Basic%20HIV%20

1
Basic HIV AIDS Education for Health Care
Providers

• Patricia R Jennings DrPH, PA-C
• Professor
• University of Alabama at Birmingham

2
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.

3
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.

4
CDC Recommendations for HIV testingAdults 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
  recommended
• Prevention counseling in conjunction with HIV
  screening in health care settings is not required

5
Recommendations for HIV testingAdults 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 providers

6
CDC AIDS case definition for surveillance of
adults and adolescents

• (1) Definitive AIDS diagnosis (with or without
  laboratory evidence of HIV infection)
• (2) Definitive AIDS diagnoses (with laboratory
  evidence of HIV infection)
• (3) Presumptive AIDS diagnoses (with laboratory
  evidence of HIV infection)

7
SummaryPatients have AIDS when

• They are HIV with a CD4 cell count that is or
  ever has been less than 200 cells/mm3
• 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 count

8
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

9
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 male-to-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.

10
Estimated Number of AIDS Cases, Deaths, and
Persons Living with AIDS,1985-2004, United States
450
90
AIDS
1993 definition
implementation
400
Deaths
80
Prevalence
350
70
60
300
No. of cases and deaths (in thousands)
250
50
Prevalence (in thousands)
200
40
150
30
20
100
10
50
0
0
Year of diagnosis or death
Note. Data adjusted for reporting delays.
11
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.

12
Pathogenesis

• 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 co-receptors
  (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 slowly.

13
HIV Lifecycle
14
Natural History of Untreated HIV Infection
15
Untreated HIV Infection Stages

• 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
• Death

16
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
  detection.
• 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.

17
Testing Methods

• Screening test ELISA, high sensitivity
• Confirmatory test Western Blot, high specificity
• NEVER suggest that a client/patient donate blood
  to determine their HIV Status

18
CLIA Waived Rapid Tests
Uni-Gold Recombigen
OraQuick Advance
19
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 IFA
• Indeterminate tests should be repeated in 1 month

20
Mass Screening

• The recommendation is to pool seronegative
  specimens for PCR testing, with PCR testing of
  individual samples from any batch that tests
  positive.
• In N.C., use of this method found that acute
  infections accounted for 4-10 of all newly
  detected HIV infections.

21
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

22

• Diagrammatic representation of the manifestations
  of HIV seroconversion.

23
(No Transcript)
24
Clinical Latency

• usually asymptomatic
• lymph nodes site of ongoing viral latency
• massive viral production
• destruction of CD4 cells

25
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 dementia

26
(No Transcript)
27
(No Transcript)
28
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

29
Initial Laboratory TestingTable

• 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 gt1 major
  mutation in treatment naïve patients is 6-19
• genotype if newly diagnosed pt
• naïve patient with elevated viral load

30
Initial Laboratory Tests

• CBC G6-PD
• renal and liver function tests, cholesterol and
  triglyceride panel (fasting baseline)
• RPR, STD screening (including wet mount for
  trichomonas in women), hepatitis serologies
• toxoplasmosis IgG CMV IgG Varicella IgG (if
  negative history of chickenpox)
• PPD /- chest radiograph
• Pap smear (cervical, /- anal)

31
HIV Lifecycle
32
Therapeutic Arsenal

• Fusion Inhibitors
• CCR5 inhibitors
• Nucleoside Reverse Transcriptase Inhibitors
  (NRTIs)
• Nucleotide Reverse Transcriptase Inhibitors
• Non-nucleoside Reverse Transcriptase Inhibitors
  (NNRTIs)
• Integrase Inhibitors
• Protease Inhibitors (PIs)

33
Initiate Antiretroviral Therapy

• Treat all symptomatic patients
• AIDS or severe symptoms
• Treat asymptomatic patients with CD4 lt 200
• Offer treatment to asymptomatic patients CD4 200
  500
• Defer treatment to patients with CD4 gt
  500 unless VLgt 100,000

34
Goals of Therapy

• Clinical Goals
• Virologic Goals
• Immunologic Goals
• Therapeutic Goals
• Epidemiologic Goals

35
Health MaintenanceTable

• Memorize table 31-3

36
Relationship of CD4 count to development of
opportunistic infections (Figure 31-1)

• Bacterial infections, HSV, VZV, Vaginal
  candidiasis, KS, M Tuberculosis (PPD gt 5mm
  induration)
• Pneumocystis jiroveci
• CD4 lt 200
• Toxoplasmosis gondii, cryptococcosis
• CD4 lt 100
• M avium complex, CMV retinitis, CNS lymphoma
• CD4 lt 50

37
Pulmonary

• Pneumocystis jiroveci pneumonia is the most
  common opportunistic infection associated with
  AIDS.
• Hypoxemia may be severe with PO2 lt60
• 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.

38
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.)

39
Noninfectious Pulmonary Diseases

• Kaposi sarcoma
• Non-Hodgkins 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

40
CNS disease

• Toxoplasmosis is the most common space-occupying
  lesion in HIV-infected patients.
• Headaches, focal neurologic deficits, seizures or
  altered mental status may be presenting symptoms.
• 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

41
Toxoplasmosis
42
Other CNS infections

• Primary non-Hodgkins 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

43
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 gabapentin.

44
Retinitis

• CMV retinitis, characterized by perivascular
  hemorrhages and white fluffy exudates, is the
  most common retinal infection in AIDS patients.

45
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 Epstein-Barr
  virus.
• Angular cheilitis (fissures at the sides of the
  mouth), Aphthous ulcers, herpes stomatitis,
  gingivitis, Kaposi sarcoma, and warts (HPV)

46
Gastrointestinal Manifestations

• 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.

47
Endocrinologic Manifestations

• 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.

48
Skin manifestations

• Herpes simplex infections occur more frequently,
  tend to be more severe and are more likely to
  disseminate in AIDS patients.
• Herpes zoster common manifestation in HIV
  infection.
• Staphylococcus is the most common bacterial cause
  of skin disease in HIV-infected persons.

49
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.

50
Prevention

• 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 setting.
• Primary care clinicians should routinely obtain a
  sexual history and provide risk factor assessment
  of their patients.

51
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

52
Summary

• With improvements in therapy, patients are living
  longer after the diagnosis of AIDS.
• Sustaining lower mortality will require
  developing new treatments for patients in whom
  resistance to existing agents develops.
• Unfortunately, not all individuals have access to
  care.

53
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
• 205-934-4432