Paul Allyn, MD African American HIV University University of California Los Angeles August 26, 2015.

Slides:



Advertisements
Similar presentations
Key1 World Bank Training Program on HIV/AIDS Drugs Training Module 3 Selection and Quantification based on the World Bank document Battling HIV/AIDS: A.
Advertisements

24th June World Health Organization Clinical Staging, AIDS surveillance and Mortality in resource-poor settings a clinicians view of strategic information.
Review of HIV and Opportunistic Infections (OI) in Children
ARV Nurse Training Programme Marcus McGilvray & Nicola Willis
BORDERNETwork Training on Late Presenter Dr. med. Wolfgang Güthoff / Alexander Leffers, M.A.
Acute Retroviral Syndrome
Module 1: Overview of HIV Infection Unit 01.03: Natural History and Progression Of HIV Infection 1.
HIV 101 Review Evaluation Center for HIV and Oral Health Boston University School of Public Health Health & Disability Working Group.
The HIV virus. Committee on Oversight and Government Reform. HIV/AIDS Today, 1(1):1, January 18, 2008.
P AUL A LLYN, MD A FRICAN A MERICAN HIV U NIVERSITY U NIVERSITY OF C ALIFORNIA L OS A NGELES A UGUST 28, 2014.
Immunodeficiencies HIV/AIDS. Immunodeficiencies Due to impaired function of one or more components of the immune or inflammatory responses. Problem may.
Diagnostic testing for HIV: The symptomatic patient.
AWARENESS OF HIV AIDS GIMANDA NAHDIAH DIANA B.11.1.
Adapted from curriculum by Tucson Interfaith HIV/AIDS Network
HIV AND AIDS.
Diagnosing HIV UCLA AAHU Science and Treatment College Science Academy 2014.
Medical-Surgical Nursing: An Integrated Approach, 2E Chapter 23
Catalyst: Week 30 Class 1 1.In 2001, 92 rabbits were born, and 60 died. 14 rabbits immigrated to the area, and 17 emigrated from the area. Find the population.
Viruses.
Natural History and Clinical Staging of HIV Training for Medical Officers Day 2 Session 7.
Late presenters and opportunistic infections Jane Bruton Clinical Research Nurse Imperial College.
Chronic HIV Infection Clinical Manifestations Opportunistic Infections O.I. Prophylaxis.
HIV and AIDS: Protecting Yourself, Protecting Others David Lee, Mollie Williams, and Andrew Frankart.
Do Now Make two lists: one with a list of HIV symptoms and one with a list of AIDS symptoms. Make two lists: one with a list of HIV symptoms and one with.
 Heterosexual  Bi-sexual  Homosexual Blood and Blood Products  Blood transfusion  Tissue Transplantation e.g Kidney Transmission Modes for HIV (2)
VIRUSES. Lytic vs. Lysogenic Vaccines First made was in 1700’s- fight smallpox Help prevent viral infections, but they cannot cure most viral infection.
Immunology, the HIV life cycle and stages of infection Anele Waters HIV Research Nurse North Middlesex Hospital, London.
Classification of HIV and Expanded AIDS Surveillance Case Definition.
Affordable healthcare Product Selection for Opportunistic Infections IDA HIV/AIDS Group, Nienke Gruppelaar “ HIV does not kill, opportunistic infections.
PMTCT Generic Training PackageModule 1Slide 1 Introduction to HIV/AIDS M O D U L E 1.
