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Medical management of HIV:

Medical management of HIV

HIV – Human Immunodeficiency Virus AIDS – Acquired Immuno Deficiency Syndrome :

HIV – Human Immunodeficiency Virus AIDS – Acquired Immuno Deficiency Syndrome HIV I – Most common HIV ,There are 3 groups of HIV I Group M ( Major ) – It is the most common HIV I , Sub types A,B,C,D,E,F,G,H,I,J and K ( C in common in India ) Group O ( Outlier ) –Seen in west central Africa. Group N ( New ) –Discovered in 1998 in Cameroon. HIV II – HIV II is restricted mainly to Western Africa.


MODES OF TRANSMISSION Sexual (> 75%) – Risk is 1% Homosexual, Heterosexual Parenteral – Blood, blood product transfusion - Risk is > 90% Mother to child - Risk is 0.5 to 1% Injection drug use - Risk 0.2 to 0.5%

HIV Infectious Fluids   :

HIV Infectious Fluids Blood Fluids containing blood Semen Vaginal Secretions Human Breast milk CSF Synovial Fluid Pleural Fluid Peritoneal Fluid Pericardial Fluid Amniotic Fluid

Transmission is possible, if HIV containing material enters the body by :

Transmission is possible, if HIV containing material enters the body by Accidental needle stick injury or by surgical instruments Exposure of damaged skin or mucosal membrane Unprotected sexual intercourse with an HIV infected person Sharing of needles by IV drug abusers Transfusion of HIV contaminated blood or blood products


PATHOPHYSIOLOGY Qualitative and Quantitative deficiency of T. Helper / Inducer cells ( CD4 cells ). Reduction in CD4 count leads to low immunity. Opportunistic infections can occur when the immunity is low.

Lab investigations :

Lab investigations P 24 Antigen HIV Elisa and Western blot (Anti HIV Antibodies) will be positive (Seroconversion) after 3 to 12 weeks(WINDOW period) CD 4 count HIV RNA PCR (Viral load)

HIV antibodies - Enzyme-linked immunosorbent assay(ELISA) :

HIV antibodies - Enzyme-linked immunosorbent assay ( ELISA ) Negative during window period High sensitivity( >99.5%) The test is reported as reactive or nonreactive (Positive or negative) Reactive tests should be repeated. Confirm reactive tests by western blot.

HIV antibodies - Western blot :

HIV antibodies - Western blot Test results can be positive, negative, or indeterminate. Indeterminate test results from nonspecific reactions of HIV-negative sera with some HIV proteins. Reaction with 2 of the following bands is the criteria for positivity: P24, Gp 41, Gp 120/160 If the test is indeterminate, repeat after 3-6 months.

According to UNAIDS/WHO :

According to UNAIDS/WHO The conduct of HIV testing should be confidential Testing should be accompanied by counseling(pre and post test counseling) Informed consent should be taken

CLINICAL PROBLEMS IN HIV / AIDS depending on CD4 count :

CLINICAL PROBLEMS IN HIV / AIDS depending on CD4 count Stage of disease CD 4 count cells/µL Clinical features Early symptomatic disease 200 - 500 Fever ,Unexplained weight loss Seborrhoeic dermatitis , Oral candidiasis Herpes zoster, Pneumonia, TB Late symptomatic disease 50 - 200 Opportunistic infections and malignancy Oesophagial candidiasis Toxoplasma encephalitis Pneumocystis carinii pneumonia Kaposi’s sarcoma Lymphoma Advanced HIV disease <50 Cytomegalo virus retinitis Cryptococcal meningitis Mycobacterium avium complex Histoplasmosis Progressive multifocal leukoencephalopathy AIDS dementia CNS lymphoma AIDS wasting syndrome

Natural History of HIV Infection:

Natural History of HIV Infection Acute HIV syndrome Asymptomatic infection Symptoms of HIV infection AIDS

Acute HIV Syndrome:

Acute HIV Syndrome Acute Fever Rash Pharyngitis Cervical Lymphadenopathy Myalgia Arthralgia

Asymptomatic Infection:

Asymptomatic Infection Patients will be asymptomatic for a longer period for 7 to 10 years Long term non progressors Asymptomatic even after 10 years with normal CD 4 count

Symptoms of Disease:

Symptoms of Disease Oral hairy leukoplakia Recurrent oropharyngeal candidiasis Recurrent vaginal candidiasis Severe pelvic inflammatory disease Bacillary angiomatosis Cervical dysplasia Idiopathic thrombocytopenia Chronic diarrhoea, weight loss Herpes Zoster, peripheral neuropathy Low grade fever, night sweats

Acquired Immuno Deficiency Syndrome (AIDS):

Acquired Immuno Deficiency Syndrome (AIDS) When CD 4 count falls < 200 cells patient develop all types of opportunistic infections AIDS defining diseases Oesophageal candidiasis Pulmonary / Extrapulmonary TB Invasive cervical cancer. Kaposi’s Sarcoma Pneumocystis jiroveci pneumonia

Acquired Immuno Deficiency Syndrome (AIDS):

AIDS defining diseases Cryptococcal meningitis Cryptosporidal diarrhoea CMV Retinitis Disseminated Mycobacterium Avium infection Extrapulmonary histoplasmosis / coccidiodo mycosis Cerebral toxoplasmosis CNS lymphoma HIV - Dementia Acquired Immuno Deficiency Syndrome (AIDS)


HIGHLY ACTIVE ANTI RETROVIRAL TREATMENT (HAART) Indications for starting HAART All patients with AIDS defining illness All patients with CD 4 < 200 cells/mm 3 CD 4 200 to 350 cells/mm 3 should be offered HAART HIV RNA > 100000 copies/ml Antiretroviral therapy should also be initiated in the following groups of patients regardless of CD4 T-cell count: Pregnant women Patients with HIV-associated nephropathy Patients coinfected with HBV when treatment for HBV infection is indicated


HIGHLY ACTIVE ANTI RETROVIRAL TREATMENT (HAART) DRUGS USED IN HAART NRTI NNRTI PI Zidovudine (ZDV, AZT) 300 mg BD Lamivudine (3TC) 150 mg BD Emtricitabine (FTC) 200 mg OD Tenofovir 300 mg OD Zalcitabine 0.75 mg TID Abacavir 300 mg BD Didanosine ( ddI ) (400 OD if weight > 60 kg, 250 OD weight < 60Kg) Stavudine (d4T) (40 BD if weight >60 kg, 30 BD weight < 60Kg) Delavirdine 400 TID Efavirenz 600 HS Nevirapine 200 mg OD for 1 st 14 days ,Then 200 mg BD Indinavir Lopinavir Nelfinavir Ritonavir Saquinavir Most preferred NNRTI based regimen Efavirenz(not in pregnancy) + ( Lamivudine or Emtricitabine) + (Zidovudine or Tenofovir) Most preferred PI based regimen (Lopinavir + ritonavir ) + ( Lamivudine or Emtricitabine) + Zidovudine


HIV IN PREGNANCY Pregnant women should be offered screening for HIV early in pregnancy because appropriate antenatal interventions can reduce maternal-to-child transmission of HIV infection. Advanced maternal HIV disease, low antenatal CD4 T-lymphocyte counts and high maternal plasma viral loads are associated with an increased risk of mother-to-child transmission Women who are HIV positive are advised not to breastfeed . It is estimated that breastfeeding increases the overall mother-to-child HIV transmission rate by 14% All women who are HIV positive should be advised to take anti-retroviral therapy during pregnancy and at delivery.

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