H.I.V.

WHAT IS HIV?? “Human Immunodeficiency Virus” A unique type of virus (a retrovirus) Invades the helper T cells (CD4 cells) in the body of the host (defense mechanism of a person) Threatening a global epidemic. Preventable, managable but not curable.

HIV/AIDS Info & History  In 1981, 1 the first cases of AIDS were identified among gay men in the US. However, scientists later found evidence that the disease existed in the world as early as  The first documented case of HIV was traced back to 1959 using preserved blood samples, which were analyzed in  In first-world countries, AIDS is now a chronic disease, but this was not the case in the past.  AIDS is 100% preventable, and yet there were 56,300 new infections in 2006 in the US alone Advert.org 2.2. Centers for Disease Control and Prevention

AIDS is a Global Problem  33 million people worldwide have HIV/AIDS.  571,378 people in the United States are HIV-positive.  New HIV infections occur every 6 seconds UNAIDS

From Terminal to Chronic Infection 3 Months 27 Years…and counting! Today 1980s

Statistics  Worldwide: Over 33 million people are living with HIV percent are women. 1 2 million are children under age 15 years. 1  United States: Over 570,000 people are living with HIV UNAIDS 2. Centers for Disease Control and Prevention

An individual is at risk if she or he…  Has had unprotected sex—ever.  Has had multiple partners within one year.  Has shared needles, or if the partner has shared needles.  Has had a sexually transmitted disease, or sexually transmitted infection—ever.  Uses alcohol or drugs. This is an indirect risk factor as it causes impaired judgment, which can lead to high-risk behaviors.

Definitions  H -  I -  V - Human Immunodeficiency Virus

OTHER NAMES FOR HIV Former names of the virus include:  Human T cell lymphotrophic virus (HTLV-III)  Lymphadenopathy associated virus (LAV)  AIDS associated retrovirus (ARV)

Definitions  A -Acquired  I - Immune  D - Deficiency  S - Syndrome

WHAT IS AIDS ??? “Acquired Immunodeficiency Syndrome” HIV is the virus that causes AIDS Disease limits the body’s ability to fight infection due to markedly reduced helper T cells. Patients have a very weak immune system (defense mechanism) Patients predisposed to multiple opportunistic infections leading to death.

Normal Immune Response T- cells Virus Virus binds to T-cells Antibodi es bind to virus Normal response: Virus invades blood stream and binds to lymphocytes. Lymphocytes make antibodies to the virus. Antibodies bind to the virus and destroy the virus. Vir us T-cells make antibodies Antibodies kill virus

Immune Response to HIV HIV destroys T-cells (CD4 cells) Cannot destroy virus HIV T-cells cannot produce antibodies

What’s the difference between HIV and AIDS? Blood tests positive Healthy, HIV+ can last for years Symptomatic HIV/AIDS Spectrum of HIV Infection Possible Minor Symptoms  HIV, a virus, eventually causes AIDS, a syndrome.

T-Cell Count  If 1,200 or higher, the individual has a normal immune system.  If 800 or less, the immune system is weakened and individual is susceptible to infection.  If 200 or less, AIDS is diagnosed.  Once a person is diagnosed with AIDS, she or he is always categorized as having AIDS, even if her or his T-cell count increases.

Criteria for Diagnosing AIDS  A CD4 cell (type of T-cell) count of 200 or less, or  One opportunistic infection. An opportunistic infection is an infection that typically does not affect individuals with normal immune systems.

AIDS (definition) Opportunistic infections and malignancies that rarely occur in the absence of severe immunodeficiency (eg, Pneumocystis pneumonia, central nervous system lymphoma). Persons with positive HIV serology who have ever had a CD4 lymphocyte count below 200 cells/mcL or a CD4 lymphocyte percentage below 14% are considered to have AIDS.

Opportunistic Infections  Mycobacterium Avium Complex  Salmonellosis  Syphilis and Neurosyphilis  Tuberculosis  Bacillary angiomatosis  Aspergillosis  Candidiasis  Coccidioidomycosis  Cryptococcal Meningitis  Histoplasmosis  Kaposi’s Sarcoma  Systemic Non-Hodgkin’s Lymphoma  Primary CNS Lymphoma  Cryptosporidiosis  Isosporiasis  Microsporidiosis  Pneumocystis Carinii Pneumonia  Toxoplasmosis  Cytomegalovirus  Hepatitis  Herpes Simplex  Herpes Zoster  Human Papillomavirus  Molluscum Contagiosum  Oral Hairy Leukoplakia  Progressive Multifocal Leukoencephalopathy  AIDS Dementia Complex  Peripheral Neuropathy  Apthous Ulcers  Malabsorption  Depression  Diarrhea  Thrombocytopenia  Wasting Syndrome  Idiopathic Thrombocytopenic Purpura  Listeriosis  Pelvic Inflammatory Disease  Burkitt’s Lymphoma  Immunoblastic Lymphoma  Valley Fever  MRSA Source: AIDS Education Global Information System

“THE VIRAL GENOME” Icosahedral (20 sided), enveloped virus of the lentivirus subfamily of retroviruses. Retroviruses transcribe RNA to DNA. Two viral strands of RNA found in core surrounded by protein outer coat. Outer envelope contains a lipid matrix within which specific viral glycoproteins are imbedded. These knob-like structures responsible for binding to target cell.

Modes of HIV/AIDS Transmission

Through Bodily Fluids Blood products Semen Vaginal fluids

Fluids that can transmit HIV Fluids that DO transmit HIV:  Blood  Semen  Vaginal Fluid  Breast Milk (in order of the highest concentration of HIV) Fluids that DO NOT transmit HIV:  Saliva  Tears  Mucus  Urine  Sweat  Feces

IntraVenous Drug Abuse Sharing Needles  Without sterilization Increases the chances of contracting HIV Unsterilized blades

Relative Risk High risk:  Sharing needles  Unprotected sex  Breast feeding Lower risk:  Protected sex  Any opportunity for exchange of body fluids No risk:  Casual contact

Through Sex Unprotected Intercourse  Oral  Anal

Mother-to-Baby Before Birth During Birth

Myths about transmission

Universal Precautions  Wash your hands!  Disinfect utensils and living space.  Use barriers—preferably latex. HIV cannot be spread through casual contact, but these are good practices for preventing opportunistic infections.

Barriers include:  Latex Gloves  Latex Condoms  Sheepskin condoms do NOT protect!  Latex Dental Dams  Anything that protects your skin from a fluid

Prevention  What is the only 100% effective way to prevent HIV infection? ABSTINENCE!  What does abstinence include?  Do not have sex with infected, possibly infected, or multiple partners.  Do not share needles.

Other Prevention Options  If not abstinence, barriers can greatly reduce the risk of HIV transmission.  Use latex condoms and water-based lubricants or dental dams.

NATURAL COURSE OF HIV/AIDS

Stage 1 - Primary Short, flu-like illness - occurs one to six weeks after infection Mild symptoms Infected person can infect other people

Stage 2 - Asymptomatic Lasts for an average of ten years This stage is free from symptoms There may be swollen glands The level of HIV in the blood drops to low levels HIV antibodies are detectable in the blood

Stage 3 - Symptomatic The immune system deteriorates Opportunistic infections and cancers start to appear.

Stage 4 - HIV  AIDS The immune system weakens too much as CD4 cells decrease in number.

Opportunistic Infections associated with AIDS CD4<500 Bacterial infections Tuberculosis (TB) Herpes Simplex Herpes Zoster Vaginal candidiasis Hairy leukoplakia Kaposi’s sarcoma

Opportunistic Infections associated with AIDS CD4<200 Pneumocystic carinii Toxoplasmosis Cryptococcosis Coccidiodomycosis Cryptosporiosis Non hodgkin’s lymphoma

CD4 <50 Disseminated mycobacterium avium complex (MAC) infection Histoplasmosis CMV retinitis CNS lymphoma Progressive multifocal leukoencephalopathy HIV dementia

TB & HIV CO-INFECTION TB is the most common opportunistic infection in HIV and the first cause of mortality in HIV infected patients (10- 30%) 10 million patients co-infected in the world. Immunosuppression induced by HIV modifies the clinical presentation of TB : 1. Subnormal clinical and roentgen presentation 2. High rate of MDR/XDR 3. High rate of treatment failure and relapse (5% vs < 1% in HIV)

Testing Options for HIV

Anonymous Testing No name is used Unique identifying number Results issued only to test recipient Anonymous

Testing  The test is for antibodies against HIV, not for the virus itself.  It can take up to three months for the body to produce antibodies against HIV.  A negative test result may mean recent infection. It is possible to infect others during this stage.  An individual should be tested three months after possible exposure to guarantee an accurate result.

Timeline Second exposure First exposure Three-month window from first exposure Three-month window from second exposure New Test Date Test Date

Blood Detection Tests HIV enzyme-linked immunosorbent assay (ELISA) Screening test for HIV Sensitivity > 99.9% Western blot Confirmatory test Speicificity > 99.9% (when combined with ELIZA) HIV rapid antibody test Screening test for HIV Simple to perform Absolute CD4 lymphocyte count Predictor of HIV progression Risk of opportunistic infections and AIDS when <200 HIV viral load tests Best test for diagnosis of acute HIV infection Correlates with disease progression and response to HAART

Urine Testing Urine Western Blot  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 Orasure  The only FDA approved HIV antibody.  As accurate as blood testing  Draws blood-derived fluids from the gum tissue.  NOT A SALIVA TEST!

Real Life Application  At a party three months ago, I engaged in some high-risk behaviors….When should I get tested?  Before I came here today, I got high with a used needle…now what do I need to do? Avoid the possibility of infecting others!

The ONLY way to know is to get TESTED! Find a Testing Site Near You!  Go to  Enter your zip code.  Instantly receive list of all HIV-testing sites in your area.

Treatment Options

Treatment  Today, in the US, HIV/AIDS is a chronic disease.  Anti-retroviral drugs are used in combination, known as Highly Active Anti-Retroviral Therapy (HAART).  Side effects can be severe, but the risks of not being treated are more severe.  Cornell University estimates the monthly cost of treatment as $2,100, with a lifetime cost of treatment of $618,900.

HAART = highly active anti-retroviral treatment

Antiretroviral Drugs (HAART) Nucleoside Reverse Transcriptase inhibitors  AZT (Zidovudine) Non-Nucleoside Transcriptase inhibitors  Viramune (Nevirapine) Protease inhibitors  Norvir (Ritonavir)

EFFECTIVENESS OF HAART IN REDUCING MORTALITY

HEALTH CARE FOLLOW UP OF HIV INFECTED PATIENTS For all HIV-infected individuals: CD4 counts every 3–6 months Viral load tests every 3–6 months and 1 month following a change in therapy PPD INH for those with positive PPD and normal chest radiograph RPR or VDRL for syphilis Toxoplasma IgG serology CMV IgG serology Pneumococcal vaccine Influenza vaccine in season Hepatitis B vaccine for those who are HBsAb-negative Haemophilus influenzae type b vaccination Papanicolaou smears every 6 months for women

For HIV-infected individuals with CD4 < 200 cells/mcL:  Pneumocystis jiroveci 1 prophylaxis For HIV-infected individuals with CD4 < 75 cells/mcL:  Mycobacterium avium complex prophylaxis For HIV-infected individuals with CD4 < 50 cells/mcL:  Consider CMV prophylaxis

PRIMARY PREVENTION: Five ways to protect yourself? Abstinence Monogamous Relationship Protected Sex Sterile needles New shaving/cutting blades

Abstinence It is the most effective method of not acquiring HIV/AIDS. Refraining from unprotected sex: oral, anal, or vaginal. Refraining from intravenous drug use

Monogamous relationship A mutually monogamous (only one sex partner) relationship with a person who is not infected with HIV HIV testing before intercourse is necessary to prove your partner is not infected

Protected Sex Use condoms every time you have sex Always use latex or polyurethane condom (not a natural skin condom) Always use a latex barrier during oral sex

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

GLOBAL ESTIMATES 2008

ESCALATING EPIDEMIC !!! Source: WHO/UNAIDS/UN The Millennium Development Goals Report, 2009, p.32 and WHO.

HIV PREVALENCE IN VARIOUS REGIONS Source: UNAIDS, AIDS Epidemic Update, December Total = 39.4 million Sub-Saharan Africa South/South-East Asia Oceania Caribbean North Africa/Middle East Western Europe North America East Asia Eurasia Latin America < 42%

NEWLY INFECTED CASES OF HIV IN VARIOUS REGIONS Source: UNAIDS, AIDS Epidemic Update, December 2004 Total = 4.9 million 63%

ESTIMATED HIV BURDEN IN PAKISTAN 0.1% of the adult population in Pakistan Total Population (2008) = 180,800,000 People living with HIV/AIDS (2008) = 96,000 Women (aged 15+) with HIV/AIDS (2008) = 27,000 Children with HIV/AIDS (2008) = nd Adult HIV prevalence(%) (2008) = 0.1% AIDS deaths (2008) = 5,100

ESCALATING EPIDEMIC OF HIV IN HIGH RISK GROUPS IN PAKISTAN

POTENTIAL THREATS IN PAKISTAN 100,000 commercial sex workers with poor safe sex awareness in three major cities Estimated 60,000 iv drug users in pakistan (1 in 5 infected with HIV) 38,000 homosexuals reported in lahore in % of 1.5 million annual blood donors not screened for HIV 20% of blood transfusions come from professional donors with high prevalence of infectious diseases Significantly large number of migrants and refugees.

UNDER-REPORTING Until September 2004, only 300 cases of full-blown AIDS and another 2300 cases of HIV infection were reported to the National AIDS Control Program. The reasons for under reporting are: Social stigma attached to the infection, Limited surveillance Voluntary counseling and testing systems Lack of knowledge among the general population and health practitioners.

NATIONAL RESPONSE TO HIV/AIDS Pakistan’s Federal Ministry of Health initiated a National AIDS Prevention and Control Program (NACP) in 1987  In its early stages, the program was focused on diagnosis of cases that came to hospitals, but progressively began to shift toward a community focus The government has indicated in the recent scaling up of its response to HIV/AIDS, more needs to be done.

NON GOVERNMENTAL ORGANIZATIONS 54 NGOs are involved in HIV/AIDS public awareness and in the care and support of persons living with HIV/AIDS. Also working on education and prevention interventions targeting sex workers, truck drivers, and other high-risk groups. But reaching less than 5 percent of the vulnerable population.

WORLD BANK RESPONSE Largest financer of HIV/AIDS program in Pakistan Providing 37.1 million US dollars Enhanced program is making encouraging progress with expansion of coverage.

WHAT WE CAN DO?? UNAIDS Outcome Framework 2009–2011: nine priority areas We can reduce sexual transmission of HIV. We can prevent mothers from dying and babies from becoming infected with HIV. We can ensure that people living with HIV receive treatment. We can prevent people living with HIV from dying of tuberculosis. We can protect drug users from becoming infected with HIV. We can remove punitive laws, policies, practices, stigma and discrimination that block effective responses to AIDS. We can stop violence against women and girls. We can empower young people to protect themselves from HIV. We can enhance social protection for people affected by HIV.

LIVING WITH HIV/AIDS