1 Pediatric HIV Infection HAIVN Harvard Medical School AIDS Initiative in Vietnam.
26 YEARS OF HIV EPIDEMY 10 years HAART Dan Turner, MD, Tel-Aviv Sourasky Medical Center.
Background There is uncertainty regarding the frequency, predictors, and outcomes of IRIS events Prior studies on IRIS have been limited to convenience.
1 Natural Course of HIV Infection HAIVN Harvard Medical School AIDS Initiative in Vietnam.
HIV related Opportunistic Diseases HIV related Opportunistic Diseases M.MEIDANI,MPH.MD.
Clinical Care of HIV, AIDS and Opportunistic Infections
Homework # 2 A2 Subsection Dr. Sandra Navarra USTFMS.
Connie van Marrewijk IDA Foundation Product Selection for Opportunistic Infections.
HIV/AIDS. Human Immunodeficiency Virus  Virus attacks the immune system  Invades and destroys certain white blood cells  Takes time for the HIV to.
Stage 1: Primary HIV Infection This stage of infection lasts a few weeks and feels like the flu. During this stage there is a large amount of HIV in the.
1 HIV Clinical Staging HAIVN Harvard Medical School AIDS Initiative in Vietnam.
AIDS Dr. Gerrard Uy. AIDS Definition: – According to the CDC classification system, any HIV infected individual with a CD4 T cell count of
AIDS Dr. Meg-angela Christi Amores. AIDS Etiologic agent: – HIV (Human Immunodeficiency Virus) – 2 types: HIV 1 and HIV 2 – Most common cause: HIV 1.
Prophylaxis of Opportunistic Infections
HIV and AIDS PM2 PATHOPHYSIOLOGY. HIV is the causative agent of AIDS Human immunodeficiency virus Human immunodeficiency virus retrovirus retrovirus most.
Human Immunodeficiency Virus & Acquired Immunodeficiency Syndrome Community Medicine - Reporting October 10, 2011.
Questions, Answers, and Explanations Infectious Diseases Blueprint.
HIV D S O’Briain March Pathology of HIV Epidemic disease Influenza pandemic Legionnaire’s disease 1976 HIV 1981 Heroin, Dublin 2000 SARS.
29-1 A Human Perspective HIV Disease and Complications of Immunodeficiency Eugene Nester Denise Anderson Evans Roberts, Jr. Nancy Pearsall Martha Nester.
Interventions for Clients with HIV/AIDS and Other Immunodeficiencies.
Syndrome Acquired Immune Deficiency. AIDS is caused by a virus called HIV.
Chapter 5: The Medical Side of Living with HIV/AIDS.
Treatment and Prevention of Opportunistic Infections: Options for the Caribbean Region Jonathan E. Kaplan, M.D.
DR.S. MANSORI INFECTIOUS DISEASE SPECIALIST QAZVIN UNIVERCITY OF MEDICAL SCIENCE.
Chapter 2: The Path from HIV to AIDS
Look -- Look.
HIV / AIDS HUMAN IMMUNODEFICIENCY Virus (HIV) ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS)
HIV/AIDS Review.
What is HIV? Human Immunodeficiency Virus.
Chapter 85 HIV and AIDS.
Adapted from curriculum by Tucson Interfaith HIV/AIDS Network
PAEDIATRIC AIDS ¨     Acquired immunodeficiency Syndrome (AIDS) is caused by Human Immunodeficiency Virus type 1 and 2 ¨     World wide problem, more.
AIDS Dr. Amitabha Basu MD.
CLINICAL MANIFESTATIONS OF HIV
What is HIV? Human Immunodeficiency Virus.
What is HIV? Human Immunodeficiency Virus.
What is HIV? Human Immunodeficiency Virus.
What is HIV? Human Immunodeficiency Virus.
HIV and AIDS.
Presentation transcript:

Paul Allyn, MD African American HIV University University of California Los Angeles August 26, 2015

To illustrate the natural progression of HIV-1 if left untreated To highlight common clinical manifestations of HIV by CD4 count To discuss exceptions to this overall trend

AIDS Clinical AIDSAdvanced AIDS and Death Clinical Latency Asymptomatic DiseaseEarly Symptomatic Disease Acute HIV-1 Infection Primary InfectionAcute Retroviral Syndrome

Stages based on CD4 cell count and symptoms.

StageDescription Stage 1Asymptomatic or with persistent generalized lymphadenopathy, not AIDS. Stage 2Minor mucocutaneous manifestations and recurrent upper respiratory tract infections, herpes zoster, mild weight loss (<10% of body weight). Stage 3Unexplained chronic diarrhea, prolonged fever, severe bacterial infections, pulmonary tuberculosis, weight loss (>10% of body weight). Stage 4PCP pneumonia, toxoplasmosis of the brain, esophageal candidiasis, Kaposi’s sarcoma, CMV, extrapulmonary TB, lymphoma, disseminated MAC, wasting syndrome, encephalopathy. Stages defined clinically, designed for resource-poor areas.

Adapted from Pantaleo et al. NEJM 1993

Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7 th Ed

Timeframe: 0 weeks (immediately after transmission) Characterized by: High viral load (high concentration of HIV RNA in the blood) Declining CD4+ lymphocyte count (average about 1000 cells/mm 3 prior to infection) Initially asymptomatic

Adapted from Pantaleo et al. NEJM 1993.

Timeframe: 1-6 weeks after exposure (peaks at 3 weeks) High viral load, low CD4 count Mononucleosis-like illness in 1/2 -2/3 of patients Symptoms typically resolve within days Up to 50% patients asymptomatic

Symptoms variable in those who have them: Fever (96%) Enlarged lymph nodes (74%) Sore throat/Pharyngitis (70%) Rash (70%) Muscle or joint aches (54%) Low blood counts, platelets, and white cells (45%, 38%) Diarrhea (32%) Headache (32%) Nausea/Vomiting (27%) Hair loss (alopecia) Mood changes (depression, irritability) Data from Niu MT et al. JID 1993.

Adapted from Pantaleo et al. NEJM 1993.

After acute infection, most patients remain asymptomatic for years Immune system develops antibodies to suppress the virus and the viral load stabilizes (viral set point) Over time, there is typically a gradual decline in CD4+ lymphocytes (on average cells per year) Median time from infection to development of AIDS is approximately 8-10 years Some may develop AIDS in <5 years (approximately 20%) Few will remain asymptomatic without evidence of immunosuppression for more than 10 years (<5%) Many factors impact prognosis, but HIV-1 RNA levels (viral load) combined with CD4+ cell counts are the best predictor of disease progression to AIDS and death from AIDS

Egger et al. Lancet 2002.

Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7 th Ed

Chaisson RE et al. NEJM >200 <=200 Female Male Female Male

Long-term nonprogressors: Remain asymptomatic without treatment or evidence of immunologic decline for many years 2 Groups: 1. Those with detectable viral load but adequate CD4+ cells to protect them from opportunistic disease (though these gradually decline over time) 2. Elite Controllers: Small group, have undetectable viral loads and maintain normal CD4+ lymphocyte counts Able to contain viral replication

Patients with CD4+ counts > 500 generally asymptomatic May have mild or moderate lymphadenopathy (persistent generalized lymphadenopathy) Recurrent herpes infections may be present as well May have exacerbation of skin conditions: Psoriasis Eosinophilic folliculitis Aphthous ulcers Hairy Leukoplakia (benign white plaques on tongue)

Mandell 2009

Most patients with CD4+ counts between 200 and 500 cells remain asymptomatic or have mild disease. May have: Worsening of chronic skin conditions Recurrent herpes simplex or varicella-zoster virus (shingles) Vaginal or oropharyngeal candidiasis (thrush) Recurrent diarrhea Intermittent fever Weight loss Muscle aches, joint aches, headache, and fatigue commonly reported Common to have bacterial sinusitis, bronchitis, pneumonia

Adapted from Pantaleo et al. NEJM AIDS

Patients with CD4+ Cells <200 are classified as having AIDS by 1993 CDC definition Certain opportunistic infections seen at this stage and are indicative of AIDS, including: Pneumocystis carinii (jirovecii) pneumonia (PCP) Toxoplasmosis Cryptosporidiosis Esophageal candidiasis Tuberculosis Increased risk of certain cancers: Invasive cervical cancer in women Rectal or anal carcinoma in men Hematologic abnormalities (ITP, anemia, neutropenia) HIV-associated nephropathy (kidney disease)

Multiple or recurrent bacterial infections CandidiasisInvasive Cervical Cancer Coccidioidomycosis, disseminated or extrapulmonary Cryptococcosis, extrapulmonaryCryptosporidiosis Cytomegalovirus diseaseCytomegalovirus retinitisHIV-related encephalopathy Herpes simplex, chronic ulcers, bronchitis, pneumonitis, esophagitis Histoplasmosis, disseminated or extrapulmonary Isosporiasis, chronic intestinal Kaposi’s sarcomaLymphoid interstitial pneumoniaBurkitt’s lymphoma Immunoblastic lymphomaPrimary CNS lymphomaMAI, M. kansasii, disseminated or extrapulmonary Mycobacterium tuberculosis, any site Pneumocystis carinii (jirovecii) pneumonia Recurrent pneumonia Progressive multifocal leukoencephalopathy Salmonella septicemia, recurrent Wasting syndrome of HIV infection CNS toxoplasmosis

CT Chest PCP Pneumonia (From Mandell 2009) Normal CT Chest (From radiopaedia.org)

Mandell 2009 Abnormal brain CT with toxoplasma ring-enhancing lesion in an AIDS patient.

Normal retina (from somerseye.com) Toxo chorioretinitis from Mandell 2009

Patients with CD4+ cells < 50 have end-stage immunodeficiency At risk for additional opportunistic illnesses: Disseminated Mycobacterium avium complex (MAC) Progressive multifocal leukoencephalopathy (PML) Cryptococcal meningitis Other disseminated fungal infections (coccidiomycosis, histoplasmosis, aspergillosis, Penicillium marneffei) Primary CNS lymphoma CMV Retinitis Wasting syndrome

Enlarged painless lymph node. Mandell 2009

Abnormal brain MRI AIDS patient with PML.

Normal retina (from somerseye.com) Early disease with involvement along blood vessels. Extensive disease with retinal hemorrhage. Mandell 2009

Moore RD and Chaisson RE. Ann Intern Med Herpes simplex Herpes zoster (shingles) Candida esophagitis PCP Pneumonia Toxoplasmosis CMV Disseminated MAC HIV Dementia

Adapted from Pantaleo et al. NEJM AIDS

Mean survival after reaching a CD4+ count of 200 is months without treatment Mean survival after the development of clinically- defined AIDS is months (9 months in initial San Francisco cohort) Opportunistic infections independently increase risk of death

CDC

Overall Death Rate 9513 per 100,000 person years (General population 267) Adapted from Wada N et al. Am J Epidemiol (Percentages are approximate to show general trend)

Overall Death Rate 2842 per 100,000 person years (General population 463) Adapted from Wada N et al. Am J Epidemiol (Percentages are approximate to show general trend)

1-6 weeks (average 3 weeks) after primary infection 1/2 to 2/3 of patients develop an acute mononucleosis-like illness called the acute retroviral syndrome that lasts days. Following the acute infection, patients enter a period of clinical latency where they may remain mostly asymptomatic for up to 8-10 years on average, though this duration varies considerably. Disease progression can be predicted by baseline viral load and CD4+ cell count. Over time most patients (except for nonprogressors) will have declining CD4+ cells with increasing risk of developing symptoms. When CD4+ cells fall below 200 or with specific opportunistic infections, patients are defined as having AIDS. Risk of death increases dramatically when patients develop clinical symptoms of AIDS. HAART dramatically reduces this risk.

Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 7 th Edition. Churchill Livingstone Vergis EN and Mellors JW. Natural History of HIV-1 Infection. Infectious Disease Clinics of North America CDC: WHO: