estimated 20.93 thousand (15.33 thousand–29.08 thousand) pregnant
women in 2020 who were estimated to require ART to PMTCT of HIV

• SOURCE: NACO 2020

Virus Characteristics:
Viral genes:
Pathogenesis and Life cycle of HIV:

1.Binding and Fusion

2,3.Reverse transcription
4.Integration
5.Transcription
6.Assembly
7.Budding
Drug targets:
Transmission:
Exposure route Transmission
Blood transfusion 90-95%
Perinatal 15-30%
Sexual intercourse 0.1-1%
Vaginal 0.08-0.19%
Anal 0.5-3.38 % for receptive
anal intercourse
0.06-0.16% for insertive
anal intercourse
Oral 0.005-0.01%
Injection drug users 0.63-2.14%
Needle stick injury 0.23%
Mucous membrane 0.09%
splash to eye or oro-nasal
• Incubation period – For AIDS development, ranges from months to 10
years or even more

• Window period: Time between potential exposure to HIV infection

and appearance of antibodies in blood: 4-12 weeks

• Sero-conversion: Development of evidence of antibody response to a

disease

• Viral Load: The amount of HIV in the blood.

Staging and clinical features:
WHO CLINICAL STAGING
• Primary HIV Infection:
• Asymptomatic
• Acute retroviral syndrome

• Clinical stage 1:
• Asymptomatic
• Persistent generalised lymphadenopathy
Acute HIV syndrome:
DISEASE PROGRESSION THROUGH DIFFERENT
STAGES:
Clinical stage 2:
• Moderate unexplained weight loss
(<10% of presumed or measured body weight)
• Recurrent respiratory tract infections
(sinusitis, bronchitis, otitis media, pharyngitis)
• Herpes zoster
• Angular cheilitis
• Recurrent oral ulcerations
• Papular pruritic eruptions
• Seborrhoeic dermatitis
• Fungal nail infections of fingers
Clinical stage 3:
• Severe weight loss (>10% of presumed or measured body weight)
• Unexplained chronic diarrhoea for longer than one month
• Unexplained persistent fever (intermittent or constant for longer than
one month)
• Oral candidiasis
• Oral hairy leukoplakia
• Pulmonary tuberculosis (TB) diagnosed in last two years
• Severe bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone or
joint infection, meningitis, bacteraemia)
• Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
• Unexplained Anaemia(<8gm/dL), Neutropenia (<0.5x10*9/L)
And/Or Chronic Thrombocytopenia (50x10*9/L)
Clinical stage 4:
• HIV wasting syndrome
• Pneumocystis carinii pneumonia (PCP)
• Recurrent severe bacterial pneumonia
• Chronic Herpes Simplex infection
( Orolabial, Genital or ano-rectal of <1 months duration or visceral at any site)
• Candidiasis (Esophageal/ Trachea/ Bronchi/Lungs)
• EPTB
• Kaposis Sarcoma
• CMV infection (Retina or other organs)
• CNS Toxoplasmosis
• HIV Encephalopathy
• Extra-Pulmonary Cryptoccocosis
• Disseminated Mycosis
• Recurrent Septicaemia
• Lymphoma (B-cell Non Hodgkins)
• Invasive Cervical Carcinoma
• Atypical disseminated Leishmaniasis
• Symptomatic HIV-associated Nephropathy or Cardiomyopathy.
OPPORTUNISTIC INFECTIONS:
CDC case definition of HIV infection:
Category A

• Asymptomatic or Latent infection

• Acute HIV infection
• Persistent generalized lymphadenopathy (PGL)
Category B
HIV infection with symptoms that are directly attributable to HIV infection (or a defect in T-cell–
mediated immunity) or that are complicated by HIV infection

• Constitutional symptoms, such as fever (>38.5°C) or diarrhoea lasting more than 1 month
• Bacillary angiomatosis
• Oropharyngeal candidiasis (thrush)
• Vulvovaginal candidiasis, persistent or resistant
• Pelvic inflammatory disease (PID)
• Cervical dysplasia (moderate or severe)/cervical carcinoma in situ
• Oral hairy leukoplakia
• Herpes zoster (shingles), involving 2 or more episodes or 1 or more dermatomes
• Idiopathic thrombocytopenic purpura
• Peripheral neuropathy
Category C:

Same as WHO stage 4 with

included
• Pulmonary TB
• Recurrent salmonella septicemia
Neurological diseases:
Malignancies:
Patterns of HIV progression:
Non controller: Plasma HIV-RNA >10,000 copies/ml
Rapid progressors: CD4 count < 300 cells/ μL within 3 years after the
last HIV seronegative test
Slow progressors: 8 or more years with a CD4 cell counts above 500
Long term non progressors: 10 years during follow up, asymptomatic
with a CD4 count above 500 cells/ μL
Elite controllers: Viral load below 50 copies/ml and maintain normal
CD4 counts
Viremic controller: Maintain viral loads of < 2000 RNA copies/ml
Diagnosis:
1.Serology
ELISA
3. Recognition of
RDT
SDT
immunodeficiency
Western blot/Immunoblot
CD4+ T cell count
2.Antigen detection
p24 antigen detection
Culture
RNA PCR
DNA PCR 4.Recognition of AIDS
related disease
Monitoring response to ART:
Opportunistic infections: