1

HIV & AIDS ARE

DIFFERENT ENTITIES
Receptor
Nucleus

DNA

• 38 million
•70% of the people
• 2.1 million children
 Top HIV/AIDS-Infected Countries
1. South Africa 9. United States
2. Nigeria 10. Russian Federation
3. Zimbabwe 11.China
Sub- 4. Tanzania
Saharan 12. Brazil
Africa 5. The Congo
13. Thailand
6. Ethiopia
7. Kenya
8. Mozambique

Source: Steinbrook R. The AIDS epidemic in 2004. NEJM. 2004;351:115-117.

 Figure 1
The U.S. Epidemic: Snapshot of Key
Data
New infections 40,000
each year
People living with 1,039,000 –
HIV/AIDS 1,185,000
People with 42 – 59%
HIV/AIDS not in
care
People with HIV 24 – 27%
who don’t know
they’re infected
Note: Data are estimates.
Sources: CDC, 2005; Glynn, K. et al., CDC, "Estimated HIV prevalence in the United States at the end
of 2003", Presentation at the National HIV Prevention Conference, 2005; Fleming, P., et al., “HIV
Prevalence in the United States 2000”, 9th Conference on Retroviruses and Opportunistic Infections,
2002.
 Perjalanan Klinis Infeksi HIV.

TERINFEKSI 2-3 mgg Acute Retroviral

Syndrome

2-3 mgg

Sembuh
Seroconvesion

1,3 TH AIDS 8 THN ASIMTOMATIK

IS THERE A CURE?

There is
NO
cure for
HIV/AIDS
 Figure 20

HIV Prevention
• Centers for Disease Control and
HIV Prevention Funding Prevention (CDC)
at CDC, FY 1995-2005 – Most prevention
(US $ Millions) funding
– Funds go to states; some
1995 $589.8 cities; community based
1997 $616.8 organizations; other
All Other entities/programs
1999
Medicare 51% ($6.0B) $656.6 • Additional prevention funding also at:
Department of Veterans Affairs,
2001 $749.7 SAMHSA, and other agencies
Ryan
White • National HIV prevention goal (reduce
2003 $793.6 new infections by 50% by 2005) was
not met
2005 $731.7

Sources: CDC, Personal Communication, 2006; CDC, HIV Prevention

Strategic Plan Through 2005.
Pertama Kali Timbul di Afrika, Haiti dan USA 1978
 1979 Sarkoma Kaposi pada orang Afrika yang mukim di Eropa
 1981 USA . Sarkoma Kaposi di kalangan Homo Seks
 1982 Luc Montagnier ,Paris.
LAV (Limphadenonathy Associated Virus)
 1984 Transmisi Heteroseks, Galo dkk. HTLV IIII
 1986 Penyebab AIDS adalah HIV
• Indonesia :
• Kasus pertama ( BALI ) :April 1987. Wisatawan Belanda
• Kasus kedua ( Jakarta ) :Nopember 1987. Warga Kanada tinggal
di JKT.
• Kasus ketiga ( Jakarta ) : 1989. Warga Perancis tinggal di JKT
• Orang Indonesia Pertama di Bali: Juni 1988
Characteristics of the virus
HIV
• The outer shell of the virus is
known as the Viral enevlope.
Embedded in the viral
envelope is a complex protein
known as env which consists of
an outer protruding cap
glycoprotein (gp) 120, and a
stem gp14. Within the viral
envelope is an HIV protein
called p17(matrix), and within
this is the viral core or capsid,
which is made of another viral
protein p24(core antigen).
10
11
 Life Cycle
• (a) HIV (red) attaches to two cell-surface receptors (the CD4
antigen and a specific chemokine receptor).
• (b) The virus and cell membrane fuse, and the virion core enters
the cell.
• (c) The viral RNA and core proteins are released from the virion
core and are then actively transported to the nucleus.
• (d) The viral RNA genome is converted into double-stranded
DNA through an enzyme unique to viruses, reverse transcriptase
(red dot).
• (e) The double-stranded viral DNA moves into the cell nucleus.
• (f) Using a unique viral enzyme called integrase, the viral DNA is
integrated into the cellular DNA.
• (g) Viral RNA is synthesized by the cellular enzyme RNA
polymerase II using integrated viral DNA as a template. Two
types of RNA transcripts shorter spliced RNA (h) and full-length
genomic RNA (j) are produced.
• (h) Shorter spliced RNAs are transported to the cytoplasm and
used for the production of several viral proteins that are then
modified in the Golgi apparatus of the cell (i).
• (j) Full-length genomic RNAs are transported to the cytoplasm
(k).
• (l) New virion is assembled and then buds off.
• (m) Mature virus is released.
 Viral Replication
• First step, HIV attaches to susceptible host cell.
– Site of attachment is the CD4 antigen found on a variety of
cells
• helper T cells
• macrophages
• monocytes
• B cells
• microglial brain cells
• intestinal cells
– T cells infected later on.
 Early Phase HIV Infection
• In early phase HIV infection,
initial viruses are M-tropic.
Their envelope glycoprotein
gp120 is able to bind to CD4
molecules and chemokine
receptors called CCR5 found
on macrophages
• In late phase HIV infection,
most of the viruses are T-
tropic, having gp120
capable of binding to CD4
and CXCR4 found on T4-
lymphocytes.
 Early Phases of HIV Infection of
Mucosal Surfaces

Cell free
HIV

T-cell
Immature
Dendritic cell PEP

Skin or Via lymphatics or Burst of HIV

mucosa circulation replication
24 hours 48 hours

1. HIV co-receptors, 2. Selective of 3. Mature Dendritic cell in

CD4 + chemokine macrophage- regional LN undergoes
receptor CC5 tropic HIV a single replication,
which transfers HIV to
T-cell 15
HIV (arrows) Infecting a T-lymphocyte
 Human

HIV Immunodeficiency
Virus
 Virus penyebab AIDS
 Melemahkan sistem kekebalan tubuh
(sel darah putih)
Acquired
Immune
Deficiency
Syndrome
AIDS  Kumpulan beberapa gejala akibat
menurunnya sistem kekebalan tubuh
yang disebabkan oleh HIV.
 CD4 Count in HIV infection

• The CD4 cell , also known as "T4" or "helper T cell“ is responsible for
signaling other parts of the immune system to respond to an infection.

• Normal counts range from 500 to 1500 cells per cubic millimeter of blood

• Initially in HIV infection there is a sharp drop in the CD4 count and then
the count levels off to around 500-600 cells/mm3.

• CD4 count is a marker of likely disease progression. CD4 percentage tends

to decline as HIV disease progresses.

• CD4 counts can also be used to predict the risks for particular conditions
such as Pneumocystis carinii pneumonia, CMV disease or MAI disease.

• Treatment decisions are often based on Viral Load and CD4 count.
 Siapapun bisa tertular HIV, jika perilakunya
berisiko.
 Penampilan luar bukan jaminan bebas HIV.
 Orang dengan (+)HIV sering terlihat sehat dan
merasa sehat.
 Jika belum melakukan tes HIV, orang dengan
(+)HIV tidak tahu bahwa dirinya sudah tertular
HIV dan dapat menularkan HIV pada orang lain.
 Tes HIV adalah satu-satunya cara untuk
mendapatkan kepastian tertular HIV atau tidak.
Tertular Periode HIV AIDS
HIV Jendela* Positif

2 minggu - 6 bulan 3 - 10 1 - 2
Tahun Tahun
* Masa antara masuknya HIV ▪ Tanpa Gejala ▪ Timbul
kedalam tubuh manusia ▪ Tampak sehat infeksi
sampai terbentuknya antibody ▪ Dapat berakti- oportunistik
terhadap (+)HIV. vitas biasa.
Sudah bisa menularkan HIV
kepada orang lain.
 ‘typical’ primary HIV-1 infection
symptoms symptoms
HIV proviral DNA

HIV antibodies
‘window’
period

HIV viral load

HIV-1 p24 antigen

0 1 2 3 4 5 6 / 2 4 6 8 10
1° infection weeks years
Time following infection
Natural History of Untreated HIV
Infection
 Four Stages of HIV
Stage 2 -
Stage 1 - Primary
Asymptomatic
• Short, flu-like • Lasts for an average of ten
illness - occurs one years
to six weeks after • This stage is free from
infection symptoms
• no symptoms at all • There may be swollen
glands
• Infected person • The level of HIV in the
can infect other blood drops to very low
people levels
• HIV antibodies are
detectable in the blood
 Stage 3 -
Symptomatic
Stage 4 - HIV  AIDS
• The symptoms are mild
• The immune system
• The immune system
deteriorates weakens
• emergence of
opportunistic infections
and cancers
• The illnesses become
more severe leading
to an AIDS diagnosis
 Opportunistic Infections associated
with AIDS
• Bacterial
– Tuberculosis (TB)
– Strep pneumonia
• Viral
– Kaposi Sarcoma
– Herpes
– Influenza (flu)
• Parasitic
– Pneumocystis carinii
• Fungal
– Candida
– Cryptococcus
 AIDS
• CD4 count drops below 200 person is considered to have
advanced HIV disease
• If preventative medications not started the HIV infected
person is now at risk for:
– Pneumocystis carinii pneumonia (PCP)
– cryptococcal meningitis
– toxoplasmosis
• If CD4 count drops below 50:
– Mycobacterium avium
– Cytomegalovirus infections
– lymphoma
– dementia
– Most deaths occur with CD4 counts below 50.
 HIV menular melalui :
 Menggunakan jarum suntik :
 secara bergantian
 bekas pakai
 tidak steril
 Hubungan seks berganti-gantian pasangan
 Dari ibu ke bayi melalui :
 Hamil
Melahirkan
menyusui
Modes of HIV/AIDS Transmission

Through Bodily Fluids

• Blood products
• Semen
• Vaginal fluids
• Breast Milk
 Penularan AIDS dapat melalui:
• Hubungan seksual yang memungkinkan
pemindahan virus dari sperma dan cairan
vagina/ serviks

• Pemindahan darah yang mengandung HIV

• Penularan kepada janin dari ibu penderita

AIDS
 Kelompok Resiko Tinggi

• 1. Aktif dalam perilaku seksualnya( WTS, PTS )

• 2. Homoseksual.

• 3. Mereka yg suka/ pernah melakukan hubungan

seksual dgn orang asing yang berasal dari daerah
dimana insidens AIDS tinggi.
• 4. Penyalah guna obat/narkotika
Through Sex Mother-to-Baby
• Intercourse
(penile
penetration into • Before Birth
the vagina) • During Birth
• Oral
• Anal • Postpartum
• Digital Sex – After the birth
 Oral Candidiasis
(thrush)

Oral Hairy Leukoplakia

• Being that HIV reduces immunologic activity, the intraoral
environment is a prime target for chronic secondary infections
and inflammatory processes, including OHL, which is due to
the Epstein-Barr virus under immunosuppressed conditions
 Kaposi’s sarcoma (KS)
• Kaposi’s sarcoma (shown) is
a rare cancer of the blood
vessels that is associated
with HIV. It manifests as
bluish-red oval-shaped
patches that may eventually
become thickened. Lesions
may appear singly or in
clusters.
HIV tidak menular melalui :
 Gigitan nyamuk atau serangga lain
Berenang bersama
Memakai toilet umum
Bersalaman, pelukan ataupun ciuman
Terpapar batuk atau bersin
Berbagi makanan atau menggunakan alat
makan bersama
Air kotor, Udara
Bagaimana mengetahui status HIV
?
Status HIV hanya dapat diketahui melalui
Konseling dan Testing HIV Sukarela
 Testing HIV merupakan pengambilan
darah dan pemeriksaan laboratium disertai
konseling pre dan pasca testing HIV
 Konseling dan Testing HIV Sukarela
dilakukan dengan prinsip tanpa paksaan,
rahasia, tidak membeda-bedakan serta
terjamin kualitasnya.
• Anda tidak melakukan seks bukan dgn
pasangannya
• Bersikap saling setia dengan pasangan
• Cegah dengan memakai kondom lateks
• Jangan menggunakan narkoba suntik
 Beberapa Aturan Pokok Keperawatan

• Perawat disarankan memakai baju penutup dan sarung

tangan bila memegang tubuh penderita, khususnya bila
ada kemungkinan terkena sekret tubuhnya.
• Memberi makan, sama seperti pada penderita
Hepatitis B.
• Beri pelindung pada jasur dan bantal ( plastik )
• Sprei, perlu diketahui bahwa HIV sgt mudah dibunuh
dgn detergen.
• Jarum suntik: sama sekali jangan dimasukkan kembali
kedalam penutup jarum dan gunakan botol plastik/
kaleng pembuangan khusus untuk semua alat tajam.(
Perawat yg telah dilatih )
 Beberapa Aturan Pokok Keperawatan

• Bersihkan ruangan seperti biasa

• Kamar mandi/ WC , pemeliharaan seperti biasa.

• Tempelkan stiker khusus dgn tulisan BAHAN MENULAR

pd semua botol spesimen yg akan dikirim ke
laboratorium

• Tangan harus selalu dicuci selama dan sesudah segala

aktifitas pelayanan terhadap penderita, walaupun
mempergunakan sarung tangan.
 ADMINISTRATION
 Blood
 Urine

 Oral

Blood Detection Tests

• Enzyme-Linked Immunosorbent Assay/Enzyme
Immunoassay (ELISA/EIA)
• Radio Immunoprecipitation Assay/Indirect
Fluorescent Antibody Assay (RIP/IFA)
• Polymerase Chain Reaction (PCR)
• Western Blot Confirmatory test

Urine Testing
• Urine Western Blot
• Orasure
– As sensitive as testing
blood
– Safe way to screen for
HIV
– Can cause false positives
in certain people at high
risk for HIV
Oral Testing
– The only FDA approved
HIV antibody.
– As accurate as blood
testing
– Draws blood-derived
fluids from the gum
tissue.
– NOT A SALIVA TEST!
 Treatment Options

Antiretroviral Drugs
• Nucleoside Reverse Transcriptase inhibitors
– AZT (Zidovudine)
• Non-Nucleoside Transcriptase inhibitors
– Viramune (Nevirapine)
• Protease inhibitors
– Norvir (Ritonavir)
Western Blot

• Expensive – $ 80 - 100
• technically more difficult
• visual interpretation
• lack standardisation
– - performance
– - interpretation
– - indeterminate reactions –
resolution of ??
• ‘Gold Standard’ for
confirmation
 Polymerase Chain Reaction (PCR)
• Looks for HIV DNA in the WBCs of a person.
• PCR amplifies tiny quantities of the HIV DNA present, each
cycle of PCR results in doubling of the DNA sequences
present.
• The DNA is detected by using radioactive or biotinylated
probes.
• Once DNA is amplified it is placed on nitrocellulose paper and
allowed to react with a radiolabeled probe, a single stranded
DNA fragment unique to HIV, which will hybridize with the
patient’s HIV DNA if present.
• Radioactivity is determined.
 Virus isolation
• Virus isolation can be used to definitively diagnose
HIV.
• Best sample is peripheral blood, but can use CSF,
saliva, cervical secretions, semen, tears or material
from organ biopsy.
• Cell growth in culture is stimulated, amplifies
number of cells releasing virus.
• Cultures incubated one month, infection confirmed
by detecting reverse transcriptase or p24 antigen in
supernatant.
 Opportunistic
Four ways to
Infection Treatment
protect yourself?
• Issued in an event • Abstinence
where antiretroviral • Monogamous
drugs are not Relationship
available
• Protected Sex
• Sterile needles
 Monogamous Protected Sex
relationship • Use condoms (female or
• A mutually male) every time you
monogamous (only one have sex (vaginal or
sex partner) anal)
relationship with a • Always use latex or
person who is not polyurethane condom
infected with HIV (not a natural skin
• HIV testing before condom)
intercourse is necessary • Always use a latex
to prove your partner is barrier during oral sex
not infected
 When Using A Condom
Remember To:

• Make sure the package is not expired

• Make sure to check the package for damages
• Do not open the package with your teeth for risk
of tearing
• Never use the condom more than once
• Use water-based rather than oil-based condoms
 Sterile Needles

• If a needle/syringe or cooker is shared, it

must be disinfected:
– Fill the syringe with undiluted bleach and wait at
least 30 seconds.
– thoroughly rinse with water
– Do this between each person’s use
The Move Toward Lower Pill Burdens
Regimen Dosing Daily pill burden

1996
Zerit/Epivir/Crixivan 10 pills, Q8H

1998
Retrovir/Epivir/Sustiva 5 pills, BID

2002
Combivir (AZT/3TC)/EFV 3 pills, BID

2003
Viread/ Emtriva/Sustiva 3 pills, QD
2004
Truvada/Sustiva 2 pills, QD
 Truvada
• Truvada is made up of HIV drugs from a class
called nucleoside/nucleotide reverse
transcriptase inhibitors (NRTIs), also known as
“nukes.”
• The NRTIs block reverse transcriptase, a
protein that HIV needs to make more copies
of itself. This may slow down HIV disease
 Vaccines?
Whole virus vaccines
Attenuated viruses: Essentially intact, living HIV virions that have
been chemically or genetically damaged.
Whole killed virus: Intact virions that have been damaged so badly
that they are completely nonfunctional (dead).

Subunit vaccines
Clone one gene from HIV, express the protein and use it to vaccinate
patients. The disadvantage is that the person only raises antibodies
against one target. With free virus, the targets are mainly the envelope
proteins; however, these are extremely variable proteins. Six amino
acids of the V3 loop of gp120 appear to be relatively constant (some
variability exists but most antibodies cross react with the variants).
Antibodies against cocktails of different V3's are being tried.

Nucleic Acid Vaccines

Gene gun, muscle expression.
 PENUTUP
• Sesuai dgn sifat AIDS itu sendiri, maka
pencegahan AIDS relatif mudah, yaitu
menghindari pemakaian jarum suntik berganti
ganti dan menghindari hubungan seksual dgn
pasangan ganda.
• Agama dan Pancasila melarang hubungan seksual
ekstra marital. Akan tetapi penggunaan jargon
jargon Agama atau Pancasila dalam batasan
ucapan verbal saja jelas tidak ada gunanya,
bahkan bisa membuat orang tertutup terhadap
informasi yang benar