HIV and AIDS

Cimafranca, Conde, Garas, Ejera, Rivera

What is HIV?
HIV or Human Immunodeficiency Virus is a retrovirus. A retrovirus has a RNA genome and a reverse transcriptase enzyme. Using the reverse transcriptase, the virus uses its RNA as a template for making complementary DNA which can integrate into the DNA of the host organism. It attacks the immune system which is the bodys natural defense system. HIV invades and destroys certain white blood cell called CD4+ cells. If too many CD4+ cells are destroyed, the body can no longer defend itself against infection.

What is AIDS?
AIDS or Acquired Immune Deficiency Syndrome is an infectious disorder that suppresses the normal function of the immune system. It is caused by the human immunodeficiency virus (HIV), which destroys the body's ability to fight infections. Specific cells of the immune system that are responsible for the proper response to infections (T cells) are destroyed by this virus.

STRUCTURE OF THE VIRUS

An HIV particle is around 100150 billionths of a meter in diameter. The viral core (or capsid) is usually bullet-shaped and is made from the protein p24. Inside the core are three enzymes required for HIV replication called reverse transcriptase, integrase and protease. Also held within the core is HIV's genetic material, which consists of two identical strands of RNA.

Types of HIV
HIV 1 HIV 2 1. Most common 1. Less common 2. Globally spread out 2. Concentrated in areas of Western Africa 3. Greater number of antiretroviral therapies 3. Lesser number of medical development 4. Faster rate of infection, stronger strain (in 4. Slow rate of infection, earlier stages) weaker strain (in earlier stages) 5. Less infectious in late stages 5. Does more damage in late stages, more infectious

Global statistics
AIDS is the sixth leading cause of death among people ages 25 - 44 in the United States, down from number one in 1995. The World Health Organization estimates that more than 25 million people worldwide have died from this infection since the start of the epidemic. In 2008, there were approximately 33.4 million people around the world living with HIV/AIDS, including 2.1 million children under age 15.

HIV
Transmission & Symptoms

Spreading the VIRUS

through sexual contact. through blood transfusion or needle sharing. from mother to child.

Through sexual contact

+ Most commonly, HIV infection is spread by having
sex with an infected partner. The virus can enter the body through the lining of the vagina, vulva, penis, rectum, or mouth during sex. People who already have a sexually transmitted disease are more likely to acquire HIV infection during sex with an infected partner.

Through blood transfusion or needle sharing

+ HIV frequently spreads among injection-drug users

+
who share needles or syringes that are contaminated with blood from an infected person. HIV can be spread in health-care settings through accidental needle sticks or contact with contaminated fluids.

Through blood transfusion or needle sharing

+ Very rarely, HIV spreads through transfusion of

contaminated blood or blood components. Blood products are now tested to minimize this risk. If tissues or organs from an infected person are transplanted, the recipient may acquire HIV. Donors are now tested for HIV to minimize this risk.

From mother to child

+ HIV can pass to the baby during pregnancy, during
+
the birth of the baby, or through breast-feeding. Only about one in three babies born to HIV-positive mothers get HIV.

The virus does NOT spread through casual contact

+ such as preparing food, sharing towels and

bedding, or via swimming pools, telephones, or toilet seats. The virus is also unlikely to be spread by contact with saliva, unless it is contaminated with blood.

Signs & Symptoms

many people with HIV do not know they are infected.

Many people do not develop symptoms after they first get infected with HIV. Others have a flu-like illness within several days to weeks after exposure to the virus. They complain of +Fever +Headache +Fatigue +Sore throat +Muscle stiffness +Enlarged lymph nodes in the neck.

+ These symptoms usually disappear on their own

within a few weeks. After that, the person feels normal and has no symptoms. This asymptomatic phase often lasts for years. The progression of disease varies widely among individuals. This state may last from a few months to more than 10 years. During this period, the virus continues to multiply actively and infects and kills the cells of the immune system.

The infections that happen with AIDS, the later stage of HIV infection, are called opportunistic infections because they take advantage of the opportunity to infect a weakened host. The infections include (but are not limited to)

+ Pneumonia which causes wheezing;

+
+
Brain infection with toxoplasmosis which can cause trouble thinking or symptoms that mimic a stroke; Widespread infection with a bacteria called MAC (mycobacterium avium complex) which can cause fever and weight loss; Widespread diseases with certain fungi like histoplasmosis, which can cause fever, cough, anemia, and other problems.

+ Yeast infection;
+

A weakened immune system can also lead to other unusual conditions:

+ lymphoma in (a form of cancer of the lymphoid

tissue) the brain, which can cause fever and trouble thinking. a cancer of the soft tissues called Kaposi's sarcoma, which causes brown, reddish, or purple spots that develop on the skin or in the mouth.

People known to have HIV infection or AIDS should seek immediate medical attention when they develop high fever, shortness of breath, coughing up blood, severe diarrhea, severe chest or abdominal pain, generalized weakness, severe headache, seizures, confusion, or a change in mental status.

These may be the indication of a lifethreatening condition for which an urgent evaluation in the hospital's emergency department is recommended. All infected people should be under the regular care of a physician skilled in the treatment of HIV and AIDS.

TESTS and DIAGNOSIS OF HIV

Number of HIV Cases per month(2009-2011) in the Philippines

*HIV testing must be done because of the increasing cases of the spread of the virus
http://www.pnac.org.ph/uploads/documents/publications/NEC_HIV_Jan-AIDSreg2011.pdf

Purpose of Testing for HIV Infection

in Blood donors to prevent infected blood being transfused. To diagnose the patients infected with HIV virus. For surveillance purpose. Persons with high risk behavior. In Pregnant women to prevent Mother to Child transmission. Patient's presenting with opportunistic infections.

seroconversion or "window" period

period between becoming infected with HIV and when antibodies to HIV can be detected. antibody tests may give a false negative result an infected person can still spread the disease, even though a test will not detect any antibodies. After the original infection, it takes between 2 weeks and 6 months for antibodies to HIV to appear in the blood.

Screening Tests
detects antibodies or antigens (not the virus) against HIV or the genetic material (DNA or RNA) of HIV. This determines if HIV infection is present HIV infects white blood cells called CD4+ cells, which are part of the body's immune system that help fight infections. Highly Sensitive Serological test- testing of blood serum, the clear liquid that separates from the blood when it is allowed to clot. The purpose of such a test is to detect serum antibodies

MOST COMMON HIV TESTS

Tests to find out if infected with HIV
HIV antibody tests
ELISA (a screening test) Western blot (mostly a confirmatory test)

Tests if diagnosed with the virus

CD4 test PCR test/viral load test

P24 antigen test

Interpreting HIV test

Reactive or Positive
HIV antibodies are present and you are infected with HIV (called "HIV positive")

Non-reactive or Negative
most likely you are not infected with HIV. However, it can take 3 to 6 weeks, and sometimes up to 3 months(and in few cases up to 6 mo.) before HIV antibodies show up on a standard test

Interpreting HIV test

Invalid/indeterminate/inconclusive
neither positive nor negative. This may be a result of:
Recent HIV infection, Prior blood transfusions, even with non-HIV infected blood, Prior or current infection with syphilis, malaria, or other viruses, An autoimmune disease such as lupus or diabetes, Being a recipient of an experimental HIV vaccine, Or problems with the test procedure itself, such as contamination of blood sample.

Test should be repeated!

False positive results

a positive result will sometimes be obtained even there are no HIV antibodies in the blood. *All positive results must be confirmed by a 2nd test and all confirmed positive result from the 2nd test confirms that you are HIV+.

False-Negative results
A negative result when in fact the person is infected with HIV *ELISA results may produce 20-30% False Negative results in HIV-2 infection

Sensitivity and Specificity

The validity of a test is a function of both its sensitivity and specificity These indices are usually estimated by administering the test to a group of persons who have the disease and to another group who do not and then comparing the results. - true positives (TP), have the disease and have been tested positive; - false positives (FP), do not have the disease but have been tested positive; - true negatives (TN), do not have the disease and have been tested negative; - false negatives (FN), have the disease and have been tested negative.

Sensitivity and Specificity

The sensitivity, Se, is the probability that the result of the test will be positive if the person is infected

The specificity, Sp, is the probability that the result of the test will be negative if the person is not infected

Confirmatory (supplemental) Tests in AIDS

It is important to confirm all screening

tests with Confirmatory tests or we may brand someone without infection as infected Confirmatory tests differentiates false reactive tests and identifies if truly infected or not.

Differences of Screening and Confirmatory Tests

Screening test
High degree of sensitivity Few false negatives

Confirmatory test
High degree of specificity Few/No false positive results.

HIV antibody test

inexpensive and very accurate. When a person is infected with HIV, their body responds by producing special proteins that fight infection, called antibodies. Most people develop detectable HIV antibodies within 6 to 12 weeks of infection. In very rare cases, someone would take longer than 6 months to develop antibodies.

How do antibody tests work?

Antibodies looked in blood, saliva or urine. If detected, it means a person has been infected with HIV. There are only two exceptions to this rule:
Babies born to HIV infected mothers. Normally babies who are born to HIV positive mothers receive a PCR test after birth. people who have taken part in HIV vaccine trials may have HIV antibodies even if they are not infected with the virus.

(ELISA)Enzyme-linked immunosorbent assay/(EIA)enzyme immunoassay

first HIV test to be widely used. If antibodies to HIV are present, the test is usually repeated to confirm the diagnosis. If ELISA is negative, other tests are not usually needed. has low chance of having a false result after the first few weeks that a person is infected. A common method used in Blood banks in mass screening of Human blood.

Sequence of Events in ELISA test

Significance of ELISA
Most reliable screening test for HIV infection. 50% of the infected will show positive reactivity in < 22 days. 95% show reactivity < 6 weeks Sensitivity > 99.9 % But needs confirmation with Western Blot.

WESTEN BLOT TEST

A Gold standard confirmatory test. When tested combined with ELISA specificity is > 99.9 %. This test is more difficult than the ELISA to perform, but it is done to confirm the results of two positive ELISA tests.

Negative Western Blot

Absence of any reactivity to the bands is declared as Negative. False positives are rare. All doubtful results should be reported as Negative.

Limitation of Western Blot Test

If not designed for HIV 2 inclusion, we miss HIV2 infections, Can give Indeterminate results in Pregnancy After administration of Tetanus Toxoid Autoimmune conditions.

Antigen test (P24 test)

Antigens are the substances found on a foreign body that trigger the production of antibodies in the body. antigen on HIV that most commonly provokes an antibody response is the protein P24. P24 is produced in excess and can be detected in the blood serum (although as HIV becomes fully established in the body it will fade to undetectable levels). P24 antigen tests are not usually used for general HIV diagnostic purposes, as they have a very low sensitivity and they only work before antibodies are produced in the period immediately after HIV infection

Polymerase chain reaction (PCR)

This test finds either the RNA of the HIV virus or the HIV DNA in white blood cells infected with the virus. not done as frequently as antibody testing for it requires technical skill and expensive equipment. very useful to find a very recent infection, determine if an HIV infection is present when antibody test results were uncertain, and screen blood or organs for HIV before donation.

PCR test
aka viral load test and HIV NAAT (nucleic acid amplification testing). can identify HIV in the blood within two or three weeks of infection. Babies born to HIV positive mothers are usually tested using a PCR test Blood supplies in most developed countries are screened for HIV using PCR tests.

Rapid HIV tests

based on the same technology as ELISA tests, can use either a blood sample or oral fluids. do not require lab facilities or highly trained staff. All positive results from a rapid test must be followed up with a confirmatory test, the results of which can take from a few days to a few weeks.

Rapid tests in the Diagnosis of AIDS

A growing importance Results can be issued within < 20 minutes. Limited protocols, and less demanding technical skills. But needs confirmation with ELISA / Western Blot testing. Can differentiate HIV 1 and HIV 2.

Home sampling
With a home sampling kit, a person can take a sample (usually a blood sample) and send it to a laboratory for testing. advantages are convenience, speed, privacy and anonymity.

Home testing
A home self-test involves a person conducting a rapid antibody HIV test in their home. The person takes either a blood or saliva sample and can interpret the result within minutes. A positive result will require a further confirmatory bloodtest in a clinic. In many countries it is illegal to sell HIV test kits to the public. If a test is purchased over the internet, there is no guarantee that the test kit is genuine or will provide accurate results.

HIV PREVENTION

HIV can be transmitted in three ways: Sexual Transmission Transmission through Blood

Mother-to-Child Transmission

Sexual transmisson
The ABC Approach
1) 1992 VERSION
- Abstain from sex
- Be faithful if you do not abstain

- Use a Condom if you are not faithful

SEXUAL TRANSMISSION
2) UNAIDS DEFINITION OF ABC
- Abstinence
- Being safer, by being faithful to just one partner - Correct and consistent use of condoms

sexual transmission

Use A Condom
- Condoms when used consistently
and correctly are the only form of protection that can help stop the transmission of STDs, such as HIV and it also prevents pregnancy.

TRANSMISSION THROUGH BLOOD

Needle Exchange and Harm Reduction
- Needle exchange programs have been shown to reduce the number of new HIV infections without encouraging drug use. These programs distribute clean needles and safety dispose of used ones, and also offer related services such as referrals to drug treatment centers and HIV counseling and testing. Needle exchanges are a necessary part of HIV prevention in any community that contains injecting drug users.
.

TRANSMISSION THROUGH BLOOD

Blood Transfusion
- Transfusion of infected blood or blood products is the most efficient of all ways to transmit HIV. However, the chances of this happening can be greatly reduced by screening all blood supplies.

Mother to child transmission

Is when an HIV-infected woman passes the virus to her baby. This can occur during pregnancy, labor and delivery, or breastfeeding. Without treatment, around 15-30 percent of babies born to HIV-infected women will become infected with HIV during pregnancy and delivery. A further 5-20 percent will become infected through breastfeeding.

MOTHER TO CHILD TRANSMISSION

In 2009, around 400,000 children under 15 became infected with HIV, mainly through mother-to-child transmission. About 90% of these MTCT infections occurred in Africa where AIDS is beginning to reverse decades of steady progress in child survival.

MOTHER TO CHILD TRANSMISSION

Effective prevention of mother-to-child transmission (PMTCT) requires a three-fold strategy. Preventing HIV infection among prospective parents

Avoiding unwanted pregnancies among HIV positive women Preventing the transmission of HIV from HIV positive mothers to their infants during pregnancy, labour, delivery and breastfeeding.

- Integration of HIV care, treatment and support for women found to be positive and their families.

MOTHER TO CHILD TRANSMISSION

Antiretroviral drugs
- Single dose nevirapine
a) The simplest of all PMTCT drug regimens was tested in the HIVNET 012 trial, which took place in Uganda between 1997 and 1999. This study found that a single dose of nevirapine given to the mother at the onset of labor and to the baby after delivery roughly halved the rate of HIV transmission